Expert insights: Why evidence-based approaches matter more than ever in pressure injury prevention
In this expert Q&A, we speak with Michelle Barakat-Johnson, Professor of Wound Care and Skin Integrity at the University of Sydney and Sydney Local Health District, Sarah Sage, Clinical Nurse Consultant in Wound Management at the Royal Melbourne Hospital, and Sonya Dick, Mölnlycke® Global Medical Affairs Manager for Prevention, about what evidence-based therapies really mean in clinical practice, why they matter and how the latest research and technologies are reshaping pressure injury prevention.
Q: Can you explain what evidence-based therapies are and why it is critical to rely on evidence-based therapies in pressure injury prevention (PIP)?
Professor Michelle Barakat-Johnson: Evidence-based therapies are backed by high-quality research studies, such as randomised controlled trials (RCTs), systematic reviews and real-world studies.
In wound care, this means using therapies, devices and approaches that have been systematically evaluated and shown to work in reducing pressure injuries or speeding up healing. When you rely on evidence, it means you're giving a patient a treatment or an approach that we know will work, not what we think might work.
Sarah Sage: Medicine is meant to be the application of evidence to a clinical situation – that is a principle of treatment. We're also meant not to do any harm. So if we can't validate the therapy works, we've got to make sure that we're not hurting anyone.
The importance of evidence-based therapies for healthcare staff is that we don’t usually see the longer-term outcomes during the course of our shift – we may only have a patient for one or two days. So we need to ensure we use validated and effective therapies to get the outcomes we want for our patients.
Sonya Dick: Evidence-based practice has long been accepted as the gold standard in most areas of medical practice since the 1990s. Prevention and management of pressure injuries now rely heavily on clinical guidelines and international standards. For example, the North American Pressure Injury Advisory Panel (NPIAP)/European Pressure Ulcer Advisory Panel (EPUAP)/Pan Pacific Pressure Injury Alliance (PPPIA) International Guidelines for Prevention and Treatment of Pressure Ulcers/Injuries used the GRADE methodology to assess the quality of evidence supporting clinical practice1.
High-level, robust evidence has been transformative to patient outcomes – so it’s critical for clinicians to adhere to these guidelines to deliver the best results for patients. Ultimately, evidence-based care promotes consistency, accountability, and optimal healing.
Q: Can you describe the hierarchy of evidence and tell us what kinds of evidence healthcare professionals should look for when selecting PIP products?
Professor Michelle Barakat-Johnson: The hierarchy of evidence is often represented as a pyramid, with randomised controlled trials (RCTs) and systematic reviews at the top, followed by prospective clinical trials and real-world studies. High-level RCTs are considered the gold standard. Healthcare professionals should look for evidence that shows real, validated results.
Real-world effectiveness studies are also essential, as they demonstrate how well a product performs in everyday clinical settings. Economic evaluations – such as cost-effectiveness studies – are equally important, as they provide the kind of data policymakers and procurement departments need. Ultimately, the evidence should show that the product reduces pressure injuries, improves outcomes, and is practical for clinical use.
“Controlled trials will tell us if the intervention can work, but real-world studies tell us whether it does work. And that's why we need both kinds of research.”
Professor Michelle Barakat-Johnson
The evidence hierarchy for Mölnlycke multi-layer Mepilex® Border foam dressings for pressure injury prevention.
Note: Health economics outcomes research can sit anywhere on the evidence hierarchy, with trial-based evaluations usually higher, and observational or model-based studies usually in the mid-levels of evidence.
Q: What are the key challenges to employing evidence-based therapies for PIP?
Sarah Sage: Not all prophylactic dressings or devices that we use in PIP have the same level of evidence, so it’s important to apply critical reasoning as well, and I think healthcare professionals are becoming more savvy in that regard.
We have to use our clinical judgement, and sometimes might have to deviate from guidelines – but only for good reasons. For example, a patient with short gut syndrome who has loose bowels is challenging because they’re at risk of pressure injury but also at risk of faecal contamination if we apply prophylactic dressings. In this case, we’d use medications or devices to manage faecal discharge but if that’s not possible, sometimes all you can do is manage their skin, so there’s no ideal outcome.
We have so many different risk management profiles to deal with that we have to try to use clinical reasoning for everything. It’s not just a case of ticking a box.
One example I see is someone using a sacral dressing on a patient who is incontinent. They don’t want to risk contamination, so they put it on the lower back instead of the sacrum, They’ve “ticked the box” in terms of prophylaxis but the dressing is not doing the job it needs to do.
Professor Michelle Barakat-Johnson: One of the main challenges is the complexity of the healthcare setting. Clinicians often face competing priorities, such as staffing pressures, budget constraints and heavy workloads, which can hinder the implementation of evidence-based practices.Hospitals or health services need to put measures in place that enable clinicians to drive quality care through best practice. Policymakers should be listening to clinicians and considering solid evidence that links clinical outcomes and patient dignity with cost savings.
Q: What are the key benefits of using evidence-based therapies?
Sarah Sage: The key benefits of using evidence-based therapies can be broken down into several categories:
- For patients: Evidence-based therapies, such as prophylactic dressings, can really reduce the incidence and severity of pressure injuries. Patients experience better recovery outcomes and shorter hospital stays.
- For healthcare staff: You can’t underestimate the level of guilt staff feel when someone gets a pressure injury under their care. Using evidence-based therapies helps staff feel confident they’re providing the best possible care.
- For healthcare institutions: Evidence-based therapies reduce hospital stays and lower costs by preventing complications and readmissions. This leads to better resource allocation and improved discharge planning.
From research to real results
Professor Barakat-Johnson’s Hospital-Acquired Pressure Injury (HAPI) research has demonstrated that a comprehensive, evidence-based, intervention program reduced the burden and costs of pressure injuries in her healthcare district2,3.
The PIP program included changes such as replacing plastic sheets and underpads with correctly fitting incontinence pads, standardisation of incontinence products, applying prophylactic dressings (Mepilex® Border dressings from Mölnlycke) to reduce shear and friction in high-risk patients, purchase of therapeutic beds and high-back chairs, an education campaign and district-wide collaboration2.
Results published in 2019 showed that an episode of hospital-acquired pressure injury cost an average of $3,3322. The program led to a reduction in the incidence of hospital-acquired pressure injuries of 51.4% and a prevalence reduction of 71.6%, as well as a cost reduction of 23.1%, which added up to a saving of A$837,3872.
Five years down the track, data show that the incidence has decreased by 32.6% since 2018/19 and Stage III and IV hospital-acquired complications dropped by 27.3%3.
Professor Barakat-Johnson says: “If we applied the numbers we found to other cost-efficiencies including hospital re-admissions due to pressure injuries, we estimate a saving of $4.5 million a year for our district.”
Q: How do you address the belief that PIP dressings are all the same so why not buy lower-cost products?
Sarah Sage: The challenge is that not all therapies are the same, whatever a company’s marketers might say. International guidelines recommend using a multi-layer silicone foam dressing for PIP1 but there are differences in the different brands and it's very hard to find the evidence that they perform in a similar way. So it’s up to healthcare professionals to explain to the business decision-makers that not every foam dressing is the same and they don’t all have the same levels of evidence behind them.
Sonya Dick: PIP dressings can differ greatly in their construction and the type of technology used to develop the products. Mölnlycke has set a standard for these dressings grounded in scientific bench research with things like Deep Defense™ Technology, and the highest level of clinical evidence including RCTs and meta-analysis. Deep Defense Technology is proprietary to Mepilex Border dressings. It provides an optimal balance of strength and flexibility that offers optimal shear protection while maintaining its protection against extrinsic factors that contribute to pressure injuries throughout its wear time4.
Choosing quality is not just a clinical decision – it’s a strategic one that supports both fiscal responsibility and better patient care.
Apply clinical judgement to evidence-based therapies
Sarah Sage says: “I had a patient who was a below-the-knee amputee and he was really struggling. He'd had it for more than 10 years, so his limb shape and volume had changed. They were still trying to get a good fit for his new prosthetic and he had a Stage 1 pressure injury, so it was painful. We needed to add a little bit of volume, but not too much, and we didn't want to interfere with his potential limb fitting in the future. We tried several different dressings to see what worked for him and the one that he found the most comfortable was the Mölnlycke Mepilex Border Flex Lite. It's slightly different from your standard prophylaxis, but we couldn’t use Mepilex Border Sacrum or Border Heel in this case. The key is to evaluate evidence critically, apply it appropriately and tailor interventions to each patient.”
Q: What are the potential risks or downsides of not using evidence-based therapies for PIP?
Professor Michelle Barakat-Johnson: The risks of not using evidence-based therapies include patient harm, increased pain, infection, deeper injuries, longer hospital stays and higher healthcare costs. In some regions, there may also be legal implications. Using non-evidence-based therapies can lead to suboptimal outcomes and an increased burden on the system.
Sarah Sage: The differences are striking. Evidence-based products and protocols significantly reduce the incidence and severity of pressure injuries. Patients recover faster, spend less time in hospital and enjoy better quality of life. Using validated, evidence-based products is not just good practice – it’s essential for consistent, high-quality care.
Q: What would you like healthcare practitioners and procurement departments to know about the health economic impact of PIP?
Professor Michelle Barakat-Johnson: For every pressure injury prevented, money is saved and patient suffering is avoided. Investing upfront in preventative strategies isn’t an expense – it saves thousands of dollars by avoiding hospital readmissions, freeing up beds and reducing the burden across the system.
We need to distinguish between price and value. It’s not about the cost of a dressing but the value it brings. There’s no point in using a cheaper dressing if you have to change it more often so you end up using more. In my district, we were told to use a particular barrier cream cloth because it was cheaper – but it ended up costing more because we had to use more cloths, it took up more staff time and our incident reporting went up by 50%. It’s not just about money; it’s about harm to patients as well.
Sonya Dick: It is best practice to consider the value-based purchasing model not only the individual price of each device. Prophylactic dressings for PIP have shown that even with a higher cost of individual dressings, the overall costs to the hospital or healthcare system are substantially less, as can be referenced in several healthcare economics and outcomes research studies specifically utilising Mölnlycke products.
Q: Can you comment on specific evidence-based wound care therapies that have shown significant results in PIP?
Sarah Sage: Several evidence-based wound care therapies have demonstrated significant results. One notable example is the Border trial5, which I was involved with. It was a randomised controlled trial that investigated whether soft silicone, multi-layer foam dressings (Mepilex Border Sacrum, Mepilex Heel and Mepilex Border Heel) could prevent pressure injuries in critically ill patients.
We were very careful about the patient group we picked to ensure that the intervention and control groups were evenly matched, so we could confidently validate that it was the therapy that made the difference to outcomes.
We found that patients who received prophylactic dressings had significantly fewer pressure injuries than those receiving standard care, and those who did had less severe wounds that took longer to develop5. It provided strong evidence for the effectiveness of prophylactic dressings in preventing pressure injuries.
As these experts point out, evidence-based practice is vital to achieve effective and cost-efficient outcomes in PIP. From following international guidelines to choosing products backed by solid clinical data, every decision matters. Combining high-quality evidence, clinician know-how, and proven technology paves the way for better results – for patients, healthcare teams and health systems alike.
Download a copy of the Quick Guide to Pressure Injury Management by the Pressure Injury Treatment Advisory Group (PITA).
Access the latest international pressure injury guidelines
The National Pressure Injury Advisory Panel (NPIAP), European Pressure Ulcer Advisory Panel (EPUAP) and Pan Pacific Pressure Injury Alliance (PPPIA) are releasing new living guidelines. View the guidelines and download an overview from the Prevention and Treatment of Pressure Ulcers/Injuries: Quick Reference Guide here.
Explore the latest strategies, insights, and tools designed to help reduce the burden of pressure injuries.
Discover more at Pressure Injury Prevention Starts Here
References:
- Nghiem S, Campbell J, Walker RM, Byrnes J, Chaboyer W. Pressure injuries in Australian public hospitals: A cost of illness study. Int J Nurs Stud 2022;130:104191. doi: 10.1016/j.ijnurstu.2022.104191.
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Hasan B, Bechenati D, Bethel HM, Cho S, Rajjoub NS, Murad ST, Allababidi AK, Rajjo TI, Yousufuddin M. A systematic review of length of stay linked to hospital-acquired falls, pressure ulcers, central line-associated bloodstream infections, and surgical site infections. Mayo Clin Proc Innov Qual Outcomes 2025;9(3):100607.
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Barakat-Johnson M, Lai M, Wand T, White K, De Abreu Lourenco R. Costs and consequences of an intervention-based program to reduce hospital-acquired pressure injuries in one health district in Australia. Aust Health Rev 2019;43(5):516-525. doi: 10.1071/AH18131.
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Barakat-Johnson M, Lai M, Graham J, Hallahan A, Coyer F. The “HAPI” project five years on: incidence and prevalence of hospital-acquired pressure injuries in one local health district in Australia. J Tissue Viability 2025;34(1):100846. doi: 10.1016/j.jtv.2024.12.010.
