Evidence Review

Effectiveness of Pressure Ulcer Prevention

Strategies for Adult Patients in Intensive
Care Units: A Systematic Review
Nahla Tayyib, RN, MN, BN • Fiona Coyer, RN, PhD, MScNsg, CritCareCert, PGCEA

ABSTRACT
Keywords Background: Pressure ulcers are associated with substantial health burden, but could be pre-
critical care/intensive ventable. Hospital-acquired pressure ulcers (HAPUs) prevention has become a priority for all
care, healthcare settings, as it is considered a sign of quality of care providing. Intensive care unit
evidence-based (ICU) patients are at higher risk for HAPUs development. Despite the availability of published
practice, prevention strategies, there is a little evidence about which strategies can be safely integrated
injury/trauma/wounds, into routine standard care and have an impact on HAPUs prevention.
intervention Aims: The aim was to synthesize the best available evidence regarding the effectiveness of single
research, strategies designed to reduce the incidence and prevalence of HAPUs development in ICUs.
meta-analysis/data
Methods: The search strategy was designed to retrieve studies published in English across
pooling,
CINAHL, Medline, Cochrane Central Register of Controlled Trials, Embase, Scopus, and Mednar
nursing practice
between 2000 and 2015. All adult ICU participants were aged 18 years or over. This review
included randomized controlled trials, quasi-experimental and comparative studies. The studies
that were selected for retrieval were assessed by two independent reviewers for methodological
validity prior to inclusion in the review using standardized critical-appraisal instruments.
Results: The review included 25 studies, and the meta-analysis revealed a statistically significant
effect of a silicon foam dressing strategy in reducing HAPUs incidence (effect size = 4.62; 95%
CI: 0.05-0.29; p < .00001, effect size = 4.50; 95% CI: 0.05-0.31; p = .00001, respectively) in
critically ill patients. Evidence of the effectiveness of nutrition, skin-care regimen, positioning
and repositioning schedule, support surfaces, and the role of education in prevention of HAPUs
development in the ICU was limited, which precludes strong conclusions.
Linking Evidence to Action: The review provides an evidence-based guide to future priorities
for clinical practice. In particular, a silicone foam dressing has positive impact in reducing sacrum
and heel HAPUs incidence in the ICU.

INTRODUCTION & Kim, 2014; Theaker, 2003; Van Nieuwenhoven et al., 2006;
Skin injury or ulceration as a result of pressure and shear forces Verbelen, 2007). These studies aimed to inform the clinical
is being increasingly viewed as an indicator of the quality of care decision making of healthcare workers of the best predictors
given to patients. Therefore, the testing of strategies to prevent and prevention strategies for HAPUs. However, these studies
the development of hospital-acquired pressure ulcers (HAPUs) have limitations such as lack uniformity in defining and
is of growing interest in all healthcare settings. Nevertheless, staging of HAPUs and study power. It is argued that providing
pressure ulcers (PUs) remain a common problem in health concise summaries of the supporting evidence, in terms
care settings (Berlowitz, 2014), especially in intensive care units of a systematic review, increases healthcare practitioners’
(ICUs), with approximately 22%–49% of critically ill patients satisfaction with, acceptance of, and level of implementation of
affected (Berlowitz, 2014). specific strategies (Dobbins, Rosenbaum, Plews, Law, & Fysh,
The development of PUs is a complex process, dependent 2007)
on a wide variety of extrinsic and intrinsic risk factors (Tayyib, The National Pressure Ulcer Advisory Panel (NPUAP), the
Coyer, & Lewis, 2013). Various strategies have been examined European Pressure Ulcer Advisory Panel (EPUAP), and the
in the prevention of PUs with different methodological Pan Pacific Pressure Injury Alliance (PPPIA) collaborated to
approaches and in different clinical settings (Behrendt, Ghaz- produce a comprehensive guideline that provides brief sum-
navi, Mahan, Craft, & Siddiqui, 2014; Girard et al., 2014; Park maries of evidence-based recommendations for the prevention

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 Evidence Review
and treatment of HAPUs (National Pressure Ulcer Advisory METHODS
Panel, European Pressure Ulcer Advisory Panel, & Pan Pacific Search Strategy
Pressure Injury Alliance, 2014). The NPUAP, EPUAP, and
The search strategy used a three-step search strategy to iden-
PPPIA guideline is framed in two sections: prevention of PUs
tify both published and unpublished studies. An initial limited
and interventions for prevention and treatment. Prevention
search of MEDLINE (PubMed) and CINAHL was undertaken
is summarized through the topics of risk factors and the use
followed by analysis of the keywords and index terms contained
of a risk assessment scale (RAS), skin and tissue assessment
in the title and abstract. A second search using all identified key-
and preventive skin care. Interventions for prevention and
words and index terms was then undertaken across all included
treatment of PUs are addressed in sections covering nutrition,
databases. Then the reference list of all identified reports and
repositioning and early mobilization, repositioning to prevent
articles was searched for additional studies. Studies published
heel PUs, support surfaces, medical device management, and
in non-English languages were not considered for inclusion
recommendations for special populations such as bariatric,
in this review, due to lack of available resources for transla-
critically ill, older adult, with spinal cord injury, pediatric,
tion. Studies published from 2000 to 2015 were considered for
and in the operating room. Although the intensive care
inclusion in this review.
critically ill patient population was acknowledged in this
All databases were searched from 2000 to week 30 (July
international guideline, this document failed to address PU
26) 2015 and included: CINAHL, Medline, Cochrane Central
prevention in ICU from a strong evidence-based perspective
Register of Controlled Trials, Web of Science, Embase, ERIC,
(National Pressure Ulcer Advisory Panel et al., 2014). This is
Scopus, and Mednar. The search for unpublished studies in-
significant as ICU patients present the highest risk of HAPU
cluded New York Academy of Medicine Library Gray Litera-
development.
ture Report, Google, National Institute for Health and Care
To date, most systematic reviews have investigated the effec-
Excellence (NICE), Agency for Healthcare Research and Qual-
tiveness of prevention strategies in general ward or healthcare
ity (AHRQ) National Guideline Clearing House, Centers for
settings. Because there are significant differences in patient
Disease Control and Prevention (CDC), and Dissertation and
acuity and diagnoses, care provided and environmental factors
Thesis Abstracts International.
between ICU and general wards or units, it is inappropriate
Initial keywords used were: “Pressure ulcer*”; “pressure
to extrapolate general care-related results to the intensive care
injury”; “pressure sore”; “bed sore”; critical care, intensive care,
setting. Further, no review of PU prevention strategies in ICU
“prevent*”; “reduc*”; “incid*”; and “preval*”.
has been conducted since 2000 (Keller, Wille, Van Ramshorst,
& Van der Werken, 2002).
There is evidence that PU prevention is more effective with Selection Criteria
multiple prevention strategies. However, many studies employ This review considered quantitative experimental studies, ran-
a single intervention measured against standard care. There- domized controlled trials (RCT), nonrandomized controlled
fore, this systematic review examined the effectiveness of single trials, quasi-experimental, before and after, and comparative
prevention strategies on HAPUs in ICU patients with the goal studies published in English with adult participants who were
of gathering scientific evidence to support or refute the benefit aged 18 years or over and managed in intensive or critical care
of using such strategies for critically ill patients. The NPUAP, unit. Studies where the results for adult intensive care were not
EPUAP, and PPPIA prevention guideline (2014) was utilized clearly separated from general data were excluded.
as the framework for this systematic review. The results of This review considered studies that included the following
this study may serve as a reference for professional caregivers primary outcome measures: HAPU incidence, HAPU preva-
and the information provided could be put into practice during lence, PU severity, time to occurrence, and number of PUs per
the clinical skin care of ICU patients. The methods of this re- patients. Secondary outcome measure was any adverse effect
view were specified in advance in previously published protocol caused by, or associated with, the use of the preventive strategy.
(Tayyib & Coyer, 2016).

Quality Assessment
OBJECTIVE Papers selected for retrieval were assessed by two independent
The objective of this review was to identify the effectiveness of reviewers for methodological validity prior to inclusion in the
single strategies designed to reduce the incidence and preva- review using standardized critical appraisal instruments from
lence of HAPUs development in ICUs in comparison to no the Joanna Briggs Institute Meta-Analysis of Statistics Assess-
strategy, other strategies, or usual practice. The review ques- ment and Review Instrument (JBI-MAStARI; Joanna Briggs In-
tion was: What is the effectiveness of implementing single PU stitute, 2014). The JBI-MAStARI tool is standardized appraisal
prevention strategies to reduce the incidence and prevalence of tool encompassing an assessment checklist of the risk of bias
HAPUs compared to different PU prevention strategies, stan- in study selection, performance, detection, attrition and report-
dard or usual care, or no strategies in the adult intensive or ing. Any disagreements that arose between the reviewers were
critical care environment? resolved through referring the study for the adjudication of

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Pressure Ulcer Prevention for Patients in ICUS

a third reviewer. Studies that met 50% of the JBI-MAStARI Preventive Skin Care
checklist tool were included in this review. One study evaluated the impact of a strategy for fecal inconti-
nence on the rate of PU development (Pittman, Beeson, Terry,
Data Abstraction Kessler, & Kirk, 2012). The study compared three strategies of
bowel management to control fecal incontinence on the preva-
Data were abstracted from papers included in the review using
lence of HAPUs with no significant difference found in the
the standard data extraction tool from JBI-MAStARI. The data
prevalence rate of HAPUs (p = .63) in either group.
abstracted included specific details about the strategies, pop-
ulations, study methods and outcomes of significance to the
review question and specific objectives. Emerging Therapies for HAPUs Prevention
Polarized light. One study investigated the efficacy of polar-
Data Synthesis ized light once a day for 10 minutes in preventing the incidence
of HAPUs on the sacral and heel area (Verbelen, 2007). The
Quantitative data was intended to be pooled in statistical meta-
study showed no significant difference in the development of
analysis as planned in the published protocol (removed for
all stages of PUs with the use of polarized light on the sacrum
blind peer review). The heterogeneity of the studies was as-
and heels (p = .196), despite a significant decrease in the inci-
sessed by considering their population, intervention and out-
dence of HAPUs when stage I PUs were excluded (p = .019).
come. Where possible, odds ratios with 95% confidence in-
However, the control group had more assessed areas of skin at
terval (CI) were calculated for binary outcomes. As statistical
risk for PUs (39 areas/13 participants) compared to the inter-
pooling was not possible because of the studies’ heterogeneity,
vention group (28 areas/10 participants). In addition, a small
the findings are presented in narrative form.
sample size of 23 participants limited the study’s findings.

CHARACTERISTICS OF INCLUDED STUDIES Dressings. Three studies reported the effectiveness of the ap-
Searching identified 675 potentially relevant papers, and after plication of prophylactic silicone foam dressings in decreasing
sifting of titles and abstracts according to the above inclusion the incidence of sacral HAPUs (Brindle & Wegelin, 2012; Park,
criteria, 78 papers were selected for retrieval. When the full text 2014; Santamaria et al., 2015b). The overall effect size across
versions of the papers were examined, 35 of the 78 retrieved studies was 0.12 (95% CI: 0.05-0.29; p <.00001), the result
papers were found to fully meet the inclusion criteria. These 35 indicating that HAPU incidence of sacral area decreased after
studies were critically appraised by two independent reviewers the application of the dressing (see Figure 2).
using the JBI-MAStARI critical appraisal tools. Only 24 were Two studies examined the effectiveness of similar dressings
found to be of sufficient quality to include. The flowchart (see in reducing the incidence of heel HAPUs (Santamaria et al.,
Figure 1) presents further details of the search results and study 2015a,b). These two studies demonstrated that heel HAPU
selection process. incidence significantly decreased after implementation of the
The level of evidence overall was levels II to III-2 accord- dressing. The first trial’s result demonstrated a significant re-
ing to the National Health and Medical Research Council duction of heel HAPU incidence in the intervention group
(NHMRC) evidence hierarchy (National Health and Medical (5 vs. 19, p = .002) compared to the control group (Santamaria
Research Council, 2009). The majority of included studies et al., 2015b). The result was confirmed with a subsequent
were RCT designs (n = 14). One was a posttest only design study that evaluated the dressing on heel HAPU incidence.
with three-group comparisons, three were pre–post experimen- No PU was reported on heels following the implementation
tal studies, and six were two-group quasi-experimental studies. of the dressing strategy (0 vs. 19, p < .001; Santamaria et al.,
Included studies were conducted worldwide and participants 2015a). Both studies used the same control group where the
were all intensive care patients (n = 6,566). Studies details are second study (Santamaria et al., 2015a) recruited a new inter-
described further in Table 1. vention group and measured against a historical control group
(Santamaria et al., 2015b).

FINDINGS
The findings are reported according to the NPUAP, EPUAP, Nutrition
and PPPIA guideline (2014) and framed in two sections; pre- Only one study examined specific nutritional strategies to pre-
vention of PUs and interventions for prevention and treatment. vent HAPUs in critically ill patients with acute lung injuries
(Theilla, Singer, Cohen, & Dekeyser, 2007), reporting that the
intervention diet was significantly associated with reduction of
Effectiveness of Risk Assessment—Skin and Tissue HAPU incidence (p = .05). However, more participants were
Assessment recruited with existing PUs in the control group, and so were
No studies were found that examined the contribution of RASs more likely to develop subsequent PUs, therefore biasing the
as a strategy to reducing HAPUs in ICU. results.

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Table 1. The Nonpharmacological Strategies for Pressure Ulcer Prevention in Intensive Care Units

Author Design/ Industry Conflict

Guideline (year of level of Intervention Outcome/ support of interest
elementsa publication) evidence Sample Setting measure recommendation (Yes/ No) (Yes/ No)

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Skin care Pittman et al. RCT/ II 59 ICU (USA) To compare (1) bowel No significant difference in HAPU Yes No
(2012) management system (BMS) prevalence (p = .63)
catheter; (2) rectal trumpet
(RT) utilized as a rectal fecal
incontinence device; and (3)

Worldviews on Evidence-Based Nursing, 2016; 13:6, 432–444.

usual care (UC) consisting of
barrier creams and/or a fecal
pouch collector.
Emerging Brindle and Two group 85 CSICU (USA) To evaluate the silicone border No significant differences in the Not reported Not reported
therapies Wegelin quasi- foam dressing in the sacrum incidence between both
(2012) experimental/ area groups (p = .3)
III-1
Park (2014) Quasi- 102 ICU (South To evaluate the silicone foam Significant decrease in HAPUs Not reported No
experimental/ Korea) dressing in the sacrum area incidence (p < .001)
III-1
Santamaria RCT/ II 313 ICU (Australia) To evaluate silicone foam Significant decrease: Overall Not reported Not reported
et al. dressings when applied to the incidence of HAPUs
(2015b) sacrum and heel in the (p = .001), sacral event
emergency department and (p = .05), heel event
maintained throughout their (p = .002)
ICU stay
Santamaria Pre-post quasi- 341 ICU (Australia) To evaluate silicone foam Significant decrease heel HAPUs Not reported Not reported
et al. experimental/ dressings when applied on heel incidence (p < .001)
(2015a) III-1 in the emergency department
and maintained in ICU
Verbelen RCT/ II 23 ICU (Belgium) To examine the polarized light Significant decrease in HAPUs Yes No
(2007) (once a day) on the sacrum incidence (p = .019)
and heel in preventing HAPUs
grade II or above
(Continued)
Evidence Review

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Table 1. Continued

Author Design/ Industry Conflict

Guideline (year of level of Intervention Outcome/ support of interest
a
elements publication) evidence Sample Setting measure recommendation (Yes/ No) (Yes/ No)

Nutrition Theilla et al. RCT/ II 100 ICU (Israel) To compare a diet enriched in The intervention diet significantly Yes Not reported
(2007) lipids and vitamins A, C, and E decreased the incidence of
with a diet similar in HAPUs (p < .05).
macronutrient composition
Repositioning Still et al. Pre–post 1,112 SICU (USA) To evaluate a turn team with a A turn team strategy significantly No No
Pressure Ulcer Prevention for Patients in ICUS

and early (2013) experimental 2-hour repositioning schedule decreased HAPUs incidence
mobility trial/ III-1 (p < .0001)
Behrendt et al. RCT/ II 422 MICU (USA) To evaluate a continuous bedside HAPUs incidence was Yes Not reported
(2014) pressure mapping (CBPM) significantly lower in the CBPM
device with 2-hour group (p = .02).
repositioning
Manzano et al. RCT/ II 329 ICU (Spain) To compare 2- and 4-hour No significant difference between No No
(2014) repositioning with alternating both repositioning regimen
pressure air mattresses (p = 0 .73)
Van Nieuwen- RCT/ II 255 ICU (Nether- To compare 45° with 10° head of The authors compared between No No
hoven et al. lands) bed (HOB) elevation the achieved angles of HOB
(2006) (28° vs. 10°), and no
significant differences were
found between groups (28%
vs. 30%, respectively)
Girard et al. RCT/ II 466 ICU (France) To compare prone with supine Supine positioning significantly No No
(2014) positioning. decreased HAPUs incidence of
(p = 0 .005) after 7 days of


ICU stay
Schallom et al. RCT/ II 15 ICU (USA) To compare between 30° and No HAPUs developed in either No Not reported
(2015) 45° HOB elevation group.
(Continued)

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Worldviews on Evidence-Based Nursing, 2016; 13:6, 432–444.

Table 1. Continued

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Author Design/ Industry Conflict
Guideline (year of level of Intervention Outcome/ support of interest
a
elements publication) evidence Sample Setting measure recommendation (Yes/ No) (Yes/ No)

Support Theaker, RCT/ II 62 ICU (UK) To compare an alternating No significant difference between Yes Not reported

Worldviews on Evidence-Based Nursing, 2016; 13:6, 432–444.

surfaces Kuper, pressure mattresses with a low both groups (p = .35)
and Soni air loss mattress
(2005)
Malbrain et al. RCT/ II 16 MICU To compare an active alternating No difference in incidence (1 vs. Yes No
(2010) (Belgium) pressure mattress with a 2, respectively)
reactive mattress overlay
Jackson et al. Pre–post 53 CTV ICU (USA) To evaluate the effect of air Incidence decreased after No Not reported
(2011) experimental fluidized therapy beds strategy (40% pre vs.
trial/ III-1 15% post)
Black et al. Two group 52 SICU (USA) To compare a low air loss with Incidence was significantly lower Yes No
(2012) comparative microclimate management with the low air loss bed
study/ III-2 bed to the integrated powered (p = .046)
air pressure redistribution bed
Manzano et al. Two group 221 ICU (Spain) To compare an alternating Incidence was significantly lower No No
(2013) quasi- pressure mattress with a foam with the an alternating
experimental/ overlay mattress pressure mattress (p = .038)
III-1
Ozyurek and RCT/ II 105 ICU (Turkey) To compare two types of No significant difference between Not reported No
Yavuz viscoelastic mattresses both groups (p = .44)
(2015)
(Continued)
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437
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Table 1. Continued

Author Design/ Industry Conflict

Guideline (year of level of Intervention Outcome/ support of interest
elementsa publication) evidence Sample Setting measure recommendation (Yes/ No) (Yes/ No)

Medical Gregoretti RCT/ II 194 ICU (Italy) To compare prototype face The PMs significantly decrease No No
devices- et al. masks (PMs) with the incidence of MDRPU
related (2002) conventional face masks (p < .001).
PUs (CMs)
Weng (2008) Three group 60 ICU (Taiwan) To compare HAPUs incidence The protective dressings No Not reported
quasi- related to face mask when significantly decrease the
Pressure Ulcer Prevention for Patients in ICUS

experimental/ using a protective dressing HAPUs incidence (p < .001).

III-1 (hydrocolloid, or transparent However, no significant
film) with nothing applied with difference in occurrence
face mask duration time was reported
between both dressings.
Rassin et al. Three group Phase I: 57, ICU (Israel) Phase I: to compare urinary Phase I: no significant differences No No
(2013) RCT/ II Phase II: 112 catheter skin-care regimen of between both groups in the
once every 24 hours to incidence (intervention =
standard care on the incidence 24.1% vs. control = 28.6%).
of HAPUs related to urethral Phase II: the intervention
catheterization. Phase II: to Significantly decrease the
compare urinary catheter incidence (p = .002).
three times daily skin regimen
to standard care
Alali et al. Two group 1,811 ICU (Canada) To evaluate early tracheostomy Early tracheostomy significantly No No
(2013) comparative (ࣘ8 days) in trauma brain decreased the incidence of
study/ III-2 injury HAPUs (p = .001)
Education Uzun, Aylaz, Two group 186 ICU (Turkey) To evaluate the impact of an Significantly lower the incidence No Not reported


and comparative educational strategy with educational strategy
Karadag study/ III-2 (2 seminars for 2 hours) on the (p < .01)
(2009) incidence of stage II or greater
PUs
a
National Pressure Ulcer Advisory Panel, European Pressure Ulcer Advisory Panel, & Pan Pacific Pressure Injury Alliance, 2014.

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 Evidence Review

Records identified through

Identification database and other sources
searching
(n = 675)

Records after duplicates removed

(n = 132)

Records excluded (n = 465)

Screening

For English language limitation,

Records screened over 15 years full text limitation,
(n = 543) review studies, more than one
prevention strategy and different
study outcome

Full-text articles excluded, with

Full-text articles assessed for reasons (n = 43)
Not ICU specific………………23
eligibility (n = 78) Literature reviews.......................9
Eligibility

No method design.......................3
Different outcome measures …..4
Descriptive study……………………..4

Full-text articles assessed for Full-text articles excluded, with

methodology quality (n = 35) reasons (n = 11)
Unclear if both groups were
comparable ……………….……8
Different measurement between
both groups .................................1
Included

Studies included in synthesis Uncomparable sample size..........1

(n = 24) Unclear findings………………...1

Figure 1. Flow diagram: selection process for systematic review.

Repositioning and Early Mobilization (Still et al., 2013). A turn team composed of two trained pa-
Repositioning frequency. Two studies supported 2-hour tient care assistants showed significant improvement in the
repositioning intervals in reducing the incidence of HAPUs incidence of HAPUs between pre- and postimplementation
through different interventions (Behrendt et al., 2014; Still (p < .0001; Still et al., 2013). However, these two studies pose
et al., 2013). The first study investigated the efficacy of using a number of limitations, such as the compliance to turn team
continuous bed pressure mapping (CBPM) with a 2-hour repo- to the strategy (Still et al., 2013), other prevention strategies
sitioning regimen (Behrendt et al., 2014). The CBPM consists employed at the time of the study (Behrendt et al., 2014; Still
of a pressure sensing mat and control unit that provides digital et al., 2013), and the duration of time to reach peak interface
imaging of pressure. This mat is designed to measure levels pressure were not reported (Behrendt et al., 2014).
of whole-body interface pressure and to alert staff to follow Only one cluster RCT study investigated the efficacy of dif-
the 2-hour repositioning regimen. Results showed a signifi- ferent patients repositioning regimens (2 hours vs. 4 hours)
cant difference in the incidence of HAPUs, stage II or greater, in mechanically ventilated patients who were managed on an
between groups (p = .02). The second study showed improve- alternating pressure air mattress (Manzano et al., 2014). No
ments with 2-hour repositioning using a turn team strategy significant differences in reduction of HAPUs of stage II or

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Pressure Ulcer Prevention for Patients in ICUS

Figure 2. Forest plot for HAPUS events after application of the silicone foam dressing on sacrum.

greater were found between groups (p = .73). However, the nating pressure mattress in preventing PU development in the
compliance to both repositioning regimens was not reported. ICU setting in comparison to a mattress overlay. A small pilot
trial demonstrated similar impact of two support surfaces on
Positioning the patient in bed. Three studies examined the
prevention of HAPUs (1/8 in active alternating pressure mat-
effectiveness of a variety of patient positioning strategies and
tress vs. 2/8 in reactive mattress overlay; Malbrain et al., 2010).
the impact on PU development (Girard et al., 2014; Schallom,
In contrast, Manzano et al. (2013) suggest that the alternating
Dykeman, Metheny, Kirby, & Pierce, 2015; Van Nieuwenhoven
pressure mattress can significantly lower the incidence of HA-
et al., 2006). Strategies evaluated were diverse: one study com-
PUs, stage II or greater, in comparison with the foam overlay
pared the effectiveness of the backrest elevation of 28° versus
mattress (p = .038). However, these studies have limitations,
10° for semirecumbent positioning with findings revealing no
notably, small sample sizes (n = 16), the compliance to other
differences between each position (28° vs. 10°) groups in devel-
prevention strategies were not declared, and the heterogeneity
oping HAPUs (28% vs. 30% respectively; Van Nieuwenhoven
of the outcome measures.
et al., 2006). The second study compared the effectiveness of a
The efficacy of using an alternating pressure mattresses
backrest elevation of 45° versus 30°. No HAPUs developed for
compared to a low air loss mattress on reducing the HAPU
either group (Schallom et al., 2015). The third study compared
in ICU was investigated in a single study with no significant
prone versus supine position in HAPU development with se-
difference found between the groups (p = .35). This study was
vere acute respiratory distress syndrome (ARDS; Girard et al.,
limited by retrospective data collection, small sample size, lack
2014). Despite the standardization of PU prevention, includ-
of reporting of other PU preventive care strategies in place
ing application of colloid dressing as protection, results sug-
and compliance to the intervention (Theaker et al., 2005). A
gested that the prone position was associated with significantly
low air loss with microclimate management bed (LAL-MCM)
greater HAPU development compared to a supine position in
was compared to integrated powered air pressure redistribu-
the first 7 days of patient admission (p = .05). However, these
tion bed (IP-AR; Black et al., 2012). The LAL-MCM signifi-
three studies did not address the frequency of repositioning
cantly decreased the incidence of HAPUs compared to IP-AR
patients, other supportive PU prevention strategies, and the
(p = .046; Black et al., 2012).
angle of lower part of the body.
A single study examined the effectiveness of air fluidized
Repositioning the patient out of bed. No studies were identi- therapy support surface beds on preventing PU development
fied that investigated the strategy of positioning the patient out (Jackson et al., 2011) reporting that the air fluidized therapy
of bed in a chair, the types of surfaces to seat ICU patients out bed was more effective in reducing the incidence of HAPUs
of bed or the frequency and or duration of sitting out of bed to development in a cardiothoracic vascular ICU (40% preimple-
reduce the incidence of HAPUs. mentation vs. 15% postimplementation; Jackson et al., 2011).
Repositioning to prevent heel PUs. No studies were identi- The characteristics of standards beds were not reported.
fied reporting the efficacy heel repositioning and offloading the Recently, one trial compared the efficacy of two viscoelastic
heels as a strategy in preventing heel HAPUs in the ICUs. mattresses (Ozyurek & Yavuz, 2015), one composed of two
layers, whereas the second was composed of three layers. No
Support Surfaces significant differences were found in the incidence of HAPUS
Six studies investigated the efficacy of a variety of pressure- between groups (p = .44; Ozyurek & Yavuz, 2015).
relieving support surfaces (Black, Berke, & Urzendowski, 2012;
Jackson et al., 2011; Malbrain et al., 2010; Manzano et al., 2013; Medical device-related PUs
Ozyurek & Yavuz, 2015; Theaker, Kuper, & Soni, 2005). Two of One study with a two-phase design addressed the effective-
these studies investigated the efficacy of using an active alter- ness of a strategy to prevent HAPUs in the critically ill male’s

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 Evidence Review
urinary meatus (Rassin, Markovski, Fishlov, & Naveh, 2013). There was no evidence that use of an RAS, with or without
Each phase evaluated different intervention strategies com- a protocol intervention strategy, could reduce the incidence of
pared to usual standard care. The standard care was washing HAPUs in ICU. Tayyib et al. (2013) recommended developing
the area around the catheter entry point once per day. The find- an RAS specifically for ICU, as most common RASs appear to
ings for Phase I (daily washing of the area around the catheter be unreliable in prioritizing the higher risk patients in ICU,
entry point) showed no significant difference in the incidence possibly affecting deployment of available resources. Risk and
of urinary catheter-related PUs between groups (7/29 interven- skin assessment are neither standalone events, nor are inter-
tion vs. 8/28 control). In Phase II (three times daily washing of ventions. Thus, no studies have, or can, examine the association
the area around the catheter entry point) showed a significant between risk or skin assessment by itself and PU development.
difference between groups (p = .002). However, risk and skin assessments are recommended to al-
Two studies evaluated different strategies to reduce device- ways be incorporated into study protocols (NPUAP, EPUAP,
related PUs with noninvasive ventilation (Gregoretti et al., and PPPIA guideline, 2014) to identify the patient at risk and
2002; Weng, 2008). One study investigated the effectiveness guide the implementation of appropriate strategies. A gap re-
of prototype face masks (PMs) compared to conventional face mains as to what intensive care clinicians could provide for
masks (CMs) and found significant improvement in device- specific patient’s condition (e.g., sepsis, hypotension, and mul-
related PUs using PMs (p < .001). Another study investigated tiorgan failure).
the effectiveness of using different protective dressings (hydro- Evidence was inadequate to determine the effectiveness
colloid, and transparent film) with CM to prevent device-related strategies for controlling fecal incontinence, and keeping pa-
PU (Weng, 2008). The findings showed a significant differ- tients’ skin dry and clean but not excessively dry in impeding
ence in the incidence of device-related PUs between groups overall HAPU development, specifically in the sacral area of
(p = .001; Weng, 2008). However, no significant difference in ICU patients. To develop a full picture of effective skin-care
occurrence duration time was found with using different types strategies, additional studies will be needed that aim to man-
of protective dressings (Weng, 2008). age skin moisture, skin hygiene, skin dehydration, and the
Only one trial examined the timing of a tracheostomy pro- maintenance of natural skin pH.
cedure for traumatic brain injury patients in reducing the in- A few studies demonstrated the effectiveness of supine po-
cidence of HAPUs in ICU (Alali et al., 2014). The findings sitioning with different elevation angles of backrest on pre-
showed that early tracheostomy, ࣘ8 days of the patient’s ad- venting HAPUs development. Defloor (2000) reported that
mission, significantly lowered the incidence of HAPUs (p = the supine position has the lowest interface pressure. Fre-
.001; Alali et al., 2014). However, the study was limited as it quent repositioning, “2-hour repositioning,” is considered to
was retrospective study, unclear that the outcomes were mea- be standard care to prevent PU development (Behrendt et al.,
sured based on objective criteria and in reliable way, and no 2014) and is reported in this review to be effective in reducing
other PU preventive strategies for both groups were mentioned the incidence of HAPUs, which is often not achieved. Gold-
(Alali et al., 2014). hill, Badacsonyi, Goldhill, and Waldmann (2008) found that
the average time for repositioning the ICU patients was 4.85
hours. However, 4-hour repositioning using alternating pres-
Educational Strategies sure air mattress showed similar impact on HAPUs. This find-
A single study examined the effectiveness of educational strate- ing reveals a possible interaction between positioning, turning
gies on the reduction of HAPU incidence in ICU settings and using a support-surfaces strategy. In this review, differ-
(Uzun, Aylaz, & Karadağ, 2009). This study aimed to increase ent types of support surfaces were evaluated and compared.
understanding and knowledge of PU prevention strategies However, the most effective support surfaces are difficult to
through two 2-hour seminars for ICU nurses. A significant ascertain in the absence of effective sample sizes, huge variety
reduction of the HAPUs incidence was reported after imple- of support surface products availability or choice, and inconsis-
mentation of the educational strategy (p < .01; Uzun et al., tency in the use of PU staging systems as an outcome measure
2009). (Black et al., 2012; Jackson et al., 2011; Malbrain et al., 2010;
Manzano et al., 2013; Ozyurek & Yavuz, 2015; Theaker et al.,
2005). Further evaluations are therefore required between dif-
DISCUSSION ferent support-surfaces with sufficient power to identify the
Using the NHMRC (2009) evidence hierarchy for study de- most effective surfaces on the reduction of HAPU incidence in
sign, this review found 24 studies in level II to III-2 evidence ICU.
categories that evaluated different PU prevention strategies in Moreover, different prevention strategies were imple-
the ICU. However, uncertainty in interpretation of these study mented, such as high-protein diet with multivitamins, polar-
results exists due to small underpowered sample sizes with ized light, timing of a tracheostomy, and different education
wide CIs, and intention to treat was calculated (Gregoretti et al., and training strategies. These studies overall have yielded im-
2002; Jackson et al., 2011; Malbrain et al., 2010; Schallom et al., proved results in preventing PU development, however, more
2015; Theaker et al., 2005; Verbelen, 2007). research is required to valiate these finding.

Worldviews on Evidence-Based Nursing, 2016; 13:6, 432–444. 441


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Pressure Ulcer Prevention for Patients in ICUS

Medical devices could increase risk for developing HAPUs ability of these interventions’ effectiveness to different patient
in areas such as the face, neck and inner thigh. Few trials populations and settings. WVN
with small sample sizes compared and evaluated the efficacy of
different devices and different types of dressing for securement
for noninvasive ventilation devices, as well as the efficacy of
frequently cleaning the area underneath devices and changing
LINKING EVIDENCE TO ACTION
positioning. The resulting of sample size trial could affect the r This review revealed the effectiveness of using sil-
reliability of the outcome.
icon foam dressing for preventing sacral HAPUs
All studies, which examined the application of prophylactic
in ICU settings.
silicon border foam dressings, suggested statistically signifi-
cant decrease in the incidence of sacral and heel HAPUs in r RCTs for preventing HAPUs in ICUs that follow
ICU. Using a prophylactic silicon border foam dressing on the standardized criteria for reporting intervention are
sacrum was confirmed by a meta-analysis, which demonstrated needed.
a statistically significant decrease in the incidence of sacral r Future RCTs should include a standard PU defini-
HAPUs. In regards to heel HAPUs and prophylactic silicon
tion, staging systems, and intervention and com-
border foam dressings, statistical pooling was not conducted
parative care integrity.
as both studies had same control group. Further, standard care
is to offload pressure on heels. A comparison study is required
to determine if the outcomes with the use of dressings are
better than the outcomes of heel offloading devices.
In this review we found that authors of most PU prevention
Author information
strategy trials did not acknowledge or monitor the degree of Nahla Tayyib, Doctoral Candidate, School of Nursing, Queens-
compliance to either the strategy itself or other PU prevention land University of Technology, Queensland, Australia and
strategies, which may have affected the trials’ results. More- Lecturer, School of Nursing, Umm Al-Qura University, Saudi
over, the measurement tools in the study (the assessment and Arabia; Fiona Coyer, Professor of Nursing, School of Nursing,
staging of PUs) were based on different definitions. Therefore, Queensland University of Technology, Queensland, Australia
standardized PU definition and tools of measurement, mon- and Department of Intensive Care Medicine, Royal Brisbane &
itoring the intervention compliance, and the reporting other Women’s Hospital, Metro North Hospital and Health Service,
prevention strategies are required to increase the understand- Brisbane, Australia
ing of these strategies. Consequently, a more systematic meta- Address correspondence to Nahla Tayyib, School of
analysis could be developed and more effective PUs prevention Nursing, Queensland University of Technology, Victoria
guideline could be generated. Park Rd, Kelvin Grove, Queensland 4059, Australia;
nahla.tayyib@connect.qut.edu.au

CONCLUSIONS Accepted 15 April 2016

Copyright 
C 2016, Sigma Theta Tau International
The present review demonstrated different prevention strate-
gies with positive impact that reduces the incidence of HAPUs
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