Preventing Pressure Ulcers: A Systematic Review

The PICOT question that this body of literature was selected to support is as follows: “In Medical inpatient units, how does turning and repositioning every two hours compared to every four hours prevent the occurrence of pressure injuries during the hospital stay?” There needs to be an in-depth analysis of the literature to create an effective intervention strategy. The empirical data on pressure injuries, treatments, outcomes, prevalence, and financial implications requires evaluation.

The first article in the bibliography studies the incidence of Pressure Ulcers in American Medicare recipients. Lyder et al. (2012) have analyzed more than fifty-one thousand cases in Medicare-eligible hospitals across the United States. Their sample included patients discharged from hospitals in 2006 and 2007. The study has concluded that 4.5% of the entire sample has developed a Pressure Ulcer during their hospital stay. The odds of dying were significantly higher for the patients suffering from Pressure Ulcers, and their length of stay, on average, was more than twice the length of patients without Pressure Ulcers. Additionally, they were more likely to be admitted to the hospital again within a month after discharge. The Pressure Ulcer incidence rates were higher in Missouri and the Northeast region. The authors have abstracted the data from the national Medicare Patient Safety Monitoring System.

While their analysis and conclusions were purely observational, this data can be used to justify the necessity of an intervention to a hospital. Additionally, it creates a benchmark for rating the incidence of Pressure Ulcer incidence in American hospitals compared to 2006 and 2007. The treatments and prevention strategies are continually being introduced to the hospitals, and studying the incidence rates can help determine whether they have any effect. The primary shortcoming of this work in the context of the PICOT question is its age and its exclusive focus on Medicare patients.

The author of this article has written numerous other works on Pressure Ulcers. One of the more important ones is an article on preventing Pressure Ulcers in the heels, which details intervention strategies and outcomes, and can be a handy supplement for a body of literature related to Pressure Ulcer prevention (Lyder, 2011). Another important article is an overview of how Pressure Ulcer prevention, treatment, and assessment was influenced by national regulation (Lyder & Ayello, 2012). Finally, they outline some prevention measures for Pressure Ulcers, further supplementing the existing body of literature and giving credence to the intervention (Ayello & Lyder, 2007). The selected article stands out due to its broader scope and observational quality, as the intervention designs were explored somewhat more robustly in further literature selection.

The second piece of the selected body of literature is focused on device-related Pressure Ulcer cases and prevention strategies. The authors have created a position statement on Pressure Ulcers, which is based on empirical data and contained various effective prevention strategies and methods of detection (Pittman, Beeson, Kitterman, Lancaster, & Shelly, 2015). Next, they educated the medical staff by contacting effective opinion leaders and influential groups.

The development and dissemination of an evidence-based position statement increased the identification and reporting rates of device-related Hospital-Acquired Pressure Ulcers, consequently decreasing overall prevalence rates of Pressure Ulcers in the facility by 33%. They used the Iowa Model of Evidence-Based Practice to create their position statement, as well as nine additional pieces of research to create an exhaustive account of what a medical device is, what a device-related Pressure Ulcer is, and how to effectively prevent it. This article is useful in the context of the PICOT question in that it emphasizes the importance of an evidence-based solution and effective communication with the staff.

The authors of the study have several other published works on the topic of Pressure Ulcers. The most significant of them deals with the distinction between the avoidable and unavoidable Pressure Ulcers (Pittman, Beeson, Dillon, Yang, & Cuddigan, 2019). T Another article of note discusses the Braden Scale and hospital nursing staff (Beeson et al., 2010). Both of them would provide useful information to educate the staff and effectively implement a Pressure Ulcer prevention strategy.

The third literature selection is a systematic review of Pressure Ulcer prevention methods. The authors reviewed fifty-nine clinical trials using the CLEAR NPT checklist and concluded that repositioning, skincare, support surfaces, and nutritional supplements might be the most effective strategies for Pressure Ulcer prevention (Reddy, Gill, & Rochon, 2006). The article gives a rationale to the PICOT question and reinforces the validity of the repositioning method. However, many clinical trials were suboptimal and provided only broad recommendations without any definitive conclusions, which is its most significant shortcoming, along with its age.

There is a “sister article” by the authors that deals with the treatment of Pressure Ulcers. It concluded that there was little evidence in the clinical trials to support the effectiveness of nutritional supplements and non-standard wound care therapy (Reddy, Gill, Kalkar, Wu, Anderson, & Rochon, 2008). Despite its inconclusive findings, the study supports the assertion that treatment is significantly less effective and more costly than prevention, which is the basis of the PICOT question. TOther than that, there is a small number of relevant articles by the author, and they are not very useful for the project.

The fourth piece of research used in the PICOT question evaluates two different ways of collecting information on Pressure Ulcer incidence in hospitals. There has been a notable decrease in Pressure Ulcer incidence in some hospitals in the recent decade. However, the incidence rate in administrative data is calculated differently than in chart-based reports (Smith, Snyder, McMahon, Petersen, & Meddings, 2018). The authors used an extensive data set from the State Inpatient Databases of the Healthcare Cost and Utilization Project to compare the different methods of case tracking. The total population across all states and years was 34.8 million patients, which is enough for a robust assessment. There is a reason to believe that the discrepancy is due to financial incentives that hospitals receive from some agencies.

They are encouraged to underreport Pressure Ulcer cases to receive financial bonuses or avoid financial penalties. Another reason is that some chart-based reports do not distinguish Pressure Ulcer cases by severity, which leads to overreporting prevalence rates. The paper helps develop a more accurate data collection technique for the outcome measurement and recognize the potential biases of different systems. This article is the only relevant piece of research penned by these authors, but it may not signify a gap, because the subject matter or the article is rather specific.

The fifth selection in the theoretical base is a description of a successful rollout of a hospital-wide prevention program. The intervention consisted of using Braden scores to divide patients into risk groups, educating staff, using silicone adhesive dressings and fluidized repositioners, and revising the skin-care protocol (Swafford, Culpepper, & Dunn, 2016). The program resulted in a 69% decrease in Hospital-Acquired Pressure Ulcer cases, despite a 22% increase in patients. This article provides a positive example of effective collaborative intervention and may give a rationale for the continuous adjustment of Pressure Ulcer prevention strategies in hospitals. This article is the only one related to Pressure Ulcer prevention by these authors.

The sixth and selected article is an overview of unit-specific trends of Pressure Ulcer prevalence in 2008 and 2009, with comparisons to 2006 and 2007 results from a previous study. The authors used the data from The Hill-Rom International Pressure Ulcer Prevalence Survey and explained the trends in different care units. Overall, the prevalence of Pressure Ulcers had decreased, except for the emergency department, burn unit, and surgical unit (VanGilder, Amlung, Harrison, & Meyer, 2009). Some facilities were also an exception, such as long-term care, where the prevalence of Pressure Ulcers slightly increased. This article is a useful benchmark for unit-specific and facility-specific prevalence rates, as different units of a medical facility may require different resource allocation and intervention strategies.

There are several other articles by these authors related to Pressure Ulcers, mainly overviews of prevalence surveys and specific intervention strategies. One significant piece of research is an overview of the international survey results between 2006 and 2015 (VanGilder, Lachenbruch, Algrim-Boyle, & Meyer, 2017). It is a significant longitudinal study that explains a decade-long trend in Pressure Ulcer prevalence across the US. However, the downside of the data used in both articles is its self-selection and self-reporting, which may produce inaccuracies and biases.

An effective intervention needs to be rooted in empirical data and take after established positive practices. The selected literature helps establish the rationale for the intervention, effective prevention measures, and adjust data collection strategies for outcome measurement. The selected body of literature is even more robust if supplemented with other publications by the authors. Overall, there appears to be a solid theoretical foundation beneath the PICOT question and the intervention implementation.


Ayello, E. A., & Lyder, C. H. (2007). Protecting patients from harm. Nursing, 37(10), 36–40.

Beeson, T., Adams, G., Prickel, C., Treon, M. L., Mink, J., & Buelow, J. M. (2010). Thinking about the Braden scale. Clinical Nurse Specialist, 24(2), 49–50.

Lyder, C. H. (2011). Preventing heel pressure ulcers. Nursing Management (Springhouse), 42(11), 16–19.

Lyder, C. H., & Ayello, E. A. (2012). Pressure Ulcer care and public policy. Advances in Skin & Wound Care, 25(2), 72–76.

Lyder, C. H., Wang, Y., Metersky, M., Curry, M., Kliman, R., Verzier, N. R., & Hunt, D. R. (2012). Hospital-acquired pressure ulcers: Results from the national medicare patient safety monitoring system study. Journal of the American Geriatrics Society, 60(9), 1603–1608.

Pittman, J., Beeson, T., Dillon, J., Yang, Z., & Cuddigan, J. (2019). Hospital-acquired pressure injuries in critical and progressive care: Avoidable versus unavoidable. American Journal of Critical Care, 28(5), 338–350.

Pittman, J., Beeson, T., Kitterman, J., Lancaster, S., & Shelly, A. (2015). Medical device–related hospital-acquired pressure ulcers: Development of an evidence-based position statement. Journal of Wound, Ostomy and Continence Nursing, 42(2), 151–154.

Reddy, M., Gill, S. S., Kalkar, S. R., Wu, W., Anderson, P. J., & Rochon, P. A. (2008). Treatment of pressure ulcers. JAMA, 300(22), 2647.

Reddy, M., Gill, S. S., & Rochon, P. A. (2006). Preventing pressure ulcers: A systematic review. JAMA, 296(8), 974-984.

Smith, S., Snyder, A., McMahon, L. F., Petersen, L., & Meddings, J. (2018). Success in hospital-acquired pressure ulcer prevention: A tale in two data sets. Health Affairs, 37(11), 1787–1796.

Swafford, K., Culpepper, R., & Dunn, C. (2016). Use of a comprehensive program to reduce the incidence of hospital-acquired pressure ulcers in an intensive care unit. American Journal of Critical Care, 25(2), 152–155.

VanGilder, C., Amlung, S., Harrison, P., & Meyer, S. (2009). Results of the 2008-2009 international pressure ulcer prevalence survey and a 3-year acute care unit specific analysis. Ostomy Wound Manage, 55(11), 39-55.

VanGilder, C., Lachenbruch, C., Algrim-Boyle, C., & Meyer, S. (2017). The international pressure ulcer prevalence™ survey. Journal of Wound, Ostomy and Continence Nursing, 44(1), 20–28.