Three Evidence-based Strategies for Preventing Pressure Injuries in Older Patients

Pressure injuries (PIs) can be a common health concern, especially for populations like older adults, where typical changes that accompany the aging process can already increase risks for these types of injuries. There are many potential causes and factors that contribute to the development of PIs. Examples include when a person's weight continually presses the skin against a surface such as a bed or mattress; or a therapeutic device like a splint creates constant pressure. Friction, shear, heat, and moisture also increase the likelihood of PI development for bedridden patients, particularly in long-term and subacute care facilities.  

PI treatment is challenging and involves pressure relief, skin protection, and adequate wound debridement, cleansing, and dressing. Advanced PIs may require surgical debridement, reconstruction, and treatment, such as negative pressure wound therapy.  

Despite optimal management, PIs remain a major cause of serious complications (e.g., sepsis, malignant transformation, anemia, osteomyelitis) and mortality in long-term care settings. Improved PI prevention care remains an unmet medical need and is a critical component of care for at-risk patients. 

Patient risk factors include advanced age, smoking, impaired mobility, poor dietary intake of protein, dehydration, hypotension, hemodynamic instability, history of PIs, comorbidities (i.e., paralysis, neurologic disorders, diabetes, heart and vascular disorders, psychiatric disorders), impaired sensation, anemia, steroid use, and infection. Patients in intensive care units and those in nursing homes often have major risk factors for PI. 

Clinicians often use several management strategies for at-risk patients, including increasing patient mobility, improving nutrition, performing specialized skin care, using advanced wound dressings, and using therapeutic support surfaces. Here are three strategies that are supported by clinical evidence: 

Therapeutic Support Surfaces 

Therapeutic support surfaces reduce the risk of developing PIs by minimizing the effects of pressure, friction, shear, moisture, and heat on patients' skin. These surfaces include air-fluidized beds, low air-loss beds and mattress systems, foam or gel mattress systems, and alternating-pressure mattress systems. ECRI's Clinical Evidence Assessment, Therapeutic Surfaces for Preventing Pressure Injury, found: 

• Evidence from eight systematic reviews supports using specialized support surfaces for reducing PI incidence. Alternating-pressure (active) air surfaces lower PI incidence better than foam surfaces. 
• Guidelines suggest using a high-specification, reactive, single-layer foam mattress or overlay in preference to a foam mattress without high-specification qualities, considering a reactive air mattress or overlay, and assessing possible benefits of using an alternating-pressure air mattress or overlay for individuals at risk of PI development. 

Advanced Wound Dressings 

Some advanced wound care dressings provide protection when placed over bony prominences where PIs are most likely to develop. Foam dressings have two layers—a hydrophilic silicone or polyurethane-based foam inner layer and a hydrophobic, gas-permeable outer layer. The foam collects exudate, and the outer layer prevents leakage and bacterial contamination. Hydrocolloid dressings contain gel-forming agents attached to a polyurethane film. The colloid portion absorbs exudate to form a gel and create a moist wound environment. ECRI's Clinical Evidence Assessment, Wound Dressings for Preventing Pressure Injuries, found: 

• Evidence from five systematic reviews suggests that foam and hydrocolloid dressings effectively reduce PI incidence when used to protect the sacrum and heels. 
• Guidelines recommend using a “soft silicone multi-layered foam dressing to protect the skin for individuals at risk of PIs” or “prophylactic dressings to prevent sacral and heel ulcers in at-risk patients.” 

Oral Nutrition Supplements 

Oral nutrition supplements can help decrease the risk of developing PIs in wheelchair- or bed-bound patients. They contain macronutrients (protein and/or energy) and micronutrients (vitamins and minerals) at varying concentrations and are available in different styles (i.e., juice, yogurt, milkshakes), formats (e.g., liquid, powder, pudding), types (high protein, fiber-containing, low volume), energy densities (1.0 to 2.4 Kcal/mL), and flavors. ECRI's Clinical Evidence Assessment, Oral Nutrition Supplements for Preventing Pressure Injuries, found: 

• Evidence from 11 randomized controlled trials (RCTs) indicates that oral multinutrient supplements may reduce overall complications (e.g., PI, infection, venous thrombosis, pulmonary embolism, confusion). Findings from an additional RCT suggests an oral multinutrient supplement may delay PI onset and progression. Evidence from three additional studies suggests that high-protein, high-energy cookies and high-calorie oral supplements may reduce PI incidence in older patients in skilled nursing, intensive care unit, and long-term (≥7 day) hospital settings. 
• Guidelines support nutritional interventions in at-risk older patients. One guideline recommends 1 g of protein/kg of weight for polymorbid inpatients, and another recommends “high-calorie, high-protein fortified foods and/or nutritional supplements in addition to the usual diet for adults who are at risk of developing a pressure injury and who are also malnourished or at risk of malnutrition, if nutritional requirements cannot be achieved by normal dietary intake.” 

Impact 

The direct and indirect costs of PIs are enormous. The Agency for Health Care and Quality (AHRQ) estimates that treating hospitalized patients who have PIs costs the U.S. healthcare industry between $9.1 billion and $11.6 billion per year.  

Learn how ECRI’s Clinical Evidence Assessment service supports clinicians by researching evidence-based strategies that help improve care quality and reduce costs across all care settings.