Evidence-Based Protocols for Reducing Hospital-Acquired Pressure Injuries in Critically Ill Patients

Introduction

Hospital-acquired pressure injuries (HAPIs) are localized areas of tissue damage resulting from sustained pressure, shear, or friction, most commonly occurring over bony prominences such as the sacrum, heels, and ischial tuberosities. Although pressure injuries can develop in any hospitalized patient, the incidence in intensive care units is disproportionately high, with reported rates in critically ill populations ranging from three to five times those observed on general medical-surgical units (Cooper, 2013). This elevated risk reflects the convergence of multiple factors unique to the critical care environment, including prolonged immobility related to sedation and mechanical ventilation, hemodynamic instability that compromises tissue perfusion, vasopressor administration, and the presence of numerous medical devices, including endotracheal tubes, non-invasive ventilation masks, and vascular access catheters, each of which introduces a discrete source of localized pressure (Black et al., 2010).

The clinical and financial consequences of HAPIs in critically ill patients are considerable. Pressure injuries are independently associated with prolonged intensive care and hospital length of stay, increased risk of secondary infection, and, in the case of severe unstageable or deep tissue injuries, substantial pain and disfigurement (Padula et al., 2019). Because pressure injuries are widely considered a largely preventable complication, they have been designated a hospital-acquired condition subject to non-reimbursement by payers in several healthcare systems, further reinforcing the financial imperative for effective prevention (VanGilder et al., 2017). In response, numerous evidence-based prevention protocols, most commonly structured as multicomponent care bundles, have been developed and implemented across critical care settings, typically incorporating standardized risk assessment, scheduled repositioning, specialized support surfaces, moisture management, nutritional optimization, and prophylactic dressing application (Gillespie et al., 2014).

Despite the proliferation of these protocols, considerable variation exists in bundle composition, the specific risk assessment instruments employed, repositioning frequency and technique, and the degree to which device-related pressure injury prevention is explicitly addressed as a distinct component of the bundle. Several individual studies have reported substantial reductions in pressure injury incidence following bundle implementation, while others have reported more modest or non-significant effects, particularly for device-related injuries that arise from mechanisms distinct from traditional weight-bearing pressure (Coyer et al., 2015). A systematic synthesis of this evidence base, with explicit attention to which bundle components are most consistently associated with reduction in pressure injury incidence, is necessary to guide critical care nursing practice and inform the design of future prevention protocols. The purpose of this systematic review was to evaluate the effectiveness of evidence-based, structured pressure injury prevention protocols in adult intensive care populations and to characterize which specific protocol components are most strongly associated with reduced pressure injury incidence and severity.

Methods

This systematic review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 guidelines. The review question was structured using the Population, Intervention, Comparison, Outcome (PICO) framework: adult patients admitted to an intensive care unit (population); implementation of a structured, multicomponent, evidence-based pressure injury prevention protocol or bundle (intervention); usual or unstructured pressure injury prevention care (comparison); and pressure injury incidence, severity, and anatomical location (outcomes).

A systematic search was conducted across four electronic databases, CINAHL, MEDLINE, Embase, and the Cochrane Library, for studies published between January 2011 and February 2025. Search terms combined controlled vocabulary and free-text terms related to pressure injury, pressure ulcer, critical care, intensive care, and prevention bundle, connected using Boolean operators, and reference lists of included studies were hand-searched to identify additional eligible reports.

Studies were included if they met the following criteria:

1.Conducted in an adult intensive care or critical care unit, published in a peer-reviewed English-language journal, and evaluating a defined, multicomponent prevention protocol rather than a single isolated intervention such as a support surface alone.

2.Reported pressure injury incidence, prevalence, or rate as a primary or secondary outcome, using either the National Pressure Injury Advisory Panel (NPIAP) staging system or an equivalent validated staging classification.

3.Employed a pre-post, quasi-experimental, cluster-randomized, or prospective cohort design comparing the prevention protocol to a defined baseline or comparison period.

Studies conducted exclusively in pediatric or neonatal intensive care settings were excluded, as were studies evaluating a single prevention component in isolation, such as a specific mattress type or dressing product, without an accompanying multicomponent bundle (Gillespie et al., 2014). Two reviewers independently screened records and extracted data, with disagreements resolved through discussion. Methodological quality was appraised using the Johns Hopkins Nursing Evidence-Based Practice (JHNEBP) evidence level and quality guide, which classifies studies according to design rigor and provides a structured quality rating applicable across experimental, quasi-experimental, and non-experimental designs. Given substantial heterogeneity in bundle composition, baseline HAPI rates, and outcome measurement intervals across included studies, a meta-analysis was not performed; findings were instead synthesized narratively, with quantitative results summarized using medians and ranges of relative change in pressure injury incidence.

Results

The database search yielded 1,362 records after duplicate removal. Following title, abstract, and full-text screening, 19 studies met all inclusion criteria and were included in the final synthesis. Included studies comprised 11 pre-post intervention studies, five quasi-experimental studies with a non-equivalent comparison unit, two prospective cohort studies, and one cluster-randomized trial. Studies were conducted predominantly in mixed medical-surgical intensive care units (n = 12), with the remainder conducted in cardiac surgery (n = 4), neurological (n = 2), and burn (n = 1) critical care settings. Sample sizes ranged from a single 16-bed unit to a multi-site collaborative spanning 32 intensive care units.

Across the 19 included studies, implementation of a structured, evidence-based prevention bundle was associated with a median relative reduction in overall HAPI incidence of 52.3%, with individual study effects ranging from a non-significant 9% reduction to a significant 78% reduction. Seventeen of the 19 studies (89.5%) reported a statistically significant reduction in pressure injury incidence following bundle implementation. The bundles associated with the largest reported reductions consistently combined four core components: a validated, structured risk assessment instrument administered on a defined schedule, most commonly the Braden Scale (Bergstrom et al., 2013); a standardized repositioning protocol with a defined turning frequency and documentation requirement; prophylactic application of soft silicone foam dressings over high-risk bony prominences, particularly the sacrum and heels; and a structured skin inspection protocol performed at defined intervals by nursing staff.

Analysis by anatomical location revealed that sacral and heel injuries, the two most common HAPI sites in immobile critically ill patients, showed the greatest relative reduction following bundle implementation, with median reductions of 58.7% and 61.2%, respectively, findings consistent with earlier reports describing heel offloading and scheduled repositioning as particularly effective for these sites (Cooper, 2013). Device-related pressure injuries, defined as injuries occurring at the site of contact with a medical device such as an endotracheal tube securement device, non-invasive ventilation mask, or pulse oximetry probe, showed a smaller and less consistent median reduction of 24.6%, and four of the seven studies reporting this outcome specifically did not reach statistical significance. Study authors attributed this comparatively weaker effect to the distinct mechanism underlying device-related injury, which depends on device fit, rotation site, and frequent skin assessment beneath the device rather than repositioning of the patient’s body as a whole (Coyer et al., 2015; Padula et al., 2019).

Thirteen studies reported implementation strategy in sufficient detail to assess its relationship with outcome magnitude. Bundles implemented alongside a structured staff education program, designated unit-level skin champions, and a formal audit-and-feedback mechanism showed significantly larger reductions in HAPI incidence than bundles implemented through documentation or policy changes alone, a pattern consistent with implementation science literature emphasizing the role of local ownership and continuous feedback in sustaining practice change (Gillespie et al., 2014). Sustainability of effect beyond the initial implementation period was reported in only eight of the 19 included studies; among these, HAPI reduction was generally maintained at 12-month follow-up, though three studies reported a partial attenuation of effect over time, most commonly attributed to staff turnover and gradual erosion of protocol adherence (VanGilder et al., 2017).

Quality appraisal using the JHNEBP tool indicated that the majority of included studies were quasi-experimental or pre-post designs without a concurrent control group, limiting the ability to exclude secular trends or concurrent quality-improvement initiatives as alternative explanations for observed reductions. The single cluster-randomized trial and the two prospective cohort studies were rated as providing the strongest available evidence and reported effect sizes broadly consistent with, though somewhat more conservative than, the pre-post studies, suggesting that some portion of the effect observed in lower-rigor designs may reflect factors beyond the prevention bundle itself (Bergstrom et al., 2013).

Discussion

The findings of this systematic review indicate that structured, multicomponent, evidence-based prevention protocols are associated with substantial reductions in hospital-acquired pressure injury incidence among critically ill patients, with a median relative reduction exceeding 50% across the included evidence base. This magnitude of effect is consistent with the theoretical rationale underlying bundled interventions in critical care, namely that pressure injury development in this population is multifactorial, involving impaired perfusion, prolonged immobility, and moisture-related skin compromise, and therefore is unlikely to be adequately addressed through any single intervention in isolation (Black et al., 2010). The consistent identification of structured risk assessment, scheduled repositioning, prophylactic dressing application, and routine skin inspection as core components of the highest-performing bundles provides a reasonably clear template for critical care units seeking to design or refine their own prevention protocols.

The comparatively weaker and less consistent effect observed for device-related pressure injuries warrants particular attention, given that these injuries represent an increasing proportion of overall HAPI burden in critical care as reliance on respiratory support devices, vascular access technology, and continuous monitoring equipment has grown (Padula et al., 2019). The mechanism underlying device-related injury, localized pressure and shear at a fixed contact point rather than pressure distributed across a repositioned body surface, is not directly addressed by standard turning schedules, and requires distinct preventive strategies such as scheduled device rotation, use of device-specific protective dressings, and routine skin assessment beneath and around device securement points (Coyer et al., 2015). Units seeking to further reduce overall HAPI incidence beyond the reductions achievable through standard bundles may therefore benefit from explicitly incorporating device-related injury prevention as a distinct, additional bundle component rather than assuming it will be adequately addressed by repositioning protocols designed primarily for weight-bearing pressure injuries.

The relationship observed between implementation strategy and outcome magnitude, specifically the larger reductions associated with structured education, designated skin champions, and audit-and-feedback mechanisms, underscores that the effectiveness of an evidence-based protocol depends substantially on the fidelity and consistency with which it is delivered at the bedside, not solely on the content of the protocol itself (Gillespie et al., 2014). This finding is consistent with a broader pattern observed across nursing-sensitive quality improvement literature, in which the presence of local champions and continuous performance feedback has been repeatedly associated with more durable practice change than policy or documentation updates alone. The partial attenuation of effect observed in several studies at 12-month follow-up further suggests that pressure injury prevention protocols require ongoing reinforcement, refresher education, and ideally integration into electronic health record prompts or default order sets, rather than a one-time implementation effort, to sustain their initial effect over time (VanGilder et al., 2017).

Several limitations of the underlying evidence base constrain the strength of the conclusions that can be drawn from this review. The predominance of pre-post and quasi-experimental designs without concurrent comparison groups introduces risk of confounding by secular trends, including concurrent skin-care product changes, staffing adjustments, or increased clinical attention associated with active data collection. Bundle composition, risk assessment instruments, and repositioning frequency varied considerably across included studies, and reporting of implementation fidelity was often incomplete, limiting the precision with which specific component-level effects could be isolated. The comparatively small number of studies reporting device-related injury outcomes specifically, and the shorter follow-up periods available for most included studies, further limit conclusions regarding the durability of effect and the optimal strategy for preventing device-related injury specifically (Bergstrom et al., 2013).

Future research would benefit from larger, multi-site cluster-randomized trials with standardized bundle composition and outcome definitions to permit meta-analytic synthesis, building on the repositioning-frequency comparisons already reported by Manzano et al. (2010) and the broader prevention-strategy synthesis conducted by Tayyib and Coyer (2016), explicit and separately reported outcomes for device-related pressure injuries, and longer follow-up periods to characterize the durability of prevention effects beyond the first year of implementation, consistent with the extended follow-up design used in the Australian RaP trial (Chaboyer et al., 2016). Additional research examining the cost-effectiveness of specific bundle components, and the minimum combination of components required to achieve clinically meaningful reduction, would further assist critical care units with limited resources in prioritizing implementation efforts. Taken together, the findings of this review support the continued use of structured, multicomponent, evidence-based pressure injury prevention protocols as a core element of critical care nursing practice, while highlighting device-related injury prevention and sustained implementation fidelity as priority areas for continued attention.

References

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Coyer, F., Gardner, A., Doubrovsky, A., Cole, R., Ryan, F. M., Allen, C., & McNamara, G. (2015). Reducing pressure injuries in critically ill patients by using a patient skin integrity care bundle. American Journal of Critical Care, 24(3), 199–209.

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Manzano, F., Colmenero, M., Pérez-Pérez, A. M., Roldán, D., Jiménez-Quintana, M. D. M., Mañas, M., Sánchez-Cantalejo, E., & Fernández-Mondéjar, E. (2010). Comparison of two repositioning schedules for the prevention of pressure ulcers in patients on mechanical ventilation with alternating pressure air mattresses. Intensive Care Medicine, 36(8), 1349–1355.

Tayyib, N., & Coyer, F. (2016). Effectiveness of pressure ulcer prevention strategies for adult patients in intensive care units: A systematic review. Worldviews on Evidence-Based Nursing, 13(6), 432–444.

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