Influences of evidence‐based nursing intervention on pressure ulcers in intensive care units: A meta‐analysis

Abstract

A meta‐analysis was conducted comprehensively to investigate the impact of evidence‐based nursing (EBN) interventions on pressure injury (PI) in the intensive care unit (ICU) patients. Computer searches were performed, from databases inception to November 2023, in Wanfang, PubMed, China National Knowledge Infrastructure, Google Scholar, Embase, and Cochrane Library for randomized controlled trials (RCTs) on the application of EBN interventions in ICU patients. Two independent researchers conducted screenings of the literature, extracted data, and carried out quality evaluations. Stata 17.0 software was employed for data analysis. Overall, 25 RCTs, involving 2494 ICU patients, were included. It was found that compared to conventional care methods, the implementation of EBN interventions in ICU patients markedly decreased the occurrence of PI (odds ratio [OR]: 0.22, 95% confidence interval [CI]: 0.17–0.30, p < 0.001), delayed the onset time of pressure ulcers (standardized mean difference [SMD]: −1.61, 95% CI: −2.00 to −1.22, p < 0.001), and also improved nursing satisfaction (OR: 1.18, 95% CI: 1.14–1.23, p < 0.001). Our findings suggest the implementation of EBN interventions in the care of PI in ICU patients is highly valuable, can reduce the occurrence of PI, can delay the time of appearance, and is associated with relatively higher nursing satisfaction, making it worthy of promotion.

1. INTRODUCTION

Pressure ulcers (PUs), also known as pressure injuries (PIs), refer to localized damage to the skin or subcutaneous tissue usually over a bony prominence, as a result of pressure or pressure in combination with shear. It can present as localized damage to the tissue with intact skin or an open ulcer and may be accompanied by pain. ¹ , ² PIs not only inflict pain on patients, exacerbate disease prognosis, and extend hospital stays, but also, in severe cases, may lead to secondary infections, sepsis, and even death due to systemic failure. ³ , ⁴ , ⁵ Patients in intensive care units (ICUs) often face issues such as consciousness disorders, long‐term bed rest, use of special medications, malnutrition, and haemodynamic instability, making them a high‐risk group for PIs. ⁶ , ⁷ , ⁸ Studies show that about 22%–49% of ICU patients are affected by PIs, highlighting the prominence of PI prevention and management in ICU settings. ⁹

Currently, conventional care for PIs is overly basic. Evidence‐based nursing (EBN), derived from evidence‐based medicine, represents a nursing model that evolves from research findings, clinical expertise, and the requirements of patients. It uses valuable and credible scientific research findings as evidence to seek proof, thereby providing high‐quality nursing services to patients. ¹⁰ , ¹¹ Therefore, this study, through a meta‐analysis of currently published literature, aimed to provide evidence‐based evidence for the effectiveness of implementing EBN in PI care for ICU patients.

2. MATERIALS AND METHODS

2.1. Literature search

Keywords such as evidence‐based nursing, EBN, evidence‐based nursing practice, evidence‐based practice, pressure ulcer, PUs, ulcer, pressure injury, PI, bedsore, pressure sore, decubitus ulcer, intensive care, intensive care unit, critical care unit, intensive care therapy, and ICU were used to search Wanfang, PubMed, China National Knowledge Infrastructure, Google Scholar, Embase, and Cochrane Library for randomized controlled trials (RCTs), from databases inception to November 2023, on EBN interventions in ICU patients.

2.2. Eligibility criteria

Inclusion criteria were as follows: (1) participants: ICU patients; (2) intervention: the experimental group underwent EBN intervention, and the control group underwent conventional care; (3) outcomes: PIs, nursing satisfaction, and the onset time of PIs; and (4) study design: RCTs. Exclusion criteria included duplicate publications; literature with incomplete original data or unavailable full‐text information; and conference articles, reviews, systematic reviews, case reports, and animal studies.

2.3. Data extraction and quality assessment

Literature was imported into EndNote X9 for deduplication. Titles, abstracts, and full texts were independently screened by two authors. Discrepancies were resolved through discussion or with the help of a third researcher. Data extraction, including first author, year of publication, sample size, sex, age, and outcome measures (PIs, nursing satisfaction, and the onset time of PIs), was performed using Excel software. The Cochrane Collaboration's tool for assessing the risk of bias was used to assess the quality of RCTs, focusing on selection, performance, detection, attrition, reporting biases, and other biases.

2.4. Statistical analysis

Stata 17.0 software was utilized for data analysis. We reported dichotomous variables as odds ratios (ORs) with 95% confidence intervals (CIs), while we reported variables as standardized mean differences (SMDs) with 95% CIs. The chi‐square test and I ² statistic for heterogeneity were employed to determine the fixed‐ or random‐effects model. Sensitivity analysis evaluated the robustness of study outcomes. The funnel plots were employed for publication bias.

3. RESULTS

3.1. Basic characteristics

The literature screening process is shown in Figure 1. Initially, 271 articles were identified, with 132 duplicates removed manually and by software. After screening titles and abstracts, 68 articles were excluded for not meeting the research criteria, leaving 71 articles for full‐text review. Overall, 25 RCTs were included, ¹² , ¹³ , ¹⁴ , ¹⁵ , ¹⁶ , ¹⁷ , ¹⁸ , ¹⁹ , ²⁰ , ²¹ , ²² , ²³ , ²⁴ , ²⁵ , ²⁶ , ²⁷ , ²⁸ , ²⁹ , ³⁰ , ³¹ , ³² , ³³ , ³⁴ , ³⁵ , ³⁶ totalling 2494 ICU patients, with 1250 and 1244 patients in the EBN and conventional care groups, respectively. The basic characteristics of the included literature are shown in Table 1, and the quality assessment is depicted in Figure 2.

FIGURE 1.

Literature screening flowchart.

TABLE 1.

Characteristics of the included studies.

Authors	Year	Number of patients		Age (years)		Sex (male/female)
		Intervention	Control	Intervention	Control	Intervention	Control
Gao	2023	30	30	48.79 ± 7.41	48.87 ± 5.15	15/15	18/12
Hou	2022	50	45	47.23 ± 5.31	47.42 ± 5.24	28/22	25/20
Chen	2023	47	47	70.65 ± 4.36	69.28 ± 2.05	29/18	25/22
Chang	2017	42	42	59.01 ± 2.13	59.79 ± 2.58	20/22	22/20
Zeng	2020	43	42	43.69 ± 4.42	43.71 ± 4.40	23/20	24/18
Huang	2020	70	70	47.56 ± 3.79	48.61 ± 2.35	40/30	38/32
Lou	2020	25	25	52.64 ± 3.18	51.35 ± 3.87	15/10	16/9
Liu	2021	69	69	41.51 ± 7.45	40.84 ± 7.92	35/34	33/36
Li	2023	50	50	56.222 ± 2.47	55.89 ± 2.41	27/23	28/22
Ke	2018	34	34	53.12 ± 7.46	54.46 ± 7.15	19/15	21/13
Luo	2017	20	20	67.10 ± 7.52	67.15 ± 7.56	10/10	9/11
Li	2022	44	44	47.01 ± 6.19	46.05 ± 6.28	29/15	31/13
Jiang	2017	48	48	57.91 ± 5.47	57.13 ± 5.28	31/17	30/18
Shen	2018	23	23	65.8 ± 6.9	62.8 ± 5.9	12/11	10/13
Zhang	2019	205	205	48.37 ± 4.92	46.11 ± 4.73	107/98	120/85
Yu	2022	40	40	56.5 ± 4.2	57.5 ± 4.6	25/15	23/17
Yang	2021	38	38	52.52 ± 3.82	52.41 ± 3.76	23/15	22/16
Zhang	2020a	55	55	55.62 ± 1.14	55.59 ± 1.11	33/22	31/24
Zhang	2020b	47	47	47.28 ± 6.11	46.52 ± 5.92	26/21	25/22
Zhong	2018	43	43	68.0 ± 21.0	68.5 ± 20.5	Not reported
Zhang	2021	46	46	52.69 ± 7.22	53.23 ± 7.26	25/21	24/22
Zhou	2021	45	45	77.64 ± 3.25	76.73 ± 3.26	35/10	33/12
Xiang	2018	60	60	50.36 ± 4.69	51.81 ± 3.64	40/20	38/22
Sun	2017	50	50	54.98 ± 7.64	54.53 ± 7.64	26/24	30/20
Wu	2023	26	26	66.89 ± 8.21	66.37 ± 9.56	15/11	16/10

FIGURE 2.

The risk of bias graph of the included studies.

3.2. Pressure injuries

Twenty‐five RCTs reported on the occurrence of PIs. In the EBN group, 50 out of 1250 patients developed PUs; in the conventional care group, 225 out of 1244 patients developed PIs. The fixed‐effects model was employed since the examination of heterogeneity showed no heterogeneity (I ² = 0.0%, p = 1.000). The analysis revealed the EBN group was significantly lower than that of the conventional care group in terms of the incidence of PUs (OR: 0.22, 95% CI: 0.17–0.30, p < 0.001, Figure 3).

FIGURE 3.

The forest plots of incidence of pressure injuries.

3.3. Nursing satisfaction

Thirteen RCTs reported on nursing satisfaction. In the EBN group, 715 out of 743 patients were satisfied; in the conventional care group, 605 out of 743 patients were satisfied. No significant heterogeneity was noted (I ² = 36.2%, p = 0.093), and a fixed‐effects model was employed. The analysis revealed, in terms of the nursing satisfaction, the EBN group was significantly higher than that of the conventional care group (OR: 1.18, 95% CI: 1.14–1.23, p < 0.001, Figure 4).

FIGURE 4.

The forest plots of nursing satisfaction.

3.4. The onset time of PIs

Four RCTs reported on the onset time of PIs. Significant heterogeneity was noted (I ² = 58.3%, p = 0.066), and a random‐effects model was employed. The analysis revealed, in terms of the onset time of PIs, the EBN group was significantly later than that of the conventional care group (SMD: −1.61, 95% CI: −2.00 to −1.22, p < 0.001, Figure 5).

FIGURE 5.

The forest plots of the onset time of PIs.

3.5. Sensitivity analysis and publication bias

Sensitivity analysis indicated that the study conclusions were robust (Figure 6). The funnel plot results suggested potential publication bias for the outcome measures of PIs and nursing satisfaction, as shown in Figure 7.

FIGURE 6.

Sensitivity analysis. (A) Pressure injuries. (B) Nursing satisfaction. (C) The onset time of PIs.

FIGURE 7.

Funnel plots. (A) Pressure injuries. (B) Nursing satisfaction.

4. DISCUSSION

PIs are recognized as one of the nursing quality‐sensitive indicators worldwide. ³⁷ The focus on PIs by health institutions is not only due to the pain, delayed functional recovery, and infections they cause to patients and their families, but also because they prolong hospital stays, increase economic costs, morbidity, and mortality. ³⁸ , ³⁹ Moreover, patients with longer hospital stays have a higher risk of developing PIs, thus exacerbating the medical economic burden. ⁴⁰ Early proactive prevention and treatment can not only effectively reduce the incidence of PIs but also lower nursing costs and reduce the waste of medical resources, thus bringing considerable economic benefits. ⁴¹ , ⁴² Therefore, the clinical community has been committed to improving nursing schemes to reduce the incidence of PIs. ⁴³

In recent years, with the development of the EBN discipline, evidence‐based thinking and methods have been increasingly applied to clinical practice with good results. ⁴⁴ EBN can transform the blind spots of traditional nursing, making it scientific, predictive, and targeted. ⁴⁵ By using EBN intervention plans, patients can be comprehensively assessed for their risk of developing PIs, and based on the assessment results, reasonable preventive measures can be taken, such as regular turning with gentle movements, padding air rings, and soft pillows in areas like the buttocks; for patients with urinary and faecal incontinence, attention should be paid to keeping the skin dry and clean after cleaning, including using infrared baking. ⁴⁶ , ⁴⁷ The results of this study show that the EBN group had a significantly lower incidence of PIs, later occurrence time of PIs, and higher nursing satisfaction than the conventional care group. Studies indicate that applying EBN measures to ICU patients significantly improves nursing outcomes compared to conventional care, reducing the occurrence of PIs and having high clinical application value.

However, certain limitations should be addressed: firstly, only Chinese literature meeting the inclusion and exclusion criteria was retrieved, lacking literature in other languages; thus, its scientific and cutting‐edge nature still needs further verification. secondly, the disease types of ICU patients were not specified, and patients with different disease types have different physical conditions and susceptibility to PIs; and thirdly, there was significant heterogeneity in the outcome indicator of PI occurrence time among the studies, possibly related to the small number of included literature on this indicator; therefore, more high‐quality research is needed to further verify the accuracy of the results.

5. CONCLUSIONS

In conclusion, the implementation of EBN interventions in ICU patients can effectively reduce the incidence rate of PIs, delay the occurrence time of PIs, and improve patient satisfaction, making it worthy of widespread clinical application.

CONFLICT OF INTEREST STATEMENT

The authors declare that there is no conflict of interest.

Xu Y‐B, Chen Z‐Q, Su X‐H, Cao Y. Influences of evidence‐based nursing intervention on pressure ulcers in intensive care units: A meta‐analysis. Int Wound J. 2024;21(4):e14834. doi: 10.1111/iwj.14834

DATA AVAILABILITY STATEMENT

The data that support the findings of this study are available from the corresponding author upon reasonable request.