Future Research and Clinical Questions

Suggested citation

National Pressure Injury Advisory Panel, European Pressure Ulcer Advisory Panel and Pan Pacific Pressure Injury Alliance. Future Research and Clinical Questions. In: Prevention and Treatment of Pressure Ulcers/Injuries: Clinical Practice Guideline. The International Guideline: Fourth Edition. Emily Haesler (Ed.). 2025. [cited: download date]. Available from: https://internationalguideline.com.

This section is under development as the Guideline Governance Group completes each section.

Nutrition in Pressure Injury Prevention

The evidence available to address all the clinical questions on nutrition was generally of low or very low certainty. There is an ongoing need for more research on repositioning frequency and strategies for repositioning to increase the confidence in making recommendations on the topics included above. The Guideline Governance Group noted the following gaps in the evidence addressing the topics in this section that require future research:

  • There is an overall paucity of research on resource requirements, cost-effectiveness and feasibility of the interventions focused on nutrition strategies.

  • There is an overall paucity of research focussed on nutrition strategies and regimens that include patient reported outcome measures (PROMs, e.g., satisfaction with diet etc.) or that are co-designed with consumers.

  • There is a paucity of evidence on effectiveness of many interventions for neonates and children. This is considered a significant gap in the research (1, 2).

The Guideline Governance Group noted that nutrition is a complex topic that requires consideration of the individual’s complex clinical needs beyond pressure injury prevention. Nutritional interventions are complicated by the generally multi-component interventions that reduced confidence that any single specific nutrition supplement is associated with reducing PI occurrence.  Implementation research could explore:

  • What strategies are effective in promoting engagement of the individual and their informal carer in nutrition interventions?

  • Should individualized nutrition interventions be included in a PI prevention bundle?

Repositioning for Preventing Pressure Injuries

The evidence available to address all the clinical questions on repositioning was generally of low or very low certainty. There is an ongoing need for more research on repositioning frequency and strategies for repositioning to increase the confidence in making recommendations on the topics included above. The Guideline Governance Group noted the following gaps in the evidence addressing the topics in this section that require future research:

  • The body of evidence includes minimal reporting of undesirable effects associated repositioning strategies and regimens.

  • There is an overall paucity of research on resource requirements, cost-effectiveness and feasibility of the interventions focussed on repositioning strategies and regimens.

  • There is an overall paucity of research focussed on repositioning strategies and regimens that include patient reported outcome measures (PROMs, e.g., sleep quality, comfort, etc.) or that are co-designed with consumers.

  • Research is needed to evaluate repositioning frequencies in combination with different pressure reducing support surfaces (e.g., active versus reactive support surfaces with repositioning).

  • There is a paucity of evidence on effectiveness of many interventions for, and the experiences of, individuals in home settings, neonates and children, and individuals with spinal cord injury or disability that reduces mobility.

The Guideline Governance Group noted the following future clinical questions for potential/future address in the guideline:

  • Should an automated repositioning device (e.g., lateral tilt device) versus manual repositioning be used to prevent PI occurrence in individuals at risk?

  • Should a repositioning turn system versus not using a turn system be used to prevent PI occurrence in individuals at risk?

  • Are some consumer education programs more effective than others in improving consumer engagement in PI prevention, including repositioning?

  • Do longer intervals between repositioning at night improve quality of sleep without increasing incidence of pressure injury?

  • Should an interface mapping system versus no interface mapping system be used to inform repositioning frequency or evaluate effectiveness of repositioning? This research should include the  mechanisms of actions of sensor systems and a sufficient description of the prevention protocol that was implemented to action the sensor system information output.

The Guideline Governance Group noted the following areas for future research:

  • Effectiveness and implementation of sensor systems used in home care environments as prompts for repositioning for individuals and/or their informal caregivers (3). Preliminary work has explored the feasibility of using non-contact sensors, but did not evaluate effectiveness in promoting implementation of repositioning regimens or prevention of PIs.

    Movement sensors have been used to evaluate the frequency with which individuals independently move in transient ways (i.e. smaller and less obvious movement while maintaining the same overall positioning)(4). Further research on the impact of transient movement in reducing PI occurrence and consideration in PI prevention programs is required.

Full Body Support Surfaces for Prevention of Pressure Injuries

The evidence available to address all the clinical questions on support surfaces was generally of low or very low certainty. This was primarily because the studies were at high risk of bias due to challenges designing blinded studies without confounding factors and with sufficiently large populations. It has been clearly established that a support surface with pressure redistribution properties is a minimal standard in preventing pressure injuries, and in most clinical settings the default support surface is a pressure redistribution foam (reactive) full body support surface. However, in community settings and some geographic areas access to a pressure redistribution foam (reactive) full body support surface remains a challenge. The Guideline Governance Group noted the following gaps in the evidence addressing the topics in this section that require future research:

  • There is an overall paucity of research on resource requirements, cost-effectiveness and feasibility of different full body support surfaces; however, it is acknowledged that these factors are likely to vary widely across different clinical and geographic settings.

  • There is an overall paucity of research that is co-designed with consumers or that focusses on patient reported outcome measures (PROMs, e.g., sleep quality, comfort, etc.) associated with different full body support surfaces.

  • There is a paucity of evidence on effectiveness of different full body support surfaces and the experiences of, individuals in home settings and neonates and children.

The Guideline Governance Group noted the following future clinical questions for potential/future address in the guideline:

  • What are the most effective full body support surfaces for reducing PI occurrence in neonates/children at risk?

    How effective is implementation of an algorithms for selecting a full body support surface for reducing PI occurrence in individual at risk?

Seating Surfaces for Preventing Pressure Injuries

The evidence available to address clinical question on whether a pressure redistribution seated support surface is clinically effective versus no pressure redistribution support surface was of moderate quality, representing an area in pressure injury prevention that has some of the most robust research. This evidence clarifies the undisputed role that seated support surfaces with pressure distribution and shear reduction characteristics play in preventing PIs. More research comparing use of a specialized seating support surface to no specialized seating support surface is not required.

The Guideline Governance Group noted the following gaps in the evidence addressing the topics in this section that require future research:

  • The body of evidence includes minimal reporting of undesirable effects associated effects associated with any specific seating support surfaces.

  • There is an overall paucity of research on resource requirements, cost-effectiveness and feasibility of different seating support surfaces and chairs/wheelchairs; however, it is acknowledged that these factors are likely to vary widely across different clinical and geographic settings.

  • There is very limited research on effective seating regimens, especially related to time-limited sitting out of bed. More research on the relative benefits and risks of limiting the time an individual spends seated in a chair/wheelchair is required.

  • There is an overall paucity of research that is co-designed with consumers or that focuses on patient reported outcome measures (PROMs, e.g., comfort, ability to continue to perform activities of daily living etc.) associated with different seating support surfaces or chairs/wheelchairs.

  • There is an overall paucity of evidence comparing different types of specialized seating support surfaces (5).

The Guideline Governance Group noted there was no comparative evidence on following clinical questions:

  • Should tilt-in-space (dynamic) seating versus non-dynamic seating be used to prevent pressure injury occurrence in individuals at risk who are seated? 

  • Should more frequent repositioning versus less frequent repositioning be used to prevent PI occurrence in individuals at risk who are seated?

  • Should large body movements versus small body movements (micromovements) be used to prevent pressure injury occurrence in individuals at risk who are seated?

Preventive Skin Care

The evidence available to address all the clinical questions on preventive skin care was generally of low or very low certainty. This was primarily because the studies were at high risk of bias due to challenges designing blinded studies without confounding factors and with sufficiently large populations. The Guideline Governance Group noted the following gaps in the evidence addressing the topics in this section that require future research:

  • There is only limited evidence (6, 7) on the effectiveness of preventive dressings used at anatomical locations other than the heel or the sacrum. Further research on use of preventive dressings to protect pressure points in prone position and other bony prominences (e.g., elbows) is warranted.

  • There is limited evidence on the effectiveness of preventive dressings in some specific population groups (including but not limited to individuals at the end of life, individuals with spinal cord injury and individuals with dark skin tones). Exploration of the role preventive dressings can play in the care trajectory of these individuals would be beneficial.

  • There is limited evidence on the effectiveness and cost-effectiveness of preventive dressings used over time, including clinical studies that extend on the current bench science (8, 9, 10) by exploring the duration of time/clinical conditions requiring replacement of a preventive dressing or the incorporation of preventive dressings into PI prevention plans over longer durations (e.g., more than six to eight weeks).

  • There is limited recent evidence on the effectiveness of low friction fabrics, including their use in conjunction with topical skin products (e.g., moisturizers) and preventive dressings. More exploration of the potential benefits and risks and the incorporation of low friction fabrics into care pathways is required.

  • There is an overall paucity of research that is co-designed with consumers or that focuses on patient reported outcome measures (PROMs, e.g., comfort, etc.) associated with different preventive skin care interventions.

  • There is a paucity of evidence on effectiveness of different preventive skin care interventions for neonates and children.

  • There is limited evidence on the effectiveness of leave-on topical products based on prespecified mechanisms of action regarding prevention of PIs. Explanative proof-of-concept studies are warranted.

The Guideline Governance Group noted there was no comparative evidence to address the following clinical questions:

  • The effectiveness of a hydrocolloid dressing used for preventing PIs (not device-related) versus no preventive dressing.

  • The effectiveness of a multilayered soft silicone foam dressing versus any other preventive dressing for anatomical locations other than the heel and sacrum.

The Guideline Governance Group noted difficulties in evaluating the evidence related to leave-on topical skin products. There are wide discrepancies in the ways products are described and classified, and there is no strong evidence on the mechanism by which a leave-on topical skin product prevents PIs. Future research is required to attain clarity regarding the mechanisms by which oil-based products prevent PI. A transparent product classification system is also needed, as well as well-conducted clinical studies using clinically relevant head-to-head comparisons of major and widespread topical products.

Preventing Heel Pressure Injuries

The evidence available to address the clinical questions on preventing heel PIs was generally of low or very low certainty. This was primarily because the studies were at high risk of bias due to challenges designing blinded studies without confounding factors and with sufficiently large populations. The Guideline Governance Group did not identify comparative studies that provided evidence on the following clinical questions for preventing heel PIs

  • Convoluted foam cushion versus any other heel offloading cushion/device,

  • Medical grade sheepskin versus any other heel offloading cushion/device,

  • Polyfiber cushion versus any other heel offloading cushion/device, or

  • Any preventive dressing compared to a heel offloading device.

The Guideline Governance Group noted gaps in the evidence addressing the topics in this section that require future research:

  • There was limited information about potential undesirable effects associated with techniques to reduce the risk of a heel PI.

  • Establishing mechanisms by which leave-on topical products could influence PI development on the heels (11).

  • There is limited evidence on the effectiveness of preventive dressings in some specific population groups, including but not limited to individuals at the end of life, individuals with spinal cord injury, and individuals with dark skin tones. Exploration of the role preventive dressings can play in the care trajectory of these individuals would be beneficial.

  • There is limited evidence on the effectiveness of heel offloading strategies in individuals for whom heel offloading is often challenging, including those with agitation or cognitive impairment.

  • There is an overall paucity of research that is co-designed with consumers or that focuses on patient reported outcome measures (PROMs, e.g., comfort) associated with different preventive skin care interventions.

Device Related Pressure Injuries

The evidence available to address most clinical questions on preventing DRPIs was of very low certainty. This was primarily because the studies were at high risk of bias due to challenges designing blinded studies without confounding factors and with sufficiently large populations. The Guideline Governance Group noted the following gaps in the evidence addressing the topics in this section that require future research:

  • There is an overall paucity of research that is co-designed with consumers or that focuses on patient reported outcome measures (PROMs, e.g., comfort, etc.) associated with medical device use. Given that many individuals use medical devices over the long term, research that includes this perspective would be of particular value. 

  • There is a paucity of evidence on effectiveness of different strategies to prevent DRPIs in neonates and children. Given that the pediatric population experiences the highest incidence of DRPIs, exploration of strategies in this group is of particular importance.

  • There is limited evidence on the effectiveness of leave-on topical products (e.g. moisturizers) based on prespecified mechanisms of action regarding prevention of DRPIs. Given that leave-on topical products are commonly used under and around medical devices, explanative proof-of-concept studies and effectiveness studies are warranted.

The Guideline Governance Group noted there was no comparative evidence to address the following clinical questions:

  • The effectiveness of a naso-tracheal tube fixation device versus no naso-tracheal tube fixation device.

  • The effectiveness of a repositioning medical device versus no device repositioning.

  • The effectiveness of alternating the type of oxygen delivery device versus not altering the type of oxygen delivery device.

  • The effectiveness of a pressure redistributing respiratory device versus a standard respiratory device.

References

         Berry KG, Seiple SM, Stellar JJ, Nagle ML, Curry K, Immel A, et al. A scoping review to inform a multi-disciplinary approach for nutrition therapy in critically ill children with pressure injuries. Translational Pediatrics. 2021;10(10 October):2799-813.

2.      Irving SY, Berry KG, Morgan S, Seiple SM, Nagle ML, Stetzer M, et al. Nutrition association with skin integrity and pressure injury in critically ill pediatric patients. Nutrition in Clinical Practice. 2023;38 Suppl 2:S125-S38.

3.      Gabison S, Pupic N, Evans G, Dolatabadi E, Dutta T. Measuring Repositioning in Home Care for Pressure Injury Prevention and Management. Sensors. 2022;22(18).

4.      Yap TL, Alderden J, Gadhoumi K, Horn SD, Sonenblum SE, Hays JC, et al. Movement and Pressure Injury Prevention Care for Nursing Home Residents: Addressing the Nescience. Advances in Skin & Wound Care. 2024;37(7):369-75.

5.      Hosking J. The clinical effectiveness of custom-contoured seating for wheelchair users with neuromuscular disorders: a scoping review. Assistive Technology 2023;22.

6.      Otto P, Grosskreutz T, Koberich S. Silicone adhesive multilayer foam dressings for preventing facial pressure injuries in COVID-19 patients in prone position. J Intensive Care Soc. 2023;24(3):332-4.

7.      Yang TY, Shin SH. Effect of soft silicone foam dressings on intraoperatively acquired pressure injuries: a randomized study in patients undergoing spinal surgery. Wound Manage Prevent. 2020;66(11):22-9.

8.      Gefen A. Pressure ulcer prevention dressing design and biomechanical efficacy. Journal of Wound Care. 2020;29(Sup12):S6-S15.

9.      Burton JN, Fredrickson AG, Capunay C, Tanner L, Oberg C, Santamaria N, et al. New clinically relevant method to evaluate the life span of prophylactic sacral dressings. Adv Skin Wound Care. 2019;32(7S Suppl 1):S14-20.

10.   Burton JN, Fredrickson AG, Capunay C, Tanner L, Oberg C, Santamaria N, et al. Measuring tensile strength to better establish protective capacity of scral prophylactic dressings over 7 days of laboratory aging. Adv Skin Wound Care. 2019;32(7S Suppl 1):S21-7.

11.   Patton D, Moore ZEH, Boland F, Chaboyer WP, Latimer SL, Walker RM, et al. Dressings and topical agents for preventing pressure ulcers. Cochrane Database of Systematic Reviews. 2024;12:Art. No. CD009362.