BACKGROUND: Pressure injuries are one of the most frequently occurring, yet preventable hospital-acquired adverse events. Given there are many clinical practice guidelines available on the prevention and treatment of pressure injuries, it is useful to understand the quality of these guidelines and the clinical application of their recommendations.
OBJECTIVE: To critically evaluate the quality and applicability of the recommendations in pressure injury prevention and treatment clinical practice guidelines.
DESIGN: Systematic review, reported using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines.
DATA SOURCES: We systematically searched the literature published from 2005 to 2020 using MEDLINE, EMBASE, CINAHL, the Cochrane Library, ProQuest and PubMed electronic databases, and nine guideline repositories.
REVIEW METHODS: We assessed overall quality using the validated Appraisal of Guidelines for Research and Evaluation II (AGREE II) and AGREE Recommendation Excellence (AGREE-REX) tools. Overall % mean scores across AGREE II and AGREE-REX domains were calculated for each guideline. Clinical practice guidelines were then ranked in tertiles based on "high", "moderate" or "low" quality. The review protocol was registered in the International Prospective Register of Systematic Reviews.
RESULTS: Initial combined database and repository searches yielded 3247 documents. Of these,73 full text documents were reviewed. The final analysis included 12 complete guidelines and 14 related documents. Overall AGREE II scores ranged from 32% to 96% while AGREE-REX scores were generally lower ranging from 10% to 75%. Combined % mean scores across AGREE II and AGREE-REX criteria suggest that four guidelines were ranked as "high" (range 69% to 85%) and are recommended without modification. These included; the 2019 International Guideline, the 2016 Canadian Guideline, the 2014 NICE Guideline, and the 2013 Belgian Guideline.
CONCLUSIONS: There is disparity in the quality of the included guidelines, however four high quality guidelines are available. These guidelines could ideally be implemented in daily practice and adapted to local policies.
We still do not know what best practice for pressure ulcers are. The disparity in the conclusions of the guidelines calls for more clinical research, especially RCTs, to, as the authors say, reach evidence-based recommendations in key areas of pressure injury management, such as risk assessment methods, repositioning and skin care.
Comparing international guidelines is a useful approach, but probably of greatest relevance to people writing guidelines or local policy. For the 'on the ground' clinician, I would prefer a summary of the most important recommendations that are common to all the guidelines.
These are highly needed updated guidelines in pressure injury prevention. Unfortunately trial-based evidence in key areas of pressure injury prevention is still lacking.