Development of an international risk-stratified pressure injury prevention bundle for intensive care

PhD Thesis

Lovegrove, Josephine Grace. (2022). Development of an international risk-stratified pressure injury prevention bundle for intensive care [PhD Thesis]. Australian Catholic University
AuthorsLovegrove, Josephine Grace
TypePhD Thesis
Qualification nameDoctor of Philosophy

Intensive care patients are particularly vulnerable to hospital-acquired pressure injury, which is associated with significant patient harm. Pressure injury prevention begins with a risk assessment, often using a risk assessment scale; then, preventative interventions should be implemented relative to assessed risk. However, few scales are designed for intensive care and interventions are often not adequately implemented. The COMHON Index is one intensive care-specific pressure injury risk assessment scale which categorises patients as being at low, moderate or high risk, presenting an opportunity for interventions to be mandated relative to risk level in a ‘minimum preventative intervention set’. This would ensure that, at a minimum, intensive care patients have a set of preventative interventions implemented relative to their pressure injury risk level, potentially overcoming inadequate intervention application while improving resource allocation.

The aim of this program of research was to develop a minimum set of pressure injury preventative interventions relative to pressure injury risk level, as determined by the COMHON Index, for international use within intensive care units.

A three-phase program of research was undertaken to address the overall aim.
Phase One: To identify which preventative interventions are effective in preventing pressure injury in adults admitted to acute and intensive care settings, a systematic review and meta-analysis of randomised controlled trials was undertaken across five databases. Included studies were grouped by intervention type. Studies were synthesised narratively, and random-effects meta-analysis was undertaken for homogenous interventions and data.
Phase Two: To develop international consensus about which preventative interventions should be applied relative to each COMHON Index pressure injury risk level in a minimum preventative intervention set, a modified Delphi study was conducted. Singular interventions which demonstrated effectiveness to prevent pressure injury in Phase One were considered by an expert panel (experienced intensive care nurses with expert pressure injury prevention knowledge) for inclusion in the intervention set. Consensus was developed across three rounds.
Phase Three: In preparation for future international testing of the minimum intervention set, the COMHON Index was formally translated into a very commonly used language (Chinese Mandarin) using a four-step approach (forward-translation, back-translation, comparison of forward/back-translations, pilot testing). Pilot testing was undertaken in a Chinese intensive care unit with 20 nurses to assess instrument ease-of-use and understanding. A concurrent validity analysis was then undertaken using retrospective data comprising 80 paired COMHON Index and Braden scale patient assessments from the same intensive care unit.

Phase One: Overall, 69 studies were included; 45 in an acute synthesis, and 26 in an intensive care synthesis (two in both). Intention-to-treat meta-analysis indicated that only one intervention had a significant effect to reduce pressure injury in acute (Australian medical sheepskin) and intensive care settings (prophylactic dressings: sacral and heel). However, several interventions (as listed in Phase Two results) individually demonstrated intervention effectiveness.
Phase Two: Twelve pressure injury preventative interventions were considered for inclusion by 67 panel members. Consensus indicated that all patients should receive: risk assessment within two hours of admission; eight-hourly reassessment of risk; and disposable incontinence pad use. Moderate- and high-risk patients should also receive: a reactive mattress support surface and a heel off-loading device. Additionally, high-risk patients should receive: oral nutritional supplements; preventative dressings (sacral, heel, trochanteric); an active mattress support surface; and a pressure-redistributing seating cushion. Repositioning is required ≥ four-hourly for low-risk, and ≥ two-hourly for moderate- and high-risk patients. Two interventions were discarded: medical grade sheepskin overlays and a urinary catheter care intervention.
Phase Three: Five iterations of the translation approach and two sets of original instrument amendments were required to achieve translation. Pilot testing demonstrated that the scale was easy-to-use and understand. Concurrent validity testing indicated that the sum scores of the COMHON Index and Braden scale were strongly correlated but not all subscales were correlated.

A minimum pressure injury preventative intervention set, which is a significant contribution to intensive care practice internationally, has been developed. Furthermore, this research has resulted in the COMHON Index being available in the three of the most commonly spoken languages worldwide. The instrument and matching preventative intervention set have promising global clinical applicability, and the potential to assist with overcoming poor preventative care. However, the minimum intervention set requires testing on an international scale.

Keywordscare bundle; critical care; intensive care; nursing; pressure injury; pressure ulcer; prevention; risk assessment
PublisherAustralian Catholic University
Digital Object Identifier (DOI)
Page range1-359
Final version
File Access Level
Supplementary Files (Layperson Summary)
File Access Level
Output statusPublished
Publication dates
Online16 Jan 2023
Publication process dates
Completed04 Sep 2022
Deposited15 Jan 2023
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