Dressings Can Prevent Pressure Injury

Growing evidence suggests that topical dressings can reduce pressure injury, limiting the likelihood of developing a pressure ulcer. For clarity, the term “pressure injury“ will be used to describe the process by which pressure, friction, or shear stresses damage the skin, and the term “pressure ulcer” (PU) will indicate the wound resulting from such injury. Topical dressings were first mentioned in PU guidelines¹ as an intervention to prevent pressure injury by protecting the skin from friction or shear.² Subsequent research has verified this effect in a prospective randomized clinical trial (RCT), reporting that critically ill patients receiving high-risk site protection using hydrocolloid or film dressings (30 per dressing) had a lower incidence (40%) of respirator mask-related PU than 30 usual care controls (97%).³ Similar results were found for a soft silicone gel dressing preventing device-related PU in preterm infants receiving nasal continuous positive airway pressure treatment in India.⁴ Among patients (n = 133) in Canadian homes or long-term care who were randomized to receive a foam heel-protecting dressing, only 3% of heels developed a PU compared to 44% of similar patients randomized to receive a protective heel and ankle bandage.⁵ Below we add 1 more RCT to the growing evidence that dressings once indicated only for healing wounds are effective in preventing PU in critically ill patients⁶ and summarize a systematic review of that evidence.⁷ 

Reference: Santamaria N, Gerdtz M, Sage S, et al. A randomised controlled trial of the effectiveness of soft silicone multi-layered foam dressings in the prevention of sacral and heel pressure ulcers in trauma and critically ill patients: the border trial. Int Wound J. 2015;12(3):302-308. 

Rationale: Preventing hospital-acquired pressure ulcers (HAPU) is a challenge for those managing patients, especially those in critical care units. 

Objective: Conduct a randomized clinical trial (RCT) to explore effectiveness of multilayered soft silicone foam dressings in preventing heel or sacral HAPU in critically ill and/or trauma patients in an Australian university teaching hospital.

Methods: A prospective open-label RCT assigned 221 patients > 18 years of age newly admitted to the emergency department (ED) for trauma or critical illness who were then transferred to the critical care unit to receive standard usual PU prevention procedures including use of a recognized low-air-loss bed. A sample of 219 similar patients were randomly assigned to the intervention group, receiving the same usual care plus a 5-layered soft silicone foam dressing applied to each patient’s sacrum or a similar 3-layered dressing applied to each of the patient’s heels, held in place with an elastic tubular bandage. Dressings were changed every 3 days or if dislodged or soiled until discharge from the intensive care unit (ICU). A member of the study team examined each patient daily by partly peeling back dressings if needed and recording the WoundsAustralia (formerly the Australian Wound Management Association) Stage of newly developed PU. The primary endpoint was incidence of heel and sacral HAPU developed during the ICU stay in both groups. Those with spinal cord injury, trauma to the sacrum or a heel, or a pre-existing PU were excluded from the study. Covariates recorded and analyzed included reason for admission, comorbidities, Braden PU risk scale, Australia Triage Scale, APACHE-II Score, starting time of mechanical ventilation, medications, and physiological variables. Cox regression analysis derived the comparative hazard ratio for developing a PU during the ICU stay.

Results: The groups were comparable on all variables on enrollment. No adverse events related to dressings were reported throughout the study. Five patients (3.1% incidence) developed 2 sacral ulcers and 5 heel ulcers with added prophylactic dressings, while 20 patients (13.1% incidence) receiving usual care alone developed 8 sacral ulcers and 19 heel ulcers. This absolute risk reduction of 10% means that for every 10 patients receiving added dressings, 1 would be spared from developing a PU. The Cox regression analysis revealed a 5-fold reduction in the relative hazard for developing a PU in the ICU (P = 0.002), by adding PU-preventing dressings to usual care. 

Authors’ Conclusions: Recognizing the clinically and statistically significant benefit of adding multilayer soft silicone dressings to usual care for preventing sacral and heel ulcers in the ICU, the hospital now mandates their use. 

Reference: Clark M, Black J, Alves P, Brindle CT, Call E, Dealey C, Santamaria N. Systematic review of the use of prophylactic dressings in the prevention of pressure ulcers. Int Wound J. 2014;11(5):460-471.

Rationale: Evidence of dressing effects on the skin microclimate suggests their potential in preventing PU.

Objective: Conduct a systematic review of literature exploring topical dressing effects on reducing the incidence of European Pressure Ulcer Advisory Panel category I or II PU.

Methods: Commissioned by a wound dressing manufacturer, following PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) principles of review conduct, authors searched MEDLINE, CINAHL Plus, Cochrane, and PubMed databases for RCTs or nonrandomized controlled or uncontrolled studies, or case series published in English before July 25, 2013 exploring effects of topical wound dressings on incidence of PU development in samples of patients at risk of developing a PU while managed in primary or secondary care. Each study was evaluated for quality and summarized. Randomized clinical trials, nonrandomized controlled studies, and cohort studies were tested for heterogeneity before primary outcomes meta-analysis. Funnel plots were used to assess for publication bias.

Results: Of 21 qualifying studies retrieved, 10 reported comparative PU incidence: 3 RCTs, 5 cohort studies, 1 within-subject comparison, and 1 of unspecified design. A meta-analysis of 3 homogeneous studies reported that use of hydrocolloid or film dressings to protect the nose from pressure due to respirator devices reduced the incidence of nasal PU compared to no dressing use (P < 0.00001). “Number need to treat” analysis showed that for every 2 persons managed with dressings, 1 would have a pressure ulcer prevented. Similarly a soft silicone dressing or polyurethane film both reduced the incidence of sacral pressures (P < 0.0003) compared to no dressing. No consistent differences were found between dressings in any blind-evaluated RCT.

Authors’ Conclusions: One high-quality RCT and several lower-quality RCTs and case series suggest the use of topical dressings to reduce the incidence of medical device-related PU or PU developed by immobile ICU patients. There is no firm evidence supporting different PU-prevention effects of different dressings.

Dressings have been used to prevent PU in a variety of primary or secondary care settings on pediatric⁴ or adult patients at risk of developing a PU^6,7 including those recovering from cardiac surgery.⁸ These results underscore the importance of teamwork in improving the consistency and quality of patient outcomes throughout intervals of high PU risk.⁹ Preventing PU requires a multifaceted approach, with every member of the wound care team doing everything feasible to reduce shear stress and friction,¹⁰ keep the patient’s skin moist and supple, redistribute pressure by gentle repositioning, and use appropriate support surfaces. All this is done while each member of the team is helping patients thrive, meeting needs of every organ system, some critically challenged. Working to keep a patient—or a challenged area of skin—alive is not an easy job, and even best efforts may not always succeed. Dressings alone may not prevent a PU. Dressings are a complement to all elements of effective clinical practice to reduce the likelihood of any skin injury. The research described here^6,7 does not conclude that dressings are a panacea for preventing PU, but it does support using film, hydrocolloid, or soft silicone dressings over bony prominences to help tip the balance in favor of keeping patients’ skin healthy as part of best clinical PU prophylaxis.

Laura Bolton, PhD
Department of Surgery,
Rutgers Robert Wood Johnson Medical School,
New Brunswick, NJ