The quality and clinical applicability of recommendations in pressure injury guidelines: A systematic review of clinical practice guidelines

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Abstract

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.

Introduction

Pressure injuries, also known as pressure ulcers, are an area of localised damage to the skin and/or underlying tissue due to pressure or forces of the patient's body weight combined with shear. (European Pressure Ulcer Advisory Panel 2019) Hospital-acquired pressure injuries are a common cause of avoidable harm in patients. (Wounds International 2010, Kim et al., 2019, Li et al., 2020, Nguyen et al., 2015) Pressure injuries have the potential to adversely affect patients’ quality of life, causing pain and emotional distress, isolation, and, for some patients, increased risk of mortality. (Gorecki et al., 2009, Hopkins et al., 2006, Latimer et al., 2014) As well as the high personal cost for patients, pressure injuries pose a significant financial burden on healthcare systems in terms of extended hospital stays, increased nursing workloads, and diagnostic, monitoring and treatment costs. (Anand et al., 2019, Padula and Delarmente, 2019, Demarre et al., 2015) Across Australia, the economic cost of pressure injury treatment in 2012-13 was approximately A$983 million, or 1.9% of the public hospital funding for that period. (Nguyen et al., 2015) Results from Padula and Delarmente (2019) cost-effectiveness analysis modelling suggest that pressure injuries cost US $26.8 billion dollars while Demarre et al. (2015) systematic review found that daily costs of pressure injury prevention varied but could be as high as 87.57€, with costs associated with treatment being as high as 470.49€. Despite hospital-wide initiatives to prevent and eradicate hospital acquired pressure injury, clinical practice gaps and inconsistencies in clinical practice persist. (Chaboyer et al., 2017) (Jackson et al., 2016)

Clinical practice guidelines are statements and patient care recommendations based on systematic reviews of the evidence including a benefits and harms assessment of other care options. Institute of Medicine (2011) These recommendations, based on scientific knowledge (current at their time of publication), are used to standardise care and guide health professionals decision making in the management of medical conditions. Institute of Medicine (2011) Pressure injury clinical practice guidelines recommend various interventions for the prevention and treatment of pressure injuries. These include risk assessment tools, pressure relieving devices such as specialised air mattresses, wedges, booties, and chair cushions, appropriate skin care, adequate nutrition, and patient education. (Chaboyer et al., 2017) Assessment of the clinical effectiveness of strategies form the basis of clinical practice guidelines’ best-practice recommendations. Although implementation of clinical practice guidelines’ recommendations can reduce preventable harm of hospital acquired pressure injuries, (Nguyen et al., 2015) (Walker, Miles et al., 2013, Padula et al., 2016) differences in the methodology of clinical practice guidelines’ development and data collection and analysis influences both the quality and strength of the recommendations provided. However, to our knowledge, a contemporary, comprehensive and rigorous quality appraisal of pressure injury clinical practice guidelines has not been undertaken. Therefore the purpose of this systematic review was to evaluate the quality of pressure injury clinical practice guidelines using the Appraisal of Guidelines for Research and Evaluation II (AGREE II) tool (Brouwers et al., 2010) and the The Appraisal of Guidelines Research & Evaluation—Recommendation EXcellence (AGREE-REX) tool. (AGREE-REX Research Team 2019) The AGREE II tool is a methodological resource used to inform guideline development, reporting and quality assessment. (Brouwers et al., 2010) However, while meeting rigorous methodological criteria is essential, this does not necessarily mean that guideline recommendations are trustworthy, credible and feasible to implement. AGREE-REX Research Team (2019) Essentially, the validated AGREE REX tool was developed to assess trustworthiness, credibility and feasibility. AGREE-REX Research Team (2019)

The objective of the systematic review was to critically appraise the quality of the guideline and clinical applicability of the recommendations in clinical practice guidelines for the prevention and treatment of pressure injuries. The review questions are:

  • 1.

    Using the AGREE II tool, what is the quality of clinical practice guidelines published from 2005 to 2020 for pressure injury prevention and treatment?

  • 2.

    Using the AGREE-REX tool, to what extent are recommendations trustworthy, applicable and feasible to implement across particular contexts?

The results of this review may assist point of care clinicians’ guideline selection to aid clinical decision making and promote practice that is based on the best available evidence. For guideline developers, these results may ultimately drive future improvements in the quality and applicability of guidelines.

Section snippets

Design

We conducted a systematic review in accordance with the Preferred Reporting Items for Systematic Reviews and Meta‐Analyses (PRISMA) statement, and the Cochrane Handbook for Systematic Review of Interventions AGREE-REX Research Team (2020) recommendations. We identified research questions a priori and registered the review protocol with the international prospective register of systematic reviews (PROSPERO registration number: masked for blinded peer review).

Inclusion/exclusion criteria

The eligibility of documents was

Identification and selection of clinical practice guidelines

Electronic library databases and repository searches yielded 4711 documents and 1466 duplicates were removed (see PRISMA flowchart, Fig. 1). We conducted full text screening on 73 documents and excluded 61 (excluded cases listed in supplementary file 2). In all, 12 complete clinical practice guidelines (European Pressure Ulcer Advisory Panel 2019) (Beeckman et al., 2012-Wound Ostomy Continence Nurses Society 2016) were included in the final analysis. In addition to the 12 guidelines, we

Discussion

To our knowledge, this is the first systematic review of pressure injury prevention and treatment clinical practice guidelines using the AGREE II and the new AGREE-REX instrument. We acknowledge an earlier review undertaken in 200736 that included four clinical practice guidelines in the prevention and treatment of pressure injuries. Notably, since the publication of that review, guideline methodology including updating of the AGREE instrument has advanced, culminating in increased use of

Conclusions

The findings of this review suggest there is some disparity in the quality of the included guidelines. However, four high quality clinical practice guidelines are available and could be implemented in daily practice albeit they may need to be adapted to local policies. Notwithstanding, the levels of evidence upon which many of the recommendations in these guidelines are founded remains low. As such, there is a compelling need to generate rigorous, trial-based evidence in key areas of pressure

Declaration of Competing Interest

The authors declare they have no known competing financial interests or personal or professional relationships that could have appeared to influence the work reported in this paper. To avoid potential conflict, any author involved in the development of an included guideline was excluded during the assessment phases of such guideline.

Funding source

This study was partly funded by the School of Nursing and Midwifery, Griffith University.

Ethics statement

The study is a systematic review of published material, therefore ethics approval was not required.

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