performance improvement preventing pressure ulcers in … · 2011-09-30 · performance improvement...
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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
The Joint Commission Journal on Quality and Patient Safety
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
Copyright 2011 copy The Joint Commission
247June 2011 Volume 37 Number 6
The Joint Commission Journal on Quality and Patient Safety
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
Copyright 2011 copy The Joint Commission
248 June 2011 Volume 37 Number 6
The Joint Commission Journal on Quality and Patient Safety
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
Copyright 2011 copy The Joint Commission
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
249June 2011 Volume 37 Number 6
The Joint Commission Journal on Quality and Patient Safety
(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
Copyright 2011 copy The Joint Commission
250 June 2011 Volume 37 Number 6
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-
The Joint Commission Journal on Quality and Patient Safety
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
Copyright 2011 copy The Joint Commission
251June 2011 Volume 37 Number 6
The Joint Commission Journal on Quality and Patient Safety
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
Copyright 2011 copy The Joint Commission
252 June 2011 Volume 37 Number 6
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
The Joint Commission Journal on Quality and Patient Safety
Copyright 2011 copy The Joint Commission
AP1 June 2011 Volume 37 Number 6
The Joint Commission Journal on Quality and Patient Safety
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
Multifaceted intervention con-
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)
Copyright 2011 copy The Joint Commission
AP2June 2011 Volume 37 Number 6
The Joint Commission Journal on Quality and Patient Safety
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
Brief Description of
Intervention
Implementation of a pub-
lished guideline risk assess-
ment tool and a prevention
protocol based on the risk
assessment results In addi-
tion a team was assembled
staff education conducted
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
PT = Patient Outcome
PRO = Nursing
Process
1 Incidence of hospital-
acquired PUs (PT)
1 PU prevalence (PT)
1 Case mix-adjusted
PU prevalence of (Stage
II or greater) among
patients without a PU on
admission (PT)
1 PU incidence (PT)
2 PU prevalence (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
(continued on page AP3)
Copyright 2011 copy The Joint Commission
AP3 June 2011 Volume 37 Number 6
The Joint Commission Journal on Quality and Patient Safety
Online-Only Content8Appendix 1 Included Studies (continued)
Author
Year
Country
Design
Charrier13
2008
Italy
Controlled
clinical trial
Setting
10 units (not speci-
fied) in an Italian
hospital
Brief Description of
Intervention
Audit and feedback on PU
protocol adherence
Measures Reported
PT = Patient Outcome
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
(continued on page AP4)
Copyright 2011 copy The Joint Commission
AP4June 2011 Volume 37 Number 6
The Joint Commission Journal on Quality and Patient Safety
Online-Only Content8Appendix 1 Included Studies (continued)
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
Brief Description of
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
PT = Patient Outcome
PRO = Nursing
Process
1 Number of hospital-
acquired PUs (PT)
1 Incidence of hospital-
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
(continued on page AP5)
Copyright 2011 copy The Joint Commission
AP5 June 2011 Volume 37 Number 6
The Joint Commission Journal on Quality and Patient Safety
Online-Only Content8Appendix 1 Included Studies (continued)
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
Brief Description of
Intervention
Implementation of a pub-
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
Implementation of a pub-
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
PT = Patient Outcome
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-
tients without PU on ad-
mission but who screened
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-
dence of a repositioning
schedule nor a proper
mattress among at-risk
patientspatients with a
PU ge Stage I (PRO)
5 patients with evi-
dence of either a reposi-
tioning schedule or a
proper mattress among
at-risk patients or those
with a PU gt Stage I (PRO)
6 patients with evi-
dence of both a reposi-
tioning schedule and a
proper mattress among
at-risk patients or those
with a PU gt 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
(continued on page AP6)
Copyright 2011 copy The Joint Commission
AP6June 2011 Volume 37 Number 6
The Joint Commission Journal on Quality and Patient Safety
Online-Only Content8Appendix 1 Included Studies (continued)
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
Brief Description of
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
PT = Patient Outcome
PRO = Nursing Process
1 Hospital-acquired PUs
ge Stage II (entire hospital)
(PT)
2 Hospital-acquired PUs
ge Stage II (SICU only)
(PT)
1 PU prevalence ge Stage
I (Hospital B) (PT)
2 PU prevalence ge Stage
II (Hospital B) (PT)
3 Nosocomial PU rate
(Stages I-IV) Hospital A
(PT)
4 Nosocomial PU rate
(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
(continued on page AP7)
Copyright 2011 copy The Joint Commission
AP7 June 2011 Volume 37 Number 6
The Joint Commission Journal on Quality and Patient Safety
Online-Only Content8Appendix 1 Included Studies (continued)
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
Brief Description of
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
PT = Patient Outcome
PRO = Nursing Process
1 PU rates (pre-existing
and hospital-acquired) at
time of discharge (PT)
2 PU rates (pre-existing
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)
4 patients with facility-
acquired PUs (medical
ICU) (PT)
1 Average length of stay
(PT)
2 Incidence of nosoco-
mial C difficile (PT)
3 Incidence of nosoco-
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
(continued on page AP8)
Copyright 2011 copy The Joint Commission
AP8June 2011 Volume 37 Number 6
The Joint Commission Journal on Quality and Patient Safety
Online-Only Content8Appendix 1 Included Studies (continued)
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
Brief Description of
Intervention
Multidimensional 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
monitoring and feedback
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
performance monitoring and
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 = Patient Outcome
PRO = Nursing Process
1 Hospital-acquired PUs
(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)
2 PU prevalence (Stages
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
(continued on page AP9)
Copyright 2011 copy The Joint Commission
AP9 June 2011 Volume 37 Number 6
The Joint Commission Journal on Quality and Patient Safety
Online-Only Content8Appendix 1 Included Studies (continued)
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
Brief Description of
Intervention
Multidimensional 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
PT = Patient Outcome
PRO = Nursing Process
1 Prevalence of hospital-
acquired PUs (Unit A)
(PT)
2 Prevalence of hospital-
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)
4 Hospital-acquired PU
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)
14 Staging of acquired
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
(continued on page AP10)
Copyright 2011 copy The Joint Commission
June 2011 Volume 37 Number 6
The Joint Commission Journal on Quality and Patient Safety
Online-Only Content8Appendix 1 Included Studies (continued)
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
Brief Description of
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
Multidimensional intervention
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
Multidimensional intervention
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
PT = Patient Outcome
PRO = Nursing Process
1 PU incidence (all
stages) (PT)
2 of hospital-acquired
Stage I PUs (PT)
3 of hospital-acquired
Stage II PUs (PT)
4 of hospital-acquired
Stage III PUs (PT)
5 of hospital-acquired
Stage IV PUs (PT)
1 Overall hospital-
acquired prevalence (PT)
1 PU 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
(continued on page AP11)
AP10
Copyright 2011 copy The Joint Commission
June 2011 Volume 37 Number 6
The Joint Commission Journal on Quality and Patient Safety
AP11
Online-Only Content8Appendix 1 Included Studies (continued)
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
Brief Description of
Intervention
Multidimensional PU preven-
tion program consisting of
the use of a risk assessment
tool and protocol conducted
performance monitoring and
provided staff education
Systemwide educational in-
tervention targeting all levels
of patient care providers and
multispecialty care The
intervention included per-
formance monitoring and
feedback the purchase of
pressure-relieving beds and
the use of new flow sheets
Measures Reported
PT = Patient Outcome
PRO = Nursing Process
1 PU prevalence (PT)
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)
4 Prevalence of hospital-
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)
7 patients with PUs (ge
Stage I) who had a skin
assessment upon admission
completed (PRO)
8 patients with PUs (ge
Stage I) who had a skin
assessment upon admission
(PRO)
9 patients with PUs (ge
Stage I) for whom it was
unknown whether a skin
assessment upon admission
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)
11 patients with PUs
(Stages IIndashIV) with inadequate
documentation of either
admission skin assessment or
reassessment (PRO)
12 patients with PUs
(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
(continued on page AP12)
Copyright 2011 copy The Joint Commission
June 2011 Volume 37 Number 6
The Joint Commission Journal on Quality and Patient Safety
AP12
Online-Only Content8Appendix 1 Included Studies (continued)
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
One hospital 2 units
cardiac surgery ICU
and cardiac surgery
intermediate care
unit Intervention lim-
ited to patients un-
dergoing elective
open heart surgery
Brief Description of
Intervention
Implemented a published
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
PT = Patient Outcome
PRO = Nursing Process
1 patients who devel-
oped PU in hospital
excluding those present
on admission (PT)
1 of nosocomial PUs
among hip fracture
patients (PT)
1 PU prevalence (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
(continued on page AP13)
Copyright 2011 copy The Joint Commission
June 2011 Volume 37 Number 6
The Joint Commission Journal on Quality and Patient Safety
AP13
Online-Only Content8Appendix 1 Included Studies (continued)
Author
Year
Country
Design
Rashotte37
2008
Canada
Before-after
Setting
10-bed pediatric ICU
Brief Description of
Intervention
Multifaceted 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
PT = Patient Outcome
PRO = Nursing Process
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)
9 Median number of pa-
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
(continued on page AP14)
Copyright 2011 copy The Joint Commission
June 2011 Volume 37 Number 6
The Joint Commission Journal on Quality and Patient Safety
AP14
Online-Only Content8Appendix 1 Included Studies (continued)
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
One hospital 9 units
Health care system
in eastern US units
not specified
Brief Description of
Intervention
Multidimensional intervention
consisting of assembled a
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
performance monitoring and
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
wound care management
study day (2) PU prevention
training program and training
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
assembling a team imple-
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
PT = Patient Outcome
PRO = Nursing Process
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
(continued on page AP15)
Copyright 2011 copy The Joint Commission
June 2011 Volume 37 Number 6
The Joint Commission Journal on Quality and Patient Safety
AP15
Online-Only Content8Appendix 1 Included Studies (continued)
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
Brief Description of
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-
mentation of a risk assess-
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
Multidimensional intervention
consisting of assembled a
team implemented a pub-
lished guideline and care
protocol used a risk assess-
ment tool made skin care
products readily available on
the unit and provided staff
education
Measures Reported
PT = Patient Outcome
PRO = Nursing Process
1 PU incidence (PT)
1 Incidence of Stage II
PUs among patients with-
out PUs on admission
(PUs100 patient days)
(PT)
1 patients with
hospital-acquired PUs
(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
(continued on page AP16)
Copyright 2011 copy The Joint Commission
June 2011 Volume 37 Number 6
The Joint Commission Journal on Quality and Patient Safety
AP16
Online-Only Content8Appendix 1 Included Studies (continued)
Author
Year
Country
Design
Willson44
1995
USA
Before-after
Setting
One hospital
4 medicalsurgical
units
Brief Description of
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
PT = Patient Outcome
PRO = Nursing Process
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
Copyright 2011 copy The Joint Commission
246 June 2011 Volume 37 Number 6
The Joint Commission Journal on Quality and Patient Safety
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
Copyright 2011 copy The Joint Commission
247June 2011 Volume 37 Number 6
The Joint Commission Journal on Quality and Patient Safety
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
Copyright 2011 copy The Joint Commission
248 June 2011 Volume 37 Number 6
The Joint Commission Journal on Quality and Patient Safety
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
Copyright 2011 copy The Joint Commission
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
249June 2011 Volume 37 Number 6
The Joint Commission Journal on Quality and Patient Safety
(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
Copyright 2011 copy The Joint Commission
250 June 2011 Volume 37 Number 6
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-
The Joint Commission Journal on Quality and Patient Safety
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
Copyright 2011 copy The Joint Commission
251June 2011 Volume 37 Number 6
The Joint Commission Journal on Quality and Patient Safety
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
Copyright 2011 copy The Joint Commission
252 June 2011 Volume 37 Number 6
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
The Joint Commission Journal on Quality and Patient Safety
Copyright 2011 copy The Joint Commission
AP1 June 2011 Volume 37 Number 6
The Joint Commission Journal on Quality and Patient Safety
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
Multifaceted intervention con-
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)
Copyright 2011 copy The Joint Commission
AP2June 2011 Volume 37 Number 6
The Joint Commission Journal on Quality and Patient Safety
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
Brief Description of
Intervention
Implementation of a pub-
lished guideline risk assess-
ment tool and a prevention
protocol based on the risk
assessment results In addi-
tion a team was assembled
staff education conducted
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
PT = Patient Outcome
PRO = Nursing
Process
1 Incidence of hospital-
acquired PUs (PT)
1 PU prevalence (PT)
1 Case mix-adjusted
PU prevalence of (Stage
II or greater) among
patients without a PU on
admission (PT)
1 PU incidence (PT)
2 PU prevalence (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
(continued on page AP3)
Copyright 2011 copy The Joint Commission
AP3 June 2011 Volume 37 Number 6
The Joint Commission Journal on Quality and Patient Safety
Online-Only Content8Appendix 1 Included Studies (continued)
Author
Year
Country
Design
Charrier13
2008
Italy
Controlled
clinical trial
Setting
10 units (not speci-
fied) in an Italian
hospital
Brief Description of
Intervention
Audit and feedback on PU
protocol adherence
Measures Reported
PT = Patient Outcome
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
(continued on page AP4)
Copyright 2011 copy The Joint Commission
AP4June 2011 Volume 37 Number 6
The Joint Commission Journal on Quality and Patient Safety
Online-Only Content8Appendix 1 Included Studies (continued)
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
Brief Description of
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
PT = Patient Outcome
PRO = Nursing
Process
1 Number of hospital-
acquired PUs (PT)
1 Incidence of hospital-
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
(continued on page AP5)
Copyright 2011 copy The Joint Commission
AP5 June 2011 Volume 37 Number 6
The Joint Commission Journal on Quality and Patient Safety
Online-Only Content8Appendix 1 Included Studies (continued)
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
Brief Description of
Intervention
Implementation of a pub-
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
Implementation of a pub-
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
PT = Patient Outcome
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-
tients without PU on ad-
mission but who screened
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-
dence of a repositioning
schedule nor a proper
mattress among at-risk
patientspatients with a
PU ge Stage I (PRO)
5 patients with evi-
dence of either a reposi-
tioning schedule or a
proper mattress among
at-risk patients or those
with a PU gt Stage I (PRO)
6 patients with evi-
dence of both a reposi-
tioning schedule and a
proper mattress among
at-risk patients or those
with a PU gt 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
(continued on page AP6)
Copyright 2011 copy The Joint Commission
AP6June 2011 Volume 37 Number 6
The Joint Commission Journal on Quality and Patient Safety
Online-Only Content8Appendix 1 Included Studies (continued)
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
Brief Description of
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
PT = Patient Outcome
PRO = Nursing Process
1 Hospital-acquired PUs
ge Stage II (entire hospital)
(PT)
2 Hospital-acquired PUs
ge Stage II (SICU only)
(PT)
1 PU prevalence ge Stage
I (Hospital B) (PT)
2 PU prevalence ge Stage
II (Hospital B) (PT)
3 Nosocomial PU rate
(Stages I-IV) Hospital A
(PT)
4 Nosocomial PU rate
(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
(continued on page AP7)
Copyright 2011 copy The Joint Commission
AP7 June 2011 Volume 37 Number 6
The Joint Commission Journal on Quality and Patient Safety
Online-Only Content8Appendix 1 Included Studies (continued)
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
Brief Description of
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
PT = Patient Outcome
PRO = Nursing Process
1 PU rates (pre-existing
and hospital-acquired) at
time of discharge (PT)
2 PU rates (pre-existing
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)
4 patients with facility-
acquired PUs (medical
ICU) (PT)
1 Average length of stay
(PT)
2 Incidence of nosoco-
mial C difficile (PT)
3 Incidence of nosoco-
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
(continued on page AP8)
Copyright 2011 copy The Joint Commission
AP8June 2011 Volume 37 Number 6
The Joint Commission Journal on Quality and Patient Safety
Online-Only Content8Appendix 1 Included Studies (continued)
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
Brief Description of
Intervention
Multidimensional 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
monitoring and feedback
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
performance monitoring and
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 = Patient Outcome
PRO = Nursing Process
1 Hospital-acquired PUs
(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)
2 PU prevalence (Stages
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
(continued on page AP9)
Copyright 2011 copy The Joint Commission
AP9 June 2011 Volume 37 Number 6
The Joint Commission Journal on Quality and Patient Safety
Online-Only Content8Appendix 1 Included Studies (continued)
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
Brief Description of
Intervention
Multidimensional 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
PT = Patient Outcome
PRO = Nursing Process
1 Prevalence of hospital-
acquired PUs (Unit A)
(PT)
2 Prevalence of hospital-
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)
4 Hospital-acquired PU
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)
14 Staging of acquired
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
(continued on page AP10)
Copyright 2011 copy The Joint Commission
June 2011 Volume 37 Number 6
The Joint Commission Journal on Quality and Patient Safety
Online-Only Content8Appendix 1 Included Studies (continued)
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
Brief Description of
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
Multidimensional intervention
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
Multidimensional intervention
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
PT = Patient Outcome
PRO = Nursing Process
1 PU incidence (all
stages) (PT)
2 of hospital-acquired
Stage I PUs (PT)
3 of hospital-acquired
Stage II PUs (PT)
4 of hospital-acquired
Stage III PUs (PT)
5 of hospital-acquired
Stage IV PUs (PT)
1 Overall hospital-
acquired prevalence (PT)
1 PU 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
(continued on page AP11)
AP10
Copyright 2011 copy The Joint Commission
June 2011 Volume 37 Number 6
The Joint Commission Journal on Quality and Patient Safety
AP11
Online-Only Content8Appendix 1 Included Studies (continued)
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
Brief Description of
Intervention
Multidimensional PU preven-
tion program consisting of
the use of a risk assessment
tool and protocol conducted
performance monitoring and
provided staff education
Systemwide educational in-
tervention targeting all levels
of patient care providers and
multispecialty care The
intervention included per-
formance monitoring and
feedback the purchase of
pressure-relieving beds and
the use of new flow sheets
Measures Reported
PT = Patient Outcome
PRO = Nursing Process
1 PU prevalence (PT)
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)
4 Prevalence of hospital-
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)
7 patients with PUs (ge
Stage I) who had a skin
assessment upon admission
completed (PRO)
8 patients with PUs (ge
Stage I) who had a skin
assessment upon admission
(PRO)
9 patients with PUs (ge
Stage I) for whom it was
unknown whether a skin
assessment upon admission
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)
11 patients with PUs
(Stages IIndashIV) with inadequate
documentation of either
admission skin assessment or
reassessment (PRO)
12 patients with PUs
(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
(continued on page AP12)
Copyright 2011 copy The Joint Commission
June 2011 Volume 37 Number 6
The Joint Commission Journal on Quality and Patient Safety
AP12
Online-Only Content8Appendix 1 Included Studies (continued)
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
One hospital 2 units
cardiac surgery ICU
and cardiac surgery
intermediate care
unit Intervention lim-
ited to patients un-
dergoing elective
open heart surgery
Brief Description of
Intervention
Implemented a published
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
PT = Patient Outcome
PRO = Nursing Process
1 patients who devel-
oped PU in hospital
excluding those present
on admission (PT)
1 of nosocomial PUs
among hip fracture
patients (PT)
1 PU prevalence (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
(continued on page AP13)
Copyright 2011 copy The Joint Commission
June 2011 Volume 37 Number 6
The Joint Commission Journal on Quality and Patient Safety
AP13
Online-Only Content8Appendix 1 Included Studies (continued)
Author
Year
Country
Design
Rashotte37
2008
Canada
Before-after
Setting
10-bed pediatric ICU
Brief Description of
Intervention
Multifaceted 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
PT = Patient Outcome
PRO = Nursing Process
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)
9 Median number of pa-
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
(continued on page AP14)
Copyright 2011 copy The Joint Commission
June 2011 Volume 37 Number 6
The Joint Commission Journal on Quality and Patient Safety
AP14
Online-Only Content8Appendix 1 Included Studies (continued)
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
One hospital 9 units
Health care system
in eastern US units
not specified
Brief Description of
Intervention
Multidimensional intervention
consisting of assembled a
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
performance monitoring and
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
wound care management
study day (2) PU prevention
training program and training
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
assembling a team imple-
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
PT = Patient Outcome
PRO = Nursing Process
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
(continued on page AP15)
Copyright 2011 copy The Joint Commission
June 2011 Volume 37 Number 6
The Joint Commission Journal on Quality and Patient Safety
AP15
Online-Only Content8Appendix 1 Included Studies (continued)
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
Brief Description of
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-
mentation of a risk assess-
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
Multidimensional intervention
consisting of assembled a
team implemented a pub-
lished guideline and care
protocol used a risk assess-
ment tool made skin care
products readily available on
the unit and provided staff
education
Measures Reported
PT = Patient Outcome
PRO = Nursing Process
1 PU incidence (PT)
1 Incidence of Stage II
PUs among patients with-
out PUs on admission
(PUs100 patient days)
(PT)
1 patients with
hospital-acquired PUs
(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
(continued on page AP16)
Copyright 2011 copy The Joint Commission
June 2011 Volume 37 Number 6
The Joint Commission Journal on Quality and Patient Safety
AP16
Online-Only Content8Appendix 1 Included Studies (continued)
Author
Year
Country
Design
Willson44
1995
USA
Before-after
Setting
One hospital
4 medicalsurgical
units
Brief Description of
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
PT = Patient Outcome
PRO = Nursing Process
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
Copyright 2011 copy The Joint Commission
247June 2011 Volume 37 Number 6
The Joint Commission Journal on Quality and Patient Safety
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
Copyright 2011 copy The Joint Commission
248 June 2011 Volume 37 Number 6
The Joint Commission Journal on Quality and Patient Safety
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
Copyright 2011 copy The Joint Commission
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
249June 2011 Volume 37 Number 6
The Joint Commission Journal on Quality and Patient Safety
(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
Copyright 2011 copy The Joint Commission
250 June 2011 Volume 37 Number 6
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-
The Joint Commission Journal on Quality and Patient Safety
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
Copyright 2011 copy The Joint Commission
251June 2011 Volume 37 Number 6
The Joint Commission Journal on Quality and Patient Safety
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
Copyright 2011 copy The Joint Commission
252 June 2011 Volume 37 Number 6
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
The Joint Commission Journal on Quality and Patient Safety
Copyright 2011 copy The Joint Commission
AP1 June 2011 Volume 37 Number 6
The Joint Commission Journal on Quality and Patient Safety
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
Multifaceted intervention con-
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)
Copyright 2011 copy The Joint Commission
AP2June 2011 Volume 37 Number 6
The Joint Commission Journal on Quality and Patient Safety
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
Brief Description of
Intervention
Implementation of a pub-
lished guideline risk assess-
ment tool and a prevention
protocol based on the risk
assessment results In addi-
tion a team was assembled
staff education conducted
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
PT = Patient Outcome
PRO = Nursing
Process
1 Incidence of hospital-
acquired PUs (PT)
1 PU prevalence (PT)
1 Case mix-adjusted
PU prevalence of (Stage
II or greater) among
patients without a PU on
admission (PT)
1 PU incidence (PT)
2 PU prevalence (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
(continued on page AP3)
Copyright 2011 copy The Joint Commission
AP3 June 2011 Volume 37 Number 6
The Joint Commission Journal on Quality and Patient Safety
Online-Only Content8Appendix 1 Included Studies (continued)
Author
Year
Country
Design
Charrier13
2008
Italy
Controlled
clinical trial
Setting
10 units (not speci-
fied) in an Italian
hospital
Brief Description of
Intervention
Audit and feedback on PU
protocol adherence
Measures Reported
PT = Patient Outcome
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
(continued on page AP4)
Copyright 2011 copy The Joint Commission
AP4June 2011 Volume 37 Number 6
The Joint Commission Journal on Quality and Patient Safety
Online-Only Content8Appendix 1 Included Studies (continued)
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
Brief Description of
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
PT = Patient Outcome
PRO = Nursing
Process
1 Number of hospital-
acquired PUs (PT)
1 Incidence of hospital-
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
(continued on page AP5)
Copyright 2011 copy The Joint Commission
AP5 June 2011 Volume 37 Number 6
The Joint Commission Journal on Quality and Patient Safety
Online-Only Content8Appendix 1 Included Studies (continued)
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
Brief Description of
Intervention
Implementation of a pub-
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
Implementation of a pub-
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
PT = Patient Outcome
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-
tients without PU on ad-
mission but who screened
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-
dence of a repositioning
schedule nor a proper
mattress among at-risk
patientspatients with a
PU ge Stage I (PRO)
5 patients with evi-
dence of either a reposi-
tioning schedule or a
proper mattress among
at-risk patients or those
with a PU gt Stage I (PRO)
6 patients with evi-
dence of both a reposi-
tioning schedule and a
proper mattress among
at-risk patients or those
with a PU gt 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
(continued on page AP6)
Copyright 2011 copy The Joint Commission
AP6June 2011 Volume 37 Number 6
The Joint Commission Journal on Quality and Patient Safety
Online-Only Content8Appendix 1 Included Studies (continued)
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
Brief Description of
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
PT = Patient Outcome
PRO = Nursing Process
1 Hospital-acquired PUs
ge Stage II (entire hospital)
(PT)
2 Hospital-acquired PUs
ge Stage II (SICU only)
(PT)
1 PU prevalence ge Stage
I (Hospital B) (PT)
2 PU prevalence ge Stage
II (Hospital B) (PT)
3 Nosocomial PU rate
(Stages I-IV) Hospital A
(PT)
4 Nosocomial PU rate
(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
(continued on page AP7)
Copyright 2011 copy The Joint Commission
AP7 June 2011 Volume 37 Number 6
The Joint Commission Journal on Quality and Patient Safety
Online-Only Content8Appendix 1 Included Studies (continued)
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
Brief Description of
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
PT = Patient Outcome
PRO = Nursing Process
1 PU rates (pre-existing
and hospital-acquired) at
time of discharge (PT)
2 PU rates (pre-existing
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)
4 patients with facility-
acquired PUs (medical
ICU) (PT)
1 Average length of stay
(PT)
2 Incidence of nosoco-
mial C difficile (PT)
3 Incidence of nosoco-
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
(continued on page AP8)
Copyright 2011 copy The Joint Commission
AP8June 2011 Volume 37 Number 6
The Joint Commission Journal on Quality and Patient Safety
Online-Only Content8Appendix 1 Included Studies (continued)
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
Brief Description of
Intervention
Multidimensional 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
monitoring and feedback
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
performance monitoring and
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 = Patient Outcome
PRO = Nursing Process
1 Hospital-acquired PUs
(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)
2 PU prevalence (Stages
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
(continued on page AP9)
Copyright 2011 copy The Joint Commission
AP9 June 2011 Volume 37 Number 6
The Joint Commission Journal on Quality and Patient Safety
Online-Only Content8Appendix 1 Included Studies (continued)
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
Brief Description of
Intervention
Multidimensional 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
PT = Patient Outcome
PRO = Nursing Process
1 Prevalence of hospital-
acquired PUs (Unit A)
(PT)
2 Prevalence of hospital-
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)
4 Hospital-acquired PU
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)
14 Staging of acquired
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
(continued on page AP10)
Copyright 2011 copy The Joint Commission
June 2011 Volume 37 Number 6
The Joint Commission Journal on Quality and Patient Safety
Online-Only Content8Appendix 1 Included Studies (continued)
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
Brief Description of
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
Multidimensional intervention
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
Multidimensional intervention
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
PT = Patient Outcome
PRO = Nursing Process
1 PU incidence (all
stages) (PT)
2 of hospital-acquired
Stage I PUs (PT)
3 of hospital-acquired
Stage II PUs (PT)
4 of hospital-acquired
Stage III PUs (PT)
5 of hospital-acquired
Stage IV PUs (PT)
1 Overall hospital-
acquired prevalence (PT)
1 PU 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
(continued on page AP11)
AP10
Copyright 2011 copy The Joint Commission
June 2011 Volume 37 Number 6
The Joint Commission Journal on Quality and Patient Safety
AP11
Online-Only Content8Appendix 1 Included Studies (continued)
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
Brief Description of
Intervention
Multidimensional PU preven-
tion program consisting of
the use of a risk assessment
tool and protocol conducted
performance monitoring and
provided staff education
Systemwide educational in-
tervention targeting all levels
of patient care providers and
multispecialty care The
intervention included per-
formance monitoring and
feedback the purchase of
pressure-relieving beds and
the use of new flow sheets
Measures Reported
PT = Patient Outcome
PRO = Nursing Process
1 PU prevalence (PT)
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)
4 Prevalence of hospital-
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)
7 patients with PUs (ge
Stage I) who had a skin
assessment upon admission
completed (PRO)
8 patients with PUs (ge
Stage I) who had a skin
assessment upon admission
(PRO)
9 patients with PUs (ge
Stage I) for whom it was
unknown whether a skin
assessment upon admission
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)
11 patients with PUs
(Stages IIndashIV) with inadequate
documentation of either
admission skin assessment or
reassessment (PRO)
12 patients with PUs
(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
(continued on page AP12)
Copyright 2011 copy The Joint Commission
June 2011 Volume 37 Number 6
The Joint Commission Journal on Quality and Patient Safety
AP12
Online-Only Content8Appendix 1 Included Studies (continued)
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
One hospital 2 units
cardiac surgery ICU
and cardiac surgery
intermediate care
unit Intervention lim-
ited to patients un-
dergoing elective
open heart surgery
Brief Description of
Intervention
Implemented a published
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
PT = Patient Outcome
PRO = Nursing Process
1 patients who devel-
oped PU in hospital
excluding those present
on admission (PT)
1 of nosocomial PUs
among hip fracture
patients (PT)
1 PU prevalence (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
(continued on page AP13)
Copyright 2011 copy The Joint Commission
June 2011 Volume 37 Number 6
The Joint Commission Journal on Quality and Patient Safety
AP13
Online-Only Content8Appendix 1 Included Studies (continued)
Author
Year
Country
Design
Rashotte37
2008
Canada
Before-after
Setting
10-bed pediatric ICU
Brief Description of
Intervention
Multifaceted 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
PT = Patient Outcome
PRO = Nursing Process
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)
9 Median number of pa-
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
(continued on page AP14)
Copyright 2011 copy The Joint Commission
June 2011 Volume 37 Number 6
The Joint Commission Journal on Quality and Patient Safety
AP14
Online-Only Content8Appendix 1 Included Studies (continued)
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
One hospital 9 units
Health care system
in eastern US units
not specified
Brief Description of
Intervention
Multidimensional intervention
consisting of assembled a
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
performance monitoring and
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
wound care management
study day (2) PU prevention
training program and training
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
assembling a team imple-
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
PT = Patient Outcome
PRO = Nursing Process
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
(continued on page AP15)
Copyright 2011 copy The Joint Commission
June 2011 Volume 37 Number 6
The Joint Commission Journal on Quality and Patient Safety
AP15
Online-Only Content8Appendix 1 Included Studies (continued)
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
Brief Description of
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-
mentation of a risk assess-
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
Multidimensional intervention
consisting of assembled a
team implemented a pub-
lished guideline and care
protocol used a risk assess-
ment tool made skin care
products readily available on
the unit and provided staff
education
Measures Reported
PT = Patient Outcome
PRO = Nursing Process
1 PU incidence (PT)
1 Incidence of Stage II
PUs among patients with-
out PUs on admission
(PUs100 patient days)
(PT)
1 patients with
hospital-acquired PUs
(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
(continued on page AP16)
Copyright 2011 copy The Joint Commission
June 2011 Volume 37 Number 6
The Joint Commission Journal on Quality and Patient Safety
AP16
Online-Only Content8Appendix 1 Included Studies (continued)
Author
Year
Country
Design
Willson44
1995
USA
Before-after
Setting
One hospital
4 medicalsurgical
units
Brief Description of
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
PT = Patient Outcome
PRO = Nursing Process
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
Copyright 2011 copy The Joint Commission
248 June 2011 Volume 37 Number 6
The Joint Commission Journal on Quality and Patient Safety
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
Copyright 2011 copy The Joint Commission
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
249June 2011 Volume 37 Number 6
The Joint Commission Journal on Quality and Patient Safety
(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
Copyright 2011 copy The Joint Commission
250 June 2011 Volume 37 Number 6
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-
The Joint Commission Journal on Quality and Patient Safety
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
Copyright 2011 copy The Joint Commission
251June 2011 Volume 37 Number 6
The Joint Commission Journal on Quality and Patient Safety
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
Copyright 2011 copy The Joint Commission
252 June 2011 Volume 37 Number 6
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
The Joint Commission Journal on Quality and Patient Safety
Copyright 2011 copy The Joint Commission
AP1 June 2011 Volume 37 Number 6
The Joint Commission Journal on Quality and Patient Safety
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
Multifaceted intervention con-
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)
Copyright 2011 copy The Joint Commission
AP2June 2011 Volume 37 Number 6
The Joint Commission Journal on Quality and Patient Safety
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
Brief Description of
Intervention
Implementation of a pub-
lished guideline risk assess-
ment tool and a prevention
protocol based on the risk
assessment results In addi-
tion a team was assembled
staff education conducted
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
PT = Patient Outcome
PRO = Nursing
Process
1 Incidence of hospital-
acquired PUs (PT)
1 PU prevalence (PT)
1 Case mix-adjusted
PU prevalence of (Stage
II or greater) among
patients without a PU on
admission (PT)
1 PU incidence (PT)
2 PU prevalence (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
(continued on page AP3)
Copyright 2011 copy The Joint Commission
AP3 June 2011 Volume 37 Number 6
The Joint Commission Journal on Quality and Patient Safety
Online-Only Content8Appendix 1 Included Studies (continued)
Author
Year
Country
Design
Charrier13
2008
Italy
Controlled
clinical trial
Setting
10 units (not speci-
fied) in an Italian
hospital
Brief Description of
Intervention
Audit and feedback on PU
protocol adherence
Measures Reported
PT = Patient Outcome
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
(continued on page AP4)
Copyright 2011 copy The Joint Commission
AP4June 2011 Volume 37 Number 6
The Joint Commission Journal on Quality and Patient Safety
Online-Only Content8Appendix 1 Included Studies (continued)
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
Brief Description of
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
PT = Patient Outcome
PRO = Nursing
Process
1 Number of hospital-
acquired PUs (PT)
1 Incidence of hospital-
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
(continued on page AP5)
Copyright 2011 copy The Joint Commission
AP5 June 2011 Volume 37 Number 6
The Joint Commission Journal on Quality and Patient Safety
Online-Only Content8Appendix 1 Included Studies (continued)
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
Brief Description of
Intervention
Implementation of a pub-
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
Implementation of a pub-
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
PT = Patient Outcome
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-
tients without PU on ad-
mission but who screened
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-
dence of a repositioning
schedule nor a proper
mattress among at-risk
patientspatients with a
PU ge Stage I (PRO)
5 patients with evi-
dence of either a reposi-
tioning schedule or a
proper mattress among
at-risk patients or those
with a PU gt Stage I (PRO)
6 patients with evi-
dence of both a reposi-
tioning schedule and a
proper mattress among
at-risk patients or those
with a PU gt 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
(continued on page AP6)
Copyright 2011 copy The Joint Commission
AP6June 2011 Volume 37 Number 6
The Joint Commission Journal on Quality and Patient Safety
Online-Only Content8Appendix 1 Included Studies (continued)
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
Brief Description of
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
PT = Patient Outcome
PRO = Nursing Process
1 Hospital-acquired PUs
ge Stage II (entire hospital)
(PT)
2 Hospital-acquired PUs
ge Stage II (SICU only)
(PT)
1 PU prevalence ge Stage
I (Hospital B) (PT)
2 PU prevalence ge Stage
II (Hospital B) (PT)
3 Nosocomial PU rate
(Stages I-IV) Hospital A
(PT)
4 Nosocomial PU rate
(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
(continued on page AP7)
Copyright 2011 copy The Joint Commission
AP7 June 2011 Volume 37 Number 6
The Joint Commission Journal on Quality and Patient Safety
Online-Only Content8Appendix 1 Included Studies (continued)
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
Brief Description of
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
PT = Patient Outcome
PRO = Nursing Process
1 PU rates (pre-existing
and hospital-acquired) at
time of discharge (PT)
2 PU rates (pre-existing
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)
4 patients with facility-
acquired PUs (medical
ICU) (PT)
1 Average length of stay
(PT)
2 Incidence of nosoco-
mial C difficile (PT)
3 Incidence of nosoco-
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
(continued on page AP8)
Copyright 2011 copy The Joint Commission
AP8June 2011 Volume 37 Number 6
The Joint Commission Journal on Quality and Patient Safety
Online-Only Content8Appendix 1 Included Studies (continued)
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
Brief Description of
Intervention
Multidimensional 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
monitoring and feedback
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
performance monitoring and
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 = Patient Outcome
PRO = Nursing Process
1 Hospital-acquired PUs
(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)
2 PU prevalence (Stages
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
(continued on page AP9)
Copyright 2011 copy The Joint Commission
AP9 June 2011 Volume 37 Number 6
The Joint Commission Journal on Quality and Patient Safety
Online-Only Content8Appendix 1 Included Studies (continued)
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
Brief Description of
Intervention
Multidimensional 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
PT = Patient Outcome
PRO = Nursing Process
1 Prevalence of hospital-
acquired PUs (Unit A)
(PT)
2 Prevalence of hospital-
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)
4 Hospital-acquired PU
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)
14 Staging of acquired
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
(continued on page AP10)
Copyright 2011 copy The Joint Commission
June 2011 Volume 37 Number 6
The Joint Commission Journal on Quality and Patient Safety
Online-Only Content8Appendix 1 Included Studies (continued)
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
Brief Description of
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
Multidimensional intervention
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
Multidimensional intervention
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
PT = Patient Outcome
PRO = Nursing Process
1 PU incidence (all
stages) (PT)
2 of hospital-acquired
Stage I PUs (PT)
3 of hospital-acquired
Stage II PUs (PT)
4 of hospital-acquired
Stage III PUs (PT)
5 of hospital-acquired
Stage IV PUs (PT)
1 Overall hospital-
acquired prevalence (PT)
1 PU 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
(continued on page AP11)
AP10
Copyright 2011 copy The Joint Commission
June 2011 Volume 37 Number 6
The Joint Commission Journal on Quality and Patient Safety
AP11
Online-Only Content8Appendix 1 Included Studies (continued)
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
Brief Description of
Intervention
Multidimensional PU preven-
tion program consisting of
the use of a risk assessment
tool and protocol conducted
performance monitoring and
provided staff education
Systemwide educational in-
tervention targeting all levels
of patient care providers and
multispecialty care The
intervention included per-
formance monitoring and
feedback the purchase of
pressure-relieving beds and
the use of new flow sheets
Measures Reported
PT = Patient Outcome
PRO = Nursing Process
1 PU prevalence (PT)
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)
4 Prevalence of hospital-
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)
7 patients with PUs (ge
Stage I) who had a skin
assessment upon admission
completed (PRO)
8 patients with PUs (ge
Stage I) who had a skin
assessment upon admission
(PRO)
9 patients with PUs (ge
Stage I) for whom it was
unknown whether a skin
assessment upon admission
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)
11 patients with PUs
(Stages IIndashIV) with inadequate
documentation of either
admission skin assessment or
reassessment (PRO)
12 patients with PUs
(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
(continued on page AP12)
Copyright 2011 copy The Joint Commission
June 2011 Volume 37 Number 6
The Joint Commission Journal on Quality and Patient Safety
AP12
Online-Only Content8Appendix 1 Included Studies (continued)
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
One hospital 2 units
cardiac surgery ICU
and cardiac surgery
intermediate care
unit Intervention lim-
ited to patients un-
dergoing elective
open heart surgery
Brief Description of
Intervention
Implemented a published
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
PT = Patient Outcome
PRO = Nursing Process
1 patients who devel-
oped PU in hospital
excluding those present
on admission (PT)
1 of nosocomial PUs
among hip fracture
patients (PT)
1 PU prevalence (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
(continued on page AP13)
Copyright 2011 copy The Joint Commission
June 2011 Volume 37 Number 6
The Joint Commission Journal on Quality and Patient Safety
AP13
Online-Only Content8Appendix 1 Included Studies (continued)
Author
Year
Country
Design
Rashotte37
2008
Canada
Before-after
Setting
10-bed pediatric ICU
Brief Description of
Intervention
Multifaceted 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
PT = Patient Outcome
PRO = Nursing Process
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)
9 Median number of pa-
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
(continued on page AP14)
Copyright 2011 copy The Joint Commission
June 2011 Volume 37 Number 6
The Joint Commission Journal on Quality and Patient Safety
AP14
Online-Only Content8Appendix 1 Included Studies (continued)
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
One hospital 9 units
Health care system
in eastern US units
not specified
Brief Description of
Intervention
Multidimensional intervention
consisting of assembled a
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
performance monitoring and
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
wound care management
study day (2) PU prevention
training program and training
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
assembling a team imple-
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
PT = Patient Outcome
PRO = Nursing Process
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
(continued on page AP15)
Copyright 2011 copy The Joint Commission
June 2011 Volume 37 Number 6
The Joint Commission Journal on Quality and Patient Safety
AP15
Online-Only Content8Appendix 1 Included Studies (continued)
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
Brief Description of
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-
mentation of a risk assess-
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
Multidimensional intervention
consisting of assembled a
team implemented a pub-
lished guideline and care
protocol used a risk assess-
ment tool made skin care
products readily available on
the unit and provided staff
education
Measures Reported
PT = Patient Outcome
PRO = Nursing Process
1 PU incidence (PT)
1 Incidence of Stage II
PUs among patients with-
out PUs on admission
(PUs100 patient days)
(PT)
1 patients with
hospital-acquired PUs
(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
(continued on page AP16)
Copyright 2011 copy The Joint Commission
June 2011 Volume 37 Number 6
The Joint Commission Journal on Quality and Patient Safety
AP16
Online-Only Content8Appendix 1 Included Studies (continued)
Author
Year
Country
Design
Willson44
1995
USA
Before-after
Setting
One hospital
4 medicalsurgical
units
Brief Description of
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
PT = Patient Outcome
PRO = Nursing Process
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
Copyright 2011 copy The Joint Commission
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
249June 2011 Volume 37 Number 6
The Joint Commission Journal on Quality and Patient Safety
(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
Copyright 2011 copy The Joint Commission
250 June 2011 Volume 37 Number 6
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-
The Joint Commission Journal on Quality and Patient Safety
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
Copyright 2011 copy The Joint Commission
251June 2011 Volume 37 Number 6
The Joint Commission Journal on Quality and Patient Safety
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
Copyright 2011 copy The Joint Commission
252 June 2011 Volume 37 Number 6
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
The Joint Commission Journal on Quality and Patient Safety
Copyright 2011 copy The Joint Commission
AP1 June 2011 Volume 37 Number 6
The Joint Commission Journal on Quality and Patient Safety
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
Multifaceted intervention con-
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)
Copyright 2011 copy The Joint Commission
AP2June 2011 Volume 37 Number 6
The Joint Commission Journal on Quality and Patient Safety
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
Brief Description of
Intervention
Implementation of a pub-
lished guideline risk assess-
ment tool and a prevention
protocol based on the risk
assessment results In addi-
tion a team was assembled
staff education conducted
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
PT = Patient Outcome
PRO = Nursing
Process
1 Incidence of hospital-
acquired PUs (PT)
1 PU prevalence (PT)
1 Case mix-adjusted
PU prevalence of (Stage
II or greater) among
patients without a PU on
admission (PT)
1 PU incidence (PT)
2 PU prevalence (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
(continued on page AP3)
Copyright 2011 copy The Joint Commission
AP3 June 2011 Volume 37 Number 6
The Joint Commission Journal on Quality and Patient Safety
Online-Only Content8Appendix 1 Included Studies (continued)
Author
Year
Country
Design
Charrier13
2008
Italy
Controlled
clinical trial
Setting
10 units (not speci-
fied) in an Italian
hospital
Brief Description of
Intervention
Audit and feedback on PU
protocol adherence
Measures Reported
PT = Patient Outcome
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
(continued on page AP4)
Copyright 2011 copy The Joint Commission
AP4June 2011 Volume 37 Number 6
The Joint Commission Journal on Quality and Patient Safety
Online-Only Content8Appendix 1 Included Studies (continued)
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
Brief Description of
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
PT = Patient Outcome
PRO = Nursing
Process
1 Number of hospital-
acquired PUs (PT)
1 Incidence of hospital-
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
(continued on page AP5)
Copyright 2011 copy The Joint Commission
AP5 June 2011 Volume 37 Number 6
The Joint Commission Journal on Quality and Patient Safety
Online-Only Content8Appendix 1 Included Studies (continued)
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
Brief Description of
Intervention
Implementation of a pub-
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
Implementation of a pub-
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
PT = Patient Outcome
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-
tients without PU on ad-
mission but who screened
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-
dence of a repositioning
schedule nor a proper
mattress among at-risk
patientspatients with a
PU ge Stage I (PRO)
5 patients with evi-
dence of either a reposi-
tioning schedule or a
proper mattress among
at-risk patients or those
with a PU gt Stage I (PRO)
6 patients with evi-
dence of both a reposi-
tioning schedule and a
proper mattress among
at-risk patients or those
with a PU gt 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
(continued on page AP6)
Copyright 2011 copy The Joint Commission
AP6June 2011 Volume 37 Number 6
The Joint Commission Journal on Quality and Patient Safety
Online-Only Content8Appendix 1 Included Studies (continued)
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
Brief Description of
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
PT = Patient Outcome
PRO = Nursing Process
1 Hospital-acquired PUs
ge Stage II (entire hospital)
(PT)
2 Hospital-acquired PUs
ge Stage II (SICU only)
(PT)
1 PU prevalence ge Stage
I (Hospital B) (PT)
2 PU prevalence ge Stage
II (Hospital B) (PT)
3 Nosocomial PU rate
(Stages I-IV) Hospital A
(PT)
4 Nosocomial PU rate
(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
(continued on page AP7)
Copyright 2011 copy The Joint Commission
AP7 June 2011 Volume 37 Number 6
The Joint Commission Journal on Quality and Patient Safety
Online-Only Content8Appendix 1 Included Studies (continued)
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
Brief Description of
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
PT = Patient Outcome
PRO = Nursing Process
1 PU rates (pre-existing
and hospital-acquired) at
time of discharge (PT)
2 PU rates (pre-existing
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)
4 patients with facility-
acquired PUs (medical
ICU) (PT)
1 Average length of stay
(PT)
2 Incidence of nosoco-
mial C difficile (PT)
3 Incidence of nosoco-
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
(continued on page AP8)
Copyright 2011 copy The Joint Commission
AP8June 2011 Volume 37 Number 6
The Joint Commission Journal on Quality and Patient Safety
Online-Only Content8Appendix 1 Included Studies (continued)
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
Brief Description of
Intervention
Multidimensional 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
monitoring and feedback
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
performance monitoring and
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 = Patient Outcome
PRO = Nursing Process
1 Hospital-acquired PUs
(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)
2 PU prevalence (Stages
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
(continued on page AP9)
Copyright 2011 copy The Joint Commission
AP9 June 2011 Volume 37 Number 6
The Joint Commission Journal on Quality and Patient Safety
Online-Only Content8Appendix 1 Included Studies (continued)
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
Brief Description of
Intervention
Multidimensional 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
PT = Patient Outcome
PRO = Nursing Process
1 Prevalence of hospital-
acquired PUs (Unit A)
(PT)
2 Prevalence of hospital-
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)
4 Hospital-acquired PU
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)
14 Staging of acquired
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
(continued on page AP10)
Copyright 2011 copy The Joint Commission
June 2011 Volume 37 Number 6
The Joint Commission Journal on Quality and Patient Safety
Online-Only Content8Appendix 1 Included Studies (continued)
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
Brief Description of
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
Multidimensional intervention
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
Multidimensional intervention
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
PT = Patient Outcome
PRO = Nursing Process
1 PU incidence (all
stages) (PT)
2 of hospital-acquired
Stage I PUs (PT)
3 of hospital-acquired
Stage II PUs (PT)
4 of hospital-acquired
Stage III PUs (PT)
5 of hospital-acquired
Stage IV PUs (PT)
1 Overall hospital-
acquired prevalence (PT)
1 PU 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
(continued on page AP11)
AP10
Copyright 2011 copy The Joint Commission
June 2011 Volume 37 Number 6
The Joint Commission Journal on Quality and Patient Safety
AP11
Online-Only Content8Appendix 1 Included Studies (continued)
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
Brief Description of
Intervention
Multidimensional PU preven-
tion program consisting of
the use of a risk assessment
tool and protocol conducted
performance monitoring and
provided staff education
Systemwide educational in-
tervention targeting all levels
of patient care providers and
multispecialty care The
intervention included per-
formance monitoring and
feedback the purchase of
pressure-relieving beds and
the use of new flow sheets
Measures Reported
PT = Patient Outcome
PRO = Nursing Process
1 PU prevalence (PT)
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)
4 Prevalence of hospital-
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)
7 patients with PUs (ge
Stage I) who had a skin
assessment upon admission
completed (PRO)
8 patients with PUs (ge
Stage I) who had a skin
assessment upon admission
(PRO)
9 patients with PUs (ge
Stage I) for whom it was
unknown whether a skin
assessment upon admission
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)
11 patients with PUs
(Stages IIndashIV) with inadequate
documentation of either
admission skin assessment or
reassessment (PRO)
12 patients with PUs
(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
(continued on page AP12)
Copyright 2011 copy The Joint Commission
June 2011 Volume 37 Number 6
The Joint Commission Journal on Quality and Patient Safety
AP12
Online-Only Content8Appendix 1 Included Studies (continued)
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
One hospital 2 units
cardiac surgery ICU
and cardiac surgery
intermediate care
unit Intervention lim-
ited to patients un-
dergoing elective
open heart surgery
Brief Description of
Intervention
Implemented a published
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
PT = Patient Outcome
PRO = Nursing Process
1 patients who devel-
oped PU in hospital
excluding those present
on admission (PT)
1 of nosocomial PUs
among hip fracture
patients (PT)
1 PU prevalence (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
(continued on page AP13)
Copyright 2011 copy The Joint Commission
June 2011 Volume 37 Number 6
The Joint Commission Journal on Quality and Patient Safety
AP13
Online-Only Content8Appendix 1 Included Studies (continued)
Author
Year
Country
Design
Rashotte37
2008
Canada
Before-after
Setting
10-bed pediatric ICU
Brief Description of
Intervention
Multifaceted 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
PT = Patient Outcome
PRO = Nursing Process
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)
9 Median number of pa-
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
(continued on page AP14)
Copyright 2011 copy The Joint Commission
June 2011 Volume 37 Number 6
The Joint Commission Journal on Quality and Patient Safety
AP14
Online-Only Content8Appendix 1 Included Studies (continued)
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
One hospital 9 units
Health care system
in eastern US units
not specified
Brief Description of
Intervention
Multidimensional intervention
consisting of assembled a
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
performance monitoring and
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
wound care management
study day (2) PU prevention
training program and training
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
assembling a team imple-
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
PT = Patient Outcome
PRO = Nursing Process
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
(continued on page AP15)
Copyright 2011 copy The Joint Commission
June 2011 Volume 37 Number 6
The Joint Commission Journal on Quality and Patient Safety
AP15
Online-Only Content8Appendix 1 Included Studies (continued)
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
Brief Description of
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-
mentation of a risk assess-
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
Multidimensional intervention
consisting of assembled a
team implemented a pub-
lished guideline and care
protocol used a risk assess-
ment tool made skin care
products readily available on
the unit and provided staff
education
Measures Reported
PT = Patient Outcome
PRO = Nursing Process
1 PU incidence (PT)
1 Incidence of Stage II
PUs among patients with-
out PUs on admission
(PUs100 patient days)
(PT)
1 patients with
hospital-acquired PUs
(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
(continued on page AP16)
Copyright 2011 copy The Joint Commission
June 2011 Volume 37 Number 6
The Joint Commission Journal on Quality and Patient Safety
AP16
Online-Only Content8Appendix 1 Included Studies (continued)
Author
Year
Country
Design
Willson44
1995
USA
Before-after
Setting
One hospital
4 medicalsurgical
units
Brief Description of
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
PT = Patient Outcome
PRO = Nursing Process
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
Copyright 2011 copy The Joint Commission
250 June 2011 Volume 37 Number 6
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-
The Joint Commission Journal on Quality and Patient Safety
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
Copyright 2011 copy The Joint Commission
251June 2011 Volume 37 Number 6
The Joint Commission Journal on Quality and Patient Safety
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
Copyright 2011 copy The Joint Commission
252 June 2011 Volume 37 Number 6
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
The Joint Commission Journal on Quality and Patient Safety
Copyright 2011 copy The Joint Commission
AP1 June 2011 Volume 37 Number 6
The Joint Commission Journal on Quality and Patient Safety
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
Multifaceted intervention con-
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)
Copyright 2011 copy The Joint Commission
AP2June 2011 Volume 37 Number 6
The Joint Commission Journal on Quality and Patient Safety
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
Brief Description of
Intervention
Implementation of a pub-
lished guideline risk assess-
ment tool and a prevention
protocol based on the risk
assessment results In addi-
tion a team was assembled
staff education conducted
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
PT = Patient Outcome
PRO = Nursing
Process
1 Incidence of hospital-
acquired PUs (PT)
1 PU prevalence (PT)
1 Case mix-adjusted
PU prevalence of (Stage
II or greater) among
patients without a PU on
admission (PT)
1 PU incidence (PT)
2 PU prevalence (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
(continued on page AP3)
Copyright 2011 copy The Joint Commission
AP3 June 2011 Volume 37 Number 6
The Joint Commission Journal on Quality and Patient Safety
Online-Only Content8Appendix 1 Included Studies (continued)
Author
Year
Country
Design
Charrier13
2008
Italy
Controlled
clinical trial
Setting
10 units (not speci-
fied) in an Italian
hospital
Brief Description of
Intervention
Audit and feedback on PU
protocol adherence
Measures Reported
PT = Patient Outcome
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
(continued on page AP4)
Copyright 2011 copy The Joint Commission
AP4June 2011 Volume 37 Number 6
The Joint Commission Journal on Quality and Patient Safety
Online-Only Content8Appendix 1 Included Studies (continued)
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
Brief Description of
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
PT = Patient Outcome
PRO = Nursing
Process
1 Number of hospital-
acquired PUs (PT)
1 Incidence of hospital-
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
(continued on page AP5)
Copyright 2011 copy The Joint Commission
AP5 June 2011 Volume 37 Number 6
The Joint Commission Journal on Quality and Patient Safety
Online-Only Content8Appendix 1 Included Studies (continued)
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
Brief Description of
Intervention
Implementation of a pub-
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
Implementation of a pub-
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
PT = Patient Outcome
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-
tients without PU on ad-
mission but who screened
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-
dence of a repositioning
schedule nor a proper
mattress among at-risk
patientspatients with a
PU ge Stage I (PRO)
5 patients with evi-
dence of either a reposi-
tioning schedule or a
proper mattress among
at-risk patients or those
with a PU gt Stage I (PRO)
6 patients with evi-
dence of both a reposi-
tioning schedule and a
proper mattress among
at-risk patients or those
with a PU gt 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
(continued on page AP6)
Copyright 2011 copy The Joint Commission
AP6June 2011 Volume 37 Number 6
The Joint Commission Journal on Quality and Patient Safety
Online-Only Content8Appendix 1 Included Studies (continued)
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
Brief Description of
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
PT = Patient Outcome
PRO = Nursing Process
1 Hospital-acquired PUs
ge Stage II (entire hospital)
(PT)
2 Hospital-acquired PUs
ge Stage II (SICU only)
(PT)
1 PU prevalence ge Stage
I (Hospital B) (PT)
2 PU prevalence ge Stage
II (Hospital B) (PT)
3 Nosocomial PU rate
(Stages I-IV) Hospital A
(PT)
4 Nosocomial PU rate
(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
(continued on page AP7)
Copyright 2011 copy The Joint Commission
AP7 June 2011 Volume 37 Number 6
The Joint Commission Journal on Quality and Patient Safety
Online-Only Content8Appendix 1 Included Studies (continued)
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
Brief Description of
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
PT = Patient Outcome
PRO = Nursing Process
1 PU rates (pre-existing
and hospital-acquired) at
time of discharge (PT)
2 PU rates (pre-existing
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)
4 patients with facility-
acquired PUs (medical
ICU) (PT)
1 Average length of stay
(PT)
2 Incidence of nosoco-
mial C difficile (PT)
3 Incidence of nosoco-
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
(continued on page AP8)
Copyright 2011 copy The Joint Commission
AP8June 2011 Volume 37 Number 6
The Joint Commission Journal on Quality and Patient Safety
Online-Only Content8Appendix 1 Included Studies (continued)
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
Brief Description of
Intervention
Multidimensional 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
monitoring and feedback
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
performance monitoring and
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 = Patient Outcome
PRO = Nursing Process
1 Hospital-acquired PUs
(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)
2 PU prevalence (Stages
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
(continued on page AP9)
Copyright 2011 copy The Joint Commission
AP9 June 2011 Volume 37 Number 6
The Joint Commission Journal on Quality and Patient Safety
Online-Only Content8Appendix 1 Included Studies (continued)
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
Brief Description of
Intervention
Multidimensional 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
PT = Patient Outcome
PRO = Nursing Process
1 Prevalence of hospital-
acquired PUs (Unit A)
(PT)
2 Prevalence of hospital-
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)
4 Hospital-acquired PU
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)
14 Staging of acquired
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
(continued on page AP10)
Copyright 2011 copy The Joint Commission
June 2011 Volume 37 Number 6
The Joint Commission Journal on Quality and Patient Safety
Online-Only Content8Appendix 1 Included Studies (continued)
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
Brief Description of
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
Multidimensional intervention
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
Multidimensional intervention
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
PT = Patient Outcome
PRO = Nursing Process
1 PU incidence (all
stages) (PT)
2 of hospital-acquired
Stage I PUs (PT)
3 of hospital-acquired
Stage II PUs (PT)
4 of hospital-acquired
Stage III PUs (PT)
5 of hospital-acquired
Stage IV PUs (PT)
1 Overall hospital-
acquired prevalence (PT)
1 PU 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
(continued on page AP11)
AP10
Copyright 2011 copy The Joint Commission
June 2011 Volume 37 Number 6
The Joint Commission Journal on Quality and Patient Safety
AP11
Online-Only Content8Appendix 1 Included Studies (continued)
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
Brief Description of
Intervention
Multidimensional PU preven-
tion program consisting of
the use of a risk assessment
tool and protocol conducted
performance monitoring and
provided staff education
Systemwide educational in-
tervention targeting all levels
of patient care providers and
multispecialty care The
intervention included per-
formance monitoring and
feedback the purchase of
pressure-relieving beds and
the use of new flow sheets
Measures Reported
PT = Patient Outcome
PRO = Nursing Process
1 PU prevalence (PT)
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)
4 Prevalence of hospital-
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)
7 patients with PUs (ge
Stage I) who had a skin
assessment upon admission
completed (PRO)
8 patients with PUs (ge
Stage I) who had a skin
assessment upon admission
(PRO)
9 patients with PUs (ge
Stage I) for whom it was
unknown whether a skin
assessment upon admission
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)
11 patients with PUs
(Stages IIndashIV) with inadequate
documentation of either
admission skin assessment or
reassessment (PRO)
12 patients with PUs
(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
(continued on page AP12)
Copyright 2011 copy The Joint Commission
June 2011 Volume 37 Number 6
The Joint Commission Journal on Quality and Patient Safety
AP12
Online-Only Content8Appendix 1 Included Studies (continued)
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
One hospital 2 units
cardiac surgery ICU
and cardiac surgery
intermediate care
unit Intervention lim-
ited to patients un-
dergoing elective
open heart surgery
Brief Description of
Intervention
Implemented a published
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
PT = Patient Outcome
PRO = Nursing Process
1 patients who devel-
oped PU in hospital
excluding those present
on admission (PT)
1 of nosocomial PUs
among hip fracture
patients (PT)
1 PU prevalence (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
(continued on page AP13)
Copyright 2011 copy The Joint Commission
June 2011 Volume 37 Number 6
The Joint Commission Journal on Quality and Patient Safety
AP13
Online-Only Content8Appendix 1 Included Studies (continued)
Author
Year
Country
Design
Rashotte37
2008
Canada
Before-after
Setting
10-bed pediatric ICU
Brief Description of
Intervention
Multifaceted 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
PT = Patient Outcome
PRO = Nursing Process
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)
9 Median number of pa-
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
(continued on page AP14)
Copyright 2011 copy The Joint Commission
June 2011 Volume 37 Number 6
The Joint Commission Journal on Quality and Patient Safety
AP14
Online-Only Content8Appendix 1 Included Studies (continued)
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
One hospital 9 units
Health care system
in eastern US units
not specified
Brief Description of
Intervention
Multidimensional intervention
consisting of assembled a
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
performance monitoring and
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
wound care management
study day (2) PU prevention
training program and training
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
assembling a team imple-
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
PT = Patient Outcome
PRO = Nursing Process
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
(continued on page AP15)
Copyright 2011 copy The Joint Commission
June 2011 Volume 37 Number 6
The Joint Commission Journal on Quality and Patient Safety
AP15
Online-Only Content8Appendix 1 Included Studies (continued)
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
Brief Description of
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-
mentation of a risk assess-
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
Multidimensional intervention
consisting of assembled a
team implemented a pub-
lished guideline and care
protocol used a risk assess-
ment tool made skin care
products readily available on
the unit and provided staff
education
Measures Reported
PT = Patient Outcome
PRO = Nursing Process
1 PU incidence (PT)
1 Incidence of Stage II
PUs among patients with-
out PUs on admission
(PUs100 patient days)
(PT)
1 patients with
hospital-acquired PUs
(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
(continued on page AP16)
Copyright 2011 copy The Joint Commission
June 2011 Volume 37 Number 6
The Joint Commission Journal on Quality and Patient Safety
AP16
Online-Only Content8Appendix 1 Included Studies (continued)
Author
Year
Country
Design
Willson44
1995
USA
Before-after
Setting
One hospital
4 medicalsurgical
units
Brief Description of
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
PT = Patient Outcome
PRO = Nursing Process
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
Copyright 2011 copy The Joint Commission
251June 2011 Volume 37 Number 6
The Joint Commission Journal on Quality and Patient Safety
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
Copyright 2011 copy The Joint Commission
252 June 2011 Volume 37 Number 6
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
The Joint Commission Journal on Quality and Patient Safety
Copyright 2011 copy The Joint Commission
AP1 June 2011 Volume 37 Number 6
The Joint Commission Journal on Quality and Patient Safety
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
Multifaceted intervention con-
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)
Copyright 2011 copy The Joint Commission
AP2June 2011 Volume 37 Number 6
The Joint Commission Journal on Quality and Patient Safety
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
Brief Description of
Intervention
Implementation of a pub-
lished guideline risk assess-
ment tool and a prevention
protocol based on the risk
assessment results In addi-
tion a team was assembled
staff education conducted
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
PT = Patient Outcome
PRO = Nursing
Process
1 Incidence of hospital-
acquired PUs (PT)
1 PU prevalence (PT)
1 Case mix-adjusted
PU prevalence of (Stage
II or greater) among
patients without a PU on
admission (PT)
1 PU incidence (PT)
2 PU prevalence (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
(continued on page AP3)
Copyright 2011 copy The Joint Commission
AP3 June 2011 Volume 37 Number 6
The Joint Commission Journal on Quality and Patient Safety
Online-Only Content8Appendix 1 Included Studies (continued)
Author
Year
Country
Design
Charrier13
2008
Italy
Controlled
clinical trial
Setting
10 units (not speci-
fied) in an Italian
hospital
Brief Description of
Intervention
Audit and feedback on PU
protocol adherence
Measures Reported
PT = Patient Outcome
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
(continued on page AP4)
Copyright 2011 copy The Joint Commission
AP4June 2011 Volume 37 Number 6
The Joint Commission Journal on Quality and Patient Safety
Online-Only Content8Appendix 1 Included Studies (continued)
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
Brief Description of
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
PT = Patient Outcome
PRO = Nursing
Process
1 Number of hospital-
acquired PUs (PT)
1 Incidence of hospital-
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
(continued on page AP5)
Copyright 2011 copy The Joint Commission
AP5 June 2011 Volume 37 Number 6
The Joint Commission Journal on Quality and Patient Safety
Online-Only Content8Appendix 1 Included Studies (continued)
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
Brief Description of
Intervention
Implementation of a pub-
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
Implementation of a pub-
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
PT = Patient Outcome
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-
tients without PU on ad-
mission but who screened
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-
dence of a repositioning
schedule nor a proper
mattress among at-risk
patientspatients with a
PU ge Stage I (PRO)
5 patients with evi-
dence of either a reposi-
tioning schedule or a
proper mattress among
at-risk patients or those
with a PU gt Stage I (PRO)
6 patients with evi-
dence of both a reposi-
tioning schedule and a
proper mattress among
at-risk patients or those
with a PU gt 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
(continued on page AP6)
Copyright 2011 copy The Joint Commission
AP6June 2011 Volume 37 Number 6
The Joint Commission Journal on Quality and Patient Safety
Online-Only Content8Appendix 1 Included Studies (continued)
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
Brief Description of
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
PT = Patient Outcome
PRO = Nursing Process
1 Hospital-acquired PUs
ge Stage II (entire hospital)
(PT)
2 Hospital-acquired PUs
ge Stage II (SICU only)
(PT)
1 PU prevalence ge Stage
I (Hospital B) (PT)
2 PU prevalence ge Stage
II (Hospital B) (PT)
3 Nosocomial PU rate
(Stages I-IV) Hospital A
(PT)
4 Nosocomial PU rate
(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
(continued on page AP7)
Copyright 2011 copy The Joint Commission
AP7 June 2011 Volume 37 Number 6
The Joint Commission Journal on Quality and Patient Safety
Online-Only Content8Appendix 1 Included Studies (continued)
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
Brief Description of
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
PT = Patient Outcome
PRO = Nursing Process
1 PU rates (pre-existing
and hospital-acquired) at
time of discharge (PT)
2 PU rates (pre-existing
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)
4 patients with facility-
acquired PUs (medical
ICU) (PT)
1 Average length of stay
(PT)
2 Incidence of nosoco-
mial C difficile (PT)
3 Incidence of nosoco-
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
(continued on page AP8)
Copyright 2011 copy The Joint Commission
AP8June 2011 Volume 37 Number 6
The Joint Commission Journal on Quality and Patient Safety
Online-Only Content8Appendix 1 Included Studies (continued)
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
Brief Description of
Intervention
Multidimensional 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
monitoring and feedback
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
performance monitoring and
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 = Patient Outcome
PRO = Nursing Process
1 Hospital-acquired PUs
(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)
2 PU prevalence (Stages
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
(continued on page AP9)
Copyright 2011 copy The Joint Commission
AP9 June 2011 Volume 37 Number 6
The Joint Commission Journal on Quality and Patient Safety
Online-Only Content8Appendix 1 Included Studies (continued)
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
Brief Description of
Intervention
Multidimensional 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
PT = Patient Outcome
PRO = Nursing Process
1 Prevalence of hospital-
acquired PUs (Unit A)
(PT)
2 Prevalence of hospital-
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)
4 Hospital-acquired PU
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)
14 Staging of acquired
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
(continued on page AP10)
Copyright 2011 copy The Joint Commission
June 2011 Volume 37 Number 6
The Joint Commission Journal on Quality and Patient Safety
Online-Only Content8Appendix 1 Included Studies (continued)
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
Brief Description of
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
Multidimensional intervention
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
Multidimensional intervention
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
PT = Patient Outcome
PRO = Nursing Process
1 PU incidence (all
stages) (PT)
2 of hospital-acquired
Stage I PUs (PT)
3 of hospital-acquired
Stage II PUs (PT)
4 of hospital-acquired
Stage III PUs (PT)
5 of hospital-acquired
Stage IV PUs (PT)
1 Overall hospital-
acquired prevalence (PT)
1 PU 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
(continued on page AP11)
AP10
Copyright 2011 copy The Joint Commission
June 2011 Volume 37 Number 6
The Joint Commission Journal on Quality and Patient Safety
AP11
Online-Only Content8Appendix 1 Included Studies (continued)
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
Brief Description of
Intervention
Multidimensional PU preven-
tion program consisting of
the use of a risk assessment
tool and protocol conducted
performance monitoring and
provided staff education
Systemwide educational in-
tervention targeting all levels
of patient care providers and
multispecialty care The
intervention included per-
formance monitoring and
feedback the purchase of
pressure-relieving beds and
the use of new flow sheets
Measures Reported
PT = Patient Outcome
PRO = Nursing Process
1 PU prevalence (PT)
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)
4 Prevalence of hospital-
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)
7 patients with PUs (ge
Stage I) who had a skin
assessment upon admission
completed (PRO)
8 patients with PUs (ge
Stage I) who had a skin
assessment upon admission
(PRO)
9 patients with PUs (ge
Stage I) for whom it was
unknown whether a skin
assessment upon admission
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)
11 patients with PUs
(Stages IIndashIV) with inadequate
documentation of either
admission skin assessment or
reassessment (PRO)
12 patients with PUs
(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
(continued on page AP12)
Copyright 2011 copy The Joint Commission
June 2011 Volume 37 Number 6
The Joint Commission Journal on Quality and Patient Safety
AP12
Online-Only Content8Appendix 1 Included Studies (continued)
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
One hospital 2 units
cardiac surgery ICU
and cardiac surgery
intermediate care
unit Intervention lim-
ited to patients un-
dergoing elective
open heart surgery
Brief Description of
Intervention
Implemented a published
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
PT = Patient Outcome
PRO = Nursing Process
1 patients who devel-
oped PU in hospital
excluding those present
on admission (PT)
1 of nosocomial PUs
among hip fracture
patients (PT)
1 PU prevalence (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
(continued on page AP13)
Copyright 2011 copy The Joint Commission
June 2011 Volume 37 Number 6
The Joint Commission Journal on Quality and Patient Safety
AP13
Online-Only Content8Appendix 1 Included Studies (continued)
Author
Year
Country
Design
Rashotte37
2008
Canada
Before-after
Setting
10-bed pediatric ICU
Brief Description of
Intervention
Multifaceted 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
PT = Patient Outcome
PRO = Nursing Process
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)
9 Median number of pa-
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
(continued on page AP14)
Copyright 2011 copy The Joint Commission
June 2011 Volume 37 Number 6
The Joint Commission Journal on Quality and Patient Safety
AP14
Online-Only Content8Appendix 1 Included Studies (continued)
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
One hospital 9 units
Health care system
in eastern US units
not specified
Brief Description of
Intervention
Multidimensional intervention
consisting of assembled a
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
performance monitoring and
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
wound care management
study day (2) PU prevention
training program and training
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
assembling a team imple-
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
PT = Patient Outcome
PRO = Nursing Process
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
(continued on page AP15)
Copyright 2011 copy The Joint Commission
June 2011 Volume 37 Number 6
The Joint Commission Journal on Quality and Patient Safety
AP15
Online-Only Content8Appendix 1 Included Studies (continued)
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
Brief Description of
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-
mentation of a risk assess-
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
Multidimensional intervention
consisting of assembled a
team implemented a pub-
lished guideline and care
protocol used a risk assess-
ment tool made skin care
products readily available on
the unit and provided staff
education
Measures Reported
PT = Patient Outcome
PRO = Nursing Process
1 PU incidence (PT)
1 Incidence of Stage II
PUs among patients with-
out PUs on admission
(PUs100 patient days)
(PT)
1 patients with
hospital-acquired PUs
(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
(continued on page AP16)
Copyright 2011 copy The Joint Commission
June 2011 Volume 37 Number 6
The Joint Commission Journal on Quality and Patient Safety
AP16
Online-Only Content8Appendix 1 Included Studies (continued)
Author
Year
Country
Design
Willson44
1995
USA
Before-after
Setting
One hospital
4 medicalsurgical
units
Brief Description of
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
PT = Patient Outcome
PRO = Nursing Process
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
Copyright 2011 copy The Joint Commission
252 June 2011 Volume 37 Number 6
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
The Joint Commission Journal on Quality and Patient Safety
Copyright 2011 copy The Joint Commission
AP1 June 2011 Volume 37 Number 6
The Joint Commission Journal on Quality and Patient Safety
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
Multifaceted intervention con-
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)
Copyright 2011 copy The Joint Commission
AP2June 2011 Volume 37 Number 6
The Joint Commission Journal on Quality and Patient Safety
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
Brief Description of
Intervention
Implementation of a pub-
lished guideline risk assess-
ment tool and a prevention
protocol based on the risk
assessment results In addi-
tion a team was assembled
staff education conducted
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
PT = Patient Outcome
PRO = Nursing
Process
1 Incidence of hospital-
acquired PUs (PT)
1 PU prevalence (PT)
1 Case mix-adjusted
PU prevalence of (Stage
II or greater) among
patients without a PU on
admission (PT)
1 PU incidence (PT)
2 PU prevalence (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
(continued on page AP3)
Copyright 2011 copy The Joint Commission
AP3 June 2011 Volume 37 Number 6
The Joint Commission Journal on Quality and Patient Safety
Online-Only Content8Appendix 1 Included Studies (continued)
Author
Year
Country
Design
Charrier13
2008
Italy
Controlled
clinical trial
Setting
10 units (not speci-
fied) in an Italian
hospital
Brief Description of
Intervention
Audit and feedback on PU
protocol adherence
Measures Reported
PT = Patient Outcome
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
(continued on page AP4)
Copyright 2011 copy The Joint Commission
AP4June 2011 Volume 37 Number 6
The Joint Commission Journal on Quality and Patient Safety
Online-Only Content8Appendix 1 Included Studies (continued)
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
Brief Description of
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
PT = Patient Outcome
PRO = Nursing
Process
1 Number of hospital-
acquired PUs (PT)
1 Incidence of hospital-
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
(continued on page AP5)
Copyright 2011 copy The Joint Commission
AP5 June 2011 Volume 37 Number 6
The Joint Commission Journal on Quality and Patient Safety
Online-Only Content8Appendix 1 Included Studies (continued)
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
Brief Description of
Intervention
Implementation of a pub-
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
Implementation of a pub-
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
PT = Patient Outcome
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-
tients without PU on ad-
mission but who screened
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-
dence of a repositioning
schedule nor a proper
mattress among at-risk
patientspatients with a
PU ge Stage I (PRO)
5 patients with evi-
dence of either a reposi-
tioning schedule or a
proper mattress among
at-risk patients or those
with a PU gt Stage I (PRO)
6 patients with evi-
dence of both a reposi-
tioning schedule and a
proper mattress among
at-risk patients or those
with a PU gt 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
(continued on page AP6)
Copyright 2011 copy The Joint Commission
AP6June 2011 Volume 37 Number 6
The Joint Commission Journal on Quality and Patient Safety
Online-Only Content8Appendix 1 Included Studies (continued)
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
Brief Description of
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
PT = Patient Outcome
PRO = Nursing Process
1 Hospital-acquired PUs
ge Stage II (entire hospital)
(PT)
2 Hospital-acquired PUs
ge Stage II (SICU only)
(PT)
1 PU prevalence ge Stage
I (Hospital B) (PT)
2 PU prevalence ge Stage
II (Hospital B) (PT)
3 Nosocomial PU rate
(Stages I-IV) Hospital A
(PT)
4 Nosocomial PU rate
(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
(continued on page AP7)
Copyright 2011 copy The Joint Commission
AP7 June 2011 Volume 37 Number 6
The Joint Commission Journal on Quality and Patient Safety
Online-Only Content8Appendix 1 Included Studies (continued)
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
Brief Description of
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
PT = Patient Outcome
PRO = Nursing Process
1 PU rates (pre-existing
and hospital-acquired) at
time of discharge (PT)
2 PU rates (pre-existing
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)
4 patients with facility-
acquired PUs (medical
ICU) (PT)
1 Average length of stay
(PT)
2 Incidence of nosoco-
mial C difficile (PT)
3 Incidence of nosoco-
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
(continued on page AP8)
Copyright 2011 copy The Joint Commission
AP8June 2011 Volume 37 Number 6
The Joint Commission Journal on Quality and Patient Safety
Online-Only Content8Appendix 1 Included Studies (continued)
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
Brief Description of
Intervention
Multidimensional 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
monitoring and feedback
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
performance monitoring and
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 = Patient Outcome
PRO = Nursing Process
1 Hospital-acquired PUs
(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)
2 PU prevalence (Stages
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
(continued on page AP9)
Copyright 2011 copy The Joint Commission
AP9 June 2011 Volume 37 Number 6
The Joint Commission Journal on Quality and Patient Safety
Online-Only Content8Appendix 1 Included Studies (continued)
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
Brief Description of
Intervention
Multidimensional 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
PT = Patient Outcome
PRO = Nursing Process
1 Prevalence of hospital-
acquired PUs (Unit A)
(PT)
2 Prevalence of hospital-
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)
4 Hospital-acquired PU
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)
14 Staging of acquired
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
(continued on page AP10)
Copyright 2011 copy The Joint Commission
June 2011 Volume 37 Number 6
The Joint Commission Journal on Quality and Patient Safety
Online-Only Content8Appendix 1 Included Studies (continued)
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
Brief Description of
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
Multidimensional intervention
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
Multidimensional intervention
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
PT = Patient Outcome
PRO = Nursing Process
1 PU incidence (all
stages) (PT)
2 of hospital-acquired
Stage I PUs (PT)
3 of hospital-acquired
Stage II PUs (PT)
4 of hospital-acquired
Stage III PUs (PT)
5 of hospital-acquired
Stage IV PUs (PT)
1 Overall hospital-
acquired prevalence (PT)
1 PU 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
(continued on page AP11)
AP10
Copyright 2011 copy The Joint Commission
June 2011 Volume 37 Number 6
The Joint Commission Journal on Quality and Patient Safety
AP11
Online-Only Content8Appendix 1 Included Studies (continued)
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
Brief Description of
Intervention
Multidimensional PU preven-
tion program consisting of
the use of a risk assessment
tool and protocol conducted
performance monitoring and
provided staff education
Systemwide educational in-
tervention targeting all levels
of patient care providers and
multispecialty care The
intervention included per-
formance monitoring and
feedback the purchase of
pressure-relieving beds and
the use of new flow sheets
Measures Reported
PT = Patient Outcome
PRO = Nursing Process
1 PU prevalence (PT)
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)
4 Prevalence of hospital-
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)
7 patients with PUs (ge
Stage I) who had a skin
assessment upon admission
completed (PRO)
8 patients with PUs (ge
Stage I) who had a skin
assessment upon admission
(PRO)
9 patients with PUs (ge
Stage I) for whom it was
unknown whether a skin
assessment upon admission
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)
11 patients with PUs
(Stages IIndashIV) with inadequate
documentation of either
admission skin assessment or
reassessment (PRO)
12 patients with PUs
(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
(continued on page AP12)
Copyright 2011 copy The Joint Commission
June 2011 Volume 37 Number 6
The Joint Commission Journal on Quality and Patient Safety
AP12
Online-Only Content8Appendix 1 Included Studies (continued)
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
One hospital 2 units
cardiac surgery ICU
and cardiac surgery
intermediate care
unit Intervention lim-
ited to patients un-
dergoing elective
open heart surgery
Brief Description of
Intervention
Implemented a published
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
PT = Patient Outcome
PRO = Nursing Process
1 patients who devel-
oped PU in hospital
excluding those present
on admission (PT)
1 of nosocomial PUs
among hip fracture
patients (PT)
1 PU prevalence (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
(continued on page AP13)
Copyright 2011 copy The Joint Commission
June 2011 Volume 37 Number 6
The Joint Commission Journal on Quality and Patient Safety
AP13
Online-Only Content8Appendix 1 Included Studies (continued)
Author
Year
Country
Design
Rashotte37
2008
Canada
Before-after
Setting
10-bed pediatric ICU
Brief Description of
Intervention
Multifaceted 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
PT = Patient Outcome
PRO = Nursing Process
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)
9 Median number of pa-
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
(continued on page AP14)
Copyright 2011 copy The Joint Commission
June 2011 Volume 37 Number 6
The Joint Commission Journal on Quality and Patient Safety
AP14
Online-Only Content8Appendix 1 Included Studies (continued)
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
One hospital 9 units
Health care system
in eastern US units
not specified
Brief Description of
Intervention
Multidimensional intervention
consisting of assembled a
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
performance monitoring and
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
wound care management
study day (2) PU prevention
training program and training
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
assembling a team imple-
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
PT = Patient Outcome
PRO = Nursing Process
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
(continued on page AP15)
Copyright 2011 copy The Joint Commission
June 2011 Volume 37 Number 6
The Joint Commission Journal on Quality and Patient Safety
AP15
Online-Only Content8Appendix 1 Included Studies (continued)
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
Brief Description of
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-
mentation of a risk assess-
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
Multidimensional intervention
consisting of assembled a
team implemented a pub-
lished guideline and care
protocol used a risk assess-
ment tool made skin care
products readily available on
the unit and provided staff
education
Measures Reported
PT = Patient Outcome
PRO = Nursing Process
1 PU incidence (PT)
1 Incidence of Stage II
PUs among patients with-
out PUs on admission
(PUs100 patient days)
(PT)
1 patients with
hospital-acquired PUs
(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
(continued on page AP16)
Copyright 2011 copy The Joint Commission
June 2011 Volume 37 Number 6
The Joint Commission Journal on Quality and Patient Safety
AP16
Online-Only Content8Appendix 1 Included Studies (continued)
Author
Year
Country
Design
Willson44
1995
USA
Before-after
Setting
One hospital
4 medicalsurgical
units
Brief Description of
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
PT = Patient Outcome
PRO = Nursing Process
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
Copyright 2011 copy The Joint Commission
AP1 June 2011 Volume 37 Number 6
The Joint Commission Journal on Quality and Patient Safety
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
Multifaceted intervention con-
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)
Copyright 2011 copy The Joint Commission
AP2June 2011 Volume 37 Number 6
The Joint Commission Journal on Quality and Patient Safety
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
Brief Description of
Intervention
Implementation of a pub-
lished guideline risk assess-
ment tool and a prevention
protocol based on the risk
assessment results In addi-
tion a team was assembled
staff education conducted
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
PT = Patient Outcome
PRO = Nursing
Process
1 Incidence of hospital-
acquired PUs (PT)
1 PU prevalence (PT)
1 Case mix-adjusted
PU prevalence of (Stage
II or greater) among
patients without a PU on
admission (PT)
1 PU incidence (PT)
2 PU prevalence (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
(continued on page AP3)
Copyright 2011 copy The Joint Commission
AP3 June 2011 Volume 37 Number 6
The Joint Commission Journal on Quality and Patient Safety
Online-Only Content8Appendix 1 Included Studies (continued)
Author
Year
Country
Design
Charrier13
2008
Italy
Controlled
clinical trial
Setting
10 units (not speci-
fied) in an Italian
hospital
Brief Description of
Intervention
Audit and feedback on PU
protocol adherence
Measures Reported
PT = Patient Outcome
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
(continued on page AP4)
Copyright 2011 copy The Joint Commission
AP4June 2011 Volume 37 Number 6
The Joint Commission Journal on Quality and Patient Safety
Online-Only Content8Appendix 1 Included Studies (continued)
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
Brief Description of
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
PT = Patient Outcome
PRO = Nursing
Process
1 Number of hospital-
acquired PUs (PT)
1 Incidence of hospital-
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
(continued on page AP5)
Copyright 2011 copy The Joint Commission
AP5 June 2011 Volume 37 Number 6
The Joint Commission Journal on Quality and Patient Safety
Online-Only Content8Appendix 1 Included Studies (continued)
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
Brief Description of
Intervention
Implementation of a pub-
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
Implementation of a pub-
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
PT = Patient Outcome
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-
tients without PU on ad-
mission but who screened
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-
dence of a repositioning
schedule nor a proper
mattress among at-risk
patientspatients with a
PU ge Stage I (PRO)
5 patients with evi-
dence of either a reposi-
tioning schedule or a
proper mattress among
at-risk patients or those
with a PU gt Stage I (PRO)
6 patients with evi-
dence of both a reposi-
tioning schedule and a
proper mattress among
at-risk patients or those
with a PU gt 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
(continued on page AP6)
Copyright 2011 copy The Joint Commission
AP6June 2011 Volume 37 Number 6
The Joint Commission Journal on Quality and Patient Safety
Online-Only Content8Appendix 1 Included Studies (continued)
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
Brief Description of
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
PT = Patient Outcome
PRO = Nursing Process
1 Hospital-acquired PUs
ge Stage II (entire hospital)
(PT)
2 Hospital-acquired PUs
ge Stage II (SICU only)
(PT)
1 PU prevalence ge Stage
I (Hospital B) (PT)
2 PU prevalence ge Stage
II (Hospital B) (PT)
3 Nosocomial PU rate
(Stages I-IV) Hospital A
(PT)
4 Nosocomial PU rate
(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
(continued on page AP7)
Copyright 2011 copy The Joint Commission
AP7 June 2011 Volume 37 Number 6
The Joint Commission Journal on Quality and Patient Safety
Online-Only Content8Appendix 1 Included Studies (continued)
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
Brief Description of
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
PT = Patient Outcome
PRO = Nursing Process
1 PU rates (pre-existing
and hospital-acquired) at
time of discharge (PT)
2 PU rates (pre-existing
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)
4 patients with facility-
acquired PUs (medical
ICU) (PT)
1 Average length of stay
(PT)
2 Incidence of nosoco-
mial C difficile (PT)
3 Incidence of nosoco-
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
(continued on page AP8)
Copyright 2011 copy The Joint Commission
AP8June 2011 Volume 37 Number 6
The Joint Commission Journal on Quality and Patient Safety
Online-Only Content8Appendix 1 Included Studies (continued)
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
Brief Description of
Intervention
Multidimensional 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
monitoring and feedback
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
performance monitoring and
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 = Patient Outcome
PRO = Nursing Process
1 Hospital-acquired PUs
(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)
2 PU prevalence (Stages
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
(continued on page AP9)
Copyright 2011 copy The Joint Commission
AP9 June 2011 Volume 37 Number 6
The Joint Commission Journal on Quality and Patient Safety
Online-Only Content8Appendix 1 Included Studies (continued)
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
Brief Description of
Intervention
Multidimensional 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
PT = Patient Outcome
PRO = Nursing Process
1 Prevalence of hospital-
acquired PUs (Unit A)
(PT)
2 Prevalence of hospital-
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)
4 Hospital-acquired PU
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)
14 Staging of acquired
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
(continued on page AP10)
Copyright 2011 copy The Joint Commission
June 2011 Volume 37 Number 6
The Joint Commission Journal on Quality and Patient Safety
Online-Only Content8Appendix 1 Included Studies (continued)
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
Brief Description of
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
Multidimensional intervention
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
Multidimensional intervention
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
PT = Patient Outcome
PRO = Nursing Process
1 PU incidence (all
stages) (PT)
2 of hospital-acquired
Stage I PUs (PT)
3 of hospital-acquired
Stage II PUs (PT)
4 of hospital-acquired
Stage III PUs (PT)
5 of hospital-acquired
Stage IV PUs (PT)
1 Overall hospital-
acquired prevalence (PT)
1 PU 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
(continued on page AP11)
AP10
Copyright 2011 copy The Joint Commission
June 2011 Volume 37 Number 6
The Joint Commission Journal on Quality and Patient Safety
AP11
Online-Only Content8Appendix 1 Included Studies (continued)
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
Brief Description of
Intervention
Multidimensional PU preven-
tion program consisting of
the use of a risk assessment
tool and protocol conducted
performance monitoring and
provided staff education
Systemwide educational in-
tervention targeting all levels
of patient care providers and
multispecialty care The
intervention included per-
formance monitoring and
feedback the purchase of
pressure-relieving beds and
the use of new flow sheets
Measures Reported
PT = Patient Outcome
PRO = Nursing Process
1 PU prevalence (PT)
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)
4 Prevalence of hospital-
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)
7 patients with PUs (ge
Stage I) who had a skin
assessment upon admission
completed (PRO)
8 patients with PUs (ge
Stage I) who had a skin
assessment upon admission
(PRO)
9 patients with PUs (ge
Stage I) for whom it was
unknown whether a skin
assessment upon admission
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)
11 patients with PUs
(Stages IIndashIV) with inadequate
documentation of either
admission skin assessment or
reassessment (PRO)
12 patients with PUs
(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
(continued on page AP12)
Copyright 2011 copy The Joint Commission
June 2011 Volume 37 Number 6
The Joint Commission Journal on Quality and Patient Safety
AP12
Online-Only Content8Appendix 1 Included Studies (continued)
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
One hospital 2 units
cardiac surgery ICU
and cardiac surgery
intermediate care
unit Intervention lim-
ited to patients un-
dergoing elective
open heart surgery
Brief Description of
Intervention
Implemented a published
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
PT = Patient Outcome
PRO = Nursing Process
1 patients who devel-
oped PU in hospital
excluding those present
on admission (PT)
1 of nosocomial PUs
among hip fracture
patients (PT)
1 PU prevalence (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
(continued on page AP13)
Copyright 2011 copy The Joint Commission
June 2011 Volume 37 Number 6
The Joint Commission Journal on Quality and Patient Safety
AP13
Online-Only Content8Appendix 1 Included Studies (continued)
Author
Year
Country
Design
Rashotte37
2008
Canada
Before-after
Setting
10-bed pediatric ICU
Brief Description of
Intervention
Multifaceted 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
PT = Patient Outcome
PRO = Nursing Process
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)
9 Median number of pa-
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
(continued on page AP14)
Copyright 2011 copy The Joint Commission
June 2011 Volume 37 Number 6
The Joint Commission Journal on Quality and Patient Safety
AP14
Online-Only Content8Appendix 1 Included Studies (continued)
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
One hospital 9 units
Health care system
in eastern US units
not specified
Brief Description of
Intervention
Multidimensional intervention
consisting of assembled a
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
performance monitoring and
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
wound care management
study day (2) PU prevention
training program and training
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
assembling a team imple-
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
PT = Patient Outcome
PRO = Nursing Process
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
(continued on page AP15)
Copyright 2011 copy The Joint Commission
June 2011 Volume 37 Number 6
The Joint Commission Journal on Quality and Patient Safety
AP15
Online-Only Content8Appendix 1 Included Studies (continued)
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
Brief Description of
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-
mentation of a risk assess-
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
Multidimensional intervention
consisting of assembled a
team implemented a pub-
lished guideline and care
protocol used a risk assess-
ment tool made skin care
products readily available on
the unit and provided staff
education
Measures Reported
PT = Patient Outcome
PRO = Nursing Process
1 PU incidence (PT)
1 Incidence of Stage II
PUs among patients with-
out PUs on admission
(PUs100 patient days)
(PT)
1 patients with
hospital-acquired PUs
(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
(continued on page AP16)
Copyright 2011 copy The Joint Commission
June 2011 Volume 37 Number 6
The Joint Commission Journal on Quality and Patient Safety
AP16
Online-Only Content8Appendix 1 Included Studies (continued)
Author
Year
Country
Design
Willson44
1995
USA
Before-after
Setting
One hospital
4 medicalsurgical
units
Brief Description of
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
PT = Patient Outcome
PRO = Nursing Process
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
Copyright 2011 copy The Joint Commission
AP2June 2011 Volume 37 Number 6
The Joint Commission Journal on Quality and Patient Safety
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
Brief Description of
Intervention
Implementation of a pub-
lished guideline risk assess-
ment tool and a prevention
protocol based on the risk
assessment results In addi-
tion a team was assembled
staff education conducted
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
PT = Patient Outcome
PRO = Nursing
Process
1 Incidence of hospital-
acquired PUs (PT)
1 PU prevalence (PT)
1 Case mix-adjusted
PU prevalence of (Stage
II or greater) among
patients without a PU on
admission (PT)
1 PU incidence (PT)
2 PU prevalence (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
(continued on page AP3)
Copyright 2011 copy The Joint Commission
AP3 June 2011 Volume 37 Number 6
The Joint Commission Journal on Quality and Patient Safety
Online-Only Content8Appendix 1 Included Studies (continued)
Author
Year
Country
Design
Charrier13
2008
Italy
Controlled
clinical trial
Setting
10 units (not speci-
fied) in an Italian
hospital
Brief Description of
Intervention
Audit and feedback on PU
protocol adherence
Measures Reported
PT = Patient Outcome
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
(continued on page AP4)
Copyright 2011 copy The Joint Commission
AP4June 2011 Volume 37 Number 6
The Joint Commission Journal on Quality and Patient Safety
Online-Only Content8Appendix 1 Included Studies (continued)
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
Brief Description of
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
PT = Patient Outcome
PRO = Nursing
Process
1 Number of hospital-
acquired PUs (PT)
1 Incidence of hospital-
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
(continued on page AP5)
Copyright 2011 copy The Joint Commission
AP5 June 2011 Volume 37 Number 6
The Joint Commission Journal on Quality and Patient Safety
Online-Only Content8Appendix 1 Included Studies (continued)
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
Brief Description of
Intervention
Implementation of a pub-
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
Implementation of a pub-
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
PT = Patient Outcome
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-
tients without PU on ad-
mission but who screened
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-
dence of a repositioning
schedule nor a proper
mattress among at-risk
patientspatients with a
PU ge Stage I (PRO)
5 patients with evi-
dence of either a reposi-
tioning schedule or a
proper mattress among
at-risk patients or those
with a PU gt Stage I (PRO)
6 patients with evi-
dence of both a reposi-
tioning schedule and a
proper mattress among
at-risk patients or those
with a PU gt 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
(continued on page AP6)
Copyright 2011 copy The Joint Commission
AP6June 2011 Volume 37 Number 6
The Joint Commission Journal on Quality and Patient Safety
Online-Only Content8Appendix 1 Included Studies (continued)
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
Brief Description of
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
PT = Patient Outcome
PRO = Nursing Process
1 Hospital-acquired PUs
ge Stage II (entire hospital)
(PT)
2 Hospital-acquired PUs
ge Stage II (SICU only)
(PT)
1 PU prevalence ge Stage
I (Hospital B) (PT)
2 PU prevalence ge Stage
II (Hospital B) (PT)
3 Nosocomial PU rate
(Stages I-IV) Hospital A
(PT)
4 Nosocomial PU rate
(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
(continued on page AP7)
Copyright 2011 copy The Joint Commission
AP7 June 2011 Volume 37 Number 6
The Joint Commission Journal on Quality and Patient Safety
Online-Only Content8Appendix 1 Included Studies (continued)
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
Brief Description of
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
PT = Patient Outcome
PRO = Nursing Process
1 PU rates (pre-existing
and hospital-acquired) at
time of discharge (PT)
2 PU rates (pre-existing
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)
4 patients with facility-
acquired PUs (medical
ICU) (PT)
1 Average length of stay
(PT)
2 Incidence of nosoco-
mial C difficile (PT)
3 Incidence of nosoco-
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
(continued on page AP8)
Copyright 2011 copy The Joint Commission
AP8June 2011 Volume 37 Number 6
The Joint Commission Journal on Quality and Patient Safety
Online-Only Content8Appendix 1 Included Studies (continued)
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
Brief Description of
Intervention
Multidimensional 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
monitoring and feedback
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
performance monitoring and
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 = Patient Outcome
PRO = Nursing Process
1 Hospital-acquired PUs
(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)
2 PU prevalence (Stages
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
(continued on page AP9)
Copyright 2011 copy The Joint Commission
AP9 June 2011 Volume 37 Number 6
The Joint Commission Journal on Quality and Patient Safety
Online-Only Content8Appendix 1 Included Studies (continued)
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
Brief Description of
Intervention
Multidimensional 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
PT = Patient Outcome
PRO = Nursing Process
1 Prevalence of hospital-
acquired PUs (Unit A)
(PT)
2 Prevalence of hospital-
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)
4 Hospital-acquired PU
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)
14 Staging of acquired
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
(continued on page AP10)
Copyright 2011 copy The Joint Commission
June 2011 Volume 37 Number 6
The Joint Commission Journal on Quality and Patient Safety
Online-Only Content8Appendix 1 Included Studies (continued)
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
Brief Description of
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
Multidimensional intervention
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
Multidimensional intervention
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
PT = Patient Outcome
PRO = Nursing Process
1 PU incidence (all
stages) (PT)
2 of hospital-acquired
Stage I PUs (PT)
3 of hospital-acquired
Stage II PUs (PT)
4 of hospital-acquired
Stage III PUs (PT)
5 of hospital-acquired
Stage IV PUs (PT)
1 Overall hospital-
acquired prevalence (PT)
1 PU 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
(continued on page AP11)
AP10
Copyright 2011 copy The Joint Commission
June 2011 Volume 37 Number 6
The Joint Commission Journal on Quality and Patient Safety
AP11
Online-Only Content8Appendix 1 Included Studies (continued)
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
Brief Description of
Intervention
Multidimensional PU preven-
tion program consisting of
the use of a risk assessment
tool and protocol conducted
performance monitoring and
provided staff education
Systemwide educational in-
tervention targeting all levels
of patient care providers and
multispecialty care The
intervention included per-
formance monitoring and
feedback the purchase of
pressure-relieving beds and
the use of new flow sheets
Measures Reported
PT = Patient Outcome
PRO = Nursing Process
1 PU prevalence (PT)
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)
4 Prevalence of hospital-
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)
7 patients with PUs (ge
Stage I) who had a skin
assessment upon admission
completed (PRO)
8 patients with PUs (ge
Stage I) who had a skin
assessment upon admission
(PRO)
9 patients with PUs (ge
Stage I) for whom it was
unknown whether a skin
assessment upon admission
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)
11 patients with PUs
(Stages IIndashIV) with inadequate
documentation of either
admission skin assessment or
reassessment (PRO)
12 patients with PUs
(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
(continued on page AP12)
Copyright 2011 copy The Joint Commission
June 2011 Volume 37 Number 6
The Joint Commission Journal on Quality and Patient Safety
AP12
Online-Only Content8Appendix 1 Included Studies (continued)
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
One hospital 2 units
cardiac surgery ICU
and cardiac surgery
intermediate care
unit Intervention lim-
ited to patients un-
dergoing elective
open heart surgery
Brief Description of
Intervention
Implemented a published
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
PT = Patient Outcome
PRO = Nursing Process
1 patients who devel-
oped PU in hospital
excluding those present
on admission (PT)
1 of nosocomial PUs
among hip fracture
patients (PT)
1 PU prevalence (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
(continued on page AP13)
Copyright 2011 copy The Joint Commission
June 2011 Volume 37 Number 6
The Joint Commission Journal on Quality and Patient Safety
AP13
Online-Only Content8Appendix 1 Included Studies (continued)
Author
Year
Country
Design
Rashotte37
2008
Canada
Before-after
Setting
10-bed pediatric ICU
Brief Description of
Intervention
Multifaceted 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
PT = Patient Outcome
PRO = Nursing Process
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)
9 Median number of pa-
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
(continued on page AP14)
Copyright 2011 copy The Joint Commission
June 2011 Volume 37 Number 6
The Joint Commission Journal on Quality and Patient Safety
AP14
Online-Only Content8Appendix 1 Included Studies (continued)
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
One hospital 9 units
Health care system
in eastern US units
not specified
Brief Description of
Intervention
Multidimensional intervention
consisting of assembled a
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
performance monitoring and
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
wound care management
study day (2) PU prevention
training program and training
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
assembling a team imple-
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
PT = Patient Outcome
PRO = Nursing Process
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
(continued on page AP15)
Copyright 2011 copy The Joint Commission
June 2011 Volume 37 Number 6
The Joint Commission Journal on Quality and Patient Safety
AP15
Online-Only Content8Appendix 1 Included Studies (continued)
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
Brief Description of
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-
mentation of a risk assess-
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
Multidimensional intervention
consisting of assembled a
team implemented a pub-
lished guideline and care
protocol used a risk assess-
ment tool made skin care
products readily available on
the unit and provided staff
education
Measures Reported
PT = Patient Outcome
PRO = Nursing Process
1 PU incidence (PT)
1 Incidence of Stage II
PUs among patients with-
out PUs on admission
(PUs100 patient days)
(PT)
1 patients with
hospital-acquired PUs
(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
(continued on page AP16)
Copyright 2011 copy The Joint Commission
June 2011 Volume 37 Number 6
The Joint Commission Journal on Quality and Patient Safety
AP16
Online-Only Content8Appendix 1 Included Studies (continued)
Author
Year
Country
Design
Willson44
1995
USA
Before-after
Setting
One hospital
4 medicalsurgical
units
Brief Description of
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
PT = Patient Outcome
PRO = Nursing Process
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
Copyright 2011 copy The Joint Commission
AP3 June 2011 Volume 37 Number 6
The Joint Commission Journal on Quality and Patient Safety
Online-Only Content8Appendix 1 Included Studies (continued)
Author
Year
Country
Design
Charrier13
2008
Italy
Controlled
clinical trial
Setting
10 units (not speci-
fied) in an Italian
hospital
Brief Description of
Intervention
Audit and feedback on PU
protocol adherence
Measures Reported
PT = Patient Outcome
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
(continued on page AP4)
Copyright 2011 copy The Joint Commission
AP4June 2011 Volume 37 Number 6
The Joint Commission Journal on Quality and Patient Safety
Online-Only Content8Appendix 1 Included Studies (continued)
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
Brief Description of
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
PT = Patient Outcome
PRO = Nursing
Process
1 Number of hospital-
acquired PUs (PT)
1 Incidence of hospital-
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
(continued on page AP5)
Copyright 2011 copy The Joint Commission
AP5 June 2011 Volume 37 Number 6
The Joint Commission Journal on Quality and Patient Safety
Online-Only Content8Appendix 1 Included Studies (continued)
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
Brief Description of
Intervention
Implementation of a pub-
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
Implementation of a pub-
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
PT = Patient Outcome
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-
tients without PU on ad-
mission but who screened
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-
dence of a repositioning
schedule nor a proper
mattress among at-risk
patientspatients with a
PU ge Stage I (PRO)
5 patients with evi-
dence of either a reposi-
tioning schedule or a
proper mattress among
at-risk patients or those
with a PU gt Stage I (PRO)
6 patients with evi-
dence of both a reposi-
tioning schedule and a
proper mattress among
at-risk patients or those
with a PU gt 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
(continued on page AP6)
Copyright 2011 copy The Joint Commission
AP6June 2011 Volume 37 Number 6
The Joint Commission Journal on Quality and Patient Safety
Online-Only Content8Appendix 1 Included Studies (continued)
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
Brief Description of
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
PT = Patient Outcome
PRO = Nursing Process
1 Hospital-acquired PUs
ge Stage II (entire hospital)
(PT)
2 Hospital-acquired PUs
ge Stage II (SICU only)
(PT)
1 PU prevalence ge Stage
I (Hospital B) (PT)
2 PU prevalence ge Stage
II (Hospital B) (PT)
3 Nosocomial PU rate
(Stages I-IV) Hospital A
(PT)
4 Nosocomial PU rate
(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
(continued on page AP7)
Copyright 2011 copy The Joint Commission
AP7 June 2011 Volume 37 Number 6
The Joint Commission Journal on Quality and Patient Safety
Online-Only Content8Appendix 1 Included Studies (continued)
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
Brief Description of
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
PT = Patient Outcome
PRO = Nursing Process
1 PU rates (pre-existing
and hospital-acquired) at
time of discharge (PT)
2 PU rates (pre-existing
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)
4 patients with facility-
acquired PUs (medical
ICU) (PT)
1 Average length of stay
(PT)
2 Incidence of nosoco-
mial C difficile (PT)
3 Incidence of nosoco-
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
(continued on page AP8)
Copyright 2011 copy The Joint Commission
AP8June 2011 Volume 37 Number 6
The Joint Commission Journal on Quality and Patient Safety
Online-Only Content8Appendix 1 Included Studies (continued)
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
Brief Description of
Intervention
Multidimensional 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
monitoring and feedback
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
performance monitoring and
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 = Patient Outcome
PRO = Nursing Process
1 Hospital-acquired PUs
(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)
2 PU prevalence (Stages
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
(continued on page AP9)
Copyright 2011 copy The Joint Commission
AP9 June 2011 Volume 37 Number 6
The Joint Commission Journal on Quality and Patient Safety
Online-Only Content8Appendix 1 Included Studies (continued)
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
Brief Description of
Intervention
Multidimensional 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
PT = Patient Outcome
PRO = Nursing Process
1 Prevalence of hospital-
acquired PUs (Unit A)
(PT)
2 Prevalence of hospital-
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)
4 Hospital-acquired PU
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)
14 Staging of acquired
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
(continued on page AP10)
Copyright 2011 copy The Joint Commission
June 2011 Volume 37 Number 6
The Joint Commission Journal on Quality and Patient Safety
Online-Only Content8Appendix 1 Included Studies (continued)
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
Brief Description of
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
Multidimensional intervention
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
Multidimensional intervention
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
PT = Patient Outcome
PRO = Nursing Process
1 PU incidence (all
stages) (PT)
2 of hospital-acquired
Stage I PUs (PT)
3 of hospital-acquired
Stage II PUs (PT)
4 of hospital-acquired
Stage III PUs (PT)
5 of hospital-acquired
Stage IV PUs (PT)
1 Overall hospital-
acquired prevalence (PT)
1 PU 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
(continued on page AP11)
AP10
Copyright 2011 copy The Joint Commission
June 2011 Volume 37 Number 6
The Joint Commission Journal on Quality and Patient Safety
AP11
Online-Only Content8Appendix 1 Included Studies (continued)
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
Brief Description of
Intervention
Multidimensional PU preven-
tion program consisting of
the use of a risk assessment
tool and protocol conducted
performance monitoring and
provided staff education
Systemwide educational in-
tervention targeting all levels
of patient care providers and
multispecialty care The
intervention included per-
formance monitoring and
feedback the purchase of
pressure-relieving beds and
the use of new flow sheets
Measures Reported
PT = Patient Outcome
PRO = Nursing Process
1 PU prevalence (PT)
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)
4 Prevalence of hospital-
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)
7 patients with PUs (ge
Stage I) who had a skin
assessment upon admission
completed (PRO)
8 patients with PUs (ge
Stage I) who had a skin
assessment upon admission
(PRO)
9 patients with PUs (ge
Stage I) for whom it was
unknown whether a skin
assessment upon admission
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)
11 patients with PUs
(Stages IIndashIV) with inadequate
documentation of either
admission skin assessment or
reassessment (PRO)
12 patients with PUs
(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
(continued on page AP12)
Copyright 2011 copy The Joint Commission
June 2011 Volume 37 Number 6
The Joint Commission Journal on Quality and Patient Safety
AP12
Online-Only Content8Appendix 1 Included Studies (continued)
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
One hospital 2 units
cardiac surgery ICU
and cardiac surgery
intermediate care
unit Intervention lim-
ited to patients un-
dergoing elective
open heart surgery
Brief Description of
Intervention
Implemented a published
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
PT = Patient Outcome
PRO = Nursing Process
1 patients who devel-
oped PU in hospital
excluding those present
on admission (PT)
1 of nosocomial PUs
among hip fracture
patients (PT)
1 PU prevalence (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
(continued on page AP13)
Copyright 2011 copy The Joint Commission
June 2011 Volume 37 Number 6
The Joint Commission Journal on Quality and Patient Safety
AP13
Online-Only Content8Appendix 1 Included Studies (continued)
Author
Year
Country
Design
Rashotte37
2008
Canada
Before-after
Setting
10-bed pediatric ICU
Brief Description of
Intervention
Multifaceted 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
PT = Patient Outcome
PRO = Nursing Process
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)
9 Median number of pa-
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
(continued on page AP14)
Copyright 2011 copy The Joint Commission
June 2011 Volume 37 Number 6
The Joint Commission Journal on Quality and Patient Safety
AP14
Online-Only Content8Appendix 1 Included Studies (continued)
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
One hospital 9 units
Health care system
in eastern US units
not specified
Brief Description of
Intervention
Multidimensional intervention
consisting of assembled a
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
performance monitoring and
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
wound care management
study day (2) PU prevention
training program and training
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
assembling a team imple-
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
PT = Patient Outcome
PRO = Nursing Process
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
(continued on page AP15)
Copyright 2011 copy The Joint Commission
June 2011 Volume 37 Number 6
The Joint Commission Journal on Quality and Patient Safety
AP15
Online-Only Content8Appendix 1 Included Studies (continued)
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
Brief Description of
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-
mentation of a risk assess-
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
Multidimensional intervention
consisting of assembled a
team implemented a pub-
lished guideline and care
protocol used a risk assess-
ment tool made skin care
products readily available on
the unit and provided staff
education
Measures Reported
PT = Patient Outcome
PRO = Nursing Process
1 PU incidence (PT)
1 Incidence of Stage II
PUs among patients with-
out PUs on admission
(PUs100 patient days)
(PT)
1 patients with
hospital-acquired PUs
(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
(continued on page AP16)
Copyright 2011 copy The Joint Commission
June 2011 Volume 37 Number 6
The Joint Commission Journal on Quality and Patient Safety
AP16
Online-Only Content8Appendix 1 Included Studies (continued)
Author
Year
Country
Design
Willson44
1995
USA
Before-after
Setting
One hospital
4 medicalsurgical
units
Brief Description of
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
PT = Patient Outcome
PRO = Nursing Process
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
Copyright 2011 copy The Joint Commission
AP4June 2011 Volume 37 Number 6
The Joint Commission Journal on Quality and Patient Safety
Online-Only Content8Appendix 1 Included Studies (continued)
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
Brief Description of
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
PT = Patient Outcome
PRO = Nursing
Process
1 Number of hospital-
acquired PUs (PT)
1 Incidence of hospital-
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
(continued on page AP5)
Copyright 2011 copy The Joint Commission
AP5 June 2011 Volume 37 Number 6
The Joint Commission Journal on Quality and Patient Safety
Online-Only Content8Appendix 1 Included Studies (continued)
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
Brief Description of
Intervention
Implementation of a pub-
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
Implementation of a pub-
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
PT = Patient Outcome
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-
tients without PU on ad-
mission but who screened
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-
dence of a repositioning
schedule nor a proper
mattress among at-risk
patientspatients with a
PU ge Stage I (PRO)
5 patients with evi-
dence of either a reposi-
tioning schedule or a
proper mattress among
at-risk patients or those
with a PU gt Stage I (PRO)
6 patients with evi-
dence of both a reposi-
tioning schedule and a
proper mattress among
at-risk patients or those
with a PU gt 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
(continued on page AP6)
Copyright 2011 copy The Joint Commission
AP6June 2011 Volume 37 Number 6
The Joint Commission Journal on Quality and Patient Safety
Online-Only Content8Appendix 1 Included Studies (continued)
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
Brief Description of
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
PT = Patient Outcome
PRO = Nursing Process
1 Hospital-acquired PUs
ge Stage II (entire hospital)
(PT)
2 Hospital-acquired PUs
ge Stage II (SICU only)
(PT)
1 PU prevalence ge Stage
I (Hospital B) (PT)
2 PU prevalence ge Stage
II (Hospital B) (PT)
3 Nosocomial PU rate
(Stages I-IV) Hospital A
(PT)
4 Nosocomial PU rate
(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
(continued on page AP7)
Copyright 2011 copy The Joint Commission
AP7 June 2011 Volume 37 Number 6
The Joint Commission Journal on Quality and Patient Safety
Online-Only Content8Appendix 1 Included Studies (continued)
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
Brief Description of
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
PT = Patient Outcome
PRO = Nursing Process
1 PU rates (pre-existing
and hospital-acquired) at
time of discharge (PT)
2 PU rates (pre-existing
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)
4 patients with facility-
acquired PUs (medical
ICU) (PT)
1 Average length of stay
(PT)
2 Incidence of nosoco-
mial C difficile (PT)
3 Incidence of nosoco-
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
(continued on page AP8)
Copyright 2011 copy The Joint Commission
AP8June 2011 Volume 37 Number 6
The Joint Commission Journal on Quality and Patient Safety
Online-Only Content8Appendix 1 Included Studies (continued)
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
Brief Description of
Intervention
Multidimensional 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
monitoring and feedback
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
performance monitoring and
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 = Patient Outcome
PRO = Nursing Process
1 Hospital-acquired PUs
(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)
2 PU prevalence (Stages
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
(continued on page AP9)
Copyright 2011 copy The Joint Commission
AP9 June 2011 Volume 37 Number 6
The Joint Commission Journal on Quality and Patient Safety
Online-Only Content8Appendix 1 Included Studies (continued)
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
Brief Description of
Intervention
Multidimensional 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
PT = Patient Outcome
PRO = Nursing Process
1 Prevalence of hospital-
acquired PUs (Unit A)
(PT)
2 Prevalence of hospital-
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)
4 Hospital-acquired PU
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)
14 Staging of acquired
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
(continued on page AP10)
Copyright 2011 copy The Joint Commission
June 2011 Volume 37 Number 6
The Joint Commission Journal on Quality and Patient Safety
Online-Only Content8Appendix 1 Included Studies (continued)
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
Brief Description of
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
Multidimensional intervention
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
Multidimensional intervention
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
PT = Patient Outcome
PRO = Nursing Process
1 PU incidence (all
stages) (PT)
2 of hospital-acquired
Stage I PUs (PT)
3 of hospital-acquired
Stage II PUs (PT)
4 of hospital-acquired
Stage III PUs (PT)
5 of hospital-acquired
Stage IV PUs (PT)
1 Overall hospital-
acquired prevalence (PT)
1 PU 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
(continued on page AP11)
AP10
Copyright 2011 copy The Joint Commission
June 2011 Volume 37 Number 6
The Joint Commission Journal on Quality and Patient Safety
AP11
Online-Only Content8Appendix 1 Included Studies (continued)
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
Brief Description of
Intervention
Multidimensional PU preven-
tion program consisting of
the use of a risk assessment
tool and protocol conducted
performance monitoring and
provided staff education
Systemwide educational in-
tervention targeting all levels
of patient care providers and
multispecialty care The
intervention included per-
formance monitoring and
feedback the purchase of
pressure-relieving beds and
the use of new flow sheets
Measures Reported
PT = Patient Outcome
PRO = Nursing Process
1 PU prevalence (PT)
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)
4 Prevalence of hospital-
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)
7 patients with PUs (ge
Stage I) who had a skin
assessment upon admission
completed (PRO)
8 patients with PUs (ge
Stage I) who had a skin
assessment upon admission
(PRO)
9 patients with PUs (ge
Stage I) for whom it was
unknown whether a skin
assessment upon admission
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)
11 patients with PUs
(Stages IIndashIV) with inadequate
documentation of either
admission skin assessment or
reassessment (PRO)
12 patients with PUs
(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
(continued on page AP12)
Copyright 2011 copy The Joint Commission
June 2011 Volume 37 Number 6
The Joint Commission Journal on Quality and Patient Safety
AP12
Online-Only Content8Appendix 1 Included Studies (continued)
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
One hospital 2 units
cardiac surgery ICU
and cardiac surgery
intermediate care
unit Intervention lim-
ited to patients un-
dergoing elective
open heart surgery
Brief Description of
Intervention
Implemented a published
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
PT = Patient Outcome
PRO = Nursing Process
1 patients who devel-
oped PU in hospital
excluding those present
on admission (PT)
1 of nosocomial PUs
among hip fracture
patients (PT)
1 PU prevalence (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
(continued on page AP13)
Copyright 2011 copy The Joint Commission
June 2011 Volume 37 Number 6
The Joint Commission Journal on Quality and Patient Safety
AP13
Online-Only Content8Appendix 1 Included Studies (continued)
Author
Year
Country
Design
Rashotte37
2008
Canada
Before-after
Setting
10-bed pediatric ICU
Brief Description of
Intervention
Multifaceted 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
PT = Patient Outcome
PRO = Nursing Process
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)
9 Median number of pa-
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
(continued on page AP14)
Copyright 2011 copy The Joint Commission
June 2011 Volume 37 Number 6
The Joint Commission Journal on Quality and Patient Safety
AP14
Online-Only Content8Appendix 1 Included Studies (continued)
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
One hospital 9 units
Health care system
in eastern US units
not specified
Brief Description of
Intervention
Multidimensional intervention
consisting of assembled a
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
performance monitoring and
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
wound care management
study day (2) PU prevention
training program and training
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
assembling a team imple-
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
PT = Patient Outcome
PRO = Nursing Process
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
(continued on page AP15)
Copyright 2011 copy The Joint Commission
June 2011 Volume 37 Number 6
The Joint Commission Journal on Quality and Patient Safety
AP15
Online-Only Content8Appendix 1 Included Studies (continued)
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
Brief Description of
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-
mentation of a risk assess-
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
Multidimensional intervention
consisting of assembled a
team implemented a pub-
lished guideline and care
protocol used a risk assess-
ment tool made skin care
products readily available on
the unit and provided staff
education
Measures Reported
PT = Patient Outcome
PRO = Nursing Process
1 PU incidence (PT)
1 Incidence of Stage II
PUs among patients with-
out PUs on admission
(PUs100 patient days)
(PT)
1 patients with
hospital-acquired PUs
(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
(continued on page AP16)
Copyright 2011 copy The Joint Commission
June 2011 Volume 37 Number 6
The Joint Commission Journal on Quality and Patient Safety
AP16
Online-Only Content8Appendix 1 Included Studies (continued)
Author
Year
Country
Design
Willson44
1995
USA
Before-after
Setting
One hospital
4 medicalsurgical
units
Brief Description of
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
PT = Patient Outcome
PRO = Nursing Process
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
Copyright 2011 copy The Joint Commission
AP5 June 2011 Volume 37 Number 6
The Joint Commission Journal on Quality and Patient Safety
Online-Only Content8Appendix 1 Included Studies (continued)
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
Brief Description of
Intervention
Implementation of a pub-
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
Implementation of a pub-
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
PT = Patient Outcome
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-
tients without PU on ad-
mission but who screened
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-
dence of a repositioning
schedule nor a proper
mattress among at-risk
patientspatients with a
PU ge Stage I (PRO)
5 patients with evi-
dence of either a reposi-
tioning schedule or a
proper mattress among
at-risk patients or those
with a PU gt Stage I (PRO)
6 patients with evi-
dence of both a reposi-
tioning schedule and a
proper mattress among
at-risk patients or those
with a PU gt 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
(continued on page AP6)
Copyright 2011 copy The Joint Commission
AP6June 2011 Volume 37 Number 6
The Joint Commission Journal on Quality and Patient Safety
Online-Only Content8Appendix 1 Included Studies (continued)
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
Brief Description of
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
PT = Patient Outcome
PRO = Nursing Process
1 Hospital-acquired PUs
ge Stage II (entire hospital)
(PT)
2 Hospital-acquired PUs
ge Stage II (SICU only)
(PT)
1 PU prevalence ge Stage
I (Hospital B) (PT)
2 PU prevalence ge Stage
II (Hospital B) (PT)
3 Nosocomial PU rate
(Stages I-IV) Hospital A
(PT)
4 Nosocomial PU rate
(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
(continued on page AP7)
Copyright 2011 copy The Joint Commission
AP7 June 2011 Volume 37 Number 6
The Joint Commission Journal on Quality and Patient Safety
Online-Only Content8Appendix 1 Included Studies (continued)
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
Brief Description of
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
PT = Patient Outcome
PRO = Nursing Process
1 PU rates (pre-existing
and hospital-acquired) at
time of discharge (PT)
2 PU rates (pre-existing
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)
4 patients with facility-
acquired PUs (medical
ICU) (PT)
1 Average length of stay
(PT)
2 Incidence of nosoco-
mial C difficile (PT)
3 Incidence of nosoco-
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
(continued on page AP8)
Copyright 2011 copy The Joint Commission
AP8June 2011 Volume 37 Number 6
The Joint Commission Journal on Quality and Patient Safety
Online-Only Content8Appendix 1 Included Studies (continued)
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
Brief Description of
Intervention
Multidimensional 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
monitoring and feedback
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
performance monitoring and
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 = Patient Outcome
PRO = Nursing Process
1 Hospital-acquired PUs
(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)
2 PU prevalence (Stages
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
(continued on page AP9)
Copyright 2011 copy The Joint Commission
AP9 June 2011 Volume 37 Number 6
The Joint Commission Journal on Quality and Patient Safety
Online-Only Content8Appendix 1 Included Studies (continued)
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
Brief Description of
Intervention
Multidimensional 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
PT = Patient Outcome
PRO = Nursing Process
1 Prevalence of hospital-
acquired PUs (Unit A)
(PT)
2 Prevalence of hospital-
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)
4 Hospital-acquired PU
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)
14 Staging of acquired
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
(continued on page AP10)
Copyright 2011 copy The Joint Commission
June 2011 Volume 37 Number 6
The Joint Commission Journal on Quality and Patient Safety
Online-Only Content8Appendix 1 Included Studies (continued)
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
Brief Description of
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
Multidimensional intervention
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
Multidimensional intervention
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
PT = Patient Outcome
PRO = Nursing Process
1 PU incidence (all
stages) (PT)
2 of hospital-acquired
Stage I PUs (PT)
3 of hospital-acquired
Stage II PUs (PT)
4 of hospital-acquired
Stage III PUs (PT)
5 of hospital-acquired
Stage IV PUs (PT)
1 Overall hospital-
acquired prevalence (PT)
1 PU 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
(continued on page AP11)
AP10
Copyright 2011 copy The Joint Commission
June 2011 Volume 37 Number 6
The Joint Commission Journal on Quality and Patient Safety
AP11
Online-Only Content8Appendix 1 Included Studies (continued)
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
Brief Description of
Intervention
Multidimensional PU preven-
tion program consisting of
the use of a risk assessment
tool and protocol conducted
performance monitoring and
provided staff education
Systemwide educational in-
tervention targeting all levels
of patient care providers and
multispecialty care The
intervention included per-
formance monitoring and
feedback the purchase of
pressure-relieving beds and
the use of new flow sheets
Measures Reported
PT = Patient Outcome
PRO = Nursing Process
1 PU prevalence (PT)
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)
4 Prevalence of hospital-
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)
7 patients with PUs (ge
Stage I) who had a skin
assessment upon admission
completed (PRO)
8 patients with PUs (ge
Stage I) who had a skin
assessment upon admission
(PRO)
9 patients with PUs (ge
Stage I) for whom it was
unknown whether a skin
assessment upon admission
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)
11 patients with PUs
(Stages IIndashIV) with inadequate
documentation of either
admission skin assessment or
reassessment (PRO)
12 patients with PUs
(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
(continued on page AP12)
Copyright 2011 copy The Joint Commission
June 2011 Volume 37 Number 6
The Joint Commission Journal on Quality and Patient Safety
AP12
Online-Only Content8Appendix 1 Included Studies (continued)
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
One hospital 2 units
cardiac surgery ICU
and cardiac surgery
intermediate care
unit Intervention lim-
ited to patients un-
dergoing elective
open heart surgery
Brief Description of
Intervention
Implemented a published
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
PT = Patient Outcome
PRO = Nursing Process
1 patients who devel-
oped PU in hospital
excluding those present
on admission (PT)
1 of nosocomial PUs
among hip fracture
patients (PT)
1 PU prevalence (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
(continued on page AP13)
Copyright 2011 copy The Joint Commission
June 2011 Volume 37 Number 6
The Joint Commission Journal on Quality and Patient Safety
AP13
Online-Only Content8Appendix 1 Included Studies (continued)
Author
Year
Country
Design
Rashotte37
2008
Canada
Before-after
Setting
10-bed pediatric ICU
Brief Description of
Intervention
Multifaceted 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
PT = Patient Outcome
PRO = Nursing Process
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)
9 Median number of pa-
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
(continued on page AP14)
Copyright 2011 copy The Joint Commission
June 2011 Volume 37 Number 6
The Joint Commission Journal on Quality and Patient Safety
AP14
Online-Only Content8Appendix 1 Included Studies (continued)
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
One hospital 9 units
Health care system
in eastern US units
not specified
Brief Description of
Intervention
Multidimensional intervention
consisting of assembled a
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
performance monitoring and
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
wound care management
study day (2) PU prevention
training program and training
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
assembling a team imple-
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
PT = Patient Outcome
PRO = Nursing Process
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
(continued on page AP15)
Copyright 2011 copy The Joint Commission
June 2011 Volume 37 Number 6
The Joint Commission Journal on Quality and Patient Safety
AP15
Online-Only Content8Appendix 1 Included Studies (continued)
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
Brief Description of
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-
mentation of a risk assess-
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
Multidimensional intervention
consisting of assembled a
team implemented a pub-
lished guideline and care
protocol used a risk assess-
ment tool made skin care
products readily available on
the unit and provided staff
education
Measures Reported
PT = Patient Outcome
PRO = Nursing Process
1 PU incidence (PT)
1 Incidence of Stage II
PUs among patients with-
out PUs on admission
(PUs100 patient days)
(PT)
1 patients with
hospital-acquired PUs
(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
(continued on page AP16)
Copyright 2011 copy The Joint Commission
June 2011 Volume 37 Number 6
The Joint Commission Journal on Quality and Patient Safety
AP16
Online-Only Content8Appendix 1 Included Studies (continued)
Author
Year
Country
Design
Willson44
1995
USA
Before-after
Setting
One hospital
4 medicalsurgical
units
Brief Description of
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
PT = Patient Outcome
PRO = Nursing Process
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
Copyright 2011 copy The Joint Commission
AP6June 2011 Volume 37 Number 6
The Joint Commission Journal on Quality and Patient Safety
Online-Only Content8Appendix 1 Included Studies (continued)
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
Brief Description of
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
PT = Patient Outcome
PRO = Nursing Process
1 Hospital-acquired PUs
ge Stage II (entire hospital)
(PT)
2 Hospital-acquired PUs
ge Stage II (SICU only)
(PT)
1 PU prevalence ge Stage
I (Hospital B) (PT)
2 PU prevalence ge Stage
II (Hospital B) (PT)
3 Nosocomial PU rate
(Stages I-IV) Hospital A
(PT)
4 Nosocomial PU rate
(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
(continued on page AP7)
Copyright 2011 copy The Joint Commission
AP7 June 2011 Volume 37 Number 6
The Joint Commission Journal on Quality and Patient Safety
Online-Only Content8Appendix 1 Included Studies (continued)
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
Brief Description of
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
PT = Patient Outcome
PRO = Nursing Process
1 PU rates (pre-existing
and hospital-acquired) at
time of discharge (PT)
2 PU rates (pre-existing
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)
4 patients with facility-
acquired PUs (medical
ICU) (PT)
1 Average length of stay
(PT)
2 Incidence of nosoco-
mial C difficile (PT)
3 Incidence of nosoco-
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
(continued on page AP8)
Copyright 2011 copy The Joint Commission
AP8June 2011 Volume 37 Number 6
The Joint Commission Journal on Quality and Patient Safety
Online-Only Content8Appendix 1 Included Studies (continued)
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
Brief Description of
Intervention
Multidimensional 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
monitoring and feedback
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
performance monitoring and
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 = Patient Outcome
PRO = Nursing Process
1 Hospital-acquired PUs
(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)
2 PU prevalence (Stages
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
(continued on page AP9)
Copyright 2011 copy The Joint Commission
AP9 June 2011 Volume 37 Number 6
The Joint Commission Journal on Quality and Patient Safety
Online-Only Content8Appendix 1 Included Studies (continued)
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
Brief Description of
Intervention
Multidimensional 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
PT = Patient Outcome
PRO = Nursing Process
1 Prevalence of hospital-
acquired PUs (Unit A)
(PT)
2 Prevalence of hospital-
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)
4 Hospital-acquired PU
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)
14 Staging of acquired
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
(continued on page AP10)
Copyright 2011 copy The Joint Commission
June 2011 Volume 37 Number 6
The Joint Commission Journal on Quality and Patient Safety
Online-Only Content8Appendix 1 Included Studies (continued)
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
Brief Description of
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
Multidimensional intervention
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
Multidimensional intervention
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
PT = Patient Outcome
PRO = Nursing Process
1 PU incidence (all
stages) (PT)
2 of hospital-acquired
Stage I PUs (PT)
3 of hospital-acquired
Stage II PUs (PT)
4 of hospital-acquired
Stage III PUs (PT)
5 of hospital-acquired
Stage IV PUs (PT)
1 Overall hospital-
acquired prevalence (PT)
1 PU 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
(continued on page AP11)
AP10
Copyright 2011 copy The Joint Commission
June 2011 Volume 37 Number 6
The Joint Commission Journal on Quality and Patient Safety
AP11
Online-Only Content8Appendix 1 Included Studies (continued)
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
Brief Description of
Intervention
Multidimensional PU preven-
tion program consisting of
the use of a risk assessment
tool and protocol conducted
performance monitoring and
provided staff education
Systemwide educational in-
tervention targeting all levels
of patient care providers and
multispecialty care The
intervention included per-
formance monitoring and
feedback the purchase of
pressure-relieving beds and
the use of new flow sheets
Measures Reported
PT = Patient Outcome
PRO = Nursing Process
1 PU prevalence (PT)
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)
4 Prevalence of hospital-
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)
7 patients with PUs (ge
Stage I) who had a skin
assessment upon admission
completed (PRO)
8 patients with PUs (ge
Stage I) who had a skin
assessment upon admission
(PRO)
9 patients with PUs (ge
Stage I) for whom it was
unknown whether a skin
assessment upon admission
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)
11 patients with PUs
(Stages IIndashIV) with inadequate
documentation of either
admission skin assessment or
reassessment (PRO)
12 patients with PUs
(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
(continued on page AP12)
Copyright 2011 copy The Joint Commission
June 2011 Volume 37 Number 6
The Joint Commission Journal on Quality and Patient Safety
AP12
Online-Only Content8Appendix 1 Included Studies (continued)
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
One hospital 2 units
cardiac surgery ICU
and cardiac surgery
intermediate care
unit Intervention lim-
ited to patients un-
dergoing elective
open heart surgery
Brief Description of
Intervention
Implemented a published
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
PT = Patient Outcome
PRO = Nursing Process
1 patients who devel-
oped PU in hospital
excluding those present
on admission (PT)
1 of nosocomial PUs
among hip fracture
patients (PT)
1 PU prevalence (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
(continued on page AP13)
Copyright 2011 copy The Joint Commission
June 2011 Volume 37 Number 6
The Joint Commission Journal on Quality and Patient Safety
AP13
Online-Only Content8Appendix 1 Included Studies (continued)
Author
Year
Country
Design
Rashotte37
2008
Canada
Before-after
Setting
10-bed pediatric ICU
Brief Description of
Intervention
Multifaceted 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
PT = Patient Outcome
PRO = Nursing Process
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)
9 Median number of pa-
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
(continued on page AP14)
Copyright 2011 copy The Joint Commission
June 2011 Volume 37 Number 6
The Joint Commission Journal on Quality and Patient Safety
AP14
Online-Only Content8Appendix 1 Included Studies (continued)
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
One hospital 9 units
Health care system
in eastern US units
not specified
Brief Description of
Intervention
Multidimensional intervention
consisting of assembled a
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
performance monitoring and
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
wound care management
study day (2) PU prevention
training program and training
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
assembling a team imple-
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
PT = Patient Outcome
PRO = Nursing Process
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
(continued on page AP15)
Copyright 2011 copy The Joint Commission
June 2011 Volume 37 Number 6
The Joint Commission Journal on Quality and Patient Safety
AP15
Online-Only Content8Appendix 1 Included Studies (continued)
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
Brief Description of
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-
mentation of a risk assess-
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
Multidimensional intervention
consisting of assembled a
team implemented a pub-
lished guideline and care
protocol used a risk assess-
ment tool made skin care
products readily available on
the unit and provided staff
education
Measures Reported
PT = Patient Outcome
PRO = Nursing Process
1 PU incidence (PT)
1 Incidence of Stage II
PUs among patients with-
out PUs on admission
(PUs100 patient days)
(PT)
1 patients with
hospital-acquired PUs
(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
(continued on page AP16)
Copyright 2011 copy The Joint Commission
June 2011 Volume 37 Number 6
The Joint Commission Journal on Quality and Patient Safety
AP16
Online-Only Content8Appendix 1 Included Studies (continued)
Author
Year
Country
Design
Willson44
1995
USA
Before-after
Setting
One hospital
4 medicalsurgical
units
Brief Description of
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
PT = Patient Outcome
PRO = Nursing Process
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
Copyright 2011 copy The Joint Commission
AP7 June 2011 Volume 37 Number 6
The Joint Commission Journal on Quality and Patient Safety
Online-Only Content8Appendix 1 Included Studies (continued)
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
Brief Description of
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
PT = Patient Outcome
PRO = Nursing Process
1 PU rates (pre-existing
and hospital-acquired) at
time of discharge (PT)
2 PU rates (pre-existing
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)
4 patients with facility-
acquired PUs (medical
ICU) (PT)
1 Average length of stay
(PT)
2 Incidence of nosoco-
mial C difficile (PT)
3 Incidence of nosoco-
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
(continued on page AP8)
Copyright 2011 copy The Joint Commission
AP8June 2011 Volume 37 Number 6
The Joint Commission Journal on Quality and Patient Safety
Online-Only Content8Appendix 1 Included Studies (continued)
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
Brief Description of
Intervention
Multidimensional 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
monitoring and feedback
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
performance monitoring and
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 = Patient Outcome
PRO = Nursing Process
1 Hospital-acquired PUs
(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)
2 PU prevalence (Stages
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
(continued on page AP9)
Copyright 2011 copy The Joint Commission
AP9 June 2011 Volume 37 Number 6
The Joint Commission Journal on Quality and Patient Safety
Online-Only Content8Appendix 1 Included Studies (continued)
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
Brief Description of
Intervention
Multidimensional 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
PT = Patient Outcome
PRO = Nursing Process
1 Prevalence of hospital-
acquired PUs (Unit A)
(PT)
2 Prevalence of hospital-
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)
4 Hospital-acquired PU
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)
14 Staging of acquired
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
(continued on page AP10)
Copyright 2011 copy The Joint Commission
June 2011 Volume 37 Number 6
The Joint Commission Journal on Quality and Patient Safety
Online-Only Content8Appendix 1 Included Studies (continued)
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
Brief Description of
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
Multidimensional intervention
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
Multidimensional intervention
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
PT = Patient Outcome
PRO = Nursing Process
1 PU incidence (all
stages) (PT)
2 of hospital-acquired
Stage I PUs (PT)
3 of hospital-acquired
Stage II PUs (PT)
4 of hospital-acquired
Stage III PUs (PT)
5 of hospital-acquired
Stage IV PUs (PT)
1 Overall hospital-
acquired prevalence (PT)
1 PU 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
(continued on page AP11)
AP10
Copyright 2011 copy The Joint Commission
June 2011 Volume 37 Number 6
The Joint Commission Journal on Quality and Patient Safety
AP11
Online-Only Content8Appendix 1 Included Studies (continued)
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
Brief Description of
Intervention
Multidimensional PU preven-
tion program consisting of
the use of a risk assessment
tool and protocol conducted
performance monitoring and
provided staff education
Systemwide educational in-
tervention targeting all levels
of patient care providers and
multispecialty care The
intervention included per-
formance monitoring and
feedback the purchase of
pressure-relieving beds and
the use of new flow sheets
Measures Reported
PT = Patient Outcome
PRO = Nursing Process
1 PU prevalence (PT)
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)
4 Prevalence of hospital-
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)
7 patients with PUs (ge
Stage I) who had a skin
assessment upon admission
completed (PRO)
8 patients with PUs (ge
Stage I) who had a skin
assessment upon admission
(PRO)
9 patients with PUs (ge
Stage I) for whom it was
unknown whether a skin
assessment upon admission
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)
11 patients with PUs
(Stages IIndashIV) with inadequate
documentation of either
admission skin assessment or
reassessment (PRO)
12 patients with PUs
(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
(continued on page AP12)
Copyright 2011 copy The Joint Commission
June 2011 Volume 37 Number 6
The Joint Commission Journal on Quality and Patient Safety
AP12
Online-Only Content8Appendix 1 Included Studies (continued)
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
One hospital 2 units
cardiac surgery ICU
and cardiac surgery
intermediate care
unit Intervention lim-
ited to patients un-
dergoing elective
open heart surgery
Brief Description of
Intervention
Implemented a published
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
PT = Patient Outcome
PRO = Nursing Process
1 patients who devel-
oped PU in hospital
excluding those present
on admission (PT)
1 of nosocomial PUs
among hip fracture
patients (PT)
1 PU prevalence (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
(continued on page AP13)
Copyright 2011 copy The Joint Commission
June 2011 Volume 37 Number 6
The Joint Commission Journal on Quality and Patient Safety
AP13
Online-Only Content8Appendix 1 Included Studies (continued)
Author
Year
Country
Design
Rashotte37
2008
Canada
Before-after
Setting
10-bed pediatric ICU
Brief Description of
Intervention
Multifaceted 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
PT = Patient Outcome
PRO = Nursing Process
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)
9 Median number of pa-
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
(continued on page AP14)
Copyright 2011 copy The Joint Commission
June 2011 Volume 37 Number 6
The Joint Commission Journal on Quality and Patient Safety
AP14
Online-Only Content8Appendix 1 Included Studies (continued)
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
One hospital 9 units
Health care system
in eastern US units
not specified
Brief Description of
Intervention
Multidimensional intervention
consisting of assembled a
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
performance monitoring and
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
wound care management
study day (2) PU prevention
training program and training
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
assembling a team imple-
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
PT = Patient Outcome
PRO = Nursing Process
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
(continued on page AP15)
Copyright 2011 copy The Joint Commission
June 2011 Volume 37 Number 6
The Joint Commission Journal on Quality and Patient Safety
AP15
Online-Only Content8Appendix 1 Included Studies (continued)
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
Brief Description of
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-
mentation of a risk assess-
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
Multidimensional intervention
consisting of assembled a
team implemented a pub-
lished guideline and care
protocol used a risk assess-
ment tool made skin care
products readily available on
the unit and provided staff
education
Measures Reported
PT = Patient Outcome
PRO = Nursing Process
1 PU incidence (PT)
1 Incidence of Stage II
PUs among patients with-
out PUs on admission
(PUs100 patient days)
(PT)
1 patients with
hospital-acquired PUs
(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
(continued on page AP16)
Copyright 2011 copy The Joint Commission
June 2011 Volume 37 Number 6
The Joint Commission Journal on Quality and Patient Safety
AP16
Online-Only Content8Appendix 1 Included Studies (continued)
Author
Year
Country
Design
Willson44
1995
USA
Before-after
Setting
One hospital
4 medicalsurgical
units
Brief Description of
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
PT = Patient Outcome
PRO = Nursing Process
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
Copyright 2011 copy The Joint Commission
AP8June 2011 Volume 37 Number 6
The Joint Commission Journal on Quality and Patient Safety
Online-Only Content8Appendix 1 Included Studies (continued)
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
Brief Description of
Intervention
Multidimensional 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
monitoring and feedback
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
performance monitoring and
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 = Patient Outcome
PRO = Nursing Process
1 Hospital-acquired PUs
(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)
2 PU prevalence (Stages
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
(continued on page AP9)
Copyright 2011 copy The Joint Commission
AP9 June 2011 Volume 37 Number 6
The Joint Commission Journal on Quality and Patient Safety
Online-Only Content8Appendix 1 Included Studies (continued)
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
Brief Description of
Intervention
Multidimensional 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
PT = Patient Outcome
PRO = Nursing Process
1 Prevalence of hospital-
acquired PUs (Unit A)
(PT)
2 Prevalence of hospital-
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)
4 Hospital-acquired PU
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)
14 Staging of acquired
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
(continued on page AP10)
Copyright 2011 copy The Joint Commission
June 2011 Volume 37 Number 6
The Joint Commission Journal on Quality and Patient Safety
Online-Only Content8Appendix 1 Included Studies (continued)
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
Brief Description of
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
Multidimensional intervention
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
Multidimensional intervention
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
PT = Patient Outcome
PRO = Nursing Process
1 PU incidence (all
stages) (PT)
2 of hospital-acquired
Stage I PUs (PT)
3 of hospital-acquired
Stage II PUs (PT)
4 of hospital-acquired
Stage III PUs (PT)
5 of hospital-acquired
Stage IV PUs (PT)
1 Overall hospital-
acquired prevalence (PT)
1 PU 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
(continued on page AP11)
AP10
Copyright 2011 copy The Joint Commission
June 2011 Volume 37 Number 6
The Joint Commission Journal on Quality and Patient Safety
AP11
Online-Only Content8Appendix 1 Included Studies (continued)
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
Brief Description of
Intervention
Multidimensional PU preven-
tion program consisting of
the use of a risk assessment
tool and protocol conducted
performance monitoring and
provided staff education
Systemwide educational in-
tervention targeting all levels
of patient care providers and
multispecialty care The
intervention included per-
formance monitoring and
feedback the purchase of
pressure-relieving beds and
the use of new flow sheets
Measures Reported
PT = Patient Outcome
PRO = Nursing Process
1 PU prevalence (PT)
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)
4 Prevalence of hospital-
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)
7 patients with PUs (ge
Stage I) who had a skin
assessment upon admission
completed (PRO)
8 patients with PUs (ge
Stage I) who had a skin
assessment upon admission
(PRO)
9 patients with PUs (ge
Stage I) for whom it was
unknown whether a skin
assessment upon admission
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)
11 patients with PUs
(Stages IIndashIV) with inadequate
documentation of either
admission skin assessment or
reassessment (PRO)
12 patients with PUs
(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
(continued on page AP12)
Copyright 2011 copy The Joint Commission
June 2011 Volume 37 Number 6
The Joint Commission Journal on Quality and Patient Safety
AP12
Online-Only Content8Appendix 1 Included Studies (continued)
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
One hospital 2 units
cardiac surgery ICU
and cardiac surgery
intermediate care
unit Intervention lim-
ited to patients un-
dergoing elective
open heart surgery
Brief Description of
Intervention
Implemented a published
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
PT = Patient Outcome
PRO = Nursing Process
1 patients who devel-
oped PU in hospital
excluding those present
on admission (PT)
1 of nosocomial PUs
among hip fracture
patients (PT)
1 PU prevalence (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
(continued on page AP13)
Copyright 2011 copy The Joint Commission
June 2011 Volume 37 Number 6
The Joint Commission Journal on Quality and Patient Safety
AP13
Online-Only Content8Appendix 1 Included Studies (continued)
Author
Year
Country
Design
Rashotte37
2008
Canada
Before-after
Setting
10-bed pediatric ICU
Brief Description of
Intervention
Multifaceted 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
PT = Patient Outcome
PRO = Nursing Process
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)
9 Median number of pa-
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
(continued on page AP14)
Copyright 2011 copy The Joint Commission
June 2011 Volume 37 Number 6
The Joint Commission Journal on Quality and Patient Safety
AP14
Online-Only Content8Appendix 1 Included Studies (continued)
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
One hospital 9 units
Health care system
in eastern US units
not specified
Brief Description of
Intervention
Multidimensional intervention
consisting of assembled a
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
performance monitoring and
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
wound care management
study day (2) PU prevention
training program and training
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
assembling a team imple-
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
PT = Patient Outcome
PRO = Nursing Process
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
(continued on page AP15)
Copyright 2011 copy The Joint Commission
June 2011 Volume 37 Number 6
The Joint Commission Journal on Quality and Patient Safety
AP15
Online-Only Content8Appendix 1 Included Studies (continued)
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
Brief Description of
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-
mentation of a risk assess-
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
Multidimensional intervention
consisting of assembled a
team implemented a pub-
lished guideline and care
protocol used a risk assess-
ment tool made skin care
products readily available on
the unit and provided staff
education
Measures Reported
PT = Patient Outcome
PRO = Nursing Process
1 PU incidence (PT)
1 Incidence of Stage II
PUs among patients with-
out PUs on admission
(PUs100 patient days)
(PT)
1 patients with
hospital-acquired PUs
(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
(continued on page AP16)
Copyright 2011 copy The Joint Commission
June 2011 Volume 37 Number 6
The Joint Commission Journal on Quality and Patient Safety
AP16
Online-Only Content8Appendix 1 Included Studies (continued)
Author
Year
Country
Design
Willson44
1995
USA
Before-after
Setting
One hospital
4 medicalsurgical
units
Brief Description of
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
PT = Patient Outcome
PRO = Nursing Process
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
Copyright 2011 copy The Joint Commission
AP9 June 2011 Volume 37 Number 6
The Joint Commission Journal on Quality and Patient Safety
Online-Only Content8Appendix 1 Included Studies (continued)
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
Brief Description of
Intervention
Multidimensional 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
PT = Patient Outcome
PRO = Nursing Process
1 Prevalence of hospital-
acquired PUs (Unit A)
(PT)
2 Prevalence of hospital-
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)
4 Hospital-acquired PU
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)
14 Staging of acquired
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
(continued on page AP10)
Copyright 2011 copy The Joint Commission
June 2011 Volume 37 Number 6
The Joint Commission Journal on Quality and Patient Safety
Online-Only Content8Appendix 1 Included Studies (continued)
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
Brief Description of
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
Multidimensional intervention
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
Multidimensional intervention
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
PT = Patient Outcome
PRO = Nursing Process
1 PU incidence (all
stages) (PT)
2 of hospital-acquired
Stage I PUs (PT)
3 of hospital-acquired
Stage II PUs (PT)
4 of hospital-acquired
Stage III PUs (PT)
5 of hospital-acquired
Stage IV PUs (PT)
1 Overall hospital-
acquired prevalence (PT)
1 PU 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
(continued on page AP11)
AP10
Copyright 2011 copy The Joint Commission
June 2011 Volume 37 Number 6
The Joint Commission Journal on Quality and Patient Safety
AP11
Online-Only Content8Appendix 1 Included Studies (continued)
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
Brief Description of
Intervention
Multidimensional PU preven-
tion program consisting of
the use of a risk assessment
tool and protocol conducted
performance monitoring and
provided staff education
Systemwide educational in-
tervention targeting all levels
of patient care providers and
multispecialty care The
intervention included per-
formance monitoring and
feedback the purchase of
pressure-relieving beds and
the use of new flow sheets
Measures Reported
PT = Patient Outcome
PRO = Nursing Process
1 PU prevalence (PT)
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)
4 Prevalence of hospital-
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)
7 patients with PUs (ge
Stage I) who had a skin
assessment upon admission
completed (PRO)
8 patients with PUs (ge
Stage I) who had a skin
assessment upon admission
(PRO)
9 patients with PUs (ge
Stage I) for whom it was
unknown whether a skin
assessment upon admission
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)
11 patients with PUs
(Stages IIndashIV) with inadequate
documentation of either
admission skin assessment or
reassessment (PRO)
12 patients with PUs
(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
(continued on page AP12)
Copyright 2011 copy The Joint Commission
June 2011 Volume 37 Number 6
The Joint Commission Journal on Quality and Patient Safety
AP12
Online-Only Content8Appendix 1 Included Studies (continued)
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
One hospital 2 units
cardiac surgery ICU
and cardiac surgery
intermediate care
unit Intervention lim-
ited to patients un-
dergoing elective
open heart surgery
Brief Description of
Intervention
Implemented a published
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
PT = Patient Outcome
PRO = Nursing Process
1 patients who devel-
oped PU in hospital
excluding those present
on admission (PT)
1 of nosocomial PUs
among hip fracture
patients (PT)
1 PU prevalence (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
(continued on page AP13)
Copyright 2011 copy The Joint Commission
June 2011 Volume 37 Number 6
The Joint Commission Journal on Quality and Patient Safety
AP13
Online-Only Content8Appendix 1 Included Studies (continued)
Author
Year
Country
Design
Rashotte37
2008
Canada
Before-after
Setting
10-bed pediatric ICU
Brief Description of
Intervention
Multifaceted 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
PT = Patient Outcome
PRO = Nursing Process
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)
9 Median number of pa-
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
(continued on page AP14)
Copyright 2011 copy The Joint Commission
June 2011 Volume 37 Number 6
The Joint Commission Journal on Quality and Patient Safety
AP14
Online-Only Content8Appendix 1 Included Studies (continued)
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
One hospital 9 units
Health care system
in eastern US units
not specified
Brief Description of
Intervention
Multidimensional intervention
consisting of assembled a
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
performance monitoring and
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
wound care management
study day (2) PU prevention
training program and training
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
assembling a team imple-
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
PT = Patient Outcome
PRO = Nursing Process
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
(continued on page AP15)
Copyright 2011 copy The Joint Commission
June 2011 Volume 37 Number 6
The Joint Commission Journal on Quality and Patient Safety
AP15
Online-Only Content8Appendix 1 Included Studies (continued)
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
Brief Description of
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-
mentation of a risk assess-
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
Multidimensional intervention
consisting of assembled a
team implemented a pub-
lished guideline and care
protocol used a risk assess-
ment tool made skin care
products readily available on
the unit and provided staff
education
Measures Reported
PT = Patient Outcome
PRO = Nursing Process
1 PU incidence (PT)
1 Incidence of Stage II
PUs among patients with-
out PUs on admission
(PUs100 patient days)
(PT)
1 patients with
hospital-acquired PUs
(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
(continued on page AP16)
Copyright 2011 copy The Joint Commission
June 2011 Volume 37 Number 6
The Joint Commission Journal on Quality and Patient Safety
AP16
Online-Only Content8Appendix 1 Included Studies (continued)
Author
Year
Country
Design
Willson44
1995
USA
Before-after
Setting
One hospital
4 medicalsurgical
units
Brief Description of
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
PT = Patient Outcome
PRO = Nursing Process
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
Copyright 2011 copy The Joint Commission
June 2011 Volume 37 Number 6
The Joint Commission Journal on Quality and Patient Safety
Online-Only Content8Appendix 1 Included Studies (continued)
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
Brief Description of
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
Multidimensional intervention
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
Multidimensional intervention
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
PT = Patient Outcome
PRO = Nursing Process
1 PU incidence (all
stages) (PT)
2 of hospital-acquired
Stage I PUs (PT)
3 of hospital-acquired
Stage II PUs (PT)
4 of hospital-acquired
Stage III PUs (PT)
5 of hospital-acquired
Stage IV PUs (PT)
1 Overall hospital-
acquired prevalence (PT)
1 PU 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
(continued on page AP11)
AP10
Copyright 2011 copy The Joint Commission
June 2011 Volume 37 Number 6
The Joint Commission Journal on Quality and Patient Safety
AP11
Online-Only Content8Appendix 1 Included Studies (continued)
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
Brief Description of
Intervention
Multidimensional PU preven-
tion program consisting of
the use of a risk assessment
tool and protocol conducted
performance monitoring and
provided staff education
Systemwide educational in-
tervention targeting all levels
of patient care providers and
multispecialty care The
intervention included per-
formance monitoring and
feedback the purchase of
pressure-relieving beds and
the use of new flow sheets
Measures Reported
PT = Patient Outcome
PRO = Nursing Process
1 PU prevalence (PT)
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)
4 Prevalence of hospital-
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)
7 patients with PUs (ge
Stage I) who had a skin
assessment upon admission
completed (PRO)
8 patients with PUs (ge
Stage I) who had a skin
assessment upon admission
(PRO)
9 patients with PUs (ge
Stage I) for whom it was
unknown whether a skin
assessment upon admission
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)
11 patients with PUs
(Stages IIndashIV) with inadequate
documentation of either
admission skin assessment or
reassessment (PRO)
12 patients with PUs
(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
(continued on page AP12)
Copyright 2011 copy The Joint Commission
June 2011 Volume 37 Number 6
The Joint Commission Journal on Quality and Patient Safety
AP12
Online-Only Content8Appendix 1 Included Studies (continued)
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
One hospital 2 units
cardiac surgery ICU
and cardiac surgery
intermediate care
unit Intervention lim-
ited to patients un-
dergoing elective
open heart surgery
Brief Description of
Intervention
Implemented a published
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
PT = Patient Outcome
PRO = Nursing Process
1 patients who devel-
oped PU in hospital
excluding those present
on admission (PT)
1 of nosocomial PUs
among hip fracture
patients (PT)
1 PU prevalence (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
(continued on page AP13)
Copyright 2011 copy The Joint Commission
June 2011 Volume 37 Number 6
The Joint Commission Journal on Quality and Patient Safety
AP13
Online-Only Content8Appendix 1 Included Studies (continued)
Author
Year
Country
Design
Rashotte37
2008
Canada
Before-after
Setting
10-bed pediatric ICU
Brief Description of
Intervention
Multifaceted 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
PT = Patient Outcome
PRO = Nursing Process
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)
9 Median number of pa-
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
(continued on page AP14)
Copyright 2011 copy The Joint Commission
June 2011 Volume 37 Number 6
The Joint Commission Journal on Quality and Patient Safety
AP14
Online-Only Content8Appendix 1 Included Studies (continued)
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
One hospital 9 units
Health care system
in eastern US units
not specified
Brief Description of
Intervention
Multidimensional intervention
consisting of assembled a
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
performance monitoring and
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
wound care management
study day (2) PU prevention
training program and training
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
assembling a team imple-
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
PT = Patient Outcome
PRO = Nursing Process
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
(continued on page AP15)
Copyright 2011 copy The Joint Commission
June 2011 Volume 37 Number 6
The Joint Commission Journal on Quality and Patient Safety
AP15
Online-Only Content8Appendix 1 Included Studies (continued)
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
Brief Description of
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-
mentation of a risk assess-
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
Multidimensional intervention
consisting of assembled a
team implemented a pub-
lished guideline and care
protocol used a risk assess-
ment tool made skin care
products readily available on
the unit and provided staff
education
Measures Reported
PT = Patient Outcome
PRO = Nursing Process
1 PU incidence (PT)
1 Incidence of Stage II
PUs among patients with-
out PUs on admission
(PUs100 patient days)
(PT)
1 patients with
hospital-acquired PUs
(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
(continued on page AP16)
Copyright 2011 copy The Joint Commission
June 2011 Volume 37 Number 6
The Joint Commission Journal on Quality and Patient Safety
AP16
Online-Only Content8Appendix 1 Included Studies (continued)
Author
Year
Country
Design
Willson44
1995
USA
Before-after
Setting
One hospital
4 medicalsurgical
units
Brief Description of
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
PT = Patient Outcome
PRO = Nursing Process
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
Copyright 2011 copy The Joint Commission
June 2011 Volume 37 Number 6
The Joint Commission Journal on Quality and Patient Safety
AP11
Online-Only Content8Appendix 1 Included Studies (continued)
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
Brief Description of
Intervention
Multidimensional PU preven-
tion program consisting of
the use of a risk assessment
tool and protocol conducted
performance monitoring and
provided staff education
Systemwide educational in-
tervention targeting all levels
of patient care providers and
multispecialty care The
intervention included per-
formance monitoring and
feedback the purchase of
pressure-relieving beds and
the use of new flow sheets
Measures Reported
PT = Patient Outcome
PRO = Nursing Process
1 PU prevalence (PT)
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)
4 Prevalence of hospital-
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)
7 patients with PUs (ge
Stage I) who had a skin
assessment upon admission
completed (PRO)
8 patients with PUs (ge
Stage I) who had a skin
assessment upon admission
(PRO)
9 patients with PUs (ge
Stage I) for whom it was
unknown whether a skin
assessment upon admission
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)
11 patients with PUs
(Stages IIndashIV) with inadequate
documentation of either
admission skin assessment or
reassessment (PRO)
12 patients with PUs
(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
(continued on page AP12)
Copyright 2011 copy The Joint Commission
June 2011 Volume 37 Number 6
The Joint Commission Journal on Quality and Patient Safety
AP12
Online-Only Content8Appendix 1 Included Studies (continued)
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
One hospital 2 units
cardiac surgery ICU
and cardiac surgery
intermediate care
unit Intervention lim-
ited to patients un-
dergoing elective
open heart surgery
Brief Description of
Intervention
Implemented a published
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
PT = Patient Outcome
PRO = Nursing Process
1 patients who devel-
oped PU in hospital
excluding those present
on admission (PT)
1 of nosocomial PUs
among hip fracture
patients (PT)
1 PU prevalence (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
(continued on page AP13)
Copyright 2011 copy The Joint Commission
June 2011 Volume 37 Number 6
The Joint Commission Journal on Quality and Patient Safety
AP13
Online-Only Content8Appendix 1 Included Studies (continued)
Author
Year
Country
Design
Rashotte37
2008
Canada
Before-after
Setting
10-bed pediatric ICU
Brief Description of
Intervention
Multifaceted 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
PT = Patient Outcome
PRO = Nursing Process
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)
9 Median number of pa-
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
(continued on page AP14)
Copyright 2011 copy The Joint Commission
June 2011 Volume 37 Number 6
The Joint Commission Journal on Quality and Patient Safety
AP14
Online-Only Content8Appendix 1 Included Studies (continued)
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
One hospital 9 units
Health care system
in eastern US units
not specified
Brief Description of
Intervention
Multidimensional intervention
consisting of assembled a
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
performance monitoring and
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
wound care management
study day (2) PU prevention
training program and training
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
assembling a team imple-
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
PT = Patient Outcome
PRO = Nursing Process
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
(continued on page AP15)
Copyright 2011 copy The Joint Commission
June 2011 Volume 37 Number 6
The Joint Commission Journal on Quality and Patient Safety
AP15
Online-Only Content8Appendix 1 Included Studies (continued)
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
Brief Description of
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-
mentation of a risk assess-
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
Multidimensional intervention
consisting of assembled a
team implemented a pub-
lished guideline and care
protocol used a risk assess-
ment tool made skin care
products readily available on
the unit and provided staff
education
Measures Reported
PT = Patient Outcome
PRO = Nursing Process
1 PU incidence (PT)
1 Incidence of Stage II
PUs among patients with-
out PUs on admission
(PUs100 patient days)
(PT)
1 patients with
hospital-acquired PUs
(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
(continued on page AP16)
Copyright 2011 copy The Joint Commission
June 2011 Volume 37 Number 6
The Joint Commission Journal on Quality and Patient Safety
AP16
Online-Only Content8Appendix 1 Included Studies (continued)
Author
Year
Country
Design
Willson44
1995
USA
Before-after
Setting
One hospital
4 medicalsurgical
units
Brief Description of
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
PT = Patient Outcome
PRO = Nursing Process
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
Copyright 2011 copy The Joint Commission
June 2011 Volume 37 Number 6
The Joint Commission Journal on Quality and Patient Safety
AP12
Online-Only Content8Appendix 1 Included Studies (continued)
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
One hospital 2 units
cardiac surgery ICU
and cardiac surgery
intermediate care
unit Intervention lim-
ited to patients un-
dergoing elective
open heart surgery
Brief Description of
Intervention
Implemented a published
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
PT = Patient Outcome
PRO = Nursing Process
1 patients who devel-
oped PU in hospital
excluding those present
on admission (PT)
1 of nosocomial PUs
among hip fracture
patients (PT)
1 PU prevalence (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
(continued on page AP13)
Copyright 2011 copy The Joint Commission
June 2011 Volume 37 Number 6
The Joint Commission Journal on Quality and Patient Safety
AP13
Online-Only Content8Appendix 1 Included Studies (continued)
Author
Year
Country
Design
Rashotte37
2008
Canada
Before-after
Setting
10-bed pediatric ICU
Brief Description of
Intervention
Multifaceted 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
PT = Patient Outcome
PRO = Nursing Process
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)
9 Median number of pa-
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
(continued on page AP14)
Copyright 2011 copy The Joint Commission
June 2011 Volume 37 Number 6
The Joint Commission Journal on Quality and Patient Safety
AP14
Online-Only Content8Appendix 1 Included Studies (continued)
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
One hospital 9 units
Health care system
in eastern US units
not specified
Brief Description of
Intervention
Multidimensional intervention
consisting of assembled a
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
performance monitoring and
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
wound care management
study day (2) PU prevention
training program and training
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
assembling a team imple-
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
PT = Patient Outcome
PRO = Nursing Process
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
(continued on page AP15)
Copyright 2011 copy The Joint Commission
June 2011 Volume 37 Number 6
The Joint Commission Journal on Quality and Patient Safety
AP15
Online-Only Content8Appendix 1 Included Studies (continued)
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
Brief Description of
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-
mentation of a risk assess-
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
Multidimensional intervention
consisting of assembled a
team implemented a pub-
lished guideline and care
protocol used a risk assess-
ment tool made skin care
products readily available on
the unit and provided staff
education
Measures Reported
PT = Patient Outcome
PRO = Nursing Process
1 PU incidence (PT)
1 Incidence of Stage II
PUs among patients with-
out PUs on admission
(PUs100 patient days)
(PT)
1 patients with
hospital-acquired PUs
(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
(continued on page AP16)
Copyright 2011 copy The Joint Commission
June 2011 Volume 37 Number 6
The Joint Commission Journal on Quality and Patient Safety
AP16
Online-Only Content8Appendix 1 Included Studies (continued)
Author
Year
Country
Design
Willson44
1995
USA
Before-after
Setting
One hospital
4 medicalsurgical
units
Brief Description of
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
PT = Patient Outcome
PRO = Nursing Process
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
Copyright 2011 copy The Joint Commission
June 2011 Volume 37 Number 6
The Joint Commission Journal on Quality and Patient Safety
AP13
Online-Only Content8Appendix 1 Included Studies (continued)
Author
Year
Country
Design
Rashotte37
2008
Canada
Before-after
Setting
10-bed pediatric ICU
Brief Description of
Intervention
Multifaceted 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
PT = Patient Outcome
PRO = Nursing Process
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)
9 Median number of pa-
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
(continued on page AP14)
Copyright 2011 copy The Joint Commission
June 2011 Volume 37 Number 6
The Joint Commission Journal on Quality and Patient Safety
AP14
Online-Only Content8Appendix 1 Included Studies (continued)
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
One hospital 9 units
Health care system
in eastern US units
not specified
Brief Description of
Intervention
Multidimensional intervention
consisting of assembled a
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
performance monitoring and
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
wound care management
study day (2) PU prevention
training program and training
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
assembling a team imple-
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
PT = Patient Outcome
PRO = Nursing Process
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
(continued on page AP15)
Copyright 2011 copy The Joint Commission
June 2011 Volume 37 Number 6
The Joint Commission Journal on Quality and Patient Safety
AP15
Online-Only Content8Appendix 1 Included Studies (continued)
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
Brief Description of
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-
mentation of a risk assess-
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
Multidimensional intervention
consisting of assembled a
team implemented a pub-
lished guideline and care
protocol used a risk assess-
ment tool made skin care
products readily available on
the unit and provided staff
education
Measures Reported
PT = Patient Outcome
PRO = Nursing Process
1 PU incidence (PT)
1 Incidence of Stage II
PUs among patients with-
out PUs on admission
(PUs100 patient days)
(PT)
1 patients with
hospital-acquired PUs
(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
(continued on page AP16)
Copyright 2011 copy The Joint Commission
June 2011 Volume 37 Number 6
The Joint Commission Journal on Quality and Patient Safety
AP16
Online-Only Content8Appendix 1 Included Studies (continued)
Author
Year
Country
Design
Willson44
1995
USA
Before-after
Setting
One hospital
4 medicalsurgical
units
Brief Description of
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
PT = Patient Outcome
PRO = Nursing Process
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
Copyright 2011 copy The Joint Commission
June 2011 Volume 37 Number 6
The Joint Commission Journal on Quality and Patient Safety
AP14
Online-Only Content8Appendix 1 Included Studies (continued)
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
One hospital 9 units
Health care system
in eastern US units
not specified
Brief Description of
Intervention
Multidimensional intervention
consisting of assembled a
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
performance monitoring and
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
wound care management
study day (2) PU prevention
training program and training
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
assembling a team imple-
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
PT = Patient Outcome
PRO = Nursing Process
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
(continued on page AP15)
Copyright 2011 copy The Joint Commission
June 2011 Volume 37 Number 6
The Joint Commission Journal on Quality and Patient Safety
AP15
Online-Only Content8Appendix 1 Included Studies (continued)
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
Brief Description of
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-
mentation of a risk assess-
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
Multidimensional intervention
consisting of assembled a
team implemented a pub-
lished guideline and care
protocol used a risk assess-
ment tool made skin care
products readily available on
the unit and provided staff
education
Measures Reported
PT = Patient Outcome
PRO = Nursing Process
1 PU incidence (PT)
1 Incidence of Stage II
PUs among patients with-
out PUs on admission
(PUs100 patient days)
(PT)
1 patients with
hospital-acquired PUs
(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
(continued on page AP16)
Copyright 2011 copy The Joint Commission
June 2011 Volume 37 Number 6
The Joint Commission Journal on Quality and Patient Safety
AP16
Online-Only Content8Appendix 1 Included Studies (continued)
Author
Year
Country
Design
Willson44
1995
USA
Before-after
Setting
One hospital
4 medicalsurgical
units
Brief Description of
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
PT = Patient Outcome
PRO = Nursing Process
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
Copyright 2011 copy The Joint Commission
June 2011 Volume 37 Number 6
The Joint Commission Journal on Quality and Patient Safety
AP15
Online-Only Content8Appendix 1 Included Studies (continued)
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
Brief Description of
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-
mentation of a risk assess-
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
Multidimensional intervention
consisting of assembled a
team implemented a pub-
lished guideline and care
protocol used a risk assess-
ment tool made skin care
products readily available on
the unit and provided staff
education
Measures Reported
PT = Patient Outcome
PRO = Nursing Process
1 PU incidence (PT)
1 Incidence of Stage II
PUs among patients with-
out PUs on admission
(PUs100 patient days)
(PT)
1 patients with
hospital-acquired PUs
(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
(continued on page AP16)
Copyright 2011 copy The Joint Commission
June 2011 Volume 37 Number 6
The Joint Commission Journal on Quality and Patient Safety
AP16
Online-Only Content8Appendix 1 Included Studies (continued)
Author
Year
Country
Design
Willson44
1995
USA
Before-after
Setting
One hospital
4 medicalsurgical
units
Brief Description of
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
PT = Patient Outcome
PRO = Nursing Process
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
Copyright 2011 copy The Joint Commission
June 2011 Volume 37 Number 6
The Joint Commission Journal on Quality and Patient Safety
AP16
Online-Only Content8Appendix 1 Included Studies (continued)
Author
Year
Country
Design
Willson44
1995
USA
Before-after
Setting
One hospital
4 medicalsurgical
units
Brief Description of
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
PT = Patient Outcome
PRO = Nursing Process
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
Copyright 2011 copy The Joint Commission