Skin status for predicting pressure ulcer development: A systematic review and meta-analyses

https://doi.org/10.1016/j.ijnurstu.2018.07.003Get rights and content

Abstract

Background

People with altered skin status are conventionally considered to have a higher risk of developing new ulcers. However, the evidence underpinning this potentially prognostic relationship is unclear.

Objectives

To systematically review the evidence for the prognostic association of skin status with pressure ulcer risk.

Methods

We performed a comprehensive electronic database search in February 2017 to identify longitudinal studies that considered skin status in multivariable analysis for predicting pressure ulcer risk in any population. Study selection was conducted by two reviewers independently. We collected data on the characteristics of studies, participants, skin status, and results of multivariable analyses of skin status–pressure ulcer incidence associations. We applied the Quality In Prognosis Studies tool to assess risk of bias. We conducted meta-analyses using STATA where data were available from multivariable analyses. We used the Grades of Recommendation Assessment, Development and Evaluation approach to assess the certainty of evidence generated from each meta-analysis.

Results

We included 41 studies (with 162,299 participants, and 7382 having new ulcers) that investigated 15 skin descriptors. Participants were predominantly hospitalised adults and long-term care residents (with a median age of 75.2 years). Studies had a median follow-up duration of 7.5 weeks. 61.0% (25/41) of studies were judged as being high risk of bias. 53.7% (22/41) of studies had small sample sizes. Subsequently, the certainty of evidence was rated as low or very low for all 13 meta-analyses that we conducted though all analyses showed statistically significant associations of specific skin descriptors–pressure ulcer incidence. People with non-blanchable erythema may have higher odds of developing pressure ulcers than those without (Odds Ratio 3.08, 95% Confidence Interval 2.26–4.20 if pressure ulcer preventive measures were not adjusted in multivariable analysis; 1.99, 1.76–2.25 if adjusted) (both low-certainty evidence). The evidence for other skin descriptors was judged as very low-certainty and their prognostic value is uncertain.

Conclusions

There is low-certainty evidence that people with non-blanchable erythema may be more likely to develop new pressure ulcers than those without non-blanchable erythema. The evidence for the prognostic effects of other skin descriptors (e.g., history of pressure ulcer) is of very low-certainty. The findings support regular skin assessment and preventive action being taken in the presence of non-blanchable erythema. Given the millions at risk of ulceration and the widely recommended use of skin status as part of risk assessment there is a need for more, high quality confirmatory studies.

Section snippets

What is already known about the topic?

  • Skin assessments by eye and touch are routinely carried out for pressure ulcer prevention to check for abnormalities (e.g., non-blanchable erythema), and people with such skin abnormalities are often considered to be at a particularly high risk of developing new ulcers.

  • Guidelines recommend that nurses should increase the provision of preventive interventions (e.g., specific support surfaces) in the presence of non-blanching erythema.

  • Three previous systematic reviews summarising the evidence for

What this paper adds

  • This prognostic factor systematic review includes thirteen meta-analyses of data for corresponding skin status descriptors and identifies their prognostic value in pressure ulcer development.

  • There is no high-certainty evidence that any of the 15 skin descriptors are strong predictors of the risk of new pressure ulcer development. People with non-blanchable erythema may be more likely to develop new pressure ulcers than those without however this evidence is low certainty.

  • High-quality,

Objectives

To assess the independent prognostic value of a variety of skin status descriptors in predicting pressure ulcer development.

Methods

This review was based on recent methods developments in the design and conduct of prognosis systematic reviews proposed by the Cochrane Prognosis Methods Group (Riley et al., 2007). It was registered with PROSPERO (CRD42016042140) and complies with the Meta-analyses Of Observational Studies in Epidemiology statement for its reporting (Stroup et al., 2000).

Search results

We retrieved 6908 records through electronic searching and other resources. Full-text screening of 561 potentially relevant studies led to the inclusion of 41 studies (with 50 publications) (see Fig. 1 Allegretti, 2008; Allman et al., 1995; Anthony et al., 2000, 2003; Baumgarten et al., 2004,2006,2009; Bergquist-Beringer and Gajewski, 2011; Berlowitz et al., 1996,2001a,2001b; Compton et al., 2008; de Groot et al., 2006; de Souza and Santos, 2007; Defloor and Grypdonck, 2005; DeJong et al., 2014

Main findings

We have conducted the first systematic review with meta-analyses to summarise the evidence on the prognostic value of a variety of skin status descriptors that were considered as patient-level factors for predicting pressure ulcer risk. We include 41 studies with 15 skin descriptors. We found that over half of the 41 studies were judged as being at high risk of bias and they were heterogeneous in terms of settings, populations, skin assessment methods, confounders and other adjustment

Conclusions

Low-certainty evidence suggests that more people with non-blanchable erythema might develop a new pressure ulcer than those without non-blanchable erythema. There is very low-certainty evidence on the prognostic effects of other skin status (e.g., current pressure ulcers, a history of pressure ulcers). In contrast with previous reviews, this review uses recently established prognosis research methods to synthesise the evidence for specific skin status descriptors being predictors of future

Acknowledgements

This research was funded by the President’s Doctoral Scholar award of the University of Manchester (CS) and supported by the NIHR Manchester Biomedical Research Centre. The funder had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

The authors would like to acknowledge the contribution of Ross Atkinson, Maggie Westby, and Gillian Norman who conducted independent screening of search results for eligible studies, as well as Zhenmi Liu

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