Running head: PREVENTING HAPI 1

Preventing Hospital Acquired Pressure Injuries

Lacey Ruby, RN
Western Washington University
NURS 402: Translational Research
Christine Espina, DNP, MN, RN

March 13, 2017

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Abstract
Background: PeaceHealth St. Josephs Hospital has two standards of care to prevent pressure

injuries: Mepilex dressings and Critic-Aid barrier cream. No policy is in place in which to

choose one over the other in nursing care. Objective: To compare the two standards of care to

where and when they are effective and what limitations each has. Methods: Literature searches

were performed through the Cumulative Index to Nursing and Allied Health Literature

(CINAHL) database. Results limited to English language, strength in evidence, and articles

published since 2010. Results: Lack of evidence in utilizing preventative dressings outside of

Emergency Department or ICU. Exclusion of incontinent adults from research on dressing

effectiveness. Conclusion: Mepilex dressings should not be utilized outside of researched

parameters and the continual use of Critic-Aid for preventative care should continue in less

critical areas of the hospital.

Keywords: pressure injuries, Critic-Aid, Mepilex, prophylaxis, incontinence
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Preventing Hospital-Acquired Pressure Injuries

Hospital-acquired pressure injuries (HAPIs) cause unnecessary suffering to the patient

and expense to the hospitals as hospitals are no longer reimbursed for injuries or illnesses that are

acquired after admit (U.S. Centers for Medicare & Medicaid Services, 2014). Cubit, McNally,

and Lopez (2013) state that type I pressure injuries can occur within two hours and type II

pressure injuries are related to shearing or friction. The authors also discuss the impact of

prolonged moisture and the resulting increased risk of breakdown through maceration of the

skin. Conley, McKinsey, Ross, Ramsey, and Feeback (2014) concur that moisture, such as

incontinence-associated dermatitis (IAD) can lead to pressure injuries. Nursing interventions,

such as routine repositioning and inspection of bony prominences, are standards of care that are

utilized in addition to barrier creams or preventative dressings to decrease the risk of pressure

injuries. Barrier creams, such as Critic-Aid, are used to prevent or treat IAD and friction which

can help prevent pressure injuries (Coloplast Corp, 2016). While such creams have been used in

multiple settings and for some time, prophylaxis dressings are much newer in their use to prevent

pressure injuries due to shear and friction (Conley et al., 2014; Mlnlycke Health Care, 2016).
Regardless of how new the research is on preventative dressings, PeaceHealth Saint

Josephs Medical Center (PHSJMC) has made Mepilex preventative sacral dressings the

hospital-wide policy but has also left Critic-Aid barrier ointment policies in place. Having both

policies allows for nursing judgement and patient preference but does not give guidelines for

what is best practice on the individual patients. Both standards of care cannot be utilized together

as the manufacturer guidelines on the sacral dressings application require clean, dry skin without

creams (Mlnlycke Health Care, 2016). For incontinent adult patients in acute care settings, are

Mepilex sacral dressings more effective in preventing HAPIs than Critic-Aid barrier ointment?

Purpose
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The purpose of this paper is to review research and literature on the two standards of care

used at PHSJMC in preventing HAPIs to the patients sacral areas in order to compare and

contrast their effectiveness hospital-wide.

Methods
Literature searches were performed through the Cumulative Index to Nursing and Allied

Health Literature (CINAHL) database. Search terms used were prophylactic sacral dressing,

incontinence prophylactic sacral, barrier cream incontinence, and barrier cream

prophylactic. Articles were chosen for inclusion by limiting by time range within the last five

years and study designs using the highest level of evidence utilizing the Pyramid of Evidence

(Schmidt & Brown, 2015, p. 322). Articles were excluded for language only articles utilizing

the English language were kept.

Findings
Effectiveness of Critic-Aid
While no research specifically on Critic-Aid was utilized in this literature review,

evidence suggests that barrier creams in general are effective in preventing and treating

incontinence-acquired dermatitis (IAD) as well as preventing and treating pressure injuries

secondary to IAD and friction when used with nursing interventions such as repositioning or

incontinence care (Cubit, McNally, & Lopez, 2013; Corcoran & Woodward, 2013; Conley et al.,

2014; Coloplast Corp, 2016). Corcoran and Woodward (2013) conclude that while evidence does

suggest that barrier creams are effective in treating IAD, there in insufficient evidence that any

barrier cream is significantly better than the others. The effectiveness and limitations of barrier

creams discussed will be non-specific in brand.

Barrier creams are intended to be used on incontinent patients. Most barrier creams in

general, and Critic-Aid in particular, are intended to treat IAD and thus are safe to use in the

event of urinary or fecal incontinence (Coloplast Corp, 2016). Conley et al. (2014) concluded

barrier cream as prophylaxis prevented IAD from becoming moderate or severe and was
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effective for treatment, however did not find statistical significance in changing the frequency

from an every twelve-hour application schedule to a more frequent application of barrier cream.

Those authors also suggested that barrier creams were low in cost as a benefit of utilizing creams

for prophylaxis and treatment of IAD or pressure injuries secondary to IAD.

However, not all research suggests that barrier creams are effective in preventing pressure

injuries. Some authors discuss the limited and poor quality research found on the efficacy of

barrier creams in that they could find no significant results in either how well barrier creams

prevent and treat IAD and pressure injuries, or if the barrier creams affect outcomes at all past

the baseline nursing interventions. (Chou, et al., 2013; Corcoran & Woodward, 2013).
Effectiveness of Mepilex Sacral Dressings
Mepilex dressings with nursing interventions are more effective than nursing

interventions alone or nursing interventions with barrier cream in the intensive care unit (ICU)

and emergency department (ED) setting (Mlnlycke Health Care, 2016). Evidence suggests that

prevention should begin in the ED and not wait for admittance to the hospital floors; and that

utilizing sacral dressings for prophylaxis in the ED can help mitigate injury in high risk patients

(Cubit, et al., 2013).

There is some discussion as to whether Mepilex dressings themselves are more effective

than other similar dressings for preventing shear. Research that specified Mepilex dressings

acknowledge that there is potential conflict of interest because of funding or the providing of

supplies by Mlnlycke Health Care, the company that produces and sells Mepilex dressings

(Cubit, et al., 2013; Clark, et al., 2014; Truong, Grigson, Patel, & Liu, 2016).
The benefits of Mepilex specific sacral dressings are that the guidelines state the dressing

does not need to be removed and changed for up to three days and that it is designed to be able to

peel part of the dressing away from the skin for assessment and reapply the same dressing

afterwards without a decrease in adherence and without damaging the skin (Mlnlycke Health

Care, 2016).
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There is insufficient evidence that preventative sacral dressings on incontinent adult

patient population is helpful or cost effective. Most research specifically excluded incontinent

patient populations from their samples (Brown, 2016; Chou, et al., 2013; Truong, et al., 2016).

Walker et al. (2016) finds Mepilex dressings require more frequent changing than the

manufacturer guidelines suggest is necessary due to saturation from incontinence and dressing

dislodgement from movement that occur on medical-surgical floors. Cubit et al. (2013) agrees

that the dressing requires changing more frequently than three days when soiled. Incontinence

can cause more frequent changes and therefore be more expensive.

Mepilex dressings are designed and sold for treatment of wounds but it is listed that the

dressings can be used for prophylaxis as well. There is also the risk that because Mepilex sacral

dressings are intended to keep a wound moist to prevent drying out the wound that this may hold

moisture from incontinence against the skin (Mlnlycke Health Care, 2016). If the patient is

unable to know when they voided or if dislodgement of the bandage does not cause discomfort,

needing more frequent changes might not be noted immediately. Cubit et al. (2013) suggests that

more thorough research should be done and that research should consider continence and

mobility. Because in lower-acuity settings, patients are less often catheterized and fewer have

fecal containment as an option of care, and because patients in the ED and ICU are often less

mobile because of critical health or necessary sedation for treatments such as endotracheal

intubation, the patients needs and requirements are significantly different for preventing

pressure injuries by unit and thus research for one unit does not necessarily generalize to other

units.
There is also some argument as to how strong the evidence is that dressings decrease

incidents of pressure ulcers. Brown (2016) suggests that the studies do not take into account

other factors that cause pressure injuries and because the studies cannot safely have a control
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group without any protocols, it is difficult to assume that the dressings were as effective as some

limited studies suggest. The author encourages a more holistic look at the client instead of

focusing simply on shear as a risk for injury.

Recommendations
Based off this literature review, it is recommended that PHSJMC continue in utilizing the

Mepilex sacral dressings for preventative care where research has stated it is more effective than

other standards of care alone; this includes areas where the patients are in critical care such as

ICU and ED but not in lower-acuity settings where there is inadequate research and deficient

evidence of effectiveness.
It is further recommended to return to utilizing Critic-Aid barrier cream, with other

standards of care such as rotation or specialty mattresses, on patients in acute settings and where

urinary and fecal incontinence can require frequent changes in dressings.

Implications for Practice
A policy or protocol would need to be in place, potentially with a screening tool, to make

certain that the best care is being provided for the patient. It would be necessary to have either a

protocol that includes Mepilex sacral dressings for prophylaxis on ICU and ED order sets only or

to have an order set that specifies patients without catheters who are incontinent do not utilize

Mepilex sacral dressings and instead require the use of the Critic-Aid barrier cream for

prophylaxis. Education and training on proper use of the dressings and the new policies and

protocols would have to be provided hospital wide. Because Mepilex dressings are more

expensive than barrier cream, this could potentially decrease cost for the hospital and patient.
Conclusions
For incontinent adult patients in acute care settings, there is insufficient evidence that

Mepilex sacral dressings are more effective in preventing HAPIs than Critic-Aid barrier

ointment. The needs of patients in the ED and ICU are different than those in lower-acuity

settings and thus research cannot be generalized when it only considers the patient population in

critical care settings.

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Further research is necessary in the use of preventative dressings with incontinent adult

patients to have any evidence of effectiveness in preventing hospital-acquired pressure injuries

and cost effectiveness of use with the frequency of required soiled bandage changes. However,

research suggests that when used correctly in the ICU and ED settings, preventative dressings are

more effective than barrier creams. There are also potential biases in the research that Mepilex

dressings are superior to other similar dressings for prophylaxis. There is some evidence that

barrier creams are more effective than nursing guidelines alone but the research is poor quality.

Because barrier creams are intended for use with moisture or incontinence, Critic-Aid may be as

effective as Mepilex dressings when utilized on incontinent patients. Mepilex sacral dressings are

more expensive than barrier cream when only changed every three days as recommended by the

product guidelines; the additional dressing changes required from displacement or moisture is

potentially costlier and less effective for patient populations in lower-acuity settings.
Recommendations for PHSJMC include using Mepilex dressings on ICU and ED order

sets only or having a protocol that states patients who are incontinent are alternatively treated

with Critic-Aid for prophylaxis. These recommendations would require policy or order set

changes as well as education hospital wide but could potentially save money for the hospital and

patients overall.
Until there is sufficient research that includes care of patient populations in lower-acuity

settings for preventative dressings, there is not enough evidence to continue with a policy of

using Mepilex sacral dressings on incontinent patients in place of Critic-Aid ointment.

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Nursing, 25(15), S6, S8, S10, S12.

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Pressure ulcer risk assessment and prevention: a systematic comparative effectivness

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