Comparison of Silicone Foam Dressings Versus Pressure Reduction Techniques

Comparison of Silicone Foam Dressings Versus Pressure Reduction Techniques

Student Name

Minnesota State University, Mankato

NURS 320-W 02 Critical Inquiry and Evidenced-Based Practice for RNs

Dr. Ellen Vorbeck

Date: mm/dd/year

Abstract

The purpose of this paper was to determine if silicone foam dressings are more beneficial for preventing pressure injuries than pressure reduction techniques alone. Special focus was placed on patients who have the additional risk factor of incontinence. Discussion was focused on assessment tools and differentiating between incontinence-associated dermatitis and pressure injury. Eleven studies were reviewed for this paper. Evidence suggested that applying silicone foam dressings may be beneficial for preventing pressure injuries in addition to pressure reduction techniques. However, the evidence was not strong related to difficulty creating double blind studies and small sample sizes. More evidence will be needed in the form of randomized controlled studies or piloting programs prior to implementing practice change in a hospital system.

Keywords: pressure injury, prevention, incontinence, silicone foam dressing

Findings

In the case study about nurse practices and preventing pressure injuries, Teo et al. found that “timely escalation of care, effective communication, support from the wound nurses, and bridging the knowledge-practice gap” were the most effective mechanisms (2019, p. 153). For more information regarding this case study, see Appendix Table 2. This research aims to help bridge the knowledge-practice gap specifically for the hospitalized patient with IAD and pressure injury. In the cross-case analysis by Ghiasas et al., occupational therapy researchers examined how patient involvement contributes to pressure injury development and healing. They found that of 25 participants, 19 participants who adopted positive lifestyle changes also experienced improvement of pressure injuries (2020). See Appendix Table 4 for more detailed information.

Several studies were found comparing the use of silicone foam dressings with pressure reduction techniques alone. Walker, et al. performed a pilot study regarding the prophylactic use of silicone foam dressings to prevent sacral pressure injuries in a general medical surgical setting. In the study, silicone foam dressings were applied to the sacrum of patients indicated as high risk on the Waterlow Scale, in addition to pressure reduction techniques (Walker, et al. 2015). In the follow-up report, they found that of 67 patients that completed the trial, only one patient within the intervention group developed pressure injury, compared to two in the control group (Walker & Aitken, 2015). This study offered promising results, however greater sample size is needed.

Two studies were identified utilizing silicone foam dressings in intensive care hospital settings. Santamaria et al., found that of the 440 trauma patients studied, only 5 patients in the intervention group developed pressure injury compared with 20 in the control group (2015). In this study, dressings were applied to sacrum and heels of patients admitted to the ED who transferred to ICU. Dressings were applied prophylactically in addition to pressure reduction techniques. For more information regarding this study see Appendix Table 1. Park specifically studied silicone foam dressings for prevention of pressure injury and incontinence-associated dermatitis (IAD) in intensive care. This study examined 102 patients with Braden scores of 16 or less and utilized the Incontinence Associated Dermatitis and its Severity Instrument (IADS) for evaluation. They found that as the IADS score increased, so did the incidence of pressure injuries. They also found that in the intervention group, both the incidence of pressure injury (6% vs.46%) and IADS were decreased (Park, 2014). This study was limited in that it was not blind, and the sacral dressings were applied for only 9 days. Even so, the results were positive toward using silicone foam dressings for decreasing incidence of both pressure injuries and IAD. See Appendix Table 2.

In the systematic review regarding effectiveness of pressure injury prevention strategies, Tayyib and Coyer found that the three studies included involving silicone foam dressings indicated a statistically significant decrease of pressure injuries in ICU. However, because of small sample sizes, lack of randomization and overall differences in structure of studies, “no conclusions could be reached regarding effectiveness” (Tayyib & Coyer, 2016, p. 442). The Cochrane Systematic Review that was utilized in this paper had similar concerns with data reliability related to quality of evidence and reliability (Moore, et al., n.d.). This review included 18 trials, six of which compared silicone dressings versus pressure reduction techniques. They did find that of the 1247 participants across six studies, 16 participants within the intervention group compared with 65 in the control group, developed pressure injury. With these findings, Moore et al. concluded that “silicone dressings may reduce the incidence of pressure ulcers. However the low level of evidence certainty means that additional research is required to confirm these result.” (n.d., p. 28). See Appendix Table 3 for more information regarding this review.

Discussion

These studies indicate that silicone foam dressings may prevent further skin breakdown in hospitalized patients with stage 1 pressure injury and incontinence. They also may help to decrease incontinence associated dermatitis. However, more and better data is necessary to support this intervention. It is difficult to have a true blind study related to the nature of the question (dressing vs. no dressing). But factors like sample size and standardized evaluation practices, could be improved for future studies. Patient experience case studies would be helpful for determining if patient experience is improved by these interventions. Cost-benefit analysis may also be helpful for hospital systems interested in implementing this intervention. The recommendation at this point as indicated by the JHNEBP model would be to consider a pilot or research study prior to implementing a larger scale change.

Recommendations for Nursing Practice

The research is generally supporting utilizing silicone foam dressings, however the evidence is not very strong. With this population it is very difficult to create double blind scenarios, but thought should be given to make them as blind as possible for credibility. Because of the lack of strong evidence nursing recommendations would be for further studies. Additionally, a piloting period would be recommended prior to implementing this intervention in a hospital system. Cost, efficacy, and risk versus benefit should be part of this analysis of the pilot prior to large scale intervention or practice change. Webster & Moore advised that “future trials should be large enough to show meaningful differences; include patient-related outcomes, such as product acceptability, adverse events and quality of life, and economic evaluations to assist healthcare managers to make rational decisions” (p. 29, 2018). Hospital systems may choose to determine specific requirements of when silicone foam dressings should be added to maximize effectiveness and cost vs. benefit.

The Agency for Healthcare Research and Quality (AHRQ) website offers a toolkit and a training program for hospitals. This would be an excellent place to start when implementing this policy change. It offers a plethora of information in addition to resources to roll out a new program (Berlowitz et al., n.d.). In addition, further training on assessing pressure injuries, risk for skin breakdown, and the differences between pressure and dermatitis would be helpful training points.

Conclusion

This research project sought to answer whether a silicone foam dressing was more effective than pressure reduction techniques alone in preventing pressure injury in hospitalized patients with incontinence. Evidence from all steps of the Strength-of-evidence rating pyramid was reviewed (Melnyk & Fineout-Overholt, 2019, p. 116, Figure 4.2). Further research is needed in the form of a piloting period or additional randomized controlled trials. Prior to implementation, the research team should focus on determining the most effective scenarios to utilize silicone foam dressings, cost versus benefit for hospitals, and patient experience related to this intervention.

References

Berlowitz, D., VanDeuzen Lukas, C., Parker, V., Niederhauser, A., Silver, J., Logan, C., Ayello, E., Zulkowski, K. (2014). Preventing Pressure Ulcers in Hospitals. Agency for Healthcare Research and Quality. https://www.ahrq.gov/patient-safety/settings/hospital/resource/pressureulcer/tool/index.html.

Campbell, J., Barakat-Johnson, M., Hogan, M., Maddison, K., McLean, J., Rando, T., Samolyk, M., Sage, S., Weger, K., & Dunk, A. M. (2020). A clinical guide to pelvic skin assessment. Wounds International, 11(1), 30–39.

Ghaisas, S., Pyatak, E. A., Blanche, E., Blanchard, J., & Clark, F. (2015). Lifestyle Changes and Pressure Ulcer Prevention in Adults With Spinal Cord Injury in the Pressure Ulcer Prevention Study Lifestyle Intervention. The American Journal of Occupational Therapy, 69(1), 1-10. http://dx.doi.org.ezproxy.mnsu.edu/10.5014/ajot.2015.012021

Gray M, Giuliano KK. (2018). Incontinence-Associated Dermatitis, Characteristics and Relationship to Pressure Injury: A Multisite Epidemiologic Analysis. J Wound Ostomy Continence Nurs, 45(1), 63-67. doi:10.1097/WON.0000000000000390

Melnyk, B. & Fineout-Overholt, E. (2019). Evidence-based Practice in Nursing & Healthcare (4th ed). Philadelphia: Lippincott, Williams & Wilkins.

Park K. H. (2014). The effect of a silicone border foam dressing for prevention of pressure ulcers and incontinence-associated dermatitis in intensive care unit patients. Journal of wound, ostomy, and continence nursing : official publication of The Wound, Ostomy and Continence Nurses Society, 41(5), 424–429. https://doi-org.ezproxy.mnsu.edu/10.1097/WON.0000000000000046

Santamaria, N., Gerdtz, M., Sage, S., McCann, J., Freeman, A., Vassiliou, T., De Vincentis, S., Ng, A. W., Manias, E., Liu, W., & Knott, J. (2015). A randomised controlled trial of the effectiveness of soft silicone multi-layered foam dressings in the prevention of sacral and heel pressure ulcers in trauma and critically ill patients: the border trial. International Wound Journal, 12(3), 302–308. https://doi-org.ezproxy.mnsu.edu/10.1111/iwj.12101

Tayyib, N., & Coyer, F. (2016). Effectiveness of Pressure Ulcer Prevention Strategies for Adult Patients in Intensive Care Units: A Systematic Review. Worldviews on evidence-based nursing, 13(6), 432–444. https://doi-org.ezproxy.mnsu.edu/10.1111/wvn.12177

Teo, C., Claire, C. A., Lopez, V., & Shorey, S. (2019). Pressure injury prevention and management practices among nurses: A realist case study. International wound journal, 16(1), 153–163. https://doi-org.ezproxy.mnsu.edu/10.1111/iwj.13006

Walker, R., Aitken, L.M., Huxley, L. & Juttner, M. (2015) Prophylactic dressing to minimize sacral pressure injuries in high‐risk hospitalized patients: a pilot study. Journal of Advanced Nursing 71( 3), 688– 696. doi: 10.1111/jan.12543

Walker, R., & Aitken, L. (2015). Pressure injury prevention pilot study: a follow-up. Queensland Nurse, 34(3), 33.

Webster, J., & Moore, Z. E. (n.d.). Dressings and topical agents for preventing pressure ulcers. Cochrane Database of Systematic Reviews, 12.

Appendix

Literature Review Table 1

Article, Source, year

Purpose

To measure the prevalence of incontinence-associated dermatitis (IAD) among incontinent persons in acute care setting, characteristics of IAD in this group, and associations among IAD, urinary, fecal, and dual incontinence, immobility, and pressure injury in the sacral area.

To investigate the effectiveness of multi-layered soft silicone foam dressings in preventing intensive care unit pressure ulcers when applied in the emergency department.

Sample

N=5342

(n=2492/5342, 46%) incontinent or urine, stool or both

(n=1140/5342, 21.3%) prevalence of IAD

(n=1140/2492, 45.7%) prevalence of IAD within incontinent population

(n=596/1140, 52.3%) IAD considered mild within incontinent population

(n=318/1140, 27.9%) IAD considered moderate within incontinent population

(n=105/1140, 9.2%) IAD considered severe within incontinent population

(n=169/1140, 14.8%) patients with IAD who also had a fungal rash

(n=427/2492, 17.1%) prevalence of pressure injury in sacral area among individuals with incontinence

(n=95/2492, 3.8%) prevalence of full-thickness pressure injury among individuals with incontinence

N=440

(n=219) Mepilex Border Sacrum and Mepilex Heel dressings applied in ED and maintained throughout ICU stay.

(n=221) Control group receiving usual care.

Design and level of evidence

(Melnyk 4.2)

Epidemiologic analysis utilizing multivariate analysis. This type of study seeks to describe the distribution of diseases in the population and analyze the causes of these diseases – analyzing multiple variables at one time.

Categorized as non-experimental study. Variables are not being changed, data is gathered at particular time. In the second level of the Strength-of-evidence rating pyramid seen in Melnyk & Fineout-Overholt (2019, p.116, Figure 4.2).

Randomized controlled trial – this type of study seeks to reduce bias while testing the effectiveness of a certain treatment by having two groups – control group and experimental group.

Categorized as experimental research study, it is an RCT. This is found in the third level of the Strength-of-evidence rating pyramid from Melnyk & Fineout-Overholt (2019, p. 116, Figure 4.2).

Variables, measurement

Clinical variables include incontinence of urine, stool, or both urine and stool, immobility, concurrent fungal infection.

Clinical variables include reason for admission, comorbidity, physiological variables, Australasian Triage scale score, and time commenced on mechanical ventilation.

Results, findings

Prevalence of facility-acquired pressure injury in sacral area among individuals with incontinence was 17.1%.

Patients with IAD were more likely to experience a facility-acquired pressure injury of the sacral area compared to those without IAD (32.3% vs. 1.5%).

Patients who were immobile were almost 3.5 times more likely to develop facility-acquired sacral pressure injury than those who were mobile (12.1% vs. 3.2%).

Prevalence of IAD and facility-aquired pressure injury in the sacral area remained statistically significant even after adjusting for immobility (P<0.0001).

The intervention group had significantly less patients who developed a pressure ulcer in ICU (5 vs. 20, P=0.001).

Implications

Both mobility and incontinence – specifically incontinence associated dermatitis – are significant risk factors for developing sacral pressure injuries in acute care. IAD was found to be an independent risk factor apart from immobility.

A benefit was found for applying mepilex dressings to sacrum and heels of ICU patients, in combination with pressure reduction and skin care. As a result, this hospital has now mandated the use of these dressings for all patients who are high risk for pressure injury.

Limitations of Research

Not all data was filled out on each electronic survey as each field was not mandatory.

Participants did not receive standardized training in assessment of IAD and pressure injury.

Assessments of IAD were not made using a validated instrument.

Interventions and products used for prevention of skin breakdown was not standardized.

Study was conducted at a single site for a limited time.

It was impossible to blind data collectors to the nature of the treatment intervention.

Only studied patients who admitted to ICU from ED, cannot be generalized to other patient populations.

While patients with incontinence were not excluded from the study, there was no comment toward how much of the population was incontinent and if that affected the results in any way.

Comments

The purpose of this study was to establish the link between IAD and pressure injury. Further study is needed to indicate which interventions best prevent pressure injuries specific to the population of patients who are incontinent in acute care.

This is promising evidence for using a particular silicone foam dressing to prevent pressure injury in a specific population. More research would need to be done to determine whether these results can be duplicated in the medical/surgical population, with a greater sample size, and for my research specifically examining the implications of concurrent incontinence.

Literature Review Table 2

Article, Source, year

Purpose

To determine if the development of pressure injuries and incontinence-associated dermatitis are lessened when silicone border foam dressings are applied to patients in ICU.

To portray what nurses current pressure injury prevention practices are in a hospital in Singapore.

Sample

N=102

n=52, experimental group

n=50, control group

N=24

Design and level of evidence

(Melnyk 4.2)

Quasi-Experimental Study. This type of study is a nonrandomized control study, which falls under the category of experimental research studies. This is in the third level of the Strength-of-evidence pyramid in Melnyk & Fineout-Overholt (2019, p. 116, Figure 4.2).

Case Study. This type of study uses a small case size and interviews participants to obtain data. It falls on the bottom of the Strength-of-evidence rating pyramid mentioned by Melnyk & Fineout-Overholt (2019, p. 116, Figure 4.2).

Variables, measurement

Clinical variables include gender, age, reason for ICU admission, urinary continence, stool form, BMI and braden score.

Clinical variables include gender, ethnicity, years of nursing experience, and type of nursing employment (those not responsible for pressure injury prevention were excluded).

Results, findings

Patients in experimental group (with silicone foam dressing applied) had lower occurrence of pressure injury than control group (6% vs. 46%, P <0.001)

Patient’s in experimental group (with silicone foam dressing applied) had lower occurrence of incontinence-associated dermatitis than control group (0.54 +/- 0.73 vs 0.98 +/- 1.25, P <0.033).

Correlation between pressure injury and incontinence-associated dermatitis (r = 0.264, P = 0.005).

With every 1-point increase in IADS score, risk of developing pressure injury increased by a ratio of 1.9.

There were 5 conjectured context-mechanism-outcomes (CCMOs) that arose throughout the study: escalation of care, maximizing opportunities for communication, adopting novel forms of communication, support from wound nurses, and bridging theory-practice gaps (Teo et al., 2019).

Implications

In this study they found that the silicone foam dressing did decrease the occurrence of pressure injury development in ICU setting. They found that the dressing improved both the incidence of pressure injuries and incontinence-associated dermatitis. It also found a link between incontinence-associated dermatitis and pressure injuries.

The study found that nurses need hands-on training of information that is directly applicable to their work. Education should be individualized to the nurses role (this study included nursing assistants, nurses, and specialists). Resources should be appropriately allocated to maximize pressure injury prevention.

Limitations of Research

This was not a randomized study. Also it is taking place in one hospital with only 100 patients. Silicone dressings were only applied for 9 days. More research would be needed on a wider scope of patients to determine if this is duplicable.

The hospital that this study took place at is 3 years old, so each nurse had only worked there for maximum of 3 years. Age range of participants was predominantly younger. Participant observation was not completed due to time restraints. May be difficult to generalize data related to case study design.

Comments

Further study is needed to determine if these results can be duplicated outside of this study. Also, further research is needed to explore the link between incontinence-associated dermatitis and pressure injury.

Further study is needed to test the CCMO’s to determine if this study can be generalized to other countries. Some findings may transfer where as others may be found to be cultural or related to the specific structure of healthcare delivery in this country.

Literature Review Table 3

Article, Source, year

Moore, Z. E., Webster, J., & Moore, Z. E. (n.d.). Dressings and topical agents for preventing pressure ulcers. Cochrane Database of Systematic Reviews, 12.

Purpose

To determine how effective dressings and topical agents are at preventing pressure injuries, in at risk populations in any healthcare setting.

Sample

18 trials, N=3629

6 trials, n=1247 – silicone dressing vs. no dressing

4 trials took place in ICU, 2 in med-surg

Design and level of evidence

(Melnyk 4.2)

Systematic review, which is also known as an evidence summary. These types of studies collect and analyze data from multiple studies. This is at the top of the Strength-of-evidence rating pyramid outlined in Melnyk & Fineout-Overholt (2019, p.116, Figure 4.2).

Variables, measurement

Variables within the studies include different interventions: this study looked at topical applications, dressings, and both topical agents and dressings.

Variables in the participants of the studies include: age, country of origin, Braden pressure ulcer scale score, level of acuity of care during study.

Results, findings

Per Moore et al., “Silicone dressings may reduce pressure ulcer incidence at any stage” (n.d. p. 24). Just 3% of patients who had silicone dressings applied developed pressure injuries, and 11% of patients with no dressing developed pressure injuries. However, Moore, et al., caution about the risk of bias in these studies especially as it is impossible to create a true blind study with this intervention.

Pressure Ulcer Incidence: RR 0.25, 95% CI, low-certainty evidence

Stage 1 Pressure Ulcer Incidence: RR 0.27, 95% CI, low-certainty evidence

Stage 2 Pressure Ulcer Incidence: RR 0.40, 95% CI, low-certainty evidence

Implications

All studies stated that silicone foam dressings prevented pressure injuries better than no dressings, however more evidence is needed because this study found a “low level of evidence certainty” related to bias (Moore, et al., n.d., p. 28). The authors suggested future studies should include large sample sizes, validated tools, and include more patient-related outcomes. They also suggested looking at the cost vs. benefit of these interventions.

Limitations of Research

Only RCT’s were used, and most of the studies had considerable risk of bias. Evidence needed to be downgraded to low or very low quality related to risk of bias and/or imprecision.

Comments

There is positive evidence for utilizing silicone foam dressings to prevent pressure injuries, however, more research is needed and studies should be created to decrease bias in this particular situation. Also more evidence is needed specifically as it relates to incontinence.

Literature Review Table 4

Article, Source, year

Ghaisas, S., Pyatak, E. A., Blanche, E., Blanchard, J., & Clark, F. (2015). Lifestyle Changes and Pressure Ulcer Prevention in Adults With Spinal Cord Injury in the Pressure Ulcer Prevention Study Lifestyle Intervention. The American Journal of Occupational Therapy, 69(1), 1-10. http://dx.doi.org.ezproxy.mnsu.edu/10.5014/ajot.2015.012021

Purpose

A cross-case analysis of a previous randomized controlled trial of lifestyle interventions for preventing pressure injuries in adults with spinal cord injuries.

Sample

N=47 Total Participants in Pressure Ulcer Prevention Program

n=17 participants did not develop pressure injuries and were excluded

n=2 participants had poor adherence to program and were excluded

n=25 participants involved in this cross-case analysis

Design and level of evidence

(Melnyk 4.2)

This is a secondary cross-case analysis of treatment notes of 47 participants in a previous randomized controlled trial. Analyzed treatment notes from previous study in case-study format. It is considered a non-experimental study which is on the second level of the Strength of evidence rating pyramid found in Melnyk & Fineout-Overholt (2019, p.116, Figure 4.2).

Variables, measurement

Clinical variables include primary language spoken, education, gender, income, residence type, years since spinal cord injury, BMI, comorbidities, paralysis type and spinal cord injury type.

Results, findings

19 of participants made positive lifestyle changes and had improved pressure injuries, 3 made positive lifestyle changes but pressure injuries did not improve, 1 participant made minimal or no changes and pressure injuries improved and 2 participants made minimal or no changes and pressure injuries worsened.

Implications

There is a relationship between lifestyle factors and development of pressure injuries for patients with spinal cord injuries, however, there are many additional outside factors that also affect pressure injury development and healing.

Limitations of Research

This is a small sample size that is in a concentrated geographic area from one clinic in California. More information would be helpful regarding how cultural and socio-economic factors affect patient’s success with interventions. For the purpose of this paper it would be helpful to see a broader group of diagnoses in the sample size, and how these interventions would hold when introduced during inpatient hospital stays.

Comments

This shows promising design for Occupational Therapists to work with their patients with spinal cord injuries toward lifestyle changes to prevent pressure injuries in the community. It would be interesting to see if the interventions discussed would help improve outcomes in the hospitalized population that is being discussed in this research project.

Comparison of Silicone Foam Dressings Versus Pressure Reduction Techniques

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