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. Floyd1, 2, 3, Karen A. Dominguez-Cancino4, 5, 6, Linda G. Butler7, Oriana Rivera-Lozada5, 8, Juan M. Leyva-Moral5, 9, Patrick A. Palmieri1, 5, 10, 11, *
1 College of Nursing, Walden University, Minneapolis, USA
2 Jefferson State Community College, Birmingham, USA
3 Department of Nursing, Dannon Training Institute, Birmingham, USA
4 Escuela de Enfermería, Universidad Científica del Sur, Lima, Perú
5 EBHC South America: A Joanna Briggs Institute Affiliated Group, Lima, Perú
6 Escuela de Salud Pública, Universidad de Chile, Santiago, Chile
7 Public Health and Wellness Program, Alabama Department of Health, Birmingham, United States
8 South American Center for Education and Research in Public Health, Universidad Norbert Wiener, Lima, Perú
9 Grup de Recerca Infermera en Vulnerabilitati Salut, Departament d'Infermeria, Universitat Autònoma de Barcelona, Barcelona, Spain
10 South American Center for Qualitative Research, Universidad Norbert Wiener, Lima, Perú
11 College of Graduate Health Studies, A. T. Still University, Kirksville, United States

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© 2021 Floyd et al.

open-access license: This is an open access article distributed under the terms of the Creative Commons Attribution 4.0 International Public License (CC-BY 4.0), a copy of which is available at: This license permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

* Address correspondence to this author at the South American Center for Qualitative Research, Universidad Norbert Wiener, Lima, Perú 15046; Tel: +51 1-706-5555. Email:



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.


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.


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.


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.


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.

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