1. Considering the evidence for pressure injuries
Andrew Jull
Associate Professor, UoA
Nurse Advisor, Quality, ADHB

2. What goes in a change package
Bundle acronyms often insufficient for identifying interventions
SSKIN (Scottish change package)
Surface selection
Skin inspection
Keep moving
Incontinence
Nutrition
What surfaces and when?

3. Starting point
Haynes RB. ACP Journal Club 2009;151(3):2-3.

4. Guidelines High level summaries Information quality assessed
Recommendations graded by quality of evidence
A, B, C, D, CBR
Practice points (consensus)

5. Surface selection when at risk
At Risk of PI
Use a high specification reactive (constant low pressure) support foam mattress on beds and trolleys for patients at
risk of pressure injuries.
Graded A
At high risk of PI
Active (alternating pressure) support mattresses could be used as an alternative in patients at high risk of pressure injuries.
Graded A
Evidence sourced from Cochrane review

6. Using imperfect information
Trials of both devices compared to standard hospital mattresses
Trials recruited patients at high risk of PI to both devices
Interpretation and consensus needed
Use less expensive device with lower risk
More expensive device with higher risk

7. Evidence gap
High spec foam vs AP mattress
RCT of alternating pressure overlay vs high spec foam mattress (and Q4 turning)
Not included in GL
Unfair comparison? Repositioning in one group but not in the other. Or does it model clinical practice?

8. Surface selection if has PI
Manage patients with existing pressure injuries on a high specification reactive (constant low pressure) or active alternating pressure) support surface on beds and trolleys and when seated.
Grade A
Evidence drawn from same source as when patient at risk or higher (not patients with PI)
If patient has PI are they not at high risk and thus above recommendation soemwhat inconsistent with previous recommendation?

9. Limitations of guideline
Data source systematic reviews or previous guidelines
Currency of evidence
Missed RCTs of recent evidence
Heel off-loading devices
Curious re-interpretations
Honey

10. Heel off-loading devices (HOLD)
Any device used to prevent heel pressure injuries should be selected and fitted appropriately to ensure pressure is adequately offloaded.
Graded CBR (consensus-based recommendation)
Missed reasonable quality RCT that showed 19% reduction in all PIs when HOLD used in addition to pressure-redistributing surfaces
Donnelly J et al. J Wound Care 2011;20:

11. Honey as wound dressing
Systematic review found one trial comparing honey to saline dressings
Review finding
The effect of honey on pressure ulcers cannot be determined from the single trial
Guideline recommendation
Consider using topical medical grade honey to promote healing in pressure injuries
Grade D
Jull A, et al. Cochrane Database Sys Rev 2008.

12. Other idiosyncrasies

13. Systematic reviews Cochrane database the best source of SRs
Access free via
Other SRs published
Require own quality check

14. Quick quality assessment
Does it have an objective
Does it use exhaustive searches
Does it quality assess studies
Does it use processes to reduce bias
More than one person checking processes
Does it assess publication bias
Positive studies more likely to be published

16. Sheepskins “Medical grade” sheepskin Four RCTs
Incidence halved in sheepskin group
No cost-effectiveness information
If evidence accepted, questionable whether feasible in acute care setting
May be more feasible in residential care setting?

17. AP Mattress vs AP overlay
Large high quality RCT & cost-effectiveness study
No difference in incidence of Grade≥2 PI
Small difference in number requesting change in device (19% vs 23%)
Mattresses more cost-effective due to longer time to development of PI
10.6 days longer to develop PI

18. Individual studies Type of study important Require own quality check
Privilege RCT over other designs
Require own quality check
Tools available
CEBM-type CAT (
GATE (

20. Conclusion Information rarely perfect
Clear answer to clinical need in all or even specific circumstances not common
What to include in change package will almost always require interpretation and consensus
Agreement on sources of information, but be aware of source’s idiosyncrasies