The State of Pressure Injury Science: Going Beyond Cochrane to Inform Prevention and Guideline Development

Abstract

he 2020 Cochrane Review, “Repositioning for Pressure Injury Prevention in Adults” (a recently T updated meta-analysis), stimulated discussion among researchers and clinicians experienced in clinical guideline development, leading to a critical evaluation of themethods and findings. The objective of the updated review (hereafter, the Review) was to assess the clinical effectiveness and cost-effectiveness of repositioning regimens (repositioning schedule and patient positions) on prevention of pressure injuries (PrIs) in adults, regardless of risk level, support surface, or care settings. The previous 2014 search of the literature covered the period up to September 2013; the updated Review overlaps partially with the previous time period and reports research from 2004 to 2018. The Review has been expanded to include two economic and five trial publications, or a total of eight trials (3,941 participants) from acute and long-term care settings. Using a priori criteria, studies were selected and assessed for inclusion; once selected, three reviewers independently assessed the quality of evidence using the GRADE (Grading of Recommendations Assessment, Development, and Evaluation) criteria. The Cochrane system is one example of a grading system; the literature is replete with various methodologies for examining and evaluating the evidence reported in research with the aim of improving clinical practice. Most, including the GRADE criteria, involve the subjective judgment of the quality of findings reported. The GRADE criteria evaluate evidence based on risk of bias in randomized controlled trials (RCTs) to establish the certainty of findings. Further, the GRADE criteria are concerned with details reflecting internal and to some extent external validity regarding treatment and responses of experimental and control participants. Efficacy studies (RCTs) are important, but as Finley so aptly paraphrased Berwick, RCTs are the criterion standard only for some purposes, for example, highly controlled drug studies. Cochrane and other evidence