Skin care strategies to prevent pressure ulcer for patients in acute care settings: a systematic review

Abstract

Background Pressure ulcers are a serious health issue for patients in all kinds of settings, even at home. It may be classified as hospitalized acquired problem when patients admitted to hospital.1 Pressure ulcer can be defined as the damaged of skin that is allocated on particular areas due to pressure or in combination with friction and shear.2 The prevalence of pressure ulcer varies in health care services such as long term care, acute care and rehabilitation centre. Reddy and colleagues found that the prevalence of pressure ulcer in rehabilitation centres long term care and acute care are 2.4%, 17.1% and 67.9% respectively.3 Similarly, the prevalence of pressure ulcer in patients admitted to hospitals was reported significantly high, especially in intensive care and geriatric care setting.4, 5 A study revealed the prevalence of pressure ulcer in the intensive care unit in Germany was 49% in 2000.6 However, the later study found that it decreased to 27.7% in 2007.7 Another study in Indonesia also found similar rate in intensive care unit setting, which was more than 30%.8 Several studies indicated the importance of pressure ulcer assessment.4, 9 It is also found that more than 70% of pressure ulcer is grade one pressure ulcer.10 According to National Pressure Ulcer Advisory Panel (NPUAP) of pressure ulcer grading, grade one pressure ulcer is characterised by the change of skin colour into non-blanchable redness of particular area that are soft, warm and painful.2 Grade one of pressure ulcer indicates that the patients are at risk of developing pressure ulcers. If patients develop pressure ulcer, the may comprise to other major problem such as lengthen their hospitalised period.11 In addition, Kottner and colleagues found that to rate the prevalence of pressure ulcer may be very costly.9 There are several risk factors that may lead to the high incidence of pressure ulcer in health care setting. Immobility, limitation in movement and loss of consciousness may be factors that result in development of pressure ulcer for the patients admitted in hospital.5, 7, 11-15 Additionally, maceration of skin and dry skin may form pressure ulcer.15, 16 Poor nutritional state as indicated by lymphopenia and decreased body weight are also factors that increase the risk of pressure ulcer.15 Moreover, duration of hospitalisation may also lead to the development of pressure ulcer17 as Lyder noted that three week hospitalized will increase the risk of pressure ulcer development15 and the pressure ulcer may be developed within 2 to 6 hours in immobile patients because it is associated with the obstruction of capillary flow that may induce tissue necrosis.18 There are considerably plenty of studies conducted to examine the preventions of pressure ulcer in many areas of care, including acute care setting. Preventing pressure ulcers is crucially important to decrease the rate of pressure ulcer incidence and the health care expenses.18 It is also found that the prevention of pressure ulcer is less costly compared to the treatment of pressure ulcer.13, 14 There are several studies conducted to examine the effectiveness of pressure ulcer preventions strategies. The intervention varies from support surfaces, repositioning, nutrition, staff education and skin care. In terms of skin care, a study noted that preventive dressing is effective and safe for the reducing the risk of pressure ulcers.19 Skin care is known as less harmful intervention and also less costly that are usually performed by nurses.3, 18 Several studies have established the evidence for the preventions of pressure ulcer such as support surface, risk assessment and nutrition.3, 20-22 However, there is a lack of high quality evidence for the effectiveness of skin care in the prevention of pressure ulcer Therefore, it is imperative to explore which skin care strategies are the best to prevent pressure ulcer for patients in acute care. Objective The objective of this systematic review is to identify the best available evidence for the effectiveness of skin care interventions in preventing pressure ulcer amongst patients in acute care settings. Review Question How effective are skin care interventions to prevent pressure ulcer in adults (18 years old) when compared with standard practice or no intervention? Criteria for Considering Studies for this Review Population The review will consider all studies that involved adult patients (more than or equal to 18 years old) in acute care hospitals. Since the prevalence of pressure ulcer is considerably high in acute care, the patients admitted to acute care settings will be included in this review. Patients in long-term care, rehabilitation centre and nursing homes will be excluded in the review. Moreover, this review will exclude patients who have pre-existing pressure ulcer. Intervention This review will identify the skin care in preventing pressure ulcers. The skin care is usually performed by nurses in hospitals. Types of the interventions are massage, skin inspection, skin dressing and providing skin topical (moisturizer, powder and solutions).23 Other types of prevention such as risk assessment, repositioning, using support surface, risk assessment, educational program and supplementation of nutrition will be excluded in the interventions. Comparison The comparison of the review will be standard care or no intervention. Outcome Patients do not develop grade one pressure ulcer will be consider as a primary outcome in this review. The stage is based on grading scale from National Pressure Ulcer Advisory Panel NPUAP.2 In addition, the outcome is measured by skin assessment using any scale such as Norton scale, Waterlow Scale, Braden Scale or nurse clinical judgement.21 The secondary outcome will be the length of stay in hospital. Study Types Randomised controlled trials (RCTs) will be considered as the primary focus. In the absence of RCTs, other research designs such as quasi-experimental studies, case-controlled studies and cohort studies will be examined. However, descriptive studies and expert opinion will be excluded. All studies will be categorised according to the JBI Levels of Evidence (Appendix I) Search Strategy The search strategy aims to find both published and unpublished studies and publications. The search will be limited to English language papers published from 1990 to 2009. A three-step search strategy will be utilised in this review. An initial limited search of MEDLINE and CINAHL will be undertaken followed by an analysis of the text words contained in the title and abstract, and of the index terms used to describe the article. A second search using all identified keywords and index terms will then be undertaken. Thirdly, the reference list of all identified reports and articles will be searched for additional studies. The databases searched included: MEDLINE CINAHL Cochrane Library EMBASE Current Contents PsycINFO The search for unpublished studies included: Digital Dissertations (Proquest) Conference Proceedings MEDNAR Initial terms to be used are: Pressure ulcer, prevent, acute care and skin care. Other terms to be used are: Decubitus, bed sore, prevention, massage, topical agent and skin dressing. Methodological Quality Critical Appraisal All papers selected for retrieval will be assessed by two independent reviewers for methodological validity prior to inclusion in the review. Since the review will evaluate the experimental studies only, The Joanna Briggs Institute Meta Analysis of Statistics Assessment and Review Instrument (JBI-MAStARI) (Appendix II) will be used to evaluate each study's methodological validity. If there is a disagreement between the two reviewers, there will be a discussion with the third reviewer to solve the dissimilarity. Data Extraction Data will be extracted from papers included in the review using JBI-MAStARI (Appendix III). In this stage, any relevant studies will be extracted in relation to their population, interventions, study methods and outcomes. Data Synthesis Where possible quantitative research study results will be pooled in statistical metaanalysis using Review Manager Software from the Cochrane Collaboration. Odds ratio (for categorical outcome data) or standardised mean differences (for continuous data) and their 95% confidence intervals will be calculated for each study. Heterogeneity will be assessed using the standard Chi-square. Where statistical pooling is not possible the findings will be presented in narrative form Conflicts of Interest There is no conflict of interest in this review. Acknowledgements This protocol is supported by the Endeavour Award from the Department of Education, Employment and Workplace Relations of Australian Government. The primary author wish to acknowledge Dr Rasika Jayasekara as her supervisor and Dr. Jemal Nath as Visiting Scholar Program Coordinator for their, supervision, assistance and support at the Joanna Briggs Institute. The author would like to thank the Joanna Briggs Institute for providing Systematic Review Training, Qualitative Research Method Training and Visiting Scholar Program as well as facilities during the author's visit.