Prevention of Pressure Injuries and Nursing Interventions in Critical Care Settings: a Synthesis Without Meta-Analysis (SWiM)

Introduction

The European Pressure Ulcer Advisory Panel defines pressure injury (PI)¹ as localized skin or underlying tissue damage caused by pressure, pressure combined with shear, or the use of medical devices. The clinical practice guidelines categorize these injuries into stages I, II, III, IV, unstageable, and deep tissue injury (EPUAP, 2019). These stages help clinicians understand the severity and nature of the injuries. A comprehensive skin assessment conducted by nursing professionals is the basis of the diagnostic framework.² However, the international guidelines list several interventions and practice recommendations for PI prevention (EPUAP, 2019). Based on the five levels of evidence in the guideline, which range from A (more than one high-quality study) to GPS (good practice statement), the strength of evidence regarding nursing interventions related to PI (pressure injury) prevention in critical care shows an absence of any A level of evidence. Most of the evidence ranges from B2 to C levels, with a good amount of GPS level of evidence.

Therefore, additional support and recommendations are needed to strengthen the evidence for preventing pressure injury formation in critically ill patients who were in higher risk for developing PI due to the complex nature of their health conditions.² Factors such as limited mobility, using ventilators and vasopressor agents, and invasive medical devices have been identified as contributing to PI development in critical care settings.³ Moreover, PIs give rise to serious complications, including severe pain, infections, prolonged hospital stays, psychological distress, delayed recovery, and even mortality (Lin et al, 2020). So, patients with PI in critical care significantly impact comorbidities and negatively affect patient outcomes.⁴ This comprehensive perspective enlightens healthcare practitioners, researchers, and policymakers, fostering a collective understanding crucial for effectively managing and preventing pressure injuries in clinical settings.

Critically ill patients commonly experience pressure injuries due to the complex nature of their health conditions.² Factors such as limited mobility, using ventilators and vasopressor agents, and invasive medical devices have been identified as contributing to PI development in critical care settings.³ Moreover, PIs give rise to serious complications, including severe pain, infections, prolonged hospital stays, psychological distress, delayed recovery, and even mortality (Lin et al, 2020). So, patients with PI in critical care significantly impact comorbidities and negatively affect patient outcomes.⁴ Nurses face a substantial challenge in preventing pressure injuries (PIs) while caring for critically ill patients.⁵ To mitigate pressure injuries (PIs), nurses must employ evidence-based interventions, possess a comprehensive understanding of PI prevention, adopt a structured yet personalized approach to address individual patient care requirements, and involve the multidisciplinary team in collaborative efforts toward PI prevention.⁶

Successive editions of international clinical practice guidelines on preventing and treating pressure injuries (PIs) were published in 2009, 2014, and 2019.⁷ However, research has shown that the mere availability of guidelines does not guarantee the implementation of best practices in care settings,⁸ as these guidelines often need more specific strategies for improving care.^6,9 Also, presenting the policies is not associated with staff compliance with the required interventions.¹⁰ To enhance the care provided to critically ill patients, various PI prevention programs incorporating multiple interventions, commonly called bundles, have been developed.⁴ Nonetheless, disparities and variations in nursing interventions within these PI prevention bundles and across different practice settings pose challenges to PI prevention efforts.¹¹ Hence, this review aimed to identify and critique the most effective nursing interventions for preventing PIs in critical care unit patients.

Methods

Following the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA),¹² and Synthesis without meta- analysis (SWiM) guidelines,¹³ this systematic review has been conducted.

Information Sources and Search Strategy

To identify relevant studies, a comprehensive search was conducted in PubMed, SCOPUS, CINAHL, MEDLINE, and Web of Science databases for research publications on bout nursing intervention for pressure ulcer between Jan 1st 2007 and May 31st 2023, using the words nurs* AND “pressure ulcer” (OR) “pressure injury” (OR) “bed sore*” (OR) “decubitus ulcer” (OR) “pressure sore” AND “intensive care” (OR) “critical care” (OR) ICU (OR) “high depend*”. Phrases used for the Medical Subject Heading (MeSH) search included: (“Nurses”[Mesh]) AND “Pressure Ulcer”[Mesh] OR “Pressure injury” [Mesh] OR “bed sore” [Mesh] OR “decubitus ulcer” [Mesh] OR “pressure sore” [Mesh] AND “intensive care” [Mesh] OR “critical care” [Mesh] OR “ICU” [Mesh] OR “high depend*” [Mesh].

Eligibility Criteria and Study Selection

The inclusion criteria were utilized to determine which studies would be incorporated into this review; (a) adult patients (≥18 age), (b) studies reported nursing interventions, nurses’ knowledge, nursing skills, attitudes towards PI prevention, (c) critical care/intensive care unit settings, (d) studies reporting nursing interventions randomize contorted trials (RCTs), Quasi-Experimental Studies, cohort (either prospective, retrospective), case–control, Case Series, and cross-sectional, (e) English report publication. The following exclusion criteria were applied: (a) duplicate reports, including repetitive patient information; (b) insufficient data; and (c) reviews and reports.

Three authors, AA, MRW, and HM independently assessed the full texts of the articles and applied the inclusion criteria for filtering by EndNote© X9 software. In cases of disagreement, discussions were held with senior authors ARA until a consensus was reached.

Quality Assessment

Two reviewers (AM and ARA) conducted the quality assessment of the included studies independently, and any discrepancies were resolved through mutual agreement. Various critical appraisal tools, such as the Joanna Briggs Institute (JBI) tools for Quasi-Experimental Studies, Randomized Controlled Trials (RCTs), Cross-Sectional Studies, and Case Series were employed to assess the quality of the studies. Each item was assessed and assigned a score of 1 for “yes” or 0 for “no” or “unclear”. The total score for each study was then converted into a percentage. Based on the JBI critical appraisal tools guidance,^14–16 the authors categorized studies as high (>80% quality score), moderate (50%–80% quality score), or low (<50% quality score). No studies were classified as low-quality (Table 1), and consequently, no studies were excluded based on methodological quality.

Table 1 Characteristics of Included Studies and Results

Data Extraction

Three authors extracted variables from the information, including the author’s first name, study design, publication year, sample size, country, and more. These variables were stratified based on the main criteria, such as author, country, aim, intervention, and findings.

Result

Study Selection

Having searched five bibliographic databases, this review returned 14,030 citations. We subsequently removed 1,318 duplicates. Additionally, we excluded 12,609 records by evaluating their titles and abstracts against the criteria outlined in Figure 1.

Figure 1 PRISMA diagram of literature search.

Among the remaining 103 references, 83 publications were excluded during the full-text screening process. Despite performing backward and forward reference list checks, the number of studies remained at 20, indicating no change. These 20 studies, which met our inclusion criteria, form the final synthesis.

Study Characteristics

A total of 20 studies were included in this review, consisting of 3 quasi-experimental study, 8 randomized controlled trials (RCTs), 1 cross-sectional study, 1 Sequential pretest and post-test, 1 retrospective, 1 mixed method, and 5 prospective studies. The cumulative sample size encompassed 305,149 patients who received treatment in critical care units across 9 countries (5 studies USA, 3 Australia, 3 Spain, 2 China, 2 Brazil, 1 Saudi Arabia, 1 turkey, 1 Netherland, and 1 Norway). All studies^17–36 were conducted in critical care settings between 2007 and 2023, with a focus on adult patients. Detailed information for all studies can be found in Table 1.

Most of the studies do describe the demographic characteristics and severity of illness for all patients included in the studies, with ages ranging from 24 to 92 years old. Additionally, several studies did not specify the length of stay in the intensive care unit (ICU). One study excluded patients who developed a pressure injury within 24 hours of admission,²⁴ while another excluded patients with a longer stay than 48 hours in the ICU.²⁶ Another study excluded patients who stayed in the ICU for less than 48 hours,¹⁹ and one study included patients with an expected length of stay of at least 7 days and excluded those with pressure injuries upon admission.²⁰

Primary Outcomes

The primary outcome measure in all the included studies was the development of pressure injuries (PIs). Of the 20 studies, 18 directly reported a reduction in the incidence of PIs^21–36, while one study demonstrated an indirect improvement by enhancing compliance with nursing interventions.¹⁷ Regarding Medical Device-Related Pressure Injuries (MDRPI), eight studies examined this outcome and observed a decrease in the incidence of MDRPIs.^{22–24,28,30,33,34,36}

In 17 studies, the assessment of pressure injuries was conducted by critical care nurses at the respective study sites.^{20,22–28,31,32,34–36} Among these, 11 studies reported that critical care unit nurses received training on identifying and staging pressure injuries within their facilities.^{24,26–28,31,32,34,35} Additionally, two studies provided training on measuring outcomes related to pressure injuries. In 7 studies, the assessments focused on identifying the initial presence of a pressure injury within 48 hours of admission. This included one study that assessed for pressure injuries at the time of admission,²² two studies that conducted assessments within 4 hours,^20,24 one study within 8 hours,³⁵ and three studies that assessed during the first 48 hours of admission.^26,32,36

In four studies,^21,22,25,31 data regarding the presence of a pressure injury was extracted from electronic datasets. However, none of the studies provided information on how the presence of a pressure injury at or following discharge from the critical care unit was assessed.

Secondary Outcomes

Several included studies utilized various risk assessment tools to identify patients at a higher risk of developing pressure injuries. Among these tools, the Braden scale was the most frequently employed, appearing in 11 studies.^{19–22,27–29,32–35}

Additionally, alongside the risk assessment tools, some studies collected data on the severity of illness. The Sequential Organ Failure Assessment (SOFA) score was used in two studies,^24,34 while the Acute Physiology and Chronic Health Evaluation (APACHE III) score was employed in one study.²⁵ Two studies incorporated the SOFA and APACHE III scores, and another two utilized a combination of the SOFA and APACHE II scores.³⁶

Interventions

Use of Comprehensive PI Prevention Strategy

A total of 11 studies implemented comprehensive bundles to prevent and manage pressure injuries (PIs) in critical care patients, and all of them demonstrated improvement in PI prevention and management.^{20–22,24,26,27,29,33–36} The interventions in these 11 studies were comprehensive, with certain interventions being commonly implemented among the strategies. These included skin assessment, risk and nutrition assessment, skin hygiene and moisturizing, heel elevation, repositioning, and nursing education and training. Furthermore, additional interventions were included in some studies as part of their comprehensive strategies. These interventions encompassed the application of prophylactic dressing and support surface, minimizing linen layers, head elevation, change of orotracheal catheter and/or nasoenteral catheter fixation device, rotation of pulse-oximeter sensor, temperature monitoring, use of fluidized positioners and application of gel adhesive dressings. Two studies listed multiple interventions but did not describe them as PI prevention “bundles”.^31,32 Although both studies reported decreased incidence of PIs related to their interventions, they did not provide statistical analysis or a rationale for their chosen interventions. Among these comprehensive strategies and bundles, the interventions could be categorized into the following categories: (a) training and education, (b) assessment prevention and protection against pressure forces. Two studies explicitly framed their interventions within these categories,^24,27 reporting decreased incidence of PIs.

Repositioning

In addition to being included as part of a comprehensive bundle and strategy in multiple studies,^{20–22,24,26,27,29,33–36} one study focused specifically on the repositioning intervention as the main intervention. This study aimed to assess the impact of different repositioning intervals on reducing the incidence and occurrence of PIs.

The study compared a repositioning interval of every 2 hours in the intervention group with a 4-hour interval in the control group. Although no statistically significant difference was observed, the study found that the incidence of PIs was higher in the control group (13.4%) compared to the intervention group (10.3%).²⁸

Use of Special Devices and Technology

A total of 8 studies acknowledged the utilization of various technologies and devices as part of interventions to prevent pressure injuries (PIs).^{17,18,20,23,25,28,30,36} One study specifically incorporated alternating-pressure air mattresses as an element of their inclusion criteria.²⁸ Additionally, two studies integrated special devices and technology within their bundle of interventions to prevent PIs. These included prophylactic dressings such as five-layer silicone-bordered foam dressings for the heels and sacrum,^25,36 as well as the implementation of pressure-relieving mattresses.²⁵ Furthermore, one study indirectly mentioned the beneficial impact of special devices, such as Foley catheters and fecal management systems, on preventing PIs in critical care patients, which could explain the low prevalence of skin breakdown observed.¹⁸

Finally, four studies highlighted the utilization of special technology and devices as primary interventions in their respective research papers.^17,20,23,30 These interventions included the use of wearable sensors to prompt critical care patient repositioning,¹⁷ the implementation of pressure-redistribution mattresses with different intervals,²⁰ the use of a fluidized positioner to reduce occipital pressure injuries,²³ and the application of hyper-oxygenated fatty acids (HOFA) to prevent facial pressure injuries in non-invasive mechanical ventilation patients.³⁰

Provide Training, Increase Knowledge and Skills, and Expertise

Pressure injury assessment was conducted by critical care nurses in 13 studies, as documented within each respective study.^{20,22–28,31,32,34–36} Among these studies, 9 of them involved critical care unit nurses receiving training on identifying and staging pressure injuries in their facilities.^{24–28,31,32,34,35} Additionally, two studies offered training specifically related to measuring outcomes associated with pressure injuries.^22,24

Five studies emphasized the crucial role of knowledgeable and highly skilled nurses in preventing pressure injuries, highlighting them as expert practitioners in implementing nursing interventions for PI prevention.^{22,25,26,35,36} One study explicitly reported a significant improvement in nurses’ knowledge scores and compliance, resulting in a substantial decrease in device-related pressure injuries from 24.39% to 4.26%.

Furthermore, the findings of the remaining four papers^22,25,26,35 suggest that having trained and knowledgeable nurses to provide assistance and guidance in practice contributes to lower incidences of pressure injuries. Some PI preventive strategies mentioned in the literature involved the active involvement of highly skilled nurses and the provision of specialized training, which facilitated the implementation of effective nursing interventions.²⁵

Discussion

This systematic revise of various studies focused on preventing pressure injuries (PIs) in critical care patients to determine the most effective PIs prevention. The results provide valuable insights into PI prevention. From the United States in the west to China in the east, passing through Australia, Spain, Brazil, and so on, nurses over the globe report their concerns about the need for pressure injury prevention. Also, the review shows general agreements on the interventions for pressure injury prevention during their stay in critical care units, including skin assessment, offloading, repositioning, and skin care. However, these studies also have different representations for these interventions; in some reports, the researchers adopt the term “Bundle” to refer to the set of interventions and create an acronym to refer to these interventions,^{20–22,24,26,27,29,33–36} while others stick to the direct terminology of these each intervention. The review shows a general agreement about how PIs prevention had to occur and the importance of these interventions with different levels of the significant impact of these interventions on PI prevention.

On the other hand, the reports show wide variations in how these interventions had been followed, monitored, measured, or assured. For instance, assessing skin conditions formulates a general agreement between the studies. However, there must be a standard on when this must be done, whether immediately, after four hours,²¹ eight hours³⁵ or 48 hours.^26,32,36 This was also observed among the tool adopted for skin risk assessment; Braden was the most utilized assessment tool,^{19–22,27–29,32–35} but other tools also adopted for evaluating the general patient’s conditions such as Sequential Organ Failure Assessment (SOFA),^24,34 or Acute Physiology and Chronic Health Evaluation (APACHE III) which both initially created for other than PIs purpose²³ but formulated in the review as actual applications, which refers for disagreements between experts about the best assessment tool.

Furthermore, the literature shows that time is essential to PI development. PIs occur during the long duration of pressure on the organs. So, prevention strategies must be monitored over time to prevent injury. However, there were no agreements on the aspects of time in offloading the pressure. For instance, the frequency of conducting the repositioning appears as a disagreement point. The studies report a variation in performing the repositioning from two, three, or even every five hours.^17,28 Although the results did not show statistically significant differences in PI incidence with the changes in the repositioning frequencies, studies indicated a trend toward reduced PIs with more frequent repositioning intervals. Therefore, this suggests further research to establish agreeable tools for evaluating the complaint and standardize the measurements of nursing performance for repositioning after assessing the significant impact of these changes on PIs incidences. However, the challenges of repositioning continued time; instead, they also manifested in the term applied. Repositioning appears as not having the same reflection term between the studies; even though majorities adopt the term repositioning, other studies use the positioning, turn, or turning with a lack of assurance if these terms refer to the same actions performed by nurses or a different set of actions.

Expert practitioners’ involvement and specialized training provision were associated with lower incidences of PIs. This systematic review provides valuable insights into the continuous need of nurses (all over the globe) to receive education and training in Pi prevention, and this is common among all varieties of nurses in different cultures. However, the studies need more comprehensive descriptions of what these educational programs include and what learning theories are applied to these changes. This makes comparing these educational activities as one “thing” inapplicable.

It is essential to note a gap in the literature about pressure injury prevention interventions. While the studies have explained the immediate impacts of these interventions, they have yet to explore their long-term effects and sustained compliance. The scope of these studies mainly covers the aftermath of the interventions, leaving the long-term impact and adherence to these preventive measures unexplored. For instance, studies have been about repositioning to prevent patient pressure injuries. These studies have shown how vital repositioning can be, but researchers may need to look at the bigger picture of how nurses approach pressure injury prevention in general. It is essential to understand how long these changes in behavior will last beyond just the initial implementation of the intervention. Although some studies have shown how vital repositioning is for critically ill patients—something widely accepted by the scientific community—there are still issues with low compliance. The initial studies showed low compliance with repositioning, but there has yet to be much analysis on why this is the case. Other studies from the same country, conducted a few years later, still reported low to moderate compliance. This suggests that more work needs to be done to improve compliance with pressure injury prevention methods like repositioning. This is the required intervention in the future among the scientific community.

The question arises about how to ensure sustained compliance among healthcare practitioners. While the efficacy of pressure injury prevention interventions is acknowledged, there needs to be more insight into the dynamics governing the enduring adherence to these measures across diverse healthcare settings. It is crucial to ensure compliance for a comprehensive understanding of the landscape of pressure injury prevention. It was observed that the studies had a common initial condition regarding their country of origin. They all had low-quality adoption of interventions, which improved after specific recommendations were given. However, subsequently, they reverted to the initial condition of low quality, which is an indication of the inability of these studies to find their way into the actual nursing practice. For example, the studies conducted in the USA, Anderson 2015 and Edsberg 2022 are related to nursing care for PI management. The authors note the initial conditions in the nursing units were similar. That means the recommendation from Anderson’s study after seven years did not find a practical application for nursing care, which makes Edsberg’s study conduct the study and document that the stays of nursing care could be more satisfactory. This means that despite similarities in the initial conditions, the recommendations from different studies did not impact nursing care, which needs further exploration on the nature of the compliance of the PI management and its applicability in the actual clinical conditions for a long-term practice.

Pressure injury prevention is multifaceted, and it is necessary to consider not only how these interventions occur but also how they endure over time within the healthcare facilities. Future research must transcend the temporal constraints of existing studies and delve into the intricate fabric of sustained compliance and the pragmatic shifts in nurses’ approaches to pressure injury prevention beyond the immediate implementation phase. Such holistic exploration is essential for refining evidence-based practices and fortifying the resilience of pressure injury prevention protocols across diverse healthcare contexts.

In summary, the studies add valuable information about the PIs prevention adopted in critical care: assessing the skin condition at regular intervals, providing regular offloading for the pressure over the patient’s body tissues, and dressing for prevention. However, there is a need to build a more substantial consensus among experts in PIs prevention strategies in evaluating the benefits of these interventions and ensuring compliance with the performance. The current review concludes with scattered information about the impact of these interventions with difficulties in comparing these results due to differences in the measurements applied for the prevention applications and changes in the methods of evaluating its effect on pressure injury prevention. A pressure injury panel of experts and stakeholders is asked to organize these efforts toward unifying the ways of PIs prevention evaluation in a similar way of creating a PI staging system. At that time, nurses can detect the impact of these interventions and methods of evaluating the Pi prevention performance.

Strength and Limitation

Nurses equipped with appropriate knowledge and skills can prevent pressure injuries (PIs) in critically ill patients. PI prevention strategies must be grounded in evidence and empower nurses to utilize their decision-making abilities. To enhance the efficiency of care, intervention bundles should be designed within a framework that prioritizes evidence-based practices.

Continuing education plays a vital role in enabling nurses to identify strengths and weaknesses in their practice and promote compliance with best practices.

It is important to note that the studies included in this review displayed varying levels of methodological quality, particularly concerning their sampling methods, measurement validity, and statistical analyses. As a result of the heterogeneity observed in the interventions and study designs, conducting a meta-analysis was not feasible. These considerations should be considered when interpreting the results of the review. Secondly, it is worth mentioning that a few studies were omitted from our analyses due to insufficient or ambiguous information. Additionally, it is important to recognize that the search and inclusion process focused on the most current and up-to-date evidence available in the published literature.

Conclusion

This systematic review encompasses all nursing interventions documented in the literature for preventing pressure injuries (PIs) in critical care settings. Our study offers valuable guidance regarding the utilization of evidence-based PI prevention bundles, regular repositioning, the prevention of medical device-related pressure injuries (MDRPIs), and the role of education in enhancing PI outcomes. It is crucial to incorporate basic PI prevention interventions into the routine care schedule for critically ill patients, with a specific emphasis on mitigating MDRPIs. The implementation of PI prevention interventions resulted in a notable decrease in both the frequency and severity of PIs across all the studies included in this review. To enhance the outcomes of critically ill patients, it is imperative to adopt evidence-based PI prevention bundles. Furthermore, nurses must receive comprehensive education, clinical practice and fully comprehend their pivotal role in PI prevention.