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Evidence-Based Versus Conventional Methods to Prevent Pressure Injuries

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Ramzy H. Rimawi, MD
12/13/2024
 
This Concise Critical Appraisal discusses a recent meta-analysis that analyzed the likelihood of developing pressure injuries when evidence-based nursing interventions are implemented in critically ill patients as compared to conventional nursing interventions.
 
Pressure injuries (PIs), caused by shear stress and insufficient offloading of pressure to the skin or subcutaneous tissue, occur in approximately 14% of intensive care unit (ICU) patients and are associated with increased morbidity, higher healthcare costs, multisystem organ failure, sepsis, and death.1,2 Of all hospitalized patients, ICU patients have the highest risk of developing PIs because of immobility, impaired level of consciousness, malnutrition, hemodynamic instability, and/or use of vasopressors or medical devices.3,4 Therefore, nursing and other clinician interventions are essential to avoiding PIs in ICU patients.

Conventional nursing PI prevention methods are often not consistent or detailed enough. Institutions using conventional methods typically lack a detailed protocol for avoiding PIs, such as recorded frequency of position changes, application of topical therapies or dressings, wound care specialist consultations, and application of pressure offloading devices or mattresses

Evidence-based nursing (EBN) interventions include regular turning (typically every two hours), proper support surfaces for pressure redistribution (i.e., alternating pressure mattresses), comprehensive proactive skin assessments, moisture management (i.e., fecal management systems), and immediate interventions when skin changes are recognized. Measurements may involve validated risk assessment tools such as the Braden Scale to identify high-risk patients.

Xu et al conducted a computerized database search for randomized controlled trials on the prevention of PIs in ICU patients using terms including evidence‐based nursing, EBN, evidence‐based nursing practice, evidence‐based practice, pressure ulcer, PUs, ulcer, pressure injury, PI, bedsore, pressure sore, decubitus ulcer, intensive care, intensive care unit, critical care unit, intensive care therapy, and ICU. Duplicate publications, literature with incomplete original data or unavailable full‐text information, conference articles, reviews, systematic reviews, case reports, and animal studies were excluded. Of the 271 articles retrieved, 71 were included and combined 2494 patients, of whom 1250 received EBN interventions while 1244 received conventional nursing interventions.

Twenty-five randomized controlled trials reported on the occurrence of PIs. In the EBN group, 50 patients (4%) acquired a PI, while 225 patients (18%) in the conventional nursing group acquired a PI, a statistically significant lower relative risk of 0.22 (P <0.001). The authors concluded that EBN is more effective in reducing the risk of PIs in those patients at the highest risk of acquiring them.

Regarding nursing satisfaction, 715 (96%) of the 743 patients were satisfied in the EBN group while 604 (81%) of the 743 patients were satisfied in the conventional group. The onset time of the PIs was significantly later in the EBN group than in the conventional care group.

Management of PIs by collaboration among nurses, physicians, physical and occupational therapists, dietitians, wound care specialists, surgeons, and infectious disease specialists is also based on evidence-based practices.6,7 Combined multidisciplinary expertise allows various contributing factors, including mobility, nutrition/dietary modifications, optimization of skin integrity, hemodynamic stability, wound debridement, antibiotic modifications, and pressure relief interventions, to be addressed. This can lead to better collaboration, reduced PI incidence, reduced healthcare costs, and better patient outcomes.

References:
  1. Kottner J, Cuddigan J, Carville K, et al. Prevention and treatment of pressure ulcers/injuries: the protocol for the second update of the international clinical practice guideline 2019. J Tissue Viability. 2019 May;28(2):51‐58.
  2. Cox J, Edsberg LE, Koloms K, VanGilder CA. Pressure injuries in critical care patients in US hospitals: results of the international pressure ulcer prevalence survey. J Wound Ostomy Continence Nurs. 2022 Jan-Feb;49(1):21‐28.
  3. Kayser SA, VanGilder CA, Ayello EA, Lachenbruch C. Prevalence and analysis of medical device‐related pressure injuries: results from the international pressure ulcer prevalence survey. Adv Skin Wound Care. 2018 Jun;31(6):276‐285.
  4. Tayyib N, Coyer F. Effectiveness of pressure ulcer prevention strategies for adult patients in intensive care units: a systematic review. Worldviews Evid Based Nurs. 2016 Dec;13(6):432‐444.
  5. Xu YB, Chen ZQ, Su XH, Cao Y. Influences of evidence-based nursing intervention on pressure ulcers in intensive care units: a meta-analysis. Int Wound J. 2024 Apr;21(4): e14834.
  6. Gu YH, Wang X, Sun SS. Benefits of multidisciplinary collaborative care team-based nursing services in treating pressure injury wounds in cerebral infarction patients. World J Clin Cases. 2022 Jan 7;10(1):43-50.
  7. Richerbach S, Hockenberry T, Richey K, Foster KN. Evaluation of a multidisciplinary approach to pressure injury prevention among patients in a burn center. Abstract 40. J Burn Care Res. 2022 Mar 23;43(Suppl 1): S27-S28.
 
Ramzy H. Rimawi, MD
Author
Ramzy H. Rimawi, MD
Ramzy H. Rimawi, MD, is an assistant professor of medicine in the Division of Pulmonary, Critical Care, Sleep and Allergy Medicine at Emory University. Dr. Rimawi is an editor of Concise Critical Appraisal.
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