Pressure injury prevention measures: overview of systematic reviews

Overview of systematic reviews conducted in accordance with Cochrane guidelines. A search was performed in databases, repositories and systematic review registration sites.

Results:

15 reviews were included in this overview. The sensitivity analysis showed a reduction in the incidence of pressure injuries with nutritional supplementation compared to the standard hospital diet (Relative Risk (RR) = 0.83; 95% Confidence Interval (CI): 0.72–0.95). There was evidence of the superiority of constant low-pressure surfaces (RR = 0.38; 95% CI;0.24–0.61), alternating pressure devices (RR = 0.31; 95% CI:0.17–0.58) and alternative foams (RR = 0.40; 95% CI:0.21–0.74) when compared to the standard hospital mattress or standard foam. The use of a silicone cover reduced the incidence of pressure injuries by 75% (RR = 0.25; 95%CI:0.16–0.41) when compared to no cover.

Conclusion:

Although some interventions have been shown to be effective in reducing the incidence of pressure injury, the evidence is limited or very limited and subject to change. Registration CRD42017064586.

DESCRIPTORS
Evidence-Based Nursing; Pressure Injury; Review; Nursing; Wounds and Injuries

Identification of SR/Category/No. of studies included/Total no. of participants	Comparison of Interventions	n	RR (CI 95%)
SR1(⁹9. Moore ZE, Patton D. Risk assessment tools for the prevention of pressure ulcers. Cochrane Database Syst Rev. 2019;1(1):CD006471. doi: http://dx.doi.org/10.1002/14651858.CD006471.pub4. PubMed PMID: 30702158. https://doi.org/10.1002/14651858.CD00647... )	Braden Scale × Training + Unstructured	150	0.97 (0.53 – 1.77)
“Risk Assessment	Braden Scale × Unstructured	180	1.43 (0.77 – 2.68)
# 2	Waterlow Scale × Unstructured	821	1.10 (0.68 – 1.81)
1487	Ramstadius Scale × Unstructured	820	0.79 (0.46 – 1.35)
	Waterlow Scale × Ramstadius Scale	831	1.44 (0.85 – 2.44)
SR2(¹⁰10. Langer G, Fink A. Nutritional interventions for preventing and treating pressure ulcers. Cochrane Database Syst Rev. 2014;2014(6):CD003216. doi: http://dx.doi.org/10.1002/14651858.CD003216.pub2. PubMed PMID: 24919719. https://doi.org/10.1002/14651858.CD00321... )	Mixed Nutritional Supplement × Standard Hospital Diet	6064	0.86 (0.73 – 1.00)
“Nutritional Assessment and Support”	Mixed Nutritional Supplement (FE TAG) × DEP (ATC)	30	0.77 (0.37 – 1.57)
#11	Mixed Nutritional Supplement (FE ATG BTC EL) × SNM (FE ATG BTC)	95	0.85 (0.37 – 1.97)
6605
SR4(¹²12. Gillespie BM, Walker RM, Latimer SL, Thalib L, Whitty JA, McInnes E, et al. Repositioning for pressure injury prevention in adults. Cochrane Database Syst Rev. 2020;6(6):CD009958. PubMed PMID: 32484259.)	Repositioning: 2h × 4h (PI grade 1 to 4); any support surface)	1074	1.06 (0.80 – 1.41)
“Repositioning and Mobilization”	Repositioning: 2h × 3h (pressure injury grade 1 to 4); HP mattress	129	0.90 (0.69 – 1.16)
# 8	Repositioning: 2h × 3h (grade 2 to 4 pressure injuries);	252	0.59 (0.28 – 1.26)
3941	Repositioning: 2h × 3h ; High density foam	967	4.06 (0.87 – 18.98)
	Repositioning: 3h × 4h; High density foam	407	0.20 (0.04 – 0.92)
	Repositioning: 4h × 6h Viscoelastic mattress (PI grade 1 to 4)	129	0.73 (0.53 – 1.02)
	Repositioning: 30° 3h × 90° (overnight)	252	0.62 (0.10 – 3.97)
	Repositioning: 2h 20º × “standard treatment”	1312	0.28 (0.10 a 0.75)
	Head-of-bed tilt at 30º × 45º (Mobilization every 2h)	120	–
	Prone position × supine position	116	–
SR5(¹³13. Moore ZE, Webster J. Dressings and topical agents for preventing pressure ulcers. Cochrane Database Syst Rev. 2018;12(12):CD009362. doi: http://dx.doi.org/10.1002/14651858.CD009362.pub3. PubMed PMID: 30537080. https://doi.org/10.1002/14651858.CD00936... )	Fatty Acid × Olive Oil	1060	1.28 (0.76 – 2.17)
“Protective Covers (Other Interventions)”	Fatty acid × Control compound	331	0.42 (0.22 – 0.80)
#18	Fatty acid × Standard treatment	187	0.70 (0.41 – 1.18)
3629	Active lotion × placebo/control	1,67	0.73 (0.45 – 1.19)
	DMSO-Cream × placebo/control	61	1.99 (1.10 – 3.57)
	Conotrane × placebo/control	258	0.74 (0.52 – 1.07)
	Mepentol × placebo/control	331	0.42 (0.22 – 0.80)
	Prevasore × placebo/control	120	0.33 (0.04 – 3.11)
	Silicone cover vs. no cover	1246	0.25 (0.16 – 0.41)
	Polyurethane film vs. hydrocolloid	160	0.58 (0.24 – 1.41)
	Kang’ huier × care routine	100	0.42 (0.08 – 2.05)
	PPD × no coverage	74	0.18 (004 – 0.76)
	Thin polyurethane foam × no coverage	74	1.31 (0.83 – 2.07]
	Adhesive foam cover × no cover	78	1.65 (1.10 – 2.48)
SR6(¹⁴14. Zhang Q, Sun Z, Yue J. Massage therapy for preventing pressure ulcers. Cochrane Database Syst Rev. 2015;2015(6):CD010518. doi: http://dx.doi.org/10.1002/14651858.CD010518.pub2. PubMed PMID: 26081072. https://doi.org/10.1002/14651858.CD01051... ) “Massage (Other interventions)” # 0
	Empty review	0	–
	No randomized or quasi-randomized clinical trials comparing massage with placebo, standard treatment or other therapies were identified by the review authors

SR7(¹⁵15. Moore ZE, Webster J, Samuriwo R. Wound-care teams for preventing and treating pressure ulcers. Cochrane Database Syst Rev. 2015;2015(9):CD011011. doi: http://dx.doi.org/10.1002/14651858.CD011011.pub2. PubMed PMID: 26373268. https://doi.org/10.1002/14651858.CD01101... ) “Specialized team (Other interventions)” # 0
	Empty review	0	–
	No studies were included in the review because they did not meet the inclusion criteria pre-established by the authors

SR8(¹⁶16. Reddy M, Gill SS, Rochon PA. Preventing pressure ulcers: a systematic review. JAMA. 2006;296(8):974–84. doi: http://dx.doi.org/10.1001/jama.296.8.974. PubMed PMID: 16926357. https://doi.org/10.1001/jama.296.8.974... )	Exercises + Incontinence Care vs. Usual Care	144	0.88 (0.41 – 1.91)
“Exercises + Incontinence Care (Other Interventions)”
# 59
144
SR9(¹⁷17. Cai JY, Zha ML, Chen HL. Use of a hydrocolloid dressing in the prevention of device- related pressure ulcers during noninvasive ventilation: a meta-analysis of randomized controlled trials. Wound Manag Prev. 2019;65(2):30–8. doi: http://dx.doi.org/10.25270/wmp.2019.2.3038. PubMed PMID: 30730303. https://doi.org/10.25270/wmp.2019.2.3038... )	Hydrocolloid cover vs. control	2519	0.22 (0.17 – 0.29)
“Protective Covers (Other Interventions)”	Hydrocolloid cover × Control (Children)	626	0.11 (0.04 – 0.29)
# 22	Hydrocolloid cover × Control (Adults and elderly)	1893	0.24 (0.19 – 0.31)
2519	Hydrocolloid cover × Gauze	908	0.26 (0.17 – 0.38)
	Hydrocolloid cover × Skin care	1611	0.21 (0.15 – 0.29)

Identification of SR/Category/No. of studies included/Total no. of participants	Comparison	Studies	n	RR
SR3(¹¹11. McInnes E, Jammali-Blasi A, Bell-Syer SE, Dumville JC, Middleton V, Cullum N. Support surfaces for pressure ulcer prevention. Cochrane Database Syst Rev. 2015;2015(9):CD001735. doi: http://dx.doi.org/10.1002/14651858.CD001735.pub5. PubMed PMID: 26333288. https://doi.org/10.1002/14651858.CD00173... )	Constant Low Pressure x Standard Hospital Mattress	7	2407	0.38 (0.24 – 0.61)
“Support Surfaces”	Alternative Foam x Standard Foam Mattress	5	2016	0.40 (0.21 – 0.74)
# 59	Alternative Foam x Standard Foam	1	505	0.36 (0.22 – 0.59)
12624	Foam mattress (MAXIFLOAT) x Foam overlay	11	40	0.42 (0.18 – 0.96)
	Solid foam x convoluted foam		84	0.66 (0.37 – 1.16)
	Transfoam mattress x Transfoam wave mattress	1	100	1.00 (0.06 – 15.55)
	Cold foam mattress x cold foam mattress and static air overlay	1	83	3.59 (0.79 – 16.25)
	Constant Low-Pressure Devices	11	2138	0.45 (0.36 – 0.56)
	Optima x Standard foam mattress	1	40	0.06 (0.00 – 0.99)
	Sofflex x ROHO	1	84	0.63 (0.16 – 2.47)
	Gel mattress x Air-filled overlay	1	66	0.80 (0.24 – 2.72)
	Static air x water mattress	1	37	0.43 (0.04 – 4.29)
	Foam overlay x Silicone overlay	1	68	1.17 (0.64 – 2.14)
	Sheepskin x No sheepskin	1	539	0.57 (0.34 – 0.94)
	Sheepskin x No sheepskin	1	297	0.30 (0.17 – 0.52)
	Sheepskin x No sheepskin	1	588	0.60 (0.37 – 0.96)
	Foam support x no support	1	70	0.16 (0.05 – 0.49)
	Heel-lift suspension boot and various SS x SS only	1	239	0.26 (0.12 – 0.53)
	Static inflated vs. Microfluidized static or BPA mattress	1	110	0.33 (0.07 – 1.58)
	Sheepskin vs. no sheepskin (PI grade 2)	3	1424	0.59 (0.33 – 1.05)
	Alternating Pressure x Standard Foam Mattress	2	409	0.31 (0.17 – 0.58)
	Low Pressure Alternating Bed x Standard Bed	2	221	0.33 (0.16 – 0.67)
	Viscoelastic polymer pillow x SS	1	416	0.53 (0.33 – 0.85)
	Micropulse system for surgical patients x standard care	1	368	0.21 (0.06 – 0.70)
SR10(¹⁸18. Shi C, Dumville JC, Cullum N, Rhodes S, Jammali-Blasi A, McInnes E. Alternating pressure (active) air surfaces for preventing pressure ulcers. Cochrane Database Syst Rev. 2021;5(5):CD013620. PubMed PMID: 33969911.)	Alternating Pressure Air Surface (Active) x Reactive Foam Surface	4	2247	0.63 (0.34 – 1.17)
“Support Surfaces	Alternating Pressure Air Surface (Active) x Reactive Air Surface	6	1648	1.61 (0.90 – 2.88)
# 32	Alternating Pressure Air Surface (Active) x Reactive Water Surface	2	358	1.21 (0.52 – 2.83)
9058	Alternating Pressure Air Surface (Active) x Reactive Fiber Surface	3	285	0.90 (0.68 – 1.19)
	Alternating Pressure Air Surfaces (Active) on operating tables and later on the ward bed x Reactive Gel Surfaces on operating tables and followed by Foam Surfaces on the ward bed	2	415	0.22 (0.06 – 0.76)
SR11(¹⁹19. Shi C, Dumville JC, Cullum N, Rhodes S, McInnes E. Alternative reactive support surfaces (non-foam and non-air-filled) for preventing pressure ulcers. Cochrane Database Syst Rev. 2021;5(5):CD013623. PubMed PMID: 34097764.)	Water Reactive Surface vs. Air Reactive Surface	1	37	2.35 (0.23 – 23.75)
“Support Surfaces	Reactive Fiber Surface x Foam Surface	1	68	0.86 (0.47 – 1.57)
# 20	Reactive Gel Surface x Reactive Air Surface	1	66	0.80 (0.36 – 1.77)
4653	Water Reactive Surface x “Undefined” Standard Hospital Surfaces	1	316	0.35 (0.15 – 0.79)
	Reactive Gel Surface x “undefined” Standard Hospital Surfaces	2	446	0.53 (0.33 – 0.85)
SR12(²⁰20. Shi C, Dumville JC, Cullum N, Rhodes S, Leung V, McInnes E. Reactive air surfaces for preventing pressure ulcers. Cochrane Database Syst Rev. 2021;5(5):CD013622. PubMed PMID: 33999463.) “Support Surfaces # 17 2604 SR13(21) “Support Surfaces # 29 9566
	Reactive Air Surface x Foam Surface	4	229	0.42 (0.18 – 0.96)
	Reactive Air Surface (KinAir) x Reactive Air Surface (EHOB Waffle) – Two types of Reactive Air Surface	1	123	0.66 (0.29 – 1.49)
	Foam Surface vs. Reactive Gel Surface	1	270	–
	Foam Surface x Reactive Foam Surface and Gel Surface	1	182	–




SR14(²²22. Stephens M, Bartley C, Dumville JC. Pressure redistributing static chairs for preventing pressure ulcers. Cochrane Database Syst Rev. 2022; 2(2):CD013644. PubMed PMID: 35174477.) “Support Surfaces” # 0 0
	Empty review	0	–	–
	No studies were included in the review because they did not meet the inclusion criteria pre-established by the authors


SR15(²³23. Kim SY, Kim HJ, An JW, Lee Y, Shin YS. Effects of alternating pressure air mattresses on pressure injury prevention: a systematic review of randomized controlled trials. Worldviews Evid Based Nurs. 2022;19(2):94–9. doi: http://dx.doi.org/10.1111/wvn.12570. PubMed PMID: 35229980. https://doi.org/10.1111/wvn.12570... ) “Support Surfaces # 6 4697
	Alternating pressure air mattress with repositioning interval every 2 hours x Viscoelastic foam mattress with repositioning interval every 4 hours	1	1194	9.97 (1.28 – 77.61)
	Alternating pressure air mattress vs. static air mattress	1	308	8.22 (0.95 – 4.78)
	Alternating pressure air mattress x Static air mattress	1	1074	0.12 (0.09 – 0.15)
	Alternating pressure air mattress x Static air mattress	1	16	0.15 (0.04 – 0.60)
	Alternating pressure air mattress x High specification foam mattress	1	2029	0.91 (0.28 – 2.98)
	Alternating pressure air mattress x Memory foam mattress	1	76	1.00 (0.18 – 5.46)

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E-mail: reeusp@usp.br

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[1] Corresponding author: Franciele Soares Pott, Rua Constante Moro Sobrinho, 376, Quissisana, 83085-300 – São José dos Pinhais, PR, Brazil, franciele.pott@gmail.com