Interventions for Pressure Ulcer Prevention

This rapid review evaluates the most effective interventions for preventing pressure injuries and bed sores among patients in all healthcare settings. Findings from systematic reviews published between 2009 and 2019 are analyzed to identify effective interventions and outcomes. The review highlights the need for multiple interventions and further research in this area.

Running head: RAPID REVIEW
RAPID REVIEW: THE MOST EFFECTIVE INTERVENTIONS IN PREVENTION
FOR PRESSURE INJURIES AND BED SORES AMONG PATIENTS IN ALL
HEALTHCARE SETTINGS
Name of the Student:
Name of the University:
Author note:

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Executive Summary
Background: Incorporation of preventive interventions for pressure injuries and bed sores
management across all healthcare settings, will not only ensure effective patient care and timely
prevention of symptom aggravation but will also mitigate financial losses across healthcare
organizations and ensure positive levels of patient satisfaction, feedback and perceptions related
to healthcare care. Hence, this review focusses on evaluation of the various interventions for
pressure injury and bed sore prevention.
Objective: To systematically review the most effective interventions in prevention for pressure
injuries and bed sores among patients admitted in all healthcare settings.
Inclusion Criteria: Systematic reviews, published within 2009 to 2019, evaluating preventive
measures for pressure injuries and bed sores management were included.
Types of Studies: For obtaining findings pertaining to the primary objective of the study, the
types of studies which were selected were qualitative in nature, that is, studies which involved
the usage of systematic reviews.
Types of Participants: The systematic reviews included patients admitted in all types of
healthcare settings, who are severely diseased, malnourished, bed ridden, elderly or suffering
from mobility disruptive conditions such as spinal injuries, along with being inflicted with
pressure injuries and bed sores s.
Outcomes: The primary outcome targeted by all the selected articles was the incidence and rate
of prevalence of pressure injuries and bed sores s upon administration of preventive
interventions.

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Search Strategy: The first phase of searching consisted of insertion of keywords relevant to the
research and screening the abstracts of the papers so obtained which showed considerable
similarity to the same. For improved article acquisition, the second search was conducted using
advanced search options and setting limiters in terms of English language, study subjects
selected to humans, time period ranging from 2009 to 2019, MeSH terms and Boolean operators
Methodological Quality: For the purpose of critically appraising, validating and evaluating the
articles selected for the rapid review, the critical appraisal tool of Assessment of Multiple
Systematic Reviews (AMSTAR) was used. AMSTAR is a beneficial, reliable and efficient tool
formulated for the assessment of the significance, methodological quality and relevance of
qualitative based studies such as systematic reviews, which is of relevance for this study.
Data Extraction and Synthesis: The data and findings so obtained from the systematic review
were categorized in terms of the interventions used which were found to be effective for pressure
injuries and bed sores prevention, the population so selected, methods used for study and
outcomes as per the identified aims and objectives of the review. The findings so obtained from
the systematic review were analyzed in the form of a narrative synthesis resulting in the
development of relevant themes and inclusion of tables and figures for the purpose of sufficiently
fulfilling the research objective
Result: A total of 5 studies were included for this research, of which 3 of them were obtained
from Cochrane and 2 of the studies were obtained from Medline databases. 1 study discussed on
patient repositioning, 1 study on massage therapy, 1 on topical agents and dressing, 1 on Braden
score assessment and 1 on repositioning, skin regimen, dressings, nutrition, staff education and
support surfaces. The studies scored moderate to high (5 to 8) in terms of methodological quality
as per AMSTAR scores.

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Conclusion: To conclude, it was observed that pressure ulcers result in considerably detrimental
health implications and financial costs in the patient as well as in the healthcare organization,
hence necessitating their immediate prevention. There is a need to rely on not just one, but
multiple interventions for pressure ulcer prevention, preferable in the form of a care bundle,
since no single intervention has been scientifically proven for efficacy. Considering limitations
in quality and quantity of evidence, further research on multiple interventions with credible
quality studies is required to be conducted in a wide variety of settings and populations.

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Background
Pressure injuries and bed sores s are a debilitating dermal condition, characterized by
injuries and damages to the skin and the associated dermal tissues and bony prominences
adjacent to the same. Pressure injuries and bed sores s are also known as decubiti, bed sores or
pressure injuries and undergo emergence due to prolonged application of pressures along with
the presence of additional risk factors such as friction, shearing and excessive levels of moisture
in the form of urine, sweat and feces (Moore & Cowman, 2015). Areas of the body which have
the highest risk factor for pressure injuries and bed sores occurrence, include heels, elbows,
knees, shoulders, ankles and the cranium. One of the primary causative factors for pressure
injuries and bed sores s include the prolonged administration of pressure resulting in restrictions
in the flow of circulating blood. It is worthwhile to remember that adequate blood circulation is
required for the deliverance of oxygen and essential nutrients to the surrounding cells and tissues
of the body (et al., 2015). Hence, the presence of excessive pressures results in hindrances in the
flow of blood and nutrients leading to nutrient deprivation, death of surrounding tissues and
hence the emergence of symptoms of skin damages and injuries. Additional factors which affect
the occurrence of pressure injuries and bed sores s in individuals include friction and shearing
(Norman et al., 2016).Friction is the result of the skin rubbing excessively at surfaces of bedding
and clothing further leading to increased skin fragility and susceptibility to injury. Shearing is a
resultant of the application of forces opposite to the surface of the skin. A prevalent example of
this is during situations of bed elevation which occurs as a result of the skin sliding upon the bed
surface in directions opposite to that of elevation. Such factors coupled with increased moisture

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and engagement in long hours of lying down are key determinants of pressure injuries and bed
sores occurrence (Dumville et al., 2015).
As evident from the above mentioned influencing circumstances, it be evident that
individuals who are primarily bed ridden, are malnourished, are inflicted with spinach injuries or
are suffering from detrimental chronic conditions such as cystic fibrosis, chronic obstructive
pulmonary disorders, or serious illnesses such as after surgery, cardiovascular illnesses
associated with cerebrovascular accidents, strokes and neurological or neurocognitive disorders
such as paralysis, dementia or Alzheimer’s are at increased risk of developing pressure injuries
and bed sores s. A number of health conditions and determining factors wcompel individuals to
lie down and be at rest for prolonged periods (McInnes et al., 2015). These include factors like:
immobility in the patient, limitations in terms of sensory abilities, inadequate status of hydration
and nutrition and health issues which result in restrictions in terms of the flow of blood. While
such factors and hence the resultant susceptibility of pressure injuries and bed sores s, may be
present across any diseased of affected individual who remains primarily bedridden irrespective
of age groups or genders, the population of the elderly, especially individuals aged above the age
of 65 years along with those adult patients who are suffering from serious illnesses resulting
metabolic, cardiovascular and neurological disturbances as mentioned above, pose greater
susceptibilities to the acquisition of this harmful skin condition (Qaseem et al., 2015).
Post-surgical patients, patients with serious illnesses and the elderly, as a result of being
inflicted with the physiological deficits associated with diseases, malnourishment and ageing, are
victims of increased of levels of oxidative stress, catabolism, muscle wastage, loss of muscular
fibers resulting in compromised musculoskeletal systems, deficits in bone and muscle volumes
and flexibilities, resulting in difficulties to conduct normal motor movements which compels

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them to be bed ridden with mobility issues. Additionally, as will be discussed in the succeeding
sections, pressure injuries and bed sores s are a resultant of constant lying down whose severity
can be prevented by alteration of positions (Dealey et al., 2015). Issue of immobility prevalent
among the severely diseased and malnourished patients and the elderly not only result in their
increased adherence to being bed ridden for long but also hinder their ability to switch positions
in order to reduce the pressure. Further, loss of neuronal functioning evident in neurological
conditions in adult diseased patients and age associated degradation of nerve fibers due to ageing
in the elderly results in loss of sensory perceptions within patients resulting in difficulties to
sense pain, the need to report or alter positions for the same and hence increased susceptibility to
pressure injuries and bed sores symptoms (Black et al., 2015). Further detrimental symptoms
associated with chronic disease conditions in severely ill adults patients include deficits in the
absorption of nutrients and deceased ability to ingest and swallow required food resulting in
nutritional deficiencies and poor nutritional status. Maintenance of optimum nutritional status is
required for the healing and repair of damaged tissues which is compromised in the severely ill
patients and hence contributes to their increased susceptibility of pressure injuries and bed sores
acquisition (Jaul & Calderon‐Margalit, 2015). Patients with neurological diseases are also
susceptible to reduced thirst sensation and perception, reduced thirst perceptions and hence poor
status of hydration further aggravating to symptoms of skin dryness and increased vulnerability
to forces of shearing and friction – risk factors of pressure injuries and bed sores prevalence in
the severely ill patients. Lastly, the compromised immunological and metabolic functioning
within the diseased patients as well as the elderly resulting in the increased acquisition of chronic
diseases such as diabetes and cardiovascular deficits which further lead to restrictions in blood

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flow, deprivation of essential nutrients and hence increased susceptibility of pressure injuries and
bed sores acquisition (Neloska et al., 2016).
Hence, as evident from the above, patients who are elderly, suffering from chronic or
severe disease conditions, are malnourished or inflicted with mobility issues due to neurological
or spinal injury associated conditions are at an increased risk in the acquisition of pressure
injuries and bed sores s hence necessitating immediate administration of preventive and
treatment interventions. Authors Jaul et al. (2018), reviewed the various co-morbidities
associated as risk factors for pressure injuries and bed sores acquisition in acute, community as
well as long term care facilities of healthcare organizations. Among adult patients, disease
conditions contributing as risk factors for pressure injuries and bed sores acquisition include
diabetes, cardiovascular diseases, renal diseases, chronic pulmonary diseases and
neurodegenerative disorders, along with additional complications such as malnutrition, anemia
and occurrences of infectious diseases. Additional co-morbidities which increase the prevalence
of pressure injuries and bed sores s in the elderly include frailty, disability, incontinence,
polypharmacy and increased experiences with hospitalization. Additionally, Biçer et al. (2019),
with the aid of a cross sectional study, researched that the highest incidences of pressure injuries
and bed sores s were reported across individuals with disease conditions such as cancer or with
neurodegenerative conditions such as Alzheimer’s and is hence, indicative of the widespread
prevalence of pressure injuries and bed sores s across healthcare settings. It has been estimated
that patients who are elderly and undergoing admissions for receiving orthopedic treatments
which are non-elective, comprise of almost 66% of the patients suffering from pressure injuries
and bed sores s (Kirman, 2018). Elderly patients, aged 65 years or older, have been reported to
acquire symptoms of a pressure injuries and bed sores within 32 days of being admitted to the

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hospital at the rate of 36.1%. It has been further postulated that the prevalence rate of pressure
injuries and bed sores s across patients aged 65 years or more, is 70%, of which 5 to 32%
incidences are prevalent across hospital settings and 22% of incidences are prevalent across
nursing homes. As compared to administration of wound management and treatment
interventions, adherence to practices aimed at prevention of pressure injuries and bed sores s
have been implicated to reverse the harmful effects of pressure injuries and bed sores s. It has
been estimated that 70% of pressure injuries and bed sores s treated at stage II undergo
successful healing within 6 months, whereas only 50% and 30% of ulcers belonging to stages III
and IV undergo complete healing within 6 months, despite administration of adequate treatment
(Dawoudi, 2018).
Hence, such alarming figures necessitate the need to adopt and implement preventive
interventions for pressure injuries and bed sores management at the earliest to further prevent the
progression of symptoms associated with the same at irreversible stages of treatment. Further,
the occurrences of detrimental patient health conditions associated with pressure injuries and bed
sores s are indicative of practices of low quality services and lack of clinical excellence in
healthcare organizations further resulting in reduced patient satisfaction, negative perceptions
among customers, reduced patient flow and hence, overall financial losses in the healthcare
organization. Further, pressure injuries and bed soress are also associated with increased
requirements of patient care services for symptom and wound management further adding on to
the financial burden of the concerned healthcare organizations. Hence, incorporation of
preventive interventions for pressure injuries and bed sores management across all healthcare
settings, will not only ensure effective patient care and timely prevention of symptom

9RAPID REVIEW: INTERVENTIONS FOR PRESSURE ULCER PREVENTION
aggravation but will also mitigate financial losses across healthcare organizations and ensure
positive levels of patient satisfaction, feedback and perceptions related to healthcare care.
Objectives: Hence, based on the existing problem the aim of this rapid review is to
systematically review the most effective interventions in prevention for pressure injuries and bed
sores among patients admitted in all healthcare settings.
Criteria of Study Selection
Types of Studies
For obtaining findings pertaining to the primary objective of the study, the types of
studies which were selected were qualitative in nature, that is, studies which involved the usage
of systematic reviews. The systematic reviews so selected involved the studies which explored
interventions targeted against the prevention and management of pressure injuries and bed sores
s among elderly patients admitted across healthcare settings.
Types of Participants
The systematic reviews included patients admitted in all types of healthcare settings, who
are severely diseased, malnourished, bed ridden, elderly or suffering from mobility disruptive
conditions such as spinal injuries, along with being inflicted with pressure injuries and bed sores.
Types of Interventions
As evidenced by existing literature discussed previously, preventive interventions which
focused upon repositioning the patient, have been implicated as the most effective method for the
prevention of pressure injuries and bed sores s, considering the issues with immobility and
prolonged duration of being bed ridden in severely diseased, malnourished or elderly patients

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(Moore & Cowman, 2015). Hence studies emphasizing on repositioning the patient were
emphasized upon during selection and included for the final findings of the study. In addition to
the same, a number of interventions have been proven to be beneficial in the prevention of
pressure injuries and bed sores s. These included conductance of timely assessments and
interventions, provision of wound management or dressing interventions, usage of pillows and
maintaining adequate levels of dryness and moisture upon skin surfaces (Boyko, Longaker&
Yang, 2018). Hence, in addition to the preferred interventions, studies which incorporated
multiple pressure injuries and bed sores interventions were also selected.
Types of Outcome Measures
The primary outcome targeted by all the selected articles was the incidence and rate of
prevalence of pressure injuries and bed sores s upon administration of preventive interventions.
A number of secondary interventions were also considered such the level of education,
awareness and training of staff concerning the knowledge associated with prevention of pressure
injuries and bed sores. Additionally, the staff belonging to the healthcare organizations who were
studied in the selected systematic reviews relied on conductance of pressure injuries and bed
sores screening such as skin assessments for measuring outcomes of pressure injuries and bed
sores status and incidences.
Search Strategy
An electronic search strategy was incorporated which included screening articles across
relevant databases. Articles containing studies published between the years 2010 to 2019, to
ensure usage of research of considerable currency and hence, containing updated information in
terms of validity. The search strategy can be categorized in to two phases, conducted across two
databases, Cochrane and Medline.

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Phase 1
The first phase of searching consisted of insertion of keywords relevant to the research
and screening the abstracts of the papers so obtained which showed considerable similarity to the
same. For improved article acquisition, the second search was conducted using advanced search
options and setting limiters in terms of English language, study subjects selected to humans, time
period ranging from 2009 to 2019, MeSH terms and Boolean operators
Phase 2
In the second phase of search strategy, for the purpose of ensuring a detailed, accurate
and comprehensive article selection, an inclusion and exclusion criteria was followed. Studies
which did not use qualitative research methodologies of systematic review and meta-analysis or
had a title irrelevant to the inserted keywords, underwent exclusion. Additional studies which
were not conducted in healthcare settings, such as home based interventions or residential based
care and did not include reduction of pressure injuries and bed sores incidences as the primary
outcome were excluded. To ensure that the articles selected were relevant, the abstracts and titles
of obtained studies were reviewed extensively by the researcher. To further ensure adherence of
the articles to the inclusion and exclusion criteria, the researcher also engaged in extensively
reviewing full texts of the chosen studies.

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Figure 1: PRISMA Flowchart
Records identified through
database searching (n=81)
Studies included (n=5)
(n=6)
Records after Duplicates removed (n=1)
Records screened (n=26
(n=453)
Full text articles excluded with reasons
(n=21)
 Not as a preventable
intervention (n=10)
 Not healthcare setting based
(n=11)
Full-text articles assessed for eligibility
(n=26)
Records excluded based on title only
(n=55)
Records excluded based on
IdentificationScreening
EligibilityIncluded
Medline (Ovid)
(n=9)
Cochrane library
(n=72)

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Methods of Review
Methodological Quality Assessment
For the purpose of critically appraising, validating and evaluating the articles selected for
the rapid review, the critical appraisal tool of Assessment of Multiple Systematic Reviews
(AMSTAR) was used. AMSTAR is a beneficial, reliable and efficient tool formulated for the
assessment of the significance, methodological quality and relevance of qualitative based studies
such as systematic reviews, which is of relevance for this study. The final score of AMSTAR is
acquired by adding a point all answers indicating ‘yes’ and no point for answers indicating a ‘no;
as well as other answers indicted by ‘not applicable’ and ‘can’t answer’. The total sum of scores
range from 0 to 11. The systematic reviews which were selected was rated in terms of quality by
using sores of three levels: high quality indicted from 8 to 11, medium quality indicated by 5 to 7
and low quality indicated by 0 to 4 (See Appendix).
Data Extraction
The data and findings so obtained from the systematic review were categorized in terms
of the interventions used which were found to be effective for pressure injuries and bed sores
prevention, the population so selected, methods used for study and outcomes as per the identified
aims and objectives of the review. Such data so collected were presented using a table (See
Appendix).
Data Synthesis
The findings so obtained from the systematic review were analyzed in the form of a
narrative synthesis resulting in the development of relevant themes and inclusion of tables and
figures for the purpose of sufficiently fulfilling the research objective.

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Review Results
Description of Studies
A total of 5 studies were included for this research, of which 3 of them were obtained
from Cochrane and 2 of the studies were obtained from Medline databases. Originally during the
search strategy, a total of 72 articles were obtained from Cochrane and a total of 9 articles were
obtained from Medline databases. From the articles which were obtained from the Cochrane
databases, a total of 64 articles were excluded since 1 of these was an editorial and 63 of these
were trials. From the Cochrane databases and Medline databases, of the 8 and 9 systematic
reviews so obtained, 5 and 7 of these were excluded, either due to their irrelevance to the
keywords or due to the usage of treatment interventions and not preventive measures for pressure
injuries and bed sores management.
The study conducted by Gillespie et al., (2014) is a systematic review concerning the
evaluation of the effectiveness underlying repositioning strategies in the prevention of pressure
injuries and bed sores among elderly patients. The study reviewed four researchers of which,
three studies comprised of randomized controlled trials and one comprised of an economic study.
However, critical analysis by the authors revealed the prevalence of a high risk of bias for every
study along with detection of low quality evidence and lack of reporting of any of the studies on
the patients’ perception of quality of life and pain. While the review included comprehensive
findings concerning the comparative effectiveness between reposition at 30° and 90° tilted
positions, the studies evaluating the same were found to be imprecise and erroneous due to small
sample size and events. Another study reviewed by the authors comprising of high risk of bias,
evaluated the effectiveness of repositioning in terms of intervals ranging from 2 to 3 hours.
Additional studies included in this systematic review was economic study where increased cost

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effectiveness associated with nursing times with interventions consisting of 30° overnight tilting,
standard care and lateral repositioning of 90° after every 6 hours. Comparing with the above
study by Gillespie et al., (2014), which focused primarily on the evaluation of pressure ulcers
prevention strategies of repositioning across elderly patients, a mixed group of populations were
evaluated by the additional systematic reviews selected. All the studies however, focused upon
the preventive interventions implemented across healthcare settings (Moore & Webster, 2013;
Zhang, Suen & Yue, 2015; Tayyib & Coyer, 2016; Wilchesky & Lungu, 2015). Among the
interventions focusing upon an adult population, the systematic review conducted by Moore and
Webster (2013), evaluated the effectiveness of application of topical agents and addition of
dressings in the prevention of pressure ulcers, of which, all studies included for review assessed
incidences in pressure ulcers as the primary outcome, followed by review results indicating that
greater effectiveness in terms of reduction in pressure ulcer incidences was associated with usage
of silicone dressings and a topic cream or agent including fatty acids. In contrast the systematic
review conducted by Zhang, Sun and Yue (2015), evaluated the effectiveness of massage therapy
in pressure ulcer prevention with however, focusing on the proportion of patients being inflicted
with the development of pressure ulcers of any severity or grade. However, the inability of the
authors to retrieve studies evaluating specifically the credibility of massage therapy raises
difficulties in future consideration of the usage of this intervention in professional healthcare
preventive practice. However, while three of the systematic reviews which were selected focused
primarily on therapeutic or treatment based interventions for pressure ulcer prevention (Gillespie
et al., 2014; Moore & Webster, 2013; Zhang, Suen & Yue, 2015), the systematic review by
Wilchesky and Lungu (2015), aimed to research upon the effectiveness of a timely assessment
framework in the form of the Braden Scale for the prevention of pressure ulcers in the long term

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healthcare settings. Despite the benefits underlying the implementation of effective screening
and assessment frameworks, the studies reviewed and evaluated by the authors using meta-
analysis revealed low levels of validity, positive predictive value and specificity in terms of
efficacy and usage of Braden Scale as a preventive intervention, for which, greater preference
underlying therapeutic strategies among healthcare organizations. Lastly, contrasting all these
studies, each of which explored the effectiveness underlying individual preventive interventions
for reduction of pressure ulcer incidences across healthcare settings (Gillespie et al., 2014;
Moore & Webster, 2013; Zhang, Suen & Yue, 2015; Wilchesky & Lungu, 2015), the systematic
review conducted by Tayyib and Coyer (2016), explored the effectiveness underlying a number
of preventive interventions such as nutrition therapy, schedule of positioning and repositionin,
skin care regimen, provision of surfaces for support and dissemination of education on pressure
ulcer management among staff, of which the implementation of a preventive strategy
incorporating silicon foam dressing was reviewed to yield effects which were statistically
significant. Overall, only one systematic review (Wilchesky & Lungu, 2015), engaged in usage
of a meta-analysis, while the rest of the 4 systematic reviews concentrated on usage of systematic
reviews (Gillespie et al., 2014; Moore & Webster, 2013; Zhang, Suen & Yue, 2015; Tayyib &
Coyer, 2016). Overall, all the systematic reviews focused extensively on the pressure ulcer
intervention strategies across healthcare settings and in bed ridden patients of all ages, health
conditions and severities of pressure ulcer stages.
Quality Assessment
For the quality assessment of articles, the Assessment of Multiple Systematic Reviews
(AMSTAR) items (for Review of Systematic Reviews) critical appraisal tool was used. The
lowest score was 5 and the highest score was 8, indicating inclusion of articles ranging from

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moderate to high in terms of methodological quality. The AMSTAR items like conflict of
interest, presence of inclusion criteria and incorporation of grey literature were missing most
articles.
Findings and Themes
From the five systematic reviews selected, the following themes in the form of
interventions for prevention of pressure ulcer incidences in healthcare settings could be
identified:
Patient Repositioning
Repositioning the patient to prevent occurrences of pressure injuries and relieve areas of
the body from undergoing excessive pressures, comprises of turning, rotating or alternating the
position of the patient, preferably after every 2 to 3 hours. Reposition for pressure ulcer
prevention was reviewed by Gillespie et al., (2018) and Tayyib & Coyer (2016).
Topical Agents and Dressing
Topical agents as preventive interventions include the application of gels, creams and
ointments while dressing interventions include the administration of silicone, alginate, collagen,
hydrocolloid and hydrogel based coverings to ensure protection from external agents and
maintenance of adequate moisture levels for wound and injury healing. Such interventions were
researched by Moore and Webster (2013) and Tayyib et al., (2016).
Massage Therapy
Massage therapy interventions include the application of pressure in selected areas
resulting in increased flow of nutrients and blood, reduced swelling, fluid retention and improved

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immunity resulting in reduction of pressure ulcer risk in patients susceptible to the same.
Massage therapy has been reviewed by Zhang, Sun and Yue (2015).
Pressure Ulcer Assessment
The Braden Score is an assessment tool used for evaluating the risk of developing
pressure ulcers in patients using a scoring range of less than or equal to greater than or equal to
23, in terms of the fields of moisture, mobility, nutrition, sensory perception, activity and shear
of friction. The intervention was reviewed by Wilchesky and Lung (2015).
Additional Interventions
Interventions like provision of adequate nutrition, regimen for skin scare, staff
educational and training framework and support surfaces have also been evidenced to be
effective in pressure ulcer prevention. Such interventions were explored by Tayyib et al., (2016).
Discussion
Summary of Findings
The studies so obtained provide a useful insight on a wide variety of strategies deemed to
be effective for prevention of pressure ulcers in patients. Considering that immobility resulting in
prolonged hours of being bed ridden is a major risk factor for pressure ulcer occurrence,
repositioning the patient has been regarded as the most effective preventive measure used
traditionally, since the same results in pressure relief in selected areas of the body (Powers,
2016). Repositioning however, has been questioned scientifically considered the dearth of high
quality studies evaluating the same. Further, the usage of repositioning strategies continue to
remain difficult for patients who are wheelchair bound or using prosthetics (Engels et al., 2016).

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However, novel technologies, using silk or egg crate mattresses allow increased air circulation
and pressure distribution across the skin surface hence paving the way for future improvements
(Boyko, Longaker & Yang, 2018). Similarly, in terms of usage of topical agents and dressings, a
range of conflicting evidence exists with none of the dressings being scientifically proven to
yield the best results. Nevertheless, the effectiveness of a dressing can be improved by regularly
conducting wound assessments, timely changing of dressings and ensuring to maintain adequate
moisture and microbe-free conditions (Westby et al., 2017). Additional interventions like
massage therapy has been traditionally referred to with the rationale that it improves blood
circulation. However, limited evidence remains on its effectiveness along with evidence that
massage therapy may be counterproductive in patients and associated with chronic inflammation
(Field, 2016). Similarly, assessment techniques such as skin assessments and the Braden score
are primarily considered as a scale for monitoring and not as a preventive approach alone.
Further, subscales in the Braden score have been criticized to be inadequate in terms of
predictability (Miller et al., 2016). Lastly, considering that pressure ulcers are caused due to
disruptive blood and nutrient circulation, an adequate nutritional plan is necessary to aid in tissue
repair and recovery – but however, may not be effective as a preventive tool and must be
delivered as a part of a pressure ulcer preventive care bundle (Posthauer et al., 2015).
Quality of Evidence
The methodological quality of all articles have been ensured, with the usage of a credible
critical appraisal tool like AMSTAR. The effectiveness of this tool lies in its ability to aid
researchers in evaluating the validity of articles relevant to evidence based research and practice
(Shea et al., 2017). Overall moderate to quality studies have been incorporated hence making this
research a useful tool for guiding researchers and practitioners.

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Potential Biases
While this review incorporates a wide range of comprehensive interventions along with
relatively recent studies, there still lies certain limitations. Most of the studies incorporated in the
reviews which were selected were reported by the authors to be of questionable quality, which
may hinder validity of the findings of this systematic review. Further, inclusion of studies
conducted at only healthcare settings may affect the applicability of this study in home based
care of pressure ulcer (Noble & Smith, 2015). Hence, it is recommended that more robust
research be conducted with inclusion of a wide variety of studies incorporating a wider range of
pressure ulcer intervention methods such as policy or workforce educational frameworks.
Conclusion
To conclude, it was observed that pressure ulcers result in considerably detrimental
health implications and financial costs in the patient as well as in the healthcare organization,
hence necessitating their immediate prevention. This review was useful for the identification of
various interventions for pressure ulcer prevention, namely: repositioning, topical agents and
dressing, assessments, massage therapy and strategies like nutrition. Considering the same, the
following recommendations can guide future practice:
For practitioners: There is a need to rely on not just one, but multiple interventions for
pressure ulcer prevention, preferable in the form of a care bundle, since no single intervention
has been scientifically proven for efficacy.
For researchers: Considering limitations in quality and quantity of evidence, further
research on multiple interventions with credible quality studies is required to be conducted in a
wide variety of settings and populations.

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Dealey, C., Brindle, C. T., Black, J., Alves, P., Santamaria, N., Call, E., & Clark, M. (2015).
Challenges in pressure ulcer prevention. International wound journal, 12(3), 309-312.
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Demarre, L., Van Lancker, A., Van Hecke, A., Verhaeghe, S., Grypdonck, M., Lemey,
J., ...&Beeckman, D. (2015). The cost of prevention and treatment of pressure ulcers: a
systematic review. International journal of nursing studies, 52(11), 1754-1774. doi:
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treating pressure ulcers. Cochrane Database of Systematic Reviews, (5). doi:
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Engels, D., Austin, M., McNichol, L., Fencl, J., Gupta, S., & Kazi, H. (2016). Pressure ulcers:
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pressure ulcers. International wound journal, 12(3), 254-259. doi:
https://doi.org/10.1111/iwj.12086.

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Jaul, E., Barron, J., Rosenzweig, J. P., & Menczel, J. (2018). An overview of co-morbidities and
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(2015). Support surfaces for pressure ulcer prevention. Cochrane Database of Systematic
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27RAPID REVIEW: INTERVENTIONS FOR PRESSURE ULCER PREVENTION
Appendices
Appendix 1: Database search history
Keywords Number of Searches
Cochrane: Pressure ulcer prevention in elderly 72 (8 systematic reviews, 63 trials, 1 editorial)
Medline: Pressure ulcer prevention in elderly 7
Medline: (pressure ulcer or bedsore or
decubitus ulcer or pressure sore) AND
(prevention or intervention or treatment) AND
(prevention or reduction or intervention) AND
(elderly or aged or older or elder or geriatric)
AND (systematic review)
9 (limitations to full text, English language,
human subjects, January 2009 – 2010
publication)
Appendix 2: Reason for Excluding Studies
References Reason for Exclusion
Machado, R. S., Viana, S., & Sbruzzi, G. (2017). Low-level
laser therapy in the treatment of pressure ulcers: systematic
review. Lasers in medical science, 32(4), 937-944. doi:
https://doi.org/10.1007/s10103-017-2150-9.
Does not research on preventive
interventions
Van Herck, P., Sermeus, W., Jylha, V., Michiels, D., & Van
den Heede, K. (2009). Using hospital administrative data to
evaluate the knowledge‐to‐action gap in pressure ulcer
preventive care. Journal of evaluation in clinical practice,
15(2), 375-382. doi: https://doi.org/10.1111/j.1365-
2753.2008.01019.x.
Does not research on preventive
interventions
Tricco, A. C., Cogo, E., Isaranuwatchai, W., Khan, P. A.,
Sanmugalingham, G., Antony, J., ... & Straus, S. E. (2015).
Does not research on preventive
interventions

28RAPID REVIEW: INTERVENTIONS FOR PRESSURE ULCER PREVENTION
A systematic review of cost-effectiveness analyses of
complex wound interventions reveals optimal treatments for
specific wound types. BMC medicine, 13(1), 90. doi:
https://doi.org/10.1186/s12916-015-0326-3.
Wong, J. K., Amin, K., & Dumville, J. C. (2016).
Reconstructive surgery for treating pressure ulcers.
Cochrane Database of Systematic Reviews, (12). doi:
https://doi-org.ezproxy.uow.edu.au/
10.1002/14651858.CD012032.pub2.
Does not research on preventive
interventions
Samuel, N., Carradice, D., Wallace, T., Smith, G. E., &
Chetter, I. C. (2013). Endovenous thermal ablation for
healing venous ulcers and preventing recurrence. Cochrane
Database of Systematic Reviews, (10). doi: https://doi-
org.ezproxy.uow.edu.au/10.1002/14651858.CD009494.pub2.
Irrelevance to keywords
Garner, S. E., Fidan, D., Frankish, R. R., & Maxwell, L.
(2005). Rofecoxib for osteoarthritis. Cochrane Database of
Systematic Reviews, (1). doi: https://doi-
org.ezproxy.uow.edu.au/10.1002/14651858.CD005115.
Irrelevance to keywords and
publication year
Corcoran, E., & Woodward, S. (2013). Incontinence-
associated dermatitis in the elderly: treatment options. British
Journal of Nursing, 22(8), 450-457. doi:
https://doi.org/10.12968/bjon.2013.22.8.450.
Irrelevance to keywords

Running head: RAPID REVIEW
Appendix 3: Quality Assessment using Assessment of Multiple Systematic Reviews (AMSTAR) items (for Review of
Systematic Reviews)
AMSTAR Questions Gillespie et al.,
(2014)
Moore & Webster
(2013)
Zhang, Sun & Yue
(2015)
Wilchesky &
Lung (2015)
Tayyib & Coyer
(2016)
1. Was an a piori design
provided?
1 1 1 1 0
2. Was there duplicate
study selection and data
extraction?
1 1 0 0 0
4. Was the status of
publication (that is, grey
literature) used as an
inclusion criterion?
0 1 1 1 1
5. Was a list of studies
(included and excluded)
provided?
1 1 0 1 0
6. Were the 1 0 1 1 1

1RAPID REVIEW: INTERVENTIONS FOR PRESSURE ULCER PREVENTION
characteristics of the
included studies
provided?
7. Was the scientific
quality of the studies
assessed and
documented?
1 1 1 1 1
8. Was the scientific
quality of the included
studies used
appropriately in
formulating conclusions?
1 1 1 0 1
9. Were the methods
used to combine the
findings of studies
appropriate?
1 1 1 1 1
10. Was the likelihood of 0 0 1 0 0

2RAPID REVIEW: INTERVENTIONS FOR PRESSURE ULCER PREVENTION
publication bias
assessed?
11. Was the conflict of
interest included?
1 1 0 0 0
Total 8 8 7 6 5

Running head: RAPID REVIEW
Appendix 4: Review Findings
Pressure Injury and
Bed Sore Preventive
Intervention
Specific Intervention Positive Outcomes Negative Outcomes Unclear Outcomes
Repositioning of Patients
(Gillespie et al., 2014)
(Tayyib & Coyer, 2016)
30° overnight tilting,
standard care and lateral
repositioning of 90° after
every 6 hours.
Increased cost
effectiveness in terms of
nursing work hours and
reduced pressure ulcer
incidences
Low quality and high
risk of bias across
studies, increase pressure
ulcer risk in other areas
Reasons on how cost
effectiveness and
reduced work hours
can prevent pressure
ulcer incidences
Topical agents and
Dressings (Moore &
Webster, 2013) (Tayyib
& Coyer, 2016)
Topical agents as
preventive interventions
include the application of
gels, creams and
ointments while dressing
interventions include the
administration of
Fatty acid based creams
and silicone dressings
reduced pressure ulcer
incidences
Low evidence based,
increased organizational
expenditures
Unclear on the reasons
underlying
effectiveness of fatty
acid topical agents and
silicone dressings

1RAPID REVIEW: INTERVENTIONS FOR PRESSURE ULCER PREVENTION
silicone, alginate,
collagen, hydrocolloid
and hydrogel based
coverings to ensure
protection from external
agents and maintenance
of adequate moisture
levels for wound and
injury healing.
Zhang, Sun & Yue
(2015)
Application of pressure in
selected areas
Increased flow of
nutrients and blood,
reduced swelling, fluid
retention and improved
immunity resulting in
reduction of pressure
ulcer risk
Lack of studies
compliant to inclusion
criteria or low quality
studies, increase chronic
inflammation and
pressure ulcer risk
Lack of information
on the relationship
between chronic
inflammation and
massage therapy
Wilchesky & Lung Braden score assessment Timely monitoring, Low specificity and Unclear information

2RAPID REVIEW: INTERVENTIONS FOR PRESSURE ULCER PREVENTION
(2015) screening and facilitator
of intervention
implementation
predictive value of
subscales, errors in
detection leading to
increased pressure ulcer
risk
on how this
assessment is effective
as compared to
alternative pressure
ulcer assessment tools
Tayyib & Coyer (2016) Nutritious diet for
patients and educational
training for staff
Reduced pressure ulcer
incidence
Increased medical
expenditures in the
organization,
Unclear information
on the nutritional
composition and the
components to be
addressed in a staff
educational program