performance improvement preventing pressure ulcers in … · 2011-09-30 · performance improvement...

245June 2011 Volume 37 Number 6

The Joint Commission Journal on Quality and Patient Safety

Lynn M Soban RN MPH PhD Susanne Hempel MA PhD Brett A Munjas MS Jeremy Miles PhD Lisa V Rubenstein MD MSPH

Pressure ulcers (PUs) are a common costly and potentiallypreventable condition Since the 1990s governmental agen-

cies and professional organizations have published clinical prac-tice guidelines for PU prevention However translating theseguidelines to the bedside continues to be a challenge Increas-ingly health care organizations are deploying interventions toimprove PU prevention yet there is little evidence about whichof these interventions can be successfully implemented in routinecare settings through quality improvement (QI) Accordinglywe sought to identify and characterize nursing-focused QI in-terventions for inpatient PU prevention

Literature synthesis to identify the features and outcomes ofQI intervention studies can yield important information aboutwhat approaches to consider when aiming to achieve specific QIgoals1 Previous literature syntheses on PU prevention have in-cluded articles from multiple settings but have not focusedspecifically on QI For example Gould et al (2000) who ex-amined hospital and community interventions for PU preven-tion in the United Kingdom concluded that the evidence basefor PU preventive interventions is sparse2 Tooher et al (2003)reviewing studies of successful PU guideline implementationacross health care settings concluded that active as compared topassive strategies were associated with better outcomes and thatthe relative effectiveness of strategies could not be determined3

We know of no other literature syntheses targeting inpatientnursing QI interventions

QI interventions in health care organizations address struc-tural andor process changes as defined in the Donabedianframework4 We identified studies of structural features relevantto PU prevention (for example implementation of care proto-cols wound care teams) and examined their effects on processesof care (for example percentage of patients who received PUscreening within 24 hours of admission) andor patient out-comes (for example PU incidence) The objectives of this re-view were to (1) describe the kinds of intervention strategiesused (2) describe the types of process and outcome measures

Performance Improvement

Preventing Pressure Ulcers in Hospitals A Systematic Review ofNurse-Focused Quality Improvement Interventions

Article-at-a-Glance

Background A systematic review of the literature onnurse-focused interventions conducted in the hospital set-ting informs the evidence base for implementation of pres-sure ulcer (PU) prevention programs Despite the availabilityof published guidelines there is little evidence about whichinterventions can be successfully integrated into routine carethrough quality improvement (QI) The two previous liter-ature syntheses on PU prevention have included articlesfrom multiple settings but have not focused specifically onQIMethods A search of six electronic databases for publica-tions from January 1990 to September 2009 was conductedTrial registries and bibliographies of retrieved studies and re-views and Internet sites of funding agencies were alsosearched Using standardized forms two independent re-viewers screened publications for eligibility into the sampledata were abstracted and study quality was assessed for thosethat passed screening Findings Thirty-nine studies met the inclusion criteriaMost of them used a before-and-after study design in a sin-gle site Intervention strategies included PU-specific changesin combination with educational andor QI strategies Moststudies reported patient outcome measures while fewer re-ported nursing process of care measures For nearly all thestudies the authors concluded that the intervention had apositive effect The pooled risk difference for developing PUswas ndash07 (95 confidence interval [CI] ndash00976 ndash00418)comparing the pre- and postintervention statusConclusion Future research can build the evidence basefor implementation through an increased emphasis on un-derstanding the mechanisms by which improved outcomesare achieved and describing the conditions under which spe-cific intervention strategies are likely to succeed or fail

Copyright 2011 copy The Joint Commission

246 June 2011 Volume 37 Number 6


reported and (3) examine the interventionsrsquo effects on outcomes

MethodsSEARCH METHODS

We searched six electronic databases (PubMed the CumulativeIndex to Nursing and Allied Health Literature [CINAHL] theCochrane Library of Systematic Reviews the Cochrane CentralRegister of Controlled Trials [CENTRAL] the Database of Ab-stracts and Reviews of Effect [DARE] and the Web of Science)for English-language publications from January 1990 to September 2009 We also searched the Effective Practice andOrganization of Care (EPOC) Cochrane Group and theCochrane Wound Group register and Web sites of two agen-ciesmdashthe Robert Wood Johnson Foundation and the USAgency for Healthcare Research and Qualitymdashthat fund QI in-terventions Bibliographies of included studies and pertinent re-views were also screened Sidebar 1 (right) shows the PubMedsearch strategy which was adapted accordingly for the otherdatabases

ARTICLE SCREENING

Two independent reviewers [LMS SH] screened titles andabstracts from the initial search We included studies publishedin English after 1990 Papers selected as potentially relevant byeither reviewer underwent a full paper screening using the fol-lowing criteria

Setting (hospital) Use of an experimental study design (that is randomized

controlled trials controlled clinical trials cohort studies timeseries and pre-post studies [controlled and uncontrolled]

Testing of a QI intervention designed to change routinecare for PU prevention

Presence of data for at least one nursing process or patientoutcome measure

We excluded studies focusing solely on educational interven-tions that were not accompanied by other interventions We alsoexcluded studies focusing on wound care and those that focusedon site-specific (for example cervical and heel) PUs We resolvedreviewer disagreements about eligibility into the final samplethrough discussion

DATA ABSTRACTION

All studies meeting the inclusion criteria were abstracted induplicate by three reviewers [including LMS] We used an ab-straction tool that included setting study design interventionstrategies results and authorsrsquo conclusions We extracted all de-

scribed interventions with particular emphasis on the followingelements

Team assembled Guideline implemented Protocol developedimplemented Risk assessment tool Iterative (Plan-Do-Study-Act [PDSA]) cycles Staff education LinkResource nurse Performance monitoring FeedbackWe abstracted data on measures of both processes of care and

patient outcomes specifically values prior to the intervention

The following search strategy was used in PubMed

pressure ulcer[mh] OR pressure ulcer OR decubitus ulcer OR

pressure sore OR bed sore OR bedsore

AND

nursing homes OR nursing OR nurses OR nurse

AND

(prevention and control) OR prevent[tiab] OR quality assurance

health care OR total quality management OR practice guidelines as

topic OR quality indicators health care OR quality[tiab] OR reduc-

tion OR reduce OR prophylactic

AND

before-after OR pre-post OR randomized controlled trial[pt] OR

randomized controlled trials OR rct OR random allocation OR con-

trolled clinical trial[pt] OR controlled clinical trials OR research de-

sign OR evaluation studies OR followup studies OR follow-up

studies OR follow up studies OR prospective OR longitudinal OR

cohort OR compar OR random OR evaluative OR trial OR case

control OR (economic AND model) OR (economics AND models)

OR (economic AND modeling) OR (economic AND modelling) OR

evaluat[ti] OR effect[ti] OR differen[ti] OR impact[ti] OR experi-

ment OR quasi-experiment OR quasi experiment OR test OR

statistically significant OR odds ratio OR relative risk OR chi

square

AND

evaluation studies as topic OR outcome and process assessment

(health care) OR nursing assessment OR assess[tiab] OR health

plan implementation OR structural change OR organizational

change OR (quality AND improv) OR test OR tests OR testing OR

interven OR ((change OR changes OR changing) AND (structur

OR organization))

OR initiative OR strategy OR program OR collaborative OR de-

clin

NOT

case report OR case study OR case studies

The complete search strategy can be obtained by request from the

authors

Sidebar 1 PubMed Search Strategy




and following the intervention sample sizes length of study fol-low-up and results of tests for statistical significance For eachstudy we compared two independently prepared abstractions forconsistency and resolved discrepancies through discussion Weconsidered multiple publications on the same project during dataabstraction and informed details on the interventions and out-comes but entered the study into the analysis only once

META-ANALYSIS

We performed a random effects meta-analysis of studies thatreported a measure of PU incidence Only studies that reportedPU incidence (or nosocomial PU prevalence) along with thesample sizes were pooled For studies with multiple data pointsthe data point immediately prior to the intervention implemen-tation and the last data point reported were used All analyseswere conducted using Stata 92 (Stata Statistical Software Re-lease 9 StataCorp LP College Station Texas)

QUALITY APPRAISAL

We appraised the quality of each study using criteria based inpart on those published by the Center for Reviews and Dissem-ination (CRD)5 We considered eight areas in judging article qual-ity clarity of intervention description statement of inclusion

criteria adequacy of sample size the use of objective criteria forassessing skin integrity (for example the European Pressure UlcerClassification System6) whether the intervention was appliedevenly across all groups in the study the length of follow-up thetypes of outcomes measured and the clarity with which analysisand results were reported We graded each item on a 3-point scale(0 = feature clearly absent to 2 = feature clearly present) The eightelements were summed for each paper such that the lowest scorepossible was 0 and the highest possible score was 16

FindingsSTUDY FLOW

The search of the electronic databases and hand searches of bib-liographies yielded 1646 records The study flow is shown inFigure 1 (above) We assessed full paper copies of 314 publica-tion records for inclusion and exclusion criteria and to identifyfurther relevant research articles

The most common reason for exclusion was ineligible studydesign (n = 135) within this group the use of during-after studydesigns was common (for example contaminated baseline QIintervention has already started when data are collected) Thirty-nine studies met the inclusion criteria7mdash44 Details of the includedstudies are shown in Appendix 1 (available in online article)

Study Flow Diagram

Figure 1 The search of the electronic databases and hand searches of bibliographies yielded 1646 records Assessment of full paper copies of 314 publication recordsfor inclusion and exclusion criteria and for identification of additional relevant research articles Thirty-eight papers (39 studies) met the inclusion criteria




STUDY DESIGN AND SETTING

The 39 studies represent nine different countries UnitedStates (n = 27) Australia (n = 1) the United Kingdom (n = 2)the Netherlands (n = 3) Israel (n = 1) Sweden (n = 1) Canada(n = 2) Turkey (n =1 ) and Italy (n = 1) The study settings var-ied and included multihospital studies (n = 5) single hospitalstudies with multiple units (n = 31) and a few one-unit studies(n = 3) Most of the studies used an uncontrolled before-afterdesign with four exceptions one time series11 and three con-trolled trials132139

INTERVENTION STRATEGIES

The majority of studies used multiple intervention strategiesincluding PU-specific changes (for example use of risk assess-ments) in combination with educational andor QI strategies(for example performance measurement) Table 1 (above) showsthe most frequently reported intervention strategies Examples ofother strategies employed less frequently included changes tonursing documentation consultations with skin care experts (forexample enterostomal therapy [ET] nurses) and various re-minders (for example signs stickers music) indicating eitherpatient risk andor the need for repositioning

Considerable variation existed among the studies in terms ofoperational implementation of strategies For example strate-gies for nursing staff education ranged from simple one-timeevents (for example distribution of written materials in-servicetraining) to more complex and ongoing activities (for examplemonthly teaching rounds incorporating PU prevention intonew staff orientation) Some papers described using multiple ed-ucational activities others described fewer or those more narrowin scope Performance monitoring varied considerably Of the20 studies that used performance measurement almost half (n

= 9) collected data at least quarterly and half (n = 10) collecteddata less than quarterly (that is every 6 to 12 months)

We noted patterns among the combinations of interventionstrategies implemented Among the 29 studies where a protocolchange was implemented 8 studies implemented a protocolchange in conjunction with the adoption of a risk assessmenttool92530 3236404344 and 10 studies implemented a protocol changealong with a risk assessment tool and changes in support sur-faces9101522262731353842

In contrast performance monitoring and feedbackmdashcore QIstrategies that are generally used together as a means to reinforceawareness and adherence to QI interventionsmdashwere frequentlynot used together Among the 20 studies where performancemonitoring was used fewer than half (n = 9) coupled perfor -mance monitoring with the provision of feedback to nurse man-agers or nursing staff71315182224313338

MEASURES REPORTED

Some 31 studies reported only patient outcome measuressuch as PU incidence and 2 studies1337 reported only process ofcare measures such as the percent of patients who received a skinrisk assessment within 24 hours of admission The remaining 6studies reported both patient outcome and nursing process ofcare measures161723262833

Most studies reported a patient outcome measure that re-flected PU incidence However there was inconsistency acrossthe papers in definitions of this measure including differences inthe stages included in the measure (that is all stages versus StagesII-IV) and differences in measure computation (for examplePUs per 100 or 1000 patient days) Across the studies theprocess of care measures reported were heterogeneous there wereno patterns in these measures

Intervention Component Definition Frequency

Protocol developedimplemented Implementation of protocol-based care 29

Staff education Use of written didactic or other means to improve nursesrsquo 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

Bedssupport 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 andor nursing staff with the goal of creating

awareness of intervention progress 10

Linkresource nurse Identification of nursing unit staff member(s) to receive additional training with roles

such as information sharing 9

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


QUALITY

The quality of the studies was assessed using a quality scorecomposed of eight items each scored 0 1 or 2 (low mediumhigh) The eight elements were summed for each paper such thatthe lowest score possible was 0 and the highest possible score was16 The frequencies of quality score components and definitionsof quality criteria are shown in Table 2 (above)

The mean quality score was 105 (minimum 4 maximum15) The individual components with the overall highest levelsof quality were (1) the consistency with which the intervention

was applied across groups and (2) the clarity of the interventiondescription The individual components with the overall lowestlevels of quality were (1) the clarity with which inclusion crite-ria were stated and (2) types of measures reported (that isprocess of care measures patient outcome measures)

EFFECT OF THE INTERVENTIONS ON OUTCOMES

Nearly all the authorsrsquo conclusions stated an effect of the in-tervention on at least one nursing process or patient health out-come measure in the intended direction (3639) as outlined in



(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 (ge 30 observations)

1 Unsure or sample size not stated or 19 19 1

inconsistent sample sizes

0 Small sample (lt 30 observations)

2 Clarity of intervention description 2 Very clear

1 Somewhatmostly 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 ge 12 months

follow-up (number of months 1 ge 6 months but lt 12 months 22 15 2

between intervention deployment since or unclear

and outcomes reported) 0 lt 6 months

5 Clarity of inclusion criteria 2 Inclusionexclusion criteria are

clearly stated

1 Unclear (ie incomplete description 18 2 19

of inclusion criteria)

0 No inclusionexclusion 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

(ie 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 amp not computable

0 Very unclear and results doubtful

Table 2 Quality Criteria Definitions and Frequencies of Score Components



Appendix 1 Of the 16 studies reporting data for the outcome PU incidence the pooled risk differenceacross studies was ndash07 (95 confidence interval[CI] ndash00976 ndash00418 p lt 0001) indicating thatoverall PU incidence decreased after the interventions(Figure 2 right) There was evidence of statistical het-erogeneity across studies (I-squared = 697)

DiscussionThis study aimed to describe the literature on hospitalPU prevention in terms of the intervention strategiesused the types of nursing process and patient outcomemeasures reported and the interventionsrsquo effects onprocess and patient outcomes We identified a substan-tial volume of relevant publications the majority ofstudies were conducted in the United States

Our findings can inform the design of future PUprevention programs The most frequently reported in-tervention strategies (Table 1) comprise a set of ldquobestpracticesrdquo or strategies believed to be important ele-ments of PU prevention programs For the most partthese strategies reflect suggestions from government andprofessional organizations64546 A number of novel in-terventions such as the redefinition of roles and respon-sibilities15 and the translation of performance data intographical displays8 are also described and may serve tostimulate creativity in intervention design

Our findings also provide insights into the nature ofhospital-based nursing-focused QI activities Althoughthe use of one or more core QI techniquesmdashsuch as as-sembling a team perfor mance monitoring and feed-backmdashwas evident in all but one study the use of other QItechniques such as quality collaboratives and PDSA cycles wasscant Most striking was our finding that the use of the core QItechniques was often inconsistent with QI methodology Theusefulness of audit and feedback for example as a means tochange provider behavior is empirically documented47 Amongthe studies in our sample we noted a frequent disconnect be-tween performance monitoring and the provision of feedback tonurse managersstaff The reason for this disconnect is unclearOne possible explanation is that the presence of initiatives suchas the National Database of Nursing Quality Indicators(NDNQI)48 has led to an increased awareness of the importanceof performance measure collection and monitoring but the link-age to feedback has been lost The implications of this disconnectshould be explored in future research

The level of evidence represented by the identified studies is

low Nearly all the studies employed a simple before-after studydesign without adequate control group or control site Thismakes it difficult to assess whether observed changes are due tothe intervention or other factors that may have changed overtime Most studies reported one-time snapshots before and afterthe intervention rather than sampling multiple times to allowfor natural variation

Nearly all the included studies concluded that the interven-tion had a positive effect on at least one nursing process or patienthealth outcome The pooled analysis showed a small statisticallysignificant decrease in overall PU incidence following the inter-ventions There was considerable heterogeneity across studies sothe pooled effect should be viewed with caution In addition theeffect is based on a before-after design not a controlled design

Our findings suggest that interventions aimed at PU preven-tion may improve patient outcomes by reducing overall inci-


Figure 2 Of the 16 studies reporting data for the outcome PU incidence the pooled riskdifference across studies was ndash07 (95 confidence interval [CI] ndash00976 ndash00418 p lt 0001) indicating that overall PU incidence decreased after the interventions TheBergstrom article is listed twice because it reported two separate studies

Results of Pooled Data Analysis for Studies Reporting the Outcome Pressure Ulcer

(PU) Incidence (n = 16)

Bergstrom 1995 (9)

Bergstrom 1995 (9)

Catania 2007 (12)

DeLaat 2007 (16)

DeLaat 2006 (17)

Hiser 2006 (22)

Hopkins 2000 (24)

Jones 1993 (26)

Lyder 2004 (28)

Moore 1997 (31)

OrsquoBrien 1998 (33)

Olson 1998 (34)

Peich 2004 (35)

Saleh 2009 (39)

VanEtten 1990 (43)

Uzun 2009 (42)

Difference in PU Incidence




dence of hospital-acquired PUs A barrier to implementing thesefindings into practice persists because how the interventionsachieve intended results remains poorly understood This prob-lem is not new The heterogeneity of QI interventions in healthcare has led to a call for the use of theory-driven evaluation ap-proaches to establish when how and why the interventionworks49 Reporting process measures and describing the organi-zational setting of the QI intervention are two elements of thisapproach

Most of the studies in our review reported patient outcomemeasures only six studies reported both nursing process and pa-tient outcome measures This is consistent with the previous lit-erature which has noted a failure among implementation studiesto measure and report process of care measures50 Process meas-ures serve to verify the extent to which the intervention was im-plemented as planned and can help to clarify why anintervention succeeded or failed51 Improved reporting of the in-tended effects of the intervention on both processes of care andpatient outcomes will provide valuable insights into the mecha-nisms by which the intervention operated and will aid in under-standing the success or failure of specific interventions

Organizational context is a broad multidimensional conceptthat includes culture leadership and resources52ndash54 Organiza-tional context is increasingly recognized as an important influ-ence on the success or failure of QI interventions Futurepublications describing PU prevention interventions should in-clude documentation of the contextual features considered likelyto influence the intervention55 For example registered nursestaffing is a contextual feature associated with improved patientoutcomes including lower PU incidence56 However whetherand how nurse staffing and other features influence the successof interventions for PU prevention is not known In additionauthors should provide commentary as to how features of theintervention and the context may have led to the success or fail-ure of the intervention5557 Through improved attention to thereporting of contextual features we can improve our understand-ing of which intervention strategies for PU prevention are best-suited to which contexts

CONCLUSION

Our review provides evidence that QI interventions aimed atPU prevention may reduce overall incidence of hospital-acquiredPUs We also identify gaps in the literature that pose barriers toimplementation One gap is the need for an improved under-standing of the mechanisms by which improved outcomes areachieved (that is intervention causal pathways) A second gap isthe role of local conditions (context) in the success or failure of

specific intervention strategies By attending to and document-ing these details authors of future studies will advance our understanding of the implementation of PU prevention programs The views expressed in this article are those of the authors and do not necessarily

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

Greater Los Angeles HSRampD Center of Excellence (LIP Project 65-119) Dr Soban

is currently supported by a Career Development Award from the VA HSRampD pro-

gram (Project CDA 06-301) The authors thank Roberta Shanman for performing

the literature searches Breanne Johnson and Tracy Yee for assistance in retrieving

articles Zhen Wang and Cleopatra Aquino for assistance with data extraction Roger

Wasserman for administrative assistance Marika Suttorp for assistance with the

meta-analysis and Paul Shekelle for comments on an earlier draft of this manuscript

References1 Rubenstein LV et al Finding order in heterogeneity Types of quality-im-provement intervention publications Qual Saf Health Care 17403ndash408 Dec20082 Gould D et al Intervention studies to reduce the prevalence and incidenceof pressure sores A literature review J Clin Nurs 9163ndash177 Mar 20003 Tooher R et al Implementation of pressure ulcer guidelines What consti-tutes a successful strategy J Wound Care 12373ndash382 Nov 20034 Donabedian A The quality of care How can it be assessed JAMA2601743ndash1748 Sep 23ndash30 19885 NHS Center for Reviews and Dissemination Undertaking Systematic Reviewsof Research on Effectiveness CRDrsquos Guidance for those Carrying Out or Commis-sioning Reviews CRD Report No 4 New York NHS Center for Reviews andDissemination Mar 2001 httpwwwmedepinetmetaguidelinesOverview_CRD_Guidelinespdf (last accessed Apr 19 2011)6 National PU Advisory Panel (NPUAP) and European Pressure Ulcer Advi-sory Panel (EPUAP) Prevention and Treatment of Pressure Ulcers Clinical Prac-tice Guideline Washington DC NPUAP 20097 Bales I Padwojski A Reaching for the moon Achieving zero pressure ulcerprevalence J Wound Care 18137ndash144 Apr 20098 Ballard N et al How our ICU decreased the rate of hospital-acquired pres-sure ulcers J Nurs Care Qual 2392ndash96 JanndashMar 2008

J

Lynn M Soban RN MPH PhD is Research Health Scientist

Department of Veterans Affairs (VA) Greater Los Angeles HSRampD

Center of Excellence Sepulveda VA Ambulatory Care Center VA

Greater Los Angeles Healthcare System Sepulveda California Su-

sanne Hempel PhD is Behavioral Scientist RAND Santa Mon-

ica California Brett A Munjas MS is Statistical Project Associate

and Jeremy Miles PhD is Behavioral Scientist Lisa V Ruben-

stein MD MSPH is Director VA Greater Los Angeles HSRampD

Center of Excellence Professor of Medicine VA Greater Los Ange-

les Healthcare System and the David Geffen School of Medicine

University of California Los Angeles and Senior Natural Scientist

RAND Please address correspondence to Lynn M Soban

lynnsobanvagov

Online-Only Content

See the online version of this article for

Appendix 1 Included Studies

8



9 Bergstrom N et al Using a research-based assessment scale in clinical prac-tice Nurs Clin North Am 30539ndash551 Sep 199510 Bethell E The development of a strategy for the prevention and manage-ment of pressure sores J Wound Care 3342ndash343 Oct 199411 Bours GJ et al A pressure ulcer audit and feedback project across multi-hospital settings in the Netherlands Int J Qual Health Care 16211ndash218 Jun200412 Catania K et al Wound wise PUPPI The Pressure Ulcer Prevention Pro-tocol Interventions Am J Nurs 10744ndash52 Apr 200713 Charrier L et al Integrated audit as a means to implement unit protocolsA randomized and controlled study J Eval Clin Pract 14847ndash853 Oct 200814 Chicano SG Drolshagen C Reducing hospital-acquired pressure ulcersJ Wound Ostomy Continence Nurs 3645ndash50 JanndashFeb 200915 Courtney BA Ruppman JB Cooper HM Save our Skin Initiative cutspressure ulcer incidence in half Nurs Manage 37363840 Apr 200616 De Laat E et al Guideline implementation results in a decrease of pres-sure ulcer incidence in critically ill patients Crit Care Med 35815ndash820 Mar200717 De Laat EH et al Implementation of a new policy results in a decreaseof pressure ulcer frequency Int J Qual Health Care 18107ndash112 Apr 200618 Dibsie LG Implementing evidence-based practice to prevent skin break-down Crit Care Nurs Q 31140ndash149 AprndashJun 200819 Dukich J OrsquoConnor D Impact of practice guidelines on support surfaceselection incidence of pressure ulcers and fiscal dollars Ostomy Wound Man-age 4744ndash53 Mar 200120 Gibbons W et al Eliminating facility-acquired pressure ulcers at Ascen-sion Health Jt Comm J Qual Patient Saf 32488ndash496 Sep 200621 Gunningberg L et al Implementation of risk assessment and classificationof pressure ulcers as quality indicators for patients with hip fractures J ClinNurs 8396ndash406 Jul 199922 Hiser B et al Implementing a pressure ulcer prevention program and en-hancing the role of the CWOCN Impact on outcomes Ostomy Wound Man-age 5248ndash59 Feb 200623 Hobbs BK Reducing the incidence of pressure ulcers Implementation ofa turn-team nursing program J Gerontol Nurs 3046ndash51 Nov 200424 Hopkins B et al Reducing nosocomial pressure ulcers in an acute care fa-cility J Nurs Care Qual 1428ndash36 Apr 200025 Hunter SM et al The effectiveness of skin care protocols for pressure ul-cers Rehabil Nurs 20250ndash255 SepndashOct 199526 Jones S et al A pressure ulcer prevention program Ostomy Wound Man-age 3933ndash39 May 199327 LeMaster K Reducing incidence and prevalence of hospital-acquired pres-sure ulcers at Genesis Medical Center Jt Comm J Qual Patient Saf 33611ndash616Oct 200728 Lyder CH et al Preventing pressure ulcers in Connecticut hospitals byusing the Plan-Do-Study-Act model of quality improvement Jt Comm J QualSaf 30205ndash214 Apr 200429 McErlean B et al Implementation of a preventative pressure managementframework Primary Intention 1061ndash66 May 200230 McInerney JA Reducing hospital-acquired pressure ulcer prevalencethrough a focused prevention program Adv Skin Wound Care 2175ndash78 Feb200831 Moore SM Wise L Reducing nosocomial pressure ulcers J Nurs Adm2728ndash34 Oct 199732 Murray M Blaylock B Maintaining effective pressure ulcer preventionprograms Medsurg Nurs 385ndash93 Apr 199433 OrsquoBrien SP et al Sequential biannual prevalence studies of pressure ulcersat Allegheny-Hahnemann University Hospital Ostomy Wound Manage 44(3ASuppl)78Sndash88S Mar 199834 Olson K et al Preventing pressure sores in oncology patients Clin NursRes 7 207ndash224 May 1998

35 Peich S Calderon-Margalit R Reduction of nosocomial pressure ulcersin patients with hip fractures A quality improvement program Int J HealthCare Qual Assur Leadersh Health Serv 17(2ndash3)75ndash80 200436 Pokorny ME et al Skin care intervention for patients having cardiac sur-gery Am J Crit Care 12535ndash544 Nov 200337 Rashotte J et al Implementation of a two-part unit-based multiple inter-vention Moving evidence-based practice into action Can J Nurs Res4094ndash114 Jun 200838 Sacharok C Drew J Use of a total quality management model to reducepressure ulcer prevalence in the acute care setting J Wound Ostomy ContinenceNurs 2588ndash92 Mar 199839 Saleh M et al The impact of pressure ulcer risk assessment on patientoutcomes among hospitalised patients J Clin Nurs 181923ndash1929 Jul 200940 Stier L et al Reinforcing organizationwide pressure ulcer reduction onhigh-risk geriatric inpatient units Outcomes Manag 828ndash32 JanndashMar 200441 Stoelting J et al Prevention of nosocomial pressure ulcers A process im-provement project J Wound Ostomy Continence Nurs 34382ndash388 JulndashAug200742 Uzun O et al Prospective study Reducing pressure ulcers in intensivecare units at a Turkish medical center J Wound Ostomy Continence Nurs36404ndash411 JulndashAug 200943 VanEtten NK et al Development and implementation of a skin care pro-gram Ostomy Wound Manage 2740ndash54 MarndashApr 199044 Willson D et al Computerized support of pressure ulcer prevention andtreatment protocols Proc Annu Symp Comput Appl Med Care 646ndash650OctndashNov 199545 Panel on the Prediction and Prevention of Pressure Ulcers in Adults Pres-sure Ulcers in Adults Prediction and Prevention Clinical Practice Guideline No3 Publication No 92-0047 Rockville MD Agency for Health Care Policyand Research 1992 httpwwwncbinlmnihgovbooksNBK12157 (last ac-cessed Apr 19 2011)46 Dimant J Implementing pressure ulcer prevention and treatment pro-grams Using AMDA Clinical Practice Guidelines J Am Med Dir Assoc2315ndash325 NovndashDec 200147 Jamtvedt G et al Does telling people what they have been doing changewhat they do A systematic review of the effects of audit and feedback Qual SafHealth Care 15433ndash436 Dec 200648 American Nurses Association The National Database of Nursing Quality In-dicatorsreg httpswwwnursingqualityorg (last accessed Apr 15 2011)49 Walshe K Understanding what worksmdashand whymdashin quality improve-ment The need for theory-driven evaluation Int J Qual Health Care 1957ndash59Mar 2 2007 50 Grol R Grimshaw J Evidence-based implementation of evidence-basedmedicine Jt Comm J Qual Improv 25503ndash513 Oct 199951 Hulscher ME et al Process evaluation on quality improvement interven-tions Qual Saf Health Care 1240ndash46 Feb 200352 Kitson A et al Enabling the implementation of evidence-based practiceA conceptual framework Qual Health Care 7149ndash158 Sep 199853 McCormack B et al Getting evidence into practice The meaning of lsquocon-textrsquo J Adv Nurs 3194ndash104 Apr 200254 Estabrooks CA et al Development and assessment of the Alberta Con-text Tool BMC Health Serv Res 9234 Dec 200955 Davidoff F et al Publication guidelines for quality improvement in healthcare Evolution of the SQUIRE project Qual Saf Health Care 17(Suppl1)i3ndashi9 Oct 200856 Kane R et al Nursing Staffing and Quality of Patient Care Evidence Re-portTechnology Assessment No 151 Rockville MD Agency for HealthcareQuality and Research Mar 2007 httpwwwahrqgovclinictpnursesttphtm(last accessed Apr 19 2011)57 Oslashvretveit J Gustafson D Using research to inform quality programmesBMJ 326(7392)759ndash761 Apr 2003



AP1 June 2011 Volume 37 Number 6


Online-Only Content8Appendix 1 Included Studies

Author

Year

Country

Design

Bales7

2009

USA

Before-after

Ballard8

2008

USA

Before-after

Bergstrom9

1995

USA

Before-after

Setting

300-bed community

hospital units not

specified

2 ICUs in same

facility one 26-bed

ICU with focus on

trauma neurosurgi-

cal general surgical

and an 18-bed med-

ical ICU

Tertiary care hospi-

tal one high-acuity

medicalsurgical unit

Brief Description of

Intervention

Multifaceted intervention con-

sisting of new support sur-

faces protocol for surgical

patients at high risk of pres-

sure ulcers (PUs) staff educa-

tion performance mon itoring

and feedback music played to

prompt turning staff in emer-

gency room assess skin com-

puter tool for assessment and

initial PU care certified wound

ostomy and continence nurse

(CWOCN) increased hours

formal recognition and re-

wards


sisting of assembling team re-

vised existing protocols

staff education weekly per-

formance monitoring in-

creased frequency of the

Braden Scale conducting turn

rounds every two hours (Q2h)

use of new skin wipe new

documentation for skin

created database to enhance

performance measurement

data and translated data into

graphs

Intervention focused on proto-

cols for risk assessment along

with preventive interventions

based on level of risk In addi-

tion a team was assembled

staff education conducted

skin care products reviewed

performance monitoring con-

ducted and therapeutic beds

managed

Measures Reported

PT = Patient Outcome

PRO = Nursing

Process

1 Prevalence of

hospital-acquired PUs

(entire hospital) (PT)

1 Percent patients with

nosocomial PU (PT)

1 PU incidence (PT)

2 PU prevalence (PT)

Effect

Udagger

Udagger

+||

+||

Months

16Dagger

18sect

44Dagger

44Dagger

Authorsrsquo

Conclusions

PU prevalence

can be reduced

to zero impor-

tant to success

are the involve-

ment of the

leadership

team staff in-

volvement in

decision mak-

ing and a de-

sire to foster

interdisciplinary

relationships

A substantial

reduction in PU

rates was

achieved The

use of perfor -

mance data

and a change

in unit culture

were key to this

success

Through the

implementation

of a research-

based risk as-

sessment tool

and prevention

program in-

formed by

assessment

findings PU

incidence can

be decreased

Quality

Score

8

9

11

(continued on page AP2)


AP2June 2011 Volume 37 Number 6


Online-Only Content8Appendix 1 Included Studies (continued)

Author

Year

Country

Design

Bergstrom9

1995

USA

Before-after

Bethell10

1994

USA

Before-after

Bours11

2004

The

Netherlands

Time series

Catania12

2007

USA

Before-after

Setting

240-bed hospital

units not specified

One hospital

multiple units units

not specified

Six acute care

hospitals in the

Netherlands children

lt 13 years of age

excluded from

analysis

A cancer hospital 5

units 2 medical 2

surgical and the

critical care unit


Intervention

Implementation of a pub-

lished guideline risk assess-

ment tool and a prevention

protocol based on the risk

assessment results In addi-



and the Braden Scale added

to Kardex

Intervention involved con-

vening a multidisciplinary

team use of a risk assess-

ment tool implementation of

a protocol use of a link

nurse and patient education

Performance monitoring via

yearly prevalence surveys

for 5 years and the provision

of feedback to hospitals

Multidimensional intervention

consisting of assembling a

team use of published

guideline to guide interven-

tion protocol implementa-

tion staff education and

performance monitoring

Clinical nurse specialists

supported the intervention

(for example by helping staff

complete forms)

Measures Reported


PRO = Nursing

Process

1 Incidence of hospital-

acquired PUs (PT)


1 Case mix-adjusted

PU prevalence of (Stage

II or greater) among

patients without a PU on

admission (PT)

1 PU incidence (PT)


Effect

+||

Udagger

Udagger

+||

+||

Months

12Dagger

16Dagger

60sect

21sect

21sect

Authorsrsquo

Conclusions

The program

effectively re-

duced PUs

Teamwork was

an important

aspect of the

intervention

PU prevalence

decreased

more than a

quarter

Monitoring

prevalence and

providing feed-

back to hospi-

tals resulted in

improvement in

PU prevention

Implementation

resulted in a

greater than

50 decrease

in PU preva-

lence and has

been main-

tained for more

than 2 years

Quality

Score

12

7

12

11






Author

Year

Country

Design

Charrier13

2008

Italy

Controlled

clinical trial

Setting

10 units (not speci-

fied) in an Italian

hospital


Intervention

Audit and feedback on PU

protocol adherence

Measures Reported


PRO = Nursing

Process

1 Protocol present in

the department (PRO)

2 Operator knows there

is a protocol and

location (PRO)

3 Braden form present

(PRO)

4 (Braden form) com-

pletely filled in (PRO)

5 (Braden form)

updated (PRO)

6 (Braden form) filled in

for all at-risk patients

(PRO)

7 Used change in

posture form (PRO)

8 (Change in posture

form) completely filled

out (PRO)

9 If (change in posture

form) not used patient

mobilized (PRO)

10 Products for

patientrsquos posture (PRO)

11 If Braden lt 16 anti-

decubitus device (PRO)

12 If not other criteria

(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-

ticed according to proto-

col (PRO)

20 Medication equip-

ment always available

(PRO)

Effect

Udagger

Udagger

0

0

0

0

0

0

+||

ndash

0

Udagger

+||

+||

+||

+||

+||

+||

0

0

Months

18Dagger

Authorsrsquo

Conclusions

7 of 20

processes

showed signifi-

cant improve-

ment in the

intervention

group relative

to the control

group

Quality

Score

4






Author

Year

Country

Design

Chicano14

2009

USA

Before-after

Courtney15

2006

USA

Before-after

Setting

One 25-bed interme-

diate care unit

710-bed multisite

facility units not

specified


Intervention

Multifaceted intervention

consisting of new protocol to

improve skin assessment amp

documentation of risk using

ldquostop skin alertrdquo stamp repo-

sitioning schedule for at-risk

patients use of automatic

trigger system that suggests

interventions for patients with

Braden le 18 performance

monitoring staff education

revised policies and practice

standards

Incorporated Six Sigma prin-

ciples into a multidimen-

sional program consisting of

assembling a team imple-

mentation of a risk assess-

ment tool in the operating

room (OR) and initiation of

care planning in OR proto-

col implementation pur-

chase of pressure-relieving

mattresses conducted Plan-

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

Measures Reported


PRO = Nursing

Process

1 Number of hospital-

acquired PUs (PT)


acquired PUs (PT)

Effect

Udagger

Udagger

Months

21Dagger

30sect

Authorsrsquo

Conclusions

PU strategies

proved effec-

tive in decreas-

ing incidence

during a 1-year

period The

commitment amp

diligence of the

quality im-

provement (QI)

team amp mem-

bers of the

staffrsquos self-gov-

ernance coun-

cils were

important fac-

tors in achiev-

ing this goal

Incidence of

PUs decreased

by nearly 70

as a result of

intervention

the overall cul-

ture change at

the medical

center remains

a work in

progress

Quality

Score

8

10






Author

Year

Country

Design

deLaat16

2007

The

Netherlands

Before-after

deLaat17

2006

The

Netherlands

Before-after

Setting

28-bed adult inten-

sive care department

consisting of 4 units

2 general medical

surgical units 1 neu-

rologic unit 1 cardiac

surgical unit

900-bed university

medical center


Intervention


lished guideline that involved

the timely transfer of patients

to a specific pressure-

relieving device A contact

nurse (for each ward) was

designated and a PU con-

sultant appointed The

intervention was announced

via newspaper and intranet


lished guideline combined

with introduction of vis-

coelastic foam mattresses

A contact nurse was

designated (for each ward)

and a PU consultant

appointed The intervention

was announced via newspa-

per and intranet

Measures Reported


PRO = Nursing Process

1 PU incidence density for

grade IIndashIV (measured as

PUs1000 pt days) (PT)

2 Median time (days)

until onset of PU Stage II-

IV (PT)

3 PU incidence Stage

IIndashIV (PT)

4 Mean PU free time as a

proportion of total length

of stay (PT)

5 patients who needed

a transfer to pressure re-

ducing mattress who were

transferred (PRO)

1 patients with PUs

(Stages IndashIV) among pa-

tients without PU on ad-

mission but who screened

as high risk (PT)

2 patients with PUs

(Stages IIndashIV) among pa-



as high risk (PT)

3 patients with evi-

dence of a repositioning

schedule among at-risk

patients with a PU ge

Stage I (PRO)

4 patients with no evi-


schedule nor a proper

mattress among at-risk

patientspatients with a

PU ge Stage I (PRO)


dence of either a reposi-

tioning schedule or a

proper mattress among

at-risk patients or those

with a PU gt Stage I (PRO)


dence of both a reposi-

tioning schedule and a




Effect

+||

Udagger

+||

+||

+||

+||

+||

0

+||

+||

0

Months

12Dagger

11sect

Authorsrsquo

Conclusions

Implementation

of guideline for

PU care re-

sulted in signifi-

cant and

sustained de-

crease in the

incidence of

Stage II-IV PU

in ICU patients

PU frequency

can be

successfully

decreased

introduction of

adequate

mattresses and

guidelines for

prevention and

treatment are

promising

tools

Quality

Score

15

13






Author

Year

Country

Design

Dibsie18

2008

USA

Before-after

Dukich19

2001

USA

Before-after

Gibbons20

2006

USA

Before-after

Setting

Multisite academic

medical center units

not specified

2 hospitals (Level 1

Trauma Center and

a tertiary care hospi-

tal) multiple units at

each site ICUs and

medicalsurgical

units

528-bed hospital in

Florida all units


Intervention

Implemented a new practice

protocol conducted

performance monitoring and

provided feedback standard-

ized all skin care products

and provided staff education

on new products

Implemented a published

guideline and new protocol

for bed selection In addition

a team was assembled staff

education conducted mat-

tresses upgraded and gate-

keepers were used to

approve and monitor the use

of support surfaces

Implemented a comprehen-

sive care protocol targeting

surfaces patient turning

incontinence management

and nutritional consults In

addition a team was assem-

bled staff education was

conducted performance

monitoring was used and

compression stockings

product changed

Measures Reported



1 Hospital-acquired PUs

ge Stage II (entire hospital)

(PT)


ge Stage II (SICU only)

(PT)

1 PU prevalence ge Stage

I (Hospital B) (PT)


II (Hospital B) (PT)

3 Nosocomial PU rate

(Stages I-IV) Hospital A

(PT)


(Stages II-IV) Hospital A

(PT)

1 Facility-acquired

PUs1000 pt days (PT)

Effect

Udagger

Udagger

Udagger

Udagger

Udagger

Udagger

Udagger

Months

21Dagger

12Dagger

14sect

Authorsrsquo

Conclusions

Implementation

of an evidence-

based practice

protocol led to

improvements

in PU preva-

lence

A modest de-

crease in an-

nual expendi -

tures for rental

support sur-

faces was real-

ized results for

incidence and

prevalence dif-

fered across

hospitals and

may be attribut-

able to non-

standardized

documentation

tools

The program

enabled the

identification of

at-risk popula-

tions the im-

plementation of

appropriate

actions and

the achieve-

ment of posi-

tive measura-

ble results

Quality

Score

9

6

8






Author

Year

Country

Design

Gunningberg21

1999

Sweden

Controlled

study

Hiser22

2006

USA

Before-after

Hobbs23

2004

USA

Before-after

Setting

One hospital 4

wards in the depart-

ment of orthopedics

intervention limited to

patients with hip frac-

tures

One hospital 5 units

including a medical

ICU

280-bed geriatric

hospital 4 units

geriatrics oncology

surgical postop and

orthopedicsneurol-

ogy


Intervention

There were two groups

Intervention group (I) risk

assessment performed on

admission on a daily basis

at 2 weeks postsurgery and

at discharge use of risk

alarm sticker for high-risk

patients and staff education

conducted Control group

(C) risk assessment

performed on admission at

2 weeks postsurgery and at

discharge and staff educa-

tion conducted

Multidimensional interven-

tion assembled a team to

develop protocols based on

published guidelines imple-

mented a new risk assess-

ment tool created new

orders for use in conjunction

with verbal orders estab-

lished a skin resource team

use of dietary consults con-

ducted staff education per-

formance monitoring and

feedback and purchased

new support surfaces

Instituted a turn team pro-

gram consisting of assem-

bling a team implementation

of a new protocol and staff

education

Measures Reported



1 PU rates (pre-existing

and hospital-acquired) at

time of discharge (PT)


and hospital-acquired)

14 +ndash 6 days postsurgery

(PT)

1 patients with PUs

(prevalence) entire

hospital (PT)

2 patients with facility-

acquired PUs entire hos-

pital (PT)

3 patients with PUs

(medical ICU) (PT)


acquired PUs (medical

ICU) (PT)

1 Average length of stay

(PT)

2 Incidence of nosoco-

mial C difficile (PT)


mial pneumonia (PT)

4 Average number refer-

rals (per month) to

enterostomal therapy

nurse for PUs ge Stage II

(PRO)

Effect

Group

I vs C

0

Group

I vs C

0

0

0

0

0

+||

+||

0

0

Months

6sect

15sect

6sect

Authorsrsquo

Conclusions

No difference in

prevalence be-

tween interven-

tion and control

groups use of

the Modified

Norton Scale

facilitated the

identification of

the majority of

patients at risk

for PUs

Changes re-

sulted in a de-

crease in

quarterly hospi-

tal-acquired PU

prevalence in

participating

units Clinicians

now approach

PUs as pre-

ventable over-

all quality of

care and finan-

cial resource

utilization are

also improved

Following im-

plementation of

the turn team

program pa-

tient referrals to

the enteros-

tomal therapy

nurse average

length of stay

and muscu-

loskeletal in-

juries to staff all

declined

Quality

Score

11

10

11






Author

Year

Country

Design

Hopkins24

2000

USA

Before-after

Hunter25

1995

USA

Before-after

Jones26

1993

USA

Before-after

Setting

One acute care hos-

pital adult medical

surgical population

units not specified

40-bed non-acute re-

habilitation hospital

350-bed community

hospital All patients

on oncology med-

ical surgical ICU

intermediate care

units and high-risk

pediatric patients


Intervention


consisting of best practices

and research-based proto-

cols A team was assembled

a unit skin care resource

person was designated staff

education performance


were conducted collabo-

rated with respiratory ther-

apy and made changes to

the cervical collar product

Developed and implemented

protocols based on pub-

lished guidelines used a risk

assessment tool conducted


staff education

PU prevention program with

many components use of a

risk assessment tool imple-

mentation of a prevention

protocol designation of a

clinical resource person

selection of new pressure-

relieving products institution

of an approval process for

cost containment of rental

charges and nursing staff

education

Measures Reported




(PT)

2 Severity of hospital-ac-

quired PUs (PT)

3 Ratio of actual to pre-

dicted PUs (PT)

1 PU prevalence

(Stages IndashIV) (PT)

1 PU prevalence (Stages

IndashIV) (PT)


IIndashIV) (PT)

3 PU incidence (PT)

4 patients with nursing

diagnosis of impaired skin

integrity on problem list

among patients with pre-

existing PUs (PRO)

5 patients who had

admission risk factor

assessments completed

(PRO)

Effect

+||

Udagger

Udagger

0

0

0

0

Udagger

Udagger

Months

24Dagger

16sect

5sect

Authorsrsquo

Conclusions

Multidimen-

sional interven-

tions as an

adjunct to best

practices and

research-based

protocols im-

proved nosoco-

mial PU rates

Following im-

plementation of

protocols PU

prevalence de-

creased Health

care facilities

can improve

the quality of

care for PU

prevention by

establishing a

well-structured

PU prevention

treatment

program

Overall de-

crease in PU

incidence was

found and the

documentation

of PUs im-

proved Educa-

tion of nursing

staff is a key

component of

PU prevention

Quality

Score

15

13

13






Author

Year

Country

Design

LeMaster27

2007

USA

Before-after

Lyder28

2004

USA

Before-after

Setting

502-bed hospital 2

units pulmonary and

oncology

17 hospitals in the

state of Connecticut

hospital sizes ranged

from 200 to 800

beds


Intervention


consisting of implementation

of a protocol (turn patients

Q2h elevate bony promi-

nences use pressure over-

lays on beds) based on a

published guideline Visual

reminders of the protocol

were placed in rooms In ad-

dition a team was assem-

bled a risk assessment tool

was used and staff educa-

tion conducted

A quality collaborative format

that included Quality Im-

provement Organization

(QIO) audit and assembling

teams to conduct PDSA cy-

cles The nature of the inter-

ventions varied across

hospitals The most com-

monly tested interventions

were Identifying patients at

high risk for PUs increasing

scheduled repositioning or-

dering nutritional consults

and improving the accuracy

of staging of PUs Results

were shared on phone calls

and at conferences

Measures Reported



1 Prevalence of hospital-

acquired PUs (Unit A)

(PT)


acquired PUs (Unit B)

(PT)

1 Admission PU that pro-

gressed to gt Stage II (PT)

2 Hospital-acquired

Stage I PU (PT)

3 Hospital-acquired PU

gt Stage II (PT)


any stage (PT)

5 Pt median length of

stay (days) (PT)

6 In-hospital mortality (PT)

7 30-day mortality (PT)

8 Identification of high-

risk patients within 2 days

of hospital admission

(PRO)

9 Use of pressure-

relieving device in bed-

or chair-bound patients

(PRO)

10 Daily skin assessment

among high-risk patients

(PRO)

11 Repositioning every 2

hours for bed-bound pa-

tients or every hour for

chair-bound patients

(PRO)

12 Nutritional consults for

malnourished patients

(PRO)

13 Staging of acquired

Stage I PUs (PRO)


Stage II PUs (PRO)

Effect

Udagger

Udagger

0

0

0

0

+||

0

0

+||

0

0

+||

+||

0

+||

Months

12sect

Not

clear

Authorsrsquo

Conclusions

The interven-

tion was suc-

cessful and

was replicated

throughout the

facility

Found clinically

and statistically

significant im-

provements in

4 PU preven-

tion-related

processes of

care concurrent

with multi-

faceted

improvement

intervention

Quality

Score

9

14



June 2011 Volume 37 Number 6



Author

Year

Country

Design

McErlean29

2002

Australia

Before-after

McInerney30

2008

USA

Before-after

Moore31

1997

USA

Before-after

Setting

250-bed hospital

units not specified

548-bed 2-hospital

system all patients

except obstetrics and

mental health

500+ bed university

hospital units not

specified


Intervention

Implemented a framework

for identifying patients at risk

for PUs by using a risk as-

sessment tool and communi-

cating risk Intervention

included assembling a team

unit manger education and

implementing a care plan

that links prevention strate-

gies to specific risks


consisting of assembled an

interdisciplinary team used

a risk assessment tool in

conjunction with automatic

consults implemented a pro-

tocol used electronic med-

ical records for nurse

charting and order entry and

hired of an additional wound

care nurse who is responsi-

ble for entering pressure

relief orders


consisting of assembled a

team implemented a new

protocol used a risk assess-

ment tool conducted staff

education implemented a

PU hotline installed new

pressure-relieving mat-

tresses conducted perfor -

mance monitoring and

feedback Clinical nurse

specialist visits 2xmonth to

reinforce nursesrsquo knowledge

Measures Reported



1 PU incidence (all

stages) (PT)

2 of hospital-acquired

Stage I PUs (PT)


Stage II PUs (PT)


Stage III PUs (PT)


Stage IV PUs (PT)

1 Overall hospital-

acquired prevalence (PT)


2 Nosocomial PUs (PT)

Effect

Udagger

Udagger

Udagger

Udagger

Udagger

Udagger

+||

+||

Months

12Dagger

59sect

19sect

Authorsrsquo

Conclusions

Both the identi-

fication of pa-

tient risk at

admission and

the implemen-

tation of appro-

priate pre-

ventive inter-

ventions have

increased this

has resulted in

a reduction in

the incidence

and severity of

PUs

The hospital

system was

able to reduce

hospital-ac-

quired PU

prevalence by

81 The re-

sultant cost

savings in ad-

dition to the

elimination of

patientsrsquo pain

and suffering

from PUs can

significantly im-

pact the cost

and quality of

care

A systematic

approach to

change includ-

ing a more

comprehensive

theory will

guide leaders

in promoting

change

Quality

Score

10

10

11


AP10




AP11


Author

Year

Country

Design

Murray32

1994

USA

Before-after

OrsquoBrien33

1998

USA

Before-after

Setting

One hospital

medicalsurgical and

intensive care units

only

750-bed university

hospital all patients

except psychiatric

labor and delivery

postpartum and

newborn nursery


Intervention

Multidimensional PU preven-

tion program consisting of

the use of a risk assessment

tool and protocol conducted


provided staff education

Systemwide educational in-

tervention targeting all levels

of patient care providers and

multispecialty care The

intervention included per-


feedback the purchase of

pressure-relieving beds and

the use of new flow sheets

Measures Reported




2 PU incidence ge Stage I

(PT)

1 PU prevalence (all stages)

(PT)

2 Prevalence of hospital-ac-

quired PUs (all stages) (PT)

3 Prevalence (overall) of PUs

Stages II-IV (PT)


acquired PUs (Stages IIndashIV)

(PT)

5 patients with PUs

(ge Stage II) who received

nutritional consult (PRO)

6 patients with PUs (ge

Stage I) with albumin level

ordered (PRO)


Stage I) who had a skin

assessment upon admission

completed (PRO)




(PRO)


Stage I) for whom it was

unknown whether a skin


was completed adequately or

not (PRO)

10 patients with PUs

(Stages IIndashIV) with adequate

documentation (skin assess-

ment within 24 hrs of admis-

sion amp wkly thereafter) (PRO)


(Stages IIndashIV) with inadequate

documentation of either

admission skin assessment or

reassessment (PRO)


(Stages IIndashIV) with no docu-

mentation of either admission

skin assessment or reassess-

ment was absent (PRO)13 patients with PUs (geStage I) who were placed on aspecialized mattress or bed(PRO)

Effect

Udagger

Udagger

+||

+||

0

+||

0

+||

0

0

0

0

ndash

0

+||

Months

28sect

48Dagger

Authorsrsquo

Conclusions

PU prevention

programs

should include

a risk assess-

ment tool pro-

tocols for PU

prevention staff

education and a

means to evalu-

ate outcomes

Systemwide

educational ef-

forts that in-

clude all levels

of professionals

and multispe-

cialty preven-

tion and care

efforts can lead

to a reduction

in PU preva-

lence

Quality

Score

13

15





AP12


Author

Year

Country

Design

Olson34

1998

Canada

Before-after

Peich35

2004

Israel

Before-after

Pokorny36

2003

USA

Before-after

Setting

One cancer hospital

2 units

300-bed teaching

hospital orthopedic

unit and recovery

room intervention

limited to patients

with hip fractures


cardiac surgery ICU

and cardiac surgery

intermediate care

unit Intervention lim-

ited to patients un-

dergoing elective

open heart surgery


Intervention


guideline and prevention

protocol consisting of daily

skin evaluation patient edu-

cation use of moisturizers

and barrier creams reposi-

tioning and decreasing fric-

tion and shear and nutrition

consults Charting was al-

tered to ensure consistent

documentation of PU risk

Implemented new care

protocols a risk assessment

tool and viscoelastic

mattresses

Implemented a skin care in-

tervention protocol consist-

ing of a risk assessment tool

and risk staging a skin care

checklist and interventions

tailored to stage of break-

down Patients with Braden

Score lt 16 andor a PU ge

Stage II receive entero -

stomal therapy nurse

consults Conducted both

staff education and patient

education

Measures Reported



1 patients who devel-

oped PU in hospital

excluding those present

on admission (PT)

1 of nosocomial PUs

among hip fracture

patients (PT)


Effect

0

+||

Udagger

Months

Not

clear

28sect

Not

clear

Authorsrsquo

Conclusions

The Braden

Scale has been

permanently in-

corporated into

the daily chart-

ing forms It is

now possible to

track the de-

gree to which

the scale and

prevention pro-

tocol are used

through the

quarterly chart

audits

PU prevention

in patients with

hip fractures is

feasible An

increased

awareness of

the problem

among hospital

staff may be

important

The develop-

ment and

progress of

PUs can be al-

tered by nurs-

ing care PU

risk can only

be predicted

through

repeated

assessments

throughout

hospitalization

Quality

Score

11

12

12





AP13


Author

Year

Country

Design

Rashotte37

2008

Canada

Before-after

Setting

10-bed pediatric ICU


Intervention


consisting of protocols for

assessing risk of PUs re-

vised documentation staff

education a unit-based

champion increased visibil-

ity of the wound and skin

specialist development of

hospital standards of care for

PU prevention

Measures Reported



1 Median number of risk

assessments evident in

nursing documentation

(PRO)

2 Median number of evi-

denced-based nursing

practices documented

(PRO)

3 Median number of dieti-

tian consults completed

(PRO)

4 Median number of nu-

tritional assessments

completed (PRO)

5 Median number of

pressure-relieving sur-

faces in use (PRO)

6 Median number of lift-

ing devices in use for pa-

tients gt 20kg (PRO)

7 Median number of pa-

tient turningrepositioning

schedules documented

per chart or Kardex (PRO)

8 Median number of

transparent dressings

liquid films and elbowheel

protectors used to

prevention friction injury

(PRO)


tients with head and bed

elevated to lt 30 degrees

(PRO)

10 Median number of

consultations with skin-

care expert (PRO)

Effect

Udagger

Udagger

Udagger

Udagger

Udagger

Udagger

Udagger

Udagger

Udagger

Udagger

Months

6sect

Authorsrsquo

Conclusions

Significant

changes in

nursing best

practice guide-

lines were

found which

highlights the

complexities of

changing prac-

tice Contextual

influences such

as teamwork

and resources

may inform

results

Quality

Score

6





AP14


Author

Year

Country

Design

Sacharok38

1998

USA

Before-after

Saleh39

2009

UK

Controlled

clinical trial

Stier40

2004

USA

Before-after

Setting

300-bed acute care

community hospital

several units adult

medical surgical

critical care and

later emergency

room


Health care system

in eastern US units

not specified


Intervention



team implemented a proto-

col used a risk assessment

tool conducted PDSA

cycles designated a skin

care resource person and a

nursing unit representative

conducted staff education


feedback Nursing care flow

sheet was redesigned and

moved to bedside several

staffing changes (for exam-

ple staggering staff meal-

times)

Three intervention groups

Group A (1) mandatory

wound care management

study day (2) PU prevention

training program and training

on Braden Scale (3) imple-

mentation of Braden Scale

Group B (1) mandatory




on Braden Scale (but Braden

Scale not required) Group

C (1) mandatory wound

care management study day

only

The program emphasized

systemwide changes in ad-

ministration and coordination

of resources consisting of


mentation of a protocol use

of a risk assessment tool

review of skin care product

line staff education perfor -

mance monitoring and feed-

back directed to quality staff

Measures Reported



1 Prevalence of

nosocomial PUs (PT)

1 Nosocomial PU inci-

dence within 8 wks of

admission (PT)

1 Nosocomial PU

incidence (PT)

Effect

Udagger

Group

A vs

C

0

Group

B vs

C

0

Udagger

Months

47sect

13Dagger

Not

clear

Authorsrsquo

Conclusions

Implementation

of a total quality

management

model resulted

in an 83 re-

duction in PU

prevalence

There were no

differences in

PU incidence in

the groups that

received addi-

tional training

Clinical judg-

ment may be

as effective as

employing a

risk assess-

ment scale to

assess risk for

PUs

The sustained

success of the

program is at-

tributed to (1) a

reliable and

valid measure-

ment system

that facilitates

performance

assessment

and evaluation

and (2) ongoing

unit educational

activities

Quality

Score

11

10

12





AP15


Author

Year

Country

Design

Stoelting41

2007

USA

Before-after

Uzun42

2009

Turkey

Before-after

Van Etten43

1990

USA

Before-after

Setting

Large teaching

hospital units not

specified

880-bed acute care

university hospital

ICU areas only 2

general medical

surgical ICUs

1 neurosurgical ICU

1 postanesthesia

care unit

One hospital 3 high-

risk care areas (1)

cardiovascular criti-

cal care (2) orthope-

dics (3) acute

neurointensive care


Intervention

Three-pronged approach

use of a PU tracking form

identification of champions

and individual case analysis

of hospital-acquired PUs In

addition staff education and

feedback were provided

Education program for new

protocol that included imple-


ment scale and use of

prevention protocol for high-

risk patients Protocol in-

cluded repositioning Q2h

daily skin inspection daily

skin care and use of pres-

sure-redistribution devices



team implemented a pub-

lished guideline and care


ment tool made skin care

products readily available on

the unit and provided staff

education

Measures Reported



1 PU incidence (PT)

1 Incidence of Stage II

PUs among patients with-

out PUs on admission

(PUs100 patient days)

(PT)

1 patients with


(PT)

Effect

Udagger

+||

+||

Months

Not

clear

35sect

6sect

Authorsrsquo

Conclusions

An intervention

targeting

awareness and

communication

regarding PUs

resulted in

more complete

adherence to

the nursing

prevention

protocol

An education

program and

implementation

of preventive

nursing inter-

ventions were

effective in de-

creasing PU in-

cidence in ICU

patients

The program

appeared to be

successful as

evidenced by a

decrease in

nosocomial PU

rates Findings

underscore the

importance of

identifying pa-

tient risk for

PUs and follow-

ing through

with a plan for

prevention and

treatment

Quality

Score

7

13

11





AP16


Author

Year

Country

Design

Willson44

1995

USA

Before-after

Setting

One hospital

4 medicalsurgical

units


Intervention

Modification of hospital infor-

mation system to support cli-

nicians in new protocols

using clinical reminders

In addition a team was

assembled a published

guideline implemented and

a risk assessment tool was

used

Measures Reported



1 PU incidence (PT)

Effect

Udagger

Months

6sect

Authorsrsquo

Conclusions

Preliminary

results indicate

that modifica-

tions to a hos-

pitalrsquos informa-

tion system can

support staff in

following new

protocols and

can lead to a

decrease in PU

incidence

Quality

Score

8

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

dagger ldquoUrdquo indicates the effect could not be determined because p values were not reported and could not be computed from data presented

Dagger Number of months between the baseline and final measure reported

sect Number of months elapsed since intervention ended and final measure reported

|| ldquo+rdquo indicates improvement at the p le 05 level

ldquo0rdquo indicates no statistically significant change p gt 05

ldquondashrdquo indicates worsening at the p le 05 level




reported and (3) examine the interventionsrsquo effects on outcomes

MethodsSEARCH METHODS

We searched six electronic databases (PubMed the CumulativeIndex to Nursing and Allied Health Literature [CINAHL] theCochrane Library of Systematic Reviews the Cochrane CentralRegister of Controlled Trials [CENTRAL] the Database of Ab-stracts and Reviews of Effect [DARE] and the Web of Science)for English-language publications from January 1990 to September 2009 We also searched the Effective Practice andOrganization of Care (EPOC) Cochrane Group and theCochrane Wound Group register and Web sites of two agen-ciesmdashthe Robert Wood Johnson Foundation and the USAgency for Healthcare Research and Qualitymdashthat fund QI in-terventions Bibliographies of included studies and pertinent re-views were also screened Sidebar 1 (right) shows the PubMedsearch strategy which was adapted accordingly for the otherdatabases

ARTICLE SCREENING

Two independent reviewers [LMS SH] screened titles andabstracts from the initial search We included studies publishedin English after 1990 Papers selected as potentially relevant byeither reviewer underwent a full paper screening using the fol-lowing criteria

Setting (hospital) Use of an experimental study design (that is randomized

controlled trials controlled clinical trials cohort studies timeseries and pre-post studies [controlled and uncontrolled]

Testing of a QI intervention designed to change routinecare for PU prevention

Presence of data for at least one nursing process or patientoutcome measure

We excluded studies focusing solely on educational interven-tions that were not accompanied by other interventions We alsoexcluded studies focusing on wound care and those that focusedon site-specific (for example cervical and heel) PUs We resolvedreviewer disagreements about eligibility into the final samplethrough discussion

DATA ABSTRACTION

All studies meeting the inclusion criteria were abstracted induplicate by three reviewers [including LMS] We used an ab-straction tool that included setting study design interventionstrategies results and authorsrsquo conclusions We extracted all de-

scribed interventions with particular emphasis on the followingelements

Team assembled Guideline implemented Protocol developedimplemented Risk assessment tool Iterative (Plan-Do-Study-Act [PDSA]) cycles Staff education LinkResource nurse Performance monitoring FeedbackWe abstracted data on measures of both processes of care and

patient outcomes specifically values prior to the intervention

The following search strategy was used in PubMed

pressure ulcer[mh] OR pressure ulcer OR decubitus ulcer OR

pressure sore OR bed sore OR bedsore

AND

nursing homes OR nursing OR nurses OR nurse

AND

(prevention and control) OR prevent[tiab] OR quality assurance

health care OR total quality management OR practice guidelines as

topic OR quality indicators health care OR quality[tiab] OR reduc-

tion OR reduce OR prophylactic

AND

before-after OR pre-post OR randomized controlled trial[pt] OR

randomized controlled trials OR rct OR random allocation OR con-

trolled clinical trial[pt] OR controlled clinical trials OR research de-

sign OR evaluation studies OR followup studies OR follow-up

studies OR follow up studies OR prospective OR longitudinal OR

cohort OR compar OR random OR evaluative OR trial OR case

control OR (economic AND model) OR (economics AND models)

OR (economic AND modeling) OR (economic AND modelling) OR

evaluat[ti] OR effect[ti] OR differen[ti] OR impact[ti] OR experi-

ment OR quasi-experiment OR quasi experiment OR test OR

statistically significant OR odds ratio OR relative risk OR chi

square

AND

evaluation studies as topic OR outcome and process assessment

(health care) OR nursing assessment OR assess[tiab] OR health

plan implementation OR structural change OR organizational

change OR (quality AND improv) OR test OR tests OR testing OR

interven OR ((change OR changes OR changing) AND (structur

OR organization))

OR initiative OR strategy OR program OR collaborative OR de-

clin

NOT

case report OR case study OR case studies

The complete search strategy can be obtained by request from the

authors

Sidebar 1 PubMed Search Strategy





META-ANALYSIS


QUALITY APPRAISAL



FindingsSTUDY FLOW



Study Flow Diagram













MEASURES REPORTED



















QUALITY
















0 No not clear










clearly stated




































Bergstrom 1995 (9)

Bergstrom 1995 (9)

Catania 2007 (12)

DeLaat 2007 (16)

DeLaat 2006 (17)

Hiser 2006 (22)

Hopkins 2000 (24)

Jones 1993 (26)

Lyder 2004 (28)

Moore 1997 (31)


Olson 1998 (34)

Peich 2004 (35)

Saleh 2009 (39)

VanEtten 1990 (43)

Uzun 2009 (42)








CONCLUSION













J













lynnsobanvagov

Online-Only Content



8










Author

Year

Country

Design

Bales7

2009

USA

Before-after

Ballard8

2008

USA

Before-after

Bergstrom9

1995

USA

Before-after

Setting

300-bed community

hospital units not

specified

2 ICUs in same

facility one 26-bed

ICU with focus on

trauma neurosurgi-


and an 18-bed med-

ical ICU


tal one high-acuity



Intervention















wards














graphs










managed

Measures Reported


PRO = Nursing

Process

1 Prevalence of




nosocomial PU (PT)

1 PU incidence (PT)


Effect

Udagger

Udagger

+||

+||

Months

16Dagger

18sect

44Dagger

44Dagger

Authorsrsquo

Conclusions

PU prevalence

can be reduced

to zero impor-

tant to success

are the involve-

ment of the

leadership

team staff in-

volvement in

decision mak-

ing and a de-

sire to foster

interdisciplinary

relationships

A substantial

reduction in PU

rates was

achieved The

use of perfor -

mance data

and a change

in unit culture

were key to this

success

Through the

implementation

of a research-

based risk as-

sessment tool

and prevention

program in-

formed by

assessment

findings PU

incidence can

be decreased

Quality

Score

8

9

11






Author

Year

Country

Design

Bergstrom9

1995

USA

Before-after

Bethell10

1994

USA

Before-after

Bours11

2004

The

Netherlands

Time series

Catania12

2007

USA

Before-after

Setting

240-bed hospital

units not specified

One hospital


not specified

Six acute care

hospitals in the


lt 13 years of age

excluded from

analysis

A cancer hospital 5

units 2 medical 2

surgical and the

critical care unit


Intervention









to Kardex





















complete forms)

Measures Reported


PRO = Nursing

Process


acquired PUs (PT)


1 Case mix-adjusted




admission (PT)

1 PU incidence (PT)


Effect

+||

Udagger

Udagger

+||

+||

Months

12Dagger

16Dagger

60sect

21sect

21sect

Authorsrsquo

Conclusions

The program

effectively re-

duced PUs

Teamwork was

an important

aspect of the

intervention

PU prevalence

decreased

more than a

quarter

Monitoring

prevalence and

providing feed-

back to hospi-

tals resulted in

improvement in

PU prevention

Implementation

resulted in a

greater than

50 decrease

in PU preva-

lence and has

been main-

tained for more

than 2 years

Quality

Score

12

7

12

11






Author

Year

Country

Design

Charrier13

2008

Italy

Controlled

clinical trial

Setting


fied) in an Italian

hospital


Intervention


protocol adherence

Measures Reported


PRO = Nursing

Process




is a protocol and

location (PRO)


(PRO)



5 (Braden form)

updated (PRO)



(PRO)

7 Used change in

posture form (PRO)



out (PRO)



mobilized (PRO)

10 Products for





(PRO)


(PRO)


to protocol (PRO)

15 Staging of LDP

(PRO)

16 Is it registered

(PRO)

17 Form completely

filled in (PRO)


respected (PRO)



col (PRO)



(PRO)

Effect

Udagger

Udagger

0

0

0

0

0

0

+||

ndash

0

Udagger

+||

+||

+||

+||

+||

+||

0

0

Months

18Dagger

Authorsrsquo

Conclusions

7 of 20

processes

showed signifi-

cant improve-

ment in the

intervention

group relative

to the control

group

Quality

Score

4






Author

Year

Country

Design

Chicano14

2009

USA

Before-after

Courtney15

2006

USA

Before-after

Setting

One 25-bed interme-

diate care unit

710-bed multisite

facility units not

specified


Intervention













standards






















care products

Measures Reported


PRO = Nursing

Process


acquired PUs (PT)


acquired PUs (PT)

Effect

Udagger

Udagger

Months

21Dagger

30sect

Authorsrsquo

Conclusions

PU strategies

proved effec-

tive in decreas-

ing incidence

during a 1-year

period The

commitment amp

diligence of the

quality im-

provement (QI)

team amp mem-

bers of the


ernance coun-

cils were

important fac-

tors in achiev-

ing this goal

Incidence of

PUs decreased

by nearly 70

as a result of

intervention

the overall cul-

ture change at

the medical

center remains

a work in

progress

Quality

Score

8

10






Author

Year

Country

Design

deLaat16

2007

The

Netherlands

Before-after

deLaat17

2006

The

Netherlands

Before-after

Setting

28-bed adult inten-



2 general medical



surgical unit

900-bed university

medical center


Intervention















A contact nurse was


and a PU consultant



per and intranet

Measures Reported








IV (PT)


IIndashIV (PT)



of stay (PT)




transferred (PRO)

1 patients with PUs




as high risk (PT)

2 patients with PUs




as high risk (PT)





Stage I (PRO)






PU ge Stage I (PRO)













Effect

+||

Udagger

+||

+||

+||

+||

+||

0

+||

+||

0

Months

12Dagger

11sect

Authorsrsquo

Conclusions

Implementation

of guideline for

PU care re-

sulted in signifi-

cant and

sustained de-

crease in the

incidence of

Stage II-IV PU

in ICU patients

PU frequency

can be

successfully

decreased

introduction of

adequate

mattresses and

guidelines for

prevention and

treatment are

promising

tools

Quality

Score

15

13






Author

Year

Country

Design

Dibsie18

2008

USA

Before-after

Dukich19

2001

USA

Before-after

Gibbons20

2006

USA

Before-after

Setting

Multisite academic


not specified


Trauma Center and



each site ICUs and

medicalsurgical

units

528-bed hospital in

Florida all units


Intervention


protocol conducted





on new products









of support surfaces











product changed

Measures Reported





(PT)



(PT)


I (Hospital B) (PT)





(PT)



(PT)

1 Facility-acquired


Effect

Udagger

Udagger

Udagger

Udagger

Udagger

Udagger

Udagger

Months

21Dagger

12Dagger

14sect

Authorsrsquo

Conclusions

Implementation

of an evidence-

based practice

protocol led to

improvements

in PU preva-

lence

A modest de-

crease in an-

nual expendi -

tures for rental

support sur-

faces was real-

ized results for

incidence and

prevalence dif-

fered across

hospitals and

may be attribut-

able to non-

standardized

documentation

tools

The program

enabled the

identification of

at-risk popula-

tions the im-

plementation of

appropriate

actions and

the achieve-

ment of posi-

tive measura-

ble results

Quality

Score

9

6

8






Author

Year

Country

Design

Gunningberg21

1999

Sweden

Controlled

study

Hiser22

2006

USA

Before-after

Hobbs23

2004

USA

Before-after

Setting

One hospital 4


ment of orthopedics



tures


including a medical

ICU

280-bed geriatric

hospital 4 units

geriatrics oncology

surgical postop and

orthopedicsneurol-

ogy


Intervention










(C) risk assessment




tion conducted



















education

Measures Reported









(PT)

1 patients with PUs

(prevalence) entire

hospital (PT)



pital (PT)

3 patients with PUs

(medical ICU) (PT)



ICU) (PT)


(PT)




mial pneumonia (PT)


rals (per month) to



(PRO)

Effect

Group

I vs C

0

Group

I vs C

0

0

0

0

0

+||

+||

0

0

Months

6sect

15sect

6sect

Authorsrsquo

Conclusions

No difference in

prevalence be-

tween interven-

tion and control

groups use of

the Modified

Norton Scale

facilitated the

identification of

the majority of

patients at risk

for PUs

Changes re-

sulted in a de-

crease in

quarterly hospi-

tal-acquired PU

prevalence in

participating

units Clinicians

now approach

PUs as pre-

ventable over-

all quality of

care and finan-

cial resource

utilization are

also improved

Following im-

plementation of

the turn team

program pa-

tient referrals to

the enteros-

tomal therapy

nurse average

length of stay

and muscu-

loskeletal in-

juries to staff all

declined

Quality

Score

11

10

11






Author

Year

Country

Design

Hopkins24

2000

USA

Before-after

Hunter25

1995

USA

Before-after

Jones26

1993

USA

Before-after

Setting

One acute care hos-

pital adult medical

surgical population

units not specified



350-bed community


on oncology med-

ical surgical ICU

intermediate care

units and high-risk

pediatric patients


Intervention


















staff education












education

Measures Reported




(PT)


quired PUs (PT)


dicted PUs (PT)

1 PU prevalence



IndashIV) (PT)


IIndashIV) (PT)

3 PU incidence (PT)





existing PUs (PRO)

5 patients who had



(PRO)

Effect

+||

Udagger

Udagger

0

0

0

0

Udagger

Udagger

Months

24Dagger

16sect

5sect

Authorsrsquo

Conclusions

Multidimen-

sional interven-

tions as an

adjunct to best

practices and

research-based

protocols im-

proved nosoco-

mial PU rates

Following im-

plementation of

protocols PU

prevalence de-

creased Health

care facilities

can improve

the quality of

care for PU

prevention by

establishing a

well-structured

PU prevention

treatment

program

Overall de-

crease in PU

incidence was

found and the

documentation

of PUs im-

proved Educa-

tion of nursing

staff is a key

component of

PU prevention

Quality

Score

15

13

13






Author

Year

Country

Design

LeMaster27

2007

USA

Before-after

Lyder28

2004

USA

Before-after

Setting

502-bed hospital 2

units pulmonary and

oncology

17 hospitals in the



from 200 to 800

beds


Intervention













tion conducted

















and at conferences

Measures Reported





(PT)



(PT)



2 Hospital-acquired

Stage I PU (PT)


gt Stage II (PT)


any stage (PT)


stay (days) (PT)






(PRO)

9 Use of pressure-



(PRO)



(PRO)





(PRO)



(PRO)


Stage I PUs (PRO)


Stage II PUs (PRO)

Effect

Udagger

Udagger

0

0

0

0

+||

0

0

+||

0

0

+||

+||

0

+||

Months

12sect

Not

clear

Authorsrsquo

Conclusions

The interven-

tion was suc-

cessful and

was replicated

throughout the

facility

Found clinically

and statistically

significant im-

provements in

4 PU preven-

tion-related

processes of

care concurrent

with multi-

faceted

improvement

intervention

Quality

Score

9

14






Author

Year

Country

Design

McErlean29

2002

Australia

Before-after

McInerney30

2008

USA

Before-after

Moore31

1997

USA

Before-after

Setting

250-bed hospital

units not specified

548-bed 2-hospital

system all patients


mental health

500+ bed university

hospital units not

specified


Intervention























relief orders














Measures Reported



1 PU incidence (all

stages) (PT)


Stage I PUs (PT)


Stage II PUs (PT)


Stage III PUs (PT)


Stage IV PUs (PT)

1 Overall hospital-




Effect

Udagger

Udagger

Udagger

Udagger

Udagger

Udagger

+||

+||

Months

12Dagger

59sect

19sect

Authorsrsquo

Conclusions

Both the identi-

fication of pa-

tient risk at

admission and

the implemen-

tation of appro-

priate pre-

ventive inter-

ventions have

increased this

has resulted in

a reduction in

the incidence

and severity of

PUs

The hospital

system was

able to reduce

hospital-ac-

quired PU

prevalence by

81 The re-

sultant cost

savings in ad-

dition to the

elimination of

patientsrsquo pain

and suffering

from PUs can

significantly im-

pact the cost

and quality of

care

A systematic

approach to

change includ-

ing a more

comprehensive

theory will

guide leaders

in promoting

change

Quality

Score

10

10

11


AP10




AP11


Author

Year

Country

Design

Murray32

1994

USA

Before-after

OrsquoBrien33

1998

USA

Before-after

Setting

One hospital

medicalsurgical and


only

750-bed university


except psychiatric

labor and delivery

postpartum and

newborn nursery


Intervention
















Measures Reported





(PT)


(PT)




Stages II-IV (PT)



(PT)

5 patients with PUs





ordered (PRO)




completed (PRO)




(PRO)






not (PRO)










reassessment (PRO)






Effect

Udagger

Udagger

+||

+||

0

+||

0

+||

0

0

0

0

ndash

0

+||

Months

28sect

48Dagger

Authorsrsquo

Conclusions

PU prevention

programs

should include

a risk assess-

ment tool pro-

tocols for PU

prevention staff

education and a

means to evalu-

ate outcomes

Systemwide

educational ef-

forts that in-

clude all levels

of professionals

and multispe-

cialty preven-

tion and care

efforts can lead

to a reduction

in PU preva-

lence

Quality

Score

13

15





AP12


Author

Year

Country

Design

Olson34

1998

Canada

Before-after

Peich35

2004

Israel

Before-after

Pokorny36

2003

USA

Before-after

Setting

One cancer hospital

2 units

300-bed teaching

hospital orthopedic

unit and recovery

room intervention

limited to patients

with hip fractures


cardiac surgery ICU

and cardiac surgery

intermediate care



dergoing elective

open heart surgery


Intervention















mattresses













education

Measures Reported




oped PU in hospital


on admission (PT)

1 of nosocomial PUs

among hip fracture

patients (PT)


Effect

0

+||

Udagger

Months

Not

clear

28sect

Not

clear

Authorsrsquo

Conclusions

The Braden

Scale has been

permanently in-

corporated into

the daily chart-

ing forms It is

now possible to

track the de-

gree to which

the scale and

prevention pro-

tocol are used

through the

quarterly chart

audits

PU prevention

in patients with

hip fractures is

feasible An

increased

awareness of

the problem

among hospital

staff may be

important

The develop-

ment and

progress of

PUs can be al-

tered by nurs-

ing care PU

risk can only

be predicted

through

repeated

assessments

throughout

hospitalization

Quality

Score

11

12

12





AP13


Author

Year

Country

Design

Rashotte37

2008

Canada

Before-after

Setting



Intervention










PU prevention

Measures Reported






(PRO)




(PRO)



(PRO)



completed (PRO)

5 Median number of


faces in use (PRO)








8 Median number of



protectors used to


(PRO)




(PRO)

10 Median number of


care expert (PRO)

Effect

Udagger

Udagger

Udagger

Udagger

Udagger

Udagger

Udagger

Udagger

Udagger

Udagger

Months

6sect

Authorsrsquo

Conclusions

Significant

changes in

nursing best

practice guide-

lines were

found which

highlights the

complexities of

changing prac-

tice Contextual

influences such

as teamwork

and resources

may inform

results

Quality

Score

6





AP14


Author

Year

Country

Design

Sacharok38

1998

USA

Before-after

Saleh39

2009

UK

Controlled

clinical trial

Stier40

2004

USA

Before-after

Setting

300-bed acute care

community hospital

several units adult

medical surgical

critical care and

later emergency

room


Health care system

in eastern US units

not specified


Intervention





tool conducted PDSA











times)
















only












Measures Reported



1 Prevalence of

nosocomial PUs (PT)



admission (PT)

1 Nosocomial PU

incidence (PT)

Effect

Udagger

Group

A vs

C

0

Group

B vs

C

0

Udagger

Months

47sect

13Dagger

Not

clear

Authorsrsquo

Conclusions

Implementation

of a total quality

management

model resulted

in an 83 re-

duction in PU

prevalence

There were no

differences in

PU incidence in

the groups that

received addi-

tional training

Clinical judg-

ment may be

as effective as

employing a

risk assess-

ment scale to

assess risk for

PUs

The sustained

success of the

program is at-

tributed to (1) a

reliable and

valid measure-

ment system

that facilitates

performance

assessment

and evaluation

and (2) ongoing

unit educational

activities

Quality

Score

11

10

12





AP15


Author

Year

Country

Design

Stoelting41

2007

USA

Before-after

Uzun42

2009

Turkey

Before-after

Van Etten43

1990

USA

Before-after

Setting

Large teaching

hospital units not

specified

880-bed acute care

university hospital

ICU areas only 2

general medical

surgical ICUs

1 neurosurgical ICU

1 postanesthesia

care unit


risk care areas (1)



dics (3) acute

neurointensive care


Intervention


























education

Measures Reported



1 PU incidence (PT)





(PT)

1 patients with


(PT)

Effect

Udagger

+||

+||

Months

Not

clear

35sect

6sect

Authorsrsquo

Conclusions

An intervention

targeting

awareness and

communication

regarding PUs

resulted in

more complete

adherence to

the nursing

prevention

protocol

An education

program and

implementation

of preventive

nursing inter-

ventions were

effective in de-

creasing PU in-

cidence in ICU

patients

The program

appeared to be

successful as

evidenced by a

decrease in

nosocomial PU

rates Findings

underscore the

importance of

identifying pa-

tient risk for

PUs and follow-

ing through

with a plan for

prevention and

treatment

Quality

Score

7

13

11





AP16


Author

Year

Country

Design

Willson44

1995

USA

Before-after

Setting

One hospital

4 medicalsurgical

units


Intervention









used

Measures Reported



1 PU incidence (PT)

Effect

Udagger

Months

6sect

Authorsrsquo

Conclusions

Preliminary

results indicate

that modifica-

tions to a hos-


tion system can

support staff in

following new

protocols and

can lead to a

decrease in PU

incidence

Quality

Score

8













META-ANALYSIS


QUALITY APPRAISAL



FindingsSTUDY FLOW



Study Flow Diagram













MEASURES REPORTED



















QUALITY
















0 No not clear










clearly stated




































Bergstrom 1995 (9)

Bergstrom 1995 (9)

Catania 2007 (12)

DeLaat 2007 (16)

DeLaat 2006 (17)

Hiser 2006 (22)

Hopkins 2000 (24)

Jones 1993 (26)

Lyder 2004 (28)

Moore 1997 (31)


Olson 1998 (34)

Peich 2004 (35)

Saleh 2009 (39)

VanEtten 1990 (43)

Uzun 2009 (42)








CONCLUSION













J













lynnsobanvagov

Online-Only Content



8










Author

Year

Country

Design

Bales7

2009

USA

Before-after

Ballard8

2008

USA

Before-after

Bergstrom9

1995

USA

Before-after

Setting

300-bed community

hospital units not

specified

2 ICUs in same

facility one 26-bed

ICU with focus on

trauma neurosurgi-


and an 18-bed med-

ical ICU


tal one high-acuity



Intervention















wards














graphs










managed

Measures Reported


PRO = Nursing

Process

1 Prevalence of




nosocomial PU (PT)

1 PU incidence (PT)


Effect

Udagger

Udagger

+||

+||

Months

16Dagger

18sect

44Dagger

44Dagger

Authorsrsquo

Conclusions

PU prevalence

can be reduced

to zero impor-

tant to success

are the involve-

ment of the

leadership

team staff in-

volvement in

decision mak-

ing and a de-

sire to foster

interdisciplinary

relationships

A substantial

reduction in PU

rates was

achieved The

use of perfor -

mance data

and a change

in unit culture

were key to this

success

Through the

implementation

of a research-

based risk as-

sessment tool

and prevention

program in-

formed by

assessment

findings PU

incidence can

be decreased

Quality

Score

8

9

11






Author

Year

Country

Design

Bergstrom9

1995

USA

Before-after

Bethell10

1994

USA

Before-after

Bours11

2004

The

Netherlands

Time series

Catania12

2007

USA

Before-after

Setting

240-bed hospital

units not specified

One hospital


not specified

Six acute care

hospitals in the


lt 13 years of age

excluded from

analysis

A cancer hospital 5

units 2 medical 2

surgical and the

critical care unit


Intervention









to Kardex





















complete forms)

Measures Reported


PRO = Nursing

Process


acquired PUs (PT)


1 Case mix-adjusted




admission (PT)

1 PU incidence (PT)


Effect

+||

Udagger

Udagger

+||

+||

Months

12Dagger

16Dagger

60sect

21sect

21sect

Authorsrsquo

Conclusions

The program

effectively re-

duced PUs

Teamwork was

an important

aspect of the

intervention

PU prevalence

decreased

more than a

quarter

Monitoring

prevalence and

providing feed-

back to hospi-

tals resulted in

improvement in

PU prevention

Implementation

resulted in a

greater than

50 decrease

in PU preva-

lence and has

been main-

tained for more

than 2 years

Quality

Score

12

7

12

11






Author

Year

Country

Design

Charrier13

2008

Italy

Controlled

clinical trial

Setting


fied) in an Italian

hospital


Intervention


protocol adherence

Measures Reported


PRO = Nursing

Process




is a protocol and

location (PRO)


(PRO)



5 (Braden form)

updated (PRO)



(PRO)

7 Used change in

posture form (PRO)



out (PRO)



mobilized (PRO)

10 Products for





(PRO)


(PRO)


to protocol (PRO)

15 Staging of LDP

(PRO)

16 Is it registered

(PRO)

17 Form completely

filled in (PRO)


respected (PRO)



col (PRO)



(PRO)

Effect

Udagger

Udagger

0

0

0

0

0

0

+||

ndash

0

Udagger

+||

+||

+||

+||

+||

+||

0

0

Months

18Dagger

Authorsrsquo

Conclusions

7 of 20

processes

showed signifi-

cant improve-

ment in the

intervention

group relative

to the control

group

Quality

Score

4






Author

Year

Country

Design

Chicano14

2009

USA

Before-after

Courtney15

2006

USA

Before-after

Setting

One 25-bed interme-

diate care unit

710-bed multisite

facility units not

specified


Intervention













standards






















care products

Measures Reported


PRO = Nursing

Process


acquired PUs (PT)


acquired PUs (PT)

Effect

Udagger

Udagger

Months

21Dagger

30sect

Authorsrsquo

Conclusions

PU strategies

proved effec-

tive in decreas-

ing incidence

during a 1-year

period The

commitment amp

diligence of the

quality im-

provement (QI)

team amp mem-

bers of the


ernance coun-

cils were

important fac-

tors in achiev-

ing this goal

Incidence of

PUs decreased

by nearly 70

as a result of

intervention

the overall cul-

ture change at

the medical

center remains

a work in

progress

Quality

Score

8

10






Author

Year

Country

Design

deLaat16

2007

The

Netherlands

Before-after

deLaat17

2006

The

Netherlands

Before-after

Setting

28-bed adult inten-



2 general medical



surgical unit

900-bed university

medical center


Intervention















A contact nurse was


and a PU consultant



per and intranet

Measures Reported








IV (PT)


IIndashIV (PT)



of stay (PT)




transferred (PRO)

1 patients with PUs




as high risk (PT)

2 patients with PUs




as high risk (PT)





Stage I (PRO)






PU ge Stage I (PRO)













Effect

+||

Udagger

+||

+||

+||

+||

+||

0

+||

+||

0

Months

12Dagger

11sect

Authorsrsquo

Conclusions

Implementation

of guideline for

PU care re-

sulted in signifi-

cant and

sustained de-

crease in the

incidence of

Stage II-IV PU

in ICU patients

PU frequency

can be

successfully

decreased

introduction of

adequate

mattresses and

guidelines for

prevention and

treatment are

promising

tools

Quality

Score

15

13






Author

Year

Country

Design

Dibsie18

2008

USA

Before-after

Dukich19

2001

USA

Before-after

Gibbons20

2006

USA

Before-after

Setting

Multisite academic


not specified


Trauma Center and



each site ICUs and

medicalsurgical

units

528-bed hospital in

Florida all units


Intervention


protocol conducted





on new products









of support surfaces











product changed

Measures Reported





(PT)



(PT)


I (Hospital B) (PT)





(PT)



(PT)

1 Facility-acquired


Effect

Udagger

Udagger

Udagger

Udagger

Udagger

Udagger

Udagger

Months

21Dagger

12Dagger

14sect

Authorsrsquo

Conclusions

Implementation

of an evidence-

based practice

protocol led to

improvements

in PU preva-

lence

A modest de-

crease in an-

nual expendi -

tures for rental

support sur-

faces was real-

ized results for

incidence and

prevalence dif-

fered across

hospitals and

may be attribut-

able to non-

standardized

documentation

tools

The program

enabled the

identification of

at-risk popula-

tions the im-

plementation of

appropriate

actions and

the achieve-

ment of posi-

tive measura-

ble results

Quality

Score

9

6

8






Author

Year

Country

Design

Gunningberg21

1999

Sweden

Controlled

study

Hiser22

2006

USA

Before-after

Hobbs23

2004

USA

Before-after

Setting

One hospital 4


ment of orthopedics



tures


including a medical

ICU

280-bed geriatric

hospital 4 units

geriatrics oncology

surgical postop and

orthopedicsneurol-

ogy


Intervention










(C) risk assessment




tion conducted



















education

Measures Reported









(PT)

1 patients with PUs

(prevalence) entire

hospital (PT)



pital (PT)

3 patients with PUs

(medical ICU) (PT)



ICU) (PT)


(PT)




mial pneumonia (PT)


rals (per month) to



(PRO)

Effect

Group

I vs C

0

Group

I vs C

0

0

0

0

0

+||

+||

0

0

Months

6sect

15sect

6sect

Authorsrsquo

Conclusions

No difference in

prevalence be-

tween interven-

tion and control

groups use of

the Modified

Norton Scale

facilitated the

identification of

the majority of

patients at risk

for PUs

Changes re-

sulted in a de-

crease in

quarterly hospi-

tal-acquired PU

prevalence in

participating

units Clinicians

now approach

PUs as pre-

ventable over-

all quality of

care and finan-

cial resource

utilization are

also improved

Following im-

plementation of

the turn team

program pa-

tient referrals to

the enteros-

tomal therapy

nurse average

length of stay

and muscu-

loskeletal in-

juries to staff all

declined

Quality

Score

11

10

11






Author

Year

Country

Design

Hopkins24

2000

USA

Before-after

Hunter25

1995

USA

Before-after

Jones26

1993

USA

Before-after

Setting

One acute care hos-

pital adult medical

surgical population

units not specified



350-bed community


on oncology med-

ical surgical ICU

intermediate care

units and high-risk

pediatric patients


Intervention


















staff education












education

Measures Reported




(PT)


quired PUs (PT)


dicted PUs (PT)

1 PU prevalence



IndashIV) (PT)


IIndashIV) (PT)

3 PU incidence (PT)





existing PUs (PRO)

5 patients who had



(PRO)

Effect

+||

Udagger

Udagger

0

0

0

0

Udagger

Udagger

Months

24Dagger

16sect

5sect

Authorsrsquo

Conclusions

Multidimen-

sional interven-

tions as an

adjunct to best

practices and

research-based

protocols im-

proved nosoco-

mial PU rates

Following im-

plementation of

protocols PU

prevalence de-

creased Health

care facilities

can improve

the quality of

care for PU

prevention by

establishing a

well-structured

PU prevention

treatment

program

Overall de-

crease in PU

incidence was

found and the

documentation

of PUs im-

proved Educa-

tion of nursing

staff is a key

component of

PU prevention

Quality

Score

15

13

13






Author

Year

Country

Design

LeMaster27

2007

USA

Before-after

Lyder28

2004

USA

Before-after

Setting

502-bed hospital 2

units pulmonary and

oncology

17 hospitals in the



from 200 to 800

beds


Intervention













tion conducted

















and at conferences

Measures Reported





(PT)



(PT)



2 Hospital-acquired

Stage I PU (PT)


gt Stage II (PT)


any stage (PT)


stay (days) (PT)






(PRO)

9 Use of pressure-



(PRO)



(PRO)





(PRO)



(PRO)


Stage I PUs (PRO)


Stage II PUs (PRO)

Effect

Udagger

Udagger

0

0

0

0

+||

0

0

+||

0

0

+||

+||

0

+||

Months

12sect

Not

clear

Authorsrsquo

Conclusions

The interven-

tion was suc-

cessful and

was replicated

throughout the

facility

Found clinically

and statistically

significant im-

provements in

4 PU preven-

tion-related

processes of

care concurrent

with multi-

faceted

improvement

intervention

Quality

Score

9

14






Author

Year

Country

Design

McErlean29

2002

Australia

Before-after

McInerney30

2008

USA

Before-after

Moore31

1997

USA

Before-after

Setting

250-bed hospital

units not specified

548-bed 2-hospital

system all patients


mental health

500+ bed university

hospital units not

specified


Intervention























relief orders














Measures Reported



1 PU incidence (all

stages) (PT)


Stage I PUs (PT)


Stage II PUs (PT)


Stage III PUs (PT)


Stage IV PUs (PT)

1 Overall hospital-




Effect

Udagger

Udagger

Udagger

Udagger

Udagger

Udagger

+||

+||

Months

12Dagger

59sect

19sect

Authorsrsquo

Conclusions

Both the identi-

fication of pa-

tient risk at

admission and

the implemen-

tation of appro-

priate pre-

ventive inter-

ventions have

increased this

has resulted in

a reduction in

the incidence

and severity of

PUs

The hospital

system was

able to reduce

hospital-ac-

quired PU

prevalence by

81 The re-

sultant cost

savings in ad-

dition to the

elimination of

patientsrsquo pain

and suffering

from PUs can

significantly im-

pact the cost

and quality of

care

A systematic

approach to

change includ-

ing a more

comprehensive

theory will

guide leaders

in promoting

change

Quality

Score

10

10

11


AP10




AP11


Author

Year

Country

Design

Murray32

1994

USA

Before-after

OrsquoBrien33

1998

USA

Before-after

Setting

One hospital

medicalsurgical and


only

750-bed university


except psychiatric

labor and delivery

postpartum and

newborn nursery


Intervention
















Measures Reported





(PT)


(PT)




Stages II-IV (PT)



(PT)

5 patients with PUs





ordered (PRO)




completed (PRO)




(PRO)






not (PRO)










reassessment (PRO)






Effect

Udagger

Udagger

+||

+||

0

+||

0

+||

0

0

0

0

ndash

0

+||

Months

28sect

48Dagger

Authorsrsquo

Conclusions

PU prevention

programs

should include

a risk assess-

ment tool pro-

tocols for PU

prevention staff

education and a

means to evalu-

ate outcomes

Systemwide

educational ef-

forts that in-

clude all levels

of professionals

and multispe-

cialty preven-

tion and care

efforts can lead

to a reduction

in PU preva-

lence

Quality

Score

13

15





AP12


Author

Year

Country

Design

Olson34

1998

Canada

Before-after

Peich35

2004

Israel

Before-after

Pokorny36

2003

USA

Before-after

Setting

One cancer hospital

2 units

300-bed teaching

hospital orthopedic

unit and recovery

room intervention

limited to patients

with hip fractures


cardiac surgery ICU

and cardiac surgery

intermediate care



dergoing elective

open heart surgery


Intervention















mattresses













education

Measures Reported




oped PU in hospital


on admission (PT)

1 of nosocomial PUs

among hip fracture

patients (PT)


Effect

0

+||

Udagger

Months

Not

clear

28sect

Not

clear

Authorsrsquo

Conclusions

The Braden

Scale has been

permanently in-

corporated into

the daily chart-

ing forms It is

now possible to

track the de-

gree to which

the scale and

prevention pro-

tocol are used

through the

quarterly chart

audits

PU prevention

in patients with

hip fractures is

feasible An

increased

awareness of

the problem

among hospital

staff may be

important

The develop-

ment and

progress of

PUs can be al-

tered by nurs-

ing care PU

risk can only

be predicted

through

repeated

assessments

throughout

hospitalization

Quality

Score

11

12

12





AP13


Author

Year

Country

Design

Rashotte37

2008

Canada

Before-after

Setting



Intervention










PU prevention

Measures Reported






(PRO)




(PRO)



(PRO)



completed (PRO)

5 Median number of


faces in use (PRO)








8 Median number of



protectors used to


(PRO)




(PRO)

10 Median number of


care expert (PRO)

Effect

Udagger

Udagger

Udagger

Udagger

Udagger

Udagger

Udagger

Udagger

Udagger

Udagger

Months

6sect

Authorsrsquo

Conclusions

Significant

changes in

nursing best

practice guide-

lines were

found which

highlights the

complexities of

changing prac-

tice Contextual

influences such

as teamwork

and resources

may inform

results

Quality

Score

6





AP14


Author

Year

Country

Design

Sacharok38

1998

USA

Before-after

Saleh39

2009

UK

Controlled

clinical trial

Stier40

2004

USA

Before-after

Setting

300-bed acute care

community hospital

several units adult

medical surgical

critical care and

later emergency

room


Health care system

in eastern US units

not specified


Intervention





tool conducted PDSA











times)
















only












Measures Reported



1 Prevalence of

nosocomial PUs (PT)



admission (PT)

1 Nosocomial PU

incidence (PT)

Effect

Udagger

Group

A vs

C

0

Group

B vs

C

0

Udagger

Months

47sect

13Dagger

Not

clear

Authorsrsquo

Conclusions

Implementation

of a total quality

management

model resulted

in an 83 re-

duction in PU

prevalence

There were no

differences in

PU incidence in

the groups that

received addi-

tional training

Clinical judg-

ment may be

as effective as

employing a

risk assess-

ment scale to

assess risk for

PUs

The sustained

success of the

program is at-

tributed to (1) a

reliable and

valid measure-

ment system

that facilitates

performance

assessment

and evaluation

and (2) ongoing

unit educational

activities

Quality

Score

11

10

12





AP15


Author

Year

Country

Design

Stoelting41

2007

USA

Before-after

Uzun42

2009

Turkey

Before-after

Van Etten43

1990

USA

Before-after

Setting

Large teaching

hospital units not

specified

880-bed acute care

university hospital

ICU areas only 2

general medical

surgical ICUs

1 neurosurgical ICU

1 postanesthesia

care unit


risk care areas (1)



dics (3) acute

neurointensive care


Intervention


























education

Measures Reported



1 PU incidence (PT)





(PT)

1 patients with


(PT)

Effect

Udagger

+||

+||

Months

Not

clear

35sect

6sect

Authorsrsquo

Conclusions

An intervention

targeting

awareness and

communication

regarding PUs

resulted in

more complete

adherence to

the nursing

prevention

protocol

An education

program and

implementation

of preventive

nursing inter-

ventions were

effective in de-

creasing PU in-

cidence in ICU

patients

The program

appeared to be

successful as

evidenced by a

decrease in

nosocomial PU

rates Findings

underscore the

importance of

identifying pa-

tient risk for

PUs and follow-

ing through

with a plan for

prevention and

treatment

Quality

Score

7

13

11





AP16


Author

Year

Country

Design

Willson44

1995

USA

Before-after

Setting

One hospital

4 medicalsurgical

units


Intervention









used

Measures Reported



1 PU incidence (PT)

Effect

Udagger

Months

6sect

Authorsrsquo

Conclusions

Preliminary

results indicate

that modifica-

tions to a hos-


tion system can

support staff in

following new

protocols and

can lead to a

decrease in PU

incidence

Quality

Score

8




















MEASURES REPORTED



















QUALITY
















0 No not clear










clearly stated




































Bergstrom 1995 (9)

Bergstrom 1995 (9)

Catania 2007 (12)

DeLaat 2007 (16)

DeLaat 2006 (17)

Hiser 2006 (22)

Hopkins 2000 (24)

Jones 1993 (26)

Lyder 2004 (28)

Moore 1997 (31)


Olson 1998 (34)

Peich 2004 (35)

Saleh 2009 (39)

VanEtten 1990 (43)

Uzun 2009 (42)








CONCLUSION













J













lynnsobanvagov

Online-Only Content



8










Author

Year

Country

Design

Bales7

2009

USA

Before-after

Ballard8

2008

USA

Before-after

Bergstrom9

1995

USA

Before-after

Setting

300-bed community

hospital units not

specified

2 ICUs in same

facility one 26-bed

ICU with focus on

trauma neurosurgi-


and an 18-bed med-

ical ICU


tal one high-acuity



Intervention















wards














graphs










managed

Measures Reported


PRO = Nursing

Process

1 Prevalence of




nosocomial PU (PT)

1 PU incidence (PT)


Effect

Udagger

Udagger

+||

+||

Months

16Dagger

18sect

44Dagger

44Dagger

Authorsrsquo

Conclusions

PU prevalence

can be reduced

to zero impor-

tant to success

are the involve-

ment of the

leadership

team staff in-

volvement in

decision mak-

ing and a de-

sire to foster

interdisciplinary

relationships

A substantial

reduction in PU

rates was

achieved The

use of perfor -

mance data

and a change

in unit culture

were key to this

success

Through the

implementation

of a research-

based risk as-

sessment tool

and prevention

program in-

formed by

assessment

findings PU

incidence can

be decreased

Quality

Score

8

9

11






Author

Year

Country

Design

Bergstrom9

1995

USA

Before-after

Bethell10

1994

USA

Before-after

Bours11

2004

The

Netherlands

Time series

Catania12

2007

USA

Before-after

Setting

240-bed hospital

units not specified

One hospital


not specified

Six acute care

hospitals in the


lt 13 years of age

excluded from

analysis

A cancer hospital 5

units 2 medical 2

surgical and the

critical care unit


Intervention









to Kardex





















complete forms)

Measures Reported


PRO = Nursing

Process


acquired PUs (PT)


1 Case mix-adjusted




admission (PT)

1 PU incidence (PT)


Effect

+||

Udagger

Udagger

+||

+||

Months

12Dagger

16Dagger

60sect

21sect

21sect

Authorsrsquo

Conclusions

The program

effectively re-

duced PUs

Teamwork was

an important

aspect of the

intervention

PU prevalence

decreased

more than a

quarter

Monitoring

prevalence and

providing feed-

back to hospi-

tals resulted in

improvement in

PU prevention

Implementation

resulted in a

greater than

50 decrease

in PU preva-

lence and has

been main-

tained for more

than 2 years

Quality

Score

12

7

12

11






Author

Year

Country

Design

Charrier13

2008

Italy

Controlled

clinical trial

Setting


fied) in an Italian

hospital


Intervention


protocol adherence

Measures Reported


PRO = Nursing

Process




is a protocol and

location (PRO)


(PRO)



5 (Braden form)

updated (PRO)



(PRO)

7 Used change in

posture form (PRO)



out (PRO)



mobilized (PRO)

10 Products for





(PRO)


(PRO)


to protocol (PRO)

15 Staging of LDP

(PRO)

16 Is it registered

(PRO)

17 Form completely

filled in (PRO)


respected (PRO)



col (PRO)



(PRO)

Effect

Udagger

Udagger

0

0

0

0

0

0

+||

ndash

0

Udagger

+||

+||

+||

+||

+||

+||

0

0

Months

18Dagger

Authorsrsquo

Conclusions

7 of 20

processes

showed signifi-

cant improve-

ment in the

intervention

group relative

to the control

group

Quality

Score

4






Author

Year

Country

Design

Chicano14

2009

USA

Before-after

Courtney15

2006

USA

Before-after

Setting

One 25-bed interme-

diate care unit

710-bed multisite

facility units not

specified


Intervention













standards






















care products

Measures Reported


PRO = Nursing

Process


acquired PUs (PT)


acquired PUs (PT)

Effect

Udagger

Udagger

Months

21Dagger

30sect

Authorsrsquo

Conclusions

PU strategies

proved effec-

tive in decreas-

ing incidence

during a 1-year

period The

commitment amp

diligence of the

quality im-

provement (QI)

team amp mem-

bers of the


ernance coun-

cils were

important fac-

tors in achiev-

ing this goal

Incidence of

PUs decreased

by nearly 70

as a result of

intervention

the overall cul-

ture change at

the medical

center remains

a work in

progress

Quality

Score

8

10






Author

Year

Country

Design

deLaat16

2007

The

Netherlands

Before-after

deLaat17

2006

The

Netherlands

Before-after

Setting

28-bed adult inten-



2 general medical



surgical unit

900-bed university

medical center


Intervention















A contact nurse was


and a PU consultant



per and intranet

Measures Reported








IV (PT)


IIndashIV (PT)



of stay (PT)




transferred (PRO)

1 patients with PUs




as high risk (PT)

2 patients with PUs




as high risk (PT)





Stage I (PRO)






PU ge Stage I (PRO)













Effect

+||

Udagger

+||

+||

+||

+||

+||

0

+||

+||

0

Months

12Dagger

11sect

Authorsrsquo

Conclusions

Implementation

of guideline for

PU care re-

sulted in signifi-

cant and

sustained de-

crease in the

incidence of

Stage II-IV PU

in ICU patients

PU frequency

can be

successfully

decreased

introduction of

adequate

mattresses and

guidelines for

prevention and

treatment are

promising

tools

Quality

Score

15

13






Author

Year

Country

Design

Dibsie18

2008

USA

Before-after

Dukich19

2001

USA

Before-after

Gibbons20

2006

USA

Before-after

Setting

Multisite academic


not specified


Trauma Center and



each site ICUs and

medicalsurgical

units

528-bed hospital in

Florida all units


Intervention


protocol conducted





on new products









of support surfaces











product changed

Measures Reported





(PT)



(PT)


I (Hospital B) (PT)





(PT)



(PT)

1 Facility-acquired


Effect

Udagger

Udagger

Udagger

Udagger

Udagger

Udagger

Udagger

Months

21Dagger

12Dagger

14sect

Authorsrsquo

Conclusions

Implementation

of an evidence-

based practice

protocol led to

improvements

in PU preva-

lence

A modest de-

crease in an-

nual expendi -

tures for rental

support sur-

faces was real-

ized results for

incidence and

prevalence dif-

fered across

hospitals and

may be attribut-

able to non-

standardized

documentation

tools

The program

enabled the

identification of

at-risk popula-

tions the im-

plementation of

appropriate

actions and

the achieve-

ment of posi-

tive measura-

ble results

Quality

Score

9

6

8






Author

Year

Country

Design

Gunningberg21

1999

Sweden

Controlled

study

Hiser22

2006

USA

Before-after

Hobbs23

2004

USA

Before-after

Setting

One hospital 4


ment of orthopedics



tures


including a medical

ICU

280-bed geriatric

hospital 4 units

geriatrics oncology

surgical postop and

orthopedicsneurol-

ogy


Intervention










(C) risk assessment




tion conducted



















education

Measures Reported









(PT)

1 patients with PUs

(prevalence) entire

hospital (PT)



pital (PT)

3 patients with PUs

(medical ICU) (PT)



ICU) (PT)


(PT)




mial pneumonia (PT)


rals (per month) to



(PRO)

Effect

Group

I vs C

0

Group

I vs C

0

0

0

0

0

+||

+||

0

0

Months

6sect

15sect

6sect

Authorsrsquo

Conclusions

No difference in

prevalence be-

tween interven-

tion and control

groups use of

the Modified

Norton Scale

facilitated the

identification of

the majority of

patients at risk

for PUs

Changes re-

sulted in a de-

crease in

quarterly hospi-

tal-acquired PU

prevalence in

participating

units Clinicians

now approach

PUs as pre-

ventable over-

all quality of

care and finan-

cial resource

utilization are

also improved

Following im-

plementation of

the turn team

program pa-

tient referrals to

the enteros-

tomal therapy

nurse average

length of stay

and muscu-

loskeletal in-

juries to staff all

declined

Quality

Score

11

10

11






Author

Year

Country

Design

Hopkins24

2000

USA

Before-after

Hunter25

1995

USA

Before-after

Jones26

1993

USA

Before-after

Setting

One acute care hos-

pital adult medical

surgical population

units not specified



350-bed community


on oncology med-

ical surgical ICU

intermediate care

units and high-risk

pediatric patients


Intervention


















staff education












education

Measures Reported




(PT)


quired PUs (PT)


dicted PUs (PT)

1 PU prevalence



IndashIV) (PT)


IIndashIV) (PT)

3 PU incidence (PT)





existing PUs (PRO)

5 patients who had



(PRO)

Effect

+||

Udagger

Udagger

0

0

0

0

Udagger

Udagger

Months

24Dagger

16sect

5sect

Authorsrsquo

Conclusions

Multidimen-

sional interven-

tions as an

adjunct to best

practices and

research-based

protocols im-

proved nosoco-

mial PU rates

Following im-

plementation of

protocols PU

prevalence de-

creased Health

care facilities

can improve

the quality of

care for PU

prevention by

establishing a

well-structured

PU prevention

treatment

program

Overall de-

crease in PU

incidence was

found and the

documentation

of PUs im-

proved Educa-

tion of nursing

staff is a key

component of

PU prevention

Quality

Score

15

13

13






Author

Year

Country

Design

LeMaster27

2007

USA

Before-after

Lyder28

2004

USA

Before-after

Setting

502-bed hospital 2

units pulmonary and

oncology

17 hospitals in the



from 200 to 800

beds


Intervention













tion conducted

















and at conferences

Measures Reported





(PT)



(PT)



2 Hospital-acquired

Stage I PU (PT)


gt Stage II (PT)


any stage (PT)


stay (days) (PT)






(PRO)

9 Use of pressure-



(PRO)



(PRO)





(PRO)



(PRO)


Stage I PUs (PRO)


Stage II PUs (PRO)

Effect

Udagger

Udagger

0

0

0

0

+||

0

0

+||

0

0

+||

+||

0

+||

Months

12sect

Not

clear

Authorsrsquo

Conclusions

The interven-

tion was suc-

cessful and

was replicated

throughout the

facility

Found clinically

and statistically

significant im-

provements in

4 PU preven-

tion-related

processes of

care concurrent

with multi-

faceted

improvement

intervention

Quality

Score

9

14






Author

Year

Country

Design

McErlean29

2002

Australia

Before-after

McInerney30

2008

USA

Before-after

Moore31

1997

USA

Before-after

Setting

250-bed hospital

units not specified

548-bed 2-hospital

system all patients


mental health

500+ bed university

hospital units not

specified


Intervention























relief orders














Measures Reported



1 PU incidence (all

stages) (PT)


Stage I PUs (PT)


Stage II PUs (PT)


Stage III PUs (PT)


Stage IV PUs (PT)

1 Overall hospital-




Effect

Udagger

Udagger

Udagger

Udagger

Udagger

Udagger

+||

+||

Months

12Dagger

59sect

19sect

Authorsrsquo

Conclusions

Both the identi-

fication of pa-

tient risk at

admission and

the implemen-

tation of appro-

priate pre-

ventive inter-

ventions have

increased this

has resulted in

a reduction in

the incidence

and severity of

PUs

The hospital

system was

able to reduce

hospital-ac-

quired PU

prevalence by

81 The re-

sultant cost

savings in ad-

dition to the

elimination of

patientsrsquo pain

and suffering

from PUs can

significantly im-

pact the cost

and quality of

care

A systematic

approach to

change includ-

ing a more

comprehensive

theory will

guide leaders

in promoting

change

Quality

Score

10

10

11


AP10




AP11


Author

Year

Country

Design

Murray32

1994

USA

Before-after

OrsquoBrien33

1998

USA

Before-after

Setting

One hospital

medicalsurgical and


only

750-bed university


except psychiatric

labor and delivery

postpartum and

newborn nursery


Intervention
















Measures Reported





(PT)


(PT)




Stages II-IV (PT)



(PT)

5 patients with PUs





ordered (PRO)




completed (PRO)




(PRO)






not (PRO)










reassessment (PRO)






Effect

Udagger

Udagger

+||

+||

0

+||

0

+||

0

0

0

0

ndash

0

+||

Months

28sect

48Dagger

Authorsrsquo

Conclusions

PU prevention

programs

should include

a risk assess-

ment tool pro-

tocols for PU

prevention staff

education and a

means to evalu-

ate outcomes

Systemwide

educational ef-

forts that in-

clude all levels

of professionals

and multispe-

cialty preven-

tion and care

efforts can lead

to a reduction

in PU preva-

lence

Quality

Score

13

15





AP12


Author

Year

Country

Design

Olson34

1998

Canada

Before-after

Peich35

2004

Israel

Before-after

Pokorny36

2003

USA

Before-after

Setting

One cancer hospital

2 units

300-bed teaching

hospital orthopedic

unit and recovery

room intervention

limited to patients

with hip fractures


cardiac surgery ICU

and cardiac surgery

intermediate care



dergoing elective

open heart surgery


Intervention















mattresses













education

Measures Reported




oped PU in hospital


on admission (PT)

1 of nosocomial PUs

among hip fracture

patients (PT)


Effect

0

+||

Udagger

Months

Not

clear

28sect

Not

clear

Authorsrsquo

Conclusions

The Braden

Scale has been

permanently in-

corporated into

the daily chart-

ing forms It is

now possible to

track the de-

gree to which

the scale and

prevention pro-

tocol are used

through the

quarterly chart

audits

PU prevention

in patients with

hip fractures is

feasible An

increased

awareness of

the problem

among hospital

staff may be

important

The develop-

ment and

progress of

PUs can be al-

tered by nurs-

ing care PU

risk can only

be predicted

through

repeated

assessments

throughout

hospitalization

Quality

Score

11

12

12





AP13


Author

Year

Country

Design

Rashotte37

2008

Canada

Before-after

Setting



Intervention










PU prevention

Measures Reported






(PRO)




(PRO)



(PRO)



completed (PRO)

5 Median number of


faces in use (PRO)








8 Median number of



protectors used to


(PRO)




(PRO)

10 Median number of


care expert (PRO)

Effect

Udagger

Udagger

Udagger

Udagger

Udagger

Udagger

Udagger

Udagger

Udagger

Udagger

Months

6sect

Authorsrsquo

Conclusions

Significant

changes in

nursing best

practice guide-

lines were

found which

highlights the

complexities of

changing prac-

tice Contextual

influences such

as teamwork

and resources

may inform

results

Quality

Score

6





AP14


Author

Year

Country

Design

Sacharok38

1998

USA

Before-after

Saleh39

2009

UK

Controlled

clinical trial

Stier40

2004

USA

Before-after

Setting

300-bed acute care

community hospital

several units adult

medical surgical

critical care and

later emergency

room


Health care system

in eastern US units

not specified


Intervention





tool conducted PDSA











times)
















only












Measures Reported



1 Prevalence of

nosocomial PUs (PT)



admission (PT)

1 Nosocomial PU

incidence (PT)

Effect

Udagger

Group

A vs

C

0

Group

B vs

C

0

Udagger

Months

47sect

13Dagger

Not

clear

Authorsrsquo

Conclusions

Implementation

of a total quality

management

model resulted

in an 83 re-

duction in PU

prevalence

There were no

differences in

PU incidence in

the groups that

received addi-

tional training

Clinical judg-

ment may be

as effective as

employing a

risk assess-

ment scale to

assess risk for

PUs

The sustained

success of the

program is at-

tributed to (1) a

reliable and

valid measure-

ment system

that facilitates

performance

assessment

and evaluation

and (2) ongoing

unit educational

activities

Quality

Score

11

10

12





AP15


Author

Year

Country

Design

Stoelting41

2007

USA

Before-after

Uzun42

2009

Turkey

Before-after

Van Etten43

1990

USA

Before-after

Setting

Large teaching

hospital units not

specified

880-bed acute care

university hospital

ICU areas only 2

general medical

surgical ICUs

1 neurosurgical ICU

1 postanesthesia

care unit


risk care areas (1)



dics (3) acute

neurointensive care


Intervention


























education

Measures Reported



1 PU incidence (PT)





(PT)

1 patients with


(PT)

Effect

Udagger

+||

+||

Months

Not

clear

35sect

6sect

Authorsrsquo

Conclusions

An intervention

targeting

awareness and

communication

regarding PUs

resulted in

more complete

adherence to

the nursing

prevention

protocol

An education

program and

implementation

of preventive

nursing inter-

ventions were

effective in de-

creasing PU in-

cidence in ICU

patients

The program

appeared to be

successful as

evidenced by a

decrease in

nosocomial PU

rates Findings

underscore the

importance of

identifying pa-

tient risk for

PUs and follow-

ing through

with a plan for

prevention and

treatment

Quality

Score

7

13

11





AP16


Author

Year

Country

Design

Willson44

1995

USA

Before-after

Setting

One hospital

4 medicalsurgical

units


Intervention









used

Measures Reported



1 PU incidence (PT)

Effect

Udagger

Months

6sect

Authorsrsquo

Conclusions

Preliminary

results indicate

that modifica-

tions to a hos-


tion system can

support staff in

following new

protocols and

can lead to a

decrease in PU

incidence

Quality

Score

8










QUALITY
















0 No not clear










clearly stated




































Bergstrom 1995 (9)

Bergstrom 1995 (9)

Catania 2007 (12)

DeLaat 2007 (16)

DeLaat 2006 (17)

Hiser 2006 (22)

Hopkins 2000 (24)

Jones 1993 (26)

Lyder 2004 (28)

Moore 1997 (31)


Olson 1998 (34)

Peich 2004 (35)

Saleh 2009 (39)

VanEtten 1990 (43)

Uzun 2009 (42)








CONCLUSION













J













lynnsobanvagov

Online-Only Content



8










Author

Year

Country

Design

Bales7

2009

USA

Before-after

Ballard8

2008

USA

Before-after

Bergstrom9

1995

USA

Before-after

Setting

300-bed community

hospital units not

specified

2 ICUs in same

facility one 26-bed

ICU with focus on

trauma neurosurgi-


and an 18-bed med-

ical ICU


tal one high-acuity



Intervention















wards














graphs










managed

Measures Reported


PRO = Nursing

Process

1 Prevalence of




nosocomial PU (PT)

1 PU incidence (PT)


Effect

Udagger

Udagger

+||

+||

Months

16Dagger

18sect

44Dagger

44Dagger

Authorsrsquo

Conclusions

PU prevalence

can be reduced

to zero impor-

tant to success

are the involve-

ment of the

leadership

team staff in-

volvement in

decision mak-

ing and a de-

sire to foster

interdisciplinary

relationships

A substantial

reduction in PU

rates was

achieved The

use of perfor -

mance data

and a change

in unit culture

were key to this

success

Through the

implementation

of a research-

based risk as-

sessment tool

and prevention

program in-

formed by

assessment

findings PU

incidence can

be decreased

Quality

Score

8

9

11






Author

Year

Country

Design

Bergstrom9

1995

USA

Before-after

Bethell10

1994

USA

Before-after

Bours11

2004

The

Netherlands

Time series

Catania12

2007

USA

Before-after

Setting

240-bed hospital

units not specified

One hospital


not specified

Six acute care

hospitals in the


lt 13 years of age

excluded from

analysis

A cancer hospital 5

units 2 medical 2

surgical and the

critical care unit


Intervention









to Kardex





















complete forms)

Measures Reported


PRO = Nursing

Process


acquired PUs (PT)


1 Case mix-adjusted




admission (PT)

1 PU incidence (PT)


Effect

+||

Udagger

Udagger

+||

+||

Months

12Dagger

16Dagger

60sect

21sect

21sect

Authorsrsquo

Conclusions

The program

effectively re-

duced PUs

Teamwork was

an important

aspect of the

intervention

PU prevalence

decreased

more than a

quarter

Monitoring

prevalence and

providing feed-

back to hospi-

tals resulted in

improvement in

PU prevention

Implementation

resulted in a

greater than

50 decrease

in PU preva-

lence and has

been main-

tained for more

than 2 years

Quality

Score

12

7

12

11






Author

Year

Country

Design

Charrier13

2008

Italy

Controlled

clinical trial

Setting


fied) in an Italian

hospital


Intervention


protocol adherence

Measures Reported


PRO = Nursing

Process




is a protocol and

location (PRO)


(PRO)



5 (Braden form)

updated (PRO)



(PRO)

7 Used change in

posture form (PRO)



out (PRO)



mobilized (PRO)

10 Products for





(PRO)


(PRO)


to protocol (PRO)

15 Staging of LDP

(PRO)

16 Is it registered

(PRO)

17 Form completely

filled in (PRO)


respected (PRO)



col (PRO)



(PRO)

Effect

Udagger

Udagger

0

0

0

0

0

0

+||

ndash

0

Udagger

+||

+||

+||

+||

+||

+||

0

0

Months

18Dagger

Authorsrsquo

Conclusions

7 of 20

processes

showed signifi-

cant improve-

ment in the

intervention

group relative

to the control

group

Quality

Score

4






Author

Year

Country

Design

Chicano14

2009

USA

Before-after

Courtney15

2006

USA

Before-after

Setting

One 25-bed interme-

diate care unit

710-bed multisite

facility units not

specified


Intervention













standards






















care products

Measures Reported


PRO = Nursing

Process


acquired PUs (PT)


acquired PUs (PT)

Effect

Udagger

Udagger

Months

21Dagger

30sect

Authorsrsquo

Conclusions

PU strategies

proved effec-

tive in decreas-

ing incidence

during a 1-year

period The

commitment amp

diligence of the

quality im-

provement (QI)

team amp mem-

bers of the


ernance coun-

cils were

important fac-

tors in achiev-

ing this goal

Incidence of

PUs decreased

by nearly 70

as a result of

intervention

the overall cul-

ture change at

the medical

center remains

a work in

progress

Quality

Score

8

10






Author

Year

Country

Design

deLaat16

2007

The

Netherlands

Before-after

deLaat17

2006

The

Netherlands

Before-after

Setting

28-bed adult inten-



2 general medical



surgical unit

900-bed university

medical center


Intervention















A contact nurse was


and a PU consultant



per and intranet

Measures Reported








IV (PT)


IIndashIV (PT)



of stay (PT)




transferred (PRO)

1 patients with PUs




as high risk (PT)

2 patients with PUs




as high risk (PT)





Stage I (PRO)






PU ge Stage I (PRO)













Effect

+||

Udagger

+||

+||

+||

+||

+||

0

+||

+||

0

Months

12Dagger

11sect

Authorsrsquo

Conclusions

Implementation

of guideline for

PU care re-

sulted in signifi-

cant and

sustained de-

crease in the

incidence of

Stage II-IV PU

in ICU patients

PU frequency

can be

successfully

decreased

introduction of

adequate

mattresses and

guidelines for

prevention and

treatment are

promising

tools

Quality

Score

15

13






Author

Year

Country

Design

Dibsie18

2008

USA

Before-after

Dukich19

2001

USA

Before-after

Gibbons20

2006

USA

Before-after

Setting

Multisite academic


not specified


Trauma Center and



each site ICUs and

medicalsurgical

units

528-bed hospital in

Florida all units


Intervention


protocol conducted





on new products









of support surfaces











product changed

Measures Reported





(PT)



(PT)


I (Hospital B) (PT)





(PT)



(PT)

1 Facility-acquired


Effect

Udagger

Udagger

Udagger

Udagger

Udagger

Udagger

Udagger

Months

21Dagger

12Dagger

14sect

Authorsrsquo

Conclusions

Implementation

of an evidence-

based practice

protocol led to

improvements

in PU preva-

lence

A modest de-

crease in an-

nual expendi -

tures for rental

support sur-

faces was real-

ized results for

incidence and

prevalence dif-

fered across

hospitals and

may be attribut-

able to non-

standardized

documentation

tools

The program

enabled the

identification of

at-risk popula-

tions the im-

plementation of

appropriate

actions and

the achieve-

ment of posi-

tive measura-

ble results

Quality

Score

9

6

8






Author

Year

Country

Design

Gunningberg21

1999

Sweden

Controlled

study

Hiser22

2006

USA

Before-after

Hobbs23

2004

USA

Before-after

Setting

One hospital 4


ment of orthopedics



tures


including a medical

ICU

280-bed geriatric

hospital 4 units

geriatrics oncology

surgical postop and

orthopedicsneurol-

ogy


Intervention










(C) risk assessment




tion conducted



















education

Measures Reported









(PT)

1 patients with PUs

(prevalence) entire

hospital (PT)



pital (PT)

3 patients with PUs

(medical ICU) (PT)



ICU) (PT)


(PT)




mial pneumonia (PT)


rals (per month) to



(PRO)

Effect

Group

I vs C

0

Group

I vs C

0

0

0

0

0

+||

+||

0

0

Months

6sect

15sect

6sect

Authorsrsquo

Conclusions

No difference in

prevalence be-

tween interven-

tion and control

groups use of

the Modified

Norton Scale

facilitated the

identification of

the majority of

patients at risk

for PUs

Changes re-

sulted in a de-

crease in

quarterly hospi-

tal-acquired PU

prevalence in

participating

units Clinicians

now approach

PUs as pre-

ventable over-

all quality of

care and finan-

cial resource

utilization are

also improved

Following im-

plementation of

the turn team

program pa-

tient referrals to

the enteros-

tomal therapy

nurse average

length of stay

and muscu-

loskeletal in-

juries to staff all

declined

Quality

Score

11

10

11






Author

Year

Country

Design

Hopkins24

2000

USA

Before-after

Hunter25

1995

USA

Before-after

Jones26

1993

USA

Before-after

Setting

One acute care hos-

pital adult medical

surgical population

units not specified



350-bed community


on oncology med-

ical surgical ICU

intermediate care

units and high-risk

pediatric patients


Intervention


















staff education












education

Measures Reported




(PT)


quired PUs (PT)


dicted PUs (PT)

1 PU prevalence



IndashIV) (PT)


IIndashIV) (PT)

3 PU incidence (PT)





existing PUs (PRO)

5 patients who had



(PRO)

Effect

+||

Udagger

Udagger

0

0

0

0

Udagger

Udagger

Months

24Dagger

16sect

5sect

Authorsrsquo

Conclusions

Multidimen-

sional interven-

tions as an

adjunct to best

practices and

research-based

protocols im-

proved nosoco-

mial PU rates

Following im-

plementation of

protocols PU

prevalence de-

creased Health

care facilities

can improve

the quality of

care for PU

prevention by

establishing a

well-structured

PU prevention

treatment

program

Overall de-

crease in PU

incidence was

found and the

documentation

of PUs im-

proved Educa-

tion of nursing

staff is a key

component of

PU prevention

Quality

Score

15

13

13






Author

Year

Country

Design

LeMaster27

2007

USA

Before-after

Lyder28

2004

USA

Before-after

Setting

502-bed hospital 2

units pulmonary and

oncology

17 hospitals in the



from 200 to 800

beds


Intervention













tion conducted

















and at conferences

Measures Reported





(PT)



(PT)



2 Hospital-acquired

Stage I PU (PT)


gt Stage II (PT)


any stage (PT)


stay (days) (PT)






(PRO)

9 Use of pressure-



(PRO)



(PRO)





(PRO)



(PRO)


Stage I PUs (PRO)


Stage II PUs (PRO)

Effect

Udagger

Udagger

0

0

0

0

+||

0

0

+||

0

0

+||

+||

0

+||

Months

12sect

Not

clear

Authorsrsquo

Conclusions

The interven-

tion was suc-

cessful and

was replicated

throughout the

facility

Found clinically

and statistically

significant im-

provements in

4 PU preven-

tion-related

processes of

care concurrent

with multi-

faceted

improvement

intervention

Quality

Score

9

14






Author

Year

Country

Design

McErlean29

2002

Australia

Before-after

McInerney30

2008

USA

Before-after

Moore31

1997

USA

Before-after

Setting

250-bed hospital

units not specified

548-bed 2-hospital

system all patients


mental health

500+ bed university

hospital units not

specified


Intervention























relief orders














Measures Reported



1 PU incidence (all

stages) (PT)


Stage I PUs (PT)


Stage II PUs (PT)


Stage III PUs (PT)


Stage IV PUs (PT)

1 Overall hospital-




Effect

Udagger

Udagger

Udagger

Udagger

Udagger

Udagger

+||

+||

Months

12Dagger

59sect

19sect

Authorsrsquo

Conclusions

Both the identi-

fication of pa-

tient risk at

admission and

the implemen-

tation of appro-

priate pre-

ventive inter-

ventions have

increased this

has resulted in

a reduction in

the incidence

and severity of

PUs

The hospital

system was

able to reduce

hospital-ac-

quired PU

prevalence by

81 The re-

sultant cost

savings in ad-

dition to the

elimination of

patientsrsquo pain

and suffering

from PUs can

significantly im-

pact the cost

and quality of

care

A systematic

approach to

change includ-

ing a more

comprehensive

theory will

guide leaders

in promoting

change

Quality

Score

10

10

11


AP10




AP11


Author

Year

Country

Design

Murray32

1994

USA

Before-after

OrsquoBrien33

1998

USA

Before-after

Setting

One hospital

medicalsurgical and


only

750-bed university


except psychiatric

labor and delivery

postpartum and

newborn nursery


Intervention
















Measures Reported





(PT)


(PT)




Stages II-IV (PT)



(PT)

5 patients with PUs





ordered (PRO)




completed (PRO)




(PRO)






not (PRO)










reassessment (PRO)






Effect

Udagger

Udagger

+||

+||

0

+||

0

+||

0

0

0

0

ndash

0

+||

Months

28sect

48Dagger

Authorsrsquo

Conclusions

PU prevention

programs

should include

a risk assess-

ment tool pro-

tocols for PU

prevention staff

education and a

means to evalu-

ate outcomes

Systemwide

educational ef-

forts that in-

clude all levels

of professionals

and multispe-

cialty preven-

tion and care

efforts can lead

to a reduction

in PU preva-

lence

Quality

Score

13

15





AP12


Author

Year

Country

Design

Olson34

1998

Canada

Before-after

Peich35

2004

Israel

Before-after

Pokorny36

2003

USA

Before-after

Setting

One cancer hospital

2 units

300-bed teaching

hospital orthopedic

unit and recovery

room intervention

limited to patients

with hip fractures


cardiac surgery ICU

and cardiac surgery

intermediate care



dergoing elective

open heart surgery


Intervention















mattresses













education

Measures Reported




oped PU in hospital


on admission (PT)

1 of nosocomial PUs

among hip fracture

patients (PT)


Effect

0

+||

Udagger

Months

Not

clear

28sect

Not

clear

Authorsrsquo

Conclusions

The Braden

Scale has been

permanently in-

corporated into

the daily chart-

ing forms It is

now possible to

track the de-

gree to which

the scale and

prevention pro-

tocol are used

through the

quarterly chart

audits

PU prevention

in patients with

hip fractures is

feasible An

increased

awareness of

the problem

among hospital

staff may be

important

The develop-

ment and

progress of

PUs can be al-

tered by nurs-

ing care PU

risk can only

be predicted

through

repeated

assessments

throughout

hospitalization

Quality

Score

11

12

12





AP13


Author

Year

Country

Design

Rashotte37

2008

Canada

Before-after

Setting



Intervention










PU prevention

Measures Reported






(PRO)




(PRO)



(PRO)



completed (PRO)

5 Median number of


faces in use (PRO)








8 Median number of



protectors used to


(PRO)




(PRO)

10 Median number of


care expert (PRO)

Effect

Udagger

Udagger

Udagger

Udagger

Udagger

Udagger

Udagger

Udagger

Udagger

Udagger

Months

6sect

Authorsrsquo

Conclusions

Significant

changes in

nursing best

practice guide-

lines were

found which

highlights the

complexities of

changing prac-

tice Contextual

influences such

as teamwork

and resources

may inform

results

Quality

Score

6





AP14


Author

Year

Country

Design

Sacharok38

1998

USA

Before-after

Saleh39

2009

UK

Controlled

clinical trial

Stier40

2004

USA

Before-after

Setting

300-bed acute care

community hospital

several units adult

medical surgical

critical care and

later emergency

room


Health care system

in eastern US units

not specified


Intervention





tool conducted PDSA











times)
















only












Measures Reported



1 Prevalence of

nosocomial PUs (PT)



admission (PT)

1 Nosocomial PU

incidence (PT)

Effect

Udagger

Group

A vs

C

0

Group

B vs

C

0

Udagger

Months

47sect

13Dagger

Not

clear

Authorsrsquo

Conclusions

Implementation

of a total quality

management

model resulted

in an 83 re-

duction in PU

prevalence

There were no

differences in

PU incidence in

the groups that

received addi-

tional training

Clinical judg-

ment may be

as effective as

employing a

risk assess-

ment scale to

assess risk for

PUs

The sustained

success of the

program is at-

tributed to (1) a

reliable and

valid measure-

ment system

that facilitates

performance

assessment

and evaluation

and (2) ongoing

unit educational

activities

Quality

Score

11

10

12





AP15


Author

Year

Country

Design

Stoelting41

2007

USA

Before-after

Uzun42

2009

Turkey

Before-after

Van Etten43

1990

USA

Before-after

Setting

Large teaching

hospital units not

specified

880-bed acute care

university hospital

ICU areas only 2

general medical

surgical ICUs

1 neurosurgical ICU

1 postanesthesia

care unit


risk care areas (1)



dics (3) acute

neurointensive care


Intervention


























education

Measures Reported



1 PU incidence (PT)





(PT)

1 patients with


(PT)

Effect

Udagger

+||

+||

Months

Not

clear

35sect

6sect

Authorsrsquo

Conclusions

An intervention

targeting

awareness and

communication

regarding PUs

resulted in

more complete

adherence to

the nursing

prevention

protocol

An education

program and

implementation

of preventive

nursing inter-

ventions were

effective in de-

creasing PU in-

cidence in ICU

patients

The program

appeared to be

successful as

evidenced by a

decrease in

nosocomial PU

rates Findings

underscore the

importance of

identifying pa-

tient risk for

PUs and follow-

ing through

with a plan for

prevention and

treatment

Quality

Score

7

13

11





AP16


Author

Year

Country

Design

Willson44

1995

USA

Before-after

Setting

One hospital

4 medicalsurgical

units


Intervention









used

Measures Reported



1 PU incidence (PT)

Effect

Udagger

Months

6sect

Authorsrsquo

Conclusions

Preliminary

results indicate

that modifica-

tions to a hos-


tion system can

support staff in

following new

protocols and

can lead to a

decrease in PU

incidence

Quality

Score

8























Bergstrom 1995 (9)

Bergstrom 1995 (9)

Catania 2007 (12)

DeLaat 2007 (16)

DeLaat 2006 (17)

Hiser 2006 (22)

Hopkins 2000 (24)

Jones 1993 (26)

Lyder 2004 (28)

Moore 1997 (31)


Olson 1998 (34)

Peich 2004 (35)

Saleh 2009 (39)

VanEtten 1990 (43)

Uzun 2009 (42)








CONCLUSION













J













lynnsobanvagov

Online-Only Content



8










Author

Year

Country

Design

Bales7

2009

USA

Before-after

Ballard8

2008

USA

Before-after

Bergstrom9

1995

USA

Before-after

Setting

300-bed community

hospital units not

specified

2 ICUs in same

facility one 26-bed

ICU with focus on

trauma neurosurgi-


and an 18-bed med-

ical ICU


tal one high-acuity



Intervention















wards














graphs










managed

Measures Reported


PRO = Nursing

Process

1 Prevalence of




nosocomial PU (PT)

1 PU incidence (PT)


Effect

Udagger

Udagger

+||

+||

Months

16Dagger

18sect

44Dagger

44Dagger

Authorsrsquo

Conclusions

PU prevalence

can be reduced

to zero impor-

tant to success

are the involve-

ment of the

leadership

team staff in-

volvement in

decision mak-

ing and a de-

sire to foster

interdisciplinary

relationships

A substantial

reduction in PU

rates was

achieved The

use of perfor -

mance data

and a change

in unit culture

were key to this

success

Through the

implementation

of a research-

based risk as-

sessment tool

and prevention

program in-

formed by

assessment

findings PU

incidence can

be decreased

Quality

Score

8

9

11






Author

Year

Country

Design

Bergstrom9

1995

USA

Before-after

Bethell10

1994

USA

Before-after

Bours11

2004

The

Netherlands

Time series

Catania12

2007

USA

Before-after

Setting

240-bed hospital

units not specified

One hospital


not specified

Six acute care

hospitals in the


lt 13 years of age

excluded from

analysis

A cancer hospital 5

units 2 medical 2

surgical and the

critical care unit


Intervention









to Kardex





















complete forms)

Measures Reported


PRO = Nursing

Process


acquired PUs (PT)


1 Case mix-adjusted




admission (PT)

1 PU incidence (PT)


Effect

+||

Udagger

Udagger

+||

+||

Months

12Dagger

16Dagger

60sect

21sect

21sect

Authorsrsquo

Conclusions

The program

effectively re-

duced PUs

Teamwork was

an important

aspect of the

intervention

PU prevalence

decreased

more than a

quarter

Monitoring

prevalence and

providing feed-

back to hospi-

tals resulted in

improvement in

PU prevention

Implementation

resulted in a

greater than

50 decrease

in PU preva-

lence and has

been main-

tained for more

than 2 years

Quality

Score

12

7

12

11






Author

Year

Country

Design

Charrier13

2008

Italy

Controlled

clinical trial

Setting


fied) in an Italian

hospital


Intervention


protocol adherence

Measures Reported


PRO = Nursing

Process




is a protocol and

location (PRO)


(PRO)



5 (Braden form)

updated (PRO)



(PRO)

7 Used change in

posture form (PRO)



out (PRO)



mobilized (PRO)

10 Products for





(PRO)


(PRO)


to protocol (PRO)

15 Staging of LDP

(PRO)

16 Is it registered

(PRO)

17 Form completely

filled in (PRO)


respected (PRO)



col (PRO)



(PRO)

Effect

Udagger

Udagger

0

0

0

0

0

0

+||

ndash

0

Udagger

+||

+||

+||

+||

+||

+||

0

0

Months

18Dagger

Authorsrsquo

Conclusions

7 of 20

processes

showed signifi-

cant improve-

ment in the

intervention

group relative

to the control

group

Quality

Score

4






Author

Year

Country

Design

Chicano14

2009

USA

Before-after

Courtney15

2006

USA

Before-after

Setting

One 25-bed interme-

diate care unit

710-bed multisite

facility units not

specified


Intervention













standards






















care products

Measures Reported


PRO = Nursing

Process


acquired PUs (PT)


acquired PUs (PT)

Effect

Udagger

Udagger

Months

21Dagger

30sect

Authorsrsquo

Conclusions

PU strategies

proved effec-

tive in decreas-

ing incidence

during a 1-year

period The

commitment amp

diligence of the

quality im-

provement (QI)

team amp mem-

bers of the


ernance coun-

cils were

important fac-

tors in achiev-

ing this goal

Incidence of

PUs decreased

by nearly 70

as a result of

intervention

the overall cul-

ture change at

the medical

center remains

a work in

progress

Quality

Score

8

10






Author

Year

Country

Design

deLaat16

2007

The

Netherlands

Before-after

deLaat17

2006

The

Netherlands

Before-after

Setting

28-bed adult inten-



2 general medical



surgical unit

900-bed university

medical center


Intervention















A contact nurse was


and a PU consultant



per and intranet

Measures Reported








IV (PT)


IIndashIV (PT)



of stay (PT)




transferred (PRO)

1 patients with PUs




as high risk (PT)

2 patients with PUs




as high risk (PT)





Stage I (PRO)






PU ge Stage I (PRO)













Effect

+||

Udagger

+||

+||

+||

+||

+||

0

+||

+||

0

Months

12Dagger

11sect

Authorsrsquo

Conclusions

Implementation

of guideline for

PU care re-

sulted in signifi-

cant and

sustained de-

crease in the

incidence of

Stage II-IV PU

in ICU patients

PU frequency

can be

successfully

decreased

introduction of

adequate

mattresses and

guidelines for

prevention and

treatment are

promising

tools

Quality

Score

15

13






Author

Year

Country

Design

Dibsie18

2008

USA

Before-after

Dukich19

2001

USA

Before-after

Gibbons20

2006

USA

Before-after

Setting

Multisite academic


not specified


Trauma Center and



each site ICUs and

medicalsurgical

units

528-bed hospital in

Florida all units


Intervention


protocol conducted





on new products









of support surfaces











product changed

Measures Reported





(PT)



(PT)


I (Hospital B) (PT)





(PT)



(PT)

1 Facility-acquired


Effect

Udagger

Udagger

Udagger

Udagger

Udagger

Udagger

Udagger

Months

21Dagger

12Dagger

14sect

Authorsrsquo

Conclusions

Implementation

of an evidence-

based practice

protocol led to

improvements

in PU preva-

lence

A modest de-

crease in an-

nual expendi -

tures for rental

support sur-

faces was real-

ized results for

incidence and

prevalence dif-

fered across

hospitals and

may be attribut-

able to non-

standardized

documentation

tools

The program

enabled the

identification of

at-risk popula-

tions the im-

plementation of

appropriate

actions and

the achieve-

ment of posi-

tive measura-

ble results

Quality

Score

9

6

8






Author

Year

Country

Design

Gunningberg21

1999

Sweden

Controlled

study

Hiser22

2006

USA

Before-after

Hobbs23

2004

USA

Before-after

Setting

One hospital 4


ment of orthopedics



tures


including a medical

ICU

280-bed geriatric

hospital 4 units

geriatrics oncology

surgical postop and

orthopedicsneurol-

ogy


Intervention










(C) risk assessment




tion conducted



















education

Measures Reported









(PT)

1 patients with PUs

(prevalence) entire

hospital (PT)



pital (PT)

3 patients with PUs

(medical ICU) (PT)



ICU) (PT)


(PT)




mial pneumonia (PT)


rals (per month) to



(PRO)

Effect

Group

I vs C

0

Group

I vs C

0

0

0

0

0

+||

+||

0

0

Months

6sect

15sect

6sect

Authorsrsquo

Conclusions

No difference in

prevalence be-

tween interven-

tion and control

groups use of

the Modified

Norton Scale

facilitated the

identification of

the majority of

patients at risk

for PUs

Changes re-

sulted in a de-

crease in

quarterly hospi-

tal-acquired PU

prevalence in

participating

units Clinicians

now approach

PUs as pre-

ventable over-

all quality of

care and finan-

cial resource

utilization are

also improved

Following im-

plementation of

the turn team

program pa-

tient referrals to

the enteros-

tomal therapy

nurse average

length of stay

and muscu-

loskeletal in-

juries to staff all

declined

Quality

Score

11

10

11






Author

Year

Country

Design

Hopkins24

2000

USA

Before-after

Hunter25

1995

USA

Before-after

Jones26

1993

USA

Before-after

Setting

One acute care hos-

pital adult medical

surgical population

units not specified



350-bed community


on oncology med-

ical surgical ICU

intermediate care

units and high-risk

pediatric patients


Intervention


















staff education












education

Measures Reported




(PT)


quired PUs (PT)


dicted PUs (PT)

1 PU prevalence



IndashIV) (PT)


IIndashIV) (PT)

3 PU incidence (PT)





existing PUs (PRO)

5 patients who had



(PRO)

Effect

+||

Udagger

Udagger

0

0

0

0

Udagger

Udagger

Months

24Dagger

16sect

5sect

Authorsrsquo

Conclusions

Multidimen-

sional interven-

tions as an

adjunct to best

practices and

research-based

protocols im-

proved nosoco-

mial PU rates

Following im-

plementation of

protocols PU

prevalence de-

creased Health

care facilities

can improve

the quality of

care for PU

prevention by

establishing a

well-structured

PU prevention

treatment

program

Overall de-

crease in PU

incidence was

found and the

documentation

of PUs im-

proved Educa-

tion of nursing

staff is a key

component of

PU prevention

Quality

Score

15

13

13






Author

Year

Country

Design

LeMaster27

2007

USA

Before-after

Lyder28

2004

USA

Before-after

Setting

502-bed hospital 2

units pulmonary and

oncology

17 hospitals in the



from 200 to 800

beds


Intervention













tion conducted

















and at conferences

Measures Reported





(PT)



(PT)



2 Hospital-acquired

Stage I PU (PT)


gt Stage II (PT)


any stage (PT)


stay (days) (PT)






(PRO)

9 Use of pressure-



(PRO)



(PRO)





(PRO)



(PRO)


Stage I PUs (PRO)


Stage II PUs (PRO)

Effect

Udagger

Udagger

0

0

0

0

+||

0

0

+||

0

0

+||

+||

0

+||

Months

12sect

Not

clear

Authorsrsquo

Conclusions

The interven-

tion was suc-

cessful and

was replicated

throughout the

facility

Found clinically

and statistically

significant im-

provements in

4 PU preven-

tion-related

processes of

care concurrent

with multi-

faceted

improvement

intervention

Quality

Score

9

14






Author

Year

Country

Design

McErlean29

2002

Australia

Before-after

McInerney30

2008

USA

Before-after

Moore31

1997

USA

Before-after

Setting

250-bed hospital

units not specified

548-bed 2-hospital

system all patients


mental health

500+ bed university

hospital units not

specified


Intervention























relief orders














Measures Reported



1 PU incidence (all

stages) (PT)


Stage I PUs (PT)


Stage II PUs (PT)


Stage III PUs (PT)


Stage IV PUs (PT)

1 Overall hospital-




Effect

Udagger

Udagger

Udagger

Udagger

Udagger

Udagger

+||

+||

Months

12Dagger

59sect

19sect

Authorsrsquo

Conclusions

Both the identi-

fication of pa-

tient risk at

admission and

the implemen-

tation of appro-

priate pre-

ventive inter-

ventions have

increased this

has resulted in

a reduction in

the incidence

and severity of

PUs

The hospital

system was

able to reduce

hospital-ac-

quired PU

prevalence by

81 The re-

sultant cost

savings in ad-

dition to the

elimination of

patientsrsquo pain

and suffering

from PUs can

significantly im-

pact the cost

and quality of

care

A systematic

approach to

change includ-

ing a more

comprehensive

theory will

guide leaders

in promoting

change

Quality

Score

10

10

11


AP10




AP11


Author

Year

Country

Design

Murray32

1994

USA

Before-after

OrsquoBrien33

1998

USA

Before-after

Setting

One hospital

medicalsurgical and


only

750-bed university


except psychiatric

labor and delivery

postpartum and

newborn nursery


Intervention
















Measures Reported





(PT)


(PT)




Stages II-IV (PT)



(PT)

5 patients with PUs





ordered (PRO)




completed (PRO)




(PRO)






not (PRO)










reassessment (PRO)






Effect

Udagger

Udagger

+||

+||

0

+||

0

+||

0

0

0

0

ndash

0

+||

Months

28sect

48Dagger

Authorsrsquo

Conclusions

PU prevention

programs

should include

a risk assess-

ment tool pro-

tocols for PU

prevention staff

education and a

means to evalu-

ate outcomes

Systemwide

educational ef-

forts that in-

clude all levels

of professionals

and multispe-

cialty preven-

tion and care

efforts can lead

to a reduction

in PU preva-

lence

Quality

Score

13

15





AP12


Author

Year

Country

Design

Olson34

1998

Canada

Before-after

Peich35

2004

Israel

Before-after

Pokorny36

2003

USA

Before-after

Setting

One cancer hospital

2 units

300-bed teaching

hospital orthopedic

unit and recovery

room intervention

limited to patients

with hip fractures


cardiac surgery ICU

and cardiac surgery

intermediate care



dergoing elective

open heart surgery


Intervention















mattresses













education

Measures Reported




oped PU in hospital


on admission (PT)

1 of nosocomial PUs

among hip fracture

patients (PT)


Effect

0

+||

Udagger

Months

Not

clear

28sect

Not

clear

Authorsrsquo

Conclusions

The Braden

Scale has been

permanently in-

corporated into

the daily chart-

ing forms It is

now possible to

track the de-

gree to which

the scale and

prevention pro-

tocol are used

through the

quarterly chart

audits

PU prevention

in patients with

hip fractures is

feasible An

increased

awareness of

the problem

among hospital

staff may be

important

The develop-

ment and

progress of

PUs can be al-

tered by nurs-

ing care PU

risk can only

be predicted

through

repeated

assessments

throughout

hospitalization

Quality

Score

11

12

12





AP13


Author

Year

Country

Design

Rashotte37

2008

Canada

Before-after

Setting



Intervention










PU prevention

Measures Reported






(PRO)




(PRO)



(PRO)



completed (PRO)

5 Median number of


faces in use (PRO)








8 Median number of



protectors used to


(PRO)




(PRO)

10 Median number of


care expert (PRO)

Effect

Udagger

Udagger

Udagger

Udagger

Udagger

Udagger

Udagger

Udagger

Udagger

Udagger

Months

6sect

Authorsrsquo

Conclusions

Significant

changes in

nursing best

practice guide-

lines were

found which

highlights the

complexities of

changing prac-

tice Contextual

influences such

as teamwork

and resources

may inform

results

Quality

Score

6





AP14


Author

Year

Country

Design

Sacharok38

1998

USA

Before-after

Saleh39

2009

UK

Controlled

clinical trial

Stier40

2004

USA

Before-after

Setting

300-bed acute care

community hospital

several units adult

medical surgical

critical care and

later emergency

room


Health care system

in eastern US units

not specified


Intervention





tool conducted PDSA











times)
















only












Measures Reported



1 Prevalence of

nosocomial PUs (PT)



admission (PT)

1 Nosocomial PU

incidence (PT)

Effect

Udagger

Group

A vs

C

0

Group

B vs

C

0

Udagger

Months

47sect

13Dagger

Not

clear

Authorsrsquo

Conclusions

Implementation

of a total quality

management

model resulted

in an 83 re-

duction in PU

prevalence

There were no

differences in

PU incidence in

the groups that

received addi-

tional training

Clinical judg-

ment may be

as effective as

employing a

risk assess-

ment scale to

assess risk for

PUs

The sustained

success of the

program is at-

tributed to (1) a

reliable and

valid measure-

ment system

that facilitates

performance

assessment

and evaluation

and (2) ongoing

unit educational

activities

Quality

Score

11

10

12





AP15


Author

Year

Country

Design

Stoelting41

2007

USA

Before-after

Uzun42

2009

Turkey

Before-after

Van Etten43

1990

USA

Before-after

Setting

Large teaching

hospital units not

specified

880-bed acute care

university hospital

ICU areas only 2

general medical

surgical ICUs

1 neurosurgical ICU

1 postanesthesia

care unit


risk care areas (1)



dics (3) acute

neurointensive care


Intervention


























education

Measures Reported



1 PU incidence (PT)





(PT)

1 patients with


(PT)

Effect

Udagger

+||

+||

Months

Not

clear

35sect

6sect

Authorsrsquo

Conclusions

An intervention

targeting

awareness and

communication

regarding PUs

resulted in

more complete

adherence to

the nursing

prevention

protocol

An education

program and

implementation

of preventive

nursing inter-

ventions were

effective in de-

creasing PU in-

cidence in ICU

patients

The program

appeared to be

successful as

evidenced by a

decrease in

nosocomial PU

rates Findings

underscore the

importance of

identifying pa-

tient risk for

PUs and follow-

ing through

with a plan for

prevention and

treatment

Quality

Score

7

13

11





AP16


Author

Year

Country

Design

Willson44

1995

USA

Before-after

Setting

One hospital

4 medicalsurgical

units


Intervention









used

Measures Reported



1 PU incidence (PT)

Effect

Udagger

Months

6sect

Authorsrsquo

Conclusions

Preliminary

results indicate

that modifica-

tions to a hos-


tion system can

support staff in

following new

protocols and

can lead to a

decrease in PU

incidence

Quality

Score

8















CONCLUSION













J













lynnsobanvagov

Online-Only Content



8










Author

Year

Country

Design

Bales7

2009

USA

Before-after

Ballard8

2008

USA

Before-after

Bergstrom9

1995

USA

Before-after

Setting

300-bed community

hospital units not

specified

2 ICUs in same

facility one 26-bed

ICU with focus on

trauma neurosurgi-


and an 18-bed med-

ical ICU


tal one high-acuity



Intervention















wards














graphs










managed

Measures Reported


PRO = Nursing

Process

1 Prevalence of




nosocomial PU (PT)

1 PU incidence (PT)


Effect

Udagger

Udagger

+||

+||

Months

16Dagger

18sect

44Dagger

44Dagger

Authorsrsquo

Conclusions

PU prevalence

can be reduced

to zero impor-

tant to success

are the involve-

ment of the

leadership

team staff in-

volvement in

decision mak-

ing and a de-

sire to foster

interdisciplinary

relationships

A substantial

reduction in PU

rates was

achieved The

use of perfor -

mance data

and a change

in unit culture

were key to this

success

Through the

implementation

of a research-

based risk as-

sessment tool

and prevention

program in-

formed by

assessment

findings PU

incidence can

be decreased

Quality

Score

8

9

11






Author

Year

Country

Design

Bergstrom9

1995

USA

Before-after

Bethell10

1994

USA

Before-after

Bours11

2004

The

Netherlands

Time series

Catania12

2007

USA

Before-after

Setting

240-bed hospital

units not specified

One hospital


not specified

Six acute care

hospitals in the


lt 13 years of age

excluded from

analysis

A cancer hospital 5

units 2 medical 2

surgical and the

critical care unit


Intervention









to Kardex





















complete forms)

Measures Reported


PRO = Nursing

Process


acquired PUs (PT)


1 Case mix-adjusted




admission (PT)

1 PU incidence (PT)


Effect

+||

Udagger

Udagger

+||

+||

Months

12Dagger

16Dagger

60sect

21sect

21sect

Authorsrsquo

Conclusions

The program

effectively re-

duced PUs

Teamwork was

an important

aspect of the

intervention

PU prevalence

decreased

more than a

quarter

Monitoring

prevalence and

providing feed-

back to hospi-

tals resulted in

improvement in

PU prevention

Implementation

resulted in a

greater than

50 decrease

in PU preva-

lence and has

been main-

tained for more

than 2 years

Quality

Score

12

7

12

11






Author

Year

Country

Design

Charrier13

2008

Italy

Controlled

clinical trial

Setting


fied) in an Italian

hospital


Intervention


protocol adherence

Measures Reported


PRO = Nursing

Process




is a protocol and

location (PRO)


(PRO)



5 (Braden form)

updated (PRO)



(PRO)

7 Used change in

posture form (PRO)



out (PRO)



mobilized (PRO)

10 Products for





(PRO)


(PRO)


to protocol (PRO)

15 Staging of LDP

(PRO)

16 Is it registered

(PRO)

17 Form completely

filled in (PRO)


respected (PRO)



col (PRO)



(PRO)

Effect

Udagger

Udagger

0

0

0

0

0

0

+||

ndash

0

Udagger

+||

+||

+||

+||

+||

+||

0

0

Months

18Dagger

Authorsrsquo

Conclusions

7 of 20

processes

showed signifi-

cant improve-

ment in the

intervention

group relative

to the control

group

Quality

Score

4






Author

Year

Country

Design

Chicano14

2009

USA

Before-after

Courtney15

2006

USA

Before-after

Setting

One 25-bed interme-

diate care unit

710-bed multisite

facility units not

specified


Intervention













standards






















care products

Measures Reported


PRO = Nursing

Process


acquired PUs (PT)


acquired PUs (PT)

Effect

Udagger

Udagger

Months

21Dagger

30sect

Authorsrsquo

Conclusions

PU strategies

proved effec-

tive in decreas-

ing incidence

during a 1-year

period The

commitment amp

diligence of the

quality im-

provement (QI)

team amp mem-

bers of the


ernance coun-

cils were

important fac-

tors in achiev-

ing this goal

Incidence of

PUs decreased

by nearly 70

as a result of

intervention

the overall cul-

ture change at

the medical

center remains

a work in

progress

Quality

Score

8

10






Author

Year

Country

Design

deLaat16

2007

The

Netherlands

Before-after

deLaat17

2006

The

Netherlands

Before-after

Setting

28-bed adult inten-



2 general medical



surgical unit

900-bed university

medical center


Intervention















A contact nurse was


and a PU consultant



per and intranet

Measures Reported








IV (PT)


IIndashIV (PT)



of stay (PT)




transferred (PRO)

1 patients with PUs




as high risk (PT)

2 patients with PUs




as high risk (PT)





Stage I (PRO)






PU ge Stage I (PRO)













Effect

+||

Udagger

+||

+||

+||

+||

+||

0

+||

+||

0

Months

12Dagger

11sect

Authorsrsquo

Conclusions

Implementation

of guideline for

PU care re-

sulted in signifi-

cant and

sustained de-

crease in the

incidence of

Stage II-IV PU

in ICU patients

PU frequency

can be

successfully

decreased

introduction of

adequate

mattresses and

guidelines for

prevention and

treatment are

promising

tools

Quality

Score

15

13






Author

Year

Country

Design

Dibsie18

2008

USA

Before-after

Dukich19

2001

USA

Before-after

Gibbons20

2006

USA

Before-after

Setting

Multisite academic


not specified


Trauma Center and



each site ICUs and

medicalsurgical

units

528-bed hospital in

Florida all units


Intervention


protocol conducted





on new products









of support surfaces











product changed

Measures Reported





(PT)



(PT)


I (Hospital B) (PT)





(PT)



(PT)

1 Facility-acquired


Effect

Udagger

Udagger

Udagger

Udagger

Udagger

Udagger

Udagger

Months

21Dagger

12Dagger

14sect

Authorsrsquo

Conclusions

Implementation

of an evidence-

based practice

protocol led to

improvements

in PU preva-

lence

A modest de-

crease in an-

nual expendi -

tures for rental

support sur-

faces was real-

ized results for

incidence and

prevalence dif-

fered across

hospitals and

may be attribut-

able to non-

standardized

documentation

tools

The program

enabled the

identification of

at-risk popula-

tions the im-

plementation of

appropriate

actions and

the achieve-

ment of posi-

tive measura-

ble results

Quality

Score

9

6

8






Author

Year

Country

Design

Gunningberg21

1999

Sweden

Controlled

study

Hiser22

2006

USA

Before-after

Hobbs23

2004

USA

Before-after

Setting

One hospital 4


ment of orthopedics



tures


including a medical

ICU

280-bed geriatric

hospital 4 units

geriatrics oncology

surgical postop and

orthopedicsneurol-

ogy


Intervention










(C) risk assessment




tion conducted



















education

Measures Reported









(PT)

1 patients with PUs

(prevalence) entire

hospital (PT)



pital (PT)

3 patients with PUs

(medical ICU) (PT)



ICU) (PT)


(PT)




mial pneumonia (PT)


rals (per month) to



(PRO)

Effect

Group

I vs C

0

Group

I vs C

0

0

0

0

0

+||

+||

0

0

Months

6sect

15sect

6sect

Authorsrsquo

Conclusions

No difference in

prevalence be-

tween interven-

tion and control

groups use of

the Modified

Norton Scale

facilitated the

identification of

the majority of

patients at risk

for PUs

Changes re-

sulted in a de-

crease in

quarterly hospi-

tal-acquired PU

prevalence in

participating

units Clinicians

now approach

PUs as pre-

ventable over-

all quality of

care and finan-

cial resource

utilization are

also improved

Following im-

plementation of

the turn team

program pa-

tient referrals to

the enteros-

tomal therapy

nurse average

length of stay

and muscu-

loskeletal in-

juries to staff all

declined

Quality

Score

11

10

11






Author

Year

Country

Design

Hopkins24

2000

USA

Before-after

Hunter25

1995

USA

Before-after

Jones26

1993

USA

Before-after

Setting

One acute care hos-

pital adult medical

surgical population

units not specified



350-bed community


on oncology med-

ical surgical ICU

intermediate care

units and high-risk

pediatric patients


Intervention


















staff education












education

Measures Reported




(PT)


quired PUs (PT)


dicted PUs (PT)

1 PU prevalence



IndashIV) (PT)


IIndashIV) (PT)

3 PU incidence (PT)





existing PUs (PRO)

5 patients who had



(PRO)

Effect

+||

Udagger

Udagger

0

0

0

0

Udagger

Udagger

Months

24Dagger

16sect

5sect

Authorsrsquo

Conclusions

Multidimen-

sional interven-

tions as an

adjunct to best

practices and

research-based

protocols im-

proved nosoco-

mial PU rates

Following im-

plementation of

protocols PU

prevalence de-

creased Health

care facilities

can improve

the quality of

care for PU

prevention by

establishing a

well-structured

PU prevention

treatment

program

Overall de-

crease in PU

incidence was

found and the

documentation

of PUs im-

proved Educa-

tion of nursing

staff is a key

component of

PU prevention

Quality

Score

15

13

13






Author

Year

Country

Design

LeMaster27

2007

USA

Before-after

Lyder28

2004

USA

Before-after

Setting

502-bed hospital 2

units pulmonary and

oncology

17 hospitals in the



from 200 to 800

beds


Intervention













tion conducted

















and at conferences

Measures Reported





(PT)



(PT)



2 Hospital-acquired

Stage I PU (PT)


gt Stage II (PT)


any stage (PT)


stay (days) (PT)






(PRO)

9 Use of pressure-



(PRO)



(PRO)





(PRO)



(PRO)


Stage I PUs (PRO)


Stage II PUs (PRO)

Effect

Udagger

Udagger

0

0

0

0

+||

0

0

+||

0

0

+||

+||

0

+||

Months

12sect

Not

clear

Authorsrsquo

Conclusions

The interven-

tion was suc-

cessful and

was replicated

throughout the

facility

Found clinically

and statistically

significant im-

provements in

4 PU preven-

tion-related

processes of

care concurrent

with multi-

faceted

improvement

intervention

Quality

Score

9

14






Author

Year

Country

Design

McErlean29

2002

Australia

Before-after

McInerney30

2008

USA

Before-after

Moore31

1997

USA

Before-after

Setting

250-bed hospital

units not specified

548-bed 2-hospital

system all patients


mental health

500+ bed university

hospital units not

specified


Intervention























relief orders














Measures Reported



1 PU incidence (all

stages) (PT)


Stage I PUs (PT)


Stage II PUs (PT)


Stage III PUs (PT)


Stage IV PUs (PT)

1 Overall hospital-




Effect

Udagger

Udagger

Udagger

Udagger

Udagger

Udagger

+||

+||

Months

12Dagger

59sect

19sect

Authorsrsquo

Conclusions

Both the identi-

fication of pa-

tient risk at

admission and

the implemen-

tation of appro-

priate pre-

ventive inter-

ventions have

increased this

has resulted in

a reduction in

the incidence

and severity of

PUs

The hospital

system was

able to reduce

hospital-ac-

quired PU

prevalence by

81 The re-

sultant cost

savings in ad-

dition to the

elimination of

patientsrsquo pain

and suffering

from PUs can

significantly im-

pact the cost

and quality of

care

A systematic

approach to

change includ-

ing a more

comprehensive

theory will

guide leaders

in promoting

change

Quality

Score

10

10

11


AP10




AP11


Author

Year

Country

Design

Murray32

1994

USA

Before-after

OrsquoBrien33

1998

USA

Before-after

Setting

One hospital

medicalsurgical and


only

750-bed university


except psychiatric

labor and delivery

postpartum and

newborn nursery


Intervention
















Measures Reported





(PT)


(PT)




Stages II-IV (PT)



(PT)

5 patients with PUs





ordered (PRO)




completed (PRO)




(PRO)






not (PRO)










reassessment (PRO)






Effect

Udagger

Udagger

+||

+||

0

+||

0

+||

0

0

0

0

ndash

0

+||

Months

28sect

48Dagger

Authorsrsquo

Conclusions

PU prevention

programs

should include

a risk assess-

ment tool pro-

tocols for PU

prevention staff

education and a

means to evalu-

ate outcomes

Systemwide

educational ef-

forts that in-

clude all levels

of professionals

and multispe-

cialty preven-

tion and care

efforts can lead

to a reduction

in PU preva-

lence

Quality

Score

13

15





AP12


Author

Year

Country

Design

Olson34

1998

Canada

Before-after

Peich35

2004

Israel

Before-after

Pokorny36

2003

USA

Before-after

Setting

One cancer hospital

2 units

300-bed teaching

hospital orthopedic

unit and recovery

room intervention

limited to patients

with hip fractures


cardiac surgery ICU

and cardiac surgery

intermediate care



dergoing elective

open heart surgery


Intervention















mattresses













education

Measures Reported




oped PU in hospital


on admission (PT)

1 of nosocomial PUs

among hip fracture

patients (PT)


Effect

0

+||

Udagger

Months

Not

clear

28sect

Not

clear

Authorsrsquo

Conclusions

The Braden

Scale has been

permanently in-

corporated into

the daily chart-

ing forms It is

now possible to

track the de-

gree to which

the scale and

prevention pro-

tocol are used

through the

quarterly chart

audits

PU prevention

in patients with

hip fractures is

feasible An

increased

awareness of

the problem

among hospital

staff may be

important

The develop-

ment and

progress of

PUs can be al-

tered by nurs-

ing care PU

risk can only

be predicted

through

repeated

assessments

throughout

hospitalization

Quality

Score

11

12

12





AP13


Author

Year

Country

Design

Rashotte37

2008

Canada

Before-after

Setting



Intervention










PU prevention

Measures Reported






(PRO)




(PRO)



(PRO)



completed (PRO)

5 Median number of


faces in use (PRO)








8 Median number of



protectors used to


(PRO)




(PRO)

10 Median number of


care expert (PRO)

Effect

Udagger

Udagger

Udagger

Udagger

Udagger

Udagger

Udagger

Udagger

Udagger

Udagger

Months

6sect

Authorsrsquo

Conclusions

Significant

changes in

nursing best

practice guide-

lines were

found which

highlights the

complexities of

changing prac-

tice Contextual

influences such

as teamwork

and resources

may inform

results

Quality

Score

6





AP14


Author

Year

Country

Design

Sacharok38

1998

USA

Before-after

Saleh39

2009

UK

Controlled

clinical trial

Stier40

2004

USA

Before-after

Setting

300-bed acute care

community hospital

several units adult

medical surgical

critical care and

later emergency

room


Health care system

in eastern US units

not specified


Intervention





tool conducted PDSA











times)
















only












Measures Reported



1 Prevalence of

nosocomial PUs (PT)



admission (PT)

1 Nosocomial PU

incidence (PT)

Effect

Udagger

Group

A vs

C

0

Group

B vs

C

0

Udagger

Months

47sect

13Dagger

Not

clear

Authorsrsquo

Conclusions

Implementation

of a total quality

management

model resulted

in an 83 re-

duction in PU

prevalence

There were no

differences in

PU incidence in

the groups that

received addi-

tional training

Clinical judg-

ment may be

as effective as

employing a

risk assess-

ment scale to

assess risk for

PUs

The sustained

success of the

program is at-

tributed to (1) a

reliable and

valid measure-

ment system

that facilitates

performance

assessment

and evaluation

and (2) ongoing

unit educational

activities

Quality

Score

11

10

12





AP15


Author

Year

Country

Design

Stoelting41

2007

USA

Before-after

Uzun42

2009

Turkey

Before-after

Van Etten43

1990

USA

Before-after

Setting

Large teaching

hospital units not

specified

880-bed acute care

university hospital

ICU areas only 2

general medical

surgical ICUs

1 neurosurgical ICU

1 postanesthesia

care unit


risk care areas (1)



dics (3) acute

neurointensive care


Intervention


























education

Measures Reported



1 PU incidence (PT)





(PT)

1 patients with


(PT)

Effect

Udagger

+||

+||

Months

Not

clear

35sect

6sect

Authorsrsquo

Conclusions

An intervention

targeting

awareness and

communication

regarding PUs

resulted in

more complete

adherence to

the nursing

prevention

protocol

An education

program and

implementation

of preventive

nursing inter-

ventions were

effective in de-

creasing PU in-

cidence in ICU

patients

The program

appeared to be

successful as

evidenced by a

decrease in

nosocomial PU

rates Findings

underscore the

importance of

identifying pa-

tient risk for

PUs and follow-

ing through

with a plan for

prevention and

treatment

Quality

Score

7

13

11





AP16


Author

Year

Country

Design

Willson44

1995

USA

Before-after

Setting

One hospital

4 medicalsurgical

units


Intervention









used

Measures Reported



1 PU incidence (PT)

Effect

Udagger

Months

6sect

Authorsrsquo

Conclusions

Preliminary

results indicate

that modifica-

tions to a hos-


tion system can

support staff in

following new

protocols and

can lead to a

decrease in PU

incidence

Quality

Score

8


















Author

Year

Country

Design

Bales7

2009

USA

Before-after

Ballard8

2008

USA

Before-after

Bergstrom9

1995

USA

Before-after

Setting

300-bed community

hospital units not

specified

2 ICUs in same

facility one 26-bed

ICU with focus on

trauma neurosurgi-


and an 18-bed med-

ical ICU


tal one high-acuity



Intervention















wards














graphs










managed

Measures Reported


PRO = Nursing

Process

1 Prevalence of




nosocomial PU (PT)

1 PU incidence (PT)


Effect

Udagger

Udagger

+||

+||

Months

16Dagger

18sect

44Dagger

44Dagger

Authorsrsquo

Conclusions

PU prevalence

can be reduced

to zero impor-

tant to success

are the involve-

ment of the

leadership

team staff in-

volvement in

decision mak-

ing and a de-

sire to foster

interdisciplinary

relationships

A substantial

reduction in PU

rates was

achieved The

use of perfor -

mance data

and a change

in unit culture

were key to this

success

Through the

implementation

of a research-

based risk as-

sessment tool

and prevention

program in-

formed by

assessment

findings PU

incidence can

be decreased

Quality

Score

8

9

11






Author

Year

Country

Design

Bergstrom9

1995

USA

Before-after

Bethell10

1994

USA

Before-after

Bours11

2004

The

Netherlands

Time series

Catania12

2007

USA

Before-after

Setting

240-bed hospital

units not specified

One hospital


not specified

Six acute care

hospitals in the


lt 13 years of age

excluded from

analysis

A cancer hospital 5

units 2 medical 2

surgical and the

critical care unit


Intervention









to Kardex





















complete forms)

Measures Reported


PRO = Nursing

Process


acquired PUs (PT)


1 Case mix-adjusted




admission (PT)

1 PU incidence (PT)


Effect

+||

Udagger

Udagger

+||

+||

Months

12Dagger

16Dagger

60sect

21sect

21sect

Authorsrsquo

Conclusions

The program

effectively re-

duced PUs

Teamwork was

an important

aspect of the

intervention

PU prevalence

decreased

more than a

quarter

Monitoring

prevalence and

providing feed-

back to hospi-

tals resulted in

improvement in

PU prevention

Implementation

resulted in a

greater than

50 decrease

in PU preva-

lence and has

been main-

tained for more

than 2 years

Quality

Score

12

7

12

11






Author

Year

Country

Design

Charrier13

2008

Italy

Controlled

clinical trial

Setting


fied) in an Italian

hospital


Intervention


protocol adherence

Measures Reported


PRO = Nursing

Process




is a protocol and

location (PRO)


(PRO)



5 (Braden form)

updated (PRO)



(PRO)

7 Used change in

posture form (PRO)



out (PRO)



mobilized (PRO)

10 Products for





(PRO)


(PRO)


to protocol (PRO)

15 Staging of LDP

(PRO)

16 Is it registered

(PRO)

17 Form completely

filled in (PRO)


respected (PRO)



col (PRO)



(PRO)

Effect

Udagger

Udagger

0

0

0

0

0

0

+||

ndash

0

Udagger

+||

+||

+||

+||

+||

+||

0

0

Months

18Dagger

Authorsrsquo

Conclusions

7 of 20

processes

showed signifi-

cant improve-

ment in the

intervention

group relative

to the control

group

Quality

Score

4






Author

Year

Country

Design

Chicano14

2009

USA

Before-after

Courtney15

2006

USA

Before-after

Setting

One 25-bed interme-

diate care unit

710-bed multisite

facility units not

specified


Intervention













standards






















care products

Measures Reported


PRO = Nursing

Process


acquired PUs (PT)


acquired PUs (PT)

Effect

Udagger

Udagger

Months

21Dagger

30sect

Authorsrsquo

Conclusions

PU strategies

proved effec-

tive in decreas-

ing incidence

during a 1-year

period The

commitment amp

diligence of the

quality im-

provement (QI)

team amp mem-

bers of the


ernance coun-

cils were

important fac-

tors in achiev-

ing this goal

Incidence of

PUs decreased

by nearly 70

as a result of

intervention

the overall cul-

ture change at

the medical

center remains

a work in

progress

Quality

Score

8

10






Author

Year

Country

Design

deLaat16

2007

The

Netherlands

Before-after

deLaat17

2006

The

Netherlands

Before-after

Setting

28-bed adult inten-



2 general medical



surgical unit

900-bed university

medical center


Intervention















A contact nurse was


and a PU consultant



per and intranet

Measures Reported








IV (PT)


IIndashIV (PT)



of stay (PT)




transferred (PRO)

1 patients with PUs




as high risk (PT)

2 patients with PUs




as high risk (PT)





Stage I (PRO)






PU ge Stage I (PRO)













Effect

+||

Udagger

+||

+||

+||

+||

+||

0

+||

+||

0

Months

12Dagger

11sect

Authorsrsquo

Conclusions

Implementation

of guideline for

PU care re-

sulted in signifi-

cant and

sustained de-

crease in the

incidence of

Stage II-IV PU

in ICU patients

PU frequency

can be

successfully

decreased

introduction of

adequate

mattresses and

guidelines for

prevention and

treatment are

promising

tools

Quality

Score

15

13






Author

Year

Country

Design

Dibsie18

2008

USA

Before-after

Dukich19

2001

USA

Before-after

Gibbons20

2006

USA

Before-after

Setting

Multisite academic


not specified


Trauma Center and



each site ICUs and

medicalsurgical

units

528-bed hospital in

Florida all units


Intervention


protocol conducted





on new products









of support surfaces











product changed

Measures Reported





(PT)



(PT)


I (Hospital B) (PT)





(PT)



(PT)

1 Facility-acquired


Effect

Udagger

Udagger

Udagger

Udagger

Udagger

Udagger

Udagger

Months

21Dagger

12Dagger

14sect

Authorsrsquo

Conclusions

Implementation

of an evidence-

based practice

protocol led to

improvements

in PU preva-

lence

A modest de-

crease in an-

nual expendi -

tures for rental

support sur-

faces was real-

ized results for

incidence and

prevalence dif-

fered across

hospitals and

may be attribut-

able to non-

standardized

documentation

tools

The program

enabled the

identification of

at-risk popula-

tions the im-

plementation of

appropriate

actions and

the achieve-

ment of posi-

tive measura-

ble results

Quality

Score

9

6

8






Author

Year

Country

Design

Gunningberg21

1999

Sweden

Controlled

study

Hiser22

2006

USA

Before-after

Hobbs23

2004

USA

Before-after

Setting

One hospital 4


ment of orthopedics



tures


including a medical

ICU

280-bed geriatric

hospital 4 units

geriatrics oncology

surgical postop and

orthopedicsneurol-

ogy


Intervention










(C) risk assessment




tion conducted



















education

Measures Reported









(PT)

1 patients with PUs

(prevalence) entire

hospital (PT)



pital (PT)

3 patients with PUs

(medical ICU) (PT)



ICU) (PT)


(PT)




mial pneumonia (PT)


rals (per month) to



(PRO)

Effect

Group

I vs C

0

Group

I vs C

0

0

0

0

0

+||

+||

0

0

Months

6sect

15sect

6sect

Authorsrsquo

Conclusions

No difference in

prevalence be-

tween interven-

tion and control

groups use of

the Modified

Norton Scale

facilitated the

identification of

the majority of

patients at risk

for PUs

Changes re-

sulted in a de-

crease in

quarterly hospi-

tal-acquired PU

prevalence in

participating

units Clinicians

now approach

PUs as pre-

ventable over-

all quality of

care and finan-

cial resource

utilization are

also improved

Following im-

plementation of

the turn team

program pa-

tient referrals to

the enteros-

tomal therapy

nurse average

length of stay

and muscu-

loskeletal in-

juries to staff all

declined

Quality

Score

11

10

11






Author

Year

Country

Design

Hopkins24

2000

USA

Before-after

Hunter25

1995

USA

Before-after

Jones26

1993

USA

Before-after

Setting

One acute care hos-

pital adult medical

surgical population

units not specified



350-bed community


on oncology med-

ical surgical ICU

intermediate care

units and high-risk

pediatric patients


Intervention


















staff education












education

Measures Reported




(PT)


quired PUs (PT)


dicted PUs (PT)

1 PU prevalence



IndashIV) (PT)


IIndashIV) (PT)

3 PU incidence (PT)





existing PUs (PRO)

5 patients who had



(PRO)

Effect

+||

Udagger

Udagger

0

0

0

0

Udagger

Udagger

Months

24Dagger

16sect

5sect

Authorsrsquo

Conclusions

Multidimen-

sional interven-

tions as an

adjunct to best

practices and

research-based

protocols im-

proved nosoco-

mial PU rates

Following im-

plementation of

protocols PU

prevalence de-

creased Health

care facilities

can improve

the quality of

care for PU

prevention by

establishing a

well-structured

PU prevention

treatment

program

Overall de-

crease in PU

incidence was

found and the

documentation

of PUs im-

proved Educa-

tion of nursing

staff is a key

component of

PU prevention

Quality

Score

15

13

13






Author

Year

Country

Design

LeMaster27

2007

USA

Before-after

Lyder28

2004

USA

Before-after

Setting

502-bed hospital 2

units pulmonary and

oncology

17 hospitals in the



from 200 to 800

beds


Intervention













tion conducted

















and at conferences

Measures Reported





(PT)



(PT)



2 Hospital-acquired

Stage I PU (PT)


gt Stage II (PT)


any stage (PT)


stay (days) (PT)






(PRO)

9 Use of pressure-



(PRO)



(PRO)





(PRO)



(PRO)


Stage I PUs (PRO)


Stage II PUs (PRO)

Effect

Udagger

Udagger

0

0

0

0

+||

0

0

+||

0

0

+||

+||

0

+||

Months

12sect

Not

clear

Authorsrsquo

Conclusions

The interven-

tion was suc-

cessful and

was replicated

throughout the

facility

Found clinically

and statistically

significant im-

provements in

4 PU preven-

tion-related

processes of

care concurrent

with multi-

faceted

improvement

intervention

Quality

Score

9

14






Author

Year

Country

Design

McErlean29

2002

Australia

Before-after

McInerney30

2008

USA

Before-after

Moore31

1997

USA

Before-after

Setting

250-bed hospital

units not specified

548-bed 2-hospital

system all patients


mental health

500+ bed university

hospital units not

specified


Intervention























relief orders














Measures Reported



1 PU incidence (all

stages) (PT)


Stage I PUs (PT)


Stage II PUs (PT)


Stage III PUs (PT)


Stage IV PUs (PT)

1 Overall hospital-




Effect

Udagger

Udagger

Udagger

Udagger

Udagger

Udagger

+||

+||

Months

12Dagger

59sect

19sect

Authorsrsquo

Conclusions

Both the identi-

fication of pa-

tient risk at

admission and

the implemen-

tation of appro-

priate pre-

ventive inter-

ventions have

increased this

has resulted in

a reduction in

the incidence

and severity of

PUs

The hospital

system was

able to reduce

hospital-ac-

quired PU

prevalence by

81 The re-

sultant cost

savings in ad-

dition to the

elimination of

patientsrsquo pain

and suffering

from PUs can

significantly im-

pact the cost

and quality of

care

A systematic

approach to

change includ-

ing a more

comprehensive

theory will

guide leaders

in promoting

change

Quality

Score

10

10

11


AP10




AP11


Author

Year

Country

Design

Murray32

1994

USA

Before-after

OrsquoBrien33

1998

USA

Before-after

Setting

One hospital

medicalsurgical and


only

750-bed university


except psychiatric

labor and delivery

postpartum and

newborn nursery


Intervention
















Measures Reported





(PT)


(PT)




Stages II-IV (PT)



(PT)

5 patients with PUs





ordered (PRO)




completed (PRO)




(PRO)






not (PRO)










reassessment (PRO)






Effect

Udagger

Udagger

+||

+||

0

+||

0

+||

0

0

0

0

ndash

0

+||

Months

28sect

48Dagger

Authorsrsquo

Conclusions

PU prevention

programs

should include

a risk assess-

ment tool pro-

tocols for PU

prevention staff

education and a

means to evalu-

ate outcomes

Systemwide

educational ef-

forts that in-

clude all levels

of professionals

and multispe-

cialty preven-

tion and care

efforts can lead

to a reduction

in PU preva-

lence

Quality

Score

13

15





AP12


Author

Year

Country

Design

Olson34

1998

Canada

Before-after

Peich35

2004

Israel

Before-after

Pokorny36

2003

USA

Before-after

Setting

One cancer hospital

2 units

300-bed teaching

hospital orthopedic

unit and recovery

room intervention

limited to patients

with hip fractures


cardiac surgery ICU

and cardiac surgery

intermediate care



dergoing elective

open heart surgery


Intervention















mattresses













education

Measures Reported




oped PU in hospital


on admission (PT)

1 of nosocomial PUs

among hip fracture

patients (PT)


Effect

0

+||

Udagger

Months

Not

clear

28sect

Not

clear

Authorsrsquo

Conclusions

The Braden

Scale has been

permanently in-

corporated into

the daily chart-

ing forms It is

now possible to

track the de-

gree to which

the scale and

prevention pro-

tocol are used

through the

quarterly chart

audits

PU prevention

in patients with

hip fractures is

feasible An

increased

awareness of

the problem

among hospital

staff may be

important

The develop-

ment and

progress of

PUs can be al-

tered by nurs-

ing care PU

risk can only

be predicted

through

repeated

assessments

throughout

hospitalization

Quality

Score

11

12

12





AP13


Author

Year

Country

Design

Rashotte37

2008

Canada

Before-after

Setting



Intervention










PU prevention

Measures Reported






(PRO)




(PRO)



(PRO)



completed (PRO)

5 Median number of


faces in use (PRO)








8 Median number of



protectors used to


(PRO)




(PRO)

10 Median number of


care expert (PRO)

Effect

Udagger

Udagger

Udagger

Udagger

Udagger

Udagger

Udagger

Udagger

Udagger

Udagger

Months

6sect

Authorsrsquo

Conclusions

Significant

changes in

nursing best

practice guide-

lines were

found which

highlights the

complexities of

changing prac-

tice Contextual

influences such

as teamwork

and resources

may inform

results

Quality

Score

6





AP14


Author

Year

Country

Design

Sacharok38

1998

USA

Before-after

Saleh39

2009

UK

Controlled

clinical trial

Stier40

2004

USA

Before-after

Setting

300-bed acute care

community hospital

several units adult

medical surgical

critical care and

later emergency

room


Health care system

in eastern US units

not specified


Intervention





tool conducted PDSA











times)
















only












Measures Reported



1 Prevalence of

nosocomial PUs (PT)



admission (PT)

1 Nosocomial PU

incidence (PT)

Effect

Udagger

Group

A vs

C

0

Group

B vs

C

0

Udagger

Months

47sect

13Dagger

Not

clear

Authorsrsquo

Conclusions

Implementation

of a total quality

management

model resulted

in an 83 re-

duction in PU

prevalence

There were no

differences in

PU incidence in

the groups that

received addi-

tional training

Clinical judg-

ment may be

as effective as

employing a

risk assess-

ment scale to

assess risk for

PUs

The sustained

success of the

program is at-

tributed to (1) a

reliable and

valid measure-

ment system

that facilitates

performance

assessment

and evaluation

and (2) ongoing

unit educational

activities

Quality

Score

11

10

12





AP15


Author

Year

Country

Design

Stoelting41

2007

USA

Before-after

Uzun42

2009

Turkey

Before-after

Van Etten43

1990

USA

Before-after

Setting

Large teaching

hospital units not

specified

880-bed acute care

university hospital

ICU areas only 2

general medical

surgical ICUs

1 neurosurgical ICU

1 postanesthesia

care unit


risk care areas (1)



dics (3) acute

neurointensive care


Intervention


























education

Measures Reported



1 PU incidence (PT)





(PT)

1 patients with


(PT)

Effect

Udagger

+||

+||

Months

Not

clear

35sect

6sect

Authorsrsquo

Conclusions

An intervention

targeting

awareness and

communication

regarding PUs

resulted in

more complete

adherence to

the nursing

prevention

protocol

An education

program and

implementation

of preventive

nursing inter-

ventions were

effective in de-

creasing PU in-

cidence in ICU

patients

The program

appeared to be

successful as

evidenced by a

decrease in

nosocomial PU

rates Findings

underscore the

importance of

identifying pa-

tient risk for

PUs and follow-

ing through

with a plan for

prevention and

treatment

Quality

Score

7

13

11





AP16


Author

Year

Country

Design

Willson44

1995

USA

Before-after

Setting

One hospital

4 medicalsurgical

units


Intervention









used

Measures Reported



1 PU incidence (PT)

Effect

Udagger

Months

6sect

Authorsrsquo

Conclusions

Preliminary

results indicate

that modifica-

tions to a hos-


tion system can

support staff in

following new

protocols and

can lead to a

decrease in PU

incidence

Quality

Score

8













Author

Year

Country

Design

Bergstrom9

1995

USA

Before-after

Bethell10

1994

USA

Before-after

Bours11

2004

The

Netherlands

Time series

Catania12

2007

USA

Before-after

Setting

240-bed hospital

units not specified

One hospital


not specified

Six acute care

hospitals in the


lt 13 years of age

excluded from

analysis

A cancer hospital 5

units 2 medical 2

surgical and the

critical care unit


Intervention









to Kardex





















complete forms)

Measures Reported


PRO = Nursing

Process


acquired PUs (PT)


1 Case mix-adjusted




admission (PT)

1 PU incidence (PT)


Effect

+||

Udagger

Udagger

+||

+||

Months

12Dagger

16Dagger

60sect

21sect

21sect

Authorsrsquo

Conclusions

The program

effectively re-

duced PUs

Teamwork was

an important

aspect of the

intervention

PU prevalence

decreased

more than a

quarter

Monitoring

prevalence and

providing feed-

back to hospi-

tals resulted in

improvement in

PU prevention

Implementation

resulted in a

greater than

50 decrease

in PU preva-

lence and has

been main-

tained for more

than 2 years

Quality

Score

12

7

12

11






Author

Year

Country

Design

Charrier13

2008

Italy

Controlled

clinical trial

Setting


fied) in an Italian

hospital


Intervention


protocol adherence

Measures Reported


PRO = Nursing

Process




is a protocol and

location (PRO)


(PRO)



5 (Braden form)

updated (PRO)



(PRO)

7 Used change in

posture form (PRO)



out (PRO)



mobilized (PRO)

10 Products for





(PRO)


(PRO)


to protocol (PRO)

15 Staging of LDP

(PRO)

16 Is it registered

(PRO)

17 Form completely

filled in (PRO)


respected (PRO)



col (PRO)



(PRO)

Effect

Udagger

Udagger

0

0

0

0

0

0

+||

ndash

0

Udagger

+||

+||

+||

+||

+||

+||

0

0

Months

18Dagger

Authorsrsquo

Conclusions

7 of 20

processes

showed signifi-

cant improve-

ment in the

intervention

group relative

to the control

group

Quality

Score

4






Author

Year

Country

Design

Chicano14

2009

USA

Before-after

Courtney15

2006

USA

Before-after

Setting

One 25-bed interme-

diate care unit

710-bed multisite

facility units not

specified


Intervention













standards






















care products

Measures Reported


PRO = Nursing

Process


acquired PUs (PT)


acquired PUs (PT)

Effect

Udagger

Udagger

Months

21Dagger

30sect

Authorsrsquo

Conclusions

PU strategies

proved effec-

tive in decreas-

ing incidence

during a 1-year

period The

commitment amp

diligence of the

quality im-

provement (QI)

team amp mem-

bers of the


ernance coun-

cils were

important fac-

tors in achiev-

ing this goal

Incidence of

PUs decreased

by nearly 70

as a result of

intervention

the overall cul-

ture change at

the medical

center remains

a work in

progress

Quality

Score

8

10






Author

Year

Country

Design

deLaat16

2007

The

Netherlands

Before-after

deLaat17

2006

The

Netherlands

Before-after

Setting

28-bed adult inten-



2 general medical



surgical unit

900-bed university

medical center


Intervention















A contact nurse was


and a PU consultant



per and intranet

Measures Reported








IV (PT)


IIndashIV (PT)



of stay (PT)




transferred (PRO)

1 patients with PUs




as high risk (PT)

2 patients with PUs




as high risk (PT)





Stage I (PRO)






PU ge Stage I (PRO)













Effect

+||

Udagger

+||

+||

+||

+||

+||

0

+||

+||

0

Months

12Dagger

11sect

Authorsrsquo

Conclusions

Implementation

of guideline for

PU care re-

sulted in signifi-

cant and

sustained de-

crease in the

incidence of

Stage II-IV PU

in ICU patients

PU frequency

can be

successfully

decreased

introduction of

adequate

mattresses and

guidelines for

prevention and

treatment are

promising

tools

Quality

Score

15

13






Author

Year

Country

Design

Dibsie18

2008

USA

Before-after

Dukich19

2001

USA

Before-after

Gibbons20

2006

USA

Before-after

Setting

Multisite academic


not specified


Trauma Center and



each site ICUs and

medicalsurgical

units

528-bed hospital in

Florida all units


Intervention


protocol conducted





on new products









of support surfaces











product changed

Measures Reported





(PT)



(PT)


I (Hospital B) (PT)





(PT)



(PT)

1 Facility-acquired


Effect

Udagger

Udagger

Udagger

Udagger

Udagger

Udagger

Udagger

Months

21Dagger

12Dagger

14sect

Authorsrsquo

Conclusions

Implementation

of an evidence-

based practice

protocol led to

improvements

in PU preva-

lence

A modest de-

crease in an-

nual expendi -

tures for rental

support sur-

faces was real-

ized results for

incidence and

prevalence dif-

fered across

hospitals and

may be attribut-

able to non-

standardized

documentation

tools

The program

enabled the

identification of

at-risk popula-

tions the im-

plementation of

appropriate

actions and

the achieve-

ment of posi-

tive measura-

ble results

Quality

Score

9

6

8






Author

Year

Country

Design

Gunningberg21

1999

Sweden

Controlled

study

Hiser22

2006

USA

Before-after

Hobbs23

2004

USA

Before-after

Setting

One hospital 4


ment of orthopedics



tures


including a medical

ICU

280-bed geriatric

hospital 4 units

geriatrics oncology

surgical postop and

orthopedicsneurol-

ogy


Intervention










(C) risk assessment




tion conducted



















education

Measures Reported









(PT)

1 patients with PUs

(prevalence) entire

hospital (PT)



pital (PT)

3 patients with PUs

(medical ICU) (PT)



ICU) (PT)


(PT)




mial pneumonia (PT)


rals (per month) to



(PRO)

Effect

Group

I vs C

0

Group

I vs C

0

0

0

0

0

+||

+||

0

0

Months

6sect

15sect

6sect

Authorsrsquo

Conclusions

No difference in

prevalence be-

tween interven-

tion and control

groups use of

the Modified

Norton Scale

facilitated the

identification of

the majority of

patients at risk

for PUs

Changes re-

sulted in a de-

crease in

quarterly hospi-

tal-acquired PU

prevalence in

participating

units Clinicians

now approach

PUs as pre-

ventable over-

all quality of

care and finan-

cial resource

utilization are

also improved

Following im-

plementation of

the turn team

program pa-

tient referrals to

the enteros-

tomal therapy

nurse average

length of stay

and muscu-

loskeletal in-

juries to staff all

declined

Quality

Score

11

10

11






Author

Year

Country

Design

Hopkins24

2000

USA

Before-after

Hunter25

1995

USA

Before-after

Jones26

1993

USA

Before-after

Setting

One acute care hos-

pital adult medical

surgical population

units not specified



350-bed community


on oncology med-

ical surgical ICU

intermediate care

units and high-risk

pediatric patients


Intervention


















staff education












education

Measures Reported




(PT)


quired PUs (PT)


dicted PUs (PT)

1 PU prevalence



IndashIV) (PT)


IIndashIV) (PT)

3 PU incidence (PT)





existing PUs (PRO)

5 patients who had



(PRO)

Effect

+||

Udagger

Udagger

0

0

0

0

Udagger

Udagger

Months

24Dagger

16sect

5sect

Authorsrsquo

Conclusions

Multidimen-

sional interven-

tions as an

adjunct to best

practices and

research-based

protocols im-

proved nosoco-

mial PU rates

Following im-

plementation of

protocols PU

prevalence de-

creased Health

care facilities

can improve

the quality of

care for PU

prevention by

establishing a

well-structured

PU prevention

treatment

program

Overall de-

crease in PU

incidence was

found and the

documentation

of PUs im-

proved Educa-

tion of nursing

staff is a key

component of

PU prevention

Quality

Score

15

13

13






Author

Year

Country

Design

LeMaster27

2007

USA

Before-after

Lyder28

2004

USA

Before-after

Setting

502-bed hospital 2

units pulmonary and

oncology

17 hospitals in the



from 200 to 800

beds


Intervention













tion conducted

















and at conferences

Measures Reported





(PT)



(PT)



2 Hospital-acquired

Stage I PU (PT)


gt Stage II (PT)


any stage (PT)


stay (days) (PT)






(PRO)

9 Use of pressure-



(PRO)



(PRO)





(PRO)



(PRO)


Stage I PUs (PRO)


Stage II PUs (PRO)

Effect

Udagger

Udagger

0

0

0

0

+||

0

0

+||

0

0

+||

+||

0

+||

Months

12sect

Not

clear

Authorsrsquo

Conclusions

The interven-

tion was suc-

cessful and

was replicated

throughout the

facility

Found clinically

and statistically

significant im-

provements in

4 PU preven-

tion-related

processes of

care concurrent

with multi-

faceted

improvement

intervention

Quality

Score

9

14






Author

Year

Country

Design

McErlean29

2002

Australia

Before-after

McInerney30

2008

USA

Before-after

Moore31

1997

USA

Before-after

Setting

250-bed hospital

units not specified

548-bed 2-hospital

system all patients


mental health

500+ bed university

hospital units not

specified


Intervention























relief orders














Measures Reported



1 PU incidence (all

stages) (PT)


Stage I PUs (PT)


Stage II PUs (PT)


Stage III PUs (PT)


Stage IV PUs (PT)

1 Overall hospital-




Effect

Udagger

Udagger

Udagger

Udagger

Udagger

Udagger

+||

+||

Months

12Dagger

59sect

19sect

Authorsrsquo

Conclusions

Both the identi-

fication of pa-

tient risk at

admission and

the implemen-

tation of appro-

priate pre-

ventive inter-

ventions have

increased this

has resulted in

a reduction in

the incidence

and severity of

PUs

The hospital

system was

able to reduce

hospital-ac-

quired PU

prevalence by

81 The re-

sultant cost

savings in ad-

dition to the

elimination of

patientsrsquo pain

and suffering

from PUs can

significantly im-

pact the cost

and quality of

care

A systematic

approach to

change includ-

ing a more

comprehensive

theory will

guide leaders

in promoting

change

Quality

Score

10

10

11


AP10




AP11


Author

Year

Country

Design

Murray32

1994

USA

Before-after

OrsquoBrien33

1998

USA

Before-after

Setting

One hospital

medicalsurgical and


only

750-bed university


except psychiatric

labor and delivery

postpartum and

newborn nursery


Intervention
















Measures Reported





(PT)


(PT)




Stages II-IV (PT)



(PT)

5 patients with PUs





ordered (PRO)




completed (PRO)




(PRO)






not (PRO)










reassessment (PRO)






Effect

Udagger

Udagger

+||

+||

0

+||

0

+||

0

0

0

0

ndash

0

+||

Months

28sect

48Dagger

Authorsrsquo

Conclusions

PU prevention

programs

should include

a risk assess-

ment tool pro-

tocols for PU

prevention staff

education and a

means to evalu-

ate outcomes

Systemwide

educational ef-

forts that in-

clude all levels

of professionals

and multispe-

cialty preven-

tion and care

efforts can lead

to a reduction

in PU preva-

lence

Quality

Score

13

15





AP12


Author

Year

Country

Design

Olson34

1998

Canada

Before-after

Peich35

2004

Israel

Before-after

Pokorny36

2003

USA

Before-after

Setting

One cancer hospital

2 units

300-bed teaching

hospital orthopedic

unit and recovery

room intervention

limited to patients

with hip fractures


cardiac surgery ICU

and cardiac surgery

intermediate care



dergoing elective

open heart surgery


Intervention















mattresses













education

Measures Reported




oped PU in hospital


on admission (PT)

1 of nosocomial PUs

among hip fracture

patients (PT)


Effect

0

+||

Udagger

Months

Not

clear

28sect

Not

clear

Authorsrsquo

Conclusions

The Braden

Scale has been

permanently in-

corporated into

the daily chart-

ing forms It is

now possible to

track the de-

gree to which

the scale and

prevention pro-

tocol are used

through the

quarterly chart

audits

PU prevention

in patients with

hip fractures is

feasible An

increased

awareness of

the problem

among hospital

staff may be

important

The develop-

ment and

progress of

PUs can be al-

tered by nurs-

ing care PU

risk can only

be predicted

through

repeated

assessments

throughout

hospitalization

Quality

Score

11

12

12





AP13


Author

Year

Country

Design

Rashotte37

2008

Canada

Before-after

Setting



Intervention










PU prevention

Measures Reported






(PRO)




(PRO)



(PRO)



completed (PRO)

5 Median number of


faces in use (PRO)








8 Median number of



protectors used to


(PRO)




(PRO)

10 Median number of


care expert (PRO)

Effect

Udagger

Udagger

Udagger

Udagger

Udagger

Udagger

Udagger

Udagger

Udagger

Udagger

Months

6sect

Authorsrsquo

Conclusions

Significant

changes in

nursing best

practice guide-

lines were

found which

highlights the

complexities of

changing prac-

tice Contextual

influences such

as teamwork

and resources

may inform

results

Quality

Score

6





AP14


Author

Year

Country

Design

Sacharok38

1998

USA

Before-after

Saleh39

2009

UK

Controlled

clinical trial

Stier40

2004

USA

Before-after

Setting

300-bed acute care

community hospital

several units adult

medical surgical

critical care and

later emergency

room


Health care system

in eastern US units

not specified


Intervention





tool conducted PDSA











times)
















only












Measures Reported



1 Prevalence of

nosocomial PUs (PT)



admission (PT)

1 Nosocomial PU

incidence (PT)

Effect

Udagger

Group

A vs

C

0

Group

B vs

C

0

Udagger

Months

47sect

13Dagger

Not

clear

Authorsrsquo

Conclusions

Implementation

of a total quality

management

model resulted

in an 83 re-

duction in PU

prevalence

There were no

differences in

PU incidence in

the groups that

received addi-

tional training

Clinical judg-

ment may be

as effective as

employing a

risk assess-

ment scale to

assess risk for

PUs

The sustained

success of the

program is at-

tributed to (1) a

reliable and

valid measure-

ment system

that facilitates

performance

assessment

and evaluation

and (2) ongoing

unit educational

activities

Quality

Score

11

10

12





AP15


Author

Year

Country

Design

Stoelting41

2007

USA

Before-after

Uzun42

2009

Turkey

Before-after

Van Etten43

1990

USA

Before-after

Setting

Large teaching

hospital units not

specified

880-bed acute care

university hospital

ICU areas only 2

general medical

surgical ICUs

1 neurosurgical ICU

1 postanesthesia

care unit


risk care areas (1)



dics (3) acute

neurointensive care


Intervention


























education

Measures Reported



1 PU incidence (PT)





(PT)

1 patients with


(PT)

Effect

Udagger

+||

+||

Months

Not

clear

35sect

6sect

Authorsrsquo

Conclusions

An intervention

targeting

awareness and

communication

regarding PUs

resulted in

more complete

adherence to

the nursing

prevention

protocol

An education

program and

implementation

of preventive

nursing inter-

ventions were

effective in de-

creasing PU in-

cidence in ICU

patients

The program

appeared to be

successful as

evidenced by a

decrease in

nosocomial PU

rates Findings

underscore the

importance of

identifying pa-

tient risk for

PUs and follow-

ing through

with a plan for

prevention and

treatment

Quality

Score

7

13

11





AP16


Author

Year

Country

Design

Willson44

1995

USA

Before-after

Setting

One hospital

4 medicalsurgical

units


Intervention









used

Measures Reported



1 PU incidence (PT)

Effect

Udagger

Months

6sect

Authorsrsquo

Conclusions

Preliminary

results indicate

that modifica-

tions to a hos-


tion system can

support staff in

following new

protocols and

can lead to a

decrease in PU

incidence

Quality

Score

8













Author

Year

Country

Design

Charrier13

2008

Italy

Controlled

clinical trial

Setting


fied) in an Italian

hospital


Intervention


protocol adherence

Measures Reported


PRO = Nursing

Process




is a protocol and

location (PRO)


(PRO)



5 (Braden form)

updated (PRO)



(PRO)

7 Used change in

posture form (PRO)



out (PRO)



mobilized (PRO)

10 Products for





(PRO)


(PRO)


to protocol (PRO)

15 Staging of LDP

(PRO)

16 Is it registered

(PRO)

17 Form completely

filled in (PRO)


respected (PRO)



col (PRO)



(PRO)

Effect

Udagger

Udagger

0

0

0

0

0

0

+||

ndash

0

Udagger

+||

+||

+||

+||

+||

+||

0

0

Months

18Dagger

Authorsrsquo

Conclusions

7 of 20

processes

showed signifi-

cant improve-

ment in the

intervention

group relative

to the control

group

Quality

Score

4






Author

Year

Country

Design

Chicano14

2009

USA

Before-after

Courtney15

2006

USA

Before-after

Setting

One 25-bed interme-

diate care unit

710-bed multisite

facility units not

specified


Intervention













standards






















care products

Measures Reported


PRO = Nursing

Process


acquired PUs (PT)


acquired PUs (PT)

Effect

Udagger

Udagger

Months

21Dagger

30sect

Authorsrsquo

Conclusions

PU strategies

proved effec-

tive in decreas-

ing incidence

during a 1-year

period The

commitment amp

diligence of the

quality im-

provement (QI)

team amp mem-

bers of the


ernance coun-

cils were

important fac-

tors in achiev-

ing this goal

Incidence of

PUs decreased

by nearly 70

as a result of

intervention

the overall cul-

ture change at

the medical

center remains

a work in

progress

Quality

Score

8

10






Author

Year

Country

Design

deLaat16

2007

The

Netherlands

Before-after

deLaat17

2006

The

Netherlands

Before-after

Setting

28-bed adult inten-



2 general medical



surgical unit

900-bed university

medical center


Intervention















A contact nurse was


and a PU consultant



per and intranet

Measures Reported








IV (PT)


IIndashIV (PT)



of stay (PT)




transferred (PRO)

1 patients with PUs




as high risk (PT)

2 patients with PUs




as high risk (PT)





Stage I (PRO)






PU ge Stage I (PRO)













Effect

+||

Udagger

+||

+||

+||

+||

+||

0

+||

+||

0

Months

12Dagger

11sect

Authorsrsquo

Conclusions

Implementation

of guideline for

PU care re-

sulted in signifi-

cant and

sustained de-

crease in the

incidence of

Stage II-IV PU

in ICU patients

PU frequency

can be

successfully

decreased

introduction of

adequate

mattresses and

guidelines for

prevention and

treatment are

promising

tools

Quality

Score

15

13






Author

Year

Country

Design

Dibsie18

2008

USA

Before-after

Dukich19

2001

USA

Before-after

Gibbons20

2006

USA

Before-after

Setting

Multisite academic


not specified


Trauma Center and



each site ICUs and

medicalsurgical

units

528-bed hospital in

Florida all units


Intervention


protocol conducted





on new products









of support surfaces











product changed

Measures Reported





(PT)



(PT)


I (Hospital B) (PT)





(PT)



(PT)

1 Facility-acquired


Effect

Udagger

Udagger

Udagger

Udagger

Udagger

Udagger

Udagger

Months

21Dagger

12Dagger

14sect

Authorsrsquo

Conclusions

Implementation

of an evidence-

based practice

protocol led to

improvements

in PU preva-

lence

A modest de-

crease in an-

nual expendi -

tures for rental

support sur-

faces was real-

ized results for

incidence and

prevalence dif-

fered across

hospitals and

may be attribut-

able to non-

standardized

documentation

tools

The program

enabled the

identification of

at-risk popula-

tions the im-

plementation of

appropriate

actions and

the achieve-

ment of posi-

tive measura-

ble results

Quality

Score

9

6

8






Author

Year

Country

Design

Gunningberg21

1999

Sweden

Controlled

study

Hiser22

2006

USA

Before-after

Hobbs23

2004

USA

Before-after

Setting

One hospital 4


ment of orthopedics



tures


including a medical

ICU

280-bed geriatric

hospital 4 units

geriatrics oncology

surgical postop and

orthopedicsneurol-

ogy


Intervention










(C) risk assessment




tion conducted



















education

Measures Reported









(PT)

1 patients with PUs

(prevalence) entire

hospital (PT)



pital (PT)

3 patients with PUs

(medical ICU) (PT)



ICU) (PT)


(PT)




mial pneumonia (PT)


rals (per month) to



(PRO)

Effect

Group

I vs C

0

Group

I vs C

0

0

0

0

0

+||

+||

0

0

Months

6sect

15sect

6sect

Authorsrsquo

Conclusions

No difference in

prevalence be-

tween interven-

tion and control

groups use of

the Modified

Norton Scale

facilitated the

identification of

the majority of

patients at risk

for PUs

Changes re-

sulted in a de-

crease in

quarterly hospi-

tal-acquired PU

prevalence in

participating

units Clinicians

now approach

PUs as pre-

ventable over-

all quality of

care and finan-

cial resource

utilization are

also improved

Following im-

plementation of

the turn team

program pa-

tient referrals to

the enteros-

tomal therapy

nurse average

length of stay

and muscu-

loskeletal in-

juries to staff all

declined

Quality

Score

11

10

11






Author

Year

Country

Design

Hopkins24

2000

USA

Before-after

Hunter25

1995

USA

Before-after

Jones26

1993

USA

Before-after

Setting

One acute care hos-

pital adult medical

surgical population

units not specified



350-bed community


on oncology med-

ical surgical ICU

intermediate care

units and high-risk

pediatric patients


Intervention


















staff education












education

Measures Reported




(PT)


quired PUs (PT)


dicted PUs (PT)

1 PU prevalence



IndashIV) (PT)


IIndashIV) (PT)

3 PU incidence (PT)





existing PUs (PRO)

5 patients who had



(PRO)

Effect

+||

Udagger

Udagger

0

0

0

0

Udagger

Udagger

Months

24Dagger

16sect

5sect

Authorsrsquo

Conclusions

Multidimen-

sional interven-

tions as an

adjunct to best

practices and

research-based

protocols im-

proved nosoco-

mial PU rates

Following im-

plementation of

protocols PU

prevalence de-

creased Health

care facilities

can improve

the quality of

care for PU

prevention by

establishing a

well-structured

PU prevention

treatment

program

Overall de-

crease in PU

incidence was

found and the

documentation

of PUs im-

proved Educa-

tion of nursing

staff is a key

component of

PU prevention

Quality

Score

15

13

13






Author

Year

Country

Design

LeMaster27

2007

USA

Before-after

Lyder28

2004

USA

Before-after

Setting

502-bed hospital 2

units pulmonary and

oncology

17 hospitals in the



from 200 to 800

beds


Intervention













tion conducted

















and at conferences

Measures Reported





(PT)



(PT)



2 Hospital-acquired

Stage I PU (PT)


gt Stage II (PT)


any stage (PT)


stay (days) (PT)






(PRO)

9 Use of pressure-



(PRO)



(PRO)





(PRO)



(PRO)


Stage I PUs (PRO)


Stage II PUs (PRO)

Effect

Udagger

Udagger

0

0

0

0

+||

0

0

+||

0

0

+||

+||

0

+||

Months

12sect

Not

clear

Authorsrsquo

Conclusions

The interven-

tion was suc-

cessful and

was replicated

throughout the

facility

Found clinically

and statistically

significant im-

provements in

4 PU preven-

tion-related

processes of

care concurrent

with multi-

faceted

improvement

intervention

Quality

Score

9

14






Author

Year

Country

Design

McErlean29

2002

Australia

Before-after

McInerney30

2008

USA

Before-after

Moore31

1997

USA

Before-after

Setting

250-bed hospital

units not specified

548-bed 2-hospital

system all patients


mental health

500+ bed university

hospital units not

specified


Intervention























relief orders














Measures Reported



1 PU incidence (all

stages) (PT)


Stage I PUs (PT)


Stage II PUs (PT)


Stage III PUs (PT)


Stage IV PUs (PT)

1 Overall hospital-




Effect

Udagger

Udagger

Udagger

Udagger

Udagger

Udagger

+||

+||

Months

12Dagger

59sect

19sect

Authorsrsquo

Conclusions

Both the identi-

fication of pa-

tient risk at

admission and

the implemen-

tation of appro-

priate pre-

ventive inter-

ventions have

increased this

has resulted in

a reduction in

the incidence

and severity of

PUs

The hospital

system was

able to reduce

hospital-ac-

quired PU

prevalence by

81 The re-

sultant cost

savings in ad-

dition to the

elimination of

patientsrsquo pain

and suffering

from PUs can

significantly im-

pact the cost

and quality of

care

A systematic

approach to

change includ-

ing a more

comprehensive

theory will

guide leaders

in promoting

change

Quality

Score

10

10

11


AP10




AP11


Author

Year

Country

Design

Murray32

1994

USA

Before-after

OrsquoBrien33

1998

USA

Before-after

Setting

One hospital

medicalsurgical and


only

750-bed university


except psychiatric

labor and delivery

postpartum and

newborn nursery


Intervention
















Measures Reported





(PT)


(PT)




Stages II-IV (PT)



(PT)

5 patients with PUs





ordered (PRO)




completed (PRO)




(PRO)






not (PRO)










reassessment (PRO)






Effect

Udagger

Udagger

+||

+||

0

+||

0

+||

0

0

0

0

ndash

0

+||

Months

28sect

48Dagger

Authorsrsquo

Conclusions

PU prevention

programs

should include

a risk assess-

ment tool pro-

tocols for PU

prevention staff

education and a

means to evalu-

ate outcomes

Systemwide

educational ef-

forts that in-

clude all levels

of professionals

and multispe-

cialty preven-

tion and care

efforts can lead

to a reduction

in PU preva-

lence

Quality

Score

13

15





AP12


Author

Year

Country

Design

Olson34

1998

Canada

Before-after

Peich35

2004

Israel

Before-after

Pokorny36

2003

USA

Before-after

Setting

One cancer hospital

2 units

300-bed teaching

hospital orthopedic

unit and recovery

room intervention

limited to patients

with hip fractures


cardiac surgery ICU

and cardiac surgery

intermediate care



dergoing elective

open heart surgery


Intervention















mattresses













education

Measures Reported




oped PU in hospital


on admission (PT)

1 of nosocomial PUs

among hip fracture

patients (PT)


Effect

0

+||

Udagger

Months

Not

clear

28sect

Not

clear

Authorsrsquo

Conclusions

The Braden

Scale has been

permanently in-

corporated into

the daily chart-

ing forms It is

now possible to

track the de-

gree to which

the scale and

prevention pro-

tocol are used

through the

quarterly chart

audits

PU prevention

in patients with

hip fractures is

feasible An

increased

awareness of

the problem

among hospital

staff may be

important

The develop-

ment and

progress of

PUs can be al-

tered by nurs-

ing care PU

risk can only

be predicted

through

repeated

assessments

throughout

hospitalization

Quality

Score

11

12

12





AP13


Author

Year

Country

Design

Rashotte37

2008

Canada

Before-after

Setting



Intervention










PU prevention

Measures Reported






(PRO)




(PRO)



(PRO)



completed (PRO)

5 Median number of


faces in use (PRO)








8 Median number of



protectors used to


(PRO)




(PRO)

10 Median number of


care expert (PRO)

Effect

Udagger

Udagger

Udagger

Udagger

Udagger

Udagger

Udagger

Udagger

Udagger

Udagger

Months

6sect

Authorsrsquo

Conclusions

Significant

changes in

nursing best

practice guide-

lines were

found which

highlights the

complexities of

changing prac-

tice Contextual

influences such

as teamwork

and resources

may inform

results

Quality

Score

6





AP14


Author

Year

Country

Design

Sacharok38

1998

USA

Before-after

Saleh39

2009

UK

Controlled

clinical trial

Stier40

2004

USA

Before-after

Setting

300-bed acute care

community hospital

several units adult

medical surgical

critical care and

later emergency

room


Health care system

in eastern US units

not specified


Intervention





tool conducted PDSA











times)
















only












Measures Reported



1 Prevalence of

nosocomial PUs (PT)



admission (PT)

1 Nosocomial PU

incidence (PT)

Effect

Udagger

Group

A vs

C

0

Group

B vs

C

0

Udagger

Months

47sect

13Dagger

Not

clear

Authorsrsquo

Conclusions

Implementation

of a total quality

management

model resulted

in an 83 re-

duction in PU

prevalence

There were no

differences in

PU incidence in

the groups that

received addi-

tional training

Clinical judg-

ment may be

as effective as

employing a

risk assess-

ment scale to

assess risk for

PUs

The sustained

success of the

program is at-

tributed to (1) a

reliable and

valid measure-

ment system

that facilitates

performance

assessment

and evaluation

and (2) ongoing

unit educational

activities

Quality

Score

11

10

12





AP15


Author

Year

Country

Design

Stoelting41

2007

USA

Before-after

Uzun42

2009

Turkey

Before-after

Van Etten43

1990

USA

Before-after

Setting

Large teaching

hospital units not

specified

880-bed acute care

university hospital

ICU areas only 2

general medical

surgical ICUs

1 neurosurgical ICU

1 postanesthesia

care unit


risk care areas (1)



dics (3) acute

neurointensive care


Intervention


























education

Measures Reported



1 PU incidence (PT)





(PT)

1 patients with


(PT)

Effect

Udagger

+||

+||

Months

Not

clear

35sect

6sect

Authorsrsquo

Conclusions

An intervention

targeting

awareness and

communication

regarding PUs

resulted in

more complete

adherence to

the nursing

prevention

protocol

An education

program and

implementation

of preventive

nursing inter-

ventions were

effective in de-

creasing PU in-

cidence in ICU

patients

The program

appeared to be

successful as

evidenced by a

decrease in

nosocomial PU

rates Findings

underscore the

importance of

identifying pa-

tient risk for

PUs and follow-

ing through

with a plan for

prevention and

treatment

Quality

Score

7

13

11





AP16


Author

Year

Country

Design

Willson44

1995

USA

Before-after

Setting

One hospital

4 medicalsurgical

units


Intervention









used

Measures Reported



1 PU incidence (PT)

Effect

Udagger

Months

6sect

Authorsrsquo

Conclusions

Preliminary

results indicate

that modifica-

tions to a hos-


tion system can

support staff in

following new

protocols and

can lead to a

decrease in PU

incidence

Quality

Score

8













Author

Year

Country

Design

Chicano14

2009

USA

Before-after

Courtney15

2006

USA

Before-after

Setting

One 25-bed interme-

diate care unit

710-bed multisite

facility units not

specified


Intervention













standards






















care products

Measures Reported


PRO = Nursing

Process


acquired PUs (PT)


acquired PUs (PT)

Effect

Udagger

Udagger

Months

21Dagger

30sect

Authorsrsquo

Conclusions

PU strategies

proved effec-

tive in decreas-

ing incidence

during a 1-year

period The

commitment amp

diligence of the

quality im-

provement (QI)

team amp mem-

bers of the


ernance coun-

cils were

important fac-

tors in achiev-

ing this goal

Incidence of

PUs decreased

by nearly 70

as a result of

intervention

the overall cul-

ture change at

the medical

center remains

a work in

progress

Quality

Score

8

10






Author

Year

Country

Design

deLaat16

2007

The

Netherlands

Before-after

deLaat17

2006

The

Netherlands

Before-after

Setting

28-bed adult inten-



2 general medical



surgical unit

900-bed university

medical center


Intervention















A contact nurse was


and a PU consultant



per and intranet

Measures Reported








IV (PT)


IIndashIV (PT)



of stay (PT)




transferred (PRO)

1 patients with PUs




as high risk (PT)

2 patients with PUs




as high risk (PT)





Stage I (PRO)






PU ge Stage I (PRO)













Effect

+||

Udagger

+||

+||

+||

+||

+||

0

+||

+||

0

Months

12Dagger

11sect

Authorsrsquo

Conclusions

Implementation

of guideline for

PU care re-

sulted in signifi-

cant and

sustained de-

crease in the

incidence of

Stage II-IV PU

in ICU patients

PU frequency

can be

successfully

decreased

introduction of

adequate

mattresses and

guidelines for

prevention and

treatment are

promising

tools

Quality

Score

15

13






Author

Year

Country

Design

Dibsie18

2008

USA

Before-after

Dukich19

2001

USA

Before-after

Gibbons20

2006

USA

Before-after

Setting

Multisite academic


not specified


Trauma Center and



each site ICUs and

medicalsurgical

units

528-bed hospital in

Florida all units


Intervention


protocol conducted





on new products









of support surfaces











product changed

Measures Reported





(PT)



(PT)


I (Hospital B) (PT)





(PT)



(PT)

1 Facility-acquired


Effect

Udagger

Udagger

Udagger

Udagger

Udagger

Udagger

Udagger

Months

21Dagger

12Dagger

14sect

Authorsrsquo

Conclusions

Implementation

of an evidence-

based practice

protocol led to

improvements

in PU preva-

lence

A modest de-

crease in an-

nual expendi -

tures for rental

support sur-

faces was real-

ized results for

incidence and

prevalence dif-

fered across

hospitals and

may be attribut-

able to non-

standardized

documentation

tools

The program

enabled the

identification of

at-risk popula-

tions the im-

plementation of

appropriate

actions and

the achieve-

ment of posi-

tive measura-

ble results

Quality

Score

9

6

8






Author

Year

Country

Design

Gunningberg21

1999

Sweden

Controlled

study

Hiser22

2006

USA

Before-after

Hobbs23

2004

USA

Before-after

Setting

One hospital 4


ment of orthopedics



tures


including a medical

ICU

280-bed geriatric

hospital 4 units

geriatrics oncology

surgical postop and

orthopedicsneurol-

ogy


Intervention










(C) risk assessment




tion conducted



















education

Measures Reported









(PT)

1 patients with PUs

(prevalence) entire

hospital (PT)



pital (PT)

3 patients with PUs

(medical ICU) (PT)



ICU) (PT)


(PT)




mial pneumonia (PT)


rals (per month) to



(PRO)

Effect

Group

I vs C

0

Group

I vs C

0

0

0

0

0

+||

+||

0

0

Months

6sect

15sect

6sect

Authorsrsquo

Conclusions

No difference in

prevalence be-

tween interven-

tion and control

groups use of

the Modified

Norton Scale

facilitated the

identification of

the majority of

patients at risk

for PUs

Changes re-

sulted in a de-

crease in

quarterly hospi-

tal-acquired PU

prevalence in

participating

units Clinicians

now approach

PUs as pre-

ventable over-

all quality of

care and finan-

cial resource

utilization are

also improved

Following im-

plementation of

the turn team

program pa-

tient referrals to

the enteros-

tomal therapy

nurse average

length of stay

and muscu-

loskeletal in-

juries to staff all

declined

Quality

Score

11

10

11






Author

Year

Country

Design

Hopkins24

2000

USA

Before-after

Hunter25

1995

USA

Before-after

Jones26

1993

USA

Before-after

Setting

One acute care hos-

pital adult medical

surgical population

units not specified



350-bed community


on oncology med-

ical surgical ICU

intermediate care

units and high-risk

pediatric patients


Intervention


















staff education












education

Measures Reported




(PT)


quired PUs (PT)


dicted PUs (PT)

1 PU prevalence



IndashIV) (PT)


IIndashIV) (PT)

3 PU incidence (PT)





existing PUs (PRO)

5 patients who had



(PRO)

Effect

+||

Udagger

Udagger

0

0

0

0

Udagger

Udagger

Months

24Dagger

16sect

5sect

Authorsrsquo

Conclusions

Multidimen-

sional interven-

tions as an

adjunct to best

practices and

research-based

protocols im-

proved nosoco-

mial PU rates

Following im-

plementation of

protocols PU

prevalence de-

creased Health

care facilities

can improve

the quality of

care for PU

prevention by

establishing a

well-structured

PU prevention

treatment

program

Overall de-

crease in PU

incidence was

found and the

documentation

of PUs im-

proved Educa-

tion of nursing

staff is a key

component of

PU prevention

Quality

Score

15

13

13






Author

Year

Country

Design

LeMaster27

2007

USA

Before-after

Lyder28

2004

USA

Before-after

Setting

502-bed hospital 2

units pulmonary and

oncology

17 hospitals in the



from 200 to 800

beds


Intervention













tion conducted

















and at conferences

Measures Reported





(PT)



(PT)



2 Hospital-acquired

Stage I PU (PT)


gt Stage II (PT)


any stage (PT)


stay (days) (PT)






(PRO)

9 Use of pressure-



(PRO)



(PRO)





(PRO)



(PRO)


Stage I PUs (PRO)


Stage II PUs (PRO)

Effect

Udagger

Udagger

0

0

0

0

+||

0

0

+||

0

0

+||

+||

0

+||

Months

12sect

Not

clear

Authorsrsquo

Conclusions

The interven-

tion was suc-

cessful and

was replicated

throughout the

facility

Found clinically

and statistically

significant im-

provements in

4 PU preven-

tion-related

processes of

care concurrent

with multi-

faceted

improvement

intervention

Quality

Score

9

14






Author

Year

Country

Design

McErlean29

2002

Australia

Before-after

McInerney30

2008

USA

Before-after

Moore31

1997

USA

Before-after

Setting

250-bed hospital

units not specified

548-bed 2-hospital

system all patients


mental health

500+ bed university

hospital units not

specified


Intervention























relief orders














Measures Reported



1 PU incidence (all

stages) (PT)


Stage I PUs (PT)


Stage II PUs (PT)


Stage III PUs (PT)


Stage IV PUs (PT)

1 Overall hospital-




Effect

Udagger

Udagger

Udagger

Udagger

Udagger

Udagger

+||

+||

Months

12Dagger

59sect

19sect

Authorsrsquo

Conclusions

Both the identi-

fication of pa-

tient risk at

admission and

the implemen-

tation of appro-

priate pre-

ventive inter-

ventions have

increased this

has resulted in

a reduction in

the incidence

and severity of

PUs

The hospital

system was

able to reduce

hospital-ac-

quired PU

prevalence by

81 The re-

sultant cost

savings in ad-

dition to the

elimination of

patientsrsquo pain

and suffering

from PUs can

significantly im-

pact the cost

and quality of

care

A systematic

approach to

change includ-

ing a more

comprehensive

theory will

guide leaders

in promoting

change

Quality

Score

10

10

11


AP10




AP11


Author

Year

Country

Design

Murray32

1994

USA

Before-after

OrsquoBrien33

1998

USA

Before-after

Setting

One hospital

medicalsurgical and


only

750-bed university


except psychiatric

labor and delivery

postpartum and

newborn nursery


Intervention
















Measures Reported





(PT)


(PT)




Stages II-IV (PT)



(PT)

5 patients with PUs





ordered (PRO)




completed (PRO)




(PRO)






not (PRO)










reassessment (PRO)






Effect

Udagger

Udagger

+||

+||

0

+||

0

+||

0

0

0

0

ndash

0

+||

Months

28sect

48Dagger

Authorsrsquo

Conclusions

PU prevention

programs

should include

a risk assess-

ment tool pro-

tocols for PU

prevention staff

education and a

means to evalu-

ate outcomes

Systemwide

educational ef-

forts that in-

clude all levels

of professionals

and multispe-

cialty preven-

tion and care

efforts can lead

to a reduction

in PU preva-

lence

Quality

Score

13

15





AP12


Author

Year

Country

Design

Olson34

1998

Canada

Before-after

Peich35

2004

Israel

Before-after

Pokorny36

2003

USA

Before-after

Setting

One cancer hospital

2 units

300-bed teaching

hospital orthopedic

unit and recovery

room intervention

limited to patients

with hip fractures


cardiac surgery ICU

and cardiac surgery

intermediate care



dergoing elective

open heart surgery


Intervention















mattresses













education

Measures Reported




oped PU in hospital


on admission (PT)

1 of nosocomial PUs

among hip fracture

patients (PT)


Effect

0

+||

Udagger

Months

Not

clear

28sect

Not

clear

Authorsrsquo

Conclusions

The Braden

Scale has been

permanently in-

corporated into

the daily chart-

ing forms It is

now possible to

track the de-

gree to which

the scale and

prevention pro-

tocol are used

through the

quarterly chart

audits

PU prevention

in patients with

hip fractures is

feasible An

increased

awareness of

the problem

among hospital

staff may be

important

The develop-

ment and

progress of

PUs can be al-

tered by nurs-

ing care PU

risk can only

be predicted

through

repeated

assessments

throughout

hospitalization

Quality

Score

11

12

12





AP13


Author

Year

Country

Design

Rashotte37

2008

Canada

Before-after

Setting



Intervention










PU prevention

Measures Reported






(PRO)




(PRO)



(PRO)



completed (PRO)

5 Median number of


faces in use (PRO)








8 Median number of



protectors used to


(PRO)




(PRO)

10 Median number of


care expert (PRO)

Effect

Udagger

Udagger

Udagger

Udagger

Udagger

Udagger

Udagger

Udagger

Udagger

Udagger

Months

6sect

Authorsrsquo

Conclusions

Significant

changes in

nursing best

practice guide-

lines were

found which

highlights the

complexities of

changing prac-

tice Contextual

influences such

as teamwork

and resources

may inform

results

Quality

Score

6





AP14


Author

Year

Country

Design

Sacharok38

1998

USA

Before-after

Saleh39

2009

UK

Controlled

clinical trial

Stier40

2004

USA

Before-after

Setting

300-bed acute care

community hospital

several units adult

medical surgical

critical care and

later emergency

room


Health care system

in eastern US units

not specified


Intervention





tool conducted PDSA











times)
















only












Measures Reported



1 Prevalence of

nosocomial PUs (PT)



admission (PT)

1 Nosocomial PU

incidence (PT)

Effect

Udagger

Group

A vs

C

0

Group

B vs

C

0

Udagger

Months

47sect

13Dagger

Not

clear

Authorsrsquo

Conclusions

Implementation

of a total quality

management

model resulted

in an 83 re-

duction in PU

prevalence

There were no

differences in

PU incidence in

the groups that

received addi-

tional training

Clinical judg-

ment may be

as effective as

employing a

risk assess-

ment scale to

assess risk for

PUs

The sustained

success of the

program is at-

tributed to (1) a

reliable and

valid measure-

ment system

that facilitates

performance

assessment

and evaluation

and (2) ongoing

unit educational

activities

Quality

Score

11

10

12





AP15


Author

Year

Country

Design

Stoelting41

2007

USA

Before-after

Uzun42

2009

Turkey

Before-after

Van Etten43

1990

USA

Before-after

Setting

Large teaching

hospital units not

specified

880-bed acute care

university hospital

ICU areas only 2

general medical

surgical ICUs

1 neurosurgical ICU

1 postanesthesia

care unit


risk care areas (1)



dics (3) acute

neurointensive care


Intervention


























education

Measures Reported



1 PU incidence (PT)





(PT)

1 patients with


(PT)

Effect

Udagger

+||

+||

Months

Not

clear

35sect

6sect

Authorsrsquo

Conclusions

An intervention

targeting

awareness and

communication

regarding PUs

resulted in

more complete

adherence to

the nursing

prevention

protocol

An education

program and

implementation

of preventive

nursing inter-

ventions were

effective in de-

creasing PU in-

cidence in ICU

patients

The program

appeared to be

successful as

evidenced by a

decrease in

nosocomial PU

rates Findings

underscore the

importance of

identifying pa-

tient risk for

PUs and follow-

ing through

with a plan for

prevention and

treatment

Quality

Score

7

13

11





AP16


Author

Year

Country

Design

Willson44

1995

USA

Before-after

Setting

One hospital

4 medicalsurgical

units


Intervention









used

Measures Reported



1 PU incidence (PT)

Effect

Udagger

Months

6sect

Authorsrsquo

Conclusions

Preliminary

results indicate

that modifica-

tions to a hos-


tion system can

support staff in

following new

protocols and

can lead to a

decrease in PU

incidence

Quality

Score

8













Author

Year

Country

Design

deLaat16

2007

The

Netherlands

Before-after

deLaat17

2006

The

Netherlands

Before-after

Setting

28-bed adult inten-



2 general medical



surgical unit

900-bed university

medical center


Intervention















A contact nurse was


and a PU consultant



per and intranet

Measures Reported








IV (PT)


IIndashIV (PT)



of stay (PT)




transferred (PRO)

1 patients with PUs




as high risk (PT)

2 patients with PUs




as high risk (PT)





Stage I (PRO)






PU ge Stage I (PRO)













Effect

+||

Udagger

+||

+||

+||

+||

+||

0

+||

+||

0

Months

12Dagger

11sect

Authorsrsquo

Conclusions

Implementation

of guideline for

PU care re-

sulted in signifi-

cant and

sustained de-

crease in the

incidence of

Stage II-IV PU

in ICU patients

PU frequency

can be

successfully

decreased

introduction of

adequate

mattresses and

guidelines for

prevention and

treatment are

promising

tools

Quality

Score

15

13






Author

Year

Country

Design

Dibsie18

2008

USA

Before-after

Dukich19

2001

USA

Before-after

Gibbons20

2006

USA

Before-after

Setting

Multisite academic


not specified


Trauma Center and



each site ICUs and

medicalsurgical

units

528-bed hospital in

Florida all units


Intervention


protocol conducted





on new products









of support surfaces











product changed

Measures Reported





(PT)



(PT)


I (Hospital B) (PT)





(PT)



(PT)

1 Facility-acquired


Effect

Udagger

Udagger

Udagger

Udagger

Udagger

Udagger

Udagger

Months

21Dagger

12Dagger

14sect

Authorsrsquo

Conclusions

Implementation

of an evidence-

based practice

protocol led to

improvements

in PU preva-

lence

A modest de-

crease in an-

nual expendi -

tures for rental

support sur-

faces was real-

ized results for

incidence and

prevalence dif-

fered across

hospitals and

may be attribut-

able to non-

standardized

documentation

tools

The program

enabled the

identification of

at-risk popula-

tions the im-

plementation of

appropriate

actions and

the achieve-

ment of posi-

tive measura-

ble results

Quality

Score

9

6

8






Author

Year

Country

Design

Gunningberg21

1999

Sweden

Controlled

study

Hiser22

2006

USA

Before-after

Hobbs23

2004

USA

Before-after

Setting

One hospital 4


ment of orthopedics



tures


including a medical

ICU

280-bed geriatric

hospital 4 units

geriatrics oncology

surgical postop and

orthopedicsneurol-

ogy


Intervention










(C) risk assessment




tion conducted



















education

Measures Reported









(PT)

1 patients with PUs

(prevalence) entire

hospital (PT)



pital (PT)

3 patients with PUs

(medical ICU) (PT)



ICU) (PT)


(PT)




mial pneumonia (PT)


rals (per month) to



(PRO)

Effect

Group

I vs C

0

Group

I vs C

0

0

0

0

0

+||

+||

0

0

Months

6sect

15sect

6sect

Authorsrsquo

Conclusions

No difference in

prevalence be-

tween interven-

tion and control

groups use of

the Modified

Norton Scale

facilitated the

identification of

the majority of

patients at risk

for PUs

Changes re-

sulted in a de-

crease in

quarterly hospi-

tal-acquired PU

prevalence in

participating

units Clinicians

now approach

PUs as pre-

ventable over-

all quality of

care and finan-

cial resource

utilization are

also improved

Following im-

plementation of

the turn team

program pa-

tient referrals to

the enteros-

tomal therapy

nurse average

length of stay

and muscu-

loskeletal in-

juries to staff all

declined

Quality

Score

11

10

11






Author

Year

Country

Design

Hopkins24

2000

USA

Before-after

Hunter25

1995

USA

Before-after

Jones26

1993

USA

Before-after

Setting

One acute care hos-

pital adult medical

surgical population

units not specified



350-bed community


on oncology med-

ical surgical ICU

intermediate care

units and high-risk

pediatric patients


Intervention


















staff education












education

Measures Reported




(PT)


quired PUs (PT)


dicted PUs (PT)

1 PU prevalence



IndashIV) (PT)


IIndashIV) (PT)

3 PU incidence (PT)





existing PUs (PRO)

5 patients who had



(PRO)

Effect

+||

Udagger

Udagger

0

0

0

0

Udagger

Udagger

Months

24Dagger

16sect

5sect

Authorsrsquo

Conclusions

Multidimen-

sional interven-

tions as an

adjunct to best

practices and

research-based

protocols im-

proved nosoco-

mial PU rates

Following im-

plementation of

protocols PU

prevalence de-

creased Health

care facilities

can improve

the quality of

care for PU

prevention by

establishing a

well-structured

PU prevention

treatment

program

Overall de-

crease in PU

incidence was

found and the

documentation

of PUs im-

proved Educa-

tion of nursing

staff is a key

component of

PU prevention

Quality

Score

15

13

13






Author

Year

Country

Design

LeMaster27

2007

USA

Before-after

Lyder28

2004

USA

Before-after

Setting

502-bed hospital 2

units pulmonary and

oncology

17 hospitals in the



from 200 to 800

beds


Intervention













tion conducted

















and at conferences

Measures Reported





(PT)



(PT)



2 Hospital-acquired

Stage I PU (PT)


gt Stage II (PT)


any stage (PT)


stay (days) (PT)






(PRO)

9 Use of pressure-



(PRO)



(PRO)





(PRO)



(PRO)


Stage I PUs (PRO)


Stage II PUs (PRO)

Effect

Udagger

Udagger

0

0

0

0

+||

0

0

+||

0

0

+||

+||

0

+||

Months

12sect

Not

clear

Authorsrsquo

Conclusions

The interven-

tion was suc-

cessful and

was replicated

throughout the

facility

Found clinically

and statistically

significant im-

provements in

4 PU preven-

tion-related

processes of

care concurrent

with multi-

faceted

improvement

intervention

Quality

Score

9

14






Author

Year

Country

Design

McErlean29

2002

Australia

Before-after

McInerney30

2008

USA

Before-after

Moore31

1997

USA

Before-after

Setting

250-bed hospital

units not specified

548-bed 2-hospital

system all patients


mental health

500+ bed university

hospital units not

specified


Intervention























relief orders














Measures Reported



1 PU incidence (all

stages) (PT)


Stage I PUs (PT)


Stage II PUs (PT)


Stage III PUs (PT)


Stage IV PUs (PT)

1 Overall hospital-




Effect

Udagger

Udagger

Udagger

Udagger

Udagger

Udagger

+||

+||

Months

12Dagger

59sect

19sect

Authorsrsquo

Conclusions

Both the identi-

fication of pa-

tient risk at

admission and

the implemen-

tation of appro-

priate pre-

ventive inter-

ventions have

increased this

has resulted in

a reduction in

the incidence

and severity of

PUs

The hospital

system was

able to reduce

hospital-ac-

quired PU

prevalence by

81 The re-

sultant cost

savings in ad-

dition to the

elimination of

patientsrsquo pain

and suffering

from PUs can

significantly im-

pact the cost

and quality of

care

A systematic

approach to

change includ-

ing a more

comprehensive

theory will

guide leaders

in promoting

change

Quality

Score

10

10

11


AP10




AP11


Author

Year

Country

Design

Murray32

1994

USA

Before-after

OrsquoBrien33

1998

USA

Before-after

Setting

One hospital

medicalsurgical and


only

750-bed university


except psychiatric

labor and delivery

postpartum and

newborn nursery


Intervention
















Measures Reported





(PT)


(PT)




Stages II-IV (PT)



(PT)

5 patients with PUs





ordered (PRO)




completed (PRO)




(PRO)






not (PRO)










reassessment (PRO)






Effect

Udagger

Udagger

+||

+||

0

+||

0

+||

0

0

0

0

ndash

0

+||

Months

28sect

48Dagger

Authorsrsquo

Conclusions

PU prevention

programs

should include

a risk assess-

ment tool pro-

tocols for PU

prevention staff

education and a

means to evalu-

ate outcomes

Systemwide

educational ef-

forts that in-

clude all levels

of professionals

and multispe-

cialty preven-

tion and care

efforts can lead

to a reduction

in PU preva-

lence

Quality

Score

13

15





AP12


Author

Year

Country

Design

Olson34

1998

Canada

Before-after

Peich35

2004

Israel

Before-after

Pokorny36

2003

USA

Before-after

Setting

One cancer hospital

2 units

300-bed teaching

hospital orthopedic

unit and recovery

room intervention

limited to patients

with hip fractures


cardiac surgery ICU

and cardiac surgery

intermediate care



dergoing elective

open heart surgery


Intervention















mattresses













education

Measures Reported




oped PU in hospital


on admission (PT)

1 of nosocomial PUs

among hip fracture

patients (PT)


Effect

0

+||

Udagger

Months

Not

clear

28sect

Not

clear

Authorsrsquo

Conclusions

The Braden

Scale has been

permanently in-

corporated into

the daily chart-

ing forms It is

now possible to

track the de-

gree to which

the scale and

prevention pro-

tocol are used

through the

quarterly chart

audits

PU prevention

in patients with

hip fractures is

feasible An

increased

awareness of

the problem

among hospital

staff may be

important

The develop-

ment and

progress of

PUs can be al-

tered by nurs-

ing care PU

risk can only

be predicted

through

repeated

assessments

throughout

hospitalization

Quality

Score

11

12

12





AP13


Author

Year

Country

Design

Rashotte37

2008

Canada

Before-after

Setting



Intervention










PU prevention

Measures Reported






(PRO)




(PRO)



(PRO)



completed (PRO)

5 Median number of


faces in use (PRO)








8 Median number of



protectors used to


(PRO)




(PRO)

10 Median number of


care expert (PRO)

Effect

Udagger

Udagger

Udagger

Udagger

Udagger

Udagger

Udagger

Udagger

Udagger

Udagger

Months

6sect

Authorsrsquo

Conclusions

Significant

changes in

nursing best

practice guide-

lines were

found which

highlights the

complexities of

changing prac-

tice Contextual

influences such

as teamwork

and resources

may inform

results

Quality

Score

6





AP14


Author

Year

Country

Design

Sacharok38

1998

USA

Before-after

Saleh39

2009

UK

Controlled

clinical trial

Stier40

2004

USA

Before-after

Setting

300-bed acute care

community hospital

several units adult

medical surgical

critical care and

later emergency

room


Health care system

in eastern US units

not specified


Intervention





tool conducted PDSA











times)
















only












Measures Reported



1 Prevalence of

nosocomial PUs (PT)



admission (PT)

1 Nosocomial PU

incidence (PT)

Effect

Udagger

Group

A vs

C

0

Group

B vs

C

0

Udagger

Months

47sect

13Dagger

Not

clear

Authorsrsquo

Conclusions

Implementation

of a total quality

management

model resulted

in an 83 re-

duction in PU

prevalence

There were no

differences in

PU incidence in

the groups that

received addi-

tional training

Clinical judg-

ment may be

as effective as

employing a

risk assess-

ment scale to

assess risk for

PUs

The sustained

success of the

program is at-

tributed to (1) a

reliable and

valid measure-

ment system

that facilitates

performance

assessment

and evaluation

and (2) ongoing

unit educational

activities

Quality

Score

11

10

12





AP15


Author

Year

Country

Design

Stoelting41

2007

USA

Before-after

Uzun42

2009

Turkey

Before-after

Van Etten43

1990

USA

Before-after

Setting

Large teaching

hospital units not

specified

880-bed acute care

university hospital

ICU areas only 2

general medical

surgical ICUs

1 neurosurgical ICU

1 postanesthesia

care unit


risk care areas (1)



dics (3) acute

neurointensive care


Intervention


























education

Measures Reported



1 PU incidence (PT)





(PT)

1 patients with


(PT)

Effect

Udagger

+||

+||

Months

Not

clear

35sect

6sect

Authorsrsquo

Conclusions

An intervention

targeting

awareness and

communication

regarding PUs

resulted in

more complete

adherence to

the nursing

prevention

protocol

An education

program and

implementation

of preventive

nursing inter-

ventions were

effective in de-

creasing PU in-

cidence in ICU

patients

The program

appeared to be

successful as

evidenced by a

decrease in

nosocomial PU

rates Findings

underscore the

importance of

identifying pa-

tient risk for

PUs and follow-

ing through

with a plan for

prevention and

treatment

Quality

Score

7

13

11





AP16


Author

Year

Country

Design

Willson44

1995

USA

Before-after

Setting

One hospital

4 medicalsurgical

units


Intervention









used

Measures Reported



1 PU incidence (PT)

Effect

Udagger

Months

6sect

Authorsrsquo

Conclusions

Preliminary

results indicate

that modifica-

tions to a hos-


tion system can

support staff in

following new

protocols and

can lead to a

decrease in PU

incidence

Quality

Score

8













Author

Year

Country

Design

Dibsie18

2008

USA

Before-after

Dukich19

2001

USA

Before-after

Gibbons20

2006

USA

Before-after

Setting

Multisite academic


not specified


Trauma Center and



each site ICUs and

medicalsurgical

units

528-bed hospital in

Florida all units


Intervention


protocol conducted





on new products









of support surfaces











product changed

Measures Reported





(PT)



(PT)


I (Hospital B) (PT)





(PT)



(PT)

1 Facility-acquired


Effect

Udagger

Udagger

Udagger

Udagger

Udagger

Udagger

Udagger

Months

21Dagger

12Dagger

14sect

Authorsrsquo

Conclusions

Implementation

of an evidence-

based practice

protocol led to

improvements

in PU preva-

lence

A modest de-

crease in an-

nual expendi -

tures for rental

support sur-

faces was real-

ized results for

incidence and

prevalence dif-

fered across

hospitals and

may be attribut-

able to non-

standardized

documentation

tools

The program

enabled the

identification of

at-risk popula-

tions the im-

plementation of

appropriate

actions and

the achieve-

ment of posi-

tive measura-

ble results

Quality

Score

9

6

8






Author

Year

Country

Design

Gunningberg21

1999

Sweden

Controlled

study

Hiser22

2006

USA

Before-after

Hobbs23

2004

USA

Before-after

Setting

One hospital 4


ment of orthopedics



tures


including a medical

ICU

280-bed geriatric

hospital 4 units

geriatrics oncology

surgical postop and

orthopedicsneurol-

ogy


Intervention










(C) risk assessment




tion conducted



















education

Measures Reported









(PT)

1 patients with PUs

(prevalence) entire

hospital (PT)



pital (PT)

3 patients with PUs

(medical ICU) (PT)



ICU) (PT)


(PT)




mial pneumonia (PT)


rals (per month) to



(PRO)

Effect

Group

I vs C

0

Group

I vs C

0

0

0

0

0

+||

+||

0

0

Months

6sect

15sect

6sect

Authorsrsquo

Conclusions

No difference in

prevalence be-

tween interven-

tion and control

groups use of

the Modified

Norton Scale

facilitated the

identification of

the majority of

patients at risk

for PUs

Changes re-

sulted in a de-

crease in

quarterly hospi-

tal-acquired PU

prevalence in

participating

units Clinicians

now approach

PUs as pre-

ventable over-

all quality of

care and finan-

cial resource

utilization are

also improved

Following im-

plementation of

the turn team

program pa-

tient referrals to

the enteros-

tomal therapy

nurse average

length of stay

and muscu-

loskeletal in-

juries to staff all

declined

Quality

Score

11

10

11






Author

Year

Country

Design

Hopkins24

2000

USA

Before-after

Hunter25

1995

USA

Before-after

Jones26

1993

USA

Before-after

Setting

One acute care hos-

pital adult medical

surgical population

units not specified



350-bed community


on oncology med-

ical surgical ICU

intermediate care

units and high-risk

pediatric patients


Intervention


















staff education












education

Measures Reported




(PT)


quired PUs (PT)


dicted PUs (PT)

1 PU prevalence



IndashIV) (PT)


IIndashIV) (PT)

3 PU incidence (PT)





existing PUs (PRO)

5 patients who had



(PRO)

Effect

+||

Udagger

Udagger

0

0

0

0

Udagger

Udagger

Months

24Dagger

16sect

5sect

Authorsrsquo

Conclusions

Multidimen-

sional interven-

tions as an

adjunct to best

practices and

research-based

protocols im-

proved nosoco-

mial PU rates

Following im-

plementation of

protocols PU

prevalence de-

creased Health

care facilities

can improve

the quality of

care for PU

prevention by

establishing a

well-structured

PU prevention

treatment

program

Overall de-

crease in PU

incidence was

found and the

documentation

of PUs im-

proved Educa-

tion of nursing

staff is a key

component of

PU prevention

Quality

Score

15

13

13






Author

Year

Country

Design

LeMaster27

2007

USA

Before-after

Lyder28

2004

USA

Before-after

Setting

502-bed hospital 2

units pulmonary and

oncology

17 hospitals in the



from 200 to 800

beds


Intervention













tion conducted

















and at conferences

Measures Reported





(PT)



(PT)



2 Hospital-acquired

Stage I PU (PT)


gt Stage II (PT)


any stage (PT)


stay (days) (PT)






(PRO)

9 Use of pressure-



(PRO)



(PRO)





(PRO)



(PRO)


Stage I PUs (PRO)


Stage II PUs (PRO)

Effect

Udagger

Udagger

0

0

0

0

+||

0

0

+||

0

0

+||

+||

0

+||

Months

12sect

Not

clear

Authorsrsquo

Conclusions

The interven-

tion was suc-

cessful and

was replicated

throughout the

facility

Found clinically

and statistically

significant im-

provements in

4 PU preven-

tion-related

processes of

care concurrent

with multi-

faceted

improvement

intervention

Quality

Score

9

14






Author

Year

Country

Design

McErlean29

2002

Australia

Before-after

McInerney30

2008

USA

Before-after

Moore31

1997

USA

Before-after

Setting

250-bed hospital

units not specified

548-bed 2-hospital

system all patients


mental health

500+ bed university

hospital units not

specified


Intervention























relief orders














Measures Reported



1 PU incidence (all

stages) (PT)


Stage I PUs (PT)


Stage II PUs (PT)


Stage III PUs (PT)


Stage IV PUs (PT)

1 Overall hospital-




Effect

Udagger

Udagger

Udagger

Udagger

Udagger

Udagger

+||

+||

Months

12Dagger

59sect

19sect

Authorsrsquo

Conclusions

Both the identi-

fication of pa-

tient risk at

admission and

the implemen-

tation of appro-

priate pre-

ventive inter-

ventions have

increased this

has resulted in

a reduction in

the incidence

and severity of

PUs

The hospital

system was

able to reduce

hospital-ac-

quired PU

prevalence by

81 The re-

sultant cost

savings in ad-

dition to the

elimination of

patientsrsquo pain

and suffering

from PUs can

significantly im-

pact the cost

and quality of

care

A systematic

approach to

change includ-

ing a more

comprehensive

theory will

guide leaders

in promoting

change

Quality

Score

10

10

11


AP10




AP11


Author

Year

Country

Design

Murray32

1994

USA

Before-after

OrsquoBrien33

1998

USA

Before-after

Setting

One hospital

medicalsurgical and


only

750-bed university


except psychiatric

labor and delivery

postpartum and

newborn nursery


Intervention
















Measures Reported





(PT)


(PT)




Stages II-IV (PT)



(PT)

5 patients with PUs





ordered (PRO)




completed (PRO)




(PRO)






not (PRO)










reassessment (PRO)






Effect

Udagger

Udagger

+||

+||

0

+||

0

+||

0

0

0

0

ndash

0

+||

Months

28sect

48Dagger

Authorsrsquo

Conclusions

PU prevention

programs

should include

a risk assess-

ment tool pro-

tocols for PU

prevention staff

education and a

means to evalu-

ate outcomes

Systemwide

educational ef-

forts that in-

clude all levels

of professionals

and multispe-

cialty preven-

tion and care

efforts can lead

to a reduction

in PU preva-

lence

Quality

Score

13

15





AP12


Author

Year

Country

Design

Olson34

1998

Canada

Before-after

Peich35

2004

Israel

Before-after

Pokorny36

2003

USA

Before-after

Setting

One cancer hospital

2 units

300-bed teaching

hospital orthopedic

unit and recovery

room intervention

limited to patients

with hip fractures


cardiac surgery ICU

and cardiac surgery

intermediate care



dergoing elective

open heart surgery


Intervention















mattresses













education

Measures Reported




oped PU in hospital


on admission (PT)

1 of nosocomial PUs

among hip fracture

patients (PT)


Effect

0

+||

Udagger

Months

Not

clear

28sect

Not

clear

Authorsrsquo

Conclusions

The Braden

Scale has been

permanently in-

corporated into

the daily chart-

ing forms It is

now possible to

track the de-

gree to which

the scale and

prevention pro-

tocol are used

through the

quarterly chart

audits

PU prevention

in patients with

hip fractures is

feasible An

increased

awareness of

the problem

among hospital

staff may be

important

The develop-

ment and

progress of

PUs can be al-

tered by nurs-

ing care PU

risk can only

be predicted

through

repeated

assessments

throughout

hospitalization

Quality

Score

11

12

12





AP13


Author

Year

Country

Design

Rashotte37

2008

Canada

Before-after

Setting



Intervention










PU prevention

Measures Reported






(PRO)




(PRO)



(PRO)



completed (PRO)

5 Median number of


faces in use (PRO)








8 Median number of



protectors used to


(PRO)




(PRO)

10 Median number of


care expert (PRO)

Effect

Udagger

Udagger

Udagger

Udagger

Udagger

Udagger

Udagger

Udagger

Udagger

Udagger

Months

6sect

Authorsrsquo

Conclusions

Significant

changes in

nursing best

practice guide-

lines were

found which

highlights the

complexities of

changing prac-

tice Contextual

influences such

as teamwork

and resources

may inform

results

Quality

Score

6





AP14


Author

Year

Country

Design

Sacharok38

1998

USA

Before-after

Saleh39

2009

UK

Controlled

clinical trial

Stier40

2004

USA

Before-after

Setting

300-bed acute care

community hospital

several units adult

medical surgical

critical care and

later emergency

room


Health care system

in eastern US units

not specified


Intervention





tool conducted PDSA











times)
















only












Measures Reported



1 Prevalence of

nosocomial PUs (PT)



admission (PT)

1 Nosocomial PU

incidence (PT)

Effect

Udagger

Group

A vs

C

0

Group

B vs

C

0

Udagger

Months

47sect

13Dagger

Not

clear

Authorsrsquo

Conclusions

Implementation

of a total quality

management

model resulted

in an 83 re-

duction in PU

prevalence

There were no

differences in

PU incidence in

the groups that

received addi-

tional training

Clinical judg-

ment may be

as effective as

employing a

risk assess-

ment scale to

assess risk for

PUs

The sustained

success of the

program is at-

tributed to (1) a

reliable and

valid measure-

ment system

that facilitates

performance

assessment

and evaluation

and (2) ongoing

unit educational

activities

Quality

Score

11

10

12





AP15


Author

Year

Country

Design

Stoelting41

2007

USA

Before-after

Uzun42

2009

Turkey

Before-after

Van Etten43

1990

USA

Before-after

Setting

Large teaching

hospital units not

specified

880-bed acute care

university hospital

ICU areas only 2

general medical

surgical ICUs

1 neurosurgical ICU

1 postanesthesia

care unit


risk care areas (1)



dics (3) acute

neurointensive care


Intervention


























education

Measures Reported



1 PU incidence (PT)





(PT)

1 patients with


(PT)

Effect

Udagger

+||

+||

Months

Not

clear

35sect

6sect

Authorsrsquo

Conclusions

An intervention

targeting

awareness and

communication

regarding PUs

resulted in

more complete

adherence to

the nursing

prevention

protocol

An education

program and

implementation

of preventive

nursing inter-

ventions were

effective in de-

creasing PU in-

cidence in ICU

patients

The program

appeared to be

successful as

evidenced by a

decrease in

nosocomial PU

rates Findings

underscore the

importance of

identifying pa-

tient risk for

PUs and follow-

ing through

with a plan for

prevention and

treatment

Quality

Score

7

13

11





AP16


Author

Year

Country

Design

Willson44

1995

USA

Before-after

Setting

One hospital

4 medicalsurgical

units


Intervention









used

Measures Reported



1 PU incidence (PT)

Effect

Udagger

Months

6sect

Authorsrsquo

Conclusions

Preliminary

results indicate

that modifica-

tions to a hos-


tion system can

support staff in

following new

protocols and

can lead to a

decrease in PU

incidence

Quality

Score

8













Author

Year

Country

Design

Gunningberg21

1999

Sweden

Controlled

study

Hiser22

2006

USA

Before-after

Hobbs23

2004

USA

Before-after

Setting

One hospital 4


ment of orthopedics



tures


including a medical

ICU

280-bed geriatric

hospital 4 units

geriatrics oncology

surgical postop and

orthopedicsneurol-

ogy


Intervention










(C) risk assessment




tion conducted



















education

Measures Reported









(PT)

1 patients with PUs

(prevalence) entire

hospital (PT)



pital (PT)

3 patients with PUs

(medical ICU) (PT)



ICU) (PT)


(PT)




mial pneumonia (PT)


rals (per month) to



(PRO)

Effect

Group

I vs C

0

Group

I vs C

0

0

0

0

0

+||

+||

0

0

Months

6sect

15sect

6sect

Authorsrsquo

Conclusions

No difference in

prevalence be-

tween interven-

tion and control

groups use of

the Modified

Norton Scale

facilitated the

identification of

the majority of

patients at risk

for PUs

Changes re-

sulted in a de-

crease in

quarterly hospi-

tal-acquired PU

prevalence in

participating

units Clinicians

now approach

PUs as pre-

ventable over-

all quality of

care and finan-

cial resource

utilization are

also improved

Following im-

plementation of

the turn team

program pa-

tient referrals to

the enteros-

tomal therapy

nurse average

length of stay

and muscu-

loskeletal in-

juries to staff all

declined

Quality

Score

11

10

11






Author

Year

Country

Design

Hopkins24

2000

USA

Before-after

Hunter25

1995

USA

Before-after

Jones26

1993

USA

Before-after

Setting

One acute care hos-

pital adult medical

surgical population

units not specified



350-bed community


on oncology med-

ical surgical ICU

intermediate care

units and high-risk

pediatric patients


Intervention


















staff education












education

Measures Reported




(PT)


quired PUs (PT)


dicted PUs (PT)

1 PU prevalence



IndashIV) (PT)


IIndashIV) (PT)

3 PU incidence (PT)





existing PUs (PRO)

5 patients who had



(PRO)

Effect

+||

Udagger

Udagger

0

0

0

0

Udagger

Udagger

Months

24Dagger

16sect

5sect

Authorsrsquo

Conclusions

Multidimen-

sional interven-

tions as an

adjunct to best

practices and

research-based

protocols im-

proved nosoco-

mial PU rates

Following im-

plementation of

protocols PU

prevalence de-

creased Health

care facilities

can improve

the quality of

care for PU

prevention by

establishing a

well-structured

PU prevention

treatment

program

Overall de-

crease in PU

incidence was

found and the

documentation

of PUs im-

proved Educa-

tion of nursing

staff is a key

component of

PU prevention

Quality

Score

15

13

13






Author

Year

Country

Design

LeMaster27

2007

USA

Before-after

Lyder28

2004

USA

Before-after

Setting

502-bed hospital 2

units pulmonary and

oncology

17 hospitals in the



from 200 to 800

beds


Intervention













tion conducted

















and at conferences

Measures Reported





(PT)



(PT)



2 Hospital-acquired

Stage I PU (PT)


gt Stage II (PT)


any stage (PT)


stay (days) (PT)






(PRO)

9 Use of pressure-



(PRO)



(PRO)





(PRO)



(PRO)


Stage I PUs (PRO)


Stage II PUs (PRO)

Effect

Udagger

Udagger

0

0

0

0

+||

0

0

+||

0

0

+||

+||

0

+||

Months

12sect

Not

clear

Authorsrsquo

Conclusions

The interven-

tion was suc-

cessful and

was replicated

throughout the

facility

Found clinically

and statistically

significant im-

provements in

4 PU preven-

tion-related

processes of

care concurrent

with multi-

faceted

improvement

intervention

Quality

Score

9

14






Author

Year

Country

Design

McErlean29

2002

Australia

Before-after

McInerney30

2008

USA

Before-after

Moore31

1997

USA

Before-after

Setting

250-bed hospital

units not specified

548-bed 2-hospital

system all patients


mental health

500+ bed university

hospital units not

specified


Intervention























relief orders














Measures Reported



1 PU incidence (all

stages) (PT)


Stage I PUs (PT)


Stage II PUs (PT)


Stage III PUs (PT)


Stage IV PUs (PT)

1 Overall hospital-




Effect

Udagger

Udagger

Udagger

Udagger

Udagger

Udagger

+||

+||

Months

12Dagger

59sect

19sect

Authorsrsquo

Conclusions

Both the identi-

fication of pa-

tient risk at

admission and

the implemen-

tation of appro-

priate pre-

ventive inter-

ventions have

increased this

has resulted in

a reduction in

the incidence

and severity of

PUs

The hospital

system was

able to reduce

hospital-ac-

quired PU

prevalence by

81 The re-

sultant cost

savings in ad-

dition to the

elimination of

patientsrsquo pain

and suffering

from PUs can

significantly im-

pact the cost

and quality of

care

A systematic

approach to

change includ-

ing a more

comprehensive

theory will

guide leaders

in promoting

change

Quality

Score

10

10

11


AP10




AP11


Author

Year

Country

Design

Murray32

1994

USA

Before-after

OrsquoBrien33

1998

USA

Before-after

Setting

One hospital

medicalsurgical and


only

750-bed university


except psychiatric

labor and delivery

postpartum and

newborn nursery


Intervention
















Measures Reported





(PT)


(PT)




Stages II-IV (PT)



(PT)

5 patients with PUs





ordered (PRO)




completed (PRO)




(PRO)






not (PRO)










reassessment (PRO)






Effect

Udagger

Udagger

+||

+||

0

+||

0

+||

0

0

0

0

ndash

0

+||

Months

28sect

48Dagger

Authorsrsquo

Conclusions

PU prevention

programs

should include

a risk assess-

ment tool pro-

tocols for PU

prevention staff

education and a

means to evalu-

ate outcomes

Systemwide

educational ef-

forts that in-

clude all levels

of professionals

and multispe-

cialty preven-

tion and care

efforts can lead

to a reduction

in PU preva-

lence

Quality

Score

13

15





AP12


Author

Year

Country

Design

Olson34

1998

Canada

Before-after

Peich35

2004

Israel

Before-after

Pokorny36

2003

USA

Before-after

Setting

One cancer hospital

2 units

300-bed teaching

hospital orthopedic

unit and recovery

room intervention

limited to patients

with hip fractures


cardiac surgery ICU

and cardiac surgery

intermediate care



dergoing elective

open heart surgery


Intervention















mattresses













education

Measures Reported




oped PU in hospital


on admission (PT)

1 of nosocomial PUs

among hip fracture

patients (PT)


Effect

0

+||

Udagger

Months

Not

clear

28sect

Not

clear

Authorsrsquo

Conclusions

The Braden

Scale has been

permanently in-

corporated into

the daily chart-

ing forms It is

now possible to

track the de-

gree to which

the scale and

prevention pro-

tocol are used

through the

quarterly chart

audits

PU prevention

in patients with

hip fractures is

feasible An

increased

awareness of

the problem

among hospital

staff may be

important

The develop-

ment and

progress of

PUs can be al-

tered by nurs-

ing care PU

risk can only

be predicted

through

repeated

assessments

throughout

hospitalization

Quality

Score

11

12

12





AP13


Author

Year

Country

Design

Rashotte37

2008

Canada

Before-after

Setting



Intervention










PU prevention

Measures Reported






(PRO)




(PRO)



(PRO)



completed (PRO)

5 Median number of


faces in use (PRO)








8 Median number of



protectors used to


(PRO)




(PRO)

10 Median number of


care expert (PRO)

Effect

Udagger

Udagger

Udagger

Udagger

Udagger

Udagger

Udagger

Udagger

Udagger

Udagger

Months

6sect

Authorsrsquo

Conclusions

Significant

changes in

nursing best

practice guide-

lines were

found which

highlights the

complexities of

changing prac-

tice Contextual

influences such

as teamwork

and resources

may inform

results

Quality

Score

6





AP14


Author

Year

Country

Design

Sacharok38

1998

USA

Before-after

Saleh39

2009

UK

Controlled

clinical trial

Stier40

2004

USA

Before-after

Setting

300-bed acute care

community hospital

several units adult

medical surgical

critical care and

later emergency

room


Health care system

in eastern US units

not specified


Intervention





tool conducted PDSA











times)
















only












Measures Reported



1 Prevalence of

nosocomial PUs (PT)



admission (PT)

1 Nosocomial PU

incidence (PT)

Effect

Udagger

Group

A vs

C

0

Group

B vs

C

0

Udagger

Months

47sect

13Dagger

Not

clear

Authorsrsquo

Conclusions

Implementation

of a total quality

management

model resulted

in an 83 re-

duction in PU

prevalence

There were no

differences in

PU incidence in

the groups that

received addi-

tional training

Clinical judg-

ment may be

as effective as

employing a

risk assess-

ment scale to

assess risk for

PUs

The sustained

success of the

program is at-

tributed to (1) a

reliable and

valid measure-

ment system

that facilitates

performance

assessment

and evaluation

and (2) ongoing

unit educational

activities

Quality

Score

11

10

12





AP15


Author

Year

Country

Design

Stoelting41

2007

USA

Before-after

Uzun42

2009

Turkey

Before-after

Van Etten43

1990

USA

Before-after

Setting

Large teaching

hospital units not

specified

880-bed acute care

university hospital

ICU areas only 2

general medical

surgical ICUs

1 neurosurgical ICU

1 postanesthesia

care unit


risk care areas (1)



dics (3) acute

neurointensive care


Intervention


























education

Measures Reported



1 PU incidence (PT)





(PT)

1 patients with


(PT)

Effect

Udagger

+||

+||

Months

Not

clear

35sect

6sect

Authorsrsquo

Conclusions

An intervention

targeting

awareness and

communication

regarding PUs

resulted in

more complete

adherence to

the nursing

prevention

protocol

An education

program and

implementation

of preventive

nursing inter-

ventions were

effective in de-

creasing PU in-

cidence in ICU

patients

The program

appeared to be

successful as

evidenced by a

decrease in

nosocomial PU

rates Findings

underscore the

importance of

identifying pa-

tient risk for

PUs and follow-

ing through

with a plan for

prevention and

treatment

Quality

Score

7

13

11





AP16


Author

Year

Country

Design

Willson44

1995

USA

Before-after

Setting

One hospital

4 medicalsurgical

units


Intervention









used

Measures Reported



1 PU incidence (PT)

Effect

Udagger

Months

6sect

Authorsrsquo

Conclusions

Preliminary

results indicate

that modifica-

tions to a hos-


tion system can

support staff in

following new

protocols and

can lead to a

decrease in PU

incidence

Quality

Score

8













Author

Year

Country

Design

Hopkins24

2000

USA

Before-after

Hunter25

1995

USA

Before-after

Jones26

1993

USA

Before-after

Setting

One acute care hos-

pital adult medical

surgical population

units not specified



350-bed community


on oncology med-

ical surgical ICU

intermediate care

units and high-risk

pediatric patients


Intervention


















staff education












education

Measures Reported




(PT)


quired PUs (PT)


dicted PUs (PT)

1 PU prevalence



IndashIV) (PT)


IIndashIV) (PT)

3 PU incidence (PT)





existing PUs (PRO)

5 patients who had



(PRO)

Effect

+||

Udagger

Udagger

0

0

0

0

Udagger

Udagger

Months

24Dagger

16sect

5sect

Authorsrsquo

Conclusions

Multidimen-

sional interven-

tions as an

adjunct to best

practices and

research-based

protocols im-

proved nosoco-

mial PU rates

Following im-

plementation of

protocols PU

prevalence de-

creased Health

care facilities

can improve

the quality of

care for PU

prevention by

establishing a

well-structured

PU prevention

treatment

program

Overall de-

crease in PU

incidence was

found and the

documentation

of PUs im-

proved Educa-

tion of nursing

staff is a key

component of

PU prevention

Quality

Score

15

13

13






Author

Year

Country

Design

LeMaster27

2007

USA

Before-after

Lyder28

2004

USA

Before-after

Setting

502-bed hospital 2

units pulmonary and

oncology

17 hospitals in the



from 200 to 800

beds


Intervention













tion conducted

















and at conferences

Measures Reported





(PT)



(PT)



2 Hospital-acquired

Stage I PU (PT)


gt Stage II (PT)


any stage (PT)


stay (days) (PT)






(PRO)

9 Use of pressure-



(PRO)



(PRO)





(PRO)



(PRO)


Stage I PUs (PRO)


Stage II PUs (PRO)

Effect

Udagger

Udagger

0

0

0

0

+||

0

0

+||

0

0

+||

+||

0

+||

Months

12sect

Not

clear

Authorsrsquo

Conclusions

The interven-

tion was suc-

cessful and

was replicated

throughout the

facility

Found clinically

and statistically

significant im-

provements in

4 PU preven-

tion-related

processes of

care concurrent

with multi-

faceted

improvement

intervention

Quality

Score

9

14






Author

Year

Country

Design

McErlean29

2002

Australia

Before-after

McInerney30

2008

USA

Before-after

Moore31

1997

USA

Before-after

Setting

250-bed hospital

units not specified

548-bed 2-hospital

system all patients


mental health

500+ bed university

hospital units not

specified


Intervention























relief orders














Measures Reported



1 PU incidence (all

stages) (PT)


Stage I PUs (PT)


Stage II PUs (PT)


Stage III PUs (PT)


Stage IV PUs (PT)

1 Overall hospital-




Effect

Udagger

Udagger

Udagger

Udagger

Udagger

Udagger

+||

+||

Months

12Dagger

59sect

19sect

Authorsrsquo

Conclusions

Both the identi-

fication of pa-

tient risk at

admission and

the implemen-

tation of appro-

priate pre-

ventive inter-

ventions have

increased this

has resulted in

a reduction in

the incidence

and severity of

PUs

The hospital

system was

able to reduce

hospital-ac-

quired PU

prevalence by

81 The re-

sultant cost

savings in ad-

dition to the

elimination of

patientsrsquo pain

and suffering

from PUs can

significantly im-

pact the cost

and quality of

care

A systematic

approach to

change includ-

ing a more

comprehensive

theory will

guide leaders

in promoting

change

Quality

Score

10

10

11


AP10




AP11


Author

Year

Country

Design

Murray32

1994

USA

Before-after

OrsquoBrien33

1998

USA

Before-after

Setting

One hospital

medicalsurgical and


only

750-bed university


except psychiatric

labor and delivery

postpartum and

newborn nursery


Intervention
















Measures Reported





(PT)


(PT)




Stages II-IV (PT)



(PT)

5 patients with PUs





ordered (PRO)




completed (PRO)




(PRO)






not (PRO)










reassessment (PRO)






Effect

Udagger

Udagger

+||

+||

0

+||

0

+||

0

0

0

0

ndash

0

+||

Months

28sect

48Dagger

Authorsrsquo

Conclusions

PU prevention

programs

should include

a risk assess-

ment tool pro-

tocols for PU

prevention staff

education and a

means to evalu-

ate outcomes

Systemwide

educational ef-

forts that in-

clude all levels

of professionals

and multispe-

cialty preven-

tion and care

efforts can lead

to a reduction

in PU preva-

lence

Quality

Score

13

15





AP12


Author

Year

Country

Design

Olson34

1998

Canada

Before-after

Peich35

2004

Israel

Before-after

Pokorny36

2003

USA

Before-after

Setting

One cancer hospital

2 units

300-bed teaching

hospital orthopedic

unit and recovery

room intervention

limited to patients

with hip fractures


cardiac surgery ICU

and cardiac surgery

intermediate care



dergoing elective

open heart surgery


Intervention















mattresses













education

Measures Reported




oped PU in hospital


on admission (PT)

1 of nosocomial PUs

among hip fracture

patients (PT)


Effect

0

+||

Udagger

Months

Not

clear

28sect

Not

clear

Authorsrsquo

Conclusions

The Braden

Scale has been

permanently in-

corporated into

the daily chart-

ing forms It is

now possible to

track the de-

gree to which

the scale and

prevention pro-

tocol are used

through the

quarterly chart

audits

PU prevention

in patients with

hip fractures is

feasible An

increased

awareness of

the problem

among hospital

staff may be

important

The develop-

ment and

progress of

PUs can be al-

tered by nurs-

ing care PU

risk can only

be predicted

through

repeated

assessments

throughout

hospitalization

Quality

Score

11

12

12





AP13


Author

Year

Country

Design

Rashotte37

2008

Canada

Before-after

Setting



Intervention










PU prevention

Measures Reported






(PRO)




(PRO)



(PRO)



completed (PRO)

5 Median number of


faces in use (PRO)








8 Median number of



protectors used to


(PRO)




(PRO)

10 Median number of


care expert (PRO)

Effect

Udagger

Udagger

Udagger

Udagger

Udagger

Udagger

Udagger

Udagger

Udagger

Udagger

Months

6sect

Authorsrsquo

Conclusions

Significant

changes in

nursing best

practice guide-

lines were

found which

highlights the

complexities of

changing prac-

tice Contextual

influences such

as teamwork

and resources

may inform

results

Quality

Score

6





AP14


Author

Year

Country

Design

Sacharok38

1998

USA

Before-after

Saleh39

2009

UK

Controlled

clinical trial

Stier40

2004

USA

Before-after

Setting

300-bed acute care

community hospital

several units adult

medical surgical

critical care and

later emergency

room


Health care system

in eastern US units

not specified


Intervention





tool conducted PDSA











times)
















only












Measures Reported



1 Prevalence of

nosocomial PUs (PT)



admission (PT)

1 Nosocomial PU

incidence (PT)

Effect

Udagger

Group

A vs

C

0

Group

B vs

C

0

Udagger

Months

47sect

13Dagger

Not

clear

Authorsrsquo

Conclusions

Implementation

of a total quality

management

model resulted

in an 83 re-

duction in PU

prevalence

There were no

differences in

PU incidence in

the groups that

received addi-

tional training

Clinical judg-

ment may be

as effective as

employing a

risk assess-

ment scale to

assess risk for

PUs

The sustained

success of the

program is at-

tributed to (1) a

reliable and

valid measure-

ment system

that facilitates

performance

assessment

and evaluation

and (2) ongoing

unit educational

activities

Quality

Score

11

10

12





AP15


Author

Year

Country

Design

Stoelting41

2007

USA

Before-after

Uzun42

2009

Turkey

Before-after

Van Etten43

1990

USA

Before-after

Setting

Large teaching

hospital units not

specified

880-bed acute care

university hospital

ICU areas only 2

general medical

surgical ICUs

1 neurosurgical ICU

1 postanesthesia

care unit


risk care areas (1)



dics (3) acute

neurointensive care


Intervention


























education

Measures Reported



1 PU incidence (PT)





(PT)

1 patients with


(PT)

Effect

Udagger

+||

+||

Months

Not

clear

35sect

6sect

Authorsrsquo

Conclusions

An intervention

targeting

awareness and

communication

regarding PUs

resulted in

more complete

adherence to

the nursing

prevention

protocol

An education

program and

implementation

of preventive

nursing inter-

ventions were

effective in de-

creasing PU in-

cidence in ICU

patients

The program

appeared to be

successful as

evidenced by a

decrease in

nosocomial PU

rates Findings

underscore the

importance of

identifying pa-

tient risk for

PUs and follow-

ing through

with a plan for

prevention and

treatment

Quality

Score

7

13

11





AP16


Author

Year

Country

Design

Willson44

1995

USA

Before-after

Setting

One hospital

4 medicalsurgical

units


Intervention









used

Measures Reported



1 PU incidence (PT)

Effect

Udagger

Months

6sect

Authorsrsquo

Conclusions

Preliminary

results indicate

that modifica-

tions to a hos-


tion system can

support staff in

following new

protocols and

can lead to a

decrease in PU

incidence

Quality

Score

8













Author

Year

Country

Design

LeMaster27

2007

USA

Before-after

Lyder28

2004

USA

Before-after

Setting

502-bed hospital 2

units pulmonary and

oncology

17 hospitals in the



from 200 to 800

beds


Intervention













tion conducted

















and at conferences

Measures Reported





(PT)



(PT)



2 Hospital-acquired

Stage I PU (PT)


gt Stage II (PT)


any stage (PT)


stay (days) (PT)






(PRO)

9 Use of pressure-



(PRO)



(PRO)





(PRO)



(PRO)


Stage I PUs (PRO)


Stage II PUs (PRO)

Effect

Udagger

Udagger

0

0

0

0

+||

0

0

+||

0

0

+||

+||

0

+||

Months

12sect

Not

clear

Authorsrsquo

Conclusions

The interven-

tion was suc-

cessful and

was replicated

throughout the

facility

Found clinically

and statistically

significant im-

provements in

4 PU preven-

tion-related

processes of

care concurrent

with multi-

faceted

improvement

intervention

Quality

Score

9

14






Author

Year

Country

Design

McErlean29

2002

Australia

Before-after

McInerney30

2008

USA

Before-after

Moore31

1997

USA

Before-after

Setting

250-bed hospital

units not specified

548-bed 2-hospital

system all patients


mental health

500+ bed university

hospital units not

specified


Intervention























relief orders














Measures Reported



1 PU incidence (all

stages) (PT)


Stage I PUs (PT)


Stage II PUs (PT)


Stage III PUs (PT)


Stage IV PUs (PT)

1 Overall hospital-




Effect

Udagger

Udagger

Udagger

Udagger

Udagger

Udagger

+||

+||

Months

12Dagger

59sect

19sect

Authorsrsquo

Conclusions

Both the identi-

fication of pa-

tient risk at

admission and

the implemen-

tation of appro-

priate pre-

ventive inter-

ventions have

increased this

has resulted in

a reduction in

the incidence

and severity of

PUs

The hospital

system was

able to reduce

hospital-ac-

quired PU

prevalence by

81 The re-

sultant cost

savings in ad-

dition to the

elimination of

patientsrsquo pain

and suffering

from PUs can

significantly im-

pact the cost

and quality of

care

A systematic

approach to

change includ-

ing a more

comprehensive

theory will

guide leaders

in promoting

change

Quality

Score

10

10

11


AP10




AP11


Author

Year

Country

Design

Murray32

1994

USA

Before-after

OrsquoBrien33

1998

USA

Before-after

Setting

One hospital

medicalsurgical and


only

750-bed university


except psychiatric

labor and delivery

postpartum and

newborn nursery


Intervention
















Measures Reported





(PT)


(PT)




Stages II-IV (PT)



(PT)

5 patients with PUs





ordered (PRO)




completed (PRO)




(PRO)






not (PRO)










reassessment (PRO)






Effect

Udagger

Udagger

+||

+||

0

+||

0

+||

0

0

0

0

ndash

0

+||

Months

28sect

48Dagger

Authorsrsquo

Conclusions

PU prevention

programs

should include

a risk assess-

ment tool pro-

tocols for PU

prevention staff

education and a

means to evalu-

ate outcomes

Systemwide

educational ef-

forts that in-

clude all levels

of professionals

and multispe-

cialty preven-

tion and care

efforts can lead

to a reduction

in PU preva-

lence

Quality

Score

13

15





AP12


Author

Year

Country

Design

Olson34

1998

Canada

Before-after

Peich35

2004

Israel

Before-after

Pokorny36

2003

USA

Before-after

Setting

One cancer hospital

2 units

300-bed teaching

hospital orthopedic

unit and recovery

room intervention

limited to patients

with hip fractures


cardiac surgery ICU

and cardiac surgery

intermediate care



dergoing elective

open heart surgery


Intervention















mattresses













education

Measures Reported




oped PU in hospital


on admission (PT)

1 of nosocomial PUs

among hip fracture

patients (PT)


Effect

0

+||

Udagger

Months

Not

clear

28sect

Not

clear

Authorsrsquo

Conclusions

The Braden

Scale has been

permanently in-

corporated into

the daily chart-

ing forms It is

now possible to

track the de-

gree to which

the scale and

prevention pro-

tocol are used

through the

quarterly chart

audits

PU prevention

in patients with

hip fractures is

feasible An

increased

awareness of

the problem

among hospital

staff may be

important

The develop-

ment and

progress of

PUs can be al-

tered by nurs-

ing care PU

risk can only

be predicted

through

repeated

assessments

throughout

hospitalization

Quality

Score

11

12

12





AP13


Author

Year

Country

Design

Rashotte37

2008

Canada

Before-after

Setting



Intervention










PU prevention

Measures Reported






(PRO)




(PRO)



(PRO)



completed (PRO)

5 Median number of


faces in use (PRO)








8 Median number of



protectors used to


(PRO)




(PRO)

10 Median number of


care expert (PRO)

Effect

Udagger

Udagger

Udagger

Udagger

Udagger

Udagger

Udagger

Udagger

Udagger

Udagger

Months

6sect

Authorsrsquo

Conclusions

Significant

changes in

nursing best

practice guide-

lines were

found which

highlights the

complexities of

changing prac-

tice Contextual

influences such

as teamwork

and resources

may inform

results

Quality

Score

6





AP14


Author

Year

Country

Design

Sacharok38

1998

USA

Before-after

Saleh39

2009

UK

Controlled

clinical trial

Stier40

2004

USA

Before-after

Setting

300-bed acute care

community hospital

several units adult

medical surgical

critical care and

later emergency

room


Health care system

in eastern US units

not specified


Intervention





tool conducted PDSA











times)
















only












Measures Reported



1 Prevalence of

nosocomial PUs (PT)



admission (PT)

1 Nosocomial PU

incidence (PT)

Effect

Udagger

Group

A vs

C

0

Group

B vs

C

0

Udagger

Months

47sect

13Dagger

Not

clear

Authorsrsquo

Conclusions

Implementation

of a total quality

management

model resulted

in an 83 re-

duction in PU

prevalence

There were no

differences in

PU incidence in

the groups that

received addi-

tional training

Clinical judg-

ment may be

as effective as

employing a

risk assess-

ment scale to

assess risk for

PUs

The sustained

success of the

program is at-

tributed to (1) a

reliable and

valid measure-

ment system

that facilitates

performance

assessment

and evaluation

and (2) ongoing

unit educational

activities

Quality

Score

11

10

12





AP15


Author

Year

Country

Design

Stoelting41

2007

USA

Before-after

Uzun42

2009

Turkey

Before-after

Van Etten43

1990

USA

Before-after

Setting

Large teaching

hospital units not

specified

880-bed acute care

university hospital

ICU areas only 2

general medical

surgical ICUs

1 neurosurgical ICU

1 postanesthesia

care unit


risk care areas (1)



dics (3) acute

neurointensive care


Intervention


























education

Measures Reported



1 PU incidence (PT)





(PT)

1 patients with


(PT)

Effect

Udagger

+||

+||

Months

Not

clear

35sect

6sect

Authorsrsquo

Conclusions

An intervention

targeting

awareness and

communication

regarding PUs

resulted in

more complete

adherence to

the nursing

prevention

protocol

An education

program and

implementation

of preventive

nursing inter-

ventions were

effective in de-

creasing PU in-

cidence in ICU

patients

The program

appeared to be

successful as

evidenced by a

decrease in

nosocomial PU

rates Findings

underscore the

importance of

identifying pa-

tient risk for

PUs and follow-

ing through

with a plan for

prevention and

treatment

Quality

Score

7

13

11





AP16


Author

Year

Country

Design

Willson44

1995

USA

Before-after

Setting

One hospital

4 medicalsurgical

units


Intervention









used

Measures Reported



1 PU incidence (PT)

Effect

Udagger

Months

6sect

Authorsrsquo

Conclusions

Preliminary

results indicate

that modifica-

tions to a hos-


tion system can

support staff in

following new

protocols and

can lead to a

decrease in PU

incidence

Quality

Score

8













Author

Year

Country

Design

McErlean29

2002

Australia

Before-after

McInerney30

2008

USA

Before-after

Moore31

1997

USA

Before-after

Setting

250-bed hospital

units not specified

548-bed 2-hospital

system all patients


mental health

500+ bed university

hospital units not

specified


Intervention























relief orders














Measures Reported



1 PU incidence (all

stages) (PT)


Stage I PUs (PT)


Stage II PUs (PT)


Stage III PUs (PT)


Stage IV PUs (PT)

1 Overall hospital-




Effect

Udagger

Udagger

Udagger

Udagger

Udagger

Udagger

+||

+||

Months

12Dagger

59sect

19sect

Authorsrsquo

Conclusions

Both the identi-

fication of pa-

tient risk at

admission and

the implemen-

tation of appro-

priate pre-

ventive inter-

ventions have

increased this

has resulted in

a reduction in

the incidence

and severity of

PUs

The hospital

system was

able to reduce

hospital-ac-

quired PU

prevalence by

81 The re-

sultant cost

savings in ad-

dition to the

elimination of

patientsrsquo pain

and suffering

from PUs can

significantly im-

pact the cost

and quality of

care

A systematic

approach to

change includ-

ing a more

comprehensive

theory will

guide leaders

in promoting

change

Quality

Score

10

10

11


AP10




AP11


Author

Year

Country

Design

Murray32

1994

USA

Before-after

OrsquoBrien33

1998

USA

Before-after

Setting

One hospital

medicalsurgical and


only

750-bed university


except psychiatric

labor and delivery

postpartum and

newborn nursery


Intervention
















Measures Reported





(PT)


(PT)




Stages II-IV (PT)



(PT)

5 patients with PUs





ordered (PRO)




completed (PRO)




(PRO)






not (PRO)










reassessment (PRO)






Effect

Udagger

Udagger

+||

+||

0

+||

0

+||

0

0

0

0

ndash

0

+||

Months

28sect

48Dagger

Authorsrsquo

Conclusions

PU prevention

programs

should include

a risk assess-

ment tool pro-

tocols for PU

prevention staff

education and a

means to evalu-

ate outcomes

Systemwide

educational ef-

forts that in-

clude all levels

of professionals

and multispe-

cialty preven-

tion and care

efforts can lead

to a reduction

in PU preva-

lence

Quality

Score

13

15





AP12


Author

Year

Country

Design

Olson34

1998

Canada

Before-after

Peich35

2004

Israel

Before-after

Pokorny36

2003

USA

Before-after

Setting

One cancer hospital

2 units

300-bed teaching

hospital orthopedic

unit and recovery

room intervention

limited to patients

with hip fractures


cardiac surgery ICU

and cardiac surgery

intermediate care



dergoing elective

open heart surgery


Intervention















mattresses













education

Measures Reported




oped PU in hospital


on admission (PT)

1 of nosocomial PUs

among hip fracture

patients (PT)


Effect

0

+||

Udagger

Months

Not

clear

28sect

Not

clear

Authorsrsquo

Conclusions

The Braden

Scale has been

permanently in-

corporated into

the daily chart-

ing forms It is

now possible to

track the de-

gree to which

the scale and

prevention pro-

tocol are used

through the

quarterly chart

audits

PU prevention

in patients with

hip fractures is

feasible An

increased

awareness of

the problem

among hospital

staff may be

important

The develop-

ment and

progress of

PUs can be al-

tered by nurs-

ing care PU

risk can only

be predicted

through

repeated

assessments

throughout

hospitalization

Quality

Score

11

12

12





AP13


Author

Year

Country

Design

Rashotte37

2008

Canada

Before-after

Setting



Intervention










PU prevention

Measures Reported






(PRO)




(PRO)



(PRO)



completed (PRO)

5 Median number of


faces in use (PRO)








8 Median number of



protectors used to


(PRO)




(PRO)

10 Median number of


care expert (PRO)

Effect

Udagger

Udagger

Udagger

Udagger

Udagger

Udagger

Udagger

Udagger

Udagger

Udagger

Months

6sect

Authorsrsquo

Conclusions

Significant

changes in

nursing best

practice guide-

lines were

found which

highlights the

complexities of

changing prac-

tice Contextual

influences such

as teamwork

and resources

may inform

results

Quality

Score

6





AP14


Author

Year

Country

Design

Sacharok38

1998

USA

Before-after

Saleh39

2009

UK

Controlled

clinical trial

Stier40

2004

USA

Before-after

Setting

300-bed acute care

community hospital

several units adult

medical surgical

critical care and

later emergency

room


Health care system

in eastern US units

not specified


Intervention





tool conducted PDSA











times)
















only












Measures Reported



1 Prevalence of

nosocomial PUs (PT)



admission (PT)

1 Nosocomial PU

incidence (PT)

Effect

Udagger

Group

A vs

C

0

Group

B vs

C

0

Udagger

Months

47sect

13Dagger

Not

clear

Authorsrsquo

Conclusions

Implementation

of a total quality

management

model resulted

in an 83 re-

duction in PU

prevalence

There were no

differences in

PU incidence in

the groups that

received addi-

tional training

Clinical judg-

ment may be

as effective as

employing a

risk assess-

ment scale to

assess risk for

PUs

The sustained

success of the

program is at-

tributed to (1) a

reliable and

valid measure-

ment system

that facilitates

performance

assessment

and evaluation

and (2) ongoing

unit educational

activities

Quality

Score

11

10

12





AP15


Author

Year

Country

Design

Stoelting41

2007

USA

Before-after

Uzun42

2009

Turkey

Before-after

Van Etten43

1990

USA

Before-after

Setting

Large teaching

hospital units not

specified

880-bed acute care

university hospital

ICU areas only 2

general medical

surgical ICUs

1 neurosurgical ICU

1 postanesthesia

care unit


risk care areas (1)



dics (3) acute

neurointensive care


Intervention


























education

Measures Reported



1 PU incidence (PT)





(PT)

1 patients with


(PT)

Effect

Udagger

+||

+||

Months

Not

clear

35sect

6sect

Authorsrsquo

Conclusions

An intervention

targeting

awareness and

communication

regarding PUs

resulted in

more complete

adherence to

the nursing

prevention

protocol

An education

program and

implementation

of preventive

nursing inter-

ventions were

effective in de-

creasing PU in-

cidence in ICU

patients

The program

appeared to be

successful as

evidenced by a

decrease in

nosocomial PU

rates Findings

underscore the

importance of

identifying pa-

tient risk for

PUs and follow-

ing through

with a plan for

prevention and

treatment

Quality

Score

7

13

11





AP16


Author

Year

Country

Design

Willson44

1995

USA

Before-after

Setting

One hospital

4 medicalsurgical

units


Intervention









used

Measures Reported



1 PU incidence (PT)

Effect

Udagger

Months

6sect

Authorsrsquo

Conclusions

Preliminary

results indicate

that modifica-

tions to a hos-


tion system can

support staff in

following new

protocols and

can lead to a

decrease in PU

incidence

Quality

Score

8












AP11


Author

Year

Country

Design

Murray32

1994

USA

Before-after

OrsquoBrien33

1998

USA

Before-after

Setting

One hospital

medicalsurgical and


only

750-bed university


except psychiatric

labor and delivery

postpartum and

newborn nursery


Intervention
















Measures Reported





(PT)


(PT)




Stages II-IV (PT)



(PT)

5 patients with PUs





ordered (PRO)




completed (PRO)




(PRO)






not (PRO)










reassessment (PRO)






Effect

Udagger

Udagger

+||

+||

0

+||

0

+||

0

0

0

0

ndash

0

+||

Months

28sect

48Dagger

Authorsrsquo

Conclusions

PU prevention

programs

should include

a risk assess-

ment tool pro-

tocols for PU

prevention staff

education and a

means to evalu-

ate outcomes

Systemwide

educational ef-

forts that in-

clude all levels

of professionals

and multispe-

cialty preven-

tion and care

efforts can lead

to a reduction

in PU preva-

lence

Quality

Score

13

15





AP12


Author

Year

Country

Design

Olson34

1998

Canada

Before-after

Peich35

2004

Israel

Before-after

Pokorny36

2003

USA

Before-after

Setting

One cancer hospital

2 units

300-bed teaching

hospital orthopedic

unit and recovery

room intervention

limited to patients

with hip fractures


cardiac surgery ICU

and cardiac surgery

intermediate care



dergoing elective

open heart surgery


Intervention















mattresses













education

Measures Reported




oped PU in hospital


on admission (PT)

1 of nosocomial PUs

among hip fracture

patients (PT)


Effect

0

+||

Udagger

Months

Not

clear

28sect

Not

clear

Authorsrsquo

Conclusions

The Braden

Scale has been

permanently in-

corporated into

the daily chart-

ing forms It is

now possible to

track the de-

gree to which

the scale and

prevention pro-

tocol are used

through the

quarterly chart

audits

PU prevention

in patients with

hip fractures is

feasible An

increased

awareness of

the problem

among hospital

staff may be

important

The develop-

ment and

progress of

PUs can be al-

tered by nurs-

ing care PU

risk can only

be predicted

through

repeated

assessments

throughout

hospitalization

Quality

Score

11

12

12





AP13


Author

Year

Country

Design

Rashotte37

2008

Canada

Before-after

Setting



Intervention










PU prevention

Measures Reported






(PRO)




(PRO)



(PRO)



completed (PRO)

5 Median number of


faces in use (PRO)








8 Median number of



protectors used to


(PRO)




(PRO)

10 Median number of


care expert (PRO)

Effect

Udagger

Udagger

Udagger

Udagger

Udagger

Udagger

Udagger

Udagger

Udagger

Udagger

Months

6sect

Authorsrsquo

Conclusions

Significant

changes in

nursing best

practice guide-

lines were

found which

highlights the

complexities of

changing prac-

tice Contextual

influences such

as teamwork

and resources

may inform

results

Quality

Score

6





AP14


Author

Year

Country

Design

Sacharok38

1998

USA

Before-after

Saleh39

2009

UK

Controlled

clinical trial

Stier40

2004

USA

Before-after

Setting

300-bed acute care

community hospital

several units adult

medical surgical

critical care and

later emergency

room


Health care system

in eastern US units

not specified


Intervention





tool conducted PDSA











times)
















only












Measures Reported



1 Prevalence of

nosocomial PUs (PT)



admission (PT)

1 Nosocomial PU

incidence (PT)

Effect

Udagger

Group

A vs

C

0

Group

B vs

C

0

Udagger

Months

47sect

13Dagger

Not

clear

Authorsrsquo

Conclusions

Implementation

of a total quality

management

model resulted

in an 83 re-

duction in PU

prevalence

There were no

differences in

PU incidence in

the groups that

received addi-

tional training

Clinical judg-

ment may be

as effective as

employing a

risk assess-

ment scale to

assess risk for

PUs

The sustained

success of the

program is at-

tributed to (1) a

reliable and

valid measure-

ment system

that facilitates

performance

assessment

and evaluation

and (2) ongoing

unit educational

activities

Quality

Score

11

10

12





AP15


Author

Year

Country

Design

Stoelting41

2007

USA

Before-after

Uzun42

2009

Turkey

Before-after

Van Etten43

1990

USA

Before-after

Setting

Large teaching

hospital units not

specified

880-bed acute care

university hospital

ICU areas only 2

general medical

surgical ICUs

1 neurosurgical ICU

1 postanesthesia

care unit


risk care areas (1)



dics (3) acute

neurointensive care


Intervention


























education

Measures Reported



1 PU incidence (PT)





(PT)

1 patients with


(PT)

Effect

Udagger

+||

+||

Months

Not

clear

35sect

6sect

Authorsrsquo

Conclusions

An intervention

targeting

awareness and

communication

regarding PUs

resulted in

more complete

adherence to

the nursing

prevention

protocol

An education

program and

implementation

of preventive

nursing inter-

ventions were

effective in de-

creasing PU in-

cidence in ICU

patients

The program

appeared to be

successful as

evidenced by a

decrease in

nosocomial PU

rates Findings

underscore the

importance of

identifying pa-

tient risk for

PUs and follow-

ing through

with a plan for

prevention and

treatment

Quality

Score

7

13

11





AP16


Author

Year

Country

Design

Willson44

1995

USA

Before-after

Setting

One hospital

4 medicalsurgical

units


Intervention









used

Measures Reported



1 PU incidence (PT)

Effect

Udagger

Months

6sect

Authorsrsquo

Conclusions

Preliminary

results indicate

that modifica-

tions to a hos-


tion system can

support staff in

following new

protocols and

can lead to a

decrease in PU

incidence

Quality

Score

8












AP12


Author

Year

Country

Design

Olson34

1998

Canada

Before-after

Peich35

2004

Israel

Before-after

Pokorny36

2003

USA

Before-after

Setting

One cancer hospital

2 units

300-bed teaching

hospital orthopedic

unit and recovery

room intervention

limited to patients

with hip fractures


cardiac surgery ICU

and cardiac surgery

intermediate care



dergoing elective

open heart surgery


Intervention















mattresses













education

Measures Reported




oped PU in hospital


on admission (PT)

1 of nosocomial PUs

among hip fracture

patients (PT)


Effect

0

+||

Udagger

Months

Not

clear

28sect

Not

clear

Authorsrsquo

Conclusions

The Braden

Scale has been

permanently in-

corporated into

the daily chart-

ing forms It is

now possible to

track the de-

gree to which

the scale and

prevention pro-

tocol are used

through the

quarterly chart

audits

PU prevention

in patients with

hip fractures is

feasible An

increased

awareness of

the problem

among hospital

staff may be

important

The develop-

ment and

progress of

PUs can be al-

tered by nurs-

ing care PU

risk can only

be predicted

through

repeated

assessments

throughout

hospitalization

Quality

Score

11

12

12





AP13


Author

Year

Country

Design

Rashotte37

2008

Canada

Before-after

Setting



Intervention










PU prevention

Measures Reported






(PRO)




(PRO)



(PRO)



completed (PRO)

5 Median number of


faces in use (PRO)








8 Median number of



protectors used to


(PRO)




(PRO)

10 Median number of


care expert (PRO)

Effect

Udagger

Udagger

Udagger

Udagger

Udagger

Udagger

Udagger

Udagger

Udagger

Udagger

Months

6sect

Authorsrsquo

Conclusions

Significant

changes in

nursing best

practice guide-

lines were

found which

highlights the

complexities of

changing prac-

tice Contextual

influences such

as teamwork

and resources

may inform

results

Quality

Score

6





AP14


Author

Year

Country

Design

Sacharok38

1998

USA

Before-after

Saleh39

2009

UK

Controlled

clinical trial

Stier40

2004

USA

Before-after

Setting

300-bed acute care

community hospital

several units adult

medical surgical

critical care and

later emergency

room


Health care system

in eastern US units

not specified


Intervention





tool conducted PDSA











times)
















only












Measures Reported



1 Prevalence of

nosocomial PUs (PT)



admission (PT)

1 Nosocomial PU

incidence (PT)

Effect

Udagger

Group

A vs

C

0

Group

B vs

C

0

Udagger

Months

47sect

13Dagger

Not

clear

Authorsrsquo

Conclusions

Implementation

of a total quality

management

model resulted

in an 83 re-

duction in PU

prevalence

There were no

differences in

PU incidence in

the groups that

received addi-

tional training

Clinical judg-

ment may be

as effective as

employing a

risk assess-

ment scale to

assess risk for

PUs

The sustained

success of the

program is at-

tributed to (1) a

reliable and

valid measure-

ment system

that facilitates

performance

assessment

and evaluation

and (2) ongoing

unit educational

activities

Quality

Score

11

10

12





AP15


Author

Year

Country

Design

Stoelting41

2007

USA

Before-after

Uzun42

2009

Turkey

Before-after

Van Etten43

1990

USA

Before-after

Setting

Large teaching

hospital units not

specified

880-bed acute care

university hospital

ICU areas only 2

general medical

surgical ICUs

1 neurosurgical ICU

1 postanesthesia

care unit


risk care areas (1)



dics (3) acute

neurointensive care


Intervention


























education

Measures Reported



1 PU incidence (PT)





(PT)

1 patients with


(PT)

Effect

Udagger

+||

+||

Months

Not

clear

35sect

6sect

Authorsrsquo

Conclusions

An intervention

targeting

awareness and

communication

regarding PUs

resulted in

more complete

adherence to

the nursing

prevention

protocol

An education

program and

implementation

of preventive

nursing inter-

ventions were

effective in de-

creasing PU in-

cidence in ICU

patients

The program

appeared to be

successful as

evidenced by a

decrease in

nosocomial PU

rates Findings

underscore the

importance of

identifying pa-

tient risk for

PUs and follow-

ing through

with a plan for

prevention and

treatment

Quality

Score

7

13

11





AP16


Author

Year

Country

Design

Willson44

1995

USA

Before-after

Setting

One hospital

4 medicalsurgical

units


Intervention









used

Measures Reported



1 PU incidence (PT)

Effect

Udagger

Months

6sect

Authorsrsquo

Conclusions

Preliminary

results indicate

that modifica-

tions to a hos-


tion system can

support staff in

following new

protocols and

can lead to a

decrease in PU

incidence

Quality

Score

8












AP13


Author

Year

Country

Design

Rashotte37

2008

Canada

Before-after

Setting



Intervention










PU prevention

Measures Reported






(PRO)




(PRO)



(PRO)



completed (PRO)

5 Median number of


faces in use (PRO)








8 Median number of



protectors used to


(PRO)




(PRO)

10 Median number of


care expert (PRO)

Effect

Udagger

Udagger

Udagger

Udagger

Udagger

Udagger

Udagger

Udagger

Udagger

Udagger

Months

6sect

Authorsrsquo

Conclusions

Significant

changes in

nursing best

practice guide-

lines were

found which

highlights the

complexities of

changing prac-

tice Contextual

influences such

as teamwork

and resources

may inform

results

Quality

Score

6





AP14


Author

Year

Country

Design

Sacharok38

1998

USA

Before-after

Saleh39

2009

UK

Controlled

clinical trial

Stier40

2004

USA

Before-after

Setting

300-bed acute care

community hospital

several units adult

medical surgical

critical care and

later emergency

room


Health care system

in eastern US units

not specified


Intervention





tool conducted PDSA











times)
















only












Measures Reported



1 Prevalence of

nosocomial PUs (PT)



admission (PT)

1 Nosocomial PU

incidence (PT)

Effect

Udagger

Group

A vs

C

0

Group

B vs

C

0

Udagger

Months

47sect

13Dagger

Not

clear

Authorsrsquo

Conclusions

Implementation

of a total quality

management

model resulted

in an 83 re-

duction in PU

prevalence

There were no

differences in

PU incidence in

the groups that

received addi-

tional training

Clinical judg-

ment may be

as effective as

employing a

risk assess-

ment scale to

assess risk for

PUs

The sustained

success of the

program is at-

tributed to (1) a

reliable and

valid measure-

ment system

that facilitates

performance

assessment

and evaluation

and (2) ongoing

unit educational

activities

Quality

Score

11

10

12





AP15


Author

Year

Country

Design

Stoelting41

2007

USA

Before-after

Uzun42

2009

Turkey

Before-after

Van Etten43

1990

USA

Before-after

Setting

Large teaching

hospital units not

specified

880-bed acute care

university hospital

ICU areas only 2

general medical

surgical ICUs

1 neurosurgical ICU

1 postanesthesia

care unit


risk care areas (1)



dics (3) acute

neurointensive care


Intervention


























education

Measures Reported



1 PU incidence (PT)





(PT)

1 patients with


(PT)

Effect

Udagger

+||

+||

Months

Not

clear

35sect

6sect

Authorsrsquo

Conclusions

An intervention

targeting

awareness and

communication

regarding PUs

resulted in

more complete

adherence to

the nursing

prevention

protocol

An education

program and

implementation

of preventive

nursing inter-

ventions were

effective in de-

creasing PU in-

cidence in ICU

patients

The program

appeared to be

successful as

evidenced by a

decrease in

nosocomial PU

rates Findings

underscore the

importance of

identifying pa-

tient risk for

PUs and follow-

ing through

with a plan for

prevention and

treatment

Quality

Score

7

13

11





AP16


Author

Year

Country

Design

Willson44

1995

USA

Before-after

Setting

One hospital

4 medicalsurgical

units


Intervention









used

Measures Reported



1 PU incidence (PT)

Effect

Udagger

Months

6sect

Authorsrsquo

Conclusions

Preliminary

results indicate

that modifica-

tions to a hos-


tion system can

support staff in

following new

protocols and

can lead to a

decrease in PU

incidence

Quality

Score

8












AP14


Author

Year

Country

Design

Sacharok38

1998

USA

Before-after

Saleh39

2009

UK

Controlled

clinical trial

Stier40

2004

USA

Before-after

Setting

300-bed acute care

community hospital

several units adult

medical surgical

critical care and

later emergency

room


Health care system

in eastern US units

not specified


Intervention





tool conducted PDSA











times)
















only












Measures Reported



1 Prevalence of

nosocomial PUs (PT)



admission (PT)

1 Nosocomial PU

incidence (PT)

Effect

Udagger

Group

A vs

C

0

Group

B vs

C

0

Udagger

Months

47sect

13Dagger

Not

clear

Authorsrsquo

Conclusions

Implementation

of a total quality

management

model resulted

in an 83 re-

duction in PU

prevalence

There were no

differences in

PU incidence in

the groups that

received addi-

tional training

Clinical judg-

ment may be

as effective as

employing a

risk assess-

ment scale to

assess risk for

PUs

The sustained

success of the

program is at-

tributed to (1) a

reliable and

valid measure-

ment system

that facilitates

performance

assessment

and evaluation

and (2) ongoing

unit educational

activities

Quality

Score

11

10

12





AP15


Author

Year

Country

Design

Stoelting41

2007

USA

Before-after

Uzun42

2009

Turkey

Before-after

Van Etten43

1990

USA

Before-after

Setting

Large teaching

hospital units not

specified

880-bed acute care

university hospital

ICU areas only 2

general medical

surgical ICUs

1 neurosurgical ICU

1 postanesthesia

care unit


risk care areas (1)



dics (3) acute

neurointensive care


Intervention


























education

Measures Reported



1 PU incidence (PT)





(PT)

1 patients with


(PT)

Effect

Udagger

+||

+||

Months

Not

clear

35sect

6sect

Authorsrsquo

Conclusions

An intervention

targeting

awareness and

communication

regarding PUs

resulted in

more complete

adherence to

the nursing

prevention

protocol

An education

program and

implementation

of preventive

nursing inter-

ventions were

effective in de-

creasing PU in-

cidence in ICU

patients

The program

appeared to be

successful as

evidenced by a

decrease in

nosocomial PU

rates Findings

underscore the

importance of

identifying pa-

tient risk for

PUs and follow-

ing through

with a plan for

prevention and

treatment

Quality

Score

7

13

11





AP16


Author

Year

Country

Design

Willson44

1995

USA

Before-after

Setting

One hospital

4 medicalsurgical

units


Intervention









used

Measures Reported



1 PU incidence (PT)

Effect

Udagger

Months

6sect

Authorsrsquo

Conclusions

Preliminary

results indicate

that modifica-

tions to a hos-


tion system can

support staff in

following new

protocols and

can lead to a

decrease in PU

incidence

Quality

Score

8












AP15


Author

Year

Country

Design

Stoelting41

2007

USA

Before-after

Uzun42

2009

Turkey

Before-after

Van Etten43

1990

USA

Before-after

Setting

Large teaching

hospital units not

specified

880-bed acute care

university hospital

ICU areas only 2

general medical

surgical ICUs

1 neurosurgical ICU

1 postanesthesia

care unit


risk care areas (1)



dics (3) acute

neurointensive care


Intervention


























education

Measures Reported



1 PU incidence (PT)





(PT)

1 patients with


(PT)

Effect

Udagger

+||

+||

Months

Not

clear

35sect

6sect

Authorsrsquo

Conclusions

An intervention

targeting

awareness and

communication

regarding PUs

resulted in

more complete

adherence to

the nursing

prevention

protocol

An education

program and

implementation

of preventive

nursing inter-

ventions were

effective in de-

creasing PU in-

cidence in ICU

patients

The program

appeared to be

successful as

evidenced by a

decrease in

nosocomial PU

rates Findings

underscore the

importance of

identifying pa-

tient risk for

PUs and follow-

ing through

with a plan for

prevention and

treatment

Quality

Score

7

13

11





AP16


Author

Year

Country

Design

Willson44

1995

USA

Before-after

Setting

One hospital

4 medicalsurgical

units


Intervention









used

Measures Reported



1 PU incidence (PT)

Effect

Udagger

Months

6sect

Authorsrsquo

Conclusions

Preliminary

results indicate

that modifica-

tions to a hos-


tion system can

support staff in

following new

protocols and

can lead to a

decrease in PU

incidence

Quality

Score

8












AP16


Author

Year

Country

Design

Willson44

1995

USA

Before-after

Setting

One hospital

4 medicalsurgical

units


Intervention









used

Measures Reported



1 PU incidence (PT)

Effect

Udagger

Months

6sect

Authorsrsquo

Conclusions

Preliminary

results indicate

that modifica-

tions to a hos-


tion system can

support staff in

following new

protocols and

can lead to a

decrease in PU

incidence

Quality

Score

8










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