The quality and clinical applicability of recommendations in pressure injury guidelines: A systematic review of clinical practice guidelines

Methodological Quality of Pulmonary Arterial Hypertension Treatment Evidence-Based Guidelines: A Systematic Review Using the AGREE II and AGREE REX Tools

PURPOSE

Pulmonary arterial hypertension (PAH) is a progressive disease with a poor prognosis, and its management should be grounded in well-developed clinical practice guidelines (CPG). Thus, we critically assess the methodological quality of the available CPG for pharmacological treatments for PAH.

METHODS

A systematic review (CRD42023387168) was performed in PubMed, Cochrane, Embase, and Tripdatabase (Jan-2023). Eligible records were appraised by four reviewers using the Appraisal of Guidelines, Research, and Evaluation Collaboration tool (AGREE II) and the complementary tool for assessing recommendations' quality and certainty, AGREE REX. Descriptive statistics were used to summarize the data.

RESULTS

Overall, 31 guidelines, mainly authored by professional societies (90%), targeting only physicians as primary users (84%), were identified. Guidelines presented a moderate overall quality (scores of 63% and 51% in AGREE II and AGREE REX, respectively), with a few domains showing slight improvements over the years. AGREE II "Scope and Purpose" (94%) and "Presentation Clarity" (99%) domains obtained the highest scores. The items related to "Stakeholder involvement," "Editorial independence," and "Clinical applicability" (AGREE REX) were fairly reported. Conversely, CPG lacks rigor in development (32% score, AGREE II), scarcely discusses the role of stakeholders, and provides deficient data on the implementation of recommendations (scores of 35% and 46% in AGREE II and AGREE REX, respectively). No differences in the quality of guidelines published by different developers or countries were observed (p > 0.05).

CONCLUSION

Methodological weaknesses are common among guidelines addressing PAH treatment, especially regarding scientific rigor, stakeholders' values and preferences, and facilitators and barriers to implementability. Particular attention should be given to developing future guidelines.

The effect of pressure injury prevention care bundles on pressure injuries in hospital patients: A complex intervention systematic review and meta-analysis

BACKGROUND

Numerous interventions for pressure injury prevention have been developed, including care bundles.

OBJECTIVE

To systematically review the effectiveness of pressure injury prevention care bundles on pressure injury prevalence, incidence, and hospital-acquired pressure injury rate in hospitalised patients.

DATA SOURCES

The Medical Literature Analysis and Retrieval System Online (via PubMed), the Cumulative Index to Nursing and Allied Health Literature, EMBASE, Scopus, the Cochrane Library and two registries were searched (from 2009 to September 2023).

STUDY ELIGIBILITY CRITERIA

Randomised controlled trials and non-randomised studies with a comparison group published in English after 2008 were included. Studies reporting on the frequency of pressure injuries where the number of patients was not the numerator or denominator, or where the denominator was not reported, and single subgroups of hospitalised patients were excluded. Educational programmes targeting healthcare professionals and bundles targeting specific types of pressure injuries were excluded.

PARTICIPANTS AND INTERVENTIONS

Bundles with ≥3 components directed towards patients and implemented in ≥2 hospital services were included.

STUDY APPRAISAL AND SYNTHESIS METHODS

Screening, data extraction and risk of bias assessments were undertaken independently by two researchers. Random effects meta-analyses were conducted. The certainty of the body of evidence was assessed using Grading of Recommendations, Assessment, Development and Evaluation.

RESULTS

Nine studies (seven non-randomised with historical controls; two randomised) conducted in eight countries were included. There were four to eight bundle components; most were core, and only a few were discretionary. Various strategies were used prior to (six studies), during (five studies) and after (two studies) implementation to embed the bundles. The pooled risk ratio for pressure injury prevalence (five non-randomised studies) was 0.55 (95 % confidence intervals 0.29-1.03), and for hospital-acquired pressure injury rate (five non-randomised studies) it was 0.31 (95 % confidence intervals 0.12-0.83). All non-randomised studies were at high risk of bias, with very low certainty of evidence. In the two randomised studies, the care bundles had non-significant effects on hospital-acquired pressure injury incidence density, but data could not be pooled.

CONCLUSIONS AND IMPLICATIONS OF KEY FINDINGS

Whilst some studies showed decreases in pressure injuries, this evidence was very low certainty. The potential benefits of adding emerging evidence-based components to bundles should be considered. Future effectiveness studies should include contemporaneous controls and the development of a comprehensive, theory and evidence-informed implementation plan.

SYSTEMATIC REVIEW REGISTRATION NUMBER

PROSPERO CRD42023423058.

TWEETABLE ABSTRACT

Pressure injury prevention care bundles decrease hospital-acquired pressure injuries, but the certainty of this evidence is very low.

Exploring the relationship between pressure ulcer knowledge and self-efficiency among nursing students: A multicenter study

AIM

To determine the relationship between the knowledge and self-efficiency regarding pressure ulcers of nursing students.

METHODS

This descriptive and correlational study was conducted with 775 nursing students from three different universities in various regions of Turkey. The "Pressure Ulcer Knowledge Assessment Tool-Updated Version" and "Pressure Ulcer Management Self-Efficiency Scale for Nurses" tool were used to collect data between May and September 2023. The Strengthening the Reporting of Observational Studies checklist was followed to report this study.

RESULTS

The mean knowledge score was 7.27 ± 3.09, and the mean self-efficiency on pressure ulcer management score was 35.5 ± 18.3. A statistically significant positive correlation was found between nursing students' knowledge and self-efficiency mean scores regarding pressure ulcers (p < 0.05). A significant difference was also found between the students' academic levels and gender and their knowledge and self-efficiency scores regarding pressure ulcers.

CONCLUSION

In this study, where the data covers these three institutions, students' pressure ulcer knowledge and self-efficiency scores were lower compared to all academic years. Accordingly, it was also determined that students with more nursing practice experience showed higher knowledge and self-efficacy scores than students with less nursing practice experience. Additionally, the students' self-efficacy increased along with their knowledge level. Training courses may be suggested to improve students' knowledge and self-efficiency regarding pressure ulcers.

Methodological quality and clinical recommendations of guidelines on the management of dyslipidaemias for cardiovascular disease risk reduction: a systematic review and an appraisal through AGREE II and AGREE REX tools

BACKGROUND

Clinical practice guidelines (CPGs) are statements to assist practitioners and stakeholders in decisions about healthcare. Low methodological quality guidelines may prejudice decision-making and negatively affect clinical outcomes in non-communicable diseases, such as cardiovascular diseases worsted by poor lipid management. We appraised the quality of CPGs on dyslipidemia management and synthesized the most updated pharmacological recommendations.

METHODS

A systematic review following international recommendations was performed. Searches to retrieve CPG on pharmacological treatments in adults with dyslipidaemia were conducted in PubMed, Scopus, and Trip databases. Eligible articles were assessed using AGREE II (methodological quality) and AGREE-REX (recommendation excellence) tools. Descriptive statistics were used to summarize data. The most updated guidelines (published after 2019) had their recommendations qualitatively synthesized in an exploratory analysis.

RESULTS

Overall, 66 guidelines authored by professional societies (75%) and targeting clinicians as primary users were selected. The AGREE II domains Scope and Purpose (89%) and Clarity of Presentation (97%), and the AGREE-REX item Clinical Applicability (77.0%) obtained the highest values. Conversely, guidelines were methodologically poorly performed/documented (46%) and scarcely provided data on the implementability of practical recommendations (38%). Recommendations on pharmacological treatments are overall similar, with slight differences concerning the use of supplements and the availability of drugs.

CONCLUSION

High-quality dyslipidaemia CPG, especially outside North America and Europe, and strictly addressing evidence synthesis, appraisal, and recommendations are needed, especially to guide primary care decisions. CPG developers should consider stakeholders' values and preferences and adapt existing statements to individual populations and healthcare systems to ensure successful implementation interventions.

Risk factors predicting hospital-acquired pressure injury in adult patients: An overview of reviews

BACKGROUND

Hospital-acquired pressure injuries remain a significant patient safety threat. Current well-known pressure injury risk assessment tools have many limitations and therefore do not accurately predict the risk of pressure injury development over diverse populations. A contemporary understanding of the risk factors predicting pressure injury in adult hospitalised patients will inform pressure injury prevention and future researchers considering risk assessment tool development may benefit from our summary and synthesis of risk factors.

OBJECTIVE

To summarise and synthesise systematic reviews that identify risk factors for hospital-acquired pressure injury development in adult patients.

DESIGN

An overview of systematic reviews.

METHODS

Cochrane and the Joanna Briggs Institute methodologies guided this overview. The Cochrane library, CINAHL, MEDLINE, and Embase databases were searched for relevant articles published in English from January 2008 to September 2022. Two researchers independently screened articles against the predefined inclusion and exclusion criteria, extracted data and assessed the quality of the included reviews using "a measurement tool to assess systematic reviews" (AMSTAR version 2). Data were categorised using an inductive approach and synthesised according to the recent pressure injury conceptual frameworks.

RESULTS

From 11 eligible reviews, 37 risk factors were categorised inductively into 14 groups of risk factors. From these, six groups were classified into two domains: four to mechanical boundary conditions and two to susceptibility and tolerance of the individual. The remaining eight groups were evident across both domains. Four main risk factors, including diabetes, length of surgery or intensive care unit stay, vasopressor use, and low haemoglobin level were synthesised. The overall quality of the included reviews was low in five studies (45 %) and critically low in six studies (55 %).

CONCLUSIONS

Our findings highlighted the limitations in the methodological quality of the included reviews that may have influenced our results regarding risk factors. Current risk assessment tools and conceptual frameworks do not fully explain the complex and changing interactions amongst risk factors. This may warrant the need for more high-quality research, such as cohort studies, focussing on predicting hospital-acquired pressure injury in adult patients, to reconsider these risk factors we synthesised.

REGISTRATION

This overview was registered with the PROSPERO (CRD42022362218) on 27 September 2022.

Critical appraisal of the Colombian clinical practice guide for the prevention, diagnosis and treatment of suicidal ideation and/or behaviour (adoption)

INTRODUCTION

Suicide is a complex, global public health problem. The Colombian clinical practice guideline provides relevant input for its prevention, diagnosis and treatment. The objective was to evaluate the methodological quality, credibility and applicability of the Colombian clinical practice guideline for suicidal behaviour.

METHODS

An academic group of 12 evaluators was established to assess the guide and its recommendations in a standardised way, using the AGREE-II and AGREE-REX instruments. The evaluations were given in the range of 0.0-1.0 with 0.7 as a cut-off point for appropriate quality.

RESULTS

The global assessment of the AGREE-II was greater than 0.7 in the dimensions: "scope and objective" (0.86), "clarity of presentation" (0.89), "applicability" (0.73) and "editorial independence" (0.89). The lowest scores were for "participation of those involved" (0.67) and "rigour in preparation" (0.69). With the AGREE-REX, the results in all dimensions were below 0.70, which indicates lower quality and suitability for use.

CONCLUSIONS

The adoption process of the Colombian guideline for suicidal behaviour was a rigorous methodological process, while the practice recommendations were valued as of low applicability due to low support in local evidence. It is necessary to strengthen the generation and synthesis of evidence at the national level to give greater support and applicability to the practice recommendations.

Prevalence and incidence of pressure injuries among older people living in nursing homes: A systematic review and meta-analysis

BACKGROUND

Pressure injuries are a fundamental safety concern in older people living in nursing homes. Recent studies report a disparate body of evidence on pressure injury prevalence and incidence in this population.

OBJECTIVES

To systematically quantify the prevalence and incidence of pressure injuries among older people living in nursing homes, and to identify the most frequently occurring PI stage(s) and anatomical location(s).

DESIGN

Systematic review and meta-analysis.

SETTING(S)

Nursing homes, aged care, or long-term care facilities.

PARTICIPANTS

Older people, 60 years and older.

METHODS

Cross-sectional and cohort studies reporting on either prevalence or incidence of pressure injuries were included. Studies published in English from 2000 onwards were systematically searched in Medline, PubMed, Embase, Cochrane Library, CINAHL and ProQuest. Screening, data extraction and quality appraisal were undertaken independently by two or more authors and adjudicated by another. Outcomes included pressure injury point prevalence, cumulative incidence, and nursing home acquired pressure injury rate. In meta-analyses, Cochrane's Q test and the I2 statistic were used to explore heterogeneity. Random effects models were used in the presence of substantial heterogeneity. Sources of heterogeneity were investigated by subgroup analyses and meta-regression.

RESULTS

3384 abstracts were screened, and 47 full-text studies included. In 30 studies with 355,784 older people, the pooled pressure injury prevalence for any stage was 11.6 % (95 % CI 9.6-13.7 %). Fifteen studies with 5,421,798 older people reported the prevalence of pressure injury excluding stage I and the pooled estimate was 7.2 % (95 % CI 6.2-8.3 %). The pooled incidence for pressure injury of any stage in four studies with 10,645 older people was 14.3 % (95 % CI 5.5-26.2 %). Nursing home acquired pressure injury rate was reported in six studies with 79,998 older people and the pooled estimate was 8.5 % (95 % CI 4.4-13.5 %). Stage I and stage II pressure injuries were the most common stages reported. The heel (34.1 %), sacrum (27.2 %) and foot (18.4 %) were the three most reported locations of pressure injuries. Meta-regression results indicated a reduction in pressure injury prevalence over the years of data collection.

CONCLUSION

The burden of pressure injuries among older people in nursing homes is similar to hospitalised patients and requires a targeted approach to prevention as is undertaken in hospitals. Future studies using robust methodologies focusing on epidemiology of pressure injury development in older people are needed to conduct as the first step of preventing pressure injuries.

REGISTRATION NUMBER

PROSPERO CRD42022328367.

TWEETABLE ABSTRACT

Pressure injury rates in nursing homes are comparable to hospital rates indicating the need for targeted programmes similar to those in hospitals.

Medical and surgical nurses' approach to patient pressure injury prevention education: An integrative review

AIMS

Identify and synthesise the published literature on the approaches and practices nurses use during the delivery of pressure injury prevention (PIP) education to hospitalised medical and surgical patients.

DESIGN

An integrated review.

METHODS

Whitmore and Knaff's (2005) five-stage methodology guided this review: (1) research problem identification; (2) literature search; (3) data evaluation; (4) data analysis; and (5) results. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (2020) Statement was followed. The quality of included studies was assessed using the Mixed Method Appraisal Tool (2018). Extracted data were analysed using inductive content analysis.

DATA SOURCES

Journal publication dates from 1992 to 2022. Systematic searches of CINAHL (Cumulative Index of Nursing and Allied Health Literature) complete, Embase, PsycINFO (via Ovid) and Scopus databases were undertaken.

RESULTS

A total of 3892 articles were initially identified, four quantitative and two qualitative studies were included. Articles were published between 2013 and 2022.Two themes were identified: responsibility and workplace culture determine nurses' approach to PIP education delivery; and nurses tailor education strategies to address challenges and opportunities for PIP education delivery.

CONCLUSION

Nurses require resources to facilitate approaches to PIP education with medical and surgical patients. In the absence of clear instruction to support nurses' practice, PIP education for patients is at best delivered in an informal and ad hoc manner. Nurses require accessible education resources to enable them to tailor the content and frequency of PIP education to patients in med-surg settings.

PATIENT OR PUBLIC CONTRIBUTION

No patient or public contribution.

Critical appraisal and comparison of recommendations of clinical practice guidelines for the treatment of schizophrenia in children and adolescents: a methodological survey

INTRODUCTION

The production of clinical practice guidelines (CPGs) has grown in the past years. Notwithstanding, the quality of these documents and their recommendations for the treatment of schizophrenia in children and adolescents is still unknown.

OBJECTIVE

To assess the quality of the guidelines and recommendations for the treatment of schizophrenia in this population.

METHODS

CPGs from 2004 to December 2020 were identified through a systematic search on EMBASE, MEDLINE, PsycINFO, PubMed, Epistemonikos, VHL, Global Index Medicus and specific CPG databases. The CPGs' quality was independently assessed by three reviewers using AGREE II and they were considered of high quality if they scored ≥60% in domains 3 and 6. The evidence classification systems were described, the quality of recommendations was assessed in pairs using AGREE-REX and the recommendations were compared.

RESULTS

The database search retrieved 3182 results; 2030 were screened and 29 were selected for full-text reading. Four guidelines were selected for extraction. Two CPGs were considered of high quality in the AGREE II assessment. We described the commonly agreed recommendations for each treatment phase. The pharmacological recommendations were described in all treatment phases. Scores of AGREE-REX were lower for psychosocial recommendations.

CONCLUSION

There are still few clinical studies and CPGs regarding schizophrenia in children and adolescents. The quality of the documents was overall low, and the quality of the recommendations report has much to improve. There is also a lack of transparency about the quality of the evidence and the strength of the recommendations.

PROTOCOL REGISTRATION NUMBER

CRD42020164899.

Quality appraisal of clinical nutrition practice guidelines for critically ill adult patients: a systematic review using the Advancing Guideline Development, Reporting and Evaluation in Health Care instrument II (AGREE-II) and AGREE-Recommendation Excellence (AGREE-REX)

Nutritional therapy should follow evidence-based practice, thus several societies regarding nutrition and critical care have developed specific Clinical Practice Guidelines (CPG). However, to be regarded as trustworthy, the quality of the CPG for critically ill patients and its recommendations need to be high. This systematic review aimed to appraise the methodology and recommendations of nutrition CPG for critically ill patients. We performed a systematic review (protocol number CRD42020184199) with literature search conducted on PubMed, Embase, Cochrane Library and other four specific databases of guidelines up to October 2021. Two reviewers, independently, assessed titles and abstracts and potentially eligible full-text reports to determine eligibility and subsequently four reviewers appraised the guidelines quality using the Advancing Guideline Development, Reporting and Evaluation in Health Care instrument II (AGREE-II) and AGREE-Recommendation Excellence (AGREE-REX). Ten CPG for nutrition in critically ill patients were identified. Only Academy of Nutrition and Dietetics and European Society of Intensive Care Medicine had a total acceptable quality and were recommended for daily practice according AGREE-II. None of the CPG recommendations had an overall quality score above 70 %, thus being classified as moderate quality according AGREE-REX. The methodological evaluation of the critically ill adult patient CPG revealed significant discrepancies and showed a need for improvement in its development and/or reporting. In addition, recommendations about nutrition care process presented a moderate quality.

Nutrition management for patients with head and neck cancer during peri-radiotherapy: A systematic review and quality appraisal of clinical practice guidelines using the AGREE II instrument

Objective

To evaluate the quality of clinical practice guidelines (CPGs) for nutrition management of patients with head and neck cancer (HNC) during peri-radiotherapy, as well as to summarize the nutrition recommendations fitting the subject.

Methods

CPGs published in English, Chinese and German were identified from databases, guideline networks, and websites of nutritional associations from the databases’ inception to March 8, 2022. Three independent appraisers used the Appraisal of Guidelines for Research and Evaluation II (AGREE II) Instrument to assess the quality of CPGs. The intraclass correlation coefficient (ICC) was used to calculate appraiser agreement.

Results

769 records were identified. After removing duplicates, 470 articles were screened. 12 CPGs were identified with nutrition-specific recommendations. 67% of CPGs were rated as high quality, and 33% as low quality. Recommendations were categorized into nutritional risk screening, nutrition assessment, nutrition counseling, nutrition interventions, nutrition intake, swallowing function management, weight management, exercise, multidisciplinary team, post-discharge care, nutrients, and pharmacologic interventions.

Conclusion

We found discrepant recommendations in existing CPGs, including nutrition screening, nutrition assessment, nutrition intake, and nutrients. We also reported the absence of essential parts of CPGs, including the views of its target users, the statement of external review, the method to formulate the recommendations, strategies to improve uptake, and resource implications of applying the CPGs. CPGs with low quality should be improved in future updates based on currently available guideline development tools. Specialized CPGs on nutrition management for HNC patients during peri-radiotherapy should be developed.

Systematic review registration

https://www.crd.york.ac.uk/PROSPERO/index.php, identifier CRD42022320322.

The Quality and Clinical Applicability of Recommendations in Ostomy Guidelines: A Systematic Review

Aim

To systematically search ostomy clinical practice guidelines, critically assess their quality and clinical applicability of recommendations, and summarize the recommendations.

Design

Systematic review.

Data Sources

The PubMed, ProQuest and CINAHL databases, eight guideline databases, and three ostomy institution websites were searched on September 3, 2021.

Review Methods

Appraisal of Guidelines for Research and Evaluation II (AGREE II) and AGREE Recommendation EXcellence (AGREE-REX) were used to assess the guideline.

Results

The initial search identified 1475 documents. Of these, 27 full-text documents were reviewed. Finally, 10 guidelines were included. Among these, the 2019 Registered Nurses’ Association of Ontario (RNAO) guidelines had the highest total scores using AGREE II and AGREE-REX. The 2019 National Institute for Health and Care Excellence (NICE) and 2018 European Hernia Society (EHS) were also ranked as high-quality and evaluated as “recommended.” The median of the “applicability” domain was the lowest (45%) among the six AGREE II domains. The median of the “values and preferences” domain was the lowest (38%) among the three AGREE-REX domains. In total, 172 recommendations were summarized and parastomal hernia received the most attention among the recommendations.

Conclusion

The quality of the 10 clinical practice guidelines varied widely. The three identified high-quality guidelines might be appropriate first choices in daily ostomy care and management practice and can be tailored to the local context. Ostomy guidelines require further improvement in the “applicability” and “values and preferences” domains.

No Patient or Public Contribution

This review only searched and evaluated relevant documents, so such details do not apply to this review.

Australian First-Year Nursing Student Knowledge and Attitudes on Pressure Injury Prevention: A Three-Year Educational Intervention Survey Study

Pressure injury prevention is a significant issue as pressure injuries are difficult to heal, painful, and create clinical complications for patients. The aim of this study was to investigate knowledge and attitudes of first-year nursing students to pressure injury prevention, and to explore whether additional educational interventions augmented learning. A previously validated online survey was administered to three cohorts of first-year nursing students in 2016, 2017 (after additional online education), and 2018 (after further simulation education), and a subsequent comparative analysis was undertaken. Overall, the knowledge of students about pressure injury was low with measures to prevent pressure injury or shear achieving the lowest score (<50%). Students aged over 25 years (p < 0.001) and men (p = 0.14) gained higher attitude scores. There were significant differences for mean knowledge scores between the 2016 and 2018 cohorts (p = 0.04), including age group (p = 0.013) and number of clinical training units undertaken (p = 0.23). The 2016 cohort scored consistently lower in the attitude survey than both other cohorts (p < 0.001). Online resources and simulation experiences marginally improved knowledge and improved attitudes towards prevention of pressure injury. Nursing curricula should include targeted education to ensure student nurses are adequately prepared to prevent pressure injury through understanding of aetiology and risk assessment.

Quality and clinical applicability of recommendations for incontinence-associated dermatitis: A systematic review of guidelines and consensus statements

AIMS AND OBJECTIVES

The aim of this study was to assess methodological quality of all currently available guidelines and consensus statements for IAD using the Appraisal of Guidelines, Research and Evaluation (AGREE) II and the AGREE Recommendation Excellence (AGREE-REX) instruments.

BACKGROUND

Globally, incontinence-associated dermatitis (IAD) is a significant health challenge. IAD is a complex healthcare problem that reduces quality of life of patients, increases healthcare costs and prolongs hospital stays. Several guidelines and consensus statements are available for IAD. However, the quality of these guidelines and consensus statements remains unclear.

DESIGN

A systematic review of guidelines and consensus statements.

METHODS

Our study was undertaken using PRISMA guidelines. We searched seven electronic databases. Guidelines and consensus statements had to be published in English, Chinese or German languages. Five independent reviewers assessed the methodological quality of guidelines and consensus statements using the AGREE II and AGREE-REX instruments. Mean with standard deviation (SD) and median with interquartile range (IQR) were calculated for descriptive analyses. We generated bubble plots to describe the assessment results of each domain of each guideline and consensus statement.

RESULTS

We included ten guidelines and consensus statements. The NICE guidelines, obtained the highest scores, fulfilled 86.11%-98.61% of criteria in AGREE II and 76.67%-91.11% for AGREE-REX. In the domains 'Stakeholder Involvement' (4.39 ± 1.64), 'Rigor of Development' (3.38 ± 1.86), 'Applicability' (3.62 ± 1.64), 'Editorial Independence' (3.91 ± 2.56) and 'Values and Preferences' (2.98 ± 1.41), the remaining guidelines and consensus statements showed deficiencies.

CONCLUSIONS

Altogether, this study demonstrated that the currently available guidelines and consensus statements for IAD have room for methodological improvement. NICE guidelines on faecal incontinence and urinary incontinence have better quality. Remaining guidelines and consensus statements showed substantial methodological weaknesses, especially the domains of 'Stakeholder Involvement', 'Rigor of Development', 'Applicability', 'Editorial independence' and 'Values and Preferences'. This study was registered on INPLASY. (Registration number: INPLASY202190078).

RELEVANCE TO CLINICAL PRACTICE

The currently available guidelines and consensus statements on IAD have room for methodological improvement.

Pressure injury prevention practices among medical surgical nurses in a tertiary hospital: An observational and chart audit study

Pressure injuries are frequently occurring adverse events in hospitals, negatively impacting patient safety and quality of care. Most pressure injuries are avoidable if effective prevention strategies are used. However, the extent to which various settings influence their use of prevention strategies is unknown. The aim of this study was to describe and compare pressure injury prevention strategies used by medical and surgical nurses in the Chinese context. In this observational study, we used semi-structured observations with chart audits to collect data in two medical and two surgical wards in a tertiary hospital from June to December 2020. Observations were patient-focused; any prevention practices the patient received were recorded, and a chart audit was used to identify documented prevention strategies. The frequency of each prevention strategy was reported, and differences between medical and surgical wards were analysed using independent t-test or χ² test. A total of 577 patients (n = 294, 50.9% medical; n = 283, 49.1% surgical) were observed and their charts audited. Risk assessment was completed on admission for all patients. Repositioning was the most frequently used strategy, with about 84% (n = 486) patients being repositioned regularly. However, skin care, nutritional risk screening and the use of support surfaces were suboptimal. Patient education was not commonly observed but was documented in 75% (n = 433) of audited charts. More medical patients' skin was kept clean and hydrated, but more surgical patients received barrier creams, had a support surface and received more nutrition support and if a prone position was used, they were more likely to be turned after 2 hr and to be repositioned after sitting in a chair for an hour. Prevention strategies were more likely to be documented in surgical patients' charts. Despite pressure injury prevention guideline recommendations provided various prevention strategies for nurses to apply, the observed use of some strategies such as nutrition, skin care and support surfaces was not ideal. Nurses relied heavily on repositioning for pressure injury prevention. Most pressure injury prevention practices need improvement although surgical patients generally received better preventative care. These findings can facilitate clinicians and nurse managers when tailoring future pressure injury prevention work.

Effectiveness of interventions to prevent pressure injury in adults admitted to acute hospital settings: A systematic review and meta-analysis of randomised controlled trials

BACKGROUND

Hospital-acquired pressure injuries cause significant harm to afflicted individuals, and financially burden hospitals. Most pressure injuries are avoidable with the use of preventative interventions. However, within acute hospital settings the effectiveness of pressure injury preventative interventions, as demonstrated by high-level evidence, requires examination.

OBJECTIVE

Analyse the effectiveness of interventions to prevent pressure injury in adults admitted to acute hospital settings.

DESIGN

Systematic review and meta-analysis of randomised controlled trials.

DATA SOURCES

CINAHL, MEDLINE, Scopus, Web of Science and Embase were searched in May/June 2019. In April 2020, searches were updated to the end of 2019.

METHODS

Randomised controlled trials which investigated the effectiveness of pressure injury preventative interventions on pressure injury incidence, within adults admitted to acute hospital settings, were included. Trials limited to pressure injury treatment or specialty areas, and non-English reports, were excluded. Screening, extraction and risk-of-bias assessment were undertaken independently by two reviewers, with a third as arbitrator. Included studies were grouped by intervention type. Studies were synthesised narratively, and meta-analysis was undertaken where study interventions were similar. Using a random-effects model, primary meta-analyses were undertaken using intention-to-treat data.

RESULTS

Of 2000 records, 45 studies were included in the systematic review which investigated nine different intervention types: continence management, heel protection devices, medication, nutrition, positioning, prophylactic dressings, support surfaces, topical preparations and bundled interventions. All studies were judged to be at unclear or high risk-of-bias. Several meta-analyses were undertaken, pooled by intervention type. Most pooled samples were heterogeneous. Based on intention-to-treat data, only one intervention demonstrated a statistically significant effect: Australian medical sheepskin surfaces compared to other standard care surfaces (risk ratio 0.42, p = 0.006, I² = 36%), but included studies were limited by bias and age. Following per protocol meta-analyses, only two intervention types demonstrated a significant effect: support surfaces (active versus other comparison [risk ratio = 0.54, p = 0.005, I² = 43%] and standard surfaces [risk ratio = 0.31, p < 0.001, I² = 0%]; and reactive versus other comparison surfaces [risk ratio = 0.53, p = 0.03, I² = 64%]) and heel protection devices versus standard care (risk ratio = 0.38, p < 0.001, I² = 36%).

CONCLUSIONS

Only one intervention was supported by intention-to-treat meta-analysis. Significantly, all trials were at unclear or high risk-of-bias; and there were several limitations regarding heterogeneity across trials and trial outcomes. Further large-scale, high-quality trials testing pressure injury preventative interventions are required to establish effectiveness within acute hospital settings. Attention should be paid to true intention-to-treat analysis, and acute and intensive care settings should be reported separately. PROSPERO registration number:CRD42019129556.