Pressure injuries (PIs), also known as pressure ulcers (PUs), are one of the most frequently occurring, costly yet preventable adverse events in hospitals (1). Critical care patients have major PI risk factors including immobility, poor perfusion, and vasopressor medication infusion (2). A recent systematic review showed the incidence and prevalence of pressure injuries (PI) in adult ICU patients was 3-40% and 12-33% respectively(2), indicating this population is at high risk of PI. Thus, proactive PI prevention (PIP) is warranted with leading quality and safety researchers suggesting a multi-component PIP care bundles are required(3). The aim of this systematic review was to describe, critically appraise and summarise the research and quality improvement (QI) evidence on PIP programs in the adult ICU context.
Methods:
To be included, papers had to report on multi-component (i.e. ≥2 components) PIP programs in any type of adult ICU. Conference proceedings where full papers were not available, editorials and letters were excluded. EMBASE, MEDLINE, CINAHL, and Cochrane Library were searched for the years 2000-2018 and Endnote was used to manage the papers. Two reviewers screened, extracted data and undertook quality assessments, with a third reviewer adjudicating. The Mixed Methods Appraisal Tool(5) was used to assess the research and the Quality Improvement Minimum Quality Criteria Set (QI-MQCS)(6) was used to assess the QI papers. Content analysis was used to synthesize the data. The protocol was registered (PROSPERO CRD42018096870).
Results:
From 1,518 titles, a total of 22 papers were included in the review (13 QI, 9 research) with two research papers reporting the same study. In total, 15 projects were conducted in developed countries (10 US, 2 UK, 2 Australia, 1 The Netherlands) and 10 were multi-site. Most projects were assessed as high quality. The number of components included in each PIP program ranged from 3-11. Common components included: PI risk assessment, skin assessment, nutrition needs assessment, repositioning/positioning, use of support surfaces, staff and patient education, documentation, multi-disciplinary team involvement, and mobilisation. Of the eight research projects, PIP programs were associated with a significant decrease in PI incidence in three studies and a significant decreased in PI prevalence in one study. Two QI projects reported reduced costs; one reported a saving of 1 million after the implementation in one 14-bed ICU; and another reported a saving of £2.6 million after implementing PI care bundles in four ICUs.
Conclusion:
Much of this work on multi-component PIP programs has been undertaken as QI projects with limited rigorous, high quality research. However, positive outcomes and strong theoretical rationales for the components in the program suggest they are beneficial.