Pressure Ulcers Protocols: Literature Review

The population that is at high risk of developing pressure ulcers includes critically ill patients who experience problems with taking care of themselves. Therefore, these patients usually require specific care and the implementation of certain interventions to prevent the development of pressure ulcers. One of the approaches to preventing pressure ulcers in high-risk patients is the focus on the procedures described in a pressure ulcer protocol. This protocol includes the list of steps to complete by medical workers and associated guidance to prevent the development of pressure injuries and organize the management of the condition (Chamanga & Ward, 2015). The National Pressure Ulcer Advisory Panel (NPUAP) and the European Pressure Ulcer Advisory Panel (EPUAP) developed their variant of a pressure ulcer protocol to be followed by nurses in the United States and European countries (Li, 2016). There are also other protocols used by nurses in their practice, but not all hospitals adopted pressure ulcer protocols for implementation in their emergency departments.

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The problem is that, if critically ill patients do not receive the required assistance and ulcer management within the first days of staying in a hospital, the risk of developing hospital-acquired pressure ulcers increases significantly. The success of preventing and managing pressure ulcers depends on the time when nurses started to offer a special care to risky patients (Bååth, Engström, Gunningberg, & Athlin, 2016). Therefore, the importance of studying the topic is in the possibility to determine the intervention that can be successfully used to prevent hospital-acquired pressure ulcers in patients belonging to the critically ill population. The purpose of this literature review is to determine whether in patients at high risk of developing a pressure ulcer, the implementation of a pressure ulcer protocol initiated in the emergency department, as compared to patients who receive usual care, reduces the incidence of hospital-acquired pressure ulcers on day 3 of hospitalization.


To retrieve six scholarly articles on the problem of preventing pressure ulcers with the help of protocols, the search in databases such as PubMed, CINAHL, and EBSCOHost was completed. The following keywords were used to organize the search individually and in their combination: “pressure ulcer,” “pressure ulcer protocol,” “intervention,” “high-risk population,” and “hospital-acquired pressure ulcer.” As a result, 231 articles were found, and their abstracts and details were reviewed to compare the information with inclusion and exclusion criteria. Determined inclusion criteria are the publication date during the past five years, the direct focus on the topic of preventing pressure ulcers, the description of protocols, and their application. It was important to select articles that are published in journals specializing in nursing-related topics. Exclusion criteria included the focus on types of interventions other than the use of a pressure ulcer protocol. After the preliminary review, six articles were selected for further detailed analysis and synthesis of information.


The literature review has indicated that researchers tend to discuss pressure ulcer protocols as effective tools to predict hospital-acquired pressure injuries in patients. Mallah, Nassar, and Badr (2015) conducted a controlled study to evaluate the effectiveness of the intervention to prevent pressure ulcers in Lebanon. The authors focused on evaluating the multidisciplinary intervention that includes a protocol and the Braden scale. They found that the number of patients with hospital-acquired pressure ulcers decreased after the implementation of the protocol-based intervention (Mallah et al., 2015). Furthermore, positive effects were achieved because of using the Braden scale for assessing patients’ skin. Additionally, Ranzani, Simpson, Japiassu, and Noritomi (2016) conducted a cohort study in Brazil based on data from 12 intensive care units. Their purpose was also to assess the efficacy of using the Braden scale in pressure ulcer protocols to eliminate risks. After analyzing information from two databases of intensive care units, it was found that the protocol based on the Braden scale (skin, mobility, and nutritional status evaluation) is effective for assessing patients in emergency departments. However, assessment results can be inappropriate to predict pressure ulcers in all groups of patients.

Other authors focused on assessing protocols as a standard approach to documenting problems to predict pressure ulcers. Li (2016) conducted a retrospective correlational study to determine the relationship between nursing documentation and the incidence of pressure ulcers in high-risk patients. The data based on filled-in protocols related to patients in 196 intensive care units were collected. The researcher found that there was no relationship between the quality of the documentation of pressure ulcers and their incidence in medical facilities. Furthermore, the researcher concluded that the problem is often in the poor recording of patients’ condition by nurses. However, the article by Stuque et al. (2017) did not support these findings. The researchers conducted an integrative review of pressure ulcer protocols to prevent injuries in patients to analyze their appropriateness. They concluded after reviewing the literature that those protocols that request detailed information are most efficient for healthcare settings. Still, this study has weaknesses because it is a review of previous research in the field.

More researchers concentrated on studying the outcomes of using protocols in emergency departments. In their randomized control study conducted in Swedish hospitals, Bååth et al. (2016) examined the effects of early interventions on the prevention of pressure ulcers in older patients. The study involved more than 180 participants, and data on patients’ conditions were collected in the emergency department and during their stay in a hospital with the help of prepared protocols. The researchers found that, when interventions (based on NPUAP and EPUAP protocols and guidelines) start early, it is possible to prevent pressure ulcers in the higher number of patients. Similar conclusions were made by Chamanga and Ward (2015), who completed a review of clinical interventions to predict pressure-related injuries in patients. They found that the use of clearly filled-in protocols is important to provide medical workers with all importation information regarding patients’ states to prevent further problems. To guarantee clarity in completing records, protocols need to be unified according to some guidelines and be early used by nurses.


The reviewed literature accentuated the importance of using protocols to decrease the incidence of hospital-acquired pressure ulcers. According to Bååth et al. (2016) and Stuque et al. (2017), the most efficient protocols are grounded in NPUAP and EPUAP guidelines. The use of these approved protocols leads to decreasing the percentage of hospital-acquired pressure ulcers in comparison to general care procedures, as was noted by researchers. The findings by Bååth et al. (2016) also support the idea that the implementation of pressure ulcer protocols in healthcare facilities as early as possible contributes to reducing the incidence of this condition in patients. The research by Mallah et al. (2015) also provided evidence to state that interventions based on special protocols and scales for pressure ulcer prevention can significantly decrease the risk of developing hospital-acquired pressure ulcers. Therefore, the implementation of the protocol in the emergency department can lead to positive outcomes for patients in comparison to providing general care.

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Still, not all researchers agreed that the use of such documents as pressure ulcer protocols directly leads to eliminating the number of pressure ulcer cases in patients. Although Chamanga and Ward (2015) also reported the importance of following national and international protocols, Li (2016) did not found a significant relationship between the use of protocols, the quality of filling-in documents, and reported pressure ulcers in facilities. Furthermore, Ranzani et al. (2016) stated that, although protocols applied for the initial assessment of patients are effective, the used Braden scale can be ineffective in some cases, and more relevant guidelines should be consulted. Thus, the actual relationship between using protocols and outcomes for patients should be further researched concerning assessing their quality.


The analysis of the literature on the topic of using pressure ulcer protocols in emergency departments to prevent hospital-acquired pressure damage indicates that this intervention is more effective than the provision of usual care. The research supports the idea that this protocol should be based on credible national and international guidelines to have positive effects on high-risk patients. The reason is that a protocol based only on the Braden scale cannot be equally effective for all cases. Nevertheless, many articles on this topic provide only reviews of previous research, and additional quantitative studies are required to be conducted to address this problem.


Bååth, C., Engström, M., Gunningberg, L., & Athlin, Å. M. (2016). Prevention of heel pressure ulcers among older patients–From ambulance care to hospital discharge: A multi-centre randomized controlled trial. Applied Nursing Research, 30, 170-175.

Chamanga, E., & Ward, R. (2015). Documentation and record-keeping in pressure ulcer management. Nursing Standard, 29(36), 56-63.

Li, D. (2016). The relationship among pressure ulcer risk factors, incidence and nursing documentation in hospital‐acquired pressure ulcer patients in intensive care units. Journal of Clinical Nursing, 25(15-16), 2336-2347.

Mallah, Z., Nassar, N., & Badr, L. K. (2015). The effectiveness of a pressure ulcer intervention program on the prevalence of hospital acquired pressure ulcers: Controlled before and after study. Applied Nursing Research, 28(2), 106-113.

Ranzani, O. T., Simpson, E. S., Japiassu, A. M., & Noritomi, D. T. (2016). The challenge of predicting pressure ulcers in critically ill patients: A multicenter cohort study. Annals of the American Thoracic Society, 13(10), 1775-1783.

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Stuque, A. G., Sasaki, V. D. M., da Silva Teles, A. A., de Santana, M. E., Rabeh, S. A. N., & Sonobe, H. M. (2017). Protocol for prevention of pressure ulcer. Revista da Rede de Enfermagem do Nordeste, 18(2), 272-282.

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