INTRODUCTION
Critically ill patients are at increased risk for hospital-acquired pressure injuries (HAPIs) due to multiple factors such as immobility, hemodynamic instability, decreased nutrition, and incontinence.1-5 Hospital-acquired pressure injuries negatively affect patient outcomes, increase length of stay, and raise hospital costs.1,6,7 There is a growing body of evidence evaluating the use of foam dressings, as one part of an individualized care plan, for prevention of HAPI in specific patient populations.5 These dressings are typically placed over the sacrum or heel and can stay in place for up to 7 days; nevertheless, they may be changed more frequently when indicated. Prophylactic foam dressings should be peeled back and the underlying skin assessed every 12 hours.
The aim of this review was to systematically review and synthesize research regarding the use of foam dressings as a preventative measure for the development of HAPIs in the intensive care unit (ICU). Our review was guided by the following question, "In adult ICU populations, will the use of preventive foam dressings compared to no foam dressings decrease the number of hospital-acquired pressure injuries (HAPIs) on the sacrum?"
METHODS
We conducted a systematic review in accordance with the Preferred Reporting Items of Systematic Reviews and Meta-analysis Statement (PRISMA).8 Articles studying the use of foam dressings, specifically on the sacral area as a preventative measure for the development of HAPI formation, in adult ICU patients (older than 18 years), were included in the review. We excluded studies that (1) evaluated preventive interventions other than application of prophylactic foam dressings, (2) exclusively addressed pressure injury risk factors and risk assessment strategies, (3) did not specifically identify HAPI, (4) exclusively focused on health care costs, and (5) did not enroll adult participants receiving care in an ICU. No restrictions related to publication date were imposed. Four researchers independently conducted searches in Health Source, Cochrane of Systematic Reviews, CINAHL, and PubMed. The last search occurred on September 24, 2018. The Boolean search terms were: "pressure* OR skin breakdown AND sacr*; "ICU patient* OR critical care patient*"; and "foam dressing OR prophyl* or prevent*."
Eligibility assessment was performed independently in an unblinded manner by 4 reviewers. Data were extracted and placed in a literature matrix (study summary table). Articles screened for eligibility were divided among the 4 reviewers, data extracted, and checked by a second reviewer. Disagreements were resolved by discussion between the 2 reviews or assessment by a third reviewed. Information was extracted from each article on methods, participants, interventions, and outcomes. For experimental studies included in the review, risk of bias was assessed at the study level, with independent reviewers determining validity by evaluating the adequacy of randomization, concealment of allocation, blinding of health care providers, data collectors, and outcome assessors, and proportion of participants not completing the study. Findings of this review were compared and contrasted based on Melnyk and Fineout-Overholt's9 levels of evidence (Box). We did not analyze risk of bias across studies and no additional summary measures or analyses were used.
BOX Melnyk & Fineout Levels of Evidence
Level I: Evidence from a systematic review of all relevant randomized controlled trials (RCTs), or evidence-based clinical practice guidelines based on systematic reviews or RCTs.
Level II: Evidence obtained from at least one well-designed RCT.
Level III: Evidence obtained from well-designed controlled trials without randomization, quasiexperimental.
Level IV: Evidence from well-designed case-control and cohort studies.
Level V: Evidence from systematic reviews of descriptive and qualitative studies.
Level VI: Evidence from a single descriptive or qualitative study.
Level VII: Evidence from the opinion of authorities and/or reports of expert committees.
Findings
The search identified a total of 380 articles, representing 348 unique elements after removal of duplicate publications. Title and abstract review eliminated 229 studies as not meeting inclusion/exclusion criteria. The remaining 119 full-text articles were then read in full and devaluated by independent assessors. Fourteen were included (Figure).10
Information extracted from each article incorporated into the literature review matrix included study design, sample/setting, findings, strengths, limitations, and level of evidence (Table). The 14 elements included in our review comprised 1 systematic review with meta-analysis of pooled findings, 2 randomized control trials, 5 nonrandomized cohort studies, 2 quasiexperimental studies, 1 quality improvement report, 1 case study, 1 consensus panel, and 1 pilot study. Based on inclusion criteria, all elements focused on patients in adult ICUs (older than 18 years). Each article analyzed the intervention of a sacral foam dressing, either as a sole intervention or in comparison to no preventative dressing. In all studies, the primary outcome assessed was occurrence of a sacral HAPI. Secondary outcomes included cost measurements, though this was not discussed in every article.
Summary of Evidence
All 14 articles suggested that the use of foam dressings could potentially lower the incident rate of sacral HAPIs. The systematic review reported a statistically significant decrease in the incidence of sacral and heel HAPIs in the ICU,11 which was reflected in findings of the 2 randomized controlled trialss.6,12 Three of the articles made specific statements pertaining to the use of preventative foam dressings in addition to current skin care practices, such as keeping skin clean and dry, turning patients every 2 hours, and ensuring adequate nutrition.5,12,13 Three other articles directly linked the use of preventative foam dressings with monetary savings.1,2,6 One consensus panel provided evidence that the prophylactic use of sacral foam dressings indicated a positive reduction of pressure injury formation.14
Limitations
Limitations across articles include the type of dressing studied, when the dressing was placed, who received the dressing, and facility-specific pressure injury prevention practices. Types of dressings studied included the Mepilex Foam Border (Molynlycke Health Care, Gothenburg, Sweden)5,6,12,15 and Allevyn Gentle Borders (Smith & Nephew, London, UK).1 In the remaining articles, the dressing brand name was not specified.3,7,13,16,17 Of the experimental and nonexperimental studies (n = 9), 5 applied the preventative dressing in the ICU on admission.1,6,7,13,17 One study applied the dressing to ICU patients in the emergency department prior to arrival in the ICU.12 The remaining 3 did not specify.3,5,16 While all articles addressed the adult, ICU population, some studies applied the preventative dressing to all patients,12,16 some only applied the dressing to patients deemed high-risk by facility-specific grading scales,1,5,17 and the remaining only applied the dressing to those deemed high-risk using the Braden Scale.3,6,15
Additional pressure injury prevention practices also varied by facility. Kalowes and colleagues6 reported using a S.K.I.N bundle that included assessment of pressure injury risk via the Braden Scale for Pressure Sore Risk. Assessments occurred on admission and once every shift. Additional elements of the bundle included full skin assessment on every shift, and use of a pressure redistributing support surface (Total Care SpO2RT 2 Therapy Bed, Hill-Rom, Batesville, Indiana), routine turning and repositioning, heel off-loading, and a structured skin care program for patients with incontinence. Santamaria and colleagues12 reported using typical skin care strategies but did not describe specific interventions.
CONCLUSION
Findings from this systematic review suggest that adult patients within an intensive care setting may benefit from application of a prophylactic sacral foam dressing to reduce the risk of HAPI. Additional research is needed to determine the benefits of a particular foam configuration, specific eligibility criteria for dressing application, timing for dressing placement, and the relative benefit of prophylactic foam dressings in a multidimensional pressure injury prevention program. In addition, we recommend additional research comparing the relative benefit of prophylactic foam sacral dressings to bundled pressure injury prevention measures.
KEY POINTS
* Our systematic review supports the use of prophylactic foam dressings for prevention of HAPI in adult critical care patients.
* Preventative sacral foam dressings are one component of a comprehensive pressure injury prevention program, along with routine positioning and skin care.
* Eligibility criteria and timing of dressing application varied across studies.
REFERENCES