Volume 27 Number 2

Key messages

General statement

• There is a connection between care bundles and the reduction in the incidence of pressure ulcers in the older adult (≥65 years) population.

Aim

• To explore the impact of care bundles on the incidence of pressure ulcers among adults aged 65 and over.

Summary of results

• The use of care bundles is an effective strategy to reduce pressure ulcer incidence while lowering treatment costs and shortening hospital stay among at-risk older adults.

Introduction

A pressure ulcer (PU) is defined as a localised injury to the skin and/or underlying tissue, typically over a bony prominence, due to pressure, or pressure combined with shear.¹ The incidence and severity of PUs are important indicators of the quality of care.²

In Europe (EU), the prevalence is approximately 14.5%, while in North America it is around 12.7%.³ In contrast, Asia has a much lower prevalence at 3%.³ Universally, the overall prevalence of PUs is approximately 12.8%.³ Higher reported prevalence of PUs in some EU countries may be due to more advanced reporting systems.⁴ However, differences in prevalence are likely multifactorial, reflecting variations in healthcare systems, documentation standards, and resource availability across regions.⁵

PUs are painful, cause discomfort, can significantly impact quality of life, and are expensive to treat.² Indeed, length of stay and treatment costs are critical factors in PU management, affecting both patient outcomes and the efficiency of healthcare services.^6,8 Effective prevention enhances health outcomes, reduces costs, and optimises resource utilisation.^6,7,8 Therefore, it is the responsibility of healthcare providers to monitor prevalence and incidence rates to ensure that implemented care strategies are effective.²

Healthcare professionals must understand how to prevent and treat PUs effectively.^9,10 Various studies strongly suggest that implementing a structured PU prevention programme is a viable strategy to reduce the incidence of PUs.^11,12,13 McInerney¹⁴  noted that PU rates can be significantly reduced through targeted prevention programs.¹⁴ Nearly two decades later, a two-arm cluster randomised controlled trial conducted by Tayyib et al¹⁵ found that care bundles improve the quality of care and patient safety.¹⁵ Additionally, systematic reviews conducted by Serra et al¹⁶, Lichterfeld-Kottner et al¹⁷ and Al Khaleefa et al¹⁸ have emphasized the importance of standardized skincare bundles in the prevention of PU.^16,17,18 Across all these studies, researchers have used risk assessment, pressure relief measures, interdisciplinary team protocol, nutrition support, repositioning education/ training, care of medical devices, decreased bathing frequency, the use of pH-neutral cleansing products, staff education, routine moisturising, and related skin-care practices as a part of the care bundles.^14-18

According to the National Health Service, older adults are defined as individuals aged 65 years and above.¹⁹ This systematic review focuses on this population group. Jaul et al²⁰ have highlighted that the prevalence of PUs is notably high among frail older adults, reinforcing the need for targeted preventive measures.²⁰ Therefore, it is essential to explore strategies to reduce PU incidence and improve the quality of life among older adults at risk of or living with PUs.²⁰ While various systematic reviews by Chaboyer et al⁴⁷, Lin et al⁴⁸, Demir et al⁴⁹ and Lovegrove et al⁵⁰  have evaluated the effectiveness of care bundles in the general adult population.^47,48,49,50 There remains a paucity of research specifically targeting individuals aged 65 years and older.²¹ Older adults aged 65 years and above represent a well-recognised at-risk group for PUs, primarily due to age-related physiological changes, such as thinning of the skin, reduced subcutaneous fat, limited mobility, and delayed wound healing.⁵¹ These risk factors may significantly influence the effectiveness of care bundle interventions.²²

This review aims to explore the impact of care bundles on the incidence of PUs among older adults by reviewing, analysing, and synthesising existing relevant literature. It is anticipated that the findings of this systematic review will demonstrate a direct relationship between the use of care bundles and a reduction in the incidence of PUs among at-risk older adults.

Review question

What is the impact of care bundles on the incidence of PUs among at-risk older adults?

Methods

The study protocol was pre-registered with the International Prospective Register of Systematic Reviews (PROSPERO, CRD42023444554).

PICO Framework

• Population: Older adults aged 65 years and above, at risk of PUs, regardless of healthcare setting or underlying medical condition
• Intervention: Care bundles, defined as a combination of at least two interventions designed to reduce PU incidence
• Comparator: Usual care or absence of a care bundle
• Outcome:
  • Primary outcome: Incidence of PUs
  • Secondary outcomes: Healthcare costs and length of hospital stay.

Inclusion criteria

This systematic review included only original single and multi-centre studies of the following designs that examined the impact of evidence-based care bundle interventions on PU development in at-risk older adults:

• Randomised controlled trial (RCT)
• Quasi-experimental study
• Prospective intervention study
• Quality improvement project
• Multi-hospital retrospective study
• Cohort study

Exclusion criteria

• Non-original research
• Studies not focused on older adults (≥65 years)
• Studies that did not assess care bundle interventions
• Studies that did not report outcomes related to PU development
• Studies lacking sufficient methodological detail
• Studies not published in English
• Qualitative studies

Older adults are defined as individuals aged 65 and above.¹⁹ No date restrictions were applied to the studies included. Although older studies may have limited relevance due to evolving guidelines and clinical practices, their inclusion was necessary to avoid overlooking valuable insights in this under-researched area. To address this, greater interpretive weight was given to recent studies and the team contextualised older findings with caution, balancing completeness with clinical relevance. ^25,26,27

Electronic searches

Comprehensive searches of databases were undertaken from inception to May 2025: PubMed, CINAHL Ultimate, Scopus, and Cochrane Central Register of Controlled Trials (CENTRAL) Google Scholar, grey literature and reference lists of included studies were manually searched for additional sources.

Information sources and search strategy

The search strategy was based on three key concepts combined as follows: pressure ulcer AND aged AND patient care bundles, with an English-language filter applied. Searches were initially conducted in July 2023 and updated in May 2025 across PubMed, CINAHL, Scopus, and Cochrane databases. The strategy was first developed in PubMed and then adapted for the other databases. Additionally, citation tracking with seed articles was employed to identify further relevant studies. The searches were developed and conducted in collaboration with an experienced librarian, and full details of the search strategies are provided in the Appendices.

Study Selection

Screening and data extraction were undertaken through a rigorous, multi-stage process designed to maximise accuracy and maintain consistency. All search results were imported into EndNote, which facilitated the automatic identification and removal of duplicate records prior to screening. Two reviewers independently screened all titles and abstracts with the eligibility criteria, followed by independent full-text screening of all potentially relevant studies. The data extraction from the included studies was performed by the reviewers using an Excel spreadsheet.  Any disagreements at screening, full-text assessment, and data extraction were resolved through discussion with a third reviewer.

Data extraction

The team used a piloted, standardised data extraction form using an Excel spreadsheet. Key data fields included: authors, year of publication, country, study design, sample size, components of the care bundle, intervention details, data collection period, primary outcome comparators: (incidence of PUs: frequency and percentage), pre- and post-intervention incidence rates, p-values and interpretation (p<0.05=significant), and secondary outcomes (cost and length of stay).

Data analysis

Due to heterogeneity in study designs, a meta-analysis was conducted for studies^{29,30,33,34,52,53,54,56} with comparable methodologies, whereas highly heterogeneous studies^31,32,55 were not pooled and were described narratively. Meta-analysis was conducted using RevMan.57 For dichotomous outcomes, Odds ratios (OR) with 95% confidence intervals (CI) were calculated; for continuous outcomes, mean differences (MD) with 95% CI were used.  Results from comparable trials were pooled using fixed and random effects models. Heterogeneity was assessed using the I² statistic.

Quality appraisal

Each study was appraised using Glynn’s Evidence-Based Librarianship (EBL) checklist.²⁸ This was carried out independently by two authors. This checklist assesses validity, applicability and appropriateness based on four main domains: population, data collection, study design and results, and is widely used to assess the quality of studies included in systematic reviews. Each domain is scored individually, and for a study to be considered valid, it must achieve an overall score of 75% or higher.²⁸

Results

Overview of included studies

A PRISMA flow diagram (Figure 1) outlines the selection process for this systematic review. An initial 1482 citations were identified through database searches. After the removal of 480 duplicate records, 1002 articles remained for screening. Of these, 948 were excluded based on title and abstract for not meeting the inclusion criteria. A total of 54 full-text articles were retrieved for detailed review. After full-text screening, 43 articles were excluded (see Table 1) (Table 1 is available from the author on request), for the following reasons: 23 studies were not related to care bundles, nine did not address the primary outcome of PU prevention, five involved an unsuitable population (such as pediatric, young adult or staff) and six focused solely on risk assessment without implementation of an intervention. Ultimately, 11 studies met the inclusion criteria and were included in this systematic review ^{29–34,52–56} (see Table 2).

 

Figure 1. PRISMA 2020 flow diagram for study selection

 

Table 2. Characteristics of included studies

 

Study design

Four studies^{30,34, 52,56} were quasi-experimental designs. One study³¹ was a prospective intervention study. Two studies^33,53 were retrospective cohort designs. One study⁵⁵ was a cross-sectional design. Two studies^29,54 were randomised controlled trials. One study³² was a quality improvement project (QIP). (See Table 2).

Geographical location

The studies, published between 1995 and 2024, were conducted in diverse geographical locations, including Sweden^29,30, Turkey⁵², China⁵³, Finland⁵⁵, Singapore^56, and the USA.^{31,32,33,34,54} (see Table 2).

Study settings

The studies were conducted across a variety of healthcare settings, including five ambulance stations, two emergency departments, and 16 wards across two hospitals²⁹, a university hospital^{30, 52, 53, 56}, nursing homes^{31, 32}, hospitals and a peer review organisation³³, acute care hospitals⁵⁵, and long-term care facilities^{34, 54} (see 2).

Participants and sample size

Sample sizes were reported in all included studies^{29–34,52–56}. The total combined sample size was 20,898, with individual study sizes ranging from 98 to 9680 participants. The mean (SD) sample size was approximately 1900 (3084) participants (see 2).

Risk assessment tool

All studies discussed the use of a risk assessment tool. The most used was the Braden Scale, reported in five out of the 11 studies^{31,32,52, 53,54} accounting for approximately 45.5% of the total. The Modified Norton Scale was used in one study²⁹ (9.1%), while two studies^34,55 employed both the Braden and Norton Scales (18.2%). Additionally, one study⁵⁶ used the Surgical Pressure Ulcer Risk Score (SPUR) (9.1%) and one study³³ (9.1%) did not specify which tool was used.

Pressure ulcer grading tool

Three studies^{32,33, 34} (27.3%) employed the National Pressure Injury Advisory Panel (NPIAP) grading system, formerly the National Pressure Ulcer Advisory Panel (NPUAP). One study³⁰ (9.1%) used the European Pressure Ulcer Advisory Panel (EPUAP) staging system, while another study⁵⁵ (9.1%) followed the joint guidelines issued by the NPUAP, EPUAP and Pan Pacific Pressure Injury Alliance (PPPIA) and  the Finnish Wound Care Society. A separate study²⁹ (9.1%) adhered solely to the joint NPUAP/EPUAP guidelines. Another study⁵⁶ (9.1%) applied a revised version of the NPUAP staging system. One study⁵⁴ (9.1%) documented pressure injury staging using data from the Minimum Data Set (MDS) and Electronic Health Record (EHR), with assessments completed by trained clinical staff. Three studies^31,52,53 (27.3%) incorporated skin assessment within their care bundles, they did not specify the use of any formal PU grading tool.

Elements of the care bundle intervention

All studies reported the specific elements included in the care bundles or protocols used (see Table 3). Analysis of the included studies revealed a diverse range of care bundle components aimed at PU prevention. A total of twelve core intervention elements were identified across the interventions. These include risk assessment; skin assessment and examination; the use of support surfaces or offloading devices; systematic patient repositioning; staff training and education; nutritional and hydration support; involvement of a multidisciplinary team; patient and family education; monitoring and technological support; documentation and audit processes; application of specialised dressings; and pain management. These elements reflect a comprehensive, multifaceted approach to PU prevention, emphasising both clinical and organisational strategies to improve patient outcomes. Additionally, three studies^31,32,33 (27.3%) referenced the Agency for Health Care Policy and Research (AHCPR) guidelines in the development of their pressure injury prevention bundles.

 

Table 3. Comparison of PU prevention bundle elements across studies

 

Primary outcomes measured

All studies^29-34,52-56 assessed primary outcomes related to PU development, specifically PU incidence or prevalence. Six studies^{29, 30, 32, 33,52,53} reported on Grade/Stage 1 PUs. Another six studies^{30, 31, 32, 33, 52,53} included data on Grade/Stage 2 PUs. Three studies^{30, 31,53} reported on Grade/Stage 3 PUs and one study³¹, included Stage 4 PU. Additionally, two studies^33,52 included PUs of any stage, as well as suspected deep tissue injuries.

Secondary outcomes measured

A total of 36.4% of the studies^{29, 30, 33, 56}(n=4) reported data on length of stay. Additionally, 27.3% of the studies^{31, 32, 34} (n=3) provided information on the cost of PU prevention.

Results for the primary outcome: incidence of PUs

All included studies assessed the primary outcome of PU incidence or prevalence among at-risk older adults.

RevMan analysis was conducted to estimate the odds ratio (OR) for PU development following the implementation of care bundles compared with usual care. Figure 2 presents the corresponding forest plot. Given the substantial heterogeneity detected between the two included trials (I² = 85%), a random effects model was applied. Across both studies, 76 out of 1,072 participants (7.1%) in the usual care group developed a PU, whereas only 15 out of 1,095 participants (1.4%) in the care bundle group experienced this outcome. The pooled odds ratio was 0.08 (95% CI: 0.00 to 3.04; p = 0.17), indicating no statistically significant difference between groups. Although the point estimate suggests a potential reduction in PU risk with care bundle implementation, the wide confidence interval and high heterogeneity limit the certainty of this effect.

 

Figure 2. Meta-Analysis of Randomized Controlled Trials on the Implementation of Care Bundles for Pressure ulcer Prevention

 

RevMan analysis was undertaken to determine the odds ratio (OR) of PU development following the implementation of care bundles compared to usual care. Figure 3 displays the forest plot generated from this meta analysis. Due to heterogeneity across the included studies (I² = 54%), a fixed effects model was applied. As illustrated in Figure 3, 195 out of 859 participants (22.7%) in the usual care group developed a PU, while only 118 out of 1017 participants (11.6 %) in the care bundle group experienced this outcome. The overall odds ratio for PU development was 0.45 (95% CI: 0.33 to 0.61; p< 0.00001), indicating that patients receiving the care bundle were 55% less likely to develop a PU compared to those receiving usual care. This result is statistically significant.

 

Figure 3. Meta-Analysis of Quasi-experimental Studies  on the Implementation of Care Bundles for Pressure ulcer Prevention

 

RevMan analysis was undertaken to determine the odds ratio (OR) of PU development following the implementation of care bundles compared to usual care. Figure 4 displays the forest plot generated from this meta-analysis. Due to heterogeneity across the included studies (I² = 78%), a random effects model was applied. As illustrated in Figure 4, 339 out of 2009 participants in the usual care group and 157 out of 951 participants in the care bundle group developed a PU. The overall odds ratio for PU development was 0.68 (95% CI: 0.27 to 1.72; p = 0.42), indicating no statistically significant difference between patients receiving the care bundle and those receiving usual care.

 

Figure 4. Meta-Analysis of Retrospective Cohort Studies  on the Implementation of Care Bundles for Pressure ulcer Prevention

 

The included studies also comprised a prospective intervention study³¹, a cross-sectional study⁵⁵, and a quality improvement project³². Due to heterogeneity in study designs, a meta-analysis was not conducted, and findings are reported narratively. Regan et al³¹ reported one of the earliest and most compelling examples: following the implementation of a comprehensive PU prevention program, incidence declined to zero by the six and eight month evaluations. Chi square analyses confirmed a significant reduction at every two month interval, thereafter, indicating an immediate and sustained impact of the intervention Similarly, Tippet³² documented dramatic improvements after introducing a wound care initiative in a long term care facility. The program achieved zero facility acquired PUs by the sixth month and maintained rates at or near zero for nearly four years. Over the full implementation period, the average incidence fell to 0.73%, representing an 86% reduction, with a fourth year incidence of 0.06% a 99% decrease from baseline. Tervo-Heikkinen et al⁵⁵, did a national cross-sectional audit of Finnish acute inpatient care. Across the two national audit days, the prevalence of PUs demonstrated modest improvement, decreasing from 97 cases among 747 patients (13.0%) in 2018 to 59 cases among 591 patients (10.0%) in 2019 a relative reduction of approximately 23%. Age related patterns were also evident: 38.8% (2,258/5,902) of the overall audited population were aged 66–80 years, yet this group accounted for 42.6% (316/747) of all PU cases. Similarly, those aged over 80 years represented 19.4% (1,128/5,902) of the total sample but comprised 28.1% (208/747) of patients with PU.

Table 4 outlines the incidence/prevalence of PUs across the included studies.

 

Table 4. Pressure ulcer incidence and prevalence

 

Secondary outcomes

The secondary outcomes measured were cost and length of stay.

Cost

Three studies^31,32,34 included in this review reported on the financial impact of PU prevention strategies. Despite some variation in reporting methods, all studies indicated meaningful cost savings associated with prevention efforts. Regan et al³¹ used a model projecting 52 PU cases over eight months with a conservative treatment cost of $5000 per case. Based on actual expenditures for preventive products, pressure-relieving surfaces, and staff time, the intervention was estimated to yield cost savings of approximately $250,000 over the study period.³¹ Tippet³² evaluated a multi-year prevention initiative that included costs for a physician wound consultant ($20,000/year initially decreasing to $7200/year) and a one-time purchase of pressure support surfaces ($11,000). Monthly prevention-related supply expenses decreased from $865 to $665, generating annual savings of $2400. Additionally, the initiative led to a reduction in nosocomial PU incidence from 7.3 to 1 case per month. Notably, these improvements were achieved without increasing staff hours or hiring new personnel.³² Lyder et al³⁴ calculated the monthly cost of PU prevention for high-risk residents to be $575.14, including labour and equipment over five months the total cost per resident was $2875.65.³⁴ The intervention reduced PU incidence from 13.2–15% to 1.7–3.5% per month, and the cost per PU free resident ranged from $4.35 to $7.53/month across two long-term care facilities, indicating a favorable cost-benefit profile.³⁴

Cost savings were achieved without substantial increases in staffing or resource burden, supporting the economic value of sustained PU prevention in both acute and long-term care setting reported on the treatment and prevention costs of PUs, though some details remain unclear.³⁴ One study estimated that preventing PUs in a single nursing home could save approximately a quarter of a million dollars over eight months.³¹ This estimate was based on a model comparing baseline PU occurrence with a conservative estimate of treatment costs at that center. ³¹ In a hospital setting monthly savings of around $10,000 and annual savings exceeding $120,000 were reported, adjusted for inflation to reflect the cost-effectiveness of prevention in acute care.³² However, the true cost of preventing PUs is not well established, and evaluating cost savings across various healthcare settings remains complex.³⁴ Although methodologies differed in all three studies they all consistently demonstrated that structured PU prevention programs can be cost-effective, primarily by reducing PU incidence and avoiding treatment related expenditures.

Table 5 outlines the cost of PUs prevention across the included studies.

 

Table 5. Summary of cost outcomes across included studies

 

Length of stay

Four studies^29,30,33,56(n=4) 36.4%, reported on length of stay (LOS). Aloweni et al⁵⁶ found a statistically significant reduction in LOS following the implementation of a PU prevention initiative. Median LOS decreased from nine days (range 4–328) pre-intervention (n=396) to four days (range 1–139) post-intervention (n=548), with p<0.001, indicating a strong association between prevention efforts and reduced hospitalisation time. Baath et al²⁹ observed a shorter average LOS in the intervention group (7.9 days) compared to the control group (10.4 days) although the difference did not reach statistical significance (p=0.739). Hommel et al³⁰ reported two LOS related outcomes, time from admission to surgery was slightly longer in the intervention group (194 patients) 26.3hours (SD±15.3) than in the control (185 patients) 23.6hours (SD±21.9), with no statistically significant difference. However, time from admission to ward placement was significantly reduced from 4.0 hours (SD±1.8) in the control group to 3.2 hours (SD±1.9) in the intervention group (p<0.001), suggesting improved patient flow post-intervention. Lyder et al³³ reported an average reduction in length of stay by one day over the course of their study.³³ Nonetheless, the authors highlighted that earlier implementation of prevention strategies may indirectly contribute to shorter stays by reducing PU incidence.

Overall, the evidence suggests that PU prevention interventions may contribute to reduced LOS. While not all reductions reached statistical significance, clinically meaningful trends were observed, reinforcing the broader value of early PU prevention in optimising patient outcomes and resource use.

Table 6 outlines the impact of PUs prevention on LOS across the included studies.

 

Table 6. Summary of length of stay (LOS) findings across included studies

 

Results of quality appraisal

The quality appraisal of the included studies (n=11)^{29–34,52–56} was conducted using Glynn’s Evidence-Based Librarianship (EBL) critical appraisal checklist.²⁸ Eight studies^{29,32,33,34,52,54,55} 72.3% met the quality threshold of ≥75%, indicating good methodological rigor. These studies were rated as high quality with clear interventions, reliable outcomes, and strong internal validity. Common limitations included small sample sizes and  limited setting diversity.

Despite these issues, most studies were of acceptable quality and findings from higher-quality studies were prioritised in the synthesis. The results support the potential effectiveness of structured care bundles in PU prevention, though more robust multi-site studies are needed. ^29,53 The mean validity score was 79.36% (SD: 8.87; range: 64% ⁽³⁰⁾ to 96.29% ⁽²⁹⁾).

In section A, population, 54.6 % (n=6) of studies^{30,31,32,53,55,56} scored <75%, and thus did not meet the validity criteria. Sample size justification and inclusion, and exclusion criteria were not mentioned in some of the studies. In section B, data collection, 63.6% (n=7) of studies ^{29,31,32,33,34,55 ,56} scored ≤75%, and thus did not meet the validity criteria. Many of the studies did not affirm whether inter-observer or intra-observer bias was reduced, it was also unknown if the data collection instrument was validated and it was not always clear if those collecting the data were also delivering direct care to the participants. In section C, study design, 100% (n=11) of studies^{29-34, 52-56} scored ≥75% and were, therefore, considered valid in this section. However, one study³³ did not require ethical approval due to being a QIP. In section D, results, 45.5% (n=5) of studies^{30, 31, 34,52,53} scored ≤75% and did not meet the validity criteria, and due to the overall nature of the studies, external validity was also unclear.

See Table 7 for a summary of the quality appraisal of the studies and overall validity.

 

Table 7. Summary of quality appraisal of studies and overall validity

 

Discussion

The main goal of this systematic review was to determine the impact of PU prevention care bundles on the incidence of PU amongst at-risk older adults. This review had a total of 11 studies with a total sample size of 20898 participants were analysed to answer the research question. The primary outcomes from the meta-analyses showed variable effects of care bundles on PU incidence. Two meta-analyses found no statistically significant differences between patients receiving care bundles and those receiving usual care, suggesting that although point estimates indicated a potential reduction in risk, wide confidence intervals and high heterogeneity limit confidence in these findings. In contrast, a third meta-analysis reported a statistically significant effect, with patients receiving care bundles being 55% less likely to develop a PU compared to usual care. Supporting this, a recent systematic review and meta-analysis found a pooled risk ratio of 0.55 (95% CI: 0.29–1.03) for overall PU prevalence and 0.31 (95% CI: 0.12–0.83) for hospital-acquired pressure injuries (HAPI), although the confidence interval for prevalence crossed unity47. Furthermore, non-randomized studies included in this review showed a significant reduction in HAPI rates with care bundle implementation49. Overall, these meta-analysis suggest that care bundles can reduce PUs, but the effect size varies according to study design, implementation fidelity, and patient population, highlighting the importance of consistent and comprehensive application in practice. Conversely, in the narrative analysis of this review, Tervo-Heikkinen et al55 study highlighted the need for structured care bundles in Finnish acute care. Risk and skin assessments were inconsistently performed, and preventive interventions were often applied only after a PU developed rather than proactively for high-risk patients. While studies such as Regan et al31 and Tippet32 demonstrated that comprehensive, well-coordinated care bundles can nearly eliminate PUs. These studies collectively highlight that meaningful reductions in PU incidence require not only evidence based protocols but also organizational commitment to ensuring their reliable, proactive, and systematic implementation.. Notably, the prevention care bundles elements were diverse within the included studies of this review. PU prevention bundles are structured sets of evidence-based interventions designed to be implemented collectively, with the aim of improving patient outcomes and enhancing consistency in care delivery.²¹ Common elements included risk assessment (e.g., Braden Scale), repositioning protocols, use of pressure-relieving devices, nutritional screening, and structured staff education.

This systematic review aimed to evaluate the impact of PU prevention care bundles on PU incidence in at-risk older adults. The primary findings suggest that PU prevention bundles, when implemented as part of routine care, are associated with reduced PU incidence. Common elements included risk assessment (such as the Braden Scale), repositioning protocols, use of pressure-relieving devices, nutritional screening, and structured staff education.

In addition to PU incidence, two key secondary outcomes, length of stay (LOS) and the cost of PU prevention, were examined. Some of the included studies reported that patients receiving care bundle-based care experienced shorter hospital stays.^29,30,33,56 Although care bundle implementation requires an investment in staff training, monitoring tools, and equipment for example pressure-relieving mattresses or heel boots and so on, some studies demonstrated long-term cost savings due to a reduction in PU development.^31,32,34 These findings reinforce the dual clinical and economic value of PU prevention bundles, particularly in resource-conscious health systems.

Despite generally positive trends, implementation of PU prevention bundles is often challenged by resource constraints, staff compliance, and organisational readiness.²¹ The Evidence Based Librarianship (EBL) critical appraisal identified several methodological limitations across the included studies, including inconsistent reporting of inclusion/exclusion criteria, absence of ethical approval documentation. Some studies were also single center, limiting external validity. These factors necessitate cautious interpretation of results and underscore the need for more rigorous research designs. This review highlights the importance of PU prevention bundles which encompasses early intervention, targeted prevention strategies, comprehensive education, an interdisciplinary approach to name a few, in preventing PUs in older adults. These findings align with other research advocating for multifaceted and sustained PU prevention efforts to improve patient outcomes and reduce healthcare-associated complications.^38,41,42

Strengths of the review

Findings from the included studies ^29-34,52-56 align with previous reviews, reinforcing the value of comprehensive prevention programs, evidence-based pathways and multi-component interventions in reducing PU incidence.¹¹ Quality improvement efforts have shown significant reductions in hospital-acquired PUs.¹¹ Ongoing staff education remains essential for effective PU prevention.⁴³ Integrating these strategies can enhance healthcare quality and improve outcomes.^38,40,44,46

One key point from this systematic review is to contribute to the existing body of evidence by emphasising the evolution and refinement of risk prediction tools and preventive interventions. This reinforces the importance of early intervention, targeted prevention, comprehensive education, multidisciplinary practice, and continuous improvement and it is consistent with the systematic review by Chou et al.⁴⁵

Limitations

The findings may not be generalisable to all settings, as care bundle implementation is context dependent. Restricting the review to English-language studies may have excluded relevant evidence. Additionally, some studies were over ten years old, and their applicability to current practice should be interpreted with caution due to evolving healthcare standards and technologies.

Conclusion

Care bundles have the potential to reduce PU incidence, particularly when implemented consistently and comprehensively. While one meta-analyses show statistically significant benefit, variability in study design, implementation fidelity, and patient populations can influence outcomes. Narrative evidence further supports the value of care bundles as a structured, multicomponent approach to prevention. Optimizing adherence to all bundle components in clinical practice is essential to maximize their effectiveness and improve patient outcomes. While the included studies were of strong methodological quality, substantial heterogeneity and potential bias limit the generalisability of results. Future research should involve larger, more diverse samples, longer follow-up periods, and standardised outcome measures to strengthen the evidence base and inform best practice guidelines tailored specifically to older adults.

Funding

No funding was received for the conduct of this systematic review.

Declaration of competing interest

The authors have no conflicts of interest to declare. All co-authors have seen and agree with the contents of the manuscript, and there is no financial interest to report.

Author(s)

Queen Edede¹ Professional Doctorate student, RN Prescriber, MSc Gerontological Nursing , PGDip Gerontological Nursing, RGN,
Declan Patton^1,2,3,4,5 PhD, MSc, PGDip.Ed, PGCRM, BNS(Hons), RNT,RPN, Pinar Avsar^1,2,6 PhD, MSc, BSc, RGN, Zena Moore^{1,2,3,4,6,7,8} PhD, MSc (Leadership in Health Profs Ed), MSc (Wound Healing & Tissue Repair), Tom O’Connor^1,2,3,4,9,10 PhD, Ed D, MSc, PG Dip Ed, BSc, Dip., RGN, Vishnu Renjith^1,6,11 RN, MSN, PhD, CTLHE, FRSPH, FFNMRCSI
¹School of Nursing and Midwifery, RCSI University of Medicine and Health Sciences, Dublin, Ireland
²Skin Wounds and Trauma Research Centre, RCSI University of Medicine and Health Sciences, Dublin, Ireland
³Fakeeh College of Health Sciences, Jeddah, Saudi Arabia
⁴School of Nursing and Midwifery, Griffith University, Queensland, Australia
⁵Faculty of Science, Medicine and Health, University of Wollongong, Australia.
⁶School of Medicine, Cardiff University, United Kingdom
⁷School of Nursing, Curtin University, Perth, Australia
⁸NHMRC Centre of Research Excellence in Wiser Wound Care, Menzies Health Institute Queensland, Queensland, Australia
⁹Lida Institute, Shanghai, China
¹⁰European Pressure Ulcer Advisory Panel
¹¹Manipal College of Nursing, Manipal Academy of Higher Education, India

*Corresponding author email queenedede@rcsi.com

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