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Rapid Evidence Synthesis Report: Outcome Indicators for Monitoring of Pressure Injury Prevention

Authors:
Yuke-Lin Kong
Yuke-Lin Kong
Salbiah Sindot at Ministry of Health Malaysia
Salbiah Sindot
Nur Azmiah Z
Nur Azmiah Z
Nur Azmiah Z
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Monica Chee at Ministry of Health Malaysia
Monica Chee
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1
RAPID EVIDENCE
SYNTHESIS
REPORT
RAPID EVIDENCE
SYNTHESIS
REPORT
Outcome
Indicators for
Monitoring of
Pressure Injury
Prevention
Produced for:
Nursing Division, MOH
Patient Safety Unit, Quality Medical Care Section,
Medical Development Division, MOH
MOH number:
MOH number:
2
Review team
members
(In alphabetical
order)
Former Health Ministry Nursing Department Director
Matron Tumble @ Tomblow Ngadiran
Institute for Health Systems Research
National Institutes of Health
Ministry of Health Malaysia
Anis Naazira Abdul Rauf
Kong Yuke Lin
Nurul Afiqah Mohd Fadzli
Nur Azmiah Zainuddin
School of Pharmacy,
Monash University Malaysia
Assoc Prof Dr Shaun Lee Wen Huey
Institute for Health Systems Research
National Institutes of Health
Ministry of Health Malaysia
Anis Syakira Jailani
Fun Weng Hong
Minyu Chan
Nor Izzah Hj Ahmad Shauki
Nur Balqis Zahirah Ali
Shakirah Md.Sharif
Sondi Sararaks
Yoon Ee Ling
Nursing Division, MoH
Monica Chee
Salbiah Sindot
Wan Haslinda Wan Hassan
Hospital Kuala Lumpur
Wan Rugayah Wan Salleh
Zahidah Idris
3
Other contributors (in no particular order)
Names listed are those who participated in stakeholder engagements throughout
the project*.
Patient Safety Unit, Quality Medical Care Section,
Medical Development Division, MoH
Dr. Ahmad Muzammil Abu Bakar
Dr. Siti Nawal Mahmood
Family Health Development Division, MoH
Matron Catherine Medan
Matron Nor Anizah Sipol
Nursing Division, MoH
Matron Devi A/P K. S. Muthu
Matron Anny Mary A/P S. Joseph @ Soosai
Matron Lai Lean Huang
Matron Noor Azlina Masdin
Matron Rosdalina Basir
Matron Rozie Amie
Ministry of Health Training Management
Pn. Rukiah Osman
Hospital Wound Care Service Providers
Dr. Harikrishna K.R. Nair
(Hospital Kuala Lumpur)
Matron Gowry A/P Narayanan
(Hospital Kuala Lumpur)
Institute for Health Systems Research,
National Institutes of Health
Dr. Izzatur Rahmi Mohd Ujang
Dr. Awatef Amer Nordin
Matron Sarimah Ibrahim
Affiliation listed is that reported during participation in meetings.
4
Publisher’s Note
Commissioning
policymaker
Nursing Division, Ministry of Health Malaysia
Intention
To identify internationally comparable indicators, with the intention to
review the appropriateness of current pressure injury indicators.
Produced and distributed by:
Malaysian Alliance for Embedding Rapid Reviews in Health Systems Decision Making (MAera)
Institute for Health Systems Research, Ministry of Health
Any inquiries or comments on this report should be directed to:
The Principal Investigator
Rapid Evidence Synthesis on Outcome Indicators for Monitoring of Pressure Injury Prevention
Centre for Health Outcomes Research
Institute for Health Systems Research, Ministry of Health Malaysia
Blok B2, Kompleks Institut Kesihatan Negara (NIH)
No.1, Jalan Setia Murni U13/52
Seksyen U13 Setia Alam
40170 Shah Alam
Selangor Darul Ehsan
Tel: 03-33627500 (ext 8533)
Fax: 03-33627501
Email: kong.yl@moh.gov.my
Rapid review registration:
Registered with the National Medical Research Register (NMRR-19-1279-47643)
Protocol registered with Open Science Framework, available at https://osf.io/e37v8/
Reviewed by NIH Research Review Panel (JPP-NIH Panel), exempted from Medical Research & Ethics
Committee (MREC) review.
© 2022. Institute for Health Systems Research, Selangor, Malaysia.
A Project under the Malaysian Alliance for Embedding Rapid Reviews for Health Systems Decision-
Making, MAera [ND RR 2/2019].
ISBN e-ISBN KKM number
e ISBN 978-967-2911-16-6
Batik design on front cover by Nur ‘Aifa Nadhira bt Adnan.
5
Acknowledgment:
We would like to thank the Director-General of Health Malaysia for permission to publish this report.
Sincerest gratitude for the ongoing support of individuals within and outside the Ministry of Health
Malaysia for their direct and indirect contribution to the MAera platform. Last but not least, thank you
to the Technical Advisory Committee from the Knowledge Translation Program of the Li Ka Shing
Knowledge Institute, St. Michael’s Hospital, Toronto, Canada for their technical assistance.
Funding:
This investigation received financial support from the Alliance for Health Policy and Systems Research.
Conflict of Interest:
There was no conflict of interest in the conduct of this review and the writing of the report was done
independently of the funding agency.
Suggestion Citations:
Kong YL, Salbiah S, Nur Azmiah Z, Monica Chee, Wan Haslinda WH, Zahidah Idris, Wan Rugayah WS,
Fun WH, Shakirah MS, Anis-Syakira J, Balqis-Ali NZ, Sararaks S. Rapid Evidence Synthesis Report:
Outcome Indicators for Monitoring of Pressure Injury Prevention. Institute for Health Systems Research
(IHSR), National Institutes of Health, Ministry of Health Malaysia. 2022.
Disclaimer:
The views expressed in this report are those of the authors alone and do not necessarily represent the
views or policy of the Ministry of Health Malaysia, World Health Organization Alliance for Health Policy
and Systems Research (WHO AHPSR), or the Technical Advisory Committees from Knowledge
Translation Program of the Li Ka Shing Knowledge Institute, St. Michael’s Hospital, Toronto, Canada
and Makerere University, College of Health Sciences, Uganda.
As this report utilizes the rapid review methodology, it does not provide an overarching view or
comprehensive analysis of all available evidence. While every effort is made to ensure that the
information provided is correct, no responsibility shall be taken in event of any errors or omissions.
6
Executive Summary
Background: The Nursing Division of the Ministry of Health Malaysia was in the process of
revising a guideline for pressure injury prevention. Revisiting of indicators used was needed
to improve service delivery. Thus, a rapid review was required to identify appropriate
indicators used internationally that could be used for comparison.
Methods: Four databases (PUBMED, CINAHLPlus, EMBASE, and MEDLINE) were searched for
any type of studies that described outcome indicators for pressure injury prevention.
Screening of articles from database search was conducted independently by two reviewers.
Although Part 1 of the review discovered the indicators used for pressure injury monitoring in
other countries, all the articles lacked details of indicators’ criteria. As a result, because the
material gathered did not match the needs of stakeholders, the second round of search was
conducted, consisting of two parts: a reference list search and a grey literature search across
many countries. Screening, data extraction, and quality assessment of documents from the
grey literature search were conducted independently by one reviewer and verified by a
second reviewer. Disagreements were resolved through discussion and consensus. A narrative
synthesis was performed based on the data extracted.
Results: A total of six countries and nine documents with published information in English
were included in this review. Pressure ulcers were monitored differently across all studies,
with three countries (United Kingdom, Australia, and the USA) measuring the prevalence and
incidence rates, while Canada monitored the incidence rate, and Belgium and New Zealand
monitored pressure ulcers using the prevalence only. All studies used different reporting
mechanisms, either through the existing hospital information systems or through periodic
surveys. The populations included for reporting differed as well, with some countries only
accounting for immobilized patients, surgical or medical patients while others had included a
broader definition and included those with ulcers in stages 2 to 4.
Conclusion: The review found that different countries use different criteria for monitoring
pressure injury. Therefore, in selecting the appropriate pressure injury indicators to be
adopted or adapted for the Malaysian population, the selection of implementation criteria
should align with the aim of monitoring and applicability of indicators in the local setting.
7
Table of Contents
Background .............................................................................................................................................. 8
Part 1 (outcome indicators)..................................................................................................................... 8
Stakeholder Engagement .................................................................................................................... 9
Review question .................................................................................................................................. 9
Methodology ....................................................................................................................................... 9
Evidence Search ............................................................................................................................... 9
Relevance assessment criteria ........................................................................................................ 9
Screening process .......................................................................................................................... 10
Quality assessment ........................................................................................................................ 10
Results ...............................................................................................................................................10
Summaries of quality assessment ................................................................................................. 13
Stakeholder debriefing ......................................................................................................................14
Part 2 ....................................................................................................................................................14
Background .................................................................................................................................... 14
Review question ................................................................................................................................14
Methodology .....................................................................................................................................14
Evidence Search ............................................................................................................................. 14
Relevance assessment criteria ...................................................................................................... 15
Screening process .......................................................................................................................... 16
Quality appraisal ............................................................................................................................ 16
Data extraction .............................................................................................................................. 16
Data analysis/synthesis ................................................................................................................. 16
Results ...............................................................................................................................................16
Results of the search ..................................................................................................................... 16
Limitations .........................................................................................................................................20
Implications for the Organisation ..........................................................................................................20
Conclusion .............................................................................................................................................21
References .............................................................................................................................................21
Appendices ............................................................................................................................................24
8
Background
Rate and prevalence are commonly used as indicators to measure the quality and burden of pressure
injury inpatient management [1]. Due to the different methods and criteria used to measure pressure
injury by countries, it is not possible to benchmark the performance of Malaysia. As such, a review on
the current practice and trends in utilising indicators for monitoring pressure injury is crucial for the
Nursing Division in the Ministry of Health (MOH) to update nursing guidelines for pressure injury
prevention.
Pressure injury is a ‘localised injury to the skin and/or underlying tissue usually over a bony
prominence, as a result of pressure, or pressure in combination with shear and/or friction’ [1], while
pressure ulcers can be broadly defined as ‘a localised injury/damage to the skin and/or underlying
tissue, usually over a bony prominence, resulting from sustained pressure, shear, friction or a
combination of these [2].
Pressure ulcers represent a significant economic burden to the healthcare system and may
substantially reduce a person’s quality of life by affecting physical, emotional health, and social well-
being [3]. The rate of pressure ulcers in hospital settings is high; ranging from 8.3% to 23% in European
hospitals and up to 26% in the Canadian healthcare setting [3]. In 2013, there were 29,000
documented deaths from pressure ulcers globally, up from 14,000 in 1990 [4]. Interdisciplinary care is
required for the prevention and treatment of pressure ulcers, which was recognised as a quality
indicator by the US Health Care Financing Administration (HCFA) [5]. It is one of the major concerns in
patient safety worldwide and is often used to measure and reflect the healthcare system’s
performance [6].
Pressure ulcer incidence or prevalence are often used to compare the relative performance in hospital
acute care as well as examine changes in performance over time. This is based upon the assumption
that a lower rate reflects a better quality of care [7]. In 2013, the Patient Safety Council of Malaysia
developed 13 Patient Safety Goals, including one on pressure ulcers [8]. Pressure ulcer monitoring is
also a key performance indicator (KPI) for MOH hospitals.
In line with this Patient Safety Goal, the Nursing Division set the KPI for the incidence of Healthcare-
Associated Pressures Ulcers (HAPU) at a target of ≤ 2.1% for inpatients who are immobile for 48 hours
or more under the Nursing Indicator Approach (NIA) [9]. In the event that a hospital or a facility
exceeds the targeted incidence rate of 2.1%, a root cause analysis must be performed to identify any
necessary corrective and preventive measures for quality health service delivery [9].
The incidence of pressure ulcer (PU) in public Malaysian hospitals is calculated using the formula
below: -
Incidence =Number of immobilised patient who develop PrU more than 48 Hours after admission
Total number of immobilised patients for 48 Hours or more 𝑥 100%
As per target set by in Patient Safety Goal, the Nursing division has constantly achieved beyond the
target since year 2013. Revisit of target set would be needed to further improve the service delivery.
As such, the Nursing Division would like to determine and if needed, re-evaluate the current
performance indicator for pressure injury. Additionally, the Nursing Division was in the process of
revising a guideline for pressure injury prevention to be used by the MOH. Thus, this rapid review aims
to support the above activities by identifying the current indicators for pressure injury prevention used
internationally.
9
Part 1 (Outcome Indicators)
Stakeholder Engagement
Several stakeholder meetings were conducted, involving representatives from Nursing Division and
wound care nurses to discuss issues and challenges on existing outcome indicators, assessment
methods, risk assessment criteria as well as the reporting systems from patient admission, ward
transfer until patient discharge. Stakeholders were informed of the review progress throughout the
project, and decisions taken throughout the review process were done in close consultation with the
stakeholders.
We presented the preliminary review findings to the stakeholders for feedback on the methodology
employed as well as the relevance of the preliminary findings.
Review question
What is/are the outcome indicator(s) used for monitoring of pressure injury prevention?
Methodology
Evidence Search
A literature search was performed on 30th March 2019 using the four databases, namely PUBMED,
CINAHLPlus, EMBASE and MEDLINE for studies published from 2000 to 2019.
Keywords used include:
Problem
Concept
Context
• pressure ulcer*
• pressure injury
• pressure injuries
• bedsore*
• pressure sore*
• measure*
• indicator*
• tool*
• quality*
• monitor*
• hospital*
• ward*
• inpatient*
• review*
All searches were restricted to English language literature and study types categorised as ‘review’.
Appendix 1 provides the details of the search strategies.
Relevance assessment criteria
Inclusion and exclusion Criteria
Type
Inclusion
Exclusion
Literature
search
• Full text available in English language.
• Publication in the last ten years for
included studies (published from 2000
to 2019).
• Secondary studies such as systematic
reviews and meta-analysis.
• Population is adult inpatient.
• Documents describing outcome
indicators for pressure injury
prevention.
• Any type of study and policy
documents involving community,
nursing homes, paediatric and
rehabilitation centres.
• Any type of study and policy
documents involving single hospital.
• Any type of medical device related
pressure ulcer.
• Documents describing structure
indicators or process indicators.
10
Screening process
Pilot study:
We piloted the eligibility criteria form on 10% of studies included for level 1 and level 2 screening.
There were two teams with two reviewers each. The pilot was done until 90% inter-rater agreement
was achieved.
Screening:
Level 1 screening
Each individual citation (title and abstracts) will be screened independently by two reviewers for
eligible articles that may potentially fulfil the inclusion criteria. Two other reviewers will independently
verify 10% of the screened papers each. Any differences would be discussed and resolved through
consensus by the reviewers involved.
Level 2 screening
The same method as above would be applied for (full-text) screening of the selected articles from Level
1 screening.
Data Extraction:
We performed a pilot on 10% studies as calibration exercise to ensure consistency before starting the
data extraction process. We went through each reference in the disagreement report and asked the
reviewer how the results were derived. The final decision was based on consensus. Each article was
extracted by two independent reviewers. Any differences would be discussed and resolved by
consensus.
Quality assessment
The quality of all included studies were assessed using the AMSTAR-2 tool [10]. The AMSTAR-2
checklist has 16 items. Each item was given one mark if completed or 0 marks if the item was not
completed and “partial yes” for some items; for analysis purposes we counted these as a full yes if
there was consensus that it was not a major limitation or a full no if there were major concerns of how
this could affect the understanding of the study. These were categorised into critically low, low,
moderate or high confidence. Two reviewers independently rated all included articles and any
disagreements were resolved by consensus.
Results
A total of 1,170 articles were found, of which 766 were screened for eligibility after duplicates were
removed. Figure 1 shows the PRISMA flowchart of the review. We included 14 articles in the review.
The list of excluded studies is in Appendix 2.
11
Figure 1: PRISMA flow diagram of search
12
We found two indicators described in the included articles. They were either incidence (n=11) alone
or incidence and prevalence (n=2) as an outcome indicator. One study did not provide the outcome
indicator as suggested but provided the documentation of process as an outcome indicator instead. In
the studies that had used incidence as an outcome indicator, incidence was calculated based on
pressure ulcers (n=5) or hospital acquired pressure ulcer (n=5). Other methods used to calculate
incidence include incidence of heel pressure ulcer (n=1); incidence of surgery-related pressure ulcer
(n=1); as well as incidence of sacral pressure ulcer (n=1). Table 1 shows the outcome indicators used
in the included studies. Please refer Appendix 3 for further details of indicators.
Table 1: Summary of outcome indicators used in the included studies (n=14)
No
ID
Title
Author, year
Outcome indicators
Prevalence
Incidence
Not mentioned
7
The Incidence of Pressure Ulcers
in Surgical Patients of the Last 5
Years: A Systematic Review
Hong Lin Chen, Xiao Yan
Chen, Juan Wu, 2011
√
12
Elevation devices for the
prevention of heel pressure
ulcers: a review
Clegg R and Palfreyman
S, 2014
√
36
Repositioning for pressure ulcer
prevention in adults (Review)
Gillespie BM et al, 2014
√
28
Measuring the quality of pressure
ulcer prevention: A systematic
mapping review of quality
indicators
Kottner J et al, 2017
√
√
25
Nursing Strategies for the
Prevention of Pressure Ulcers in
Intensive Therapy: Integrative
Review
Lima Benevides J et al,
2017
√
√
3
Support surfaces for pressure
ulcer prevention (Review)
McInnes E et al. 2012
√
37
Preventing pressure ulcers—Are
pressure-redistributing support
surfaces effective? A Cochrane
systematic review and meta-
analysis
McInnes E et al, 2011
√
2
A multilevel analysis of three
randomised controlled trials of
the Australian Medical Sheepskin
in the prevention of sacral
pressure ulcers
Mistiaen PJ et al. 2010
√
31
Risk assessment tools for the
prevention of pressure ulcers
(Review)
Moore ZEH, Patton D,
2019
√
5
Use of mobility subscale for risk
assessment of pressure ulcer
incidence and preventive
interventions: A systematic
review
Mordiffi SZ, Kent B,
Phillips N, Chi Tho P.
2011
√
16
Preventing Pressure Ulcers in
Hospitals: A Systematic Review of
Soban LM et al, 2011
√
13
Nurse-Focused Quality
Improvement Interventions
10
Preventing In-Facility Pressure
Ulcers as a Patient Safety Strategy
A Systematic Review
Sullivan N, Schoelles
KM. 2013
√
35
Effectiveness of Pressure Ulcer
Prevention Strategies for Adult
Patients in Intensive Care Units: A
Systematic Review
Tayyib N, Coyer F. 2016
√
38
Efficacy of Monitoring Devices in
Support of Prevention of Pressure
Injuries: Systematic Review and
Meta-analysis
Walia GS. et al, 2016
√
Summary of quality assessment
Of the 14 articles included, we evaluated the quality of the articles using the AMSTAR-2. Only 28%
(n=4) were high-quality articles and fulfilled all AMSTAR 2 criteria (16 items). Half of the articles (50%,
n=7) were classified as moderate and 21% (n = 3) as low quality. Further details of the critical appraisal
can be found in Table 2.
Table 2: AMSTAR 2 (Quality Assessment Rating of Included Studies by item)
14
Stakeholder debriefing
The review findings were presented to the Nursing Division, MOH on 19 September 2019. In the
discussion, the stakeholders requested for detailed information (such as definition, criteria and
formula) on indicators found, which were not available in the reviewed articles. Therefore, a second
review was conducted, detailed in the following section.
Part 2
Background
Although Part 1 of the review found the indicators used for pressure injury monitoring in other
countries, these 14 articles do not have details of indicators such as the definition of population or
setting, duration of onset, staging and monitoring frequency for adoption/adaptation in local context.
As such, this review aims to search for information on variables of pressure injury outcome indicators
implementation.
Review question
How do other countries implement their outcome indicators for pressure injury monitoring and
prevention?
Methodology
Evidence Search
This search was carried out in two parts: Part 2A: Reference List Search and Part 2B: Grey Literature
Search. For Part 2A, we hand-searched the reference lists of the 14 included studies in the previous
review for relevant articles and national guidelines for pressure injury monitoring. The keywords
searched were outcome indicators, incidence or prevalence in the title or abstract. We also searched
for documents from several countries with health systems performance better than Malaysia using
Google search engine in Part 2B. The 2000 World Health Report was used to identify the countries
included in the review (11). The search string used was “Country” AND “Prevalence OR Incidence” AND
“Pressure ulcer OR Pressure injury”. The first two pages of hits for each search string were retrieved
(Table 4).
Table 4: Reference list search and grey literature search
Component
Part 2A
Part 2B
Information source
Reference list of 14 articles in previous
review
Advanced Google
Method
Handsearching for relevant articles and
national guidelines
Keyword search for articles from
selected countries with better
health systems performance
compared to Malaysia.
Search hits from first two pages
of results retrieved.
Keywords
Outcome indicators, incidence or
prevalence in the title or abstract
“Country” AND “Prevalence” OR
Incidence” AND “Pressure ulcer”
OR “Pressure injury”
15
Relevance assessment criteria
Inclusion and exclusion criteria
The inclusion and exclusion criteria for Part 2 are listed in Table 5.
Table 5: Inclusion and exclusion criteria
Type
Inclusion
Exclusion
Part 2A: Reference List
Search
Articles
• Population: Adult inpatients
• Available in English
• Type of document: research
articles including review, RCT
and observational studies.
• Content: description of
indicator including definition,
formula and criteria.
• Description of indicators in
nursing homes, among
paediatric population and
implemented at a hospital
only.
• Articles published more than
10 years ago
Guidelines
• Guidelines describing
pressure ulcer/injury
indicators
• Population: Adult inpatients
• Content: Detailed descriptions
on indicator.
• Not available in English
Part 2B: Grey
Literature Search
Advanced Google
search
• Documents describing details
on pressure ulcer/injury
indicators
• Population: Adult inpatients
• Not available in English
• Draft or summary of the
document.
• Older version of updated
document.
• Does not include quality
indicator for outcome
measurement of pressure ulcer
• Prevalence
• Incidence
• Incidence Density
• Published by hospitals, regional
hospitals, regional associations
• Conference abstracts,
discussion papers, newsletters,
articles
16
Screening process
Table 6 summarises the screening process conducted for Part 2A and Part 2B.
Table 6: Screening process
Part 2A: Reference list search
Part 2B: Grey literature search
Each individual citation (title and abstracts) was
screened independently by one reviewer for
eligible articles. Another reviewer verified 10%
(n=60) of the screened documents.
Disagreements were discussed and resolved
through consensus by the reviewers involved.
The same form from part 1 screening was used,
hence, no pilot was done.
Screening was done by one reviewer, verified
by another reviewer. Disagreements were
discussed and resolved through consensus by
reviewers involved.
Quality appraisal
No quality appraisal was conducted as the documents reporting pressure ulcer outcomes (e.g.,
prevalence rates) were heterogeneous.
Data extraction
Documents that fulfilled the eligibility criteria data were extracted by one reviewer and verified by a
second reviewer. Disagreements were resolved through discussion and consensus.
Data analysis/synthesis
As the reporting of pressure ulcer outcomes (e.g., prevalence rates) were heterogeneous, a narrative
synthesis was performed.
Results
Results of the search
After removing duplicates, 195 articles were identified from the reference list of studies included in
Part 1. However, none of them contained the information required (Figure 2). A total of 30 guidelines
were identified from the reference list search, where seven guidelines and one book were included.
In all these guidelines, there was no detailed information on how these outcome indicators were
derived. Furthermore, the incidence and prevalence rates were described in a non-specific manner
(Appendix 4).
17
Figure 1: PRISMA flow diagram of reference list search for [Part A] articles and guideline [Part B] Google search
Part 2A: Reference list search
No articles or guidelines fulfilled the inclusion criteria (Appendix 4).
Part 2B: Grey literature search
A total of six countries and nine documents were included (Table 7 and Table 8).
The countries were United Kingdom, Belgium, Canada, Australia, United States and New Zealand.
These countries used incidence rate and/or prevalence rate to monitor pressure injury/ulcer.
Incidence rate was used to monitor the quality of care while prevalence provided a snapshot of the
pressure injury/ulcer burden.
18
Table 7 and Table 8 show an overview of the implementation of pressure injury monitoring. These
include population/setting, risk assessment tool, frequency of monitoring, reporting system and
classification of pressure injury/ulcer. The review found that the outcomes of pressure injury/ulcer
were monitored differently across countries and they were not comparable due to different ways of
implementation.
Table 7: Summary of countries using Incidence rate to measure pressure injury/pressure ulcer
Summary Incidence
Country
Population/
Setting
Risk
assessment
Frequency
Reporting
System
Staging
Onset new
pressure
injury/ulcer
Malaysia
Immobilised
patients
Braden scale
Quarterly
Notification
form
Not
specified
48 hours
United
Kingdom
[12, 13]
Acute and
community
hospitals, nursing
homes and
patients’ own
homes.
Not
specified
Monthly
NHS Safety
Thermometer
2-4
72 hours
Canada
[14, 15]
Acute inpatients,
homecare,
complex care,
continuing
care, long-term
care
MDS RAI
Monthly
Continuing
Care
Reporting
System
(CCRS)
2-4
Not
specified
Australia
[16]
Inpatient,
Residential Aged
Care (RAC),
community,
outpatient
Not
specified
Monthly
Hospital-
Acquired
Complication
s (HACs) -
Grouper
(developed
by ACSQHC)
3-4
Not
specified
United
States of
America
[17]
Surgical &
medical
Not
specified
Not
specified
ICD-10
3-4
72 hours
19
Table 8: Summary of countries using prevalence rate to measure pressure injury/pressure ulcer
Summary Prevalence
Country
Population/Setting
Risk
assessment
Frequency
Reporting System
Staging
United
Kingdom
[12, 13]
Acute and community
hospitals,
nursing homes and patients’
own homes.
European
Pressure
Ulcer Scale
Monthly
NHS Safety
Thermometer
2-4
Australia
[16]
Inpatient,
Residential Aged Care (RAC),
community, outpatient
Not specified
Monthly
Hospital-Acquired
Complications
(HACs) - Grouper
(developed by
ACSQHC), ICD 10
3-4
United
States of
America
[17]
Surgical or medical
Not specified
Not
specified
ICD 10
3-4
Belgium
[18]
Hospitals,
home for elderly
European
Pressure
Ulcer Scale
Not
specified
NA
2-4
New
Zealand
[19]
All inpatient,
apart from ED, day care,
terminal patients,
LR, mental health units.
EPUAP
classification
system
Quarterly
Quality and Safety
Markers (QSMs)
1-4
20
Limitations
The search was carried out by implementing criteria to obtain information in English language that
were published within the timeframe of the last ten years. This may have resulted in the limited
number of articles obtained in this review; thus, it may not reflect the best outcome indicator or the
best practice that could be used for Malaysia.
The review also identified that there was substantial heterogeneity in terms of reporting on the results,
such as how incidence was being reported (e.g., incidence in surgical patients), or how different
definitions were used. Moreover, the definition of a pressure ulcer and how it was interpreted have
changed in a number of ways over time. Thus, the results obtained in this review may not be applicable
to the current setting.
The incidence of pressure ulcer is dependent on the population that is being affected and the
healthcare providers who care for them. For example, an ambulatory patient will inherently have a
lower chance of pressure ulcer compared to a comatose patient, and therefore a one-size-fits-all KPI
for pressure ulcer may not be appropriate given the lack of contextual setting.
In addition, we used the WHO World Health System Performance Ranking which was published in 2000
as this was the best available global benchmark that we could retrieve. Due to the limited information
available from the databases search, sampling grey literature might be helpful. However, this could
introduce bias due to method of retrieving the information and the quality of grey literature might be
varied due to lack of peer review.
Implications for the Organisation
From the review, there are variations in terms of methodological design, purpose of monitoring and
rigour, thus affecting the overall analysis and reporting of pressure injury across countries. In general,
adopting and adapting a common gold standard is not possible as implementation of these indicators
requires customisation to the needs of an organisation.
Nevertheless, there are key learning points that can be adopted including:
1. Definition of indicators and the purpose of monitoring
The type of monitoring indicator depends on the purpose of monitoring. For example,
incidence/rate of pressure ulcer assesses the quality of service delivery, while prevalence of
pressure ulcer indicates the burden of a specific population over time. Thus, the review of
current indicators used should be aligned with the purpose of monitoring.
2. Terminology
Different countries define pressure ulcer or pressure injury differently. The term pressure
injury has a broader terminology as it is does not require any breach of skin integrity as
compared to pressure ulcer. Thus, our country should consider reviewing the terminology and
definition used. Additionally, the responsible organisation will need to consider subsequent
standardisation of definition used in relevant documents such as Clinical Practice Guideline
(CPG) and Standard Operating Procedure (SOPs) for data collection.
21
Conclusion
The review found that different countries used different variable criteria for monitoring pressure
ulcer/injury. Therefore, in selecting the appropriate pressure injury indicators to be adopted or
adapted for the Malaysian population, the selection of implementation criteria should align with the
aim of monitoring and applicability of indicators in the local setting.
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Guide. Standard 8: Preventing and Managing Pressure Injuries (October 2012). Sydney:
ACSHQC; 2012.
2. National Pressure Ulcer Advisory Panel, Panel EPUA, Alliance PPPI: Prevention and Treatment
of Pressure Ulcer: Quick Reference Guide. In. Australia: Cambridge Media: Osborne Park;
2014.
3. Gorecki C, Nixon J, Lamping DL, Alavi Y, Brown JM: Patient-reported outcome measures for
chronic wounds with particular reference to pressure ulcer research: A systematic review.
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4. Victor Aboyans, Causes of Death, Collaborators: Global, regional, and national age-sex specific
all-cause and cause-specific mortality for 240 causes of death, 1990-2013: a systematic
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385(9963):117-171.
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Agency for Healthcare Research and Quality; 2008.
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Responsibilities; June 2015 Edition.
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years: a systematic review. Wounds: a compendium of clinical research and practice 2012,
24(9):234-241.
21. Clegg R, Palfreyman S: Elevation devices for the prevention of heel pressure ulcers: a review.
British journal of nursing 2014, 23(Sup20): S4-S11.
22. Gillespie BM, Walker RM, Latimer SL, Thalib L, Whitty JA, McInnes E, Chaboyer WP:
Repositioning for pressure injury prevention in adults. Cochrane Database of Systematic
Reviews 2014(6):1465-1858.
23. Kottner J, Hahnel E, Lichterfeld-Kottner A, Blume-Peytavi U, A B: Measuring the quality of
pressure ulcer prevention: A systematic mapping review of quality indicators. International
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Karanini Paz de Oliveira S: NURSING STRATEGIES FOR THE PREVENTION OF PRESSURE ULCERS
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Enfermagem UFPE 2017, 11(5):1943-1952.
25. McInnes E, Jammali-Blasi A, Bell-Syer S, Dumville J, Cullum N: Preventing pressure ulcers—are
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analysis. International journal of nursing studies 2012, 49(3):345-359.
26. McInnes E, Jammali‐Blasi A, Bell‐Syer SE, Dumville JC, Middleton V, Cullum N: Support surfaces
for pressure ulcer prevention. Cochrane Database of Systematic Reviews 2011(9).
23
27. Mistiaen PJ, Jolley DJ, McGowan S, Hickey MB, Spreeuwenberg P, Francke AL: A multilevel
analysis of three randomised controlled trials of the Australian Medical Sheepskin in the
prevention of sacral pressure ulcers. Medical journal of Australia 2010, 193(11-12):638-641.
28. Moore ZE, Patton D: Risk assessment tools for the prevention of pressure ulcers. Cochrane
Database of Systematic Reviews 2019(1).
29. Mordiffi SZ, Kent B, Phillips N, Tho PC: Use of mobility subscale for risk assessment of pressure
ulcer incidence and preventive interventions: a systematic review. JBI Evidence Synthesis
2011, 9(56):2417-2481.
30. Soban LM, Hempel S, Munjas BA, Miles J, Rubenstein LV: Preventing pressure ulcers in
hospitals: a systematic review of nurse-focused quality improvement interventions. The Joint
Commission Journal on Quality and Patient Safety 2011, 37(6):245-AP216.
31. Sullivan N, Schoelles KM: Preventing in-facility pressure ulcers as a patient safety strategy: a
systematic review. Annals of internal medicine 2013, 158(5_Part_2):410-416.
32. Tayyib N, Coyer F: Effectiveness of pressure ulcer prevention strategies for adult patients in
intensive care units: a systematic review. Worldviews on Evidence‐Based Nursing 2016,
13(6):432-444.
33. Walia GS, Wong AL, Lo AY, Mackert GA, Carl HM, Pedreira RA, Bello R, Aquino CS, Padula WV,
Sacks JM: Efficacy of monitoring devices in support of prevention of pressure injuries:
systematic review and meta-analysis. Advances in skin & wound care 2016, 29(12):567-574.
34. Medical Advisory Secretariat: Pressure Ulcer Prevention: An Evidence-Based Analysis. Ontario
health technology assessment series 2009, 9(2):1.
35. Pressure Ulcer Guideline Panel: Pressure ulcers in adults: prediction and prevention. Agency
for Health Care Policy and Research vol. 3. US: Am Fam Physician; 1992.
36. National Collaborating Centre for Nursing and Supportive Care: The Use of Pressure-Relieving
Devices (Beds, Mattresses and Overlays) for the Prevention of Pressure Ulcers in Primary and
Secondary Care. Lonndon: Royal College of Nursing (UK); 2003.
37. Registered Nurses’ Association of Ontario: Risk Assessment & Prevention of Pressure Ulcers.
Toronto: Registered Nurses' Association of Ontario; 2005.
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RESOURCES GUIDELINES 2009. In.: Queensland Government; 2009.
39. Australian Wound Management Association (AWMA), Society NZWC, Association HKET,
Singapore WSH: Pan Pacific Clinical Practice Guideline for the Prevention and Management of
Pressure Injury (Guideline). In.: Australian Wound Management Association; 2012.
40. Thomas DR, Compton GA: Pressure Ulcers in the Aging Population: A Guide for Clinicians:
Humana Press; 2014.
24
Appendices
Appendix 1: Search strategy
Database
Search String
Filters
Number
of
Results
PUBMED
((((("Pressure Ulcer*" OR "Pressure Injury" OR
"Pressure Injuries" OR "Bedsore*" OR "Pressure
Sore*")) AND ("Measure*" OR "Indicator*" OR
"Tool*" OR "Quality*" OR "Monitor*")) AND
("Inpatient*" OR "Hospital*" OR "Ward*")) AND
"Review*")
English: 276
English + Years:
184
288
EMBASE
((((("Pressure Ulcer*" OR "Pressure Injury" OR
"Pressure Injuries" OR "Bedsore*" OR "Pressure
Sore*")) AND ("Measure*" OR "Indicator*" OR
"Tool*" OR "Quality*" OR "Monitor*")) AND
("Inpatient*" OR "Hospital*" OR "Ward*")) AND
"Review*")
English: 319
English + Years:
249
363
MEDLINE
((((("Pressure Ulcer*" OR "Pressure Injury" OR
"Pressure Injuries" OR "Bedsore*" OR "Pressure
Sore*")) AND ("Measure*" OR "Indicator*" OR
"Tool*" OR "Quality*" OR "Monitor*")) AND
("Inpatient*" OR "Hospital*" OR "Ward*")) AND
"Review*")
English: 625
English + Years:
407
652
CINAHL
((((("Pressure Ulcer*" OR "Pressure Injury" OR
"Pressure Injuries" OR "Bedsore*" OR "Pressure
Sore*")) AND ("Measure*" OR "Indicator*" OR
"Tool*" OR "Quality*" OR "Monitor*")) AND
("Inpatient*" OR "Hospital*" OR "Ward*")) AND
"Review*")
English: 522
English + Years:
330
567
25
Appendix 2: Excluded texts with reason
Source
Reasons
Mao et al. (2010): Update on pressure ulcer management and
deep tissue injury. Annals of Pharmacotherapy, 44(2), 325-
332.
Not an indicator for pressure
ulcer/pressure injury prevention.
Mclnnes et al. (2011): Support surfaces for treating pressure
ulcers. Cochrane Database of Systematic Reviews
Not an indicator for pressure
ulcer/pressure injury prevention.
Bruce et al. (2012): Reliability of Pressure Ulcer Staging: A
Review of Literature and 1 Institution's Strategy. Critical Care
Nursing Quarterly, 35(1), 85-101.
Not an indicator for pressure
ulcer/pressure injury prevention.
Marin et al. (2013): A systematic review of risk factors for the
development and recurrence of pressure ulcers in people
with spinal cord injuries
Not an indicator for pressure
ulcer/pressure injury prevention.
Chen et al. (2014): Phototherapy for treating pressure ulcers.
Cochrane Database of Systematic Reviews
Not an indicator for pressure
ulcer/pressure injury prevention.
Garcia-Fernandez et al. (2014): Predictive capacity of risk
assessment scales and clinical judgment for pressure ulcers: a
meta-analysis. Journal of Wound, Ostomy and Continence
Nursing, 41(1), 24-34.
Not an indicator for pressure
ulcer/pressure injury prevention.
Graves & Zheng (2014): Modelling the direct health care costs
of chronic wounds in Australia. Journal of the Australian
Wound Management Association 22(1).
Not an indicator for pressure
ulcer/pressure injury prevention.
Demarre et al. (2014): The cost of prevention and treatment
of pressure ulcers: A systematic review. International Journal
of Nursing Studies, 52(11), 1754-1774.
Not an indicator for pressure
ulcer/pressure injury prevention.
Tricco et al. (2015): Seeking effective interventions to treat
complex wounds: an overview of systematic reviews. BMC
Medicine, 13(1).
Not an indicator for pressure
ulcer/pressure injury prevention.
Velez-Diaz-Pallares et al. (2015): Nonpharmacologic
Interventions to Heal Pressure Ulcers in Older Patients: An
Overview of Systematic Reviews (The SENATOR-ONTOP
Series). Journal of the American Medical Directors
Association, 16(6), 448-469.
Not an indicator for pressure
ulcer/pressure injury prevention.
Wong et al. (2016): Reconstructive surgery for treating
pressure ulcers. Cochrane Database of Systematic Reviews
Not an indicator for pressure
ulcer/pressure injury prevention.
Chan et al. (2017): Cost-of-illness studies in chronic ulcers: a
systematic review. Journal of Wound Care, 269sup4), S4-S14.
Not an indicator for pressure
ulcer/pressure injury prevention.
Dissemond et al. (2017): Evidence for silver in wound care -
meta-analysis of clinical studies from 2000-2015. JDDG:
Journal Der Deutschen Dermatologischen Gesellschaftt, 15(5),
524-535.
Not an indicator for pressure
ulcer/pressure injury prevention.
Lima Serrano et al. (2017): Risk factors for pressure ulcer
development in Intensive Care Units: A systematic review.
Medicina Intensiva (English Edition), 41(6), 339-346.
Not an indicator for pressure
ulcer/pressure injury prevention.
Walker et al. (2017): Foam dressings for treating pressure
ulcers. Cochrane Database of Systematic Reviews
Not an indicator for pressure
ulcer/pressure injury prevention.
Yue et al. (2018): Local warming therapy for treating chronic
wounds: A systematic review. Medicine, 97(12), e9931
Not an indicator for pressure
ulcer/pressure injury prevention.
Yue et al. (2019): The application of moist dressings in wound
care for tracheostomy patients: a meta-analysis. Journal of
Clinical Nursing.
Not an indicator for pressure
ulcer/pressure injury prevention.
26
Zha et al. (2019): Patient-controlled Analgesia and
Postoperative Pressure Ulcer: A Meta-analysis of
Observational Studies.
Not an indicator for pressure
ulcer/pressure injury prevention.
Tinetti, Mary (2013): 2012 - Review: Acute geriatric unit care
reduces falls, delirium, and functional decline
Not an indicator for pressure
ulcer/pressure injury prevention.
Colin et al. (2012): What is the best support surface in
prevention and treatment, as of 2012, for a patient at risk
and/or suffering from pressure ulcer sore? Developing French
guidelines for clinical practice
No information on outcome indicator
Baris et al. (2015): The Use of the Braden Scale in Assessing
Pressure Ulcers in Turkey: A Systematic Review
No information on outcome indicator
Groah Groah et al. (2015): Prevention of Pressure Ulcers Among
People with Spinal Cord Injury: A Systematic Review
No information on outcome indicator
Rao et al. (2016): Risk Factors Associated with Pressure Ulcer
Formation in Critically Ill Cardiac Surgery Patients: A
Systematic Review
No information on outcome indicator
Varghese et al. (2018): Effects of computerized decision
support system implementations on patient outcomes in
inpatient care: a systematic review
No information on outcome indicator
27
Appendix 3: Summary of 14 articles included
RV
papers
ID
Author, year
Study setting
/ Population
Outcome indicator
Conclusion
7 [20].
Hong Lin Chen, Xiao
Yan Chen, Juan Wu,
2011
Ortho, surgical
and ICU
The incidence of surgery-related pressure
ulcers
The findings suggest pressure ulcers are still one of the more common
complications of these surgical procedures.
12 [21].
Clegg R and
Palfreyman S, 2014
Acute care
setting
The primary outcome considered most
important for inclusion within the studies was
the incidence of heel pressure damage.
Secondary outcomes that were included in
the review were cost of the device; patient
acceptability; and adverse events related to
the use of the device.
There is little high-quality trial evidence to support the routine use of
heel devices to prevent pressure ulcers. However, they may have a role
to play within a multifaceted programme of pressure-ulcer prevention.
36 [22].
Gillespie BM et al,
2014
long-term care
settings
The proportion of participants with a new PU
of any stage, grade, or category using
previously defined criteria (European
Pressure Ulcer Advisory Panel 1998; European
Pressure Ulcer Advisory Panel 2009; National
Pressure Ulcer Advisory Panel 2007)
There is currently insufficient evidence that the 30° tilt is more effective
than the 90° tilt (two trials, only 21 events in total). Repositioning in
some form is recommended in all clinical guide-lines though
implementation is probably variable and highly de-pendent on the
available resources (particularly staffing levels). It is noteworthy that
more recent clinical guidelines no longer advocate repositioning patients
every two hours (European Pressure Ulcer Advisory Panel 2009; National
Pressure Ulcer Advisory Panel 2007).
28 [23].
Kottner J et al, 2017
Hospital (102)
PU prevalence (7) & PU incidence (42)
There is no reliable evidence to suggest that the use of structured and
systematic pressure ulcer risk assessment tools reduce the incidence, or
severity of pressure ulcers when compared to risk assessment using
clinical judgement. Given these uncertainties, practitioners may be
influenced by other guidance. For example, the NPUAP/EPUAP/PPPIA
2014 guidelines suggest that risk assessment should be undertaken
using a structured approach, that is refined through the use of clinical
judgment and informed by knowledge of relevant risk factors.
28
RV
papers
ID
Author, year
Study setting
/ Population
Outcome indicator
Conclusion
25 [24].
Lima Benevides J et
al, 2017
ICU
incidence of pressure ulcers and prevalence
of PU
Recommendations most described in the literature were related to the
use of varied support surfaces, mostly pressure-alternating mattresses,
followed by the adherence of PU prevention protocols, and to decubitus
change routines.
9 [25].
McInnes E et al.
2012
Hospital
(medical,
surgical, ICU)
Incidence of new pressure ulcers adapted
from the EPUAP-NPUAP classification system
There is little high-quality trial evidence to support the routine use of
heel devices to prevent pressure ulcers. However, they may have a role.
A1:E4to play within a multifaceted programme of pressure ulcer
prevention.
37 [26].
McInnes E et al,
2011
From
emergency and
ICU, medical,
orthopaedic
trauma wards,
oncology units,
acute geriatric,
long term care
wards.
Incidence PU
There is good evidence that higher specification foam mattresses,
sheepskins, and that some overlays in the operative setting are effective
in preventing pressure ulcers, there is insufficient evidence to draw
conclusions on the value of seat cushions, limb protectors and various
constant low-pressure devices. The relative merits of higher-tech
constant low pressure and alternating pressure for prevention are
unclear. More robust trials are required to address these research gaps.
2[27].
Mistiaen PJ et al.
2010
Medical,
surgical and
orthopaedic
Incidence of sacral PUs. Severity of ulcers was
categorised in the three trials according to
comparable four-grade systems.
Australian Medical Sheepskin is effective in preventing sacral PUs
31 [28].
Moore ZEH, Patton
D, 2019
Emergency,
Inpatients, and
oncology units
Pressure ulcer incidence
There is no reliable evidence to suggest that the use of structured and
systematic pressure ulcer risk assessment tools reduce the incidence, or
severity of pressure ulcers when compared to risk assessment using
clinical judgement. Given these uncertainties, practitioners may be
influenced by other guidance. For example, the NPUAP/EPUAP/PPPIA
2014 guidelines suggest that risk assessment should be undertaken
using a structured approach, that is refined through the use of clinical
judgment and informed by knowledge of relevant risk factors.
29
RV
papers
ID
Author, year
Study setting
/ Population
Outcome indicator
Conclusion
5 [29].
Mordiffi SZ, Kent B,
Phillips N, Chi Tho
P. 2011
Acute care
setting
Incidence of hospital acquired pressure ulcers
according to NPUAP classification (5 stages)
and EPUAP (4 stages).
The use of risk assessment scales does not reduce the incidence of
pressure ulcer as compared to not using the risk assessment scale
16 [30].
Soban LM et al,
2011
Hospital
(medical,
surgical, ICU
1. PU incidence. 2. Incidence of Stage II PUs
among patients without PUs on admission
(PUs/100 patient days) (PT). 3. % patients with
hospital-acquired PUs (PT)
Future research can build the evidence base on understanding the
mechanisms by which improved outcomes are achieved and describing
the conditions under which specific intervention strategies are likely to
succeed or fail.
10 [31].
Sullivan N,
Schoelles KM. 2013
Hospital act
care & long-
term care
simplification and standardization of pressure
ulcer–specific interventions and
documentation, involvement of
multidisciplinary teams and leadership,
designated skin champions, ongoing staff
education, and sustained audit and feedback.
"Key issues were the simplification and standardization of pressure ulcer
specific interventions and documentation, involvement of
multidisciplinary teams and leadership, designated skin champions,
ongoing staff education, and sustained audit and feedback for
promoting both accountability and recognizing successes."
35 [32].
Tayyib N, Coyer F.
2016
ICU
Primary outcome measures: HAPU incidence,
HAPU prevalence, PU severity, time to
occurrence, and number of PUs per patients.
Secondary outcome measure was any adverse
effect caused by, or associated with, the use of
the preventive strategy.
Different prevention strategies with positive impact that reduces the
incidence of HAPUs in ICUs.
38 [33].
Walia GS. et al,
2016
Any healthcare
setting e.g., ICU
1. No. of new HAPUs developed 2. Amount of
reduction in overpressure 3. No. of new HAPUs
developed and interface pressure
Based on systematic review and meta-analysis, the current literature
demonstrates that PI-monitoring devices are associated with a strong
reduction in the risk of developing PIs. These devices provide clinicians
and patients with critical information to implement prevention
guidelines. Randomized controlled trials would help assess which
technologies are most effective at reducing the risk of developing PIs.
30
Appendix 4: Description of Included Guidelines
No.
Author, Year
Title
Type of
document
1.
NPUAP, EPUAP & PPPIA, 2014 [2].
Prevention and Treatment of Pressure Ulcer: Quick
Reference Guide
Guidelines
2.
Medical Advisory Secretariat, 2009
[34].
Pressure Ulcer Prevention: And Evidence-Based
Analysis
Guidelines
3.
Agency for HealthCare Policy and
Research, 1992 [35].
Pressure Ulcer in Adults: Prediction and Prevention.
Clinical Practice Guideline Number 3.
Guidelines
4.
National Institute for Clinical,
Excellence, 2003 [36].
The Use of Pressure-Relieving Devices (beds,
mattresses and overlays) for The Prevention of
Pressure Ulcer in Primary and Secondary Care
Guidelines
5.
Registered Nurses' Association of
Ontario, 2005 [37].
Risk Assessment and Prevention of Pressure Ulcer
Guidelines
6.
Queensland Health Patient Safety
Centre, 2009 [38].
Pressure Ulcer Prevention and Management
Resource Guidelines Queensland Health 2009
Guidelines
7.
Australian Wound Management
Association,
New Zealand Wound Care Society,
Hong Kong Enterostomal Therapists
Association &
Wound Healing Society (Singapore),
2012 [39].
Pan Pacific Clinical Practice Guideline for the
Prevention and Management of Pressure Injury
Guidelines
8.
David R. Thomas &
Gregory A. Compton, 2014 [40].
Pressure Ulcer in The Aging Population: A Guide for
Clinicians
Guidelines
31
ResearchGate has not been able to resolve any citations for this publication.
Patient-controlled Analgesia and Postoperative Pressure Ulcer: A Meta-analysis of Observational Studies
Article
Full-text available
  • Oct 2018
  • WOUNDS
Background: Patient-controlled analgesia (PCA) has become a common practice after surgery, but research has shown that the use of PCA is also a significant risk factor for pressure ulcers. However, no meta-analysis or conclusive review has investigated whether patients using PCA have a significantly higher prevalence of pressure ulcers. Objective: This study explores the association between the use of postoperative PCA and the prevalence of pressure ulcers. Materials and methods: PubMed, the Cochrane Controlled Register of Trials, Web of Science, China National Knowledge Infrastructure, Wanfang, and Vip databases were searched to identify studies, published up until November 2016, concerning the association between PCA and pressure ulcer prevalence. A manual search of the references of relevant studies also was performed. Odds ratio (OR) and corresponding 95% confidence interval (CI) were used to evaluate the strength of association between the use of PCA after surgery and pressure ulcer prevalence. The methodological quality of included case-control studies and cohort studies was assessed by the Newcastle-Ottawa Scale. The test of heterogeneity, subgroup analysis, meta-regression, Begg's funnel plot, and Egger's test also were used. Results: Four cohort studies and 1 case-control study were included. In these 5 studies, 265 participants were identified. In pooled analysis, heterogeneity was 0 among the studies. In a fixed effects model, postoperative pressure ulcer was associated with PCA (pooled OR, 3.525; 95% CI, 1.655-7.509). Subgroup analysis of these 5 studies yielded an OR of 3.29 (95% CI, 1.47-7.40) for cesarean section, 5.10 (95% CI, 0.24-107.55) for general surgery, and 5.10 (95% CI, 0.24-107.55) for orthopedic surgery. There was no heterogeneity among the 5 studies. Additional meta-regression of year and incidence did not find significant outcomes. Conclusions: This meta-analysis shows PCA may be associated with an increased risk of postoperative pressure ulcer, especially after caesarean section. More evidence-based studies on this research field are needed to draw a firmer conclusion.
View
Measuring the quality of pressure ulcer prevention: A systematic mapping review of quality indicators
Article
Full-text available
  • Nov 2017
The aim of this study was to provide a systematic overview of available pressure ulcer prevention quality indicators and to evaluate the underlying empirical evidence. A systematic mapping review was conducted with combined searches in Embase and Medline, and websites of relevant institutions and organisations. The eligibility criteria were clear use of the term “quality indicator” regarding pressure ulcer prevention; English or German language; and all settings, populations, and types of resources, including articles, brochures, and online material. In total, n = 146 quality indicators were identified. Most indicators were published in the United States (n = 50). The majority of indicators was developed for the hospital setting (n = 102). Process indicators were the most common (n = 71), followed by outcome indicators (n = 49). Less than half of identified indicators appeared to be practically used. Evidence supporting the validity and reliability were reported for n = 25 and n = 30 indicators respectively. The high number of indicators demonstrate the importance of measuring pressure ulcer prevention quality. This is not an indicator of our ability to accurately measure and evaluate this construct. There is an urgent need to develop evidence-based and internationally comparable indicators to help improve patient care and safety worldwide.
View
AMSTAR 2: A critical appraisal tool for systematic reviews that include randomised or non-randomised studies of healthcare interventions, or both
Article
Full-text available
  • Sep 2017
The number of published systematic reviews of studies of healthcare interventions has increased rapidly and these are used extensively for clinical and policy decisions. Systematic reviews are subject to a range of biases and increasingly include non-randomised studies of interventions. It is important that users can distinguish high quality reviews. Many instruments have been designed to evaluate different aspects of reviews, but there are few comprehensive critical appraisal instruments. AMSTAR was developed to evaluate systematic reviews of randomised trials. In this paper, we report on the updating of AMSTAR and its adaptation to enable more detailed assessment of systematic reviews that include randomised or non-randomised studies of healthcare interventions, or both. With moves to base more decisions on real world observational evidence we believe that AMSTAR 2 will assist decision makers in the identification of high quality systematic reviews, including those based on non-randomised studies of healthcare interventions.
View
Repositioning for pressure injury prevention in adults
Article
  • Jun 2020
Background: A pressure injury (PI), also referred to as a 'pressure ulcer', or 'bedsore', is an area of localised tissue damage caused by unrelieved pressure, friction, or shearing on any part of the body. Immobility is a major risk factor and manual repositioning a common prevention strategy. This is an update of a review first published in 2014. Objectives: To assess the clinical and cost effectiveness of repositioning regimens(i.e. repositioning schedules and patient positions) on the prevention of PI in adults regardless of risk in any setting. Search methods: We searched the Cochrane Wounds Specialised Register, the Cochrane Central Register of Controlled Trials (CENTRAL), Ovid MEDLINE, Ovid Embase, and EBSCO CINAHL Plus on 12 February 2019. We also searched clinical trials registries for ongoing and unpublished studies, and scanned the reference lists of included studies as well as reviews, meta-analyses, and health technology reports to identify additional studies. There were no restrictions with respect to language, date of publication, or study setting. Selection criteria: Randomised controlled trials (RCTs), including cluster-randomised trials (c-RCTs), published or unpublished, that assessed the effects of any repositioning schedule or different patient positions and measured PI incidence in adults in any setting. Data collection and analysis: Three review authors independently performed study selection, 'Risk of bias' assessment, and data extraction. We assessed the certainty of the evidence using GRADE. Main results: We identified five additional trials and one economic substudy in this update, resulting in the inclusion of a total of eight trials involving 3941 participants from acute and long-term care settings and two economic substudies in the review. Six studies reported the proportion of participants developing PI of any stage. Two of the eight trials reported within-trial cost evaluations. Follow-up periods were short (24 hours to 21 days). All studies were at high risk of bias. Funding sources were reported in five trials. Primary outcomes: proportion of new PI of any stage Repositioning frequencies: three trials compared different repositioning frequencies We pooled data from three trials (1074 participants) comparing 2-hourly with 4-hourly repositioning frequencies (fixed-effect; I² = 45%; pooled risk ratio (RR) 1.06, 95% confidence interval (CI) 0.80 to 1.41). It is uncertain whether 2-hourly repositioning compared with 4-hourly repositioning used in conjunction with any support surface increases or decreases the incidence of PI. The certainty of the evidence is very low due to high risk of bias, downgraded twice for risk of bias, and once for imprecision. One of these trials had three arms (967 participants) comparing 2-hourly, 3-hourly, and 4-hourly repositioning regimens on high-density mattresses; data for one comparison was included in the pooled analysis. Another comparison was based on 2-hourly versus 3-hourly repositioning. The RR for PI incidence was 4.06 (95% CI 0.87 to 18.98). The third study comparison was based on 3-hourly versus 4-hourly repositioning (RR 0.20, 95% CI 0.04 to 0.92). The certainty of the evidence is low due to risk of bias and imprecision. In one c-RCT, 262 participants in 32 ward clusters were randomised between 2-hourly and 3-hourly repositioning on standard mattresses and 4-hourly and 6-hourly repositioning on viscoelastic mattresses. The RR for PI with 2-hourly repositioning compared with 3-hourly repositioning on standard mattress is imprecise (RR 0.90, 95% CI 0.69 to 1.16; very low-certainty evidence). The CI for PI include both a large reduction and no difference for the comparison of 4-hourly and 6-hourly repositioning on viscoelastic foam (RR 0.73, 95% CI 0.53 to 1.02). The certainty of the evidence is very low, downgraded twice due to high risk of bias, and once for imprecision. Positioning regimens: four trials compared different tilt positions We pooled data from two trials (252 participants) that compared a 30° tilt with a 90° tilt (random-effects; I² = 69%). There was no clear difference in the incidence of stage 1 or 2 PI. The effect of tilt is uncertain because the certainty of evidence is very low (pooled RR 0.62, 95% CI 0.10 to 3.97), downgraded due to serious design limitations and very serious imprecision. One trial involving 120 participants compared 30° tilt and 45° tilt with 'usual care' and reported no occurrence of PI events (low certainty evidence). Another trial involving 116 ICU patients compared prone with the usual supine positioning for PI. Reporting was incomplete and this is low certainty evidence. Secondary outcomes No studies reported health-related quality of life utility scores, procedural pain, or patient satisfaction. Cost analysis Two included trials also performed economic analyses. A cost-minimisation analysis compared the costs of 3-hourly and 4-hourly repositioning with 2-hourly repositioning schedule amongst nursing home residents. The cost of repositioning was estimated at CAD 11.05 and CAD 16.74 less per resident per day for the 3-hourly or 4-hourly regimen, respectively, compared with the 2-hourly regimen. The estimates of economic benefit were driven mostly by the value of freed nursing time. The analysis assumed that 2-, 3-, or 4-hourly repositioning is associated with a similar incidence of PI, as no difference in incidence was observed. A second study compared the nursing time cost of 3-hourly repositioning using a 30° tilt with standard care (6-hourly repositioning with a 90° lateral rotation) amongst nursing home residents. The intervention was reported to be cost-saving compared with standard care (nursing time cost per patient EUR 206.60 versus EUR 253.10, incremental difference EUR -46.50, 95% CI EUR -1.25 to EUR -74.60). Authors' conclusions: Despite the addition of five trials, the results of this update are consistent with our earlier review, with the evidence judged to be of low or very low certainty. There remains a lack of robust evaluations of repositioning frequency and positioning for PI prevention and uncertainty about their effectiveness. Since all comparisons were underpowered, there is a high level of uncertainty in the evidence base. Given the limited data from economic evaluations, it remains unclear whether repositioning every three hours using the 30° tilt versus "usual care" (90° tilt) or repositioning 3-to-4-hourly versus 2-hourly is less costly relative to nursing time.
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Risk assessment tools for the prevention of pressure ulcers
Article
  • Jan 2019
Background: Use of pressure ulcer risk assessment tools or scales is a component of the assessment process used to identify individuals at risk of developing a pressure ulcer. Use of a risk assessment tool is recommended by many international pressure ulcer prevention guidelines, however it is not known whether using a risk assessment tool makes a difference to patient outcomes. We conducted a review to provide a summary of the evidence pertaining to pressure ulcer risk assessment in clinical practice, and this is the third update of this review. Objectives: To assess whether using structured and systematic pressure ulcer risk assessment tools, in any healthcare setting, reduces the incidence of pressure ulcers. Search methods: In February 2018 we searched the Cochrane Wounds Specialised Register; the Cochrane Central Register of Controlled Trials (CENTRAL); Ovid MEDLINE (including In-Process & Other Non-Indexed Citations); Ovid Embase; and EBSCO CINAHL Plus. We also searched clinical trials registries for ongoing and unpublished studies, and scanned reference lists of relevant included studies as well as reviews, meta-analyses and health technology reports to identify additional studies. There were no restrictions with respect to language, date of publication or study setting. Selection criteria: Randomised controlled trials (RCTs) comparing the use of structured and systematic pressure ulcer risk assessment tools with no structured pressure ulcer risk assessment, or with unaided clinical judgement, or RCTs comparing the use of different structured pressure ulcer risk assessment tools. Data collection and analysis: Two review authors independently performed study selection, data extraction, 'Risk of bias' assessment and GRADE assessment of the certainty of evidence. Main results: We included two studies in this review (1,487 participants). We identified no new trials for this latest update.Both studies were undertaken in acute-care hospitals. In one study, patients were eligible if they had a Braden score of 18 or less. In the second study all admitted patients were eligible for inclusion, once they were expected to have a hospital stay of more than three days and they had been in hospital for no more than 24 hours before baseline assessment took place. In the first study, most of the participants were medical patients; no information on age or gender distribution was provided. In the second study, 50.3% (619) of the participants were male, with a mean age of 62.6 years (standard deviation (SD): 19.3), and 15.4% (190) were admitted to oncology wards.The two included studies were three-armed studies. In the first study the three groups were: Braden risk assessment tool and training (n = 74), clinical judgement and training (n = 76) and clinical judgement alone (n = 106); follow-up was eight weeks. In the second study the three groups were: Waterlow risk assessment tool (n = 411), clinical judgement (n = 410) and Ramstadius risk assessment tool (n = 410); follow-up was four days. Both studies reported the primary outcome of pressure ulcer incidence and one study also reported the secondary outcome, severity of new pressure ulcers.We are uncertain whether use of the Braden risk assessment tool and training makes any difference to pressure ulcer incidence, compared to risk assessment using clinical judgement and training (risk ratio (RR) 0.97, 95% confidence interval (CI) 0.53 to 1.77; 150 participants), or compared to risk assessment using clinical judgement alone (RR 1.43, 95% CI 0.77 to 2.68; 180 participants). We assessed the certainty of the evidence as very low (downgraded twice for study limitations and twice for imprecision).Risk assessment using the Waterlow tool may make little or no difference to pressure ulcer incidence, or to pressure ulcer severity, when compared to risk assessment using clinical judgement (pressure ulcers of all stages: RR 1.10, 95% CI 0.68 to 1.81; 821 participants; stage 1 pressure ulcers: RR 1.05, 95% CI 0.58 to 1.90; 821 participants; stage 2 pressure ulcers: RR 1.25, 95% CI 0.50 to 3.13; 821 participants), or risk assessment using the Ramstadius tool (pressure ulcers of all stages: RR 1.41, 95% CI 0.83 to 2.39; 821 participants; stage 1 pressure ulcers: RR 1.16, 95% CI 0.63 to 2.15; 821 participants; stage 2 pressure ulcers: RR 2.49, 95% CI 0.79 to 7.89; 821 participants). Similarily, risk assessment using the Ramstadius tool may make little or no difference to pressure ulcer incidence, or to pressure ulcer severity, when compared to risk assessment using clinical judgement (pressure ulcers of all stages: RR 0.79, 95% CI 0.46 to 1.35; 820 participants; stage 1 pressure ulcers: RR 0.90, 95% CI 0.48 to 1.68; 820 participants; stage 2 pressure ulcers: RR 0.50, 95% CI 0.15 to 1.65; 820 participants). We assessed the certainty of the evidence as low (downgraded once for study limitations and once for imprecision).The studies did not report the secondary outcomes of time to ulcer development, or pressure ulcer prevalence. Authors' conclusions: We identified two studies which evaluated the effect of risk assessment on pressure ulcer incidence. Based on evidence from one study, we are uncertain whether risk assessment using the Braden tool makes any difference to pressure ulcer incidence, compared with training and risk assessment using clinical judgement, or risk assessment using clinical judgement alone. Risk assessment using the Waterlow tool, or the Ramstadius tool may make little or no difference to pressure ulcer incidence, or severity, compared with clinical judgement. The low, or very low certainty of evidence available from the included studies is not reliable enough to suggest that the use of structured and systematic pressure ulcer risk assessment tools reduces the incidence, or severity of pressure ulcers.
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Effects of computerized decision support system implementations on patient outcomes in inpatient care: a systematic review
Article
  • Sep 2017
  • J AM MED INFORM ASSN
Objectives: To systematically classify the clinical impact of computerized clinical decision support systems (CDSSs) in inpatient care. Materials and methods: Medline, Cochrane Trials, and Cochrane Reviews were searched for CDSS studies that assessed patient outcomes in inpatient settings. For each study, 2 physicians independently mapped patient outcome effects to a predefined medical effect score to assess the clinical impact of reported outcome effects. Disagreements were measured by using weighted kappa and solved by consensus. An example set of promising disease entities was generated based on medical effect scores and risk of bias assessment. To summarize technical characteristics of the systems, reported input variables and algorithm types were extracted as well. Results: Seventy studies were included. Five (7%) reported reduced mortality, 16 (23%) reduced life-threatening events, and 28 (40%) reduced non-life-threatening events, 20 (29%) had no significant impact on patient outcomes, and 1 showed a negative effect (weighted κ: 0.72, P < .001). Six of 24 disease entity settings showed high effect scores with medium or low risk of bias: blood glucose management, blood transfusion management, physiologic deterioration prevention, pressure ulcer prevention, acute kidney injury prevention, and venous thromboembolism prophylaxis. Most of the implemented algorithms (72%) were rule-based. Reported input variables are shared as standardized models on a metadata repository. Discussion and conclusion: Most of the included CDSS studies were associated with positive patient outcomes effects but with substantial differences regarding the clinical impact. A subset of 6 disease entities could be filtered in which CDSS should be given special consideration at sites where computer-assisted decision-making is deemed to be underutilized. Registration number: on PROSPERO: CRD42016049946.
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CMS MDS 3.0 Section M Skin Conditions in Long-term Care: Pressure Ulcers, Skin Tears, and Moisture-Associated Skin Damage Data Update
Article
  • Sep 2017
General purpose: The purpose of this learning activity is to provide information about the updates to the Centers for Medicare & Medicaid Services (CMS) MDS 3.0 Section M, Skin Conditions documentation in long-term care. Target audience: This continuing education activity is intended for physicians, physician assistants, nurse practitioners, and nurses with an interest in skin and wound care. Learning objectives/outcomes: After participating in this educational activity, the participant should be better able to:1. Explain the use of the CMS MDS 3.0 tool for documenting skin problems in long-term care.2. Demonstrate examples of proper documentation for specific skin problems. Abstract: This manuscript reviews some of the key parts of the October 2016 revised Long-term Care Resident Assessment Instrument manual for Minimum Data Set (MDS) 3.0 Section M Skin Conditions. It also reports the Centers for Medicare & Medicaid's publicly reported frequency data in long-term care for selected items on the MDS 3.0 Section M Skin Conditions. Percentages and trends of pressure ulcers/injuries, skin tears, and moisture-associated skin damage are assessed.
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Efficacy of Monitoring Devices in Support of Prevention of Pressure Injuries: Systematic Review and Meta-analysis
Article
  • Dec 2016
General purpose: To present a systematic review of the literature assessing the efficacy of monitoring devices for reducing the risk of developing pressure injuries. Target audience: This continuing education activity is intended for physicians, physician assistants, nurse practitioners, and nurses with an interest in skin and wound care. Learning objectives/outcomes: After participating in this educational activity, the participant should be better able to:1. Explain the methodology of the literature review and its results.2. Discuss the scope of the problem and the implications of the research. Abstract: OBJECTIVE: To assess the efficacy of monitoring devices for reducing the risk of developing pressure injuries (PIs). Data sources: The authors systematically reviewed the literature by searching PubMed/MEDLINE and CINAHL databases through January 2016. Study selection: Articles included clinical trials and cohort studies that tested monitoring devices, evaluating PI risk factors on patients in acute and skilled nursing settings. The articles were scored using the Methodological Index for Non-randomized Studies. Data extraction: Using a standardized extraction form, the authors extracted patient inclusion/exclusion criteria, care setting, key baseline, description of monitoring device and methodology, number of patients included in each group, description of any standard of care, follow-up period, and outcomes. Data synthesis: Of the identified 1866 publications, 9 met the inclusion criteria. The high-quality studies averaged Methodological Index for Non-randomized Studies scores of 19.4 for clinical trials and 12.2 for observational studies. These studies evaluated monitoring devices that measured interface pressure, subdermal tissue stress, motion, and moisture. Most studies found a statistically significant decrease in PIs; 2 studies were eligible for meta-analysis, demonstrating that use of monitoring devices was associated with an 88% reduction in the risk of developing PIs (Mantel-Haenszel risk ratio, 0.12; 95% confidence interval, 0.04-0.41; I = 0%). Conclusions: Pressure injury monitoring devices are associated with a strong reduction in the risk of developing PIs. These devices provide clinicians and patients with critical information to implement prevention guidelines. Randomized controlled trials would help assess which technologies are most effective at reducing the risk of developing PIs.
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Effectiveness of Pressure Ulcer Prevention Strategies for Adult Patients in Intensive Care Units: A Systematic Review
Article
  • Oct 2016
  • WORLDV EVID-BASED NU
Background: Pressure ulcers are associated with substantial health burden, but could be preventable. Hospital-acquired pressure ulcers (HAPUs) prevention has become a priority for all healthcare settings, as it is considered a sign of quality of care providing. Intensive care unit (ICU) patients are at higher risk for HAPUs development. Despite the availability of published prevention strategies, there is a little evidence about which strategies can be safely integrated into routine standard care and have an impact on HAPUs prevention. Aims: The aim was to synthesize the best available evidence regarding the effectiveness of single strategies designed to reduce the incidence and prevalence of HAPUs development in ICUs. Methods: The search strategy was designed to retrieve studies published in English across CINAHL, Medline, Cochrane Central Register of Controlled Trials, Embase, Scopus, and Mednar 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.
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