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

https://doi.org/10.1016/j.ijnurstu.2021.104027Get rights and content

Abstract

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.

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.

Section snippets

What is already known

  • While hospital-acquired pressure injuries are predominately preventable with the use of preventative interventions, they continue to occur within acute hospital settings.

  • Clinical practice recommendations and evidence syntheses for pressure injury prevention are available to guide practice across settings.

  • The body of randomised controlled trials testing pressure injury preventative interventions in adults admitted to acute hospital settings alone has not yet been synthesised.

What this paper adds

  • Included studies investigated nine different types of intervention. Six types of intervention were pooled for meta-analyses; however, most pooled samples were heterogeneous.

  • In intention-to-treat meta-analyses, only one intervention demonstrated a statistically significant effect: Australian medical sheepskin overlay. All trials were judged to be at unclear or high risk-of-bias.

  • Further acute care trials with large sample sizes are recommended for all intervention types and should be undertaken

Design

This systematic review and meta-analysis of randomised controlled trials was guided by the Cochrane Handbook (Higgins et al., 2019c). The protocol was registered a priori with PROSPERO (Lovegrove et al., 2019).

Eligibility criteria

PICOS criteria:

  • Population: adults in acute hospital settings

  • Intervention: pressure injury preventative interventions (single/bundled)

  • Comparator: inactive control (e.g. standard care, placebo, none) or active (e.g. variation of experimental intervention, other interventions outside of

Study selection

Overall, 45 acute hospital setting studies were included (Fig. 1), including nine with intensive care sub-settings. Two articles were excluded as they were duplicate reports (Nixon et al., 2006a; Nixon et al., 2019b), with more detailed reports of the same studies retained for inclusion (Nixon et al., 2019a; Nixon et al., 2006b).

Study characteristics

Study characteristics and outcomes are presented in Table 1. The earliest study was reported in 1961. Of the included studies, over half were European (n = 24), with

Meta-analyses

Where sufficient studies with intention-to-treat incidence data were available, meta-analyses were performed according to intervention type. Forest plots are shown in Fig. 3, with heterogeneity and effect size statistics shown in Table 2.

Discussion

This systematic review and meta-analysis identified a sizeable evidence base. However, all included trials were judged to be at unclear or high risk-of-bias. While randomised controlled trials are the highest level of evidence for an individual study (National Health and Medical Research Council, 2000), the validity of results may be jeopardised when bias has potentially been introduced (Higgins et al., 2019b). By extracting both intention-to-treat and per-protocol data, this review and

CRediT authorship contribution statement

Josephine Lovegrove: Conceptualization, Methodology, Validation, Formal analysis, Investigation, Data curation, Writing – original draft, Writing – review & editing, Project administration. Paul Fulbrook: Conceptualization, Methodology, Validation, Formal analysis, Investigation, Data curation, Writing – original draft, Writing – review & editing, Project administration, Supervision. Sandra J. Miles: Conceptualization, Methodology, Validation, Investigation, Writing – review & editing,

Declaration of Competing Interest

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

Funding

This study was part-funded by a PhD scholarship awarded by The Prince Charles Hospital Foundation to the first author (ref: PhD2019–01).

Acknowledgements

The authors would like to acknowledge specialist health services librarian Virginia Corfield (Australian Catholic University, Brisbane, Australia) for her assistance with search strategy development and database searching.

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