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The Cochrane Database of Systematic... May 2021Pressure ulcers (also known as pressure injuries, pressure sores, decubitus ulcers and bed sores) are localised injuries to the skin or underlying soft tissue, or both,... (Meta-Analysis)
Meta-Analysis
BACKGROUND
Pressure ulcers (also known as pressure injuries, pressure sores, decubitus ulcers and bed sores) are localised injuries to the skin or underlying soft tissue, or both, caused by unrelieved pressure, shear or friction. Alternating pressure (active) air surfaces are widely used with the aim of preventing pressure ulcers.
OBJECTIVES
To assess the effects of alternating pressure (active) air surfaces (beds, mattresses or overlays) compared with any support surface on the incidence of pressure ulcers in any population in any setting.
SEARCH METHODS
In November 2019, 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 We also searched clinical trials registries for ongoing and unpublished studies, and scanned reference lists of relevant included studies as well as reviews, meta-analyses and health technology reports to identify additional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
We included randomised controlled trials that allocated participants of any age to alternating pressure (active) air beds, overlays or mattresses. Comparators were any beds, overlays or mattresses.
DATA COLLECTION AND ANALYSIS
At least two review authors independently assessed studies using predetermined inclusion criteria. We carried out data extraction, 'Risk of bias' assessment using the Cochrane 'Risk of bias' tool, and the certainty of the evidence assessment according to Grading of Recommendations, Assessment, Development and Evaluations methodology.
MAIN RESULTS
We included 32 studies (9058 participants) in the review. Most studies were small (median study sample size: 83 participants). The average age of participants ranged from 37.2 to 87.0 years (median: 69.1 years). Participants were largely from acute care settings (including accident and emergency departments). We synthesised data for six comparisons in the review: alternating pressure (active) air surfaces versus: foam surfaces, reactive air surfaces, reactive water surfaces, reactive fibre surfaces, reactive gel surfaces used in the operating room followed by foam surfaces used on the ward bed, and another type of alternating pressure air surface. Of the 32 included studies, 25 (78.1%) presented findings which were considered at high overall risk of bias.
PRIMARY OUTCOME
pressure ulcer incidence Alternating pressure (active) air surfaces may reduce the proportion of participants developing a new pressure ulcer compared with foam surfaces (risk ratio (RR) 0.63, 95% confidence interval (CI) 0.34 to 1.17; I = 63%; 4 studies, 2247 participants; low-certainty evidence). Alternating pressure (active) air surfaces applied on both operating tables and hospital beds may reduce the proportion of people developing a new pressure ulcer compared with reactive gel surfaces used on operating tables followed by foam surfaces applied on hospital beds (RR 0.22, 95% CI 0.06 to 0.76; I = 0%; 2 studies, 415 participants; low-certainty evidence). It is uncertain whether there is a difference in the proportion of people developing new pressure ulcers between alternating pressure (active) air surfaces and the following surfaces, as all these comparisons have very low-certainty evidence: (1) reactive water surfaces; (2) reactive fibre surfaces; and (3) reactive air surfaces. The comparisons between different types of alternating pressure air surfaces are presented narratively. Overall, all comparisons suggest little to no difference between these surfaces in pressure ulcer incidence (7 studies, 2833 participants; low-certainty evidence). Included studies have data on time to pressure ulcer incidence for three comparisons. When time to pressure ulcer development is considered using a hazard ratio (HR), it is uncertain whether there is a difference in the risk of developing new pressure ulcers, over 90 days' follow-up, between alternating pressure (active) air surfaces and foam surfaces (HR 0.41, 95% CI 0.10 to 1.64; I = 86%; 2 studies, 2105 participants; very low-certainty evidence). For the comparison with reactive air surfaces, there is low-certainty evidence that people treated with alternating pressure (active) air surfaces may have a higher risk of developing an incident pressure ulcer than those treated with reactive air surfaces over 14 days' follow-up (HR 2.25, 95% CI 1.05 to 4.83; 1 study, 308 participants). Neither of the two studies with time to ulcer incidence data suggested a difference in the risk of developing an incident pressure ulcer over 60 days' follow-up between different types of alternating pressure air surfaces. Secondary outcomes The included studies have data on (1) support-surface-associated patient comfort for comparisons involving foam surfaces, reactive air surfaces, reactive fibre surfaces and alternating pressure (active) air surfaces; (2) adverse events for comparisons involving foam surfaces, reactive gel surfaces and alternating pressure (active) air surfaces; and (3) health-related quality of life outcomes for the comparison involving foam surfaces. However, all these outcomes and comparisons have low or very low-certainty evidence and it is uncertain whether there are any differences in these outcomes. Included studies have data on cost effectiveness for two comparisons. Moderate-certainty evidence suggests that alternating pressure (active) air surfaces are probably more cost-effective than foam surfaces (1 study, 2029 participants) and that alternating pressure (active) air mattresses are probably more cost-effective than overlay versions of this technology for people in acute care settings (1 study, 1971 participants).
AUTHORS' CONCLUSIONS
Current evidence is uncertain about the difference in pressure ulcer incidence between using alternating pressure (active) air surfaces and other surfaces (reactive water surfaces, reactive fibre surfaces and reactive air surfaces). Alternating pressure (active) air surfaces may reduce pressure ulcer risk compared with foam surfaces and reactive gel surfaces used on operating tables followed by foam surfaces applied on hospital beds. People using alternating pressure (active) air surfaces may be more likely to develop new pressure ulcers over 14 days' follow-up than those treated with reactive air surfaces in the nursing home setting; but as the result is sensitive to the choice of outcome measure it should be interpreted cautiously. Alternating pressure (active) air surfaces are probably more cost-effective than reactive foam surfaces in preventing new pressure ulcers. Future studies should include time-to-event outcomes and assessment of adverse events and trial-level cost-effectiveness. Further review using network meta-analysis will add to the findings reported here.
Topics: Adult; Aged; Aged, 80 and over; Air; Bedding and Linens; Beds; Bias; Elasticity; Humans; Incidence; Middle Aged; Pressure; Pressure Ulcer; Publication Bias; Quality of Life; Randomized Controlled Trials as Topic; Time Factors
PubMed: 33969911
DOI: 10.1002/14651858.CD013620.pub2 -
Journal of Foot and Ankle Research Mar 2021For patients with diabetic foot ulcers, offloading is one crucial aspect of treatment and aims to redistribute pressure away from the ulcer site. In addition to...
BACKGROUND
For patients with diabetic foot ulcers, offloading is one crucial aspect of treatment and aims to redistribute pressure away from the ulcer site. In addition to offloading strategies, patients are often advised to reduce their activity levels. Consequently, patients may avoid exercise altogether. However, it has been suggested that exercise induces an increase in vasodilation and tissue blood flow, which may potentially facilitate ulcer healing. The aim of this systematic review was to determine whether exercise improves healing of diabetic foot ulcers.
REVIEW
We conducted a systematic search of MEDLINE, CINAHL and EMBASE between July 6, 2009 and July 6, 2019 using the key terms and subject headings diabetes, diabetic foot, physical activity, exercise, resistance training and wound healing. Randomised controlled trials were included in this review. Three randomised controlled trials (139 participants) were included in this systematic review. All studies incorporated a form of non-weight bearing exercise as the intervention over a 12-week period. One study conducted the intervention in a supervised setting, while two studies conducted the intervention in an unsupervised setting. Two studies found greater improvement in percentage wound size reduction in the intervention group compared with the control group, with one of these studies achieving statistically significant findings (p < 0.05). The results of the third study demonstrated statistically significant findings for total wound size reduction (p < 0.05), however results were analysed within each treatment group and not between groups.
CONCLUSION
This systematic review found there is insufficient evidence to conclusively support non-weight bearing exercise as an intervention to improve healing of diabetic foot ulcers. Regardless, the results demonstrate some degree of wound size reduction and there were no negative consequences of the intervention for the participants. Given the potential benefits of exercise on patient health and wellbeing, non-weight bearing exercise should be encouraged as part of the management plan for treatment of diabetic foot ulcers. Further research is required to better understand the relationship between exercise and healing of diabetic foot ulcers.
Topics: Aged; Diabetic Foot; Exercise; Exercise Therapy; Female; Foot; Humans; Male; Middle Aged; Regional Blood Flow; Treatment Outcome; Vasodilation; Weight-Bearing; Wound Healing
PubMed: 33743791
DOI: 10.1186/s13047-021-00456-w -
PloS One 2023Medical device-related pressure injury (MDRPI) in intensive care unit (ICU) patients is a serious issue. We aimed to evaluate the risk factors for MDRPI associated with... (Meta-Analysis)
Meta-Analysis
BACKGROUND
Medical device-related pressure injury (MDRPI) in intensive care unit (ICU) patients is a serious issue. We aimed to evaluate the risk factors for MDRPI associated with ICU patients through systematic review and meta-analysis, and provide insights into the clinical prevention of MDRPI.
METHODS
We searched PubMed, Embase, Web of Science, China National Knowledge Infrastructure (CNKI), WanFang Database, and China BioMedical Literature Database (CBM) (from inception to January 2023) for studies that identified risk factors of MDRPI in ICU patients. In order to avoid the omission of relevant literature, we performed a secondary search of the above database on February 15, 2023. Meta-analysis was performed using Revman 5.3.
RESULTS
Fifteen studies involving 4850 participants were selected to analyze risk factors for MDRPI in ICU patients. While conducting a meta-analysis, we used sensitivity analysis to ensure the reliability of the results for cases with significant heterogeneity among studies. When the source of heterogeneity cannot be determined, we only described the risk factor. The risk factors for MDRPI in ICU patients were elder age (OR = 1.06, 95% CI: 1.03-1.10), diabetes mellitus (OR = 3.20, 95% CI: 1.96-5.21), edema (OR = 3.62, 95% CI: 2.31-5.67), lower Braden scale score (OR = 1.22, 95%CI: 1.11-1.33), higher SOFA score (OR = 4.21, 95%CI: 2.38-7.47), higher APACHE II score (OR = 1.38, 95%CI: 1.15-1.64), longer usage time of medical devices (OR = 1.11, 95%CI: 1.05-1.19), use of vasoconstrictors (OR = 6.07, 95%CI: 3.15-11.69), surgery (OR = 4.36, 95% CI: 2.07-9.15), prone position (OR = 24.71, 95% CI: 7.34-83.15), and prone position ventilation (OR = 17.51, 95% CI: 5.86-52.36). Furthermore, we found that ICU patients who used subglottic suction catheters had a higher risk of MDRPI, whereas ICU patients with higher hemoglobin and serum albumin levels had a lower risk of MDRPI.
CONCLUSION
This study reported the risk factors for MDRPI in ICU patients. A comprehensive analysis of these risk factors will help to prevent and optimize interventions, thereby minimizing the occurrence of MDRPI.
Topics: Humans; Aged; Pressure Ulcer; Reproducibility of Results; Intensive Care Units; Critical Care; Crush Injuries; Risk Factors
PubMed: 37352180
DOI: 10.1371/journal.pone.0287326 -
Journal of Wound, Ostomy, and...The purpose of this systematic review was to identify and evaluate the use of prophylactic foam dressings for prevention of hospital-acquired pressure injuries (HAPIs).
PURPOSE
The purpose of this systematic review was to identify and evaluate the use of prophylactic foam dressings for prevention of hospital-acquired pressure injuries (HAPIs).
METHODS
A systematic review was conducted in accordance with the Preferred Reporting Items of Systematic Reviews and Meta-analysis Statement (PRISMA).
SEARCH STRATEGY
Four researchers independently conducted searches in Health Source, Cochrane of Systematic Reviews, CINAHL, and PubMed. Search terms included: "pressure* OR skin breakdown AND sacrum*"; "ICU patient* OR critical care patient*"; and "foam dressing OR prophylactic* or prevent*."
FINDINGS
The search identified 380 articles; 14 met eligibility criteria. The methodological quality of the included studies was variable. Findings from all studies included in our review support a decrease in HAPI incidence with use of sacral foam dressings.
IMPLICATIONS
Findings from this review suggest that prophylactic foam dressings decrease sacral HAPI occurrences in critical care patients. While additional research is needed, current best evidence supports use of prophylactic foam sacral dressings for patients at risk for HAPI.
Topics: Bandages; Hospitals; Humans; Incidence; Pressure; Pressure Ulcer; Sacrococcygeal Region; Wound Healing
PubMed: 33951710
DOI: 10.1097/WON.0000000000000762 -
Journal of the American Academy of... Sep 2019The field of dermatology has seen numerous therapeutic innovations in the past decade with platelet-rich plasma (PRP), recently garnering significant interest in...
The field of dermatology has seen numerous therapeutic innovations in the past decade with platelet-rich plasma (PRP), recently garnering significant interest in alopecia, acne scarring, and skin rejuvenation. In other conditions of dermatology, such as chronic wounds and vitiligo, PRP has been investigated but has received less attention. The objective of this literature review was to focus on conditions of medical dermatology and to consolidate the available evidence on PRP for the practicing dermatologist. This review evaluates the literature up to October 31, 2018, and a search was conducted in the PubMed database for "platelet-rich plasma," "platelet releasate," "platelet gel," "platelet-rich fibrin" or "PRP" and "dermatology," "skin," "cutaneous," "wound," or "ulcer." In total, 14 articles met the inclusion criteria for this review. In studies representing Levels of Evidence 1b-4 according to the Centre for Evidence-Based Medicine, Oxford, PRP significantly improved wound healing in chronic diabetic ulcers, venous ulcers, pressure ulcers, leprosy ulcers, acute traumatic wounds, and ulcers of multifactorial etiologies. Two studies also documented benefits of adjunctive PRP in stable vitiligo. In chronic wounds of multiple etiologies and vitiligo, PRP warrants further investigation because it represents a potential therapeutic adjunct or alternative with a favorable side effect profile.
Topics: Alopecia; Cicatrix; Dermatology; Humans; Platelet-Rich Plasma; Rejuvenation; Skin Ulcer; Wound Healing
PubMed: 31009668
DOI: 10.1016/j.jaad.2019.04.037 -
The Cochrane Database of Systematic... Jul 2021Leg ulcers are open skin wounds on the lower leg that can last weeks, months or even years. Most leg ulcers are the result of venous diseases. First-line treatment... (Meta-Analysis)
Meta-Analysis
BACKGROUND
Leg ulcers are open skin wounds on the lower leg that can last weeks, months or even years. Most leg ulcers are the result of venous diseases. First-line treatment options often include the use of compression bandages or stockings.
OBJECTIVES
To assess the effects of using compression bandages or stockings, compared with no compression, on the healing of venous leg ulcers in any setting and population.
SEARCH METHODS
In June 2020 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 by language, date of publication or study setting.
SELECTION CRITERIA
We included randomised controlled trials that compared any types of compression bandages or stockings with no compression in participants with venous leg ulcers in any setting.
DATA COLLECTION AND ANALYSIS
At least two review authors independently assessed studies using predetermined inclusion criteria. We carried out data extraction, and risk-of-bias assessment using the Cochrane risk-of-bias tool. We assessed the certainty of the evidence according to GRADE methodology.
MAIN RESULTS
We included 14 studies (1391 participants) in the review. Most studies were small (median study sample size: 51 participants). Participants were recruited from acute-care settings, outpatient settings and community settings, and a large proportion (65.9%; 917/1391) of participants had a confirmed history or clinical evidence of chronic venous disease, a confirmed cause of chronic venous insufficiency, or an ankle pressure/brachial pressure ratio of greater than 0.8 or 0.9. The average age of participants ranged from 58.0 to 76.5 years (median: 70.1 years). The average duration of their leg ulcers ranged from 9.0 weeks to 31.6 months (median: 22.0 months), and a large proportion of participants (64.8%; 901/1391) had ulcers with an area between 5 and 20 cm. Studies had a median follow-up of 12 weeks. Compression bandages or stockings applied included short-stretch bandage, four-layer compression bandage, and Unna's boot (a type of inelastic gauze bandage impregnated with zinc oxide), and comparator groups used included 'usual care', pharmacological treatment, a variety of dressings, and a variety of treatments where some participants received compression (but it was not the norm). Of the 14 included studies, 10 (71.4%) presented findings which we consider to be at high overall risk of bias. Primary outcomes There is moderate-certainty evidence (downgraded once for risk of bias) (1) that there is probably a shorter time to complete healing of venous leg ulcers in people wearing compression bandages or stockings compared with those not wearing compression (pooled hazard ratio for time-to-complete healing 2.17, 95% confidence interval (CI) 1.52 to 3.10; I = 59%; 5 studies, 733 participants); and (2) that people treated using compression bandages or stockings are more likely to experience complete ulcer healing within 12 months compared with people with no compression (10 studies, 1215 participants): risk ratio for complete healing 1.77, 95% CI 1.41 to 2.21; I = 65% (8 studies with analysable data, 1120 participants); synthesis without meta-analysis suggests more completely-healed ulcers in compression bandages or stockings than in no compression (2 studies without analysable data, 95 participants). It is uncertain whether there is any difference in rates of adverse events between using compression bandages or stockings and no compression (very low-certainty evidence; 3 studies, 585 participants). Secondary outcomes Moderate-certainty evidence suggests that people using compression bandages or stockings probably have a lower mean pain score than those not using compression (four studies with 859 participants and another study with 69 ulcers): pooled mean difference -1.39, 95% CI -1.79 to -0.98; I = 65% (two studies with 426 participants and another study with 69 ulcers having analysable data); synthesis without meta-analysis suggests a reduction in leg ulcer pain in compression bandages or stockings, compared with no compression (two studies without analysable data, 433 participants). Compression bandages or stockings versus no compression may improve disease-specific quality of life, but not all aspects of general health status during the follow-up of 12 weeks to 12 months (four studies with 859 participants; low-certainty evidence). It is uncertain if the use of compression bandages or stockings is more cost-effective than not using them (three studies with 486 participants; very low-certainty evidence).
AUTHORS' CONCLUSIONS
If using compression bandages or stockings, people with venous leg ulcers probably experience complete wound healing more quickly, and more people have wounds completely healed. The use of compression bandages or stockings probably reduces pain and may improve disease-specific quality of life. There is uncertainty about adverse effects, and cost effectiveness. Future research should focus on comparing alternative bandages and stockings with the primary endpoint of time to complete wound healing alongside adverse events including pain score, and health-related quality of life, and should incorporate cost-effectiveness analysis where possible. Future studies should adhere to international standards of trial conduct and reporting.
Topics: Aged; Bandages, Hydrocolloid; Bias; Compression Bandages; Dermatologic Agents; Humans; Middle Aged; Pain Management; Quality of Life; Randomized Controlled Trials as Topic; Stockings, Compression; Time Factors; Varicose Ulcer; Wound Healing; Zinc Oxide
PubMed: 34308565
DOI: 10.1002/14651858.CD013397.pub2 -
Diabetes/metabolism Research and Reviews Mar 2020Offloading interventions are commonly used in clinical practice to heal foot ulcers. The aim of this updated systematic review is to investigate the effectiveness of...
BACKGROUND
Offloading interventions are commonly used in clinical practice to heal foot ulcers. The aim of this updated systematic review is to investigate the effectiveness of offloading interventions to heal diabetic foot ulcers.
METHODS
We updated our previous systematic review search of PubMed, EMBASE, and Cochrane databases to also include original studies published between July 29, 2014 and August 13, 2018 relating to four offloading intervention categories in populations with diabetic foot ulcers: (a) offloading devices, (b) footwear, (c) other offloading techniques, and (d) surgical offloading techniques. Outcomes included ulcer healing, plantar pressure, ambulatory activity, adherence, adverse events, patient-reported measures, and cost-effectiveness. Included controlled studies were assessed for methodological quality and had key data extracted into evidence and risk of bias tables. Included non-controlled studies were summarised on a narrative basis.
RESULTS
We identified 41 studies from our updated search for a total of 165 included studies. Six included studies were meta-analyses, 26 randomised controlled trials (RCTs), 13 other controlled studies, and 120 non-controlled studies. Five meta-analyses and 12 RCTs provided high-quality evidence for non-removable knee-high offloading devices being more effective than removable offloading devices and therapeutic footwear for healing plantar forefoot and midfoot ulcers. Total contact casts (TCCs) and non-removable knee-high walkers were shown to be equally effective. Moderate-quality evidence exists for removable knee-high and ankle-high offloading devices being equally effective in healing, but knee-high devices have a larger effect on reducing plantar pressure and ambulatory activity. Low-quality evidence exists for the use of felted foam and surgical offloading to promote healing of plantar forefoot and midfoot ulcers. Very limited evidence exists for the efficacy of any offloading intervention for healing plantar heel ulcers, non-plantar ulcers, and neuropathic ulcers with infection or ischemia.
CONCLUSION
Strong evidence supports the use of non-removable knee-high offloading devices (either TCC or non-removable walker) as the first-choice offloading intervention for healing plantar neuropathic forefoot and midfoot ulcers. Removable offloading devices, either knee-high or ankle-high, are preferred as second choice over other offloading interventions. The evidence bases to support any other offloading intervention is still weak and more high-quality controlled studies are needed in these areas.
Topics: Diabetes Mellitus, Type 1; Diabetes Mellitus, Type 2; Diabetic Foot; Disease Management; Evidence-Based Medicine; Humans; Practice Guidelines as Topic; Practice Patterns, Physicians'; Prognosis
PubMed: 32176438
DOI: 10.1002/dmrr.3275 -
Diabetes/metabolism Research and Reviews Mar 2024This is the 2023 International Working Group on the Diabetic Foot guideline on the prevention of foot ulcers in persons with diabetes, which updates the 2019 guideline....
AIMS
This is the 2023 International Working Group on the Diabetic Foot guideline on the prevention of foot ulcers in persons with diabetes, which updates the 2019 guideline. This guideline is targeted at clinicians and other healthcare professionals.
MATERIALS AND METHODS
We followed the Grading of Recommendations, Assessment, Development and Evaluations methodology to devise clinical questions and critically important outcomes in the PICO format, to conduct a systematic review of the medical-scientific literature including, where appropriate, meta-analyses, and to write recommendations and their rationale. The recommendations are based on the quality of evidence found in the systematic review, expert opinion where (sufficient) evidence was not available, and a weighing of the desirable and undesirable effects of an intervention, as well as patient preferences, costs, equity, feasibility and applicability.
RESULTS
We recommend screening a person with diabetes at very low risk of foot ulceration annually for the loss of protective sensation and peripheral artery disease, and screening persons at higher risk at higher frequencies for additional risk factors. For preventing a foot ulcer, educate persons at-risk about appropriate foot self-care, educate not to walk without suitable foot protection, and treat any pre-ulcerative lesion on the foot. Educate moderate-to-high risk people with diabetes to wear properly fitting, accommodative, therapeutic footwear, and consider coaching them to monitor foot skin temperature. Prescribe therapeutic footwear that has a demonstrated plantar pressure relieving effect during walking, to help prevent plantar foot ulcer recurrence. Consider advising people at low-to-moderate risk to undertake a, preferably supervised, foot-ankle exercise programme to reduce ulcer risk factors, and consider communicating that a total increase in weight-bearing activity of 1000 steps/day is likely safe with regards to risk of ulceration. In people with non-rigid hammertoe with pre-ulcerative lesion, consider flexor tendon tenotomy. We suggest not to use a nerve decompression procedure to help prevent foot ulcers. Provide integrated foot care for moderate-to-high-risk people with diabetes to help prevent (recurrence of) ulceration.
CONCLUSIONS
These recommendations should help healthcare professionals to provide better care for persons with diabetes at risk of foot ulceration, to increase the number of ulcer-free days and reduce the patient and healthcare burden of diabetes-related foot disease.
Topics: Humans; Diabetic Foot; Foot Ulcer; Risk Factors; Evidence-Based Medicine; Diabetes Mellitus
PubMed: 37302121
DOI: 10.1002/dmrr.3651 -
The Cochrane Database of Systematic... Jan 2019Use 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... (Meta-Analysis)
Meta-Analysis
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.
Topics: Humans; Incidence; Pressure Ulcer; Randomized Controlled Trials as Topic; Risk Assessment
PubMed: 30702158
DOI: 10.1002/14651858.CD006471.pub4 -
The Cochrane Database of Systematic... Jan 2016Ventilator-associated pneumonia (VAP) is associated with increased mortality, prolonged length of hospital stay and increased healthcare costs in critically ill... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Ventilator-associated pneumonia (VAP) is associated with increased mortality, prolonged length of hospital stay and increased healthcare costs in critically ill patients. Guidelines recommend a semi-recumbent position (30º to 45º) for preventing VAP among patients requiring mechanical ventilation. However, due to methodological limitations in existing systematic reviews, uncertainty remains regarding the benefits and harms of the semi-recumbent position for preventing VAP.
OBJECTIVES
To assess the effectiveness and safety of semi-recumbent positioning versus supine positioning to prevent ventilator-associated pneumonia (VAP) in adults requiring mechanical ventilation.
SEARCH METHODS
We searched CENTRAL (2015, Issue 10), which includes the Cochrane Acute Respiratory Infections Group's Specialised Register, MEDLINE (1946 to October 2015), EMBASE (2010 to October 2015), CINAHL (1981 to October 2015) and the Chinese Biomedical Literature Database (CBM) (1978 to October 2015).
SELECTION CRITERIA
We included randomised controlled trials (RCTs) comparing semi-recumbent versus supine positioning (0º to 10º), or RCTs comparing alternative degrees of positioning in mechanically ventilated patients. Our outcomes included clinically suspected VAP, microbiologically confirmed VAP, intensive care unit (ICU) mortality, hospital mortality, length of ICU stay, length of hospital stay, duration of ventilation, antibiotic use and any adverse events.
DATA COLLECTION AND ANALYSIS
Two review authors independently and in duplicate screened titles, abstracts and full texts, assessed risk of bias and extracted data using standardised forms. We calculated the mean difference (MD) and 95% confidence interval (95% CI) for continuous data and the risk ratio (RR) and 95% CI for binary data. We performed meta-analysis using the random-effects model. We used the grading of recommendations, assessment, development and evaluation (GRADE) approach to grade the quality of evidence.
MAIN RESULTS
We included 10 trials involving 878 participants, among which 28 participants in two trials did not provide complete data due to loss to follow-up. We judged all trials to be at high risk of bias. Semi-recumbent position (30º to 60º) versus supine position (0° to 10°) A semi-recumbent position (30º to 60º) significantly reduced the risk of clinically suspected VAP compared to a 0º to 10º supine position (eight trials, 759 participants, 14.3% versus 40.2%, RR 0.36; 95% CI 0.25 to 0.50; risk difference (RD) 25.7%; 95% CI 20.1% to 30.1%; GRADE: moderate quality evidence).There was no significant difference between the two positions in the following outcomes: microbiologically confirmed VAP (three trials, 419 participants, 12.6% versus 31.6%, RR 0.44; 95% CI 0.11 to 1.77; GRADE: very low quality evidence), ICU mortality (two trials, 307 participants, 29.8% versus 34.3%, RR 0.87; 95% CI 0.59 to 1.27; GRADE: low quality evidence), hospital mortality (three trials, 346 participants, 23.8% versus 27.6%, RR 0.84; 95% CI 0.59 to 1.20; GRADE: low quality evidence), length of ICU stay (three trials, 346 participants, MD -1.64 days; 95% CI -4.41 to 1.14 days; GRADE moderate quality evidence), length of hospital stay (two trials, 260 participants, MD -9.47 days; 95% CI -34.21 to 15.27 days; GRADE: very low quality evidence), duration of ventilation (four trials, 458 participants, MD -3.35 days; 95% CI -7.80 to 1.09 days), antibiotic use (three trials, 284 participants, 84.8% versus 84.2%, RR 1.00; 95% CI 0.97 to 1.03) and pressure ulcers (one trial, 221 participants, 28% versus 30%, RR 0.91; 95% CI 0.60 to 1.38; GRADE: low quality evidence). No other adverse events were reported. Semi-recumbent position (45°) versus 25° to 30° We found no statistically significant differences in the following prespecified outcomes: clinically suspected VAP (two trials, 91 participants, RR 0.74; 95% CI 0.35 to 1.56; GRADE: very low quality evidence), microbiologically confirmed VAP (one trial, 30 participants, RR 0.61; 95% CI 0.20 to 1.84: GRADE: very low quality evidence), ICU mortality (one trial, 30 participants, RR 0.57; 95% CI 0.15 to 2.13; GRADE: very low quality evidence), hospital mortality (two trials, 91 participants, RR 1.00; 95% CI 0.38 to 2.65; GRADE: very low quality evidence), length of ICU stay (one trial, 30 participants, MD 1.6 days; 95% CI -0.88 to 4.08 days; GRADE: very low quality evidence) and antibiotic use (two trials, 91 participants, RR 1.11; 95% CI 0.84 to 1.47). No adverse events were reported.
AUTHORS' CONCLUSIONS
A semi-recumbent position (≧ 30º) may reduce clinically suspected VAP compared to a 0° to 10° supine position. However, the evidence is seriously limited with a high risk of bias. No adequate evidence is available to draw any definitive conclusion on other outcomes and the comparison of alternative semi-recumbent positions. Adverse events, particularly venous thromboembolism, were under-reported.
Topics: Adult; Anti-Bacterial Agents; Hospital Mortality; Humans; Intensive Care Units; Length of Stay; Patient Positioning; Pneumonia, Ventilator-Associated; Pressure Ulcer; Randomized Controlled Trials as Topic; Respiration, Artificial; Supine Position
PubMed: 26743945
DOI: 10.1002/14651858.CD009946.pub2