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Pressure Ulcer Risk Assessment and Prevention: Comparative Effectiveness
Comparative Effectiveness Reviews, No. 87
Investigators: Roger Chou, MD, Tracy Dana, MLS, Christina Bougatsos, MPH, Ian Blazina, MPH, Amy Starmer, MD, MPH, Katie Reitel, MSW, MPH, and David Buckley, MD, MPH.
Author Information and AffiliationsStructured Abstract
Objectives:
While pressure ulcers commonly occur and are associated with significant health burdens, they are potentially preventable. This report systematically reviews the evidence on (1) risk-assessment scales for identifying people at higher risk of pressure ulcers and (2) preventive interventions to decrease incidence or severity of pressure ulcers. The Agency for Healthcare Research and Quality also commissioned a separate report on effectiveness of interventions to treat pressure ulcers.
Data sources:
Articles were identified from searches of MEDLINE® (1946 to July 2012), CINAHL (1988 to July 2012), the Cochrane Central Register of Controlled Trials and Database of Systematic Reviews (through July 2012), clinical trials registries, and reference lists. Review methods. We used predefined criteria to determine study eligibility. We selected randomized trials and cohort studies on the effects of use of risk-assessment tools and preventive interventions on clinical outcomes. We also selected prospective studies on the diagnostic accuracy of risk-assessment tools for predicting incidence of pressure ulcers. The quality of included studies was assessed, data were extracted, and results were summarized.
Results:
Of the 4,733 citations identified at the title and abstract level, we screened and reviewed 747 full-text articles. A total of 120 studies (in 122 publications) were included. One good- and two poor-quality studies evaluated effects of using a risk-assessment tool on clinical outcomes, with the good-quality randomized trial showing no difference between use of the Waterlow scale or the Ramstadius tool compared with clinical judgment in subsequent risk of pressure ulcers. Studies of diagnostic accuracy found that commonly used risk-assessment instruments (such as the Braden, Norton, and Waterlow scales) can help identify patients at increased risk for ulcers, but appear to be relatively weak predictors, with no clear difference among instruments in diagnostic accuracy. Fair-quality randomized trials consistently found that more advanced static support surfaces were associated with lower risk of pressure ulcers compared with standard mattresses in higher risk patients (relative risk range, 0.20 to 0.60), with no clear differences among different advanced static support surfaces. Evidence on the effectiveness and comparative effectiveness of other support surfaces, including more advanced dynamic support surfaces, was limited, with some trials showing no clear differences between dynamic and static support surfaces. One fair-quality trial found that stepped care with dynamic support surfaces was associated with substantially decreased risk of ulcers compared with stepped care beginning with static support surfaces. In lower risk populations of patients undergoing surgery, two trials found use of a foam overlay associated with an increased risk of pressure ulcers compared with a standard operating room mattress. Evidence on effectiveness of other preventive interventions (nutritional supplementation; repositioning; pads and dressings; lotions, creams, and cleansers; corticotropin injections; polarized light therapy; and intraoperative warming therapy for patients undergoing surgery) compared with standard care was sparse and insufficient to reach reliable conclusions.
Conclusions:
Although risk-assessment instruments can identify patients at higher risk for pressure ulcers, more research is needed to understand how the use of risk-assessment instruments impacts pressure ulcer incidence compared with clinical judgment. More advanced static support surfaces are more effective than standard mattresses for preventing ulcers in higher risk populations. More research is needed to understand the effectiveness of other preventive interventions over usual care and the comparative effectiveness of preventive interventions.
Contents
- Preface
- Acknowledgments
- Key Informants
- Technical Expert Panel
- Peer Reviewers
- Executive Summary
- Introduction
- Methods
- Results
- Overview
- Key Question 1 For adults in various settings, is the use of any risk-assessment tool effective in reducing the incidence or severity of pressure ulcers, compared with other risk-assessment tools, clinical judgment alone, and/or usual care?
- Key Question 1a Do the effectiveness and comparative effectiveness of risk-assessment tools differ according to setting?
- Key Question 1b Do the effectiveness and comparative effectiveness of risk-assessment tools differ according to patient characteristics, and other known risk factors for pressure ulcers, such as nutritional status or incontinence?
- Key Question 2 How do various risk-assessment tools compare with one another in their ability to predict the incidence of pressure ulcers?
- Key Question 2a Does the predictive validity of various risk-assessment tools differ according to setting?
- Key Question 2b Does the predictive validity of various risk-assessment tools differ according to patient characteristics?
- Key Question 3 In patients at increased risk of developing pressure ulcers, what are the effectiveness and comparative effectiveness of preventive interventions in reducing the incidence or severity of pressure ulcers?
- Key Question 3a Do the effectiveness and comparative effectiveness of preventive interventions differ according to risk level as determined by different risk-assessment methods and/or by particular risk factors?
- Key Question 3b Do the effectiveness and comparative effectiveness of preventive interventions differ according to setting?
- Key Question 3c Do the effectiveness and comparative effectiveness of preventive interventions differ according to patient characteristics?
- Key Question 4 What are the harms of interventions for the prevention of pressure ulcers?
- Key Question 4a Do the harms of preventive interventions differ according to the type of intervention?
- Key Question 4b Do the harms of preventive interventions differ according to setting?
- Key Question 4c Do the harms of preventive interventions differ according to patient characteristics?
- Discussion
- References
- Abbreviations
- Appendix A Search Strategies
- Appendix B Inclusion and Exclusion Criteria by Key Question
- Appendix C Included Studies List
- Appendix D Excluded Studies List
- Appendix E Non-English Language Titles and Abstracts
- Appendix F Quality Assessment Methods
- Appendix G Overall Strength of Evidence Tables
- Appendix H Evidence Tables and Quality Assessment Tables
Prepared for: Agency for Healthcare Research and Quality, U.S. Department of Health and Human Services1, Contract No. 290-2007-10057-I, Prepared by: Oregon Evidence-based Practice Center, Oregon Health and Science University, Portland, OR
Suggested citation:
Chou R, Dana T, Bougatsos C, Blazina I, Starmer A, Reitel K, Buckley D. Pressure Ulcer Risk Assessment and Prevention: Comparative Effectiveness. Comparative Effectiveness Review No. 87. (Prepared by Oregon Evidence-based Practice Center under Contract No. 290-2007-10057-I.) AHRQ Publication No. 12(13)-EHC148-EF. Rockville, MD: Agency for Healthcare Research and Quality. May 2013. www.effectivehealthcare.ahrq.gov/reports/final.cfm.
This report is based on research conducted by the Oregon Evidence-based Practice Center (EPC) under contract to the Agency for Healthcare Research and Quality (AHRQ), Rockville, MD (Contract No. 290-2007-10057-I). The findings and conclusions in this document are those of the authors, who are responsible for its contents; the findings and conclusions do not necessarily represent the views of AHRQ. Therefore, no statement in this report should be construed as an official position of AHRQ or of the U.S. Department of Health and Human Services.
The information in this report is intended to help health care decisionmakers—patients and clinicians, health system leaders, and policymakers, among others—make well-informed decisions and thereby improve the quality of health care services. This report is not intended to be a substitute for the application of clinical judgment. Anyone who makes decisions concerning the provision of clinical care should consider this report in the same way as any medical reference and in conjunction with all other pertinent information, i.e., in the context of available resources and circumstances presented by individual patients.
This report may be used, in whole or in part, as the basis for development of clinical practice guidelines and other quality enhancement tools, or as a basis for reimbursement and coverage policies. AHRQ or U.S. Department of Health and Human Services endorsement of such derivative products may not be stated or implied.
None of the investigators has any affiliations or financial involvement that conflicts with the material presented in this report.
- 1
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- Review Pressure ulcer risk assessment and prevention: a systematic comparative effectiveness review.[Ann Intern Med. 2013]Review Pressure ulcer risk assessment and prevention: a systematic comparative effectiveness review.Chou R, Dana T, Bougatsos C, Blazina I, Starmer AJ, Reitel K, Buckley DI. Ann Intern Med. 2013 Jul 2; 159(1):28-38.
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- Pressure ulcer prevention: an evidence-based analysis.[Ont Health Technol Assess Ser....]Pressure ulcer prevention: an evidence-based analysis.Medical Advisory Secretariat. Ont Health Technol Assess Ser. 2009; 9(2):1-104. Epub 2009 Apr 1.
- Review Support surfaces for pressure ulcer prevention.[Cochrane Database Syst Rev. 2008]Review Support surfaces for pressure ulcer prevention.McInnes E, Bell-Syer SE, Dumville JC, Legood R, Cullum NA. Cochrane Database Syst Rev. 2008 Oct 8; (4):CD001735. Epub 2008 Oct 8.
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