Large‐Scale Hospital Mattress Switch‐Out Leads to Reduction Hospital‐Acquired Pressure Ulcers: Operationalization of a Multidisciplinary Task Force

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.

Relationship Between Prescription and Documentation of Pressure Injury Prevention Interventions and Their Implementation: An Exploratory, Descriptive Study

BACKGROUND

Formal assessment by nurses of a patient's pressure injury (PI) risk level is often highlighted as being key to PI prevention. However, if no action is taken to address the determined risk (i.e., if appropriate preventative interventions are not implemented), the patient remains vulnerable to PI development, and the assessment process is rendered pointless.

AIM

To explore the relationship between the prescription (planning) and implementation of PI preventative interventions by nurses following formal risk assessment.

METHODS

Using an exploratory, descriptive design, the charts and bedside areas of 200 adult patients admitted across four hospital wards were examined. Data collected included PI risk level, documented prescribed preventative interventions, and interventions for which there was evidence of implementation.

RESULTS

Of the final sample (n = 187), 66.8% of cases were categorized as being "at-risk" or above. As the risk category of patients increased, proportionately more patients in each category were prescribed each intervention. However, in most cases, significantly fewer interventions were actually implemented than were prescribed, except for several interventions that were implemented in more cases than were prescribed. There were 14 cases, including four at-risk and three high-risk patients, in which no preventative interventions were prescribed, while 88.7% of not at-risk patients had (unnecessary) preventative interventions prescribed.

DISCUSSION

These results indicate that intervention prescription increased relative to assessed level of risk; however, the rates of intervention prescription and actual implementation were suboptimal. The results indicate a significant mismatch between these two steps of PI prevention.

LINKING EVIDENCE TO ACTION

These results indicate that intervention prescription increased relative to assessed level of risk; however, the rates of intervention prescription and actual implementation were suboptimal. A significant mismatch between these two steps of PI prevention was evident. Following patient risk assessment, there should be a greater focus on appropriate preventative intervention prescription (planning) with regular review and audit to help ensure that interventions are implemented as prescribed. Improved implementation of preventative interventions should, in turn, help to reduce hospital-acquired pressure injuries.