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Ont Health Technol Assess Ser. 2009; 9(2): 1–104.
Published online Apr 1, 2009.
PMCID: PMC3377566
Pressure Ulcer Prevention
An Evidence-Based Analysis
Health Quality Ontario
In April 2008, the Medical Advisory Secretariat began an evidence-based review of the literature concerning pressure ulcers.
Please visit the Medical Advisory Secretariat Web site, http://www.health.gov.on.ca/english/providers/program/mas/tech/tech_mn.html to review these titles that are currently available within the Pressure Ulcers series.
  • Pressure ulcer prevention: an evidence based analysis
  • The cost-effectiveness of prevention strategies for pressure ulcers in long-term care homes in Ontario: projections of the Ontario Pressure Ulcer Model (field evaluation)
  • Management of chronic pressure ulcers: an evidence-based analysis (anticipated pubicstion date - mid-2009)
Purpose
A pressure ulcer, also known as a pressure sore, decubitus ulcer, or bedsore, is defined as a localized injury to the skin/and or underlying tissue occurring most often over a bony prominence and caused by pressure, shear, or friction, alone or in combination. (1) Those at risk for developing pressure ulcers include the elderly and critically ill as well as persons with neurological impairments and those who suffer conditions associated with immobility. Pressure ulcers are graded or staged with a 4-point classification system denoting severity. Stage I represents the beginnings of a pressure ulcer and stage IV, the severest grade, consists of full thickness tissue loss with exposed bone, tendon, and or muscle. (1)
In a 2004 survey of Canadian health care settings, Woodbury and Houghton (2) estimated that the prevalence of pressure ulcers at a stage 1 or greater in Ontario ranged between 13.1% and 53% with nonacute health care settings having the highest prevalence rate (Table 1).
Table 1:
Table 1:
Quality of Evidence of Included Studies – Risk Assessment*
Table thumbnail
Executive Summary Table 1: Prevalence of Pressure Ulcers*
Pressure ulcers have a considerable economic impact on health care systems. In Australia, the cost of treating a single stage IV ulcer has been estimated to be greater than $61,000 (AUD) (approximately $54,000 CDN), (3) while in the United Kingdom the total cost of pressure ulcers has been estimated at £1.4–£2.1 billion annually or 4% of the National Health Service expenditure. (4)
Because of the high physical and economic burden of pressure ulcers, this review was undertaken to determine which interventions are effective at preventing the development of pressure ulcers in an at-risk population.
Review Strategy
The main objective of this systematic review is to determine the effectiveness of pressure ulcer preventive interventions including Risk Assessment, Distribution Devices, Nutritional Supplementation, Repositioning, and Incontinence Management.
A comprehensive literature search was completed for each of the above 5 preventive interventions. The electronic databases searched included MEDLINE, MEDLINE In-Process and Other Non-Indexed Citations, EMBASE, the Cochrane Library, and the Cumulative Index to Nursing and Allied Health Literature. As well, the bibliographic references of selected studies were searched. All studies meeting explicit inclusion and exclusion criteria for each systematic review section were retained and the quality of the body of evidence was determined using the Grading of Recommendation Assessment, Development, and Evaluation (GRADE) system. (5) Where appropriate, a meta-analysis was undertaken to determine the overall estimate of effect of the preventive intervention under review.
Summary of Findings
Risk Assessment
There is very low quality evidence to support the hypothesis that allocating the type of pressure-relieving equipment according to the person’s level of pressure ulcer risk statistically decreases the incidence of pressure ulcer development. Similarly, there is very low quality evidence to support the hypothesis that incorporating a risk assessment into nursing practice increases the number of preventative measures used per person and that these interventions are initiated earlier in the care continuum.
Pressure Redistribution Devices
There is moderate quality evidence that the use of an alternative foam mattress produces a relative risk reduction (RRR) of 69% in the incidence of pressure ulcers compared with a standard hospital mattress. The evidence does not support the superiority of one particular type of alternative foam mattress.
There is very low quality evidence that the use of an alternating pressure mattress is associated with an RRR of 71% in the incidence of grade 1 or 2 pressure ulcers. Similarly, there is low quality evidence that the use of an alternating pressure mattress is associated with an RRR of 68% in the incidence of deteriorating skin changes.
There is moderate quality evidence that there is a statistically nonsignificant difference in the incidence of grade 2 pressure ulcers between persons using an alternating pressure mattress and those using an alternating pressure overlay.
There is moderate quality evidence that the use of an Australian sheepskin produces an RRR of 58% in the incidence of pressure ulcers grade 1 or greater. There is also evidence that sheepskins are uncomfortable to use. The Pressure Ulcer Advisory Panel noted that, in general, sheepskins are not a useful preventive intervention because they bunch up in a patient’s bed and may contribute to wound infection if not properly cleaned, and this reduces their acceptability as a preventive intervention.
There is very low quality evidence that the use of a Micropulse System alternating pressure mattress used intra operatively and postoperatively produces an RRR of 79% in the incidence of pressure ulcers compared with a gel-pad used intraoperatively and a standard hospital mattress used postoperatively (standard care). It is unclear if this effect is due to the use of the alternating pressure mattress intraoperatively or postoperatively or if indeed it must be used in both patient care areas.
There is low quality evidence that the use of a vesico-elastic polymer pad (gel pad) on the operating table for surgeries of at least 90 minutes’ duration produces a statistically significant RRR of 47% in the incidence of pressure ulcers grade 1 or greater compared with a standard operating table foam mattress.
There is low quality evidence that the use of an air suspension bed in the intensive care unit (ICU) for stays of at least 3 days produces a statistically significant RRR of 76% in the incidence of pressure ulcers compared with a standard ICU bed.
There is very low quality evidence that the use of an alternating pressure mattress does not statistically reduce the incidence of pressure ulcers compared with an alternative foam mattress.
Nutritional Supplementation
There is very low quality evidence supporting an RRR of 15% in the incidence of pressure ulcers when nutritional supplementation is added to a standard hospital diet.
Repositioning
There is low quality evidence supporting the superiority of a 4-hourly turning schedule with a vesico-elastic polyurethane foam mattress compared with a 2-hourly or 3-hourly turning schedule and a standard foam mattress to reduce the incidence of grade 1 or 2 pressure ulcers.
Incontinence Management
There is very low quality evidence supporting the benefit of a structured skin care protocol to reduce the incidence of grade 1 or 2 pressure ulcers in persons with urinary and/or fecal incontinence.
There is low quality evidence supporting the benefit of a pH-balanced cleanser compared with soap and water to reduce the incidence of grade 1 or 2 pressure ulcers in persons with urinary and fecal incontinence.
Conclusions
There is moderate quality evidence that an alternative foam mattress is effective in preventing the development of pressure ulcers compared with a standard hospital foam mattress.
However, overall there remains a paucity of moderate or higher quality evidence in the literature to support many of the preventive interventions. Until better quality evidence is available, pressure ulcer preventive care must be guided by expert opinion for those interventions where low or very low quality evidence supports the effectiveness of such interventions.
Abbreviations
CIConfidence interval
GRADEGrading of Recommendation Assessment, Development, and Evaluation
ICUIntensive care unit
MASMedical Advisory Secretariat
NPUAPNational Pressure Ulcer Advisory Panel
RASRisk assessment scale
RCTRandomized controlled trial
RNAORegistered Nurses Association of Ontario
RRRelative risk
RRRRelative risk reduction

Overall Objective
The main objective of this systematic review is to determine the effectiveness of pressure ulcer preventive interventions. The following preventive interventions are reviewed in this report:
  • Risk Assessment
  • Distribution Devices
  • Nutritional Supplements
  • Repositioning
  • Incontinence Management
Methods
A comprehensive literature search was completed for each of the above 5 preventive interventions. The electronic databases searched included MEDLINE, MEDLINE In-Process and Other Non-Indexed Citations, EMBASE, the Cochrane Library, and the Cumulative Index to Nursing and Allied Health Literature. In addition, the bibliographic references of selected studies were searched. All search strategies are presented in full in Appendices 1 through 5. After a review of the title and abstracts, relevant studies were obtained and the full report evaluated. All studies meeting explicit inclusion and exclusion criteria for each preventive intervention systematic review section were retained and the quality of the body of evidence, defined as 1 or more relevant studies, was determined using GRADE. (5) Where appropriate, a meta-analysis was undertaken to determine the overall estimate of effect of the preventive intervention under review.
Assessment of Quality of Evidence
The quality of the body of evidence was examined according to the GRADE Working Group criteria. (5) Quality refers to criteria such as the adequacy of allocation concealment, blinding, and losses to follow-up and completion of an intention to treat analysis. Consistency refers to the similarity of effect estimates across studies. If there is important unexplained inconsistency in the results, confidence in the estimate of effect for that outcome decreases. Differences in the direction of effect, the size of the effect, and the significance of the differences guide the decision about whether important inconsistency exists. Directness refers to the extent to which the interventions, population, and outcome measures are similar to those of interest.
The GRADE Working Group used the following definitions in grading the quality of the evidence:
HighFurther research is very unlikely to change confidence in the estimate of effect.
ModerateFurther research is likely to have an important impact on confidence in the estimate of effect and may change the estimate.
LowFurther research is very likely to have an important impact on confidence in the estimate of effect and is likely to change the estimate.
Very LowAny estimate of effect is very uncertain.
Results of Evidence-Based Analyses
The following results of the evidence-based analysis for each preventive intervention will be reported:
  • results of literature search
  • characteristics of included studies
  • quality assessment of individual studies
  • results including meta-analysis (where applicable)
  • GRADE evidence profile
  • summary of results
Research Question
The literature was searched to determine the effect of using a pressure ulcer risk assessment tool on the incidence of pressure ulcers. The search strategy is presented in Appendix 1).
Methods
Inclusion Criteria
  • systematic reviews (with/without meta-analysis), randomized controlled trials (RCTs), and nonrandomized controlled clinical trials
  • studies involving a population at risk for developing pressure ulcers
  • studies evaluating the use of any risk assessment scale (RAS) for pressure ulcer development compared with not using an RAS or with clinical judgment
  • studies reporting the incidence of new pressure ulcer measured as the number (proportion) of persons developing a new pressure ulcer
  • studies reporting the stage of pressure ulcer or in which the stage can be inferred from the description of the ulcer
Exclusion Criteria
  • studies determining the validity and reliability properties of an RAS
  • studies reporting only the number of pressure ulcers (number of wounds) as an outcome measure
Primary Outcome Measure
The primary outcome measure was the incidence of pressure ulcers measured as the number (proportion) of persons developing a new pressure ulcer.
Results of Literature Search
Two systematic reviews (6;7) and 3 non-RCT studies (8-10) were obtained from the literature search strategy (Table 1). The objective of both systematic reviews was to determine the effectiveness of using a pressure ulcer RAS to reduce the incidence of pressure sores. McGough (6) searched the literature up to June 1997, and Pancorbo-Hidalgo et al. (7) searched up to 2003. McGough (6) limited the literature search to RCT designs and reported that there were no RCTs found that determined the effectiveness of RASs on the incidence of pressure ulcers. Pancorbo-Hidalgo et al. (7) did not limit their search to a specific study design and found 3 non-RCTs. The Medical Advisory Secretariat completed an updated literature search from 2003 to February 2008 and did not find additional studies to add to the body of evidence reported by Pancorbo-Hidalgo et al. (7) What follows is a report and evaluation of the 3 non-RCT studies described in the systematic review by Pancorbo-Hidalgo et al. (7)
Characteristics of Included Studies
Table 2 reports the characteristics of the studies included in this systematic review. Gunningberg et al. (9) used a prospective controlled study design (contemporaneous controls), whereas the studies completed by both Hodge et al. (10) and Bale (8) used a before-and-after study design. The mean ages in this body of evidence ranged from 60 to 80 years. All studies used different RASs as well as different pressure ulcer classification systems to measure the study outcome. The characteristics of the RASs used are reported in Table 3.
Table 2:
Table 2:
Characteristics of Included Studies – Risk Assessment*
Table 3:
Table 3:
Characteristics of the Risk Assessment Scales
Quality Assessment of Included Studies
The quality assessment for each of the 3 studies included in this review is reported in Table 4. Gunningberg et al. (9) used a prospective controlled study design with consecutive sampling and an alternate allocation scheme to assign participants to either the treatment or control interventions. Important study limitations included that the outcome measure of new pressure ulcers was not assessed independently of the treatment exposure status and that there was greater loss to follow-up in the control group compared with the treatment group at both discharge (41% vs. 8%, respectively) and 2 weeks postoperatively (53% vs. 26%, respectively). This latter limitation could possibly account for the lack of a statistically significant difference in the incidence of pressure ulcers between treatment groups.
Table 4:
Table 4:
Individual Study Quality Assessment – Risk Assessment*
Bale (8) used a before-and-after study design with consecutive enrollment and therefore the participants allocated to phase 1 (control) were different than those allocated to phase 2 (treatment). Major methodological limitations included the use of an adaptive version of the Norton RAS that had not been validated, and, like Gunningberg et al., (9) an outcome measure that was not assessed independently of the treatment exposure status. Interestingly, however, the patients in phase 2 (treatment) had higher risk assessment scores, indicating an increased risk for developing a pressure ulcer, than participants in phase 1 (control). It is likely this would have biased the results in favor of fewer pressure ulcers in the control group; however, instead there were statistically significantly more new pressure ulcers in the control group compared with the treatment group (22.4% vs. 2.5%).
Hodge et al. (10) also used a before-and-after study design with consecutive enrollment. Therefore, there were different participants allocated between phase 1 (control) and phase 2 (treatment). Hodge et al. did not report the incidence of pressure ulcers as a primary outcome but instead the purpose of the study was to investigate the effect on nursing practice and patients’ skin condition of using an RAS compared with not using an RAS. This was a well-conducted study with few if any methodological limitations biasing the study results. Unlike Gunningberg et al. (9) and Bale, (8) Hodge et al. (10) did assess the outcome measure independently of the treatment exposure status. In phase 1 the nurses caring for the study participants were unaware of the purpose of the study. In phase 2, the Norton RAS was done independently from the collection of the outcome measure (number of treatment interventions per patient). Finally, a standardized checklist of nursing interventions was used for data collection.
Results
The main findings from each of these 3 studies are reported in Table 5. The individual study results were not amenable to meta-analysis because of the different study designs and outcome measures used between studies. Gunningberg et al. (9) did not find a significant difference between the treatment and control groups in the incidence of pressure ulcers. The high rate of attrition from the control group in the Gunningberg et al. (9) study may have contributed to the negative results of that study.
Table 5:
Table 5:
Study Results – Risk Assessment
Bale (8) reported that using an RAS significantly reduced the incidence of pressure ulcers compared with not using one (22.4% vs. 2.5%, control vs. treatment, P < .0001). The significant result from Bale (8) may be due to the tailoring of the type of pressure-relieving preventive intervention to the person’s risk level. Figure 1 presents the results reported by Bale.
Figure 1:
Figure 1:
Risk Assessment Versus No Risk Assessment
CI indicates confidence interval; RR, relative risk.
Hodge et al. (10) reported that there was on average a significantly higher number of preventative interventions used per person (P < .0001) when an RAS was incorporated into nursing practice compared with not doing so. Furthermore, preventive interventions were used earlier in the hospital stay for persons receiving an RAS compared with the group that did not have an RAS completed (P < .002). However, there was no difference reported in the incidence of pressure ulcers between treatment groups.
Grade of Evidence
The overall quality of evidence using the GRADE assessment method is reported by outcome measure in Tables 6 and and7.7. Because of the serious limitations in attrition rate in the study by Gunningberg et al., (9) only the Bale (8) study was considered as the body of evidence for the outcome of incidence of pressure ulcers. The quality of evidence is very low, indicating an estimate of effect that is uncertain. The study by Hodge et al. (10) formed the body of evidence for the outcome “number of preventive interventions used per person.” The quality of evidence is also very low for this outcome, indicating that the estimate of effect is very uncertain.
Table 6:
Table 6:
GRADE Evidence Profile – Risk Assessment Versus No Risk Assessment Outcome: Incidence of Pressure Ulcers*
Table 7:
Table 7:
GRADE Evidence Profile – Risk Assessment Versus No Risk Assessment Outcome: Number of Preventive Interventions Used*
Summary of Results
There is very low quality evidence to support the hypothesis that allocating the type of pressure-relieving equipment according to the person’s level of pressure ulcer risk statistically decreases the incidence of pressure ulcers. Similarly, there is very low quality evidence to support the hypothesis that incorporating an RAS into nursing practice increases the number of preventative measures used per person and that these interventions are initiated earlier in the care continuum. However, completing a risk assessment did not affect the incidence of pressure ulcers.
Research Question
The literature was searched to determine the effect of using various pressure redistribution devices including mattresses, overlays, and sheepskins on the incidence of pressure ulcers in a population at risk for developing pressure ulcers. The search strategy is presented in Appendix 2.
Methods
Inclusion Criteria
  • systematic reviews (with/without meta-analysis) or RCTs
  • studies involving a population at risk for developing pressure ulcers
  • studies evaluating the use of static or dynamic mattresses and/or mattress overlays compared with standard foam and/or other static of dynamic distribution devices
  • studies evaluating the use of sheepskins compared with a standard foam mattress or other static or dynamic distribution devices
  • studies reporting the incidence of pressure ulcers measured as the number (proportion) of persons developing a new pressure ulcer
  • studies reporting the stage of pressure ulcer or in which the stage can be inferred from the description of the ulcer
Types of Devices
For the purpose of this review, dynamic pressure redistribution devices (also called high tech) were defined as alternating devices where cells in the mattress surface alternately inflate and deflate. Static devices (also called low tech) were defined as conforming surfaces that distribute the body weight over a large area.
Studies evaluating any of the following distribution devices were included in this review:
High-Tech Surfaces (Dynamic Surfaces)
  • alternating pressure
  • low air loss beds
  • air fluidized beds
  • turning beds/frames (profiling beds)
Low-Tech Surfaces (Static Surfaces)
  • alternative foam (e.g., convoluted/cubed, high density foam)
  • gel-filled
  • fiber-filled
  • water-filled
  • air-filled
  • bead-filled
  • silicore-filled
  • sheepskins
Exclusion Criteria
  • studies in which the type of redistribution support surface could not be determined
Primary Outcome Measure
The primary outcome measure was the incidence of pressure ulcers measured as the number (proportion) of participants developing a new pressure ulcer.
Results of Literature Search
One systematic review (12) and 1 systematic review with meta-analysis (13) were each obtained from the literature search strategy (Table 8). The objective of both systematic reviews was to determine the effectiveness of pressure redistribution surfaces on the incidence of pressure ulcers. Cullum et al. (13) searched the medical literature up to and including January 2004, limiting the search to RCTs comparing the effectiveness of beds, mattresses, and cushions on the incidence of pressure ulcers. A total of 41 RCTs were retrieved from the literature. Reddy et al. (12) searched the medical literature up to and including June 2006, also limiting the search to RCTs with clinically relevant outcome measures. An additional 5 RCTs to those retrieved by Cullum et al. (13) were obtained. Cullum et al. (13) completed a meta-analysis of the evidence whereas Reddy et al. (12) did not. Table 9 reports the results of the meta-analyses completed by Cullum et al. (13)
Table 8:
Table 8:
Quality of Evidence of Included Studies – Pressure Redistribution Devices*
Table 9:
Table 9:
Results of Meta-Analyses Completed by Cullum et al.*
We completed an updated literature search to that completed by Reddy et al. (12) and Cullum et al., (13) up to and including October 2007. Five new RCTs (2 large (14;15) and 3 small (16-18) were obtained. We report in this review 3 statistically significant meta-analyses from the Cullum et al. (13) review as well as 3 updated meta-analyses to those completed by Cullum et al. (13)(Table 9. In addition to these 6, we report 3 new comparisons not reported by Cullum et al. (13) (Table 10). In total, the 9 comparisons reported in this review include:
Table 10:
Table 10:
New Meta-Analyses Not Found in Cullum et al.
Acute Care Setting
Comparison 1: Alternative Foam Versus Standard Foam
Comparison 2: Alternative Foam Versus Alternative Foam
Comparison 3: Alternating Pressure Mattress or Overlay Versus Standard Foam Mattress
Comparison 4: Alternating Pressure Mattress Versus Alternating Pressure Overlay
Comparison 5: Australian Sheepskin Versus Standard Treatment
Comparison 6: Alternating Pressure Mattress (Micropulse System) Versus Standard Care
Peri-Operative and Operative Setting
Comparison 7: Dry Vesico-Elastic Polymer Pad Versus Standard Operating Table Foam Mattress
Comparison 8: Air Suspension Bed Versus Standard Intensive Care Unit (ICU) Bed
Intensive Care Unit Setting
Comparison 9: Alternating Pressure Mattress Versus Alternative Foam
Comparison 1: Alternative Foam Mattress Versus Standard Foam Mattress
Characteristics of Included Studies
Six studies compared alternative foam mattresses with standard foam mattresses. (14;1923) The study characteristics are reported in Table 11. All studies included patients admitted to an acute care setting. A variety of alternative foam mattresses were used in the treatment group. Standard mattresses in the control group were described by all included studies other than Berthe et al. (14) The author was contacted for this information but a response was not received. The follow-up study period in these 6 studies ranged from 10 days to 7 months. Four studies used an explicit pressure ulcer grading system (Table 12): 2 used different versions of the Torrence scale, the third used a modification of the Shea Scale, and the fourth used a grading system developed at the Dutch consensus meeting from 1985. Variations in the scales included grade 1 ranging from persistent erythema to blanching erythema and grade 2 from blister formation and nonblanching erythema. Collier (19) reported on the outcome of deterioration in skin condition, and Gray and Campbell (20) reported the incidence of pressure ulcers but did not report using an explicit grading system.
Table 11:
Table 11:
Study Characteristics – Alternative Foam Versus Standard Foam*
Table 12:
Table 12:
Pressure Ulcer Classification Systems – Studies of Alternative Foam Versus Standard Foam
Of note, the study by Russell et al. (22) used a vesico-elastic and polyurethane (CONFOR-Med Mattress) foam mattress in the treatment group and 5 different types of mattresses as the control. Among the 5 different types of mattress, Russell included the transfoam mattress, which both Collier (19) and Santy et al. (23) used as the treatment (alternative foam) group. As well, the Softfoam appears to be a high-density foam mattress and thus more like an alternative foam mattress than a standard foam mattress.
Quality Assessment of Included Studies
The individual study quality assessment is presented in Table 13. Only 2 studies, Russell et al. (22) and Gray and Campbell, (20) explicitly describe allocation concealment methods. Santy et al. (23) was contacted and confirmed that allocation concealment was maintained by using sealed opaque envelopes. Similarly, other than Collier, (19) appropriate blinding of the patient or outcome assessor was not completed in any study.
Table 13:
Table 13:
Individual Study Quality Assessment – Alternative Foam Versus Standard Foam*
Results
The analysis completed by Cullum et al. (13;24) included the study by Russell et al. (22) (Figure 2); however, this analysis may be criticized as the control group in the study by Russell et al. (25) included an alternative foam mattress and is therefore dissimilar to the control groups of the other studies in the meta-analysis. Given this, the resultant relative risk (RR) estimate may represent an underestimate of the effect of an alternative foam mattress. It also may account for the large statistical heterogeneity in the analysis (I2 = 77.3%). We completed a meta-analysis but removed the study by Russell et al. (22) (Figure 3). The resultant RR (random effects model) was 0.31 (95% confidence interval [CI], 0.21–0.46) with a corresponding I2 value of 0%. Because the type or description of standard mattresses was not reported by Berthe et al., (14) we did not include this study in our meta-analysis. The author of the study was contacted for this information but did not reply.
Figure 2:
Figure 2:
Alternative Foam Versus Standard Foam – Cullum et al. Meta-Analysis
Source: Cullum et al. (13;24)
Figure 3:
Figure 3:
Medical Advisory Secretariat Meta-Analysis – Alternative Foam Versus Standard Foam
CI indicates confidence interval; RR, relative risk
Grade of Evidence
Table 14 reports the GRADE evidence profile for the body of evidence evaluating the effectiveness of alternative foam mattresses compared with standard foam hospital mattresses. The quality of the body of evidence is moderate.
Table 14:
Table 14:
GRADE Evidence Profile – Alternative Foam Versus Standard Foam* Mattress Outcome: Any of Skin Deterioration, Mew Ulcer, Persistent or Nonblanching Erythema, Blister or Worse
Summary of Results
There is high quality evidence that the use of an alternative foam mattress produces an RRR of 69% in the incidence of pressure ulcers.
Comparison 2: Alternative Foam Mattress Versus Alternative Foam Mattress
Characteristics of Included Studies
Cullum et al. (13) reported 3 studies comparing different types of alternative foam mattresses including that completed by Santy et al., (23) Kemp et al., (26) and Vyhlidal et al. (27) However, the study by Santy et al. (23) was incorporated into the analysis of alternative foam mattresses compared with standard mattresses, so it is unclear why it was included in this comparison of alternative foam mattress versus alternative foam mattress. Therefore, we removed this study from the analysis. Our literature search found 1 additional study completed by Gray and Smith (16) comparing different types of alternative foam mattresses. This study was added to the body of evidence for this comparison. The study characteristics are reported in Table 15. All studies included patients admitted to an acute care setting. A variety of alternative foam mattresses were used in the treatment and control groups. All studies used an explicit pressure ulcer grading system (Table 16).
Table 15:
Table 15:
Characteristics of Included Studies – Alternative Foam Versus Alternative Foam*
Table 16:
Table 16:
Pressure Ulcer Classification System – Alternative Foam Versus Alternative Foam*
Quality Assessment of Included Studies
The individual study quality assessment is presented in Table 17. Of the 3 studies comprising the body of evidence, only 1, that by Gray and Smith, (16) reported adequate methods for both treatment allocation concealment and blinding the outcome assessments. None of the studies determined a sample size a priori. Loss to follow-up was negligible in all studies.
Table 17:
Table 17:
Quality Assessment of Included Studies*
Results
A meta-analysis for this comparison was not completed because of the variety of mattress types included in the individual studies. Figure 4 reports the results of the study completed by Vyhlidal et al. (27) Results indicate that the Maxifloat mattress statistically significantly decreases the incidence of grade 1 pressure ulcers compared with the Iris Foam Mattress. However, the Maxifloat group was significantly heavier than the Iris Foam group (body mass index 35 vs. 29, respectively) which may have lowered the risk for developing a pressure ulcer in the Maxifloat group. As well, the Maxifloat group also used heel guards. Because of this, we analyzed the study results to determine if there were fewer heel ulcers in the Maxifloat group accounting for an overall lower incidence of pressure ulcers between the Maxifloat and the Iris mattresses. Results indicated that there was no statistically significant difference in heel ulcers between groups (RR [fixed], 0.80; 95% CI, 0.25–2.60) (Figure 5). Therefore, the small sample size as well as the aforementioned issues regarding baseline characteristics of the groups may have biased the results of the study in favor of the Maxifloat mattress and thus the results of this study should be interpreted with caution.
Figure 4:
Figure 4:
Alternative Foam Mattress Versus Alternative Foam Mattress – Vyhlidal et al. – Incidence of Pressure Ulcers
CI indicates confidence interval; RR, relative risk.
Figure 5:
Figure 5:
Alternative Foam Mattress Versus Alternative Foam Mattress – Vyhlidal et al. Incidence of Heel Ulcers
CI indicates confidence interval; PU, pressure ulcers; RR, relative risk.
The results of the studies by Kemp et al. (26) and Gray and Smith (16) are reported in Figures 6 and and7,7, respectively. Both studies report a statistically nonsignificant result.
Figure 6:
Figure 6:
Alternative Foam Mattress Versus Alternative Mattress – Kemp et al.
CI indicates confidence interval; RR, relative risk.
Figure 7:
Figure 7:
Alternative Foam Mattress Versus Alternative Mattress – Gray and Smith
CI indicates confidence interval; RR, relative risk.
Grade of Evidence
Table 18 reports the GRADE evidence profile for the body of evidence evaluating the effectiveness of alternative foam mattresses (Foam 1) compared with alternative foam mattresses (Foam 2). The quality of the body of evidence is very low for the outcome of incidence of pressure ulcers grade 1 or greater.
Table 18:
Table 18:
GRADE Evidence Profile – Alternative Foam Alternative Foam Versus Alternative Foam* Outcome: Incidence of Pressure Ulcers Grade 1 or Greater
Summary of Results
The evidence does not support the superiority of any one type of alternative foam mattress. The quality of this evidence is very low.
Comparison 3: Alternating Pressure Mattress or Overlay Versus Standard Foam Mattress
Characteristics of Included Studies
In the systematic review by Cullum et al., (13) only the study by Andersen et al. (28) was reported comparing an alternating pressure mattress with a standard foam mattress. We found 1 additional RCT to add to this body of evidence, that completed by Sanada et al. (18) Therefore, 2 studies comprise the body of evidence comparing an alternating pressure mattress or overlay with a standard foam mattress. The study characteristics are reported in Table 19. All studies included patients admitted to an acute care setting. The follow-up study period was 10 days in the Andersen et al. (28) study. Sanada et al. (18) reported that follow-up was continued until a pressure ulcer developed. Both studies used an explicit but different pressure ulcer grading system (Tables 20 and and2121).
Table 19:
Table 19:
Characteristics of Included Studies – Alternating Pressure or Overlay Versus Standard Foam*
Table 21:
Table 21:
Quality Assessment of Included Studies – Alternating Pressure or Overlay Versus Standard Foam*
Table 20a:
Table 20a:
Pressure Ulcer Classification System Used by Andersen et al., 1982 – Alternating Pressure or Overlay Versus Standard Foam
Table 20b:
Table 20b:
Pressure Ulcer Classification System Used by Sanada et al., 2003 – Alternating Pressure or Overlay Versus Standard Foam*
Quality Assessment of Included Studies
The individual study quality assessment is presented in Table 21. Of the 2 studies comprising the body of evidence, only 1, that by Sanada et al., (18) reported adequate allocation concealment methods and also completed a sample size calculation a priori. Neither study used a blinded assessment method for the outcome measure. Loss to follow-up ranged from 20% to 24%.
Results
A meta-analysis was not completed because of the different outcome measures used between studies (incidence of stage 1 and 2 pressure ulcers vs. changes in skin integrity). The results of each study are reported in Figures 8 and and9,9, respectively. Both studies report similar RR (fixed) estimates and 95% CIs.
Figure 8:
Figure 8:
Alternating Pressure or Overlay Versus Standard Foam – Sanada et al.
AP indicates alternating pressure; CI, confidence interval; RR, relative risk.
Figure 9:
Figure 9:
Alternating Pressure or Overlay Versus Standard Foam – Anderson et al.
AP indicates alternating pressure; CI, confidence interval; RR, relative risk.
Grade of Evidence
Tables 22 and and2323 report the GRADE evidence profile for the body of evidence evaluating the effectiveness of an alternating pressure mattress or overlay versus a standard foam mattress. Table 22 reports that the quality of evidence is very low for the outcome of the incidence of grade 1 or 2 pressure ulcers, and Table 23 reports low quality of evidence for the outcome of changes in skin integrity.
Table 22:
Table 22:
GRADE Evidence Profile – Alternating Pressure Overlay Versus Standard Foam Mattress
Outcome: Incidence of Grade 1 or 2 Pressure Ulcer*
Table 23:
Table 23:
GRADE Evidence Profile – Alternating Pressure Mattresses Versus Standard Foam Mattress
Outcome: Changes in Skin Integrity*
Summary of Results
There is very low quality evidence that the use of an alternating pressure overlay is associated with an RRR of 71% in the incidence of grade 1 or 2 pressure ulcers compared with a standard foam mattress.
There is low quality evidence that the use of an alternating pressure mattress is associated with an RRR of 68% in the incidence of skin changes compared with a standard foam mattress.
Comparison 4: Alternating Pressure Mattress Versus Alternating Pressure Overlay
Characteristics of Included Studies
One study compared the use of an alternating pressure mattress with an alternating pressure overlay. (29) The study characteristics are reported in Table 24. This comparison is not reported in the review by Cullum et al. (13) The study by Nixon et al. (29) included patients admitted to an acute care setting. The median follow-up time period was 9 days. An explicit pressure ulcer classification system was used to measure the outcome (Table 25).
Table 24:
Table 24:
Characteristics of Included Study – Alternating Pressure Mattress Versus Alternating Pressure Overlay
Table 25:
Table 25:
Skin Classification System – Study of Alternating Pressure Mattress Versus Alternating Pressure Overlay
Quality Assessment of Included Studies
The individual study quality assessment is presented in Table 26. The study by Nixon et al. (29) was well conducted. Methodological limitations include only an unblinded outcome assessment.
Table 26:
Table 26:
Quality Assessment of Included Study – Alternating Pressure Mattress Versus Alternating Pressure Overlay
Results
The results of the study completed by Nixon et al. (29) are reported in Figure 10. There was no statistically significant difference between alternating pressure mattress and an alternating pressure overlay in the incidence of pressure ulcers grade 2 or greater.
Figure 10:
Figure 10:
Alternating Pressure Mattress Versus Alternating Pressure Overlay
AP indicates alternating pressure; CI, confidence interval; RR, relative risk.
Grade of Evidence
Table 27 reports the GRADE evidence profile for the body of evidence evaluating the effectiveness of an alternating pressure mattress compared with an alternating pressure overlay. The quality of evidence is moderate for the outcome of incidence of grade 2 or greater pressure ulcers.
Table 27:
Table 27:
GRADE Evidence Profile – Alternating Pressure Mattresses Versus Alternating Pressure Overlay
Outcome: Incidence of Pressure Ulcers Grade 2 or Greater*
Summary of Results
There is moderate quality evidence that there is a statistically nonsignificant difference in the incidence of grade 2 or greater pressure ulcers between persons using an alternating pressure mattress and using an alternating pressure overlay.
Comparison 5: Australian Sheepskin Versus Standard Treatment
Characteristics of Included Studies
Two studies compared the use of an Australian sheepskin overlay and sheepskin heel and elbow protectors with the use of a standard hospital mattress and other constant low pressure devices as needed. (17;30) The study characteristics are reported in Table 28. All studies included patients admitted to an acute care setting, and treatment and control interventions were exactly the same in both studies. In the study by McGowan et al., (30) patients were followed until discharge from hospital; however, the authors did not report the average length of hospital stay for the study population. Jolley et al. (17) reported the follow-up period to be 7 days. Both studies used the same pressure ulcer classification system (Table 29).
Table 28:
Table 28:
Characteristics of Included Studies – Australian Sheepskin Versus Standard Treatment*
Table 29:
Table 29:
Pressure Ulcer Classification System – Studies of Australian Sheepskin Versus Standard Treatment
Quality Assessment of Included Studies
The individual study quality assessment is presented in Table 30. Both studies are methodologically sound except for using an unblinded outcome assessment process.
Table 30:
Table 30:
Quality Assessment of Included Studies – Australian Sheepskin Versus Standard Treatment*
Results
Figure 11 reports the result of the meta-analysis for this body of evidence. There is a statistically significant reduction in the RR of pressure ulcers grade 1 or greater in persons using an Australian sheepskin compared with persons using standard treatment. This corresponds to an RRR of 58%. The I2 value is 67%, indicating moderate statistical heterogeneity in the analysis.
Figure 11:
Figure 11:
Australian Sheepskin Overlay Versus Standard Treatment
CI indicates confidence interval; RR, relative risk.
Complications with sheepskins were also reported in both studies. Jolley et al. (17) reported that 10 patients using sheepskins complained that the sheepskin was uncomfortable and too hot. Sensitivity to the wool surface was also reported. Participants in the McGowan et al. (30) study reported that the sheepskins were hot and curled up in the bed. Six participants withdrew before completion of the study because the sheepskin caused an irritation and was too hot or uncomfortable.
To contextualize the evidence, the secretariat convened a Pressure Ulcer Advisory Panel comprised of clinical experts in pressure ulcer management. This advisory panel noted that in general sheepskins are not an acceptable preventive intervention because they bunch up in the patient’s bed and may contribute to wound infection if not properly cleaned.
Grade of Evidence
Table 31 reports the GRADE evidence profile for the body of evidence evaluating the effectiveness of the Australian sheepskin compared with standard care. The quality of evidence is moderate for the outcome of incidence of pressure ulcers grade 1 or greater.
Table 31:
Table 31:
GRADE Evidence Profile – Australian Sheepskin Versus Standard Treatment Outcome: Incidence of Pressure Ulcers Grade 1 or Greater*
Summary of Results
There is moderate quality evidence that the use of an Australian sheepskin produces an RRR of 58% in the incidence of pressure ulcers grade 1 or greater. There is also evidence that sheepskins are uncomfortable to use. The Pressure Ulcer Advisory Panel noted that in general sheepskins are not a useful preventive intervention because they bunch up in a patient’s bed and may contribute to wound infection if not properly cleaned, and this reduces their acceptability as a preventive intervention.
Comparison 6: Alternating Pressure Mattress (Micropulse System) Versus Standard Care
Characteristics of Included Studies
Two studies compared the Micropulse System alternating pressure mattress with standard care. (31;32) The study characteristics are reported in Table 32. Both studies included patients having surgery for 2 or more hours. The follow-up study period was 7 days for both studies. Both studies used the National Pressure Ulcer Advisory Panel (NPUAP) pressure ulcer classification system (Table 33).
Table 32:
Table 32:
Characteristics of Included Studies – Alternating Pressure Mattress (Micropulse System) Versus Standard Care*
Table 33:
Table 33:
Pressure Ulcer Classification System – Alternating Pressure Mattress (Micropulse System) Versus Standard Care*
Quality Assessment of Included Studies
The individual study quality assessment is presented in Table 34. The study by Aronovitch et al. (31) did not satisfy any of the quality assessment criteria. Similarly, other than using an adequate allocation concealment process and proper randomization methodology, Russell and Lichtenstein (32) also did not satisfy many of the quality assessment criteria.
Table 34:
Table 34:
Quality Assessment of Included Studies – Alternating Pressure Mattress (Micropulse System) Versus Standard Care*
Results
Figure 12 reports the results of the meta-analysis of the Aronovitch et al. and Russell and Lichtenstein studies. (31;32) There is a statistically significant reduction in the incidence of pressure ulcers (RR, 0.21; 95% CI, 0.06–0.70), suggesting an RRR in pressure ulcers of 79%. A limitation of the study design in both studies is that the Micropulse System alternating pressure mattress was used both intraoperatively and postoperatively. Because of this, it is unknown if the effect of this system is due to its use intraoperatively or postoperatively, or indeed if it needs to be used in both phases.
Figure 12:
Figure 12:
Alternating Pressure Mattress (Micropulse System) Versus Standard Care
CI indicates confidence interval; RR, relative risk.
Grade of Evidence
Table 35 reports the GRADE evidence profile for the body of evidence evaluating the effectiveness of the alternating pressure Micropulse System (AP) compared with a gel-pad intraoperatively and a standard mattress postoperatively (Standard care, SC). The quality of evidence is very low for the outcome of incidence of pressure ulcers grade 1 or greater pressure.
Table 35:
Table 35:
GRADE Evidence Profile – Alternating Pressure Mattress Intraoperatively and Postoperatively Versus a Gel Pad Intraoperatively and a Standard Mattress Postoperatively Outcome: Incidence of Pressure Ulcers Grade 1 or Greater*
Summary of Results
There is very low quality evidence that the use of an alternating pressure Micropulse System used intraoperatively and postoperatively produces an RRR of 79% in the incidence of pressure ulcers compared with a gel-pad intraoperatively and a standard mattress postoperatively (standard care). It is unclear if the effect is due to the use of the alternating pressure mattress intra operatively or postoperatively, or if indeed it must be used in both patient care areas.
Comparison 7: Dry Vesico-Elastic Polymer Pad Versus Standard Operating Table Foam Mattress
Characteristics of Included Studies
One study compared an operating table vesico-elastic polymer pad (gel pad) with a standard operating room table foam mattress. (32;33) The study characteristics are reported in Table 36. The follow-up study period was 1 postoperative day. The Torrance pressure ulcer classification grading system was used to measure the outcome (Table 37). Of note, in this classification system a grade 1 pressure ulcer includes blanching erythema.
Table 36:
Table 36:
Characteristics of Included Studies – Dry Vesico-Elastic Polymer Pad Versus Standard Operating Table Foam Mattress
Table 37:
Table 37:
Pressure Ulcer Classification System – Study of Dry Vesico-Elastic Polymer Pad Versus Standard Operating Table Foam Mattress
Quality Assessment of Included Studies
The individual study quality assessment is presented in Table 38. The study by Nixon et al. (33) satisfied all 6 quality assessment criteria.
Table 38:
Table 38:
Quality Assessment of Included Studies*
Results
The results of the study by Nixon et al. (33) are reported in Figure 13. There is a statistically significant reduction in the incidence of pressure ulcers grade 1 or greater in person using an operating table gel pad (RR, 0.53; 95% CI, 0.33–0.85) corresponding to an RRR of 47%. Of note, 20% of participants had a surgical time less than 90 minutes including 23% of persons in the treatment group compared with 18% in the control group. There was also a trend for the control group to have a longer duration of surgery and to spend more time in a hypotensive state intraoperatively. These variables may have increased the risk for developing pressure ulcers in the control group compared with the treatment group.
Figure 13:
Figure 13:
Operating Table Overlay Versus Standard Operating Room Table
CI indicates confidence interval; O.R., operating room; RR, relative risk.
Grade of Evidence
Table 39 reports the GRADE evidence profile for the body of evidence evaluating the effectiveness of a vesico-elastic polymer pad compared with a standard operating 3-inch foam mattress (standard care). The quality of evidence is low for the outcome of incidence of grade 1 or greater pressure ulcers.
Table 39:
Table 39:
GRADE Evidence Profile - Dry Vesico-Elastic Polymer Pad Versus Standard 3-Inch Foam Mattress on Operating Table
Outcome: Incidence of Pressure Ulcers Grade 1 or Greater*
Summary of Results
There is low quality evidence that the use of a vesico-elastic polymer pad (gel pad) on the operating table for surgeries of at least 90 minutes’ duration produces a statistically significant RRR of 47% in the incidence of pressure ulcers grade 1 or greater compared with a standard operating table foam mattress.
Comparison 8: Air Suspension Bed Versus Standard Intensive Care Unit Bed
Characteristics of Included Studies
One study compared an air suspension bed with a standard intensive care unit (ICU) bed. (34) The study characteristics are reported in Table 40. The follow-up study period was 17 days on average. The Shea pressure ulcer classification grading system (35) was used to measure the outcome measure (Table 41).
Table 40:
Table 40:
Characteristics of Included Studies – Air Suspension Bed Versus Standard Intensive Care Unit Bed*
Table 41:
Table 41:
Table Pressure Ulcer Classification System – Study of Air Suspension Bed Versus Standard Intensive Care UnitBed
Quality Assessment of Included Studies
The individual study quality assessment is presented in Table 42. The study by Inman et al. (34) satisfied 4 of the 6 quality assessment criteria; allocation concealment methods were not reported and the outcome assessments were not done in a blinded fashion.
Table 42:
Table 42:
Quality Assessment of Included Studies – Air Suspension Bed Versus Standard Intensive Care Unit Bed
Results
The results of the study by Inman et al. (34) are reported in Figure 14. There is a statistically significant reduction in the incidence of pressure ulcers in person using an air suspension bed in the ICU (RR, 0.24; 95% CI, 0.11–0.53) corresponding to an RRR in the incidence of pressure ulcers of 76%.
Figure 14:
Figure 14:
Air Suspension Bed Versus Standard Intensive Care Unit Bed
CI indicates confidence interval; ICU, intensive care unit; RR, relative risk.
Grade of Evidence
Table 43 reports the GRADE evidence profile for the body of evidence evaluating the effectiveness of an air suspension bed in the ICU versus a standard ICU mattress. The quality of evidence is low for the outcome of incidence of pressure ulcers.
Table 43:
Table 43:
GRADE Evidence Profile – Air Suspension Bed Versus Standard Intensive Care Unit Bed
Outcome: Incidence of Pressure Ulcers*
Summary of Results
There is low quality evidence that the use of an air suspension bed in the ICU for ICU stays of at least 3 days produces a statistically significant RRR of 76% in the incidence of pressure ulcers compared with a standard ICU bed.
Comparison 9: Alternating Pressure Mattress Versus Alternative Foam
Characteristics of Included Studies
Two studies compared alternating pressure mattresses with an alternate foam mattress. The study characteristics are reported in Table 44. The follow-up study period was 8 days in the study conducted by Whitney et al.; (36) however, the duration of follow-up was not clearly reported in the study by Stapleton. (37) A different pressure ulcer classification grading system was used to measure the study outcome in each study (Tables 45 and and4646).
Table 44:
Table 44:
Characteristics of Included Studies – Alternating Pressure Mattress Versus Alternative Foam*
Table 45:
Table 45:
Pressure Ulcer Classification System Used by Whitney et al., 1984
Table 46:
Table 46:
Pressure Ulcer Classification System Used by Stapleton, 1986
Quality Assessment of Included Studies
The individual study quality assessment is presented in Table 47. The methods of randomization were unclearly reported by Whitney et al. Stapleton allocated patients to the first 2 groups by lottery, and thereafter patients were allocated systematically in rotation. Overall, the quality of both studies was poor.
Table 47:
Table 47:
Quality Assessment of Included Studies – Alternating Pressure Mattress Versus Alternative Foam*
Results
The results of the studies by Whitney et al. (36) and Stapleton (37) were pooled and the overall estimate of clinical effect is reported in Figure 15. There is a statistically nonsignificant reduction in the incidence of pressure ulcers in person using an alternating pressure mattress compared with an alternative foam mattress (RR, 0.89; 95% CI, 0.54–1.47).
Figure 15:
Figure 15:
Alternating Pressure Mattress Versus Alternative Foam
AP indicates alternating pressure; CI, confidence interval; RR, relative risk.
Grade of Evidence
Table 48 reports the GRADE evidence profile for the body of evidence evaluating the effectiveness of an alternating pressure mattress compared with an alternative foam mattress. The quality of evidence is very low for the outcome of incidence of pressure ulcers.
Table 48:
Table 48:
GRADE Evidence Profile – Alternating Pressure Mattress Versus Alternative Foam Outcome: Incidence of Pressure Ulcers*
Summary of Results
The use of an alternating pressure mattress does not statistically reduce the incidence of pressure ulcers compared with an alternative foam mattress. The quality of evidence supporting this conclusion is very low.
Research Question
The literature was searched to determine the effect of using various nutritional supplementation regimens on the incidence of pressure ulcers in a population at risk for developing pressure ulcers. The search strategy is presented in Appendix 3.
Methods
Inclusion Criteria
  • systematic reviews (with/without meta-analysis) or RCTs
  • studies involving a population at risk for developing pressure ulcers
  • studies evaluating the use of nutritional supplementation plus the standard hospital diet compared with the standard hospital diet only
  • studies reporting the number (proportion) of persons developing a new pressure ulcer
  • studies reporting the stage of pressure ulcer or in which the stage can be inferred from the description of the ulcer (nonblanchable erythema, blisters)
Exclusion Criteria
  • studies that looked at discrete dosages of nutritional supplementation (e.g., different dosages of vitamin C or magnesium)
Primary Outcome
The primary outcome was the incidence of pressure ulcers measured as the number (proportion) of participants developing a new pressure ulcer.
Results of Literature Search
Two systematic reviews were obtained from the literature search strategy. (38;39) Langer et al. (38) searched the electronic databases up to 2003 and retrieved 4 relevant RCTs. Stratton et al. (39) searched up to 2004 and retrieved 1 additional relevant RCT. Our search strategy did not retrieve any relevant RCTs in addition to those reported by Stratton et al. and Langer et al. (38;39) (Table 49). Therefore, in total there are 5 relevant RCTs comparing the effectiveness of nutritional supplementation in addition to the standard hospital diet compared with the standard hospital diet alone.
Table 49:
Table 49:
Quality of Evidence of Included Studies – Nutritional Supplementation*
Characteristics of Included Studies
Five studies compared the effect of nutritional supplementation on the incidence of pressure ulcers with that of a standard hospital diet. (4044) The study characteristics are reported in Table 50. Three of the 5 studies included persons with hip fractures. (41;43;44) Nutritional supplementation ranged from 1070 to 6300 kJ/day (254 to 1,500 c/day). The total energy intake in the standard hospital diet of the control groups was reported in only 2 studies. (40;42) The follow-up study period ranged from 2 weeks to 6 months. In the study by Hartgrink et al., (43) the nutritional supplementation was delivered via nasogastric tube. All studies used a different pressure ulcer classification system for the outcome measure (Table 51).
Table 50:
Table 50:
Characteristics of Included Studies – Nutritional Supplementation
Table 51:
Table 51:
Table Pressure Ulcer Classification System – Studies of Nutritional Supplementation*
Quality Assessment of Included Studies
The individual study quality assessment is presented in Table 52. All studies were RCTs. The study by Bourdel-Marchasson (40) used a cluster randomization design. None of the studies reported adequate allocation concealment methods or a blinded outcome assessment process. Two studies, Hartgrink et al. (43) and Houwing et al., (45) completed a sample size calculation a priori. The losses to follow-up were greater than 30% in all studies except that completed by Houwing et al. (45)and Ek et al. (42) An intention-to-treat analysis was completed by Bourdel-Marchasson (40) only.
Table 52:
Table 52:
Quality Assessment of Included Studies – Nutritional Supplementation*
Of note, in the study by Bourdel-Marchasson (40) the study groups were not comparable at baseline with respect to pressure ulcer risk scores. Persons in the nutritional intervention group had lower pressure ulcer risk scores, were less dependent, and had lower serum albumin levels. A multivariate analysis found that patients receiving the intervention were significantly less likely to develop a pressure ulcer compared with controls.
Results
Figure 16 reports the results of the meta-analysis of the studies comparing nutritional supplementation and a standard diet to a standard hospital diet alone. There is an overall statistically significant RRR of 15% in the incidence of pressure ulcers in favour of nutritional supplementation to a standard hospital diet. The effect estimate from the study by Hartgrink et al. (43) was not included in the meta-analysis as it was thought that the intervention of 6300 kJ/day (1,500 c/day) supplementation via nasogastric tube was clinically dissimilar to the interventions used in the other 4 studies.
Figure 16:
Figure 16:
Standard Diet Versus Standard Diet Plus Supplementation
CI indicates confidence interval; RR, relative risk.
Grade of Evidence
Table 53 reports the GRADE evidence profile for the body of evidence evaluating the effectiveness of nutritional supplementation plus a standard hospital diet compared with a standard hospital diet alone. The quality of evidence is very low for the outcome of incidence of pressure ulcers.
Table 53:
Table 53:
GRADE Evidence Profile – Standard Hospital Diet Versus Standard Hospital Diet Plus Supplementation
Outcome: Incidence of Pressure Ulcers*
Summary of Results
There is very low quality evidence supporting an RRR of 15% in the incidence of pressure ulcers when nutritional supplementation is added to a standard hospital diet.
Research Question
The literature was searched to determine the effect of using different turning schedule frequencies on the incidence of pressure ulcers in a population at risk for developing pressure ulcers. The search strategy is presented in Appendix 4.
Methods
Inclusion Criteria
  • systematic reviews (with/without meta-analysis), or RCTs
  • studies involving a population at risk for developing pressure ulcers
  • studies evaluating the use of various frequencies of turning compared with a standard 2-hour regimen for positioning frequency or other turning schedule frequencies
  • studies reporting the number (proportion) of persons developing a new pressure ulcer
  • studies reporting the stage of pressure ulcer or in which the stage can be inferred from the description of the ulcer
Exclusion Criteria
  • studies evaluating the frequency of position changes with other preventive interventions (other than pressure redistribution surfaces) such that the effect of frequency cannot be determined
Primary Outcome Measure
The primary outcome measure was the incidence of pressure ulcers measured as the number (proportion) of participants developing a new pressure ulcer.
Results of Literature Search
One systematic review and 2 large RCTs were obtained from the literature search (Table 54). (46-48) The study by Vanderwee et al. (48) compared different turning frequencies and positioning, and the study by Defloor et al. (47) compared only different turning schedule frequencies. One Cochrane protocol was also found whose purpose was to conduct a systematic review of research evidence to determine the optimal turning schedule frequency. (49)
Table 54:
Table 54:
Quality of Evidence of Included Studies – Repositioning*
The systematic review by Buss et al. (46) determined the most effective time interval for repositioning persons at risk for pressure sore development. The investigators searched Medline, the Cochrane Library, and Cumulative Index to Nursing and Allied Health Literature from the inception of these computerized databases up to the year 2000. Their literature search yielded 5 research reports, 1 of which was the study by Defloor et al. (47) The other 4 studies have not been included in our review for the following reasons: 2 evaluated small shifts in body position, 1 was a non-English thesis, and 1 was a non-RCT.
Characteristics of Included Studies
Table 55 reports the characteristics of the included studies (47;48) The mean age in both studies was 85 years. The follow-up period ranged from 15 days on average in the Vanderwee et al. (48) study to 4 weeks in the study completed by Defloor et al. (47) While both studies used a different pressure classification system for the outcome measure, the classification systems were comparable (Table 56).
Table 55:
Table 55:
Characteristics of Included Studies – Repositioning*
Table 56:
Table 56:
Table Pressure Ulcer Classification System – Studies of Repositioning*
Quality Assessment of Included Studies
The individual study quality assessment is presented in Table 57. All studies used a RCT design. The study by Vanderwee et al. (48) did not report using adequate allocation concealment methodology. Neither study used a blinded outcome assessment process.
Table 57:
Table 57:
Quality Assessment of Included Studies – Repositioning
Results
We could not pool the individual study results of the Defloor et al. (47) and the Vanderwee et al. (48) studies because the treatment and control groups received different interventions. Therefore, we will report on the individual study results.
Vanderwee et al. (48) reported no statistically significant difference in the incidence of pressure ulcers grade 2 or greater in the treatment group compared with the control group (RR, 0.66; 95% CI, 0.37–1.20). Both groups used an alternate foam mattress and were turned every 2 or 4 hours. The similarity in treatment protocols between groups may have contributed to the negative effects.
Defloor et al. (47) used multivariate logistic regression analyses using a standard-care group as a reference, and reported a statistically significant reduction in pressure ulcer lesions of grade 2 or greater in the 4-hourly turning protocol group which was using a pressure redistribution mattress (odds ratio, 0.12; 95% CI, 0.03–0.48).
We completed a subgroup analyses of the Defloor et al. (47) data and report the results in Table 58 and Figures 17 through through22.22. Results indicate that turning every 4 hours on a pressure redistribution mattress is associated with a 34% RRR in the incidence of grade 1 pressure ulcers compared with turning every 3 hours on a standard foam mattress (Figure 17). We found no difference between the incidence of grade 1 pressure ulcers using a 2-hourly turning schedule and a standard foam mattress compared with a 3-hour turning schedule and a standard foam mattress (RR, 0.90; 95% CI, 0.69–1.16). Therefore, we combined the incidence of grade 1 pressure ulcers for these 2 groups (2 h and 3 h and standard foam mattress) and compared the incidence of grade 1 pressure ulcers with that occurring in the 4-hourly turning schedule group using a pressure redistribution mattress. Results indicate a statistically significant reduction in grade 1 pressure ulcers favoring a 4-hourly turning schedule with a pressure redistribution mattress (RR, 0.70; 95% CI, 0.5– 0.93) (Figure 18).
Table 58:
Table 58:
Subgroup Analyses – Repositioning*
Figure 17:
Figure 17:
Alternate Foam Mattress and Turning 4-hourly Versus Alternate Foam Mattress Turning 3-hourly
AF indicates alternative foam mattress; CI, confidence interval; h, hours; RR, relative risk; SF, standard foam mattress.
Figure 22:
Figure 22:
Alternate Foam Mattress and Turning 4-hourly Versus Standard Foam Mattress and Turning 2-hourly and 3-hourly
AF indicates alternative foam mattress; CI, confidence interval; h, hours; RR, relative risk; SF, standard foam mattress.
Figure 18:
Figure 18:
Alternate Foam Mattress and Turning 4-hourly Versus Standard Foam Mattress Turning 2-hourly and 3-hourly
AF indicates alternative foam mattress; CI, confidence interval; h, hours; RR, relative risk; SF, standard foam mattress.
Similarly, we found a statistically significant reduction in pressure ulcers of grade 2 or greater using a 4-hourly turning schedule with a pressure redistribution mattress compared with either a 2-hourly (RRR of 79%) or 3-hourly (RRR of 87%) turning schedule with a standard foam mattress (Figure 19 and Figure 20). Likewise, a 4-hourly turning schedule with a pressure reducing mattress appears statistically superior to using a 6-hourly turning schedule with a pressure redistribution mattress (Figure 21). Again because there was no difference noted between the 2-hourly turning and 3-hourly turning schedules with a standard foam mattress we combined these 2 groups and compared the incidence of grade 2 or greater pressure ulcers with a 4-hourly turning schedule and a pressure redistribution mattress. Results indicate that a 4-hourly turning schedule was associated with a statistically significant RRR of 84% in grade 2 pressure ulcers compared with the combined incidence rate (RR, 0.16; 95% CI, 0.04–0.66) (Figure 22).
Figure 19:
Figure 19:
Alternate Foam Mattress and Turning 4-hourly Versus Standard Foam Mattress and Turning 2-hourly
AF indicates alternative foam mattress; CI, confidence interval; h, hours; RR, relative risk; SF, standard foam mattress.
Figure 20:
Figure 20:
Alternate Foam Mattress and Turning 4-hourly Versus Standard Foam Mattress and Turning 3-hourly
AF indicates alternative foam mattress; CI, confidence interval; h, hours; RR, relative risk; SF, standard foam mattress.
Figure 21:
Figure 21:
Alternate Foam Mattress and Turning 4-hourly Versus Alternate Foam Mattress and Turning 6-hourly
AF indicates alternative foam mattress; CI, confidence interval; h, hours; RR, relative risk; SF, standard foam mattress.
Grade of Evidence
Tables 59 through through6161 report the GRADE evidence profile for the body of evidence evaluating the effectiveness of a 4-hourly turning schedule with a pressure reducing mattress compared with a standard foam mattress and a 2-hourly and 3-hourly turning schedule to prevent grade 1 or greater or grade 2 or greater pressure ulcers. The quality of evidence is low.
Table 59:
Table 59:
GRADE Evidence Profile – Turning Every 4 Hours Plus Pressure Redistribution Mattress Versus Turning Every 2 or 3 Hours on a Standard Foam Mattress*
Table 61:
Table 61:
GRADE Evidence Profile – Turning Every 4 Hours Plus Pressure-Reducing Mattress Versus Turning Every 2 or 3 Hours on a Standard Foam Mattress
Table 60:
Table 60:
GRADE Evidence Profile – Turning Every 4 Hours Plus Pressure Redistribution Mattress Versus Turning Every 2 Hours on a Standard Foam Mattress*
Summary of Results
There is low quality evidence supporting the superiority of a 4-hourly turning schedule with a pressure redistribution mattress compared with a 2-hourly or 3-hourly turning schedule and a standard foam mattress to reduce the incidence of grade 1 or 2 pressure ulcers.
Research Question
  • The literature was searched to determine: The effectiveness of using a structured skin care protocol compared with no structured skin care protocol in persons who have urinary and fecal incontinence
  • The effectiveness of using a pH-balanced cleanser compared with soap and water to reduce the incidence of pressure ulcers in persons who have urinary and fecal incontinence.
The search strategy is presented in Appendix 5.
Methods
Inclusion Criteria
  • systematic reviews (with/without meta-analysis), RCTs, and non-RCT study designs
  • studies involving a population with urinary and fecal incontinence
  • studies evaluating the use of a structured skin care protocol defined as having explicit components and a defined regimen of care
  • studies comparing a pH-balanced cleanser with soap and water
  • studies reporting the number (proportion) of persons developing a new pressure ulcer
  • studies reporting the stage of pressure ulcer or in which the stage can be inferred from the description of the ulcer
Exclusion Criteria
  • studies reporting only the incidence of dermatitis as an outcome measure
Primary Outcome Measure
The primary outcome measure was the incidence of pressure ulcers measured as the number (proportion) of participants developing a new pressure ulcer.
Results of Literature Search
Skin Care Protocol
Two reports describing the same observational research study were obtained from the literature search (Table 62). The objective of the study was to assess the effectiveness of a skin care protocol on the incidence of pressure ulcers in a geriatric population. The evaluation used a before-and-after research design.
Table 62:
Table 62:
Quality of Evidence of Included Studies – Incontinence Management*
pH-Balanced Cleanser Versus Soap and Water
One small RCT was obtained from the literature that determined the effectiveness of a pH-balanced cleanser for skin care compared with soap and water in persons with urinary and fecal incontinence (Table 62).
Comparison 1: Skin Protocols Versus Standard Care
Characteristics of Included Studies
Table 63 reports the characteristics of the included studies comparing the effectiveness of a skin care protocol with that of standard care. Both studies report on the same protocol. The mean age was 81 years. The duration of each study phase was 3 months. While both reports (50;51) described the same study, Hunter et al. (50) reported using the Agency for Health Care Policy and Research pressure ulcer classification system and Thompson et al. (51) using the NPUAP system (Table 64). We were unsuccessful at contacting the authors to reconcile this discrepancy.
Table 63:
Table 63:
Characteristics of Included Studies – Skin Protocols Versus Standard Care
Table 64:
Table 64:
Table Pressure Ulcer Classification System – Studies of Skin Protocols Versus Standard Care*
Quality Assessment of Included Studies
The information in both the Thompson et al. (51) report and the Hunter et al. (50) report was used to complete the quality assessment of the study (Table 65). Of the 8 criteria used to assess the quality, 3 were not satisfied. The study used a convenience sample instead of consecutive enrollment. However, with the exception of 2 residents that declined participation, the study sample included all residents in both facilities that met the inclusion and exclusion criteria. It is unclear if the participants in both the pre phase and the post phase were comparable in terms of age and urinary and fecal incontinence status. However, it is reported that 77% of the study sample participated in both the pre- and post-study phases. Finally, the caregivers were the data collectors, and because of this the outcome measure was not assessed independently of the exposure status.
Table 65:
Table 65:
Quality Assessment of Included Studies – Skin Protocols Versus Standard Care
Of note, the investigators state that the only change in the care was the addition of the specific body wash and the skin protector. However, the treatment group (postphase group) also received structured education sessions, and specific components of the skin care protocol were stipulated as well as a skin care regimen (checking patient every 2 hours and apply skin protector at least every 8 hours). Indeed, the authors acknowledge that the education provided to the nursing staff may have influenced the study outcome by either enhancing the knowledge base of the caregivers and/or increasing the caregivers’ vigilance for skin assessment. The authors further state that it is difficult to determine whether the decrease in the incidence of pressure ulcers was due to the study treatment (skin care protocol) or an increased staff vigilance for pressure ulcer assessment.
Results
There was a significant difference in the total number of persons with stage 1 or 2 new pressure ulcers between phase 1 and phase 2 (19.8% vs. 8.1%, P = .000) and therefore a statistically significant RRR of developing a pressure ulcer in persons treated with the skin care protocol compared with the control group (RR, 0.41; 95% CI, 0.21–0.70) (Figure 23). We chose to express the estimate of effect as a RR. However, given that the baseline risk is less than 30%, the odds ratio may be the preferred estimate of effect. (52) The odds ratio is 0.36 (fixed effects model, 95% CI, 0.17–0.75).
Figure 23:
Figure 23:
Skin Care Protocol Versus No Skin Care Protocol
CI indicates confidence interval; PU, pressure ulcers; RR, relative risk.
Grade of Evidence
Table 66 reports the GRADE evidence profile for the body of evidence evaluating the effectiveness of a structured skin care protocol compared with standard care in persons with urinary and fecal incontinence. The quality of evidence is very low for the outcome incidence of pressure ulcers grade 1 or 2.
Table 66:
Table 66:
GRADE Evidence Profile – Structured Skin Care Protocol Versus Standard Care Outcome: Incidence of Pressure Ulcers Grade 1 or 2*
Summary of Results
There is very low quality evidence supporting the benefit of a structured skin care protocol to reduce the incidence of grade 1 or 2 pressure ulcers.
Comparison 2: pH-Balanced Cleanser Versus Soap and Water
Characteristics of Included Studies
Table 67 reports the characteristics of 1 study (53) comparing the effectiveness of a pH-balanced cleanser with that of soap and water. The treatment group was slightly older than the control group on average. The median number of incontinent episodes per 24 hours was comparable in both groups (4 in the control group and 5 in the treatment group). The treatment group had a longer median length of stay in the nursing home or hospital (1.72 years) compared with the control group (0.38 years). The study used the Stirling pressure sore classification system, which graded pressure sores as either grade 0 (healthy), grade 1 (erythema), or grade 2 (broken skin) (Table 68).
Table 67:
Table 67:
Characteristics of Included Studies – ph-Balanced Cleanser Versus Soap and Water*
Table 68:
Table 68:
Pressure Ulcer Classification System – Study of pH-Balanced Cleanser Versus Soap and Water*
Quality Assessment of Included Studies
The individual study quality assessment is presented in Table 69. The study by Cooper and Gray (53) used an RCT design. Initially, the first 11 subjects were randomized using unmarked envelopes which contained the treatment allocation (soap and water or Clinisan). However, because patients changed hospital rooms frequently, it was difficult to keep treatment assignment organized. Therefore, the investigators switched to a cluster randomization scheme and randomized a unit (ward) to either treatment or control. It is unknown if allocation concealment was maintained for the cluster randomization. The authors do not report completing a sample size calculation. Photographs were taken of the skin (pressure ulcer) and all slides were assessed in a blinded fashion. Loss to follow-up was minimal. An ITT analysis was not completed, but rates of pressure ulcer incidence were calculated on the per-protocol sample.
Table 69:
Table 69:
Quality Assessment of Included Studies – pH-Balanced Cleanser Versus Soap and Water*
Results
The incidence of pressure ulcer development grade 1 or 2 was 5/41 (12%) in the treatment group and 14/46 (30%) in the control group (per-protocol analysis). Figure 24 reports an ITT analysis. There is a statistically significant decrease in the incidence of pressure ulcers stage 1 or 2 in the group that received treatment with the pH-balanced cleanser compared with those using soap and water (RR, 0.32 [95% CI, 0.13–0.82]). We chose to present the estimate of effect as an RR because the baseline risk in the control group (soap and water) is 31%. (52)
Figure 24:
Figure 24:
Soap and Water Versus pH-Balanced Cleanser and Barrier Cream
CI indicates confidence interval; RR, relative risk.
Grade of Evidence
Table 70 reports the GRADE evidence profile for the body of evidence evaluating the effectiveness of a pH-balanced skin cleanser compared with soap and water in persons with urinary and fecal incontinence. The quality of evidence is low for the outcome incidence of pressure ulcers grade 1 or 2.
Table 70:
Table 70:
GRADE Evidence Profile – pH-Balanced Skin Cleanser Versus Soap and Water Outcome: Incidence of Pressure Ulcers Grade 1 or 2*
Summary of Results
There is low quality evidence supporting the benefit of a pH-balanced cleanser compared with soap and water to reduce the incidence of grade 1 or 2 pressure ulcers in persons with urinary and fecal incontinence.
Table 71 consolidates the effect estimates for the comparisons presented in this review. Moderate quality evidence is available to support the use of an alternative foam mattress to reduce the incidence of pressure ulcers compared with a standard foam mattress for patients in acute care.
Table 71:
Table 71:
Summary of Systematic Review Results*
Moderate quality evidence also exists for 2 other comparisons including:
  • alternating pressure mattress versus alternating pressure overlay
  • Australian sheepskin versus standard treatment
There is a statistically nonsignificant difference in the incidence of pressure ulcers in persons using an alternating pressure mattress compared with an alternating pressure overlay.
There is a statistically significant difference in the incidence of pressure ulcers in persons using an Australian sheepskin compared with standard care. However, clinical experts indicate this intervention is not feasible given that the sheepskins move about in the bed and may contribute to wound infection.
In 2005, the Registered Nurses Association of Ontario (RNAO) systematically reviewed similar preventive interventions for pressure ulcers. (50;54) Table 72 reports the levels of evidence for the interventions assessed in this review at the time of the RNAO review. Our systematic review has improved the level of evidence for risk assessment (from level 5 to level 3a) and skin care (use of a pH-balanced skin cleanser, level 5 to level 2); however, the quality of the evidence is still very low and low, respectively. Overall there remains a paucity of moderate or higher quality evidence in the literature to support many of the preventive interventions. Until better quality of evidence is available, pressure ulcer prevention must be guided by expert opinion for those interventions where low or very low quality evidence supports the effectiveness of such interventions.
Table 72:
Table 72:
Registered Nurses Association of Ontario Guidelines 2005
Appendices
Appendix 1: Search Strategy for Risk Assessment
Search date: February 26, 2008
Databases searched: MEDLINE, MEDLINE In-Process and Other Non-Indexed Citations, EMBASE, Cochrane Library, INHTA/CRD
Database: Ovid MEDLINE(R) <1950 to February Week 2 2008>
Search Strategy:
------------------------------------------------------------------------
  • exp Pressure Ulcer/ (7358)
  • (((pressure or bed or decubitus) adj2 (sore$ or ulcer$)) or bedsore$).mp. [mp=title, original title, abstract, name of substance word, subject heading word] (8686)
  • 1 or 2 (8686)
  • exp Risk Assessment/ (87361)
  • exp "Severity of Illness Index"/ (90294)
  • exp "Reproducibility of Results"/ (150807)
  • exp Risk Management/ (104932)
  • exp "Predictive Value of Tests"/ (80491)
  • exp Nursing Assessment/ or exp "Weights and Measures"/ or exp Validation Studies/ (211803)
  • ((Norton or Waterlow or Braden or Care Dependency) adj4 (Scale$ or instrument$)).mp. [mp=title, original title, abstract, name of substance word, subject heading word] (218)
  • (risk adj4 (assess$ or calculat$ or score$ or predict$ or scale$ or instrument$)).mp. [mp=title, original title, abstract, name of substance word, subject heading word] (125336)
  • or/4-11 (599506)
  • 3 and 12 (1627)
  • limit 13 to (english language and humans and yr="1997 - 2008") (1056)
  • limit 14 to (controlled clinical trial or meta analysis or randomized controlled trial) (77)
  • exp Technology Assessment, Biomedical/ or exp Evidence-based Medicine/ (34655)
  • (meta analy$ or metaanaly$ or pooled analysis or (systematic$ adj2 review$)).mp. or (published studies or published literature or medline or embase or data synthesis or data extraction or cochrane).ab. (67764)
  • exp Random Allocation/ or random$.mp. [mp=title, original title, abstract, name of substance word, subject heading word] (522495)
  • exp Double-Blind Method/ (94618)
  • exp Control Groups/ (822)
  • exp Placebos/ (26618)
  • RCT.mp. (2558)
  • or/15-22 (624606)
  • 14 and 23 (196)
 
Database: EMBASE <1980 to 2008 Week 08>
Search Strategy:
------------------------------------------------------------------------
  • exp DECUBITUS/ (3867)
  • ((decubitus or bed or pressure) adj1 (ulcer$ or sore$)).mp. [mp=title, abstract, subject headings, heading word, drug trade name, original title, device manufacturer, drug manufacturer name] (3146)
  • bedsore$.mp. (154)
  • or/1-3 (4758)
  • exp Validation Process/ or exp Risk Assessment/ or exp Scoring System/ (289704)
  • exp Reproducibility/ (32728)
  • exp Risk Management/ (9906)
  • exp "Prediction and Forecasting"/ (278725)
  • exp Nursing Assessment/ (40)
  • exp "NAMED INVENTORIES, QUESTIONNAIRES AND RATING SCALES"/ (33227)
  • exp Validation Study/ (4404)
  • ((Norton or Waterlow or Braden or Care Dependency) adj4 (Scale$ or instrument$)).mp. [mp=title, abstract, subject headings, heading word, drug trade name, original title, device manufacturer, drug manufacturer name] (70)
  • (risk adj4 (assess$ or calculat$ or score$ or predict$ or scale$ or instrument$)).mp. [mp=title, abstract, subject headings, heading word, drug trade name, original title, device manufacturer, drug manufacturer name] (188794)
  • exp rating scale/ (49508)
  • or/5-14 (643661)
  • 4 and 15 (633)
  • limit 16 to (human and english language and yr="1997 - 2008") (421)
  • Randomized Controlled Trial/ (154703)
  • exp Randomization/ (25108)
  • exp RANDOM SAMPLE/ (981)
  • exp Biomedical Technology Assessment/ or exp Evidence Based Medicine/ (279621)
  • (meta analy$ or metaanaly$ or pooled analysis or (systematic$ adj2 review$) or published studies or published literature or medline or embase or data synthesis or data extraction or cochrane).ti,ab. (56340)
  • Double Blind Procedure/ (68338)
  • exp Triple Blind Procedure/ (8)
  • exp Control Group/ (1437)
  • exp PLACEBO/ (110247)
  • (random$ or RCT).mp. [mp=title, abstract, subject headings, heading word, drug trade name, original title, device manufacturer, drug manufacturer name] (400713)
  • or/18-27 (609634)
  • 17 and 28 (100)
 
Database: CINAHL - Cumulative Index to Nursing & Allied Health Literature <1982 to February Week 3 2008>
Search Strategy:
------------------------------------------------------------------------
  • exp Pressure Ulcer/ (5067)
  • (((pressure or bed or decubitus) adj2 (sore$ or ulcer$)) or bedsore$).mp. [mp=title, subject heading word, abstract, instrumentation] (5741)
  • 1 or 2 (5741)
  • exp Risk Assessment/ (11570)
  • exp "Severity of Illness Indices"/ (7071)
  • exp "Reproducibility of Results"/ (4649)
  • exp Risk Management/ (5441)
  • exp "Predictive Value of Tests"/ (6607)
  • exp Nursing Assessment/ (10283)
  • exp Scales/ or exp Clinical Assessment Tools/ or exp Braden Scale for Predicting Pressure Sore Risk/ (66516)
  • exp Instrument Validation/ (9215)
  • exp Validation Studies/ (8444)
  • exp Wound Assessment/ (1587)
  • ((Norton or Waterlow or Braden or Care Dependency) adj4 (Scale$ or instrument$)).mp. [mp=title, subject heading word, abstract, instrumentation] (558)
  • (risk adj4 (assess$ or calculat$ or score$ or predict$ or scale$ or instrument$)).mp. [mp=title, subject heading word, abstract, instrumentation] (23282)
  • or/4-15 (110645)
  • 3 and 16 (1860)
  • limit 17 to (english and yr="1997 - 2008") (1341)
  • random$.mp. or exp RANDOM ASSIGNMENT/ or exp RANDOM SAMPLE/ (65135)
  • RCT.mp. (810)
  • exp Meta Analysis/ (6067)
  • exp "Systematic Review"/ (3491)
  • (meta analy$ or metaanaly$ or pooled analysis or (systematic$ adj2 review$) or published studies or medline or embase or data synthesis or data extraction or cochrane).mp. (21587)
  • exp double-blind studies/ or exp single-blind studies/ or exp triple-blind studies/ (12702)
  • exp PLACEBOS/ (4008)
  • or/19-25 (85090)
  • 18 and 26 (148)
Appendix 2: Search Strategy for Pressure Redistribution Devices
Search date: October 24, 2007
Databases searched: Databases searched: OVID MEDLINE, MEDLINE In-Process and Other Non-Indexed Citations, Embase, Cochrane Library, INAHTA/CRD
 
Database: Ovid MEDLINE(R) <1996 to October Week 3 2007>
Search Strategy:
------------------------------------------------------------------------
  • exp Beds/ (1214)
  • (bed or beds or bedding).mp. [mp=title, original title, abstract, name of substance word, subject heading word] (31944)
  • (mattress$ or cushion$ or foam$ or transfoam$ or overlay$ or pad or pads or gel).mp. [mp=title, original title, abstract, name of substance word, subject heading word] (123324)
  • (pressure adj1 (relie$ or reduc$ or device$)).mp. [mp=title, original title, abstract, name of substance word, subject heading word] (2660)
  • (positioning or reposition$).mp. [mp=title, original title, abstract, name of substance word, subject heading word] (15147)
  • (elevation adj1 device$).mp. [mp=title, original title, abstract, name of substance word, subject heading word] (1)
  • ((low adj pressure) and (support$ or device$)).mp. [mp=title, original title, abstract, name of substance word, subject heading word] (842)
  • (constant adj1 pressure).mp. [mp=title, original title, abstract, name of substance word, subject heading word] (671)
  • (alternat$ adj1 pressure).mp. [mp=title, original title, abstract, name of substance word, subject heading word] (75)
  • ((air or water) adj1 suspension).mp. [mp=title, original title, abstract, name of substance word, subject heading word] (67)
  • (static adj1 air).mp. [mp=title, original title, abstract, name of substance word, subject heading word] (25)
  • (therarest or clinifloat or vaperm or maxifloat or hammock$).mp. [mp=title, original title, abstract, name of substance word, subject heading word] (100)
  • (foot adj1 waffle).mp. [mp=title, original title, abstract, name of substance word, subject heading word] (3)
  • (silicore or pegasus).mp. [mp=title, original title, abstract, name of substance word, subject heading word] (48)
  • (cairwave adj1 therapy).mp. [mp=title, original title, abstract, name of substance word, subject heading word] (4)
  • (turning adj1 table$).mp. [mp=title, original title, abstract, name of substance word, subject heading word] (1)
  • (kinetic adj1 (table$ or therap$)).mp. [mp=title, original title, abstract, name of substance word, subject heading word] (42)
  • (air adj bag).mp. [mp=title, original title, abstract, name of substance word, subject heading word] (156)
  • or/1-18 (172565)
  • exp Pressure Ulcer/ (3354)
  • ((decubitus or bed or pressure) adj1 (ulcer$ or sore$)).mp. [mp=title, original title, abstract, name of substance word, subject heading word] (4099)
  • 20 or 21(4099)
  • 19 and 22 (1118)
  • limit 23 to (humans and english language and yr="2004 - 2007") (293)
  • limit 24 to (controlled clinical trial or meta analysis or randomized controlled trial) (35)
  • (meta analy$ or metaanaly$ or pooled analysis or (systematic$ adj2 review$)).mp. or (published studies or published literature or medline or embase or data synthesis or data extraction or cochrane).ab. (55568)
  • exp Random Allocation/ or random$.mp. [mp=title, original title, abstract, name of substance word, subject heading word] (329544)
  • exp Double-Blind Method/ (48416)
  • exp Control Groups/ (498)
  • exp Placebos/ (8441)
  • RCT.mp. (2048)
  • or/25-31 (371081)
  • 24 and 32 (61)
 
Database: CINAHL - Cumulative Index to Nursing & Allied Health Literature <1982 to October Week 3 2007>
Search Strategy:
------------------------------------------------------------------------
  • exp "bedding and linens"/ or exp "beds and mattresses"/ (2148)
  • (bed or beds or bedding).mp. [mp=title, subject heading word, abstract, instrumentation] (8804)
  • (mattress$ or cushion$ or foam$ or transfoam$ or overlay$ or pad or pads or gel).mp. [mp=title, subject heading word, abstract, instrumentation] (5222)
  • (mattress$ or cushion$ or foam$ or transfoam$ or overlay$ or pad or pads or gel).mp. [mp=title, subject heading word, abstract, instrumentation] (5222)
  • exp Patient Positioning/ (3989)
  • (positioning or reposition$).mp. [mp=title, subject heading word, abstract, instrumentation] (4577)
  • ((low adj pressure) and (support$ or device$)).mp. [mp=title, subject heading word, abstract, instrumentation] (57)
  • (constant adj1 pressure).mp. [mp=title, subject heading word, abstract, instrumentation] (45)
  • (alternat$ adj1 pressure).mp. [mp=title, subject heading word, abstract, instrumentation] (153)
  • ((air or water) adj1 suspension).mp. [mp=title, subject heading word, abstract, instrumentation] (8)
  • (therarest or clinifloat or vaperm or maxifloat or hammock$).mp. [mp=title, subject heading word, abstract, instrumentation] (15)
  • (foot adj1 waffle).mp. [mp=title, subject heading word, abstract, instrumentation] (3)
  • (silicore or pegasus).mp. [mp=title, subject heading word, abstract, instrumentation] (17)
  • (cairwave adj1 therapy).mp. [mp=title, subject heading word, abstract, instrumentation] (2)
  • (turning adj1 table$).mp. [mp=title, subject heading word, abstract, instrumentation] (2)
  • (kinetic adj1 (table$ or therap$)).mp. [mp=title, subject heading word, abstract, instrumentation] (77)
  • (air adj bag).mp. [mp=title, subject heading word, abstract, instrumentation] (54)
  • (elevation adj1 device$).mp. [mp=title, subject heading word, abstract, instrumentation] (1)
  • (static adj1 air).mp. [mp=title, subject heading word, abstract, instrumentation] (8)
  • or/1-19 (17521)
  • exp Pressure Ulcer/ (4966)
  • ((decubitus or bed or pressure) adj1 (ulcer$ or sore$)).mp. [mp=title, subject heading word, abstract, instrumentation] (5583)
  • 21 or 22 (5583)
  • 20 and 23 (1430)
  • random$.mp. or exp RANDOM ASSIGNMENT/ or exp RANDOM SAMPLE/ (61139)
  • RCT.mp. (741)
  • exp Meta Analysis/ (5741)
  • exp "Systematic Review"/ (3348)
  • (meta analy$ or metaanaly$ or pooled analysis or (systematic$ adj2 review$) or published studies or medline or embase or data synthesis or data extraction or cochrane).mp. (20170)
  • exp double-blind studies/ or exp single-blind studies/ or exp triple-blind studies/ (11627)
  • exp PLACEBOS/ (3830)
  • or/25-31 (79660)
  • 24 and (164)
  • limit 33 to (english and yr="2004 - 2007") (51)
 
Database: EMBASE <1980 to 2007 Week 42>
Search Strategy:
------------------------------------------------------------------------
  • exp Bed/ (2465)
  • (bed or beds or bedding).mp. [mp=title, abstract, subject headings, heading word, drug trade name, original title, device manufacturer, drug manufacturer name] (50844)
  • (mattress$ or cushion$ or foam$ or transfoam$ or overlay$ or pad or pads or gel).mp. [mp=title, abstract, subject headings, heading word, drug trade name, original title, device manufacturer, drug manufacturer name] (205228)
  • (pressure adj1 (relie$ or reduc$ or device$)).mp. [mp=title, abstract, subject headings, heading word, drug trade name, original title, device manufacturer, drug manufacturer name] (5470)
  • (positioning or reposition$).mp. [mp=title, abstract, subject headings, heading word, drug trade name, original title, device manufacturer, drug manufacturer name] (24928)
  • exp Patient Positioning/ (6783)
  • (elevation adj1 device$).mp. [mp=title, abstract, subject headings, heading word, drug trade name, original title, device manufacturer, drug manufacturer name] (1)
  • ((low adj pressure) and (support$ or device$)).mp. [mp=title, abstract, subject headings, heading word, drug trade name, original title, device manufacturer, drug manufacturer name] (443)
  • (constant adj1 pressure).mp. [mp=title, abstract, subject headings, heading word, drug trade name, original title, device manufacturer, drug manufacturer name] (1508)
  • (alternat$ adj1 pressure).mp. [mp=title, abstract, subject headings, heading word, drug trade name, original title, device manufacturer, drug manufacturer name] (71)
  • ((air or water) adj1 suspension).mp. [mp=title, abstract, subject headings, heading word, drug trade name, original title, device manufacturer, drug manufacturer name] (530)
  • (static adj1 air).mp. [mp=title, abstract, subject headings, heading word, drug trade name, original title, device manufacturer, drug manufacturer name] (71)
  • (therarest or clinifloat or vaperm or maxifloat or hammock$).mp. [mp=title, abstract, subject headings, heading word, drug trade name, original title, device manufacturer, drug manufacturer name] (155)
  • (foot adj1 waffle).mp. [mp=title, abstract, subject headings, heading word, drug trade name, original title, device manufacturer, drug manufacturer name] (0)
  • (silicore or pegasus).mp. [mp=title, abstract, subject headings, heading word, drug trade name, original title, device manufacturer, drug manufacturer name] (42)
  • (cairwave adj1 therapy).mp. [mp=title, abstract, subject headings, heading word, drug trade name, original title, device manufacturer, drug manufacturer name] (0)
  • (turning adj1 table$).mp. [mp=title, abstract, subject headings, heading word, drug trade name, original title, device manufacturer, drug manufacturer name] (1)
  • (kinetic adj1 (table$ or therap$)).mp. [mp=title, abstract, subject headings, heading word, drug trade name, original title, device manufacturer, drug manufacturer name] (64)
  • (air adj1 bag).mp. [mp=title, abstract, subject headings, heading word, drug trade name, original title, device manufacturer, drug manufacturer name] (174)
  • or/1-19 (286534)
  • exp Decubitus/ (3736)
  • ((decubitus or bed or pressure) adj1 (ulcer$ or sore$)).mp. [mp=title, abstract, subject headings, heading word, drug trade name, original title, device manufacturer, drug manufacturer name] (3053)
  • 21 or 22 (4571)
  • 20 and 23 (968)
  • limit 24 to (human and english language and yr="2004 - 2007") (182)
  • Randomized Controlled Trial/ (150225)
  • exp Randomization/ (24211)
  • exp RANDOM SAMPLE/ (823)
  • (meta analy$ or metaanaly$ or pooled analysis or (systematic$ adj2 review$)).ti,mp. or (published studies or published literature or medline or embase or data synthesis or data extraction or cochrane).ab. (77407)
  • Double Blind Procedure/ (66927)
  • exp Triple Blind Procedure/ (8)
  • exp Control Group/ (1062)
  • exp PLACEBO/ (105480)
  • (random$ or RCT).mp. [mp=title, abstract, subject headings, heading word, drug trade name, original title, device manufacturer, drug manufacturer name] (389019)
  • or/26-34 (514868)
  • 25 and 35 (35)
Textwords searched in INAHTA/CRD: (bed or bedding or cushion or pillow or pressure relief or pressure relieving or pressure reduction or mattress or positioning or repositioning or therarest or clinifloat or vaperm or maxifloat or hammock or silicore or pegasus or cairwave) and (pressure sore or pressure ulcer or decubitus or bedsore)
Appendix 3: Search Strategy for Nutritional Supplementation
Search date: October 26, 2007
Databases searched: OVID MEDLINE, MEDLINE In-Process and Other Non-Indexed Citations, Embase, Cochrane Library, INAHTA/CRD
Database: Ovid MEDLINE(R) <1996 to October Week 3 2007>
Search Strategy:
------------------------------------------------------------------------
  • 1 exp Pressure Ulcer/ (3354)
  • ((bed or pressure or decubit$ or isch?emic) adj2 (sore$ or ulcer$)).mp. [mp=title, original title, abstract, name of substance word, subject heading word] (4369)
  • bedsore$.mp. (93)
  • or/1-3 (4411)
  • exp Nutrition Therapy/ (21903)
  • exp Diet/ (54480)
  • exp Food/ (293634)
  • (nutri$ or diet$ or food$).mp. [mp=title, original title, abstract, name of substance word, subject heading word] (293881)
  • (enteral or parenteral or protein$ or vitamin$ or mineral$).mp. [mp=title, original title, abstract, name of substance word, subject heading word] (1339881)
  • exp “amino acids, peptides, and proteins”/ (1912805)
  • exp Dietary Supplements/ or exp Antioxidants/ (137725)
  • growth substances/ or exp vitamins/ (76725)
  • exp “enzymes and coenzymes”/ (819718)
  • exp Enzyme Inhibitors/ (341584)
  • exp Minerals/ (31108)
  • exp Lipids/ (271328)
  • exp Antilipemic Agents/ (28150)
  • or/5-17 (2657807)
  • 4 and 18 (760)
  • limit 19 to (humans and english language and yr=“2003 - 2007”) (271)
  • limit 20 to (controlled clinical trial or meta analysis or randomized controlled trial) (29)
  • (meta analy$ or metaanaly$ or pooled analysis or (systematic$ adj2 review$)).mp. or (published studies or published literature or medline or embase or data synthesis or data extraction or cochrane).ab. (55568)
  • exp Random Allocation/ or random$.mp. [mp=title, original title, abstract, name of substance word, subject heading word] (329544)
  • exp Double-Blind Method/ (48416)
  • exp Control Groups/ (498)
  • exp Placebos/ (8441)
  • RCT.mp. (2048)
  • or/21-27 (371080)
  • 20 and 28 (49)
 
Database: EMBASE <1980 to 2007 Week 43>
Search Strategy:
------------------------------------------------------------------------
  • exp Decubitus/ (3741)
  • ((bed or pressure or decubit$ or isch?emic) adj2 (sore$ or ulcer$)).mp. [mp=title, abstract, subject headings, heading word, drug trade name, original title, device manufacturer, drug manufacturer name] (3659)
  • bedsore$.mp. (146)
  • or/1-3 (5151)
  • exp nutrition/ or exp diet therapy/ (798997)
  • exp DIET/ (65465)
  • exp FOOD/ (209307)
  • (nutri$ or diet$ or food$).mp. [mp=title, abstract, subject headings, heading word, drug trade name, original title, device manufacturer, drug manufacturer name] (496473)
  • (enteral or parenteral or protein$ or vitamin$ or mineral$).mp. [mp=title, abstract, subject headings, heading word, drug trade name, original title, device manufacturer, drug manufacturer name] (1894831)
  • exp Amino Acid/ (508877)
  • exp “Peptides and Proteins”/ (3414934)
  • exp Diet Supplementation/ (26443)
  • exp Antioxidant/ (39357)
  • exp Growth Promotor/ (865)
  • exp Vitamin/ (211037)
  • exp Enzyme/ (1265606)
  • exp coenzyme/ (947)
  • exp Enzyme Inhibitor/ (842490)
  • exp Mineral/ (6830)
  • exp Lipid/ (507543)
  • exp Antilipemic Agent/ (85172)
  • or/5-21 (4763456)
  • 4 and 22 (1451)
  • limit 23 to (human and english language and yr=“2003 - 2008”) (444)
  • Randomized Controlled Trial/ (150503)
  • exp Randomization/ (24258)
  • exp RANDOM SAMPLE/ (826)
  • (meta analy$ or metaanaly$ or pooled analysis or (systematic$ adj2 review$)).ti,mp. or (published studies or published literature or medline or embase or data synthesis or data extraction or cochrane).ab. (77576)
  • Double Blind Procedure/ (67017)
  • exp Triple Blind Procedure/ (8)
  • exp Control Group/ (1076)
  • exp PLACEBO/ (105770)
  • (random$ or RCT).mp. [mp=title, abstract, subject headings, heading word, drug trade name, original title, device manufacturer, drug manufacturer name] (389627)
  • or/25-33 (515753)
  • 24 and 34 (77)
 
Database: CINAHL - Cumulative Index to Nursing & Allied Health Literature <1982 to October Week 3 2007>
Search Strategy:
------------------------------------------------------------------------
  • exp Pressure Ulcer/ (4966)
  • ((bed or pressure or decubit$ or isch?emic) adj2 (sore$ or ulcer$)).mp. [mp=title, subject heading word, abstract, instrumentation] (5618)
  • bedsore$.mp. (70)
  • or/1-3 (5632)
  • exp NUTRITION/ (32637)
  • exp Diet Therapy/ (6433)
  • exp FOOD/ (26691)
  • (nutri$ or diet$ or food$).mp. [mp=title, subject heading word, abstract, instrumentation] (78659)
  • (enteral or parenteral or protein$ or vitamin$ or mineral$).mp. [mp=title, subject heading word, abstract, instrumentation] (31657)
  • exp Amino Acids/ (4396)
  • exp Peptides/ (11963)
  • exp DIETARY PROTEINS/ or exp PROTEINS/ (32219)
  • exp Dietary Supplements/ (1903)
  • exp ANTIOXIDANTS/ (2750)
  • exp Growth Substances/ (5659)
  • exp VITAMINS/ (9680)
  • exp Enzymes/ (7839)
  • exp COENZYMES/ (374)
  • exp Enzyme Inhibitors/ (11330)
  • exp MINERALS/ (1674)
  • exp LIPIDS/ (17434)
  • exp Antilipemic Agents/ (3902)
  • or/5-22 (149452)
  • 4 and 23 (678)
  • limit 24 to (english and yr=“2003 - 2007”) (250)
  • random$.mp. or exp RANDOM ASSIGNMENT/ or exp RANDOM SAMPLE/ (61139)
  • RCT.mp. (741)
  • exp Meta Analysis/ (5741)
  • exp “Systematic Review”/ (3348)
  • (meta analy$ or metaanaly$ or pooled analysis or (systematic$ adj2 review$) or published studies or medline or embase or data synthesis or data extraction or cochrane).mp. (20170)
  • exp double-blind studies/ or exp single-blind studies/ or exp triple-blind studies/ (11627)
  • exp PLACEBOS/ (3830)
  • or/26-32 (79660)
  • 25 and 33 (31)
Appendix 4: Search Strategy for Repositioning
Search date: April 18, 2008
Databases searched: MDLINE, MEDLINE In-Process and Other Non-Indexed Citations, EMBASE, Cochrane Library, INAHTA/CRD
 
Database: Ovid MEDLINE(R) <1996 to April Week 2 2008>
Search Strategy:
------------------------------------------------------------------------
  • exp Pressure Ulcer/ (3534)
  • ((decubitus or bed or pressure) adj1 (ulcer$ or sore$)).mp. [mp=title, original title, abstract, name of substance word, subject heading word] (4336)
  • 1 or 2 (4336)
  • (reposition$ or re-position$ or position$).mp. [mp=title, original title, abstract, name of substance word, subject heading word] (160069)
  • (mobiliz$ or mobilis$).mp. [mp=title, original title, abstract, name of substance word, subject heading word] (24127)
  • exp Posture/ (19236)
  • exp Prone Position/ (1470)
  • exp Supine Position/ (2456)
  • (turn$ adj3 (patient$ or schedul$ or interval$)).mp. [mp=title, original title, abstract, name of substance word, subject heading word] (1630)
  • or/4-9 (194918)
  • 3 and 10 (412)
  • limit 11 to (english language and humans and yr=“2000 - 2008”) (259)
  • limit 12 to (case reports or comment or editorial or letter) (30)
  • 12 not 13 (229)
 
Database: EMBASE <1980 to 2008 Week 15>
Search Strategy:
------------------------------------------------------------------------
  • exp Decubitus/ (3909)
  • ((decubitus or bed or pressure) adj1 (ulcer$ or sore$)).mp. [mp=title, abstract, subject headings, heading word, drug trade name, original title, device manufacturer, drug manufacturer name] (3181)
  • 1 or 2 (4770)
  • (reposition$ or re-position$ or position$).mp. [mp=title, abstract, subject headings, heading word, drug trade name, original title, device manufacturer, drug manufacturer name] (243757)
  • (mobiliz$ or mobilis$).mp. [mp=title, abstract, subject headings, heading word, drug trade name, original title, device manufacturer, drug manufacturer name] (45414)
  • (turn$ adj3 (patient$ or schedul$ or interval$)).mp. [mp=title, abstract, subject headings, heading word, drug trade name, original title, device manufacturer, drug manufacturer name] (2735)
  • exp Patient Positioning/ (7098)
  • exp Body Posture/ (15566)
  • or/4-8 (300588)
  • 3 and 9 (542)
  • limit 10 to (human and english language and yr=“2000 - 2008”) (226)
  • limit 11 to (editorial or letter or note) (36)
  • Case Report/ (985499)
  • 11 not (12 or 13) (170)
 
Database: CINAHL - Cumulative Index to Nursing & Allied Health Literature <1982 to April Week 2 2008>
Search Strategy:
------------------------------------------------------------------------
  • exp Pressure Ulcer/ (5186)
  • ((decubitus or bed or pressure) adj1 (ulcer$ or sore$)).mp. [mp=title, subject heading word, abstract, instrumentation] (5871)
  • 1 or 2 (5871)
  • (reposition$ or re-position$ or position$).mp. [mp=title, subject heading word, abstract, instrumentation] (22332)
  • (mobiliz$ or mobilis$).mp. [mp=title, subject heading word, abstract, instrumentation] (2522)
  • (turn$ adj3 (patient$ or schedul$ or interval$)).mp. [mp=title, subject heading word, abstract, instrumentation] (678)
  • exp Patient Positioning/ (4230)
  • exp Posture/ (6653)
  • or/4-8 (29902)
  • 3 and 9 (521)
  • limit 10 to (english and yr=“2000 - 2008”) (289)
Appendix 5: Search Strategy for Incontinence Management
Search date: April 25, 2008
Databases searched: OVID MEDLINE, MEDLINE In-Process and Other Non-Indexed Citations, EMBASE, Cochrane Library, CINAHL, and INAHTA/CRD
 
Database: Ovid MEDLINE(R) <1996 to April Week 3 2008>
Search Strategy:
------------------------------------------------------------------------
  • exp Pressure Ulcer/ (3538)
  • exp Skin Ulcer/ (12680)
  • exp Wound Healing/ or exp Wound Infection/ (34511)
  • ((pressure or bed or skin or decubitus) adj2 (ulcer$ or sore$)).mp. [mp=title, original title, abstract, name of substance word, subject heading word] (7005)
  • (bedsore$ or (chronic adj2 wound$)).mp. [mp=title, original title, abstract, name of substance word, subject heading word] (1445)
  • or/1-5 (45985)
  • exp Incontinence Pads/ or exp Fecal Incontinence/ or exp Urinary Incontinence/ or exp Feces/ or exp Urine/ (36994)
  • (incontinen$ or continen$ or diaper$ or toilet$).mp. [mp=title, original title, abstract, name of substance word, subject heading word] (61681)
  • exp Diaper Rash/ (146)
  • or/7-9 (85691)
  • 6 and 10 (555)
  • limit 11 to (english language and humans and yr=“2000 - 2008”) (377)
  • *Diabetic Foot/ (2601)
  • *Burns/ (7358)
  • *Venous Ulcer/ (1089)
  • *Ischemia/ (8464)
  • *Postoperative Complication/ or *Surgical Wound/ or *Surgical Infection/ (37790)
  • or/13-17 (56875)
  • 12 not 18 (346)
  • limit 19 to (case reports or comment or editorial or letter) (37)
  • 19 not 20 (309)
  • limit 21 to medline records [Limit not valid in: Ovid MEDLINE(R); records were retained] (309)
 
Database: EMBASE <1980 to 2008 Week 17>
Search Strategy:
------------------------------------------------------------------------
  • exp Decubitus/ (3919)
  • exp Skin Ulcer/ (18030)
  • exp Chronic Wound/ (244)
  • exp Wound Healing/ or exp Wound Infection/ (51059)
  • ((pressure or bed or skin or decubitus) adj2 (ulcer$ or sore$)).mp. [mp=title, abstract, subject headings, heading word, drug trade name, original title, device manufacturer, drug manufacturer name] (9510)
  • bedsore$.mp. (158)
  • or/1-6 (67664)
  • exp Incontinence/ or exp Urine/ or exp Feces/ (52601)
  • exp diaper/ or exp diaper dermatitis/ (699)
  • (incontinen$ or continen$ or diaper$ or toilet$).mp. [mp=title, abstract, subject headings, heading word, drug trade name, original title, device manufacturer, drug manufacturer name] (43062)
  • or/8-10 (69761)
  • 7 and 11 (941)
  • limit 12 to (human and english language and yr=“2000 - 2008”) (574)
  • limit 13 to (editorial or letter or note) (34)
  • Case Report/ (987264)
  • 13 not (14 or 15) (498)
  • *Burns/ (12467)
  • *Varicosis/ (3652)
  • *MICROVASCULAR ISCHEMIA/ (47)
  • *Diabetic Foot/ (1990)
  • *Postoperative Complication/ or *Surgical Wound/ or *Surgical Infection/ (10663)
  • or/17-21 (28794)
  • 16 not 22 (487)
 
Database: CINAHL - Cumulative Index to Nursing & Allied Health Literature <1982 to April Week 3 2008>
Search Strategy:
------------------------------------------------------------------------
  • exp Pressure Ulcer/ (5204)
  • exp Skin Ulcer/ (10309)
  • exp Wound Healing/ or exp Wound Infection/ (9655)
  • exp Wounds, Chronic/ (848)
  • ((pressure or bed or skin or decubitus) adj2 (ulcer$ or sore$)).mp. [mp=title, subject heading word, abstract, instrumentation] (6621)
  • bedsore$.mp. (76)
  • or/1-6 (18545)
  • exp Incontinence/ or exp Urine/ or exp Feces/ (6728)
  • exp Diapers/ or exp Diaper Rash/ (270)
  • exp Incontinence Aids/ (605)
  • (incontinen$ or diaper$ or toilet$ or continen$).mp. [mp=title, subject heading word, abstract, instrumentation] (9065)
  • or/8-11 (10718)
  • 7 and 12 (518)
  • limit 13 to (english and yr=“2000 - 2008”) (368)
  • limit 14 to (brief item or commentary or editorial or letter) (21)
Notes
Suggested Citation
This report should be cited as follows:
Medical Advisory Secretariat. Pressure ulcer prevention: an evidence-based analysis. Ontario Health Technology Assessment Series 2009;9(2).
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About the Medical Advisory Secretariat
The Medical Advisory Secretariat is part of the Ontario Ministry of Health and Long-Term Care. The mandate of the Medical Advisory Secretariat is to provide evidence-based policy advice on the coordinated uptake of health services and new health technologies in Ontario to the Ministry of Health and Long-Term Care and to the healthcare system. The aim is to ensure that residents of Ontario have access to the best available new health technologies that will improve patient outcomes.
The Medical Advisory Secretariat also provides a secretariat function and evidence-based health technology policy analysis for review by the Ontario Health Technology Advisory Committee (OHTAC).
The Medical Advisory Secretariat conducts systematic reviews of scientific evidence and consultations with experts in the health care services community to produce the Ontario Health Technology Assessment Series.
About the Ontario Health Technology Assessment Series
To conduct its comprehensive analyses, the Medical Advisory Secretariat systematically reviews available scientific literature, collaborates with partners across relevant government branches, and consults with clinical and other external experts and manufacturers, and solicits any necessary advice to gather information. The Medical Advisory Secretariat makes every effort to ensure that all relevant research, nationally and internationally, is included in the systematic literature reviews conducted.
The information gathered is the foundation of the evidence to determine if a technology is effective and safe for use in a particular clinical population or setting. Information is collected to understand how a new technology fits within current practice and treatment alternatives. Details of the technology’s diffusion into current practice and input from practising medical experts and industry add important information to the review of the provision and delivery of the health technology in Ontario. Information concerning the health benefits; economic and human resources; and ethical, regulatory, social and legal issues relating to the technology assist policy makers to make timely and relevant decisions to optimize patient outcomes.
If you are aware of any current additional evidence to inform an existing evidence-based analysis, please contact the Medical Advisory Secretariat: MASinfo.moh/at/ontario.ca. The public consultation process is also available to individuals wishing to comment on an analysis prior to publication. For more information, please visit //www.health.gov.on.ca/english/providers/program/ohtac/public_engage_overview.html.
Disclaimer
This evidence-based analysis was prepared by the Medical Advisory Secretariat, Ontario Ministry of Health and Long-Term Care, for the Ontario Health Technology Advisory Committee and developed from analysis, interpretation, and comparison of scientific research and/or technology assessments conducted by other organizations. It also incorporates, when available, Ontario data, and information provided by experts and applicants to the Medical Advisory Secretariat to inform the analysis. While every effort has been made to reflect all scientific research available, this document may not fully do so. Additionally, other relevant scientific findings may have been reported since completion of the review. This evidence-based analysis is current to the date of publication. This analysis may be superseded by an updated publication on the same topic. Please check the Medical Advisory Secretariat Website for a list of all evidence-based analyses: http://www.health.gov.on.ca/ohtas.
List of Tables
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