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. 2025 Sep 20;12(9):e70237. doi: 10.1002/nop2.70237

Patient Referral and Pressure Injuries: A Systematic Review

Yahan Wang 1, Hongxia Tao 2, Xinmian Kang 1, Qian Su 2,3, Juhong Pei 2, Lin Han 1,3,✉
PMCID: PMC12449657  PMID: 40974192

ABSTRACT

Aims

To analyse and discuss the basic conditions and related factors of transported patients' PIs and attract the attention of healthcare providers to PIs.

Design

Systematic review.

Data Sources

Databases including CNKI, VIP, Wanfang Database, CBM, PubMed, Web of Science, EBSCO and Cochrane Library were used, and manual searches of reference lists were also performed. The search timeframe was from the inception of the databases up to December 2023.

Methods

According to the PRISMA, a systematic review and meta‐analysis was conducted. Data were combined using meta‐analysis, and relevant factors were explored through descriptive analysis.

Results

A total of eight articles were included, comprising 3512 participants. The prevalence of PIs among transported patients ranged from 5.2% to 7.92%, with an incidence rate of 9.4%. PIs were mainly classified as Stage 1 and Stage 2. Common sites included the sacrum, buttocks and heels. Risk factors included the duration and frequency of the transfer, equipment environment, age and BMI and patient source.

Conclusion

Patients during transport represent a special population at risk of developing PIs; healthcare providers and managers should increase their focus on PIs management for transported patients while ensuring the patients' life conditions.

Impact

Current evidence indicates that transferred patients are at risk of developing PIs. High‐quality studies are needed to validate these results to support healthcare providers in implementing precise and effective management.

Patient or Public Contribution

No patient or public contribution because of the review.

Trial Registration

PROSPERO registration number: CRD42023493742

Keywords: incidence, pressure injury, prevalence, referral, risk factor, transportation

1. Introduction

Patient transport refers to the process of transferring patients from the onset site or one medical institution to another medical institution for further treatment or nursing. Patient transport involves various scenarios and environments. (1) According to the mode of transport: ground transport, air transport, water transport. (2) According to the different geographical areas where transport is implemented: pre‐hospital emergency care, intra‐hospital transport, inter‐hospital transport. (3) According to the patient's condition: emergency transport and non‐emergency transport (Inter‐hospital Transfer Expert Consensus Group for Critically Ill Patients and National Emergency Professional Quality Control Center 2022). During the implementation of patient transport and rescue, medical staff prioritise the patient's vital signs (respiration and circulatory system), often considering potential safety risks such as PIs during the rescue process as secondary care issues (Haesler 2019).

PIs refer to localised damage to the skin and/or subcutaneous tissue caused by pressure or pressure in combination with shear forces, usually occurring at bony prominences and may also be related to medical devices or other items. They result from internal responses to gravity or external mechanical loads, manifesting as intact skin or open wounds, often accompanied by pain (Haesler 2019). During transport, patients may have limited mobility due to their disease status (Joseph and Nilsson Wikmar 2016; Nijs et al. 2009), changes in perfusion, circulation, oxygenation, sensation and mental status (Defloor and Grypdonck 2005; Sanada et al. 2008; Ranzani et al. 2016), leading to sustained tissue deformation at pressure points, and PIs may develop within minutes to hours (Oomens et al. 2015). Early neglect may exacerbate the severity of PIs, imposing a heavy economic burden on the individual, family and healthcare institution. Therefore, during transport, medical staff should implement earlier and more comprehensive preventive and management measures for PIs while maintaining patient safety, which can reduce treatment costs, promote patient recovery and rehabilitation, improve clinical treatment efficiency and enhance the quality of medical services.

Existing research and practice have recognised that there may be a risk of PIs among the group of patients being transported in this specific environment (Fulbrook et al. 2019; Luo et al. 2023). However, due to differences in countries and healthcare institutions, the incidence and prevalence of PIs among transported patients vary in different studies. For example, Susan et al. reported a PI incidence rate of 4.9% among patients transported by air (Dukes et al. 2018), while the results from another study (Peng and Gu 2017) showed that 34.6% of patients occurred PIs among long‐distance referral patients. Previous studies (Walker et al. 2017; Shi et al. 2018; McInnes et al. 2018; Zhu et al. 2023; Lyu et al. 2023) have focused on using preventive dressings at pressure injury‐prone sites or making improvements to support surfaces for transported patients. The results indicated that timely and effective prevention and intervention for transported patients can reduce the incidence of PIs. Although international health policies have increased attention to the management of PIs and healthcare professionals have strengthened their efforts in PIs prevention (VanGilder et al. 2017), research specifically related to PIs among transported patients remains limited. Due to constraints such as research regions, sample sizes and research methods, there are differences in conclusions among studies, and there is currently no systematic literature review on the epidemiological characteristics and related factors of PIs among transported patients.

This study aimed to determine the occurrence of PIs in transported patients. Additionally, we summarised the associated risk factors in the transportation process through research and discussions, in order to provide reference for PIs prevention and PI management for healthcare professionals.

2. Material and Methods

2.1. Protocol Registration

This study followed the Preferred Reporting Items for Systematic Reviews and Meta‐Analyses (PRISMA) guidelines for conducting a systematic review (Page et al. 2021).

2.2. Search Strategy

The search was conducted through computer databases including China Knowledge Resource Integrated Database (CNKI), Weipu Database (VIP), Wanfang Database, Chinese Biomedical Database (CBM), PubMed, Web of Science, EBSCO and Cochrane Library. The search timeframe was from the inception of the databases up to December 2023. The search strategies were performed through a combination of Mesh terms and free words. Boolean operators like ‘AND’ and ‘OR’ were used to combine search terms. Detailed search strategies were provided in the Appendix S1. Such as ‘(((pressure ulcer OR pressure ulcers OR pressure injury OR pressure injuries [MeSH Terms]) AND (incidence [MeSH Terms] OR prevalence [MeSH Terms]))) AND (risk factor)’. In addition, manual searches of the reference lists and relevant literature of all articles that met the inclusion criteria were conducted to expand the scope of the literature search. The study also examined grey literature to ensure comprehensive search results. In cases of vague or detailed information, authors were contacted when necessary for content retrieval. Since this research was a secondary study based on original research, ethical approval was not required for this study.

2.3. Study Selection

After removing duplicates, two researchers independently screened titles and abstracts based on inclusion and exclusion criteria. When at least one reviewer deemed the abstract to meet the inclusion criteria, the full‐text article was retrieved. Each publication was evaluated independently by two researchers for final inclusion. Disagreements were resolved through consultation with a third party.

The research focused on the current prevalence and incidence of PIs in patients during the transportation process and the related influencing factors. Articles were eligible if they met the following criteria: (1) Studies reporting the epidemiological characteristics of PIs in patients during transfers (including the number of patients, prevalence, incidence, influencing factors, risk factors, related factors); (2) Studies published in Chinese or English; and (3) Descriptive or interventional studies. Exclusion criteria: (1) Reporting on studies of other types of skin injuries, such as incontinence‐associated dermatitis, friction dermatitis, medical adhesive‐related skin injuries, traumatic wounds (skin tears, burns, abrasions), ulcers, herpes‐like lesions, moisture‐related skin injuries, etc.; (2) Studies that were inaccessible in full text, had missing research data, were duplicate publications or had low methodological quality scores; and (3) Articles such as policy interpretations, reviews, guidelines, letters, etc.

2.4. Data Extraction

The data were extracted by two independent researchers from the included studies. Extracted information included first author, year of publication, study region, study type, sample size, age, gender, prevalence/incidence rate of PIs, influencing factors, etc. Any discrepancies were resolved through discussion or consultation with a third researcher.

2.5. Quality Assessment

Two researchers independently assessed the quality assessment of included studies and any discrepancies were resolved through discussion to reach a consensus. Observational studies were evaluated for quality based on the standards recommended by the Agency for Health care Research and Quality (AHRQ) (Rostom et al. 2004) in the United States. The criteria consisted of 11 items, with responses categorised as ‘yes’ ‘no’ ‘unclear’. Studies with score > 3 points were considered moderate or high quality. The Newcastle‐Ottawa Scale (NOS) (Stang 2010) were used as the standard for evaluating cohort studies and case–control studies. The scale was divided into three sections: selection, comparability and outcome assessment, comprising a total of eight items. Each item meeting the evaluation criteria was awarded 1 or 2 points, with a maximum score of 9 points. Studies with score ≥ 4 points were considered medium or high quality. Randomised controlled trials (RCTs) were assessed for quality using the Cochrane Risk of Bias Assessment Tool (Higgins et al. 2011), which consisted of seven domains. Each domain was categorised as ‘high risk of bias’ ‘low risk of bias’ or ‘unclear risk of bias’ to judge and classify the quality of the study. Any discrepancies during the evaluation process were resolved through discussion with a third researcher.

2.6. Data Analysis

The meta‐analysis was performed using Stata 17.0 software. The incidence rates of transported patients were summarised and presented as the primary outcome measure. Corresponding 95% confidence intervals and statistical heterogeneity results (p value and I 2) were provided, with a significance level of p < 0.05 indicating statistical significance of the differences. Heterogeneity was quantified by the I 2 test. When p ≤ 0.1 and I 2 ≤ 50%, heterogeneity was considered acceptable and a fixed‐effects model was used. If I 2 ≥ 50% and p < 0.1, significant heterogeneity was indicated and a random‐effects model was used. Quantitative data were summarised in tabular form and presented by description.

3. Results

3.1. Search Progress

Initial search identified 4303 articles, of which 876 were duplicates. After screening titles and abstracts, 139 articles were reviewed based on inclusion and exclusion criteria. These studies underwent further detailed evaluation. Among them, 86 studies were excluded because their research topics were not relevant to the occurrence and/or influencing factors of PIs in transported patients, 42 studies were excluded because their study designs did not meet the inclusion criteria, and three studies were excluded due to insufficient data. In the end, a total of eight studies (Mok et al. 2013; Bååth et al. 2016; Liu et al. 2016; Peng and Gu 2017; Dukes et al. 2018; Fulbrook et al. 2019; He et al. 2022; Luo et al. 2023) (3 in Chinese and 5 in English) met the inclusion criteria, with four articles used for meta‐analysis (Figure 1). The sample sizes varied from 90 to 2284 participants. Among the included studies, three were cross‐sectional studies, two were cohort studies, one was a case–control study and two were RCTs. Table 1 displayed the basic characteristics of the included studies. The quality evaluation results of the literature included in the study were shown in Tables 2 and 3, and Figures 2, 3, 4.

FIGURE 1.

FIGURE 1

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PRISMA flow diagram.

TABLE 1.

Characteristics of the included studies.

Author (year) Country Type of study Sample size Age (years) M/F ratio (%) Prevalence/incidence of PIs (n, %) PIs stage Braden score Transfer time (h) BMI
Luo et al. (2023) China Cross‐sectional 101 58.3 ± 11.69 68/33 8, 7.92% I 15.32 ± 2.06 2.26 ± 0.26 22.48 ± 2.2
Dukes et al. (2018) America Case–control 282/2284 25.5 (19–48) 141/141 112, 4.9% — — 9 26
Fulbrook et al. (2019) Australia Cross‐sectional 212 60 (36–75) 107/105 11, 5.2% I II III 19.5 1 —

Mok et al. (2013)

 America Cohort 30/90 28.8 86/4 3, 10% I II — 10.2 —
He et al. (2022) China Cross‐sectional 140 70.42 ± 16.17 88/52 140, 100% I II III IV — — —

Peng and Gu (2017)

 China Cohort 52/97 52 ± 10.5 58/39 18, 34.6% I II 8.65 ± 1.85 4.0 ± 0.65 21.6 ± 2.3
Bååth et al. (2016) Sweden RCT 80/183 86.3 ± 7.2 60/114 24, 30% I II–IV — 0.5 —
Liu et al. (2016) China RCT 76/152 50.05 ± 6.03 81/71 10, 13.2% — — — —
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Note: In Susan paper, 112 of the 141 patients with pressure injury were from patients who were transported through CCATT from 2009 to 2012 (a total of 2284 patients), so the prevalence was 112/2284.

TABLE 2.

Quality assessment of NOS.

Author (year) Selection Comparability Outcome Score
(1) (2) (3) (4) (5) (6) (7) (8)
Dukes et al. (2018) 0 1 1 0 2 1 1 0 6
Mok et al. (2013) 1 1 1 1 1 1 1 0 7
Peng and Gu (2017) 1 1 1 0 1 1 0 1 6
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Note: Case–control studies: (1) Is the case definition adequate; (2) Representativeness of the cases; (3) Selection of controls; (4) Definition of controls; (5) Comparability of cases and controls on the basis of the design or analysis; (6) Ascertainment of exposure; (7) Same method of ascertainment for cases and controls; (8) Non‐Response rate. Cohort studies: (1) Representativeness of the exposed cohort; (2) Selection of the non‐exposed cohort; (3) Ascertainment of exposure; (4) Demonstration that the outcome of interest was not present at the start of the study/before ascertainment of exposure; (5) Comparability of cohorts on the basis of the design or analysis; (6) Assessment of outcome; (7) Was follow‐up long enough for outcomes to occur; (8) Adequacy of follow‐up of cohorts.

TABLE 3.

Quality assessment of AHRQ.

Author (year) (1) (2) (3) (4) (5) (6) (7) (8) (9) (10) (11) Score
Fulbrook et al. (2019) Y Y Y Y N Y Y N N Y N 7
Luo et al. (2023) Y Y Y Y N Y Y N N Y N 7
He et al. (2022) Y Y Y Y N Y N N N Y N 6
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Note: Y = yes, N = no/unclear. (1) Define the source of information (survey, record review)；(2) List inclusion and exclusion criteria for exposed and unexposed subjects (cases and controls) or refer to previous publications; (3) Indicate the time period used for identifying patients; (4) Indicate whether or not subjects were consecutive if not population‐based; (5) Indicate if evaluators of subjective components of the study were masked to other aspects of the status of the participants; (6) Describe any assessments undertaken for quality assurance purposes (e.g., test/retest of primary outcome measurements); (7) Explain any patient exclusions from analysis; (8) Describe how confounding was assessed and/or controlled; (9) If applicable, explain how missing data were handled in the analysis; (10) Summarise patient response rates and completeness of data collection; (11) Clarify what follow‐up, if any, was expected and the percentage of patients for which incomplete data or follow‐up was obtained.

FIGURE 2.

FIGURE 2

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Quality assessment of the Cochrane checklist.

FIGURE 3.

FIGURE 3

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The distribution of the methodological quality of RCT.

FIGURE 4.

FIGURE 4

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Forest plot of pressure injury incidence in transferred patients.

3.2. Main Results

3.2.1. The Prevalence and Incidence of Pressure Injuries

The prevalence of PIs in transported patients was5.2%–7.92%, and an incidence was 4.9%–34.6%.

Two studies (Fulbrook et al. 2019; Luo et al. 2023) reported the prevalence of PIs in transported patients. Paul et al. found the prevalence of 5.2% of PI among adult patients transported by ambulance to a hospital in Australia, involving 212 patients. Luo et al. conducted a study using data and image analysis methods to assess the prevalence of medical device‐related pressure injuries (MDRPIs) in ambulance‐transferred patients, revealing a prevalence rate of 7.92%. The average age or median age of the above‐mentioned subjects was over 55 years with males accounting for 55.9%.

A meta‐analysis based on a random‐effects model was conducted on the data, showing an overall incidence rate of PIs in transported patients of 9.4% (95% CI: 3.0%–15.8%, I 2 = 86.768%, p < 0.000).

3.2.2. Pressure Injuries Categories/Locations

In the analysed study, Stage 1 of PIs accounted for 66.1%, while Stage 2 accounted for 23.2%. Another report (Fulbrook et al. 2019) indicated that in ambulance‐transferred patients, in addition to Stages 1 and 2, there were also some Stage 3 (14.3%), deep tissue injuries (7.1%) and unstageable PIs (21.4%). The most common sites for PIs in the included patients were the sacrum (14.3%) and buttocks (14.3%). This was followed by the heels and ankles (5.4%). Additionally, pre‐ulcerative symptoms or PIs were documented in the occiput (12.5%), mandible (7.1%), ears (5.4%) and nasal bridge (3.6%).

3.3. Risk Factors

A total of eight articles reported the risk factors of PIs in transferred patients, and a descriptive analysis of these factors was conducted from the following aspects.

3.3.1. The Duration of the Transfer

The duration of transportation was related to the occurrence of PIs. Paul et al. found that patients who developed PIs had longer transport times in ambulances (71 min vs. 59 min) and on stretchers (44 min vs. 37 min) (Fulbrook et al. 2019). Moreover, transportation times exceeding 2 h can lead to patients experiencing pre‐ulcerative symptoms of PIs or directly developing PIs (Peng and Gu 2017).

3.3.2. Frequency of Patient Transfers

The number of transfers was also considered to be one of the risk factors for PIs in transferred patients. Studies (Dukes et al. 2018) have indicated that patients who have been transferred multiple times (≥ 2) face a 27 times higher risk of developing PIs compared to patients who have been transferred only once.

3.3.3. The Environment of Patient Transport Equipment

When patients were transferred, the environment was different from when they were hospitalised. Common modes of transportation include ambulances and flights. Patients during transportation were usually positioned on mattresses or seated in wheelchairs, and these support surfaces also increased the risk of PIs. Additionally, due to the medical condition, some medical equipment such as monitoring devices, ventilation equipment (mechanical ventilators, manual resuscitators, artificial ventilation masks), catheters (urinary catheters, tracheal tubes), protective devices (neck collars, spinal boards) or chemical medications like vasoactive drugs may need to be used for transferred patients, which can also impact the occurrence of PIs.

3.3.4. Patient Characteristics

In the literature included in this study, the populations most susceptible to PIs during transportation were young adults and elderly patients. Patients transported by aircraft were typically injured service members who were younger in age. On the other hand, patients transported by ambulance had an average age of over 50 years.

Three studies (Peng and Gu 2017; Dukes et al. 2018; Luo et al. 2023) reported the body mass index (BMI) of transported patients. Luo et al. discovered that seven patients with a BMI of 28 developed Stage I of PIs. In the study by Susan et al., the average BMI of injured patients was 26. Regression analysis results indicated that BMI is associated with the occurrence of PIs during transport, with patients with higher BMIs having a greater risk of developing PIs.

3.3.5. Patient Source

Research by He et al. (He et al. 2022) suggested that the source of patients was related to the occurrence of PIs. Specifically, patients transferred from nursing homes or other medical facilities (community hospitals/clinics, rehabilitation centers or other care facilities) had a higher risk of PIs compared to patients transferred from hospitals or their homes (even though this study specifically focused on patients with PIs in the emergency department).

4. Discussion

This study included a total of eight different types of literature, involving 3512 patients, reflecting the current management of PIs in transported patients in different regions and transport environments. The study population mainly consisted of adult patients transported to the hospital by ambulance and military personnel transported by air. Through analysis, the occurrence, common types and locations of PIs in transported patients were summarised, and it was found that the occurrence of PIs in this population was related to the duration of the transfer, frequency, equipment environment, age and BMI, as well as patient source.

Through reviewing the literature, it was found that there are few reports on the prevalence of PIs in transported patients. Therefore, this study only summarised a range, with the prevalence of PIs in transported patients estimated to be between 5.20% and 7.92%. Compared to hospitalised patients, the prevalence of PIs in transported patients was lower. This may be because during transport, patients were in the initial stages of illness, and minor tissue deformation may not progress to PIs at this stage but gradually developed over time during subsequent hospitalisation and treatment. The overall incidence rate of this study was higher than the 4.9% reported by Susan et al. (Dukes et al. 2018), and there was significant heterogeneity among the studies. This may be due to differences in the original study methodologies and the influence of sample size and study populations. This study included various types of research, including cross‐sectional studies, case–control studies, cohort studies and RCTs, while Susan et al.'s study only involved one type of research, leading to significant heterogeneity in the results of this study. Additionally, this study had a larger sample size than Susan et al., allowing for the inclusion of a more diverse population, providing a comprehensive reflection of the occurrence of PIs during patient transfers. These factors may contribute to the significant differences in the incidence of PIs among transferred patients. Despite the differences in data among the studies, they all highlighted the issue of PIs in patients during transfers that cannot be ignored.

Analysing the relevant data, it was found that during transport, Stage 1 and Stage 2 of PIs were more common, similar to the most common types of PIs seen in hospitalised patients (Li et al. 2020). However, unlike hospitalised patients, during the transfer and ambulance process, patients were generally in the initial stages of illness, and their skin condition was relatively stable; the skin function of hospitalised patients may be affected by various medications (Mizokami et al. 2016), while the skin condition of transferred patients was less affected by medication. Moreover, compared to hospitalised patients, the pressure areas of patients during transfer endured pressure for a relatively limited time. Therefore, tissue deformation typically manifested as superficial tissue damage. Nevertheless, PIs may occur and progress at the onset of injury. As the patient's condition progresses, the severity of PIs may worsen. Therefore, after stabilising the patient's condition, it is necessary to immediately begin comprehensive risk screening, assessment and appropriate preventive care measures for transported patients to control this complication at an early stage.

The report indicated that during transport, patients were most susceptible to PIs in the sacral coccygeal region, heels, ankles and buttocks. This was due to patients being in specific positions for extended periods. During transport, patients were typically lying flat or on their side on standard mattresses or sitting on stretchers while waiting for examinations or admission (Tarpey et al. 2000; Luo et al. 2023). Patients may need to remain immobile or in forced positions for extended periods among some special circumstances, such as due to critical conditions, haemodynamic instability, poor oxygenation and perfusion (Nijs et al. 2009; Dukes et al. 2018). Prolonged immobilisation in specific positions prevented the timely redistribution of pressure on the body surface, which can lead to excessive pressure on specific areas of the patient's body, affecting continuous deformation of soft tissues and causing PIs.

PIs are primarily caused by sustained mechanical loads on soft tissues (Coleman et al. 2014). The duration of the applied force can influence the magnitude of internal mechanical loads leading to tissue damage, thereby affecting the outcome of tissue injuries. Under sustained loading, cellular damage can be observed under a microscope within minutes, though it may take several hours in a clinical setting (Gefen et al. 2008; Gefen 2008). Generally, the maximum pressure that skin capillaries can withstand is 2.01–4.4 kPa, with a maximum duration of 2 h (Wang 2003). Pressure on skin tissues and capillaries can disrupt local blood circulation. Prolonged pressure can impede blood supply to capillaries, resulting in local hypoxia and ischaemia, affecting normal cell metabolism and function. Long‐term pressure can also damage or rupture capillaries, leading to local tissue ischaemic necrosis and the formation of PIs (Gefen et al. 2022). Therefore, the duration of transport influenced the occurrence and severity of PIs. The longer the transport time, the more severe the occurrence and progression of PIs.

The number of transfers was related to the severity of the patient's condition. Generally, patients with more severe conditions will require more transfers. Multiple transfers increased body movement and friction, thereby increasing the risk of skin and soft tissue damage. In addition, frequent transfers can also increase the patient's discomfort and anxiety, further increasing the risk of PIs.

The equipment environment during patient transport, including support surfaces, medical devices, preventive devices, etc., was also related to the occurrence of PIs. Support surfaces themselves do not have a preventive or therapeutic effect on PIs. However, when a patient was on a support surface during transport, their own weight could be redistributed within a certain range. Prolonged periods on a specific support surface can also compromise tissue perfusion. Additionally, when a patient slid downwards from the top of a support surface, resistance is generated, which is called friction, causing tissue deformation. Frictional resistance is somewhat related to skin humidity; higher skin moisture leads to a higher friction coefficient and increased frictional force. Continuous contact with a locally pressured area can result in greater pressure, potentially leading to more severe tissue damage (Shaked and Gefen 2013; Schwartz et al. 2018). The humidity is related to the material of the support surface (Shaked and Gefen 2013). Therefore, selecting an appropriate support surface, such as one with pressure redistribution capabilities, can effectively reduce pressure on vulnerable areas, promote more uniform distribution of body pressure, and manage frictional forces and microenvironments, thereby reducing the risk of PIs during patient transport to some extent. Guidelines (Haesler 2019) recommend using pressure redistributing support surfaces for all transported patients when conditions allow, to achieve early prevention and control of PIs. Existing research has found that various types of mattresses and support surfaces have a certain degree of preventive and control effect on the risk of PIs and in patients with PIs. Examples included single‐layer high‐specification foam mattresses and alternating pressure air mattresses. However, considering the cost and primary functions of these various mattresses, not all may be suitable for patients during transport; thus, further exploration is needed.

In addition, the use of medical devices plays a pivotal role in the occurrence of PIs. Medical devices are traditionally made of rigid polymer materials and are fixed to the skin surface using adhesive tapes (Haesler 2019). These hard‐textured devices act on soft tissues, causing deformation of the surrounding tissues. Prolonged exposure to mechanical pressure can lead to medical device‐related PIs. Moreover, contact between the device and the skin can affect the local microenvironment of the skin, resulting in moisture accumulation beneath the device, poor tissue perfusion, decreased tolerance and may lead to edema (Black et al. 2015). A large‐sample study conducted in the United States and Canada (Kayser et al. 2018) revealed that the incidence rate of MDRPI upon admission was 0.15%. Among these, nasal oxygen delivery devices were the most common cause of MDRPI (32%), followed by non‐invasive ventilation equipment, tracheal tubes and neck collars, which aligned with the devices identified in this study as causing PIs. This indicated that there were still many devices in the transport environment that were associated with the occurrence of PIs. Therefore, it is necessary to implement appropriate pressure relief strategies. This includes selecting devices that better fit the patient's characteristics, standardising the way of wearing, using, and securing, promptly identifying any patient discomfort and making necessary adjustments. In addition, the use of prophylactic dressings as auxiliary items in the early stages of transport was considered an important measure for early prevention of PIs, such as multi‐layer soft silicone foam dressings, which were considered effective in protecting the skin and preventing PIs (Walker et al. 2017). Cost‐effectiveness analysis studies have shown that the use of these dressings can save costs (Macario and Dexter 2001; Tolentino et al. 2016; Souliotis et al. 2016; Marshall et al. 2019; El Genedy et al. 2020). Guidelines (Haesler 2019) recommend the early use of prophylactic dressings during ambulance transport. When selecting prophylactic dressings, the focus should be on the type and size of the dressing, its performance and function, its impact on patient comfort and sensitivities, as well as cost. In addition to prophylactic dressings, preventive devices such as heel suspension boots can also effectively reduce the incidence of PIs (Bååth et al. 2016). However, the limited space and weight restrictions in ambulances may make it impractical to use oversized pressure relief devices inside ambulances, and cost considerations need to be taken into account. Further research is needed in this area.

This article found that the use of vasoactive drugs was also associated with an increased risk of PIs. Vasoconstrictors can stimulate alpha receptors, causing skin and mucous membrane, and visceral blood vessels to constrict and increasing venous return volume. This led to a decrease in peripheral vascular and microcirculatory blood flow, which can easily result in edema and tissue hypoxia, thereby increasing the risk of PIs (Cox and Roche 2015).

Patient characteristics, such as age and BMI, were also considered relevant risk factors. This study identified two age groups that were prone to PIs during transport. One group consisted of patients transported by air, with an average age of 26–28 years. The analysis suggested that these patients were prone to PIs during transport due to specific causes of injury, such as gunshot wounds, improvised explosive devices, etc. The types of injuries mainly included blunt trauma, penetrating wounds or combined injuries (Mok et al. 2013; Dukes et al. 2018). These patients often required forced positions or prolonged immobilisation, which hindered proper skin care, leading to sustained tissue compression, resulting in inevitable skin damage. The other group comprised elderly patients transported by ambulance, often due to acute illnesses, accidents or acute exacerbations of chronic diseases (Liu et al. 2016; Peng and Gu 2017; Fulbrook et al. 2019; Luo et al. 2023). The decreased skin and subcutaneous tissue strength and atrophy in elderly patients increased the risk of PIs. Additionally, the reduced capillary density in elderly patients can lead to impaired tissue perfusion, causing chronic tissue inflammation, decreased tissue tolerance, and weakened repair capabilities (Gefen 2018). Consequently, when soft tissues underwent continuous deformation due to pressure, local tissue ischemia and hypoxia occurred, leading to reduced nutrient supply, slowed metabolism, accumulation of metabolic waste, increasing extracellular acidity, slowed cell migration, potentially weakening the ability of cells to repair minor damage and accelerating the overall rate of tissue damage (Topman et al. 2012; Gefen 2018; Gefen et al. 2022). In addition, BMI as a patient‐related factor was also associated with the occurrence of PIs during the transport process: studies have shown that for every 1‐unit increase in BMI, the chance of a patient developing PIs increases by 16% (Dukes et al. 2018). A high BMI increased weight pressure and weight‐related shear forces, intensifying the deformation of soft tissues, causing more severe vascular impairment, obstructing lymphatic drainage and exacerbating the biochemical stress in deformed tissues, leading to pressure skin injuries (Gray et al. 2016). A low BMI indicated malnutrition and being underweight, which may result in fragile and easily damaged skin, increasing the likelihood of developing PIs (Kottner et al. 2011).

The reason why patients from nursing homes and other medical institutions had a higher risk of PIs may be due to insufficient attention and care from caregivers in nursing homes regarding skin management, potentially leading elderly patients to have underlying risks of skin damage. Patients referred from other medical institutions to hospitals may already have PIs due to hospitalisation or existing medical conditions, increasing their risk of developing PIs. Research (Reed et al. 2003; Smith et al. 2017) indicated that patients with Stage 1 of PIs were at risk of developing Stage 2 or more severe PIs. Following transport, the combined effects of transport duration, transport environment and patient condition made these individuals more likely to suffer PIs.

5. Limitation

Firstly, the included studies were limited to Chinese and English language, which may result in a lack of comprehensive literature inclusion. Secondly, the number of articles included in this study was relatively small, which may affect the representativeness of the sample. Lastly, there was a high heterogeneity among the included studies, which may introduce a risk of bias in the conclusions regarding the occurrence of PIs in transported patients and related risk factors.

6. Conclusion

This article summarised the current situation of PIs in transported patients and discussed related risk factors. It is hoped that the conclusions of this study can provide effective information for clinical healthcare personnel and managers, increase the awareness of healthcare providers on skin injuries in transported patients, further explore the prevalence/incidence and risk factors and assist managers in making more comprehensive decisions in PIs management.

Author Contributions

Yahan Wang: conceptualization, formal analysis, investigation, writing – original draft. Hongxia Tao: conceptualization, formal analysis, writing – original draft, project administration. Xinmian Kang: formal analysis, investigation, data curation. Qian Su: investigation, data curation. Juhong Pei: writing – review and editing, supervision. Lin Han: project administration, funding acquisition, writing – review and editing.

Ethics Statement

The authors have nothing to report.

Conflicts of Interest

The authors declare no conflicts of interest.

Supporting information

Appendix S1.

NOP2-12-e70237-s001.docx (67.1KB, docx)

Acknowledgements

This research was financially supported by the major project of Gansu Province Joint Scientific Research Fund and Research Fund Program of Gansu Provincial Hospital. We would like to express our gratitude to the foundations provided above for the financial support.

Wang, Y. , Tao H., Kang X., Su Q., Pei J., and Han L.. 2025. “Patient Referral and Pressure Injuries: A Systematic Review.” Nursing Open 12, no. 9: e70237. 10.1002/nop2.70237.

Funding: This work was supported by the major project of Gansu Province Joint Scientific Research Fund (23JRRA1538) and Research Fund Program of Gansu Provincial Hospital (22GSSYD‐7).

Yahan Wang and Hongxia Tao are co‐first authors.

Data Availability Statement

The data that support the findings of this study are available from the corresponding author, (Yahan Wang), upon reasonable request.

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Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Supplementary Materials

Appendix S1.

NOP2-12-e70237-s001.docx (67.1KB, docx)

Data Availability Statement

The data that support the findings of this study are available from the corresponding author, (Yahan Wang), upon reasonable request.

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