Joyce P, Moore ZE, Christie J, et al.
The Cochrane database of systematic reviews. Date of publication 2018 Dec 9;volume 12():CD012132.
1. Cochrane Database Syst Rev. 2018 Dec 9;12:CD012132. doi:
10.1002/14651858.CD012132.pub2.
Organisation of health services for preventing and treating pressure ulcers.
Joyce P(1), Moore ZE, Christie J.
Author information:
(1)School of Medicine, Royal College of Surgeons in Ireland, 121 St. Stephens
Green, Dublin, Ireland, 2.
BACKGROUND: Pressure ulcers, which are a localised injury to the skin, or
underlying tissue, or both, occur when people are unable to reposition themselves
to relieve pressure on bony prominences. Pressure ulcers are often difficult to
heal, painful, expensive to manage and have a negative impact on quality of life.
While individual patient safety and quality care stem largely from direct
healthcare practitioner-patient interactions, each practitioner-patient
wound-care contact may be constrained or enhanced by healthcare organisation of
services. Research is needed to demonstrate clearly the effect of different
provider-orientated approaches to pressure ulcer prevention and treatment.
OBJECTIVES: To assess the effects of different provider-orientated interventions
targeted at the organisation of health services, on the prevention and treatment
of pressure ulcers.
SEARCH METHODS: In April 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 three 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and unpublished studies, and scanned reference lists of relevant included studies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), cluster-RCTs, non-RCTs,
controlled before-and-after studies and interrupted time series, which enrolled
people at risk of, or people with existing pressure ulcers, were eligible for
inclusion in the review.
DATA COLLECTION AND ANALYSIS: Two review authors independently performed study
selection, risk of bias assessment, data extraction and GRADE assessment of the
certainty of evidence.
MAIN RESULTS: The search yielded a total of 3172 citations and, following
screening and application of the inclusion and exclusion criteria, we deemed four
studies eligible for inclusion. These studies reported the primary outcome of
pressure ulcer incidence or pressure ulcer healing, or both.One controlled
before-and-after study explored the impact of transmural care (a care model that
provided activities to support patients and their family/partners and activities
to promote continuity of care), among 62 participants with spinal cord injury. It
is unclear whether transmural care leads to a difference in pressure ulcer
incidence compared with usual care (risk ratio (RR) 0.93, 95% confidence interval
(CI) 0.53 to 1.64; very low-certainty evidence, downgraded twice for very serious
study limitations and twice for very serious imprecision).One RCT explored the
impact of hospital-in-the-home care, among 100 older adults. It is unclear
whether hospital-in-the-home care leads to a difference in pressure ulcer
incidence risk compared with hospital admission (RR 0.32, 95% CI 0.03 to 2.98;
very low-certainty evidence, downgraded twice for very serious study limitations
and twice for very serious imprecision).A third study (cluster-randomised
stepped-wedge trial), explored the impact of being cared for by enhanced
multidisciplinary teams (EMDT), among 161 long-term-care residents. The analyses
of the primary outcome used measurements of 201 pressure ulcers from 119
residents. It is unclear if EMDT reduces the pressure ulcer incidence rate
compared with usual care (hazard ratio (HR) 1.12, 95% CI 0.74 to 1.68; very
low-certainty evidence, downgraded twice for very serious study limitations and
twice for very serious imprecision). It is unclear whether there is a difference
in the number of wounds healed (RR 1.69, 95% CI 1.00 to 2.87; very low-certainty
evidence, downgraded twice for very serious study limitations and twice for very
serious imprecision). It is unclear whether there is a difference in the
reduction in surface area, with and without EMDT, (healing rate 1.006; 95% CI
0.99 to 1.03; very low-certainty evidence, downgraded twice for very serious
study limitations and twice for very serious imprecision). It is unclear if EMDT
leads to a difference in time to complete healing (HR 1.48, 95% CI 0.79 to 2.78,
very low-certainty evidence, downgraded twice for very serious study limitations
and twice for very serious imprecision).The final study (quasi-experimental
cluster trial), explored the impact of multidisciplinary wound care among 176
nursing home residents. It is unclear whether there is a difference in the number
of pressure ulcers healed between multidisciplinary care, or usual care (RR 1.18,
95% CI 0.98 to 1.42; very low-certainty evidence, downgraded twice for very
serious study limitations and twice for very serious imprecision). It is unclear
if this type of care leads to a difference in time to complete healing compared
with usual care (HR 1.73, 95% CI 1.20 to 2.50; very low-certainty evidence;
downgraded twice for very serious study limitations and twice for very serious
imprecision).In all studies the certainty of the evidence is very low due to high
risk of bias and imprecision. We downgraded the evidence due to study
limitations, which included selection and attrition bias, and sample size.
Secondary outcomes, such as adverse events were not reported in all studies.
Where they were reported it was unclear if there was a difference as the
certainty of evidence was very low.
AUTHORS' CONCLUSIONS: Evidence for the impact of organisation of health services
for preventing and treating pressure ulcers remains unclear. Overall, GRADE
assessments of the evidence resulted in judgements of very low-certainty
evidence. The studies were at high risk of bias, and outcome measures were
imprecise due to wide confidence intervals and small sample sizes, meaning that
additional research is required to confirm these results. The secondary outcomes
reported varied across the studies and some were not reported. We judged the
evidence from those that were reported (including adverse events), to be of very
low certainty.
DOI: 10.1002/14651858.CD012132.pub2
PMID: 30536917
