Evidence Based Practice: Preventing Hospital Acquired Pressure Ulcers

This essay presents a critical appraisal of a systematic review paper on preventing hospital acquired pressure ulcers. It discusses the research problem, literature search, quality of the reviews, results, and discussion. The study focuses on the effectiveness of different interventions and strategies to prevent pressure ulcers in the ICU. The findings highlight the importance of skin assessment and the effectiveness of silicone foam dressing in reducing pressure ulcers. However, there are limitations and biases in the study's findings that need to be considered. Overall, the study provides valuable insights for healthcare professionals in preventing hospital acquired pressure ulcers.

0Running head: EVIDENCE BASED PRACTICE
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Table of Contents
Introduction:...............................................................................................................................1
Research problem/ focus question:............................................................................................2
Literature search:........................................................................................................................2
Quality of the reviews:...............................................................................................................4
Results:.......................................................................................................................................5
Discussion:.................................................................................................................................7
Conclusion:................................................................................................................................9
References:.................................................................................................................................9

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Introduction:
Hospital acquired pressure ulcer is a major problem in health care system and the
incidence rate of pressure ulcer is increasing leading to additional pain and sufferings for
patient and increased medical cost. As high incidence of pressure ulcer can reduce the
quality of care, taking steps to inform health care professionals about current prevention
strategies for HAPUs is crucial (Gill, 2015). Due to this problem, considering systematic
review papers that provide concise summary of effective intervention is necessary to increase
awareness and health practitioner’s intention and acceptance of the strategies in daily setting.
To fulfil this propose, the essay presents a critical appraisal of a systematic review paper by
Tayyib and Coyer (2016) which gave idea about different interventions or strategies to
prevent pressure ulcer. The critical appraisal will focus on analysis of validity and reliability
of the findings by evaluation of rigour used in search process, assessing the quality of the
papers obtained, overall results of the study and the discussion regarding the applicability of
the research findings. This method of critical appraisal will help to give final conclusion
regarding the utility of the paper and its application in practical clinical setting.
Research problem/ focus question:
In response to the research topic, the research article by Tayyib and Coyer (2016) is
found most relevant to topic. The main research question for the study included ‘what is the
effectiveness of pressure ulcer prevention strategies for adults patients in intensive care unit
(ICU)?’. The significance of this research question is that it clearly defines the population of
interest, key interventions to be reviewed and the target outcome of interest. The details for
all are as follows:
Research population: Adult patients in intensive care units
Intervention: Pressure ulcer prevention strategies

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Outcome: Reducing prevalence of Hospital-acquired pressure ulcers (HAPUs)
According to Doody and Bailey (2016), PICO is the most common format for developing a
clear and researchable question and the key advantage of this approach is that it helps to
dissect the question and become clear about the search process.
Literature search:
By conducting systematic review on pressure ulcer prevention strategies for patients
in ICU, the authors retrieved articles published between 2000 and 2015. It included all those
papers which had adult ICU patients. In addition, randomized controlled trials (RCTs), quasi
experimental studies and comparative studies were included in the review. The papers chosen
is appropriate to the research question because the main aim was to evaluate effectiveness of
pressure ulcer and RCTs are the most appropriate design that specifically test the
effectiveness of new treatments or interventions. In RCTs, the effect of treatment is
compared with a control group and the participants are randomly assigned to two groups. By
reducing the element of choice through randomization, RCT eliminates any selection bias
(Kahan, Rehal & Cro, 2015). Hence, selection of research papers with RCT design is
appropriate as it can give valid results regarding the effectiveness of pressure ulcer preventive
steps in ICU.
Apart from RCTs, papers with quasi experimental designs and comparative studies
were included in the review too. Quasi experimental design is an intervention based study
that focuses on evaluation of causal impact of an intervention and this study does not
included randomization process to evaluate outcomes (Creswell & Creswell, 2017). The key
advantage of including papers with this research design in the review is that it directly gives
evidence regarding the causal impact under naturally occurring conditions. The advantage of
this research design is that it achieves balance between internal and external validity

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(Campbell & Stanley, 2015). In addition, the advantage of including comparative studies in
the review is that it gives overview of both harm and benefits associated with an intervention
(Glaser & Strauss, 2017).
The review included 25 papers and the papers were appropriate according to the
research question. This is said because all studies focussed on one particular intervention
related to pressure ulcer. For example, the papers selected in the review evaluated the
effectiveness of polarized light, dressing, nutrition, repositioning and early mobilization and
positioning the patient in bed. The research papers were categorized in accordance with these
interventions. All the above interventions are current standards to prevent pressure ulcer.
However, other important interventions that are missing in the study included lack of
consideration of other preventive strategies such as skin hygiene, assessment and skin
dehydration. The State Government of Victoria (2018) revealed the effectiveness of air
mattresses in preventing pressure ulcer. In addition, skin care is important as per the
guidelines for preventing pressure ulcer in Australia.
Quality of the reviews:
In systematic reviews, the manner in which selected papers are analyzed for quality is
most important as it gives idea regarding the validity and reliability of the review findings
(Ahn & Kang, 2018). According to standard criteria, assessment of the quality, importance,
relevance, originality and other attributes of papers selected are important to identify any
limitation or influence of confounding factors on study outcome (DerSimonian & Laird,
2015). To fulfil this criterion, Tayyib and Coyer (2016) assessed the quality of the paper by
two independent reviewers using the standardized critical appraisal instrument by the Joanna
Briggs Institute Meta-Analysis of Statistics Assessment and Review Instrument. The main
feature of JBI-MAStARI tool is that it assessed papers based on evaluation of risk of bias in

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study selection, performance, detection, attrition and reporting. The advantage of including
this tool in the quality assessment of papers is that this tool has been created by evidence
based organization that are committed to develop methodologies on conducting systematic
review process (Quigley et al., 2019). However, one limitation of using this tool is that JBI is
designed particularly for evaluation of systematic review papers. However, the review
included other types of research designs. In contrast, advantage is review by two authors that
eliminates misinterpretation of study findings.
The method of data analysis was determined by the consideration of the homogeneity
or heterogeneity of the study. The author justified use of narrative analysis to present the
study finding because of presence of heterogeneous study type. Narrative analysis is an
analytical frame to interpret stories that are expressed by research participants in research. In
this paper, narrative form was used just to present findings from both qualitative and
quantitative studies. However, it does specifically considered participant’s narrative about
the research topic. It was based on review of numerical data too.
The clarity in presentation of research is seen because the findings from the selected
papers were displayed individually in table forms. For individual papers, data was extracted
regarding the level of evidence, year of publication, sample size, setting, intervention,
outcome and conflict of interest. Presentation of findings in tabular form clearly helped in
identifying types of interventions reported in each study. In addition, the common
interventions or similarities reported in each articles were grouped together in the form of
heading. This further supported in clearly interpreting the most prevalent interventions to
prevent pressure ulcer. For each intervention, the number of papers using similar
intervention was provided, outcomes were discussed and methodological limitations like
sample size, biases and recruitment related issues were discussed. Hence, it can be said that
the results of the review of were combined and similar results in different studies were

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appropriately considered. The overall conclusion is that data synthesis or presentation of
findings has been done in an accurate way reducing any reporting related biases. This is a
major feature of systematic review as all such papers present results by combining and
analyzing data from different studies (Ahn & Kang, 2018).
Results:
Total 25 studies were reviewed and meta-analysis of the findings from the papers
were framed in two sections namely prevention of pressure ulcers and interventions for
prevention and treatment. In the area of prevention, no studies reported about skin and tissue
assessment to reduce HAPUs in ICU. However, according to evidence based prevention
strategies for reducing pressure in the ICU, conducting a skin assessment in each shift is most
important preventive measures as it reinforces individual staff’s accountability to prevent
development of pressure ulcer and it also suggest the need to use quality tool for identifying
areas which are prone to risk of developing pressure ulcer (Cooper, 2013). Hence, absence of
studies in the area of skin in the systematic review is a major drawback.
Other emerging therapies that were reported in the findings section included use of
polarized light, dressings, nutritional strategies, repositioning and early mobilization and
educational strategies. One study reported about the use of polarized light to prevent pressure
ulcer. The study reported about the precision of the outcomes by reporting about p-values for
each intervention. The study reported no statistically significance outcome in this area
making results insignificant for actual practice. More research in relation to use of polarized
light is needed. Three studies reported on the use of dressings for pressure ulcer prevention
and for each of three studies, the overall effect size was considered by calculating confidence
interval and p-value. These studies revealed statistically significant outcome in relation to
incidence of HAPUs with the use of silicone foam dressing. This findings is consistent with

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past research evidence as Santamaria et al. (2015) revealed the clinical effectiveness of
silicone foam dressing too by showing its impact on reducing ICU acquired heel pressure
ulcer. The use of cohort based study design and large sample size further makes the study
outcomes reliable.
In contrast to silicone dressing, the results of the systematic review did not give
statistically significant outcomes for other interventions or the results were confounded by
presence of several bias. For example, statistically significant outcome was found for
nutritional intervention. However, this study was affected by confounding factors like
recruiting more patients with pressure ulcer in the control group. In addition, inconsistent
outcomes were found for use of interventions like positioning and repositioning strategies.
Six studies reported about the efficacy of support strategies. It included use of different types
of mattresses such as active alternating pressure mattress, use of air fluidized therapy support
service bed and efficacy of two viscoelastic mattresses. Evidence based guideline shows the
importance of using air-filled pressure matters to redistribute pressure (Sauvage et al., 2017).
Only one study reported about the use of educational strategies to prevent pressure ulcer. The
overall conclusion is that the findings gave statistically outcome for preventing HAPUs with
the use of silicon foam dressing strategy. However, statistically significant outcome or large
numbers of studies for use of other interventions like repositioning, education, support
services and skin-care was limited.
Discussion:
On critical evaluation and assessment of study findings, it can be said the systematic
review does not gives a concise summary of all preventive steps and interventions to prevent
HAPUs in clinical setting. This is said because although the studies gave idea about the use
of dressings, support services, education and repositioning to prevent incidence of HAPUs.

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However, the review failed to provide evidence regarding the most effective initial preventive
steps to prevent occurrence of pressure ulcers, which included skin assessment to identify risk
of developing pressure ulcer before it becomes more serious. Richardson et al. (2017)
supports that skin assessment should always be included in clinical protocols as it helps in
early identification of risk and provides guidance regarding the best step to prevent ulcers. A
4-year quality improvement study revealed that focussed risk assessment is an important part
of bundle interventions too thus giving the implication to introduce appropriate pressure ulcer
risk assessment tool. This shows that the study focused only on occurrence or reducing
incidence of pressure ulcer. It ignored other important outcome such as risk of developing
pressure ulcer.
The study gave valid results for the effectiveness of silicone foam dressing in
reducing pressure ulcer cases. However, due to presence of several biases and variability in
confidence interval for other studies, the study cannot be applied in local population. For
example, in case of educational intervention, only finding was found. This affects the
reliability of the work. This should have been supported by many more references. In
addition, in the area of positioning strategies, the benefit of supine positioning strategy was
ignored. Zuo and Meng (2015) highlight the significance of alternating from a lateral to
supine position and revealed it as an important part of standard care strategies. In addition,
several biases were found in other interventions such as small sample size, inconsistent
findings and lack of utilization of current guidelines. Presence of biases or lack of strong
evidence for other intervention is a major limitation that prevents direct use of the findings to
educate health care professionals regarding systematic process to prevent HAPUs.
Apart from methodological limitations, the key advantages and strength of the
systematic review paper is that it gave strong evidence regarding the utilization of silicone
foam dressing for preventing HAPUs. In addition, the study used appropriate method to

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assess the quality of the findings. For this reason, all limitations and inconsistencies in the
findings has been adequately identified. However, the study is not cost-effective as included
studies had many limitations which prevented making any final conclusion regarding
effectiveness of other interventions in ICU. Therefore, to enhance the applicability of the
research findings, future research is needed with use of rigorous designs like RCT method to
assess effectiveness of interventions and include other outcomes like compliance to
interventions too.
Conclusion:
To conclude, the critical appraisal of a systematic review paper on strategies to reduce
incidence of HAPUs in ICUs suggested use of interventions like silicone foam dressing,
educational strategies, surface devices, positioning and repositioning. However, the
application of the findings in local population and the overall reliability of the work is
affected by lack of strong evidence for effectiveness of all interventions except silicone
dressing. In addition, limited number of studies supporting effectiveness and presence of
methodological biases such as low sample size, poor recruitment strategy and presence of
confounding factors affected the quality of study. It is recommended to conduct studies with
strong research design to assess overall effectiveness of educational and positioning
interventions.

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References:
Ahn, E., & Kang, H. (2018). Introduction to systematic review and meta-analysis. Korean
journal of anesthesiology, 71(2), 103.
Campbell, D. T., & Stanley, J. C. (2015). Experimental and quasi-experimental designs for
research. Ravenio Books.
Cooper, K. L. (2013). Evidence-based prevention of pressure ulcers in the intensive care
unit. Critical care nurse, 33(6), 57-66.
Creswell, J. W., & Creswell, J. D. (2017). Research design: Qualitative, quantitative, and
mixed methods approaches. Sage publications.
DerSimonian, R., & Laird, N. (2015). Meta-analysis in clinical trials revisited. Contemporary
clinical trials, 45, 139-145.
Doody, O., & Bailey, M. E. (2016). Setting a research question, aim and objective. Nurse
researcher, 23(4).
Gill, E. C. (2015). Reducing hospital acquired pressure ulcers in intensive care. BMJ Open
Quality, 4(1), u205599-w3015.
Glaser, B. G., & Strauss, A. L. (2017). Discovery of grounded theory: Strategies for
qualitative research. Routledge.
Kahan, B. C., Rehal, S., & Cro, S. (2015). Risk of selection bias in randomised
trials. Trials, 16(1), 405.
Quigley, J. M., Thompson, J. C., Halfpenny, N. J., & Scott, D. A. (2019). Critical appraisal of
nonrandomized studies—A review of recommended and commonly used
tools. Journal of evaluation in clinical practice, 25(1), 44-52.

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Retrieved from: https://www.betterhealth.vic.gov.au/health/servicesandsupport/skin-care-
and-preventing-pressure-sores-in-hospital
Richardson, A., Peart, J., Wright, S. E., & McCullagh, I. J. (2017). Reducing the incidence of
pressure ulcers in critical care units: a 4-year quality improvement. International
Journal for Quality in Health Care, 1-7.
Santamaria, N., Gerdtz, M., Liu, W., Rakis, S., Sage, S., Ng, A. W., ... & Smith, K. (2015).
Clinical effectiveness of a silicone foam dressing for the prevention of heel pressure
ulcers in critically ill patients: Border II Trial. Journal of wound care, 24(8), 340-345.
Sauvage, P., Touflet, M., Pradere, C., Portalier, F., Michel, J. M., Charru, P., ... & Scherrer,
B. (2017). Pressure ulcers prevention efficacy of an alternating pressure air mattress
in elderly patients: E²MAO a randomised study. Journal of wound care, 26(6), 304-
312.
State Government of Victoria (2018). Skin care and preventing pressure sores in hospital
Tayyib, N., & Coyer, F. (2016). Effectiveness of pressure ulcer prevention strategies for adult
patients in intensive care units: a systematic review. Worldviews on Evidence
‐Based
Nursing, 13(6), 432-444.
Zuo, X. L., & Meng, F. J. (2015). A care bundle for pressure ulcer treatment in intensive care
units. International Journal of Nursing Sciences, 2(4), 340-347.