The effectiveness of care bundles including the braden scale for preventing hospital acquired pressure ulcers in older adults hospitalized in ICUs: A systematic review

Natalie A. Floyd, Karen A. Dominguez-Cancino, Linda G. Butler, Oriana Rivera-Lozada, Juan M. Leyva-Moral, Patrick A. Palmieri*

*Corresponding author for this work

Research output: Contribution to journalArticleResearchpeer-review

1 Citation (Scopus)


Background: Despite technological and scientific advances, Hospital Acquired Pressure Ulcers (HAPUs) remain a common, expensive, but preventable adverse event. The global prevalence ranges from 9% to 53% while three million people develop HAPUs in the United States and 60, 000 people die from associated complications. HAPU prevalence is reported as high as 42% in ICUs (ICU) costing on average $48, 000 to clinically manage. Objective: The purpose of this systematic review was to evaluate the effectiveness of multi-component interventions (care bundles), incorporating the Braden scale for assessment, in reducing the prevalence of HAPUs in older adults hospitalized in ICUs. Methods: This was a systematic review of the literature using the Cochrane method. A systematic search was performed in six databases (CINAHL, Cochrane Library, Google Scholar, JBI Evidence-Based Practice Database, PubMed, and ProQuest) from January 2012 until December 2018. Bias was assessed with the Critical Appraisal Skills Programme Checklist, and the quality of evidence was evaluated with the American Association of Critical-Care Nurses Levels of Evidence. Results: The search identified 453 studies for evaluation; 9 studies were reviewed. From the analysis, pressure ulcer prevention programs incorporated three strategies: 1) Evidence-based care bundles with risk assessments upon admission to the ICU; 2) Unit-based skincare expertise; and 3) Staff education with auditing feedback. Common clinical management processes included in the care bundles were frequent risk reassessments, daily skin inspections, moisture removal treatments, nutritional and hydration support, offloading pressure techniques, and protective surface protocols. The Braden scale was an effective risk assessment for the ICU. Through early risk identification and preventative strategies, HAPU programs resulted in prevalence reduction, less severe ulcers, and reduced care costs. Conclusion: Older adults hospitalized in the ICU are most vulnerable to developing HAPUs. Early and accurate identification of risk factors for pressure is essential for prevention. Care bundles with three to five evidence-based interventions, and risk assessment with the Braden scale, were effective in preventing HAPUs in older adults hospitalized in intensive care settings. Higher quality evidence is essential to better understanding the impact of HAPU prevention programs using care bundles with risk assessments on patient outcomes and financial results.

Original languageEnglish
Pages (from-to)74-84
Number of pages11
JournalOpen Nursing Journal
Issue number1
Publication statusPublished - 2021


  • Braden scale
  • Care bundle
  • Geriatric
  • Hospital-acquired pressure ulcers
  • Intensive care unit
  • Multi-component interventions
  • Older adults
  • Pressure ulcer
  • Skin assessment


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