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.

Objectives

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 intervention types 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 three interventions were supported by meta-analyses. 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: Blinded for peer review.

中文翻译：

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预防急性住院成人压力性损伤的干预措施的有效性：随机对照试验的系统评价和荟萃分析

背景

医院获得性压力性损伤对患者造成重大伤害，并给医院带来经济负担。大多数压力性损伤可以通过使用预防性干预措施来避免。然而，在急诊医院环境中，需要检查高级别证据证明的压力损伤预防干预措施的有效性。

目标

分析预防急性住院成人压力性损伤的干预措施的有效性。

设计

随机对照试验的系统评价和荟萃分析。

数据源

CINAHL、Medline、Scopus、Web of Science 和 Embase 于 2019 年 5 月/6 月检索。2020 年 4 月，检索更新至 2019 年底。

方法

纳入了随机对照试验，这些试验调查了急诊住院成人中压力损伤预防干预措施对压力损伤发生率的有效性。仅限于压力损伤治疗或专业领域的试验以及非英语报告被排除在外。筛选、提取和偏倚风险评估由两名审查员独立进行，第三名作为仲裁员。纳入的研究按干预类型分组。研究以叙述方式进行综合，并在研究干预类型相似的情况下进行荟萃分析。使用随机效应模型，使用意向治疗数据进行主要荟萃分析。

结果

在 2000 条记录中，系统评价纳入了 45 项研究，这些研究调查了九种不同的干预类型：失禁管理、足跟保护装置、药物、营养、体位、预防性敷料、支撑面、局部制剂和捆绑干预。所有研究都被判断为存在不明确或高偏倚风险。进行了几项荟萃分析，按干预类型汇总。大多数合并样本是异质的。根据意向治疗数据，只有一项干预措施显示出统计学上的显着效果：澳大利亚医用羊皮表面与其他标准护理表面相比（风险比 0.42，p= 0.006，I ²=36%），但纳入的研究受到偏倚和年龄的限制。根据协议荟萃分析，只有两种干预类型表现出显着效果：支撑面（主动与其他比较 [风险比 = 0.54，p = 0.005，I ² =43%] 和标准表面 [风险比 = 0.31，p < 0.001，I ² =0%]；反应性与其他比较表面 [风险比 = 0.53，p= 0.03，I ² =64%]）和脚跟保护装置与标准护理（风险比 = 0.38，p < 0.001，I ² = 36%）。

结论

只有三种干预措施得到荟萃分析的支持。值得注意的是，所有试验都存在不明确或高偏倚风险；并且在试验和试验结果之间的异质性方面存在一些局限性。需要进一步大规模、高质量的试验来测试压力损伤预防干预措施，以在急诊医院环境中建立有效性。应注意真正的意向治疗分析，急性和重症监护环境应分别报告。PROSPERO 注册号： 同行评审不知情。