Preventing Pressure Ulcers in Hospitals: a Systematic Review of Nurse-Focused Quality Improvement Interventions

The Joint Commission Journal on Quality and Patient Safety

Performance Improvement Preventing Pressure Ulcers in Hospitals: A Systematic Review of Nurse-Focused Quality Improvement Interventions

Lynn M. Soban, R.N., M.P.H., Ph.D.; Susanne Hempel, M.A., Ph.D.; Brett A. Munjas, M.S.; Jeremy Miles, Ph.D.; Lisa V. Rubenstein, M.D., M.S.P.H.

ressure ulcers (PUs) are a common, costly, and potentially Article-at-a-Glance Ppreventable condition. Since the 1990s, governmental agencies and professional organizations have published clinical prac- Background: A systematic review of the literature on tice guidelines for PU prevention. However, translating these nurse-focused interventions conducted in the hospital set- guidelines to the bedside continues to be a challenge. Increas- ting informs the evidence base for implementation of pres- ingly, health care organizations are deploying interventions to sure ulcer (PU) prevention programs. Despite the availability improve PU prevention, yet there is little evidence about which of published guidelines, there is little evidence about which of these interventions can be successfully implemented in routine interventions can be successfully integrated into routine care care settings through quality improvement (QI). Accordingly, through quality improvement (QI). The two previous liter- we sought to identify and characterize nursing-focused QI in- ature syntheses on PU prevention have included articles terventions for inpatient PU prevention. from multiple settings but have not focused specifically on Literature synthesis to identify the features and outcomes of QI. QI intervention studies can yield important information about Methods: A search of six electronic databases for publica- what approaches to consider when aiming to achieve specific QI tions from January 1990 to September 2009 was conducted. goals.1 Previous literature syntheses on PU prevention have in- Trial registries and bibliographies of retrieved studies and re- cluded articles from multiple settings but have not focused views, and Internet sites of funding agencies were also specifically on QI. For example, Gould et al. (2000), who ex- searched. Using standardized forms, two independent re- amined hospital and community interventions for PU preven- viewers screened publications for eligibility into the sample; tion in the United Kingdom, concluded that the evidence base data were abstracted and study quality was assessed for those for PU preventive interventions is sparse.2 Tooher et al. (2003), that passed screening. reviewing studies of successful PU guideline implementation Findings: Thirty-nine studies met the inclusion criteria. across health care settings, concluded that active as compared to Most of them used a before-and-after study design in a sin- passive strategies were associated with better outcomes and that gle site. Intervention strategies included PU-specific changes the relative effectiveness of strategies could not be determined.3 in combination with educational and/or QI strategies. Most We know of no other literature syntheses targeting inpatient studies reported patient outcome measures, while fewer re- nursing QI interventions. ported nursing process of care measures. For nearly all the QI interventions in health care organizations address struc- studies, the authors concluded that the intervention had a tural and/or process changes, as defined in the Donabedian positive effect. The pooled risk difference for developing PUs framework.4 We identified studies of structural features relevant was –.07 (95% confidence interval [CI]: –0.0976, –0.0418) to PU prevention (for example, implementation of care proto- comparing the pre- and postintervention status. cols, wound care teams), and examined their effects on processes Conclusion: Future research can build the evidence base of care (for example, percentage of patients who received PU for implementation through an increased emphasis on un- screening within 24 hours of admission), and/or patient out- derstanding the mechanisms by which improved outcomes comes (for example, PU incidence). The objectives of this re- are achieved and describing the conditions under which spe- view were to: (1) describe the kinds of intervention strategies cific intervention strategies are likely to succeed or fail. used; (2) describe the types of process and outcome measures

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Copyright 2011 © The Joint Commission The Joint Commission Journal on Quality and Patient Safety reported; and (3) examine the interventions’ effects on Sidebar 1. PubMed Search Strategy outcomes. The following search strategy was used in PubMed: Methods pressure ulcer[mh] OR pressure ulcer* OR decubitus ulcer* OR EARCH ETHODS S M pressure sore* OR bed sore* OR bedsore* We searched six electronic databases (PubMed, the Cumulative AND Index to Nursing and Allied Health Literature [CINAHL], the nursing homes OR nursing OR nurses OR nurse Cochrane Library of Systematic Reviews, the Cochrane Central AND (prevention and control) OR prevent*[tiab] OR quality assurance, Register of Controlled Trials [CENTRAL], the Database of Ab- health care OR total quality management OR practice guidelines as stracts and Reviews of Effect [DARE], and the Web of Science) topic OR quality indicators, health care OR quality[tiab] OR reduc- for English-language publications from January 1990 to tion OR reduce* OR prophylactic* AND September 2009. We also searched the Effective Practice and before-after OR pre-post OR randomized controlled trial[pt] OR Organization of Care (EPOC) Cochrane Group and the randomized controlled trials OR rct* OR random allocation OR con- Cochrane Wound Group register and Web sites of two agen- trolled clinical trial[pt] OR controlled clinical trials OR research de- cies—the Robert Wood Johnson Foundation and the U.S. sign* OR evaluation studies OR followup studies OR follow-up studies OR follow up studies OR prospective OR longitudinal OR Agency for Healthcare Research and Quality—that fund QI in- cohort OR compar* OR random* OR evaluative OR trial* OR case terventions. Bibliographies of included studies and pertinent re- control OR (economic AND model) OR (economics AND models) views were also screened. Sidebar 1 (right) shows the PubMed OR (economic AND modeling) OR (economic AND modelling) OR evaluat*[ti] OR effect*[ti] OR differen*[ti] OR impact*[ti] OR experi- search strategy, which was adapted accordingly for the other ment* OR quasi-experiment* OR quasi experiment* OR test OR databases. statistically significant OR odds ratio OR relative risk* OR chi square ARTICLE SCREENING AND evaluation studies as topic OR outcome and process assessment Two independent reviewers [L.M.S., S.H.] screened titles and (health care) OR nursing assessment OR assess*[tiab] OR health abstracts from the initial search. We included studies published plan implementation OR "structural change" OR "organizational in English after 1990. Papers selected as potentially relevant by change" OR (quality AND improv*) OR test OR tests OR testing OR interven* OR ((change OR changes OR changing) AND (structur* either reviewer underwent a full paper screening using the fol- OR organization*)) lowing criteria: OR initiative* OR strategy* OR program* OR collaborative* OR de- ■ Setting (hospital) clin* ■ Use of an experimental study design (that is, randomized NOT case report* OR case study OR case studies controlled trials, controlled clinical trials, cohort studies, time series, and pre-post studies [controlled and uncontrolled] The complete search strategy can be obtained by request from the ■ Testing of a QI intervention designed to change routine authors. care for PU prevention ■ Presence of data for at least one nursing process or patient outcome measure. scribed interventions, with particular emphasis on the following We excluded studies focusing solely on educational interven- elements: tions that were not accompanied by other interventions. We also ■ Team assembled excluded studies focusing on wound care and those that focused ■ Guideline implemented on site-specific (for example, cervical and heel) PUs. We resolved ■ Protocol developed/implemented reviewer disagreements about eligibility into the final sample ■ Risk assessment tool through discussion. ■ Iterative (Plan-Do-Study-Act [PDSA]) cycles ■ Staff education DATA ABSTRACTION ■ Link/Resource nurse All studies meeting the inclusion criteria were abstracted in ■ Performance monitoring duplicate by three reviewers [including L.M.S.]. We used an ab- ■ Feedback straction tool that included setting, study design, intervention We abstracted data on measures of both processes of care and strategies, results, and authors’ conclusions. We extracted all de- patient outcomes, specifically: values prior to the intervention

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Study Flow Diagram

Figure 1. The search of the electronic databases and hand searches of bibliographies yielded 1,646 records. Assessment of full paper copies of 314 publication records for inclusion and exclusion criteria and for identification of additional relevant research articles. Thirty-eight papers (39 studies) met the inclusion criteria. and following the intervention; sample sizes; length of study fol- criteria; adequacy of sample size; the use of objective criteria for low-up; and results of tests for statistical significance. For each assessing skin integrity (for example, the European Pressure Ulcer study, we compared two independently prepared abstractions for Classification System6); whether the intervention was applied consistency and resolved discrepancies through discussion. We evenly across all groups in the study; the length of follow-up; the considered multiple publications on the same project during data types of outcomes measured; and the clarity with which analysis abstraction and informed details on the interventions and out- and results were reported. We graded each item on a 3-point scale comes but entered the study into the analysis only once. (0 = feature clearly absent to 2 = feature clearly present). The eight elements were summed for each paper, such that the lowest score META-ANALYSIS possible was 0 and the highest possible score was 16. We performed a random effects meta-analysis of studies that reported a measure of PU incidence. Only studies that reported Findings PU incidence (or nosocomial PU prevalence) along with the STUDY FLOW sample sizes were pooled. For studies with multiple data points, The search of the electronic databases and hand searches of bib- the data point immediately prior to the intervention implemen- liographies yielded 1,646 records. The study flow is shown in tation and the last data point reported were used. All analyses Figure 1 (above). We assessed full paper copies of 314 publica- were conducted using Stata 9.2. (Stata Statistical Software: Re- tion records for inclusion and exclusion criteria and to identify lease 9; StataCorp LP, College Station, Texas.) further relevant research articles. The most common reason for exclusion was ineligible study QUALITY APPRAISAL design (n = 135); within this group, the use of during-after study We appraised the quality of each study using criteria based in designs was common (for example, contaminated baseline, QI part on those published by the Center for Reviews and Dissem- intervention has already started when data are collected). Thirty- ination (CRD).5 We considered eight areas in judging article qual- nine studies met the inclusion criteria.7—44 Details of the included ity: clarity of intervention description; statement of inclusion studies are shown in Appendix 1 (available in online article).

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Table 1. Definitions and Frequencies of the Most Commonly Employed Intervention Components

Intervention Component Definition Frequency Protocol developed/implemented Implementation of protocol-based care 29 Staff education Use of written, didactic, or other means to improve nurses’ understanding of pressure ulcer prevention or the intervention specifically. 28 Risk assessment tool Implementation of a pressure ulcer risk assessment tool such as the Braden Scale. 21 Performance monitoring The collection of process or outcome data at least 3 times during the course of the study 20 Team assembled Assembly of a new team to plan the intervention 19 Beds/support surfaces Use of new equipment or processes related to beds or support surfaces (for example, purchased new mattresses or mattress overlays) 14 Guideline implemented Intervention design is based on published guidelines, which were specified in the text. 11 Feedback Provision of feedback to nurse managers and/or nursing staff with the goal of creating awareness of intervention progress 10 Link/resource nurse Identification of nursing unit staff member(s) to receive additional training with roles such as information sharing 9

STUDY DESIGN AND SETTING = 9) collected data at least quarterly and half (n = 10) collected The 39 studies represent nine different countries: United data less than quarterly (that is, every 6 to 12 months). States (n = 27), Australia (n=1), the United Kingdom (n = 2), We noted patterns among the combinations of intervention the Netherlands (n = 3), Israel (n = 1), Sweden (n = 1), Canada strategies implemented. Among the 29 studies where a protocol (n = 2), Turkey (n =1 ), and Italy (n = 1). The study settings var- change was implemented, 8 studies implemented a protocol ied and included multihospital studies (n = 5), single hospital change in conjunction with the adoption of a risk assessment studies with multiple units (n = 31), and a few one-unit studies tool,9,25,30, 32,36,40,43,44 and 10 studies implemented a protocol change (n = 3). Most of the studies used an uncontrolled before-after along with a risk assessment tool and changes in support sur- design with four exceptions: one time series11 and three con- faces.9,10,15,22,26,27,31,35,38,42 trolled trials.13,21,39 In contrast, performance monitoring and feedback—core QI strategies that are generally used together as a means to reinforce INTERVENTION STRATEGIES awareness and adherence to QI interventions—were frequently The majority of studies used multiple intervention strategies, not used together. Among the 20 studies where performance including PU-specific changes (for example, use of risk assess- monitoring was used, fewer than half (n = 9) coupled perfor- ments) in combination with educational and/or QI strategies mance monitoring with the provision of feedback to nurse man- (for example, performance measurement). Table 1 (above) shows agers or nursing staff.7,13,15,18,22,24,31,33,38 the most frequently reported intervention strategies. Examples of other strategies employed less frequently included changes to MEASURES REPORTED nursing documentation, consultations with skin care experts (for Some 31 studies reported only patient outcome measures, example, enterostomal therapy [ET] nurses), and various re- such as PU incidence, and 2 studies13,37 reported only process of minders (for example, signs, stickers, music) indicating either care measures, such as the percent of patients who received a skin patient risk and/or the need for repositioning. risk assessment within 24 hours of admission. The remaining 6 Considerable variation existed among the studies in terms of studies reported both patient outcome and nursing process of operational implementation of strategies. For example, strate- care measures.16,17,23,26,28,33 gies for nursing staff education ranged from simple, one-time Most studies reported a patient outcome measure that re- events (for example, distribution of written materials, in-service flected PU incidence. However, there was inconsistency across training) to more complex and ongoing activities (for example, the papers in definitions of this measure, including differences in monthly teaching rounds, incorporating PU prevention into the stages included in the measure (that is, all stages versus Stages new staff orientation). Some papers described using multiple ed- II-IV) and differences in measure computation (for example, ucational activities, others described fewer or those more narrow PUs per 100 or 1,000 patient days). Across the studies, the in scope. Performance monitoring varied considerably: Of the process of care measures reported were heterogeneous; there were 20 studies that used performance measurement, almost half (n no patterns in these measures.

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Table 2. Quality Criteria: Definitions and Frequencies of Score Components

(n) High (n) Medium (n) Low Quality Criterion Definitions for Item Scoring Item Score = 2 Item Score = 1 Item Score = 0 1. Adequacy of sample size 2: Large sample (≥ 30 observations) 1: Unsure; or sample size not stated; or 19 19 1 inconsistent sample sizes 0: Small sample (< 30 observations) 2. Clarity of intervention description 2: Very clear 1: Somewhat/mostly clear 26 12 1 0: No, not clear 3. Objective criteria used for 2: A published tool was used assessment of patient skin integrity 1: Self-made tool was used; or tool 20 17 2 (source) not referenced 0: Tool was not stated or no tool used 4. Sufficiency of the length of 2: ≥ 12 months follow-up (number of months 1: ≥ 6 months but < 12 months 22 15 2 between intervention deployment since or unclear and outcomes reported) 0: < 6 months 5. Clarity of inclusion criteria 2: Inclusion/exclusion criteria are clearly stated 1: Unclear (i.e., incomplete description 18 2 19 of inclusion criteria) 0: No inclusion/exclusion criteria mentioned 6. Consistency with which 2: No subgroups; same intervention; intervention was delivered same measures 1: Unclear (not enough information); 30 8 1 or some subgroups of intervention 0: Intervention or outcomes reported different across groups 7. Types of outcomes reported 2: Both patient and process outcomes 1: Pressure ulcer incidence only; or reported only patient outcome measures 0: Only the prevalence of pressure ulcers 6 27 6 (i.e., pressure ulcer frequency included patients with pre-existing pressure ulcers); or reported process measures only 8. Clarity of analysis and 2: Analysis and results clearly presented, reporting of results p values computable if not reported 15 20 4 1: P value(s) not reported & not computable 0: Very unclear and results doubtful

QUALITY was applied across groups, and (2) the clarity of the intervention The quality of the studies was assessed using a quality score description. The individual components with the overall lowest composed of eight items, each scored 0, 1, or 2 (low, medium, levels of quality were (1) the clarity with which inclusion crite- high). The eight elements were summed for each paper such that ria were stated, and (2) types of measures reported (that is, the lowest score possible was 0 and the highest possible score was process of care measures, patient outcome measures). 16. The frequencies of quality score components and definitions of quality criteria are shown in Table 2 (above). EFFECT OF THE INTERVENTIONS ON OUTCOMES The mean quality score was 10.5 (minimum 4, maximum Nearly all the authors’ conclusions stated an effect of the in- 15). The individual components with the overall highest levels tervention on at least one nursing process or patient health out- of quality were (1) the consistency with which the intervention come measure in the intended direction (36/39), as outlined in

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Appendix 1. Of the 16 studies reporting data for Results of Pooled Data Analysis for the outcome PU incidence, the pooled risk difference Studies Reporting the Outcome Pressure Ulcer across studies was –.07 (95% confidence interval (PU) Incidence (n = 16) [CI]: –0.0976, –0.0418; p < .0001), indicating that overall PU incidence decreased after the interventions Bergstrom, 1995 (9) (Figure 2, right). There was evidence of statistical het- Bergstrom, 1995 (9) erogeneity across studies (I-squared = 69.7%). Catania, 2007 (12) DeLaat, 2007 (16) Discussion DeLaat, 2006 (17) This study aimed to describe the literature on hospital Hiser, 2006 (22) PU prevention in terms of the intervention strategies Hopkins, 2000 (24) used, the types of nursing process and patient outcome Jones, 1993 (26) measures reported, and the interventions’ effects on Lyder, 2004 (28) process and patient outcomes. We identified a substan- Moore, 1997 (31) tial volume of relevant publications; the majority of O’Brien, 1998 (33) studies were conducted in the United States. Olson, 1998 (34) Our findings can inform the design of future PU Peich, 2004 (35) prevention programs. The most frequently reported in- Saleh, 2009 (39) tervention strategies (Table 1) comprise a set of “best VanEtten, 1990 (43) practices” or strategies believed to be important ele- Uzun, 2009 (42) ments of PU prevention programs. For the most part, these strategies reflect suggestions from government and professional organizations.6,45,46 A number of novel interventions, such as the redefinition of roles and respon- sibilities15 and the translation of performance data into Difference in PU Incidence graphical displays8 are also described and may serve to stimulate creativity in intervention design. Figure 2. Of the 16 studies reporting data for the outcome PU incidence, the pooled risk Our findings also provide insights into the nature of difference across studies was –.07 (95% confidence interval [CI]: –0.0976, –0.0418; hospital-based, nursing-focused QI activities. Although p < .0001), indicating that overall PU incidence decreased after the interventions. The Bergstrom article is listed twice because it reported two separate studies. the use of one or more core QI techniques—such as assembling a team, performance monitoring, and feedback—was evident in all but one study, the use of other QI low. Nearly all the studies employed a simple before-after study techniques, such as quality collaboratives and PDSA cycles, was design, without adequate control group or control site. This scant. Most striking was our finding that the use of the core QI makes it difficult to assess whether observed changes are due to techniques was often inconsistent with QI methodology. The the intervention or other factors that may have changed over usefulness of audit and feedback, for example, as a means to time. Most studies reported one-time snapshots before and after change provider behavior is empirically documented.47 Among the intervention rather than sampling multiple times to allow the studies in our sample, we noted a frequent disconnect be- for natural variation. tween performance monitoring and the provision of feedback to Nearly all the included studies concluded that the interven- nurse managers/staff. The reason for this disconnect is unclear. tion had a positive effect on at least one nursing process or patient One possible explanation is that the presence of initiatives such health outcome. The pooled analysis showed a small, statistically as the National Database of Nursing Quality Indicators significant decrease in overall PU incidence following the inter- (NDNQI)48 has led to an increased awareness of the importance ventions. There was considerable heterogeneity across studies, so of performance measure collection and monitoring, but the link- the pooled effect should be viewed with caution. In addition, the age to feedback has been lost. The implications of this disconnect effect is based on a before-after design, not a controlled design. should be explored in future research. Our findings suggest that interventions aimed at PU preven- The level of evidence represented by the identified studies is tion may improve patient outcomes by reducing overall inci-

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dence of hospital-acquired PUs. A barrier to implementing these specific intervention strategies. By attending to and document- findings into practice persists because how the interventions ing these details, authors of future studies will advance our achieve intended results remains poorly understood. This prob- understanding of the implementation of PU prevention lem is not new. The heterogeneity of QI interventions in health programs. J care has led to a call for the use of theory-driven evaluation ap- The views expressed in this article are those of the authors and do not necessarily proaches to establish when, how, and why the intervention reflect the position or policy of the Department of Veterans Affairs or the United States government. This project was funded as a Locally Initiated Project through the VA works.49 Reporting process measures and describing the organi- Greater Los Angeles HSR&D Center of Excellence (LIP Project # 65-119). Dr. Soban zational setting of the QI intervention are two elements of this is currently supported by a Career Development Award from the VA HSR&D program (Project # CDA 06-301). The authors thank Roberta Shanman for performing approach. the literature searches; Breanne Johnson and Tracy Yee for assistance in retrieving Most of the studies in our review reported patient outcome articles; Zhen Wang and Cleopatra Aquino for assistance with data extraction; Roger Wasserman for administrative assistance; Marika Suttorp for assistance with the measures; only six studies reported both nursing process and pa- meta-analysis; and Paul Shekelle for comments on an earlier draft of this manuscript. tient outcome measures. This is consistent with the previous literature, which has noted a failure among implementation studies Online-Only Content to measure and report process of care measures.50 Process meas- 8 ures serve to verify the extent to which the intervention was im- See the online version of this article for plemented as planned and can help to clarify why an Appendix 1. Included Studies intervention succeeded or failed.51 Improved reporting of the intended effects of the intervention on both processes of care and patient outcomes will provide valuable insights into the mecha- Lynn M. Soban, R.N., M.P.H., Ph.D., is Research Health Scientist, nisms by which the intervention operated and will aid in under- Department of Veterans Affairs (VA) Greater Los Angeles HSR&D standing the success or failure of specific interventions. Center of Excellence, Sepulveda VA Ambulatory Care Center, VA Greater Los Angeles Healthcare System, Sepulveda, California. Su- Organizational context is a broad, multidimensional concept sanne Hempel, Ph.D., is Behavioral Scientist, RAND, Santa Mon- that includes culture, leadership, and resources.52–54 Organiza- ica, California; Brett A. Munjas, M.S., is Statistical Project Associate; tional context is increasingly recognized as an important influ- and Jeremy Miles, Ph.D., is Behavioral Scientist. Lisa V. Ruben- stein, M.D., M.S.P.H., is Director, VA Greater Los Angeles HSR&D ence on the success or failure of QI interventions. Future Center of Excellence; Professor of Medicine, VA Greater Los Ange- publications describing PU prevention interventions should in- les Healthcare System and the David Geffen School of Medicine, University of California, Los Angeles; and Senior Natural Scientist, clude documentation of the contextual features considered likely RAND. Please address correspondence to Lynn M. Soban, to influence the intervention.55 For example, registered nurse [email protected]. staffing is a contextual feature associated with improved patient outcomes, including lower PU incidence.56 However, whether and how nurse staffing and other features influence the success References of interventions for PU prevention is not known. In addition, 1. Rubenstein L.V., et al.: Finding order in heterogeneity: Types of quality-improvement intervention publications. Qual Saf Health Care 17:403–408, Dec. authors should provide commentary as to how features of the 2008. intervention and the context may have led to the success or fail- 2. Gould D., et al.: Intervention studies to reduce the prevalence and incidence ure of the intervention.55,57 Through improved attention to the of pressure sores: A literature review. J Clin Nurs 9:163–177, Mar. 2000. 3. Tooher R., et al.: Implementation of pressure ulcer guidelines: What consti- reporting of contextual features, we can improve our understand- tutes a successful strategy? J Wound Care 12:373–382, Nov. 2003. ing of which intervention strategies for PU prevention are best- 4. Donabedian A.: The quality of care: How can it be assessed? JAMA suited to which contexts. 260:1743–1748, Sep. 23–30, 1988. 5. NHS Center for Reviews and Dissemination: Undertaking Systematic Reviews of Research on Effectiveness. CRD’s Guidance for those Carrying Out or Commis- CONCLUSION sioning Reviews. CRD Report No. 4. New York: NHS Center for Reviews and Our review provides evidence that QI interventions aimed at Dissemination, Mar. 2001. http://www.medepi.net/meta/guidelines/Overview_ CRD_Guidelines.pdf (last accessed Apr. 19, 2011). PU prevention may reduce overall incidence of hospital-acquired 6. National PU Advisory Panel (NPUAP) and European Pressure Ulcer Advi- PUs. We also identify gaps in the literature that pose barriers to sory Panel (EPUAP): Prevention and Treatment of Pressure Ulcers: Clinical Prac- tice Guideline. Washington, DC: NPUAP, 2009. implementation. One gap is the need for an improved under- 7. Bales I., Padwojski A.: Reaching for the moon: Achieving zero pressure ulcer standing of the mechanisms by which improved outcomes are prevalence. J Wound Care 18:137–144, Apr. 2009. achieved (that is, intervention causal pathways). A second gap is 8. Ballard N., et al.: How our ICU decreased the rate of hospital-acquired pressure ulcers. J Nurs Care Qual 23:92–96, Jan.–Mar. 2008. the role of local conditions (context) in the success or failure of

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Hunter S.M., et al.: The effectiveness of skin care protocols for pressure ul- 48. American Nurses Association: The National Database of Nursing Quality In- cers. Rehabil Nurs 20:250–255, Sep.–Oct. 1995. dicators®. https://www.nursingquality.org/ (last accessed Apr. 15, 2011). 26. Jones S., et al.: A pressure ulcer prevention program. Ostomy Wound Man- 49. Walshe K.: Understanding what works—and why—in quality improve- age 39:33–39, May 1993. ment: The need for theory-driven evaluation. Int J Qual Health Care 19:57–59, 27. LeMaster K.: Reducing incidence and prevalence of hospital-acquired pres- Mar. 2, 2007. sure ulcers at Genesis Medical Center. Jt Comm J Qual Patient Saf 33:611–616, 50. Grol R., Grimshaw J.: Evidence-based implementation of evidence-based Oct. 2007. medicine. Jt Comm J Qual Improv 25:503–513, Oct. 1999. 28. Lyder C.H., et al.: Preventing pressure ulcers in Connecticut hospitals by 51. Hulscher M.E., et al.: Process evaluation on quality improvement interven- using the Plan-Do-Study-Act model of quality improvement. Jt Comm J Qual tions. Qual Saf Health Care 12:40–46, Feb. 2003. Saf 30:205–214, Apr. 2004. 52. Kitson A., et al.: Enabling the implementation of evidence-based practice: 29. McErlean B., et al.: Implementation of a preventative pressure management A conceptual framework. Qual Health Care 7:149–158, Sep. 1998. framework. Primary Intention 10:61–66, May 2002. 53. McCormack B., et al.: Getting evidence into practice: The meaning of ‘con- 30. McInerney J.A.: Reducing hospital-acquired pressure ulcer prevalence text.’ J Adv Nurs 31:94–104, Apr. 2002. through a focused prevention program. Adv Skin Wound Care 21:75–78, Feb. 54. Estabrooks C.A., et al.: Development and assessment of the Alberta Con- 2008. text Tool. BMC Health Serv Res 9:234, Dec. 2009. 31. Moore S.M., Wise L.: Reducing nosocomial pressure ulcers. J Nurs Adm 55. Davidoff F., et al.: Publication guidelines for quality improvement in health 27:28–34, Oct. 1997. care: Evolution of the SQUIRE project. Qual Saf Health Care 17(Suppl 32. Murray M., Blaylock B.: Maintaining effective pressure ulcer prevention 1):i3–i9, Oct. 2008. programs. Medsurg Nurs 3:85–93, Apr. 1994. 56. Kane R., et al., Nursing Staffing and Quality of Patient Care, Evidence Re- 33. O’Brien S.P., et al.: Sequential biannual prevalence studies of pressure ulcers port/Technology Assessment No 151. Rockville, MD: Agency for Healthcare at Allegheny-Hahnemann University Hospital. Ostomy Wound Manage 44(3A Quality and Research, Mar. 2007. http://www.ahrq.gov/clinic/tp/nursesttp.htm Suppl):78S–88S, Mar. 1998. (last accessed Apr. 19, 2011). 34. Olson K., et al.: Preventing pressure sores in oncology patients. Clin Nurs 57. Øvretveit J., Gustafson D.: Using research to inform quality programmes. Res 7 207–224, May 1998. BMJ 326(7392):759–761, Apr. 2003.

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Author Measures Reported Year PT = Patient Outcome Country Brief Description of PRO = Nursing Authors’ Quality Design Setting Intervention Process Effect Months Conclusions Score* Bales7 300-bed community Multifaceted intervention con- 1. Prevalence of U† 16‡ PU prevalence 8 hospital; units not sisting of new support sur- hospital-acquired PUs can be reduced 2009 specified faces, protocol for surgical (entire hospital) (PT) to zero; impor- patients at high risk of pres- tant to success USA sure ulcers (PUs), staff educa- are the involve- tion, performance mon itoring ment of the Before-after and feedback, music played to leadership prompt turning, staff in emer- team, staff in- gency room assess skin, com- volvement in puter tool for assessment and decision mak- initial PU care, certified wound, ing, and a de- ostomy and continence nurse sire to foster (CWOCN) increased hours, interdisciplinary formal recognition and re- relationships. wards.

Ballard8 2 ICUs in same Multifaceted intervention con- 1. Percent patients with U† 18§ A substantial 9 facility: one 26-bed sisting of assembling team, re- nosocomial PU (PT) reduction in PU 2008 ICU with focus on vised existing protocols, rates was trauma, neurosurgi- staff education, weekly per- achieved. The USA cal, general surgical; formance monitoring, in- use of perfor- and an 18-bed med- creased frequency of the mance data Before-after ical ICU Braden Scale, conducting turn and a change rounds every two hours (Q2h), in unit culture use of new skin wipe, new were key to this documentation for skin, success. created database to enhance performance measurement data, and translated data into graphs.

Bergstrom9 Tertiary care hospi- Intervention focused on proto- 1. PU incidence (PT) +|| 44‡ Through the 11 tal; one high-acuity cols for risk assessment, along 2. PU prevalence (PT) +|| 44‡ implementation 1995 medical/surgical unit with preventive interventions of a research- based on level of risk. In addi- based risk as- USA tion, a team was assembled, sessment tool staff education conducted, and prevention Before-after skin care products reviewed, program in- performance monitoring con- formed by ducted, and therapeutic beds assessment managed. findings, PU incidence can be decreased.

(continued on page AP2)

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Author Measures Reported Year PT = Patient Outcome Country Brief Description of PRO = Nursing Authors’ Quality Design Setting Intervention Process Effect Months Conclusions Score* Bergstrom9 240-bed hospital; Implementation of a pub- 1. Incidence of hospital- +|| 12‡ The program 12 units not specified lished guideline, risk assess- acquired PUs (PT) effectively re- 1995 ment tool, and a prevention duced PUs. protocol based on the risk USA assessment results. In addition, a team was assembled, Before-after staff education conducted, and the Braden Scale added to Kardex.

Bethell10 One hospital, Intervention involved con- 1. PU prevalence (PT) U† 16‡ Teamwork was 7 multiple units; units vening a multidisciplinary an important 1994 not specified team, use of a risk assess- aspect of the ment tool, implementation of intervention; USA a protocol, use of a link PU prevalence nurse, and patient education. decreased Before-after more than a quarter.

Bours11 Six acute care Performance monitoring via 1. Case mix-adjusted U† 60§ Monitoring 12 hospitals in the yearly prevalence surveys PU prevalence of (Stage prevalence and 2004 Netherlands; children for 5 years and the provision II or greater) among providing feed- < 13 years of age of feedback to hospitals. patients without a PU on back to hospi- The excluded from admission (PT) tals resulted in Netherlands analysis improvement in PU prevention. Time series

Catania12 A cancer hospital; 5 Multidimensional intervention 1. PU incidence (PT) +|| 21§ Implementation 11 units: 2 medical, 2 consisting of assembling a 2. PU prevalence (PT) +|| 21§ resulted in a 2007 surgical, and the team, use of published greater than critical care unit. guideline to guide interven- 50% decrease USA tion, protocol implementa- in PU preva- tion, staff education, and lence and has Before-after performance monitoring. been main- Clinical nurse specialists tained for more supported the intervention than 2 years. (for example, by helping staff complete forms).

(continued on page AP3)

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Author Measures Reported Year PT = Patient Outcome Country Brief Description of PRO = Nursing Authors’ Quality Design Setting Intervention Process Effect Months Conclusions Score* Charrier13 10 units (not speci- Audit and feedback on PU 1. Protocol present in U† 18‡ 7 of 20 4 fied) in an Italian protocol adherence the department (PRO) processes 2008 hospital 2. Operator knows there U† showed signifi- is a protocol and cant improve- Italy location (PRO) ment in the 3. Braden form present 0# intervention Controlled (PRO) group relative clinical trial 4. (Braden form) com- 0# to the control pletely filled in (PRO) group 5. (Braden form) 0# updated (PRO) 6. (Braden form) filled in 0# for all at-risk patients (PRO) 7. Used change in 0# posture form (PRO) 8. (Change in posture 0# form) completely filled out (PRO) 9. If (change in posture +|| form) not used, patient mobilized? (PRO) 10. Products for –** patient’s posture (PRO) 11. If Braden < 16, anti- 0# decubitus device (PRO) 12. If not, other criteria U† (PRO) 13. Fluid balance form +|| (PRO) 14. Hygiene according +|| to protocol (PRO) 15. Staging of LDP? +|| (PRO) 16. Is it registered? +|| (PRO) 17. Form completely +|| filled in? (PRO) 18. Re-evaluation time +|| respected? (PRO) 19. Medications prac- 0# ticed according to protocol? (PRO) 20. Medication equip- 0# ment always available? (PRO)

(continued on page AP4)

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Author Measures Reported Year PT = Patient Outcome Country Brief Description of PRO = Nursing Authors’ Quality Design Setting Intervention Process Effect Months Conclusions Score* Chicano14 One 25-bed interme- Multifaceted intervention 1. Number of hospital- U† 21‡ PU strategies 8 diate care unit consisting of new protocol to acquired PUs (PT) proved effec- 2009 improve skin assessment & tive in decreas- documentation of risk using ing incidence USA “stop skin alert” stamp, repo- during a 1-year sitioning schedule for at-risk period. The Before-after patients, use of automatic commitment & trigger system that suggests diligence of the interventions for patients with quality im- Braden ≤ 18, performance provement (QI) monitoring, staff education, team & mem- revised policies and practice bers of the standards staff’s self-gov- ernance coun- cils were important factors in achieving this goal.

Courtney15 710-bed, multisite Incorporated Six Sigma prin- 1. Incidence of hospital- U† 30§ Incidence of 10 facility; units not ciples into a multidimen- acquired PUs (PT) PUs decreased 2006 specified sional program consisting of by nearly 70% assembling a team, imple- as a result of USA mentation of a risk assess- intervention; ment tool in the operating the overall cul- Before-after room (OR) and initiation of ture change at care planning in OR, proto- the medical col implementation, pur- center remains chase of pressure-relieving a work in mattresses, conducted Plan- progress. Do-Study Act (PDSA) cycles, staff education, performance monitoring and feedback, designated a champion for each unit, role redefinition, used cues to turn patients, used chart stickers and signs to signal at-risk patients, conducted record review of incident cases, new skin care products

(continued on page AP5)

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Author Year Measures Reported Country Brief Description of PT = Patient Outcome Authors’ Quality Design Setting Intervention PRO = Nursing Process Effect Months Conclusions Score* deLaat16 28-bed adult inten- Implementation of a pub- 1. PU incidence density for +|| 12‡ Implementation 15 sive care department lished guideline that involved grade II–IV (measured as of guideline for 2007 consisting of 4 units: the timely transfer of patients PUs/1,000 pt days) (PT) PU care re- 2 general medical/ to a specific pressure- 2. Median time (days) sulted in signifi- The surgical units; 1 neu- relieving device. A contact until onset of PU Stage II- U† cant and Netherlands rologic unit; 1 cardiac nurse (for each ward) was IV (PT) sustained de- surgical unit. designated and a PU con- 3. PU incidence Stage +|| crease in the Before-after sultant appointed. The II–IV (PT) incidence of intervention was announced 4. Mean PU free time as a +|| Stage II-IV PU via newspaper and intranet. proportion of total length in ICU patients. of stay (PT) 5. % patients who needed +|| a transfer to pressure reducing mattress who were transferred (PRO)

deLaat17 900-bed university Implementation of a pub- 1. % patients with PUs +|| 11 § PU frequency 13 medical center lished guideline combined (Stages I–IV) among pa- can be 2006 with introduction of vis- tients without PU on ad- successfully coelastic foam mattresses. mission but who screened decreased; The A contact nurse was as high risk (PT) introduction of Netherlands designated (for each ward) 2. % patients with PUs +|| adequate and a PU consultant (Stages II–IV) among pa- mattresses and Before-after appointed. The intervention tients without PU on ad- guidelines for was announced via newspa- mission but who screened prevention and per and intranet. as high risk (PT) treatment are 3. % patients with evi- 0# promising dence of a repositioning tools. schedule among at-risk patients with a PU ≥ Stage I (PRO) 4. % patients with no evi- +|| dence of a repositioning schedule nor a proper mattress among at-risk patients/patients with a PU ≥ Stage I (PRO) 5. % patients with evi- +|| dence of either a repositioning schedule or a proper mattress among at-risk patients or those with a PU > Stage I (PRO) 6. % patients with evi- 0# dence of both a repositioning schedule and a proper mattress among at-risk patients or those with a PU > Stage I (PRO) (continued on page AP6)

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Author Year Measures Reported Country Brief Description of PT = Patient Outcome Authors’ Quality Design Setting Intervention PRO = Nursing Process Effect Months Conclusions Score* Dibsie18 Multisite academic Implemented a new practice 1. Hospital-acquired PUs U† 21‡ Implementation 9 medical center; units protocol, conducted ≥ Stage II (entire hospital) of an evidence- 2008 not specified performance monitoring and (PT) based practice provided feedback, standard- 2. Hospital-acquired PUs U† protocol led to USA ized all skin care products, ≥ Stage II (SICU only) improvements and provided staff education (PT) in PU preva- Before-after on new products lence.

Dukich19 2 hospitals (Level 1 Implemented a published 1. PU prevalence, ≥ Stage U† 12‡ A modest de- 6 Trauma Center and guideline and new protocol I (Hospital B) (PT) crease in an- 2001 a tertiary care hospi- for bed selection. In addition, 2. PU prevalence, ≥ Stage U† nual expendi - tal); multiple units at a team was assembled, staff II (Hospital B) (PT) tures for rental USA each site: ICUs and education conducted, mat- 3. Nosocomial PU rate U† support sur- medical/surgical tresses upgraded, and gate- (Stages I-IV), Hospital A faces was real- Before-after units keepers were used to (PT) ized; results for approve and monitor the use 4. Nosocomial PU rate U† incidence and of support surfaces. (Stages II-IV), Hospital A prevalence dif- (PT) fered across hospitals and may be attribut- able to non- standardized documentation tools.

Gibbons20 528-bed hospital in Implemented a comprehen- 1. Facility-acquired U† 14§ The program 8 Florida; all units sive care protocol targeting PUs/1,000 pt days (PT) enabled the 2006 surfaces, patient turning, identification of incontinence management, at-risk popula- USA and nutritional consults. In tions, the im- addition, a team was assem- plementation of Before-after bled, staff education was appropriate conducted, performance actions, and monitoring was used, and the achieve- compression stockings ment of posi- product changed. tive, measura- ble results.

(continued on page AP7)

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Author Year Measures Reported Country Brief Description of PT = Patient Outcome Authors’ Quality Design Setting Intervention PRO = Nursing Process Effect Months Conclusions Score* Gunningberg21 One hospital, 4 There were two groups: 1. PU rates (pre-existing Group 6§ No difference in 11 wards in the depart- Intervention group (I): risk and hospital-acquired) at I vs. C prevalence be- 1999 ment of orthopedics; assessment performed on time of discharge (PT) 0# tween interven- intervention limited to admission, on a daily basis, 2. PU rates (pre-existing Group tion and control Sweden patients with hip frac- at 2 weeks postsurgery and and hospital-acquired) I vs. C groups; use of tures at discharge; use of risk 14 +/– 6 days postsurgery 0# the Modified Controlled alarm sticker for high-risk (PT) Norton Scale study patients; and staff education facilitated the conducted. Control group identification of (C): risk assessment the majority of performed on admission, at patients at risk 2 weeks postsurgery, and at for PUs. discharge; and staff education conducted.

Hiser22 One hospital, 5 units, Multidimensional interven- 1. % patients with PUs 0# 15§ Changes re- 10 including a medical tion: assembled a team to (prevalence) entire sulted in a de- 2006 ICU develop protocols based on hospital (PT) crease in published guidelines, imple- 2. % patients with facility- 0# quarterly hospi- USA mented a new risk assess- acquired PUs entire hos- tal-acquired PU ment tool, created new pital (PT) prevalence in Before-after orders for use in conjunction 3. % patients with PUs 0# participating with verbal orders, estab- (medical ICU) (PT) units. Clinicians lished a skin resource team, 4. % patients with facility- 0# now approach use of dietary consults, con- acquired PUs (medical PUs as pre- ducted staff education, per- ICU) (PT) ventable; over- formance monitoring and all quality of feedback, and purchased care and finan- new support surfaces cial resource utilization are also improved.

Hobbs23 280-bed geriatric Instituted a turn team pro- 1. Average length of stay +|| 6§ Following im- 11 hospital; 4 units: gram consisting of assem- (PT) plementation of 2004 geriatrics, oncology, bling a team, implementation 2. Incidence of nosoco- +|| the turn team surgical postop, and of a new protocol, and staff mial C. difficile (PT) program, pa- USA orthopedics/neurol- education 3. Incidence of nosoco- 0# tient referrals to ogy mial pneumonia (PT) the enteros- Before-after 4. Average number refer- 0# tomal therapy rals (per month) to nurse, average enterostomal therapy length of stay, nurse for PUs ≥ Stage II and muscu- (PRO) loskeletal in- juries to staff all declined.

(continued on page AP8)

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Author Year Measures Reported Country Brief Description of PT = Patient Outcome Authors’ Quality Design Setting Intervention PRO = Nursing Process Effect Months Conclusions Score* Hopkins24 One acute care hos- Multidimensional intervention 1. Hospital-acquired PUs +|| 24‡ Multidimen- 15 pital, adult medical/ consisting of best practices (PT) sional interven- 2000 surgical population; and research-based proto- 2. Severity of hospital-ac- U† tions, as an units not specified cols. A team was assembled; quired PUs (PT) adjunct to best USA a unit skin care resource 3. Ratio of actual to pre- U† practices and person was designated; staff dicted PUs (PT) research-based Before-after education, performance protocols, im- monitoring, and feedback proved nosoco- were conducted; collabo- mial PU rates. rated with respiratory therapy; and made changes to the cervical collar product.

Hunter25 40-bed non-acute re- Developed and implemented 1. PU prevalence 0# 16§ Following im- 13 habilitation hospital protocols based on pub- (Stages I–IV) (PT) plementation of 1995 lished guidelines, used a risk protocols, PU assessment tool, conducted prevalence de- USA performance monitoring, and creased. Health staff education care facilities Before-after can improve the quality of care for PU prevention by establishing a well-structured PU prevention/ treatment program.

Jones26 350-bed community PU prevention program with 1. PU prevalence (Stages 0# 5§ Overall de- 13 hospital. All patients many components: use of a I–IV) (PT) crease in PU 1993 on oncology, med- risk assessment tool, imple- 2. PU prevalence (Stages 0# incidence was ical, surgical, ICU, mentation of a prevention II–IV) (PT) found and the USA intermediate care protocol, designation of a 3. PU incidence (PT) 0# documentation units, and high-risk clinical resource person, 4. % patients with nursing U† of PUs im- Before-after pediatric patients selection of new pressure- diagnosis of impaired skin proved. Educa- relieving products, institution integrity on problem list tion of nursing of an approval process for among patients with pre- staff is a key cost containment of rental existing PUs (PRO) component of charges, and nursing staff 5. % patients who had U† PU prevention. education admission risk factor assessments completed (PRO)

(continued on page AP9)

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Author Year Measures Reported Country Brief Description of PT = Patient Outcome Authors’ Quality Design Setting Intervention PRO = Nursing Process Effect Months Conclusions Score* LeMaster27 502-bed hospital; 2 Multidimensional intervention 1. Prevalence of hospital- U† 12§ The interven- 9 units: pulmonary and consisting of implementation acquired PUs (Unit A) tion was suc- 2007 oncology of a protocol (turn patients (PT) U† cessful and Q2h, elevate bony promi- 2. Prevalence of hospital- was replicated USA nences, use pressure over- acquired PUs (Unit B) throughout the lays on beds) based on a (PT) facility. Before-after published guideline. Visual reminders of the protocol were placed in rooms. In addition, a team was assembled, a risk assessment tool was used, and staff education conducted.

Lyder28 17 hospitals in the A quality collaborative format 1. Admission PU that pro- 0# Not Found clinically 14 state of Connecticut; that included Quality Im- gressed to > Stage II (PT) clear and statistically 2004 hospital sizes ranged provement Organization 2. Hospital-acquired 0# significant im- from 200 to 800 (QIO) audit, and assembling Stage I PU (PT) provements in USA beds. teams to conduct PDSA cy- 3. Hospital-acquired PU, 0# 4 PU preven- cles. The nature of the inter- > Stage II (PT) tion-related Before-after ventions varied across 4. Hospital-acquired PU, 0# processes of hospitals. The most com- any stage (PT) care concurrent monly tested interventions 5. Pt median length of +|| with multi- were: Identifying patients at stay (days) (PT) faceted high risk for PUs, increasing 6. In-hospital mortality (PT) 0# improvement scheduled repositioning, or- 7. 30-day mortality (PT) 0# intervention. dering nutritional consults, 8. Identification of high- +|| and improving the accuracy risk patients within 2 days of staging of PUs. Results of hospital admission were shared on phone calls (PRO) and at conferences. 9. Use of pressure- 0# relieving device in bed- or chair-bound patients (PRO) 10. Daily skin assessment 0# among high-risk patients (PRO) 11. Repositioning every 2 +|| hours for bed-bound patients or every hour for chair-bound patients (PRO) 12. Nutritional consults for +|| malnourished patients (PRO) 13. Staging of acquired 0# Stage I PUs (PRO) 14. Staging of acquired +|| Stage II PUs (PRO) (continued on page AP10)

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Author Year Measures Reported Country Brief Description of PT = Patient Outcome Authors’ Quality Design Setting Intervention PRO = Nursing Process Effect Months Conclusions Score* McErlean29 250-bed hospital; Implemented a framework 1. PU incidence (all U† 12‡ Both the identi- 10 units not specified for identifying patients at risk stages) (PT) fication of pa- 2002 for PUs by using a risk as- 2. % of hospital-acquired U† tient risk at sessment tool and communi- Stage I PUs (PT) admission and Australia cating risk. Intervention 3. % of hospital-acquired U† the implemen- included assembling a team, Stage II PUs (PT) tation of appro- Before-after unit manger education, and 4. % of hospital-acquired U† priate pre- implementing a care plan Stage III PUs (PT) ventive inter- that links prevention strate- 5. % of hospital-acquired U† ventions have gies to specific risks Stage IV PUs (PT) increased; this has resulted in a reduction in the incidence and severity of PUs.

McInerney30 548-bed, 2-hospital Multidimensional intervention 1. Overall hospital- U† 59§ The hospital 10 system; all patients consisting of: assembled an acquired prevalence (PT) system was 2008 except obstetrics and interdisciplinary team, used able to reduce mental health a risk assessment tool in hospital-ac- USA conjunction with automatic quired PU consults, implemented a pro- prevalence by Before-after tocol, used electronic med- 81%. The re- ical records for nurse sultant cost charting and order entry, and savings, in ad- hired of an additional wound dition to the care nurse who is responsi- elimination of ble for entering pressure patients’ pain relief orders. and suffering from PUs, can significantly impact the cost and quality of care.

Moore31 500+ bed university Multidimensional intervention 1. PU prevalence (PT) +|| 19§ A systematic 11 hospital, units not consisting of: assembled a 2. Nosocomial PUs (PT) +|| approach to 1997 specified team, implemented a new change, includ- protocol, used a risk assessing a more USA ment tool, conducted staff comprehensive education, implemented a theory, will Before-after PU hotline, installed new guide leaders pressure-relieving mat- in promoting tresses, conducted perfor - change. mance monitoring and feedback. Clinical nurse specialist visits 2x/month to reinforce nurses’ knowledge.

(continued on page AP11)

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Author Year Measures Reported Country Brief Description of PT = Patient Outcome Authors’ Quality Design Setting Intervention PRO = Nursing Process Effect Months Conclusions Score* Murray32 One hospital: Multidimensional PU preven- 1. PU prevalence (PT) U† 28§ PU prevention 13 medical/surgical and tion program consisting of 2. PU incidence ≥ Stage I U† programs 1994 intensive care units the use of a risk assessment (PT) should include only tool and protocol, conducted a risk assess- USA performance monitoring, and ment tool, pro- provided staff education. tocols for PU Before-after prevention, staff education and a means to evalu- ate outcomes.

|| O’Brien33 750-bed university Systemwide educational in- 1. PU prevalence (all stages) + 48‡ Systemwide 15 (PT) hospital; all patients tervention targeting all levels || educational ef- 2. Prevalence of hospital-ac- + 1998 except psychiatric, of patient care providers and quired PUs (all stages) (PT) forts that in- labor and delivery, multispecialty care. The 3. Prevalence (overall) of PUs 0# clude all levels USA postpartum, and intervention included per- Stages II-IV (PT) of professionals 4. Prevalence of hospital- +|| newborn nursery. formance monitoring and acquired PUs (Stages II–IV) and multispe- Before-after feedback, the purchase of (PT) cialty preven- pressure-relieving beds, and 5. % patients with PUs 0# tion and care the use of new flow sheets. (≥ Stage II) who received efforts can lead nutritional consult (PRO) 6. % patients with PUs (≥ +|| to a reduction Stage I) with albumin level in PU preva- ordered (PRO) lence. 7. % patients with PUs (≥ 0# Stage I) who had a skin assessment upon admission completed (PRO) 8. % patients with PUs (≥ 0# Stage I) who had a skin assessment upon admission (PRO) 9. % patients with PUs (≥ 0# Stage I) for whom it was unknown whether a skin assessment upon admission was completed adequately or not (PRO) 10. % patients with PUs 0# (Stages II–IV) with adequate documentation (skin assessment within 24 hrs of admission & wkly thereafter) (PRO) 11. % patients with PUs –** (Stages II–IV) with inadequate documentation of either admission skin assessment or reassessment (PRO) 12. % patients with PUs 0# (Stages II–IV) with no documentation of either admission skin assessment or reassessment was absent (PRO) 13. % patients with PUs (≥ +|| Stage I) who were placed on a specialized mattress or bed (PRO) (continued on page AP12)

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Author Year Measures Reported Country Brief Description of PT = Patient Outcome Authors’ Quality Design Setting Intervention PRO = Nursing Process Effect Months Conclusions Score* Olson34 One cancer hospital, Implemented a published 1. % patients who devel- 0# Not The Braden 11 2 units guideline and prevention oped PU in hospital, clear Scale has been 1998 protocol consisting of daily excluding those present permanently in- skin evaluation, patient edu- on admission (PT) corporated into Canada cation, use of moisturizers the daily chart- and barrier creams, reposi- ing forms. It is Before-after tioning and decreasing fric- now possible to tion and shear, and nutrition track the de- consults. Charting was al- gree to which tered to ensure consistent the scale and documentation of PU risk. prevention protocol are used through the quarterly chart audits.

Peich35 300-bed teaching Implemented new care 1. % of nosocomial PUs +|| 28§ PU prevention 12 hospital; orthopedic protocols, a risk assessment among hip fracture in patients with 2004 unit and recovery tool, and viscoelastic patients (PT) hip fractures is room; intervention mattresses. feasible. An Israel limited to patients increased with hip fractures awareness of Before-after the problem among hospital staff may be important.

Pokorny36 One hospital; 2 units: Implemented a skin care in- 1. PU prevalence (PT) U† Not The develop- 12 cardiac surgery ICU tervention protocol consist- clear ment and 2003 and cardiac surgery ing of a risk assessment tool progress of intermediate care and risk staging, a skin care PUs can be al- USA unit. Intervention lim- checklist, and interventions tered by nurs- ited to patients un- tailored to stage of break- ing care. PU Before-after dergoing elective down. Patients with Braden risk can only open heart surgery. Score < 16 and/or a PU ≥ be predicted Stage II receive entero - through stomal therapy nurse repeated consults. Conducted both assessments staff education and patient throughout education. hospitalization.

(continued on page AP13)

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Author Year Measures Reported Country Brief Description of PT = Patient Outcome Authors’ Quality Design Setting Intervention PRO = Nursing Process Effect Months Conclusions Score* Rashotte37 10-bed pediatric ICU Multifaceted intervention 1. Median number of risk U† 6§ Significant 6 consisting of protocols for assessments evident in changes in 2008 assessing risk of PUs, re- nursing documentation nursing best vised documentation, staff (PRO) practice guide- Canada education, a unit-based 2. Median number of evi- U† lines were champion, increased visibil- denced-based nursing found, which Before-after ity of the wound and skin practices documented highlights the specialist, development of (PRO) complexities of hospital standards of care for 3. Median number of dieti- U† changing prac- PU prevention. tian consults completed tice. Contextual (PRO) influences such 4. Median number of nu- U† as teamwork tritional assessments and resources completed (PRO) may inform 5. Median number of U† results. pressure-relieving surfaces in use (PRO) 6. Median number of lift- U† ing devices in use for patients > 20kg (PRO) 7. Median number of pa- U† tient turning/repositioning schedules documented per chart or Kardex (PRO) 8. Median number of U† transparent dressings, liquid films and elbow/heel protectors used to prevention friction injury (PRO) U† 9. Median number of patients with head and bed elevated to < 30 degrees (PRO) U† 10. Median number of consultations with skin- care expert (PRO)

(continued on page AP14)

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Appendix 1. Included Studies (continued)

Author Year Measures Reported Country Brief Description of PT = Patient Outcome Authors’ Quality Design Setting Intervention PRO = Nursing Process Effect Months Conclusions Score* Sacharok38 300-bed acute care, Multidimensional intervention 1. Prevalence of U† 47§ Implementation 11 community hospital; consisting of: assembled a nosocomial PUs (PT) of a total quality 1998 several units: adult team, implemented a proto- management medical, surgical, col, used a risk assessment model resulted USA critical care, and tool, conducted PDSA in an 83% re- later emergency cycles, designated a skin duction in PU Before-after room care resource person and a prevalence. nursing unit representative, conducted staff education, performance monitoring and feedback. Nursing care flow sheet was redesigned and moved to bedside, several staffing changes (for example, staggering staff meal- times).

Saleh39 One hospital, 9 units Three intervention groups: 1. Nosocomial PU inci- Group 13‡ There were no 10 Group A: (1) mandatory dence within 8 wks of A vs. differences in 2009 wound care management admission (PT) C PU incidence in study day, (2) PU prevention 0# the groups that UK training program and training received addi- on Braden Scale, (3) imple- Group tional training. Controlled mentation of Braden Scale. B vs. Clinical judg- clinical trial Group B: (1) mandatory C ment may be wound care management 0# as effective as study day, (2) PU prevention employing a training program and training risk assess- on Braden Scale (but Braden ment scale to Scale not required). Group assess risk for C: (1) mandatory wound PUs. care management study day only.

Stier40, Health care system The program emphasized 1. Nosocomial PU U† Not The sustained 12 in eastern U.S.; units systemwide changes in ad- incidence (PT) clear success of the 2004 not specified ministration and coordination program is at- of resources consisting of tributed to (1) a USA assembling a team; imple- reliable and mentation of a protocol, use valid measure- Before-after of a risk assessment tool, ment system review of skin care product that facilitates line, staff education; perfor - performance mance monitoring and feed- assessment back directed to quality staff. and evaluation; and (2) ongoing unit educational activities.

(continued on page AP15)

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Appendix 1. Included Studies (continued)

Author Year Measures Reported Country Brief Description of PT = Patient Outcome Authors’ Quality Design Setting Intervention PRO = Nursing Process Effect Months Conclusions Score* Stoelting41 Large teaching Three-pronged approach: 1. PU incidence (PT) U† Not An intervention 7 hospital; units not use of a PU tracking form, clear targeting 2007 specified identification of champions, awareness and and individual case analysis communication USA of hospital-acquired PUs. In regarding PUs addition, staff education and resulted in Before-after feedback were provided. more complete adherence to the nursing prevention protocol.

Uzun42 880-bed acute care Education program for new 1. Incidence of Stage II +|| 35§ An education 13 university hospital; protocol that included imple- PUs among patients with- program and 2009 ICU areas only: 2 mentation of a risk assess- out PUs on admission implementation general medical/ ment scale and use of (PUs/100 patient days) of preventive Turkey surgical ICUs; prevention protocol for high- (PT) nursing inter- 1 neurosurgical ICU; risk patients. Protocol in- ventions were Before-after 1 postanesthesia cluded repositioning Q2h, effective in de- care unit daily skin inspection, daily creasing PU in- skin care, and use of pres- cidence in ICU sure-redistribution devices. patients.

Van Etten43 One hospital, 3 high- Multidimensional intervention 1. % patients with +|| 6§ The program 11 risk care areas: (1) consisting of assembled a hospital-acquired PUs appeared to be 1990 cardiovascular criti- team, implemented a pub- (PT) successful, as cal care, (2) orthope- lished guideline and care evidenced by a USA dics, (3) acute protocol, used a risk assess- decrease in neurointensive care ment tool, made skin care nosocomial PU Before-after products readily available on rates. Findings the unit, and provided staff underscore the education. importance of identifying patient risk for PUs and following through with a plan for prevention and treatment.

(continued on page AP16)

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Appendix 1. Included Studies (continued)

Author Year Measures Reported Country Brief Description of PT = Patient Outcome Authors’ Quality Design Setting Intervention PRO = Nursing Process Effect Months Conclusions Score* Willson44 One hospital, Modification of hospital infor- 1. PU incidence (PT) U† 6§ Preliminary 8 4 medical/surgical mation system to support cli- results indicate 1995 units nicians in new protocols that modifica- using clinical reminders. tions to a hos- USA In addition, a team was pital’s informa- assembled, a published tion system can Before-after guideline implemented, and support staff in a risk assessment tool was following new used. protocols and can lead to a decrease in PU incidence.

* The sum of eight elements each scored on a 3-point scale (0 = feature clearly absent to 2 = feature clearly present). The lowest score possible is 0, the highest possible score is 16; a higher score indicates better quality.

† “U” indicates the effect could not be determined because p values were not reported and could not be computed from data presented.

‡ Number of months between the baseline and final measure reported.

§ Number of months elapsed since intervention ended and final measure reported.

|| “+” indicates improvement at the p ≤ .05 level.

# “0” indicates no statistically significant change p > .05.

** “–” indicates worsening at the p ≤ .05 level.

AP16 June 2011 Volume 37 Number 6