Intervention in Healthcare Teams to Promote Adherence to the Integration of Care for People at Risk of Pressure Injuries Between Hospitals and Communities: A Scoping Review

ABSTRACT

Pressure injuries (PIs) remain a problem for patient safety and the sustainability of healthcare systems. Difficulties persist in their assessment, prevention and monitoring by multidisciplinary teams. International recommendations point to this problem as a priority area for resolution in terms of patient safety. Research on the subject has been positive, resulting in several guidelines for clinical practice, but professionals' adherence remains below what is expected for their implementation. This scoping review aimed to identify interventions that increase multidisciplinary teams' adherence to the prevention and management of PIs between hospitals and the communities. The search was carried out in the MEDLINE (via PubMed), CINAHL, Scopus, Web of Science, JBI, Cochrane and grey literature databases by two independent reviewers, and led to the identification of 16 articles that met the eligibility criteria and made it possible to answer the research question. Strategies to improve adherence by health professionals include the creation and training of multidisciplinary teams, the implementation of new risk assessment models, Wound Boards, injury prevention reminders, video consultation apps, multidisciplinary rounds, documentation and recording. No studies were identified that assessed staff adherence to interventions aimed at preventing and managing PIs in the continuum between hospitals and communities, which is suggestive of the need for further research in this area.

Summary.

• Health teams need to guarantee continuity of care between hospitals and communities for people who are at high risk of, or have pressure, injuries (PI).

• Research has produced results that help to solve this problem, but they are not always systematically implemented in clinical settings, with consequences for patient safety.

• There is consensus that the adherence of teams to pressure injury management (risk assessment, prevention and early treatment of injuries) reduces incidence, prevalence and associated costs.

• Creating multidisciplinary teams in hospital services is the most widely studied intervention to increase adherence to prevention and treatment. This has led to an 86% reduction in hospital‐acquired PIs, improved education and quality of data reporting, increased reporting of adverse events and increased patient and professional satisfaction.

1. Introduction

Pressure injuries (PIs) have a high incidence and prevalence in healthcare institutions, even though in most situations they are preventable, particularly in the elderly population, with the adoption of a set of appropriate measures [1]. PIs can be defined as injuries in the skin and underlying tissue, usually over a bony prominence, as a result of pressure, or pressure in combination with shear [2].

PIs are classified according to the severity and level of tissue injury [2] including skin, subcutaneous fat, bone, muscle, tendon and ligament [3]. According to the European Pressure Ulcer Advisory Panel, National Pressure Injury Advisory Panel, and Pan Pacific Pressure Injury Alliance, this injuries can be classified into: Category/Grade I: non‐blanchable erythema; Category/Grade II: Partial loss of skin thickness; Category/Grade III: Total loss of skin thickness; Category/Grade IV: Total loss of tissue thickness with bone, tendon or muscle exposure Two other stages ‘unstageable’ and ‘deep tissue injury’ are now acknowledged [2, 3].

The major risk factors for the development of PIs include being bed‐or chair‐bound, being unable to reposition without assistance, having difficulty with ambulation, faecal incontinence, low body weight, lymphopenia, history of stroke, difficulty with independent feeding, impaired nutritional intake, nonblanchable erythema of intact skin and dry sacral skin [1]. A literature review aimed at systematically quantifying the prevalence and incidence of PIs and the rate of hospital‐acquired PIs in hospitalised adults concluded that the prevalence remains high, with over one in ten adult patients admitted to hospitals affected [2].

A cost‐effective measure that has been associated with the prevention of this type of injury is the education of both health professionals [4] and patients [5]. Health professionals play a crucial role in reducing the prevalence and incidence of PIs in people admitted to hospitals and nursing homes [4, 5, 6].

A study aimed at introducing a care bundle for the prevention of PIs in nursing homes in the United Kingdom concluded that combining interventions (education, training and modelling) with behaviour change techniques (information on social, environmental and health consequences; feedback on the behaviour and its outcome, prompts/cues, instructions on how to perform the behaviour, and demonstration of the behaviour) is important for getting stakeholders to adhere to preventive measures [6].

There is a consensus that the complexity of PIs, associated with the economic burden and consequences for patients' quality of life, justifies the adoption of preventive measures by multidisciplinary teams for efficient management of prevention and adequate and timely treatment of erythema and early‐stage injuries [1, 2, 3, 4, 5, 6, 7] and even to mitigate the physical and psychological suffering associated with these injuries [5].

Superficial PIs, such as stage I and II, are the most common stages and are preventable [2]. The management of these injuries (prevention and treatment) presents complex challenges that include individual risk assessment, timely access to appropriate equipment to perform PI prevention and treatment, maintaining turning schedules and involving multidisciplinary teams in shared decision‐making [7].

Teams' involvement should include a patient‐centered and interprofessional approach to patient education for PI prevention and management [1, 5, 6, 7, 8] to improve health literacy and empower patients and caregivers in PI care [5, 8]. This is because the risk factors identified in hospitals tend to remain when patients return home, as they are older, have co‐morbidities, and are often more dependent at the time of hospital discharge than when they were admitted [9]. For this reason, investment in preventive measures and training for teams, patients and caregivers [5, 8] should be started in hospital and continued after discharge by health teams in the community to enhance patient care [8], qualify caregivers [5] and promote effective PI‐prevention strategies [8].

Integrating care and providing holistic care, ensuring continuity of care and improving its standards ensure that PIs are adequately prevented and that any existing PIs are treated efficiently and effectively [10].

In view of the above, the aim of this study was to identify interventions that increase multidisciplinary teams' adherence to the prevention and management of PIs between hospitals and communities.

2. Materials and Methods

2.1. Study Design

An initial exploratory search of the MEDLINE (via PubMed) and CINAHL databases and systematic review protocol registration platforms did not identify any protocols or systematic reviews that answered the research question: What interventions increase multidisciplinary teams' adherence to the prevention and management of PIs between hospitals and communities?

Given the state of the art, the methodological option for this secondary study was to carry out a scoping review (SR), which followed the JBI protocol [11]. This type of systematic review makes it possible to map the evidence; analyse how the topic under study is being approached by research; identify related factors; and identify and analyse gaps in scientific knowledge [11].

The protocol for this SR was registered with the Open Science Framework (OSF) (https://osf.io/ax652/) under doi:10.17605/OSF.IO/AX652.

2.2. Eligibility Criteria

The research question was structured according to the acronym PCC (Population, Concept and Context) (Table 1).

TABLE 1.

Eligibility criteria.

	Inclusion criteria	Exclusion criteria
Population	Multidisciplinary teams; nurses, nursing students, physicians, nutritionists, physical therapists and social workers	Informal caregivers Patients
Concept	Studies with measures to sensitise multidisciplinary teams to the prevention of pressure injuries Psycho‐educational strategies to increase team adherence to prevention and correct monitoring of injuries In‐service training Continuous improvement programmes
Context	Studies produced in hospitals and/or community settings	Studies produced in nursing homes and rehabilitation units

The target population is multidisciplinary teams. Given the objective of the study and the results of the first search carried out in February 2023, studies investigating the adherence of entire teams to injury management measures or studies focusing on professional groups (nurses, doctors and nutritionists, amongst others) were accepted.

The concept under study was interventions that increased team adherence to the management of PIs (considering that this management includes prevention, risk assessment and early treatment) and that ensured continuity of this management between hospitals and communities. Based on the recommendations of authors who believe that transitional care includes interventions implemented beginning with hospital admission, throughout hospitalisation, at hospital discharge, and up to 30 days after returning home [12, 13], this SR included studies that addressed staff adherence to injury management at three times: during hospitalisation, at hospital discharge, and between 48 h and 30 days after discharge [12]. The predefined context was hospital settings and communities.

The exclusion criteria included studies of patient PI prevention measures, studies of the prevention and treatment of PIs, and studies produced in nursing homes and rehabilitation units. The articles were restricted to being available in full text, published in the last 5 years, and written in English, Spanish, French or Portuguese.

2.3. Searching and Selection of Studies

The search was carried out in March 2024 in the MEDLINE (via PubMed), CINAHL, Scopus, Web of Science, JBI, and Cochrane databases. Chart 1 shows the search strategy used in the PubMed database. The search was adjusted for each database used.

Chart 1.

Search strategy used in the MEDLINE databases.

MEDLINE (via PubMed)

(((((((((((((((((((((((((((((((((((((((((((((((((((multidisciplin* team*[MeSH Terms]) OR (health teams[MeSH Terms])) OR (nurse[MeSH Terms])) OR (doctor[MeSH Terms])) OR (medical team[MeSH Terms])) OR (healthcare team[MeSH Terms])) OR (care team, health[MeSH Terms])) OR (care team, medical[MeSH Terms])) OR (care team, patient[MeSH Terms])) OR (advanced practice nursing[MeSH Terms])) OR (hospital medical staff[MeSH Terms])) OR (hospital medical staffs[MeSH Terms])) OR (hospital clinicians[MeSH Terms])) OR (senior nurse[MeSH Terms])) OR (nursing, supervisory[MeSH Terms])) OR (administrative nursing research[MeSH Terms])) OR (hospital nursing staff[MeSH Terms])) OR (nurse managers[MeSH Terms])) OR (nurse manager[MeSH Terms])) OR (nurse administrator[MeSH Terms])) OR (supervisor nurse[MeSH Terms])) OR (co‐chief nurse[MeSH Terms])) OR (clinical nurse specialist[MeSH Terms])) OR (clinical nurse specialists[MeSH Terms])) OR (nurse educator[MeSH Terms])) OR (woc nurse[MeSH Terms])) OR (multidisciplin* team*[Title/Abstract])) OR (health teams[Title/Abstract])) OR (nurse[Title/Abstract])) OR (doctor[Title/Abstract])) OR (medical team[Title/Abstract])) OR (healthcare team[Title/Abstract])) OR (care team, health[Title/Abstract])) OR (care team, medical[Title/Abstract])) OR (care team, pacient[Title/Abstract])) OR (advanced practice nursing[Title/Abstract])) OR (hospital medical staff[Title/Abstract])) OR (hospital medical staffs[Title/Abstract])) OR (hospital clinicians[Title/Abstract])) OR (senior nurse[Title/Abstract])) OR (nursing, supervisory[Title/Abstract])) OR (administrative nursing research[Title/Abstract])) OR (hospital nursing staff[Title/Abstract])) OR (nurse managers[Title/Abstract])) OR (nurse manager[Title/Abstract])) OR (nurse administrator[Title/Abstract])) OR (supervisor nurse[Title/Abstract])) OR (co‐chief nurse[Title/Abstract])) OR (clinical nurse specialist[Title/Abstract])) OR (clinical nurse specialists[Title/Abstract])) OR (nurse educator[Title/Abstract])) OR (woc nurse[Title/Abstract]) AND ((((((((((((((((((((((((pressur* ulcer[MeSH Terms]) OR (pressure lesion[MeSH Terms])) OR (pressure sores[MeSH Terms])) OR (pressure sore[MeSH Terms])) OR (pressure injuries[MeSH Terms])) OR (pressure injury[MeSH Terms])) OR (bed sore[MeSH Terms])) OR (bed sores[MeSH Terms])) OR (decubitus ulcer[MeSH Terms])) OR (decubitus ulcers[MeSH Terms])) OR (decubitus sores[MeSH Terms])) OR (decubitus sore[MeSH Terms])) OR (pressure damage[MeSH Terms])) OR (pressur* ulcer[Title/Abstract])) OR (pressure lesion[Title/Abstract])) OR (pressure sores[Title/Abstract])) OR (pressure sore[Title/Abstract])) OR (pressure injuries[Title/Abstract])) OR (pressure injury[Title/Abstract])) OR (decubitus ulcers[Title/Abstract])) OR (decubitus sores[Title/Abstract])) OR (decubitus sore[Title/Abstract])) OR (pressure damage[Title/Abstract])) OR (bed sore[Title/Abstract])) OR (bed sores[Title/Abstract]) AND (((((((((((((((((((((((((((((((((((((((((((formation[MeSH Terms]) OR (education[MeSH Terms])) OR (educat*[MeSH Terms])) OR (psychoeducation[MeSH Terms])) OR (capacitation[MeSH Terms])) OR (interventions[MeSH Terms])) OR (strategies for teamwork[MeSH Terms])) OR (coaching[MeSH Terms])) OR (management[MeSH Terms])) OR (organization[MeSH Terms])) OR (team leader[MeSH Terms])) OR (audit, management[MeSH Terms])) OR (activity, educational[MeSH Terms])) OR (activities, educational[MeSH Terms])) OR (building, capacity[MeSH Terms])) OR (nursing care[MeSH Terms])) OR (management, nursing care[MeSH Terms])) OR (nursing care management[MeSH Terms])) OR (hospital nursing service[MeSH Terms])) OR (hospital nursing services[MeSH Terms])) OR (adherence, guideline[MeSH Terms])) OR (adherence[MeSH Terms])) OR (formation[Title/Abstract])) OR (education[Title/Abstract])) OR (educat*[Title/Abstract])) OR (psychoeducation[Title/Abstract])) OR (capacitation[Title/Abstract])) OR (interventions[Title/Abstract])) OR (strategies for teamwork[Title/Abstract])) OR (choaching[Title/Abstract])) OR (management[Title/Abstract])) OR (organization[Title/Abstract])) OR (team leader[Title/Abstract])) OR (audit management[Title/Abstract])) OR (educational actitivy[Title/Abstract])) OR (educational activities[Title/Abstract])) OR (building, capacity[Title/Abstract])) OR (nursing care[Title/Abstract])) OR (management, nursing care[Title/Abstract])) OR (nursing care management[Title/Abstract])) OR (hospital nursing service[Title/Abstract])) OR (hospital nursing services[Title/Abstract])) OR (adherence, guideline[Title/Abstract])) OR (adherence[Title/Abstract]) AND (((((((((((((((((((((((((((((care settings[MeSH Terms]) OR (general ward[MeSH Terms])) OR (general wards[MeSH Terms])) OR (wards[MeSH Terms])) OR (hospital wards[MeSH Terms])) OR (hospital ward[MeSH Terms])) OR (hospital[MeSH Terms])) OR (hospitals[MeSH Terms])) OR (community settings[MeSH Terms])) OR (Care Facilities[MeSH Terms])) OR (Health care facilities[MeSH Terms])) OR (care network[MeSH Terms])) OR (community health[MeSH Terms])) OR (community health service[MeSH Terms])) OR (hospital environment[MeSH Terms])) OR (care settings[Title/Abstract])) OR (general ward[Title/Abstract])) OR (general wards[Title/Abstract])) OR (wards[Title/Abstract])) OR (hospital wards[Title/Abstract])) OR (hospital ward[Title/Abstract])) OR (hospital[Title/Abstract])) OR (hospitals[Title/Abstract])) OR (community settings[Title/Abstract])) OR (care facilities[Title/Abstract])) OR (heath care facilities[Title/Abstract])) OR (care network[Title/Abstract])) OR (community health[Title/Abstract])) OR (community health service[Title/Abstract])) OR (hospital environment[Title/Abstract])

In the second phase, a search was carried out based on the references of the articles included and subsequently in the grey literature, which included consulting Google Scholar and the Portuguese Open Access Scientific Repository, using the keywords ‘healthcare teams’; ‘pressure ulcer’; ‘pressure lesion’; ‘prevention’; ‘education’; ‘hospital’ and ‘community’. In this phase were accepted e‐books, online handbooks, books, reports, dissertations, conference proceedings, documents from the ministry of health and guidelines available. Research was also carried out on the websites of reference organisations: The Directorate‐General for Health (DGS) (https://www.dgs.pt/), The European Wound Management Association (EWMA) (https://ewma.org) and The Pan Pacific Pressure Injury Alliance (PPPIA) (https://pppia.org/).

2.4. Data Extraction

The articles identified in the different databases were exported to the Rayyan platform, which made it possible to identify and remove duplicate articles and supported the screening process carried out by two independent reviewers (D.A. and L.G.). A third reviewer was called in when there was no consensus (C.L.B.).

An Excel file was created to facilitate the extraction of the results of the studies included in this SR. It contained the following information: article title, author name(s), publication year, article type, objectives, methods and main results/conclusions. The articles were analysed for their suitability to answer the research question based on the predefined eligibility criteria.

2.5. Data Synthesis

The heterogeneity of the studies included, in terms of study design, participants and intervention, meant that a narrative synthesis of the results of the articles found was made, which did not allow for any other type of analysis.

3. Results

3.1. Screening of Studies

The search in the different databases identified 755 articles, 133 of which were duplicates. After reading their titles, 489 articles were excluded. Amongst the remaining 133, 97 were not retrieved. Of the 36 articles included for reading in full and after applying the eligibility criteria, 13 remained. The search in references and grey literature identified 15 articles, three of which met the eligibility criteria and answered the research question. Therefore, the final sample consisted of 16 articles, according to the PRISMA flow diagram (Figure 1) [14].

FIGURE 1.

PRISMA 2020 flow diagram for updated systematic reviews, which included searches of databases, registers and other sources [14].

3.1.1. Characteristics of Included Studies

The studies in the literature sample [15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30] are heterogeneous in terms of study design and the interventions implemented to improve team adherence to pressure injury management (Table 2). As for the country of origin of the articles, six are from the United States [21, 22, 23, 24, 25, 30], and two from China [19, 29]. The remaining articles were carried out by researchers from Switzerland [15], Qatar [16], Japan [17], Portugal [18], Georgia [20], South Korea [26], Egypt [27] and the United Kingdom [28].

TABLE 2.

Literature sample, intervention and results.

Article/(year)/country	Type of study/objective	Team intervention	Results
A1 [15] (2023) Switzerland	Retrospective study aiming to develop a predictive model to detect patients at risk of developing a PI and compare its performance with that of the Braden Scale.	Developing a model to support nurses in clinical decision‐making regarding the assessment of the risk of PIs.	Implementing the model in the hospital information system could improve the assessment of patients at risk, saving time by allowing nurses to focus on higher‐priority interventions.
A2 [16] (2020) Qatar	Quality improvement report to reduce the incidence of PIs by 60% within 2 years.	The multidisciplinary teams tested various changes and implemented the Surface, Skin inspection, Keep moving, Incontinence, and Nutrition bundle programme. Posters, clocks, and PI incidence calendars were used in the units as reminders.	The interventions proved successful, reducing the incidence of PIs by >80%. The results were sustained over a 4‐year period.
A3 [17] (2022) Japan	Case study to present the case of a patient who received real‐time remote consultations through the app.	Remote wound assessment application for primary health care, with the help of a wound team.	The app CARES4WOUNDS‐JP could help wound, ostomy and continence nurses (WOCNs) and home visit nurses to assess wounds together through video consultations. Sharing patient data via the app prior to video calls supported individualised assessment and intervention. This app could contribute to connecting WOCNs, visiting nurses, and patients remotely and effectively.
A4 [18] (2020) Portugal	Systematic literature review with the aim of identifying the effects of the use of clinical decision support systems by nurses on the clinical decision to perform PI monitoring.	Implementation of clinical decision support systems in clinical practice with follow‐up periods ranging from 1 to 12 months or more.	The available literature still lacks evidence of the effects achieved with the use of clinical decision support for the prevention or treatment of PIs. No significant effects were found on nurses' knowledge after integrating clinical decision support systems into workflows, with evaluations carried out for a short period of up to 6 months of implementation.
A5 [19] (2022) China	Randomised study to evaluate the effectiveness of an interactive training programme in an e‐book application to improve nurses' knowledge, attitudes, and confidence to prevent and treat PIs.	The intervention group participated in the PI e‐book application training programme, and the control group received a traditional lecture programme with similar content.	The training program successfully increased nurses' knowledge of PI care and had positive results in relation to evidence‐based PI management.
A6 [20] (2019) Georgia	Retrospective study with the aim of summarising the highlights of the first PI summit.	The SCI Pressure Ulcer Monitoring Tool (SCI‐PUMT) is a tool developed to support the implementation of PI prevention guidelines and protocols with interdisciplinary collaboration.	An interdisciplinary team approach with education of providers, patients and caregivers is critical to the success of programs to prevent and manage PIs.
A7 [21] (2022) USA	Quality improvement study to describe the implementation of a comprehensive skin and wound care program.	Creating a comprehensive, interprofessional, and evidence‐based skin and wound care committee, and a wound board for presenting cases and consulting experts, providing educational programmes, and streamlining the processes of evaluating, acquiring and using products.	Multidisciplinary, multifaceted, and interventional approaches can reduce the incidence of PIs and improve their treatment.
A8 [22] (2022) USA	Retrospective study to examine the implementation of a multidisciplinary approach to prevent PIs in a burn unit.	The frequency of multidisciplinary patient rounds was increased from once to twice a day, and involved discussions about functional status, mobility and nutrition. The practice of ordering specialised beds was modified to require three‐part approval by the Medical Director of Burn Services, the Director of Nursing, and a burn therapy supervisor.	After implementing a multidisciplinary approach to PI prevention, it was possible to reduce the incidence of PIs and drastically reduce the costs associated with renting specialised beds. This supports an effort to identify additional practices that can increase quality while decreasing costs.
A9 [23] (2022) USA	Quality improvement study to reduce PIs by 20% within 12 months of the project's implementation.	The Skin Response (SR) project team has developed a multidisciplinary approach to identifying and treating skin disorders in the hospital environment. When the skin alteration is identified, the assistant is contacted to request an appointment with the SR team, where the client's name and bed are given. The assistant notifies everyone on the team; they have a maximum of 20 min to go to the site and assess the injury, care measures, and care plan as a team.	The implementation of the multidisciplinary response team for the identification and treatment of PIs led to an 86% reduction in hospital‐acquired PIs and an estimated cost reduction of $2 to $14 million in 12 months.
A10 [24] (2023) USA	Retrospective study to optimise methods for reducing the incidence of PIs in hospitals.	It implemented a three‐pronged intervention to reduce the incidence of PIs. The intervention included: a multidisciplinary surgical team; improved nursing education; and better‐quality data reporting.	The average incidence of PIs was reduced from 0.746% before the intervention to 0.022% after the intervention. The intervention of a multidisciplinary surgical team improved nursing education and the quality of data reporting and reduced the incidence of PIs.
A11 [25] (2023) USA	Cross‐sectional study with two objectives: to examine determinants of adherence to patient safety protocols; and to investigate the relationship between adherence and adverse patient events.	Adherence to patient safety protocols and reporting of adverse events.	Greater adherence to patient safety protocols resulted in an increase in the reporting of adverse patient events.
A12 [26] (2023) South Korea	Descriptive qualitative study to elucidate the benefits of a simple wound care team by reporting on the experiences of setting up the team.	Creation of a team to treat simple, uncomplicated wounds.	A simple wound care team can increase satisfaction among patients and health professionals.
A13 [27] (2019) Egypt	Longitudinal study with the aim of applying a multidisciplinary approach to the prevention and management of PIs.	Creation of a multidisciplinary team to eliminate the incidence of PIs through assessment, prevention and effective management.	The study found that that the mean scores of cases with PIs decreased after the application of the interdisciplinary team approach.
A14 [28] (2019) UK	Quantitative study to reduce the percentage of PIs developed by patients.	Creation of a multidisciplinary team.	This collaborative approach to PI proved successful in reducing the percentage of PIs in the North East and North Cumbria by 36% in year 1 and 33% in year 2.
A15 [29] (2029) China	Descriptive qualitative study to explore nurses' approaches to PI prevention in the Chinese context.	Nurses' delivery of PI prevention care	Nurses in this study elucidated their leading role in PI prevention. The findings identified the importance of collaboration between different levels of nurses and wound care specialists to facilitate high‐quality PI prevention.
A16 [30] (2022) USA	Quality improvement study aimed at developing and implementing up‐to‐date documentation fields, making them consistent in electronic records.	Standardised skin and risk assessment; PI prevention documentation shared and common to all clinical areas.	Multidisciplinary work improved PI documentation to make it consistent for all professionals, who are now able to visualise and document PI risk assessment and preventive and curative PI interventions.

It is noteworthy that nine articles address interventions involving multidisciplinary teams [16, 19, 20, 21, 22, 23, 26, 27, 30], while the others focus on interventions exclusively for nursing teams [15, 17, 18, 24, 25, 28, 29]. Five articles address adherence to PI prevention measures [19, 20, 22, 23, 27], four discuss interventions to improve PI risk assessment [16, 19, 27, 30] and four studies address team interventions to improve the effectiveness of treatment for these wounds [17, 19, 21, 27]. Only one study was carried out in a community [16], the remaining studies were in hospital settings [15, 16, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30].

Table 3 summarises the interventions for managing pressure injuries identified in each article.

TABLE 3.

Team interventions to increase adherence to PI management.

Article	Education/ training of multidisciplinary teams	Wound management teams	Wound Boards	PI risk assessment	PI prevention reminders	Applications for video consultation	Multidisciplinary rounds	Documentation and recording
15	x				x
16		x			x	x
17			x				x
18	x
19	x	x
20	x	x
21		x		x
22		x						x
23		x	x		x
24	x		x
25	x		x
26		x	x
27	x	x	x
28	x		x
29	x
30	x				x

Note: The X means that the article presents that intervention.

Teams' interventions for adherence to PI management include education and training of multidisciplinary teams, creation of wound management teams, wound boards, assessment of the risk of developing PIs, reminders to prevent injuries, video consultation apps, multidisciplinary rounds, and documentation and recording.

The creation of wound teams in hospital services is the most widely studied [17, 23, 24, 25, 26, 27, 28], leading to an 86% reduction in hospital‐acquired PIs [23], improved nursing education and the quality of data reporting [24], increased reporting of adverse events [25], and increased satisfaction amongst clients and professionals [26].

The results also highlight the importance of education strategies to increase the adherence of multidisciplinary teams and/or nursing staff to PI management [16, 19, 20, 22, 23, 26, 27]. The implementation of programmes such as the Surface, Skin inspection, Keep moving, Incontinence and Nutrition bundle reduced the incidence of PIs by 80% [16], and the implementation of the PI e‐book increased nurses' knowledge of PI care [19].

The importance of assessing the risk of developing PIs is mentioned in four articles [15, 16, 23, 30], with three proposing new assessment models [15, 16, 23].

Another intervention with good results was the proposal to hold Wound Boards [21], with the presentation of clinical cases and consultation with experts on the subject, as well as providing educational programmes.

It should be noted that the majority of studies use quantitative approaches [15, 19, 20, 22, 24, 25, 27, 28], four report results from quality improvement studies [16, 21, 23, 30], two results from qualitative research [26, 29], one study is a systematic review [18] and one is a case study [17]. The diversity of approaches makes it difficult to compare results between different studies.

4. Discussion

The 16 articles that make up the literature sample of this systematic review present various interventions that can increase professional adherence to the implementation of measures that enable risk identification [15, 16, 23, 30],, preventive measures [19, 20, 22, 23, 27], and the early and appropriate treatment of injuries in their initial stage [17, 19, 21, 27].

There is a consensus amongst authors that a multidisciplinary team approach is crucial for the assessment, prevention and monitoring of PIs in people who develop or are at risk of developing PIs [16, 19, 20, 22, 23, 26, 27]. Other studies corroborate this importance, recognising that although there are satisfactory levels of knowledge and attitudes in relation to PI prevention overall [31], this care is not always maintained by everyone over time. In prevention programmes that involve care maintained over time and carried out several times a day, the practices and behaviours of everyone involved are vital to ensure compliance with the guidelines and prevent adverse events [32].

Amongst the articles exploring risk identification [15, 16, 23, 30], the Skin Response project that developed a multidisciplinary team approach to both identify the risk and treat skin alterations in the hospital setting stands out [23]. That is because this project, with a multidisciplinary response team for PI identification and treatment, led to an 86% reduction in sentinel events and an estimated cost savings of $2 to $14 million within 12 months of implementing the protocol [23]. A reduction in patient harm was achieved through a 20‐min response time, integrative multidisciplinary discussion and real‐time education for the bedside nurses [23].

Another intervention with good results was the implementation of Wound Boards [21], with the presentation and discussion of clinical cases with experts who advised on interventions and concomitantly invested in educational programmes for the teams. In fact, the education of professionals to determine risk, the appropriate use of the Braden scale [23], and the association of preventive measures with each person's individual risk are recognised elements of PI prevention guidelines. They also influence a change in behaviour of healthcare professionals, moving away from curative care and towards prevention [33].

The use of video consultations by primary healthcare professionals is a viable and safe option to ensure support from teams with advanced training, which can help in decision‐making about preventive measures and/or wound treatment. The use of digital health technologies makes it possible to manage human resources, make the most of time and minimise costs [34]. The results of the studies indicate that telemedicine is a feasible way to prevent PIs, which can decrease the incidence and severity of these injuries and accelerate patients' healing without imposing an economic burden [35].

However, these findings confirm that the evidence regarding the use of telewound prevention and treatment care is weak. Findings related to the impact of telewound care on outcomes are inconsistent [36], although some studies indicate that it is not inferior to in‐person care [36, 37]. The term telewound refers to the use of telemedicine in wound care, such as remote wound assessment, consultation with patients, discussions amongst medical professionals, and e‐health interventions to the prevention and management of this injuries [36, 37]. A study that aimed to describe an inaugural telewound monitoring service designed for the remote monitoring of acute wounds to empower primary care patients, concluded that telewound monitoring is a valuable alternative to face‐to‐face wound care service and has the potential to engage more patients with acute wounds in their own wound care [37].

Long‐term multidisciplinary follow‐up is difficult after patients are discharged. Telemedicine promises to provide convenient and effective support for the prevention and treatment of PIs [35].

It should be noted that none of the studies identified explored team interventions to ensure continuity of care in the management of PIs between hospitals and communities. It is known that people at high risk of developing PIs remain at risk when they return home, which is often aggravated by the absence of pressure relief surfaces, difficulties in repositioning by caregivers, increased sliding and friction forces due to the characteristics of beds and chairs, and difficulties in mobilising in beds [5, 9, 38]. This finding reinforces the need to improve the continuity of care and communication mechanisms in hospital and primary care, to ensure proper coordination and facilitate continuity of care and patient safety [38].

The challenges in communities are different and more complex, because health professionals are not available 24 h a day. Caregivers need to be trained to continue with interventions [5] that are new to them and often difficult to ensure, such as alternating decubitus positions or lifting people with mobility difficulties. At home, the provision and planning of materials or technologies to facilitate care also becomes more difficult [38]. Specifically with regard to the prevention of PIs, it is important to note that its development can be related to many factors, such as difficulties and limitations in the structure of services, in the work process and in the actions of caregivers [38, 39].

A study carried out in France, which aimed to measure the effectiveness of home healthcare PI prevention devices for at‐risk patients after hospital discharge, observed that patients with access to them had significantly fewer PIs than those without (5.5% vs. 8.9%, respectively p < 0.001). The adoption of PI prevention devices reduced by 39% the risk of PIs in hospitals, and patients equipped within the first 30 days at home after hospitalisation had fewer PIs than those equipped later (4.8% vs. 5.9%, respectively) [39].

The PI prevention devices includes pressure relieving and redistributing devices, offloading footwear, protectors that help to reduce injury caused by friction or shear forces; positioners that help to change position [3, 39].

These results highlight the need to improve guidelines for home care during hospitalisation [38] and to create communication mechanisms between health services, ensuring adequate coordination and facilitating continuity of care and patient safety [38, 39].

The literature review identifies a gap in research on transitional care programmes and interventions for the management of PIs that ensure continuity of care between hospitals and communities.

In view of the objective of this systematic review, it is also a warning to the need for studies that analyse the training of teams to adhere to the management of PIs and studies that explore the potential of new technologies to ensure patient and family adherence to (new) PI preventive measures.

5. Limitations

The aim of this SR was to identify studies on interventions that increase multidisciplinary teams' adherence to the prevention and management of PIs between hospitals and the communities. The option does not assess the methodological quality of the studies in the bibliographic sample, the heterogeneity of the studies included, the identification of a single randomised study [19] and the fact that interventions and measures described in each study have different limits comparison and makes recommendations for clinical practice difficult.

Large‐scale and well‐designed randomised controlled trials [35] are recommended to assess the effectiveness of the interventions identified.

The search strategy, carried out using a librarian with experience in this type of study, was aimed at the elements of the PCC acronym, but given the scope of this SR, it may not have been sensitive enough for this purpose. The definition of the inclusion criteria, the identification of the MESH terms and the key words used in the indexing of articles on the prevention and treatment of PIs tried to guarantee the sensitivity, specificity and efficiency of the search strategy, reducing the risk of bias.

The restrictions of the time limit, free full text and language probably excluded some articles that answered the research question. Another limitation is that, in general, SRs evaluate neither the quality of research methodology nor any study bias [11].

6. Conclusions

The results of these SR allowed to identify interventions that increase multidisciplinary teams' adherence to the prevention and management of PIs between hospitals and the communities, such as education and training, creation of wound management teams, Wound Boards, assessment of the risk of developing PIs, reminders for injury prevention, video consultation apps, multidisciplinary rounds, and documentation and recording.

The existence of trained multidisciplinary teams increases team adherence to risk assessment, prevention and early treatment of PIs. The implementation and updating of documentation systems common to all professionals and the use of new models for assessing the risk of developing PIs allow for increased safety and continuity of care.

The prevention and treatment of PIs is complex and involves multidimensional interventions. Evidence should support the design of multidisciplinary interventions that guarantee continuity of care between the hospital and the community for the prevention of wounds in people at high risk of developing them. In people with PIs the intervention should guarantee continuity of treatment. This area benefits from the implementation of non‐pharmacological clinical trials to evaluate the effectiveness of the team's interventions for the prevention and treatment of PIs between the hospital and the community and also qualitative to understand patients' and caregivers' difficulties in managing PI prevention measures.

Conflicts of Interest

The authors declare no conflicts of interest.

Amêndoa D., Gugg L., Gomes C., Diniz C., Ferreira Ó., and Baixinho C. L., “Intervention in Healthcare Teams to Promote Adherence to the Integration of Care for People at Risk of Pressure Injuries Between Hospitals and Communities: A Scoping Review,” International Wound Journal 22, no. 9 (2025): e70212, 10.1111/iwj.70212.

Data Availability Statement

Data available on request from the authors.