SNPG 905 Minor Project: Rapid Review of Pressure Injury Interventions

This rapid review examines the most effective interventions for preventing pressure injuries and bed sores across all healthcare settings. The study included systematic reviews published between 2009 and 2019, focusing on interventions like patient repositioning, massage therapy, topical agents, and skin assessments. The review included patients in all healthcare settings, particularly those at high risk, such as the elderly or those with mobility issues. The findings highlight the need for multiple interventions, potentially in a care bundle, due to the lack of evidence supporting a single, universally effective approach. The review emphasizes the detrimental health implications and financial costs associated with pressure ulcers, underscoring the importance of immediate prevention strategies and further research to enhance patient outcomes.

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

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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.