Presenter. Protocols for the Prevention and Treatment of Pressure Injuries: Sustaining Outcomes at the Point of Care. Learning Objectives

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1 Presenter Protocols for the Prevention and Treatment of Pressure Injuries: Sustaining Outcomes at the Point of Care Joyce Pittman, PhD, ANP-BC, FNP-BC, CWOCN Coordinator Wound, Ostomy, Continence Program Indiana University Health Indianapolis, Indiana Learning Objectives Definition of Pressure Injury Describe the pathogenesis of pressure injury (PI) formation Recognize the implications of pressure injuries on patient quality of life and health Examine recent guidelines for the NPUAP and AHRQ on the use of foam dressings along with a comprehensive prevention/treatment protocol in the prevention and treatment of pressure injuries Develop comprehensive protocols for the prevention and treatment of pressure injuries and sustained outcomes at the point of service Pressure injury Localized damage to the skin and underlying soft tissue Usually over a bony prominence or related to a medical or other device Injury can present as intact skin or an open ulcer May be painful Injury occurs as result of intense and/or prolonged pressure or pressure in combination with shear Tolerance of soft tissue for pressure and shear may also be affected by Microclimate Nutrition Perfusion Comorbid conditions Condition of soft tissue NPUAP = National Pressure Ulcer Advisory Panel; AHRQ = Agency for Healthcare Research and Quality. Edsberg LE, et al. J Wound Ostomy Continence Nurs. 2016;43(6). Pathogenesis of Pressure Injury Etiology of Pressure Injuries Bottom-up theory: External pressure leads to necrosis that first develops in subcutaneous fat and/or muscle tissue and then appears later in the skin It is thought that external pressure and/or shear force and its counteractive force from bone prominences directly cause tissue ischemia and deformation, leading to deep tissue necrosis Duration and Intensity of Pressure Reperfusion injury due to oxidative stress also adds to the damage Skin is more tolerant to ischemia than subcutaneous adipose and muscle tissue Pressure Injury Skin vascularity strongly depends on the underlying tissues Severe damage to the deep tissue impairs skin viability Injury progression may be caused in part by loss of perfusion, oxidative stress, influx of calcium, efflux of alarmins, or other disruptions of the environment Tissue Tolerance Aoi N, et al. Plast Reconstruct Surg. 2009;124(2): Duncan K. Cell Tissue Res. 1988;253: Gissel H, et al. Ann NY Acad Sci. 2005;1066: Hirth D, et al. Wound Repair Regen. 2012;20(6): Braden B, et al. Rehabilitation Nursing. 1987;12(1):8-16.

2 Significance: Are Pressure Injuries a Concern? Prevalence Significance: Are Pressure Injuries a Concern? (cont) Financial 2.2% to 24%: Skilled nursing facilities 0.4% to 38%: Acute care CMS: In 2007, monetary penalties were attached to HAPI stage 3/4 Cost of HAPU-1 HAPU: Approximately $20,900 to $151,700 0% to 17%: Home care Hospital length of stay doubles with a pressure injury Pressure injuries in elderly persons have also been associated with increased mortality rates The estimated cost of treating pressure injuries: $11 billion a year Regulatory Quality measure: Publically reported Magnet: National Database of Nursing Quality Indicators (NDNQI ) benchmark Magnet accreditation High-reliability organizations 70% in patients aged 70 years CMS 2 to 6 times greater mortality risk Joint Commission (JCAHO) Increases 6-fold with a pressure injury Quality and outcome-based reimbursement Transparency: Outcomes reportable to the public State departments of health Increases 4-fold with a healed pressure injury CMS = Centers for Medicare & Medicaid Services; HAPI = hospital-acquired pressure injury; HAPU = hospital-acquired pressure ulcer. Sen CK, et al. Wound Repair Regen. 2009;17(6): National Pressure Ulcer Advisory Panel [Web site]. World wide pressure ulcer prevention day 2015 [press release]. September 18, Lyder CH. JAMA. 2003;289: Significance The Dangers of Going to Bed Look at the patient laying long in bed Recognize the implications of pressure injuries on patient quality of life and health What a pathetic picture he makes. The blood clotting in his veins, The lime draining from his bones, The scybala stacking up in his colon, The flesh rotting from his seat, The urine leaking from his distended bladder, And the spirit evaporating from his soul. Asher RAJ. Br Med J. 1947;2(4536): Pressure Injury Prevention: Essential Components 1. Conduct a pressure injury admission assessment 2. Assess risks daily (eg, Braden, Norton) 3. Inspect skin daily 4. Manage moisture 5. Maximize nutrition 6. Minimize pressure Pressure Injury Prevention: Essential Components (cont) 1. Evaluate the individual s clinical condition and risk factors for pressure injuries 2. Define and implement interventions that are consistent with individual needs, goals, and recognized standards of practice 3. Monitor and evaluate the impact of the interventions 4. Revise the approaches as appropriate Education (staff, provider, patient, family) Armstrong D, et al. Opportunities to Improve Pressure Ulcer Prevention and Treatment: Implications of the CMS Acute Care Present on Admission (POA) Indicators/Hospital-Acquired Conditions (HAC) Ruling. A consensus paper from the International Expert Wound Care Advisory Panel: Roundtable discussion held February 2, Chicago, IL. Gibbons W, et al. Eliminating facility-acquired pressure ulcers at Ascension Health. Joint Commission Journal on Quality and Patient Safety. 2006;32: National Pressure Ulcer Advisory Panel. 2010; Centers for Medicare & Medicaid Services.

3 Sustaining Improvements: Structure-Process-Outcomes Four Magnet Model Domains 1. Transformational leadership 2. Structural empowerment 3. Exemplary professional practice 4. New knowledge: Innovation and improvement Successful implementation of these elements yields measurable positive outcomes Transformational Leadership Examples of PIP strategies incorporating transformational leadership Key leader stakeholder (vice president) appointed to facilitate/support PIP initiatives PIP clinical program facilitator appointed/designated Sets clear expectations for benchmarking, outcomes, and accountability Removes barriers Padula WV, et al. Adv Skin Wound Care. 2014;27(6): PIP = pressure injury prevention. Padula WV, et al. Adv Skin Wound Care. 2014;27(6): Transformational Leadership (cont) Structural Empowerment Clear reporting structure and bidirectional communication for the PIP program in the nursing organizational framework identified Board level (safety and risk board) ó Nurse Executive Council ó PPS committee ó WOC/PIP committee ó Facility PPC ó Facility PIP unit Time and resources for group meetings and projects are supported Supports use of full-time equivalent to do the work: System ó facility ó unit Communicates those expectations to all levels Supports interdisciplinary team development PPS = Performing Provider System. Padula WV, et al. Adv Skin Wound Care. 2014;27(6): Examples of PIP strategies incorporating the Magnet component of Structural Empowerment PIP team established: System, facility, unit level, multidisciplinary Bi-directional reporting/accountability Multidisciplinary: WOC, CNS, RN, RT, PT, RD, risk, social work, educator (staff/patient), ethics, supply chain, IT Continuum of care: Acute care, home care, long-term care, long-term acute care Recognition of excellence: System, facility, unit, individual PIP member role/responsibilities/expectations: Established and approved by the New Engineering Contract PIP education expectations/opportunities Embedded annual/orientation staff education/competencies WTA program Professional growth program Conference presentations/attendance IT = information technology; WTA = wound treatment associate. Pittman J National Pressure Ulcer Advisory Panel. WOCN Society [Web site] am/webprogram/Paper10529.html. Accessed March 10, Exemplary Professional Practice Pressure Ulcer Prevention Do No Harm Through Elimination of HAPUs Examples of PIP strategies incorporating Exemplary Professional Practice Evidence-based PIP protocol, plan of care, order sets developed and embedded into EMR PIP is hard-wired into care at the bedside but also ancillary areas: Operating room, emergency department, transportation Safe handoff, order sets, triggers, etc HAPI prevalence/processes benchmarking monthly rather than quarterly Transparent at unit level PI integration into IT: Quality data reports, triggers, e-measures EMR design triggers specific nursing interventions based on risk assessment EMR generates daily/real-time occurrences of pressure injuries Moving toward meaningful data Incidence rather than prevalence Culture of safety through standardized root-cause analysis process NPUAP root-cause analysis template Avoidable vs unavoidable HAPI Complete Document Assess Braden risk POA skin and skin within 24 hours assessment Process Measures % skin assessment completed and documented POA within 24 hours % accuracy with wound order set completion based on risk Braden 18 or POA No Initiate phases 1 and 2 of skin care PPOC Yes Evaluate skin Risk or skin integrity changed No Continue PU PPOC Implement skin/wound interventions/ orders based on risk Surface selection Keep turning Incontinence/ moisture management Nutrition Yes Initiate Evaluate Risk Continue phases 1 and 2 skin based on or skin integrity No skin plan of skin care implemented changed of care PPOC interventions Standard Work Requirement (discussed in huddles/bedside report, etc) 1. Skin wound order set included in admission packet and placed on every chart 2. Assess risk with Braden and anytime change in status 3. Complete skin wound order set based on risk NPUAP = National Pressure Ulcer Advisory Panel; EMR = electronic medical record; HAPI = hospital-acquired pressure injury. Lyder CH, et al. Jt Comm J Qual Saf. 2004;30(4): POA = present on admission; PPOC = prevention plan of care. Slide courtesy of J Pittman, Indiana University Health. Indianapolis, IN

4 Prevention of HAPI HAPI Data: Communicating Results Did you know? HAPU care can cost up to $70,000 Patients with a HAPI have a 2 to 6 times greater mortality risk 70% of pressure ulcers occur in patients aged >70 years Bundle these pieces together...when completed together, they are more effective! Document your skin assessment on admission and every shift Assess patients pressure injury risk by documenting their Braden score within 4 hours of admission and every shift S 1. Braden risk completed on admission and every shift 2. Skin assessment on admission and every shift Revise interventions according to patient condition Save Our SKIN! N Nutrition addressed S Surface Appropriate Surface Appropriate K Keep turning every 2 hours... including devices I Incontinence Management (Breathable pads and/or moisture barriers) Rate of Stage 2 + HAPU JAN Cerner redesign HAPI (Stage 2 and greater) 9 APR Skin/wound protocol revised 11 Mar 16 Apr 16 Jun 16 Aug 16 Oct 16 Jan 16 Nov 16 Feb 16 May 16 Jul 16 Sep 16 Dec JAN DEC Multimethod education across UH/MH 4 JUL WTA EBP projects 7 MAR DEC UH/MH WOC team integration & cross-training 8 OCT UH WTA HAPI days 5 8 DEC MH WTA HAPI days No. of Stage 2 + HAPU Commit to putting ALL of the pieces together to prevent HAPUs! HAPU Rate Magnet Mean Slide courtesy of J Pittman, Indiana University Health. Indianapolis, IN Slide courtesy of J Pittman, Indiana University Health. Indianapolis, IN New Knowledge: Innovation and Improvement Examples of PIP strategies incorporating the Magnet component of New Knowledge Research activities Wound, Ostomy, and Continence Nurses Society grant recipient x 3: BMS RCT, BMS translation into practice, PIPI Device-related HAPI: American Association of Critical-Care Nurses grant recipient/webinar, November 2014 Soft silicone dressing as prevention: Cost savings of $271,000 to $1,972,100 WOC team redesign: Indiana University Health quality award Supports evidence-based practice projects to improve PIP: WTA program evidence-based practice projects PIP and linen use PIP and progressive mobility PIP and Braden risk assessment PIP and support surface Supports publication of clinical work: Journal articles, abstract submissions, poster presentations, podium presentations Recognizes innovation: Standing-agenda item (tests of change) Promotes PIP beyond organization into the community: WTA community program Indiana University Health Pressure Ulcer Prevention Inventory Based on NPUAP/CMS Definitions Subject ID: Admission Date: / / HAPU Acquisition Date: / / HAPU Location: 1 = Sacrum/Coccyx 2 = Ischium 3 = Hip 4 = Heel 5 = Occipital 6 = Ear 7 = Other HAPU Laterality: 1 = Right 2 = Left 3 = Midline HAPU Stage: 1 = DTI 2 = 2 3 = 3 4 = 4 5 = Unstageable Audit Date: Auditor: Review medical record 3 days prior to the documented development of the HAPU Assign the appropriate score for each item: 1 = NO, not appropriate 2 = YES, appropriate 1. Clinical Condition Evaluation History and Physical completed upon admission Braden Pressure Ulcer Assessment upon admission Braden Pressure Ulcer Assessment per policy (daily or every shift) Skin assessment (Nursing) completed upon admission Review medical record 3 days prior to the documented development of the HAPU Assign the appropriate score for each item: 1 = NO, not appropriate 2 = YES, appropriate 2. Defined and Implemented Intervention(s) consistent with Patient s Needs HAPU DAY 0 1 day prior to HAPU 2 days prior to HAPU 3 days prior to HAPU 2.1 Sensory Perception Interventions Appropriate? 2.2 Moisture Interventions Appropriate? 2.3 Activity Interventions Appropriate? 2.4 Mobility Interventions Appropriate 2.5 Nutritional Interventions Appropriate 2.6 Friction & Shear Interventions Appropriate 3. Monitored/ Evaluated Impact of Interventions Skin Assessment completed every shift 4. Revised Interventions as Appropriate 5. Pressure Ulcer Avoidable SCORE! Case Study Think SKIN! An 84-year-old white woman S Surface selection Admitting diagnoses: Fractured left hip, type 2 diabetes mellitus, hypertension, peripheral vascular disease Braden scale score: 12 K Keep turning (pressure redistribution) I Incontinence management N Nutrition Interventions?

5 Support surface: Know your beds! Interventions Turn, turn, turn reposition THERE ARE NO MAGIC BEDS! Prevention dressings: Foam Incontinent? Moisture barriers Consider a nutrition consultation if patient has poor nutrition risk score, weight loss, a low albumin or pre-albumin level, multiple wounds, or poor intake and output Provide adequate fluids Consider medical devices: Nasogastric tube, sequential compression device, endotracheal tube, tracheostomy, intravenous tubing, indwelling catheter (Foley catheter), braces, casts Evidence and NPUAP/AHRQ Guidelines for Prevention Dressings The use of dressings can reduce the amplitude of shear stress and friction reaching the skin of patients at risk Dressings can also effectively redirect these forces to wider areas, which minimizes the mechanical loads upon skeletal prominences Shear force is believed to affect pressure ulceration Dressing materials that reduce shear force may prevent ulceration and facilitate healing AHRQ = Agency for Healthcare Research and Quality. National Pressure Ulcer Advisory Panel and European Pressure Ulcer Advisory Panel [Web site]. New 2014 Prevention and treatment of pressure ulcers: clinical practice guideline. Accessed March 16, Washington, DC: National Pressure Ulcer Advisory Panel, Call E, et al. Int Wound J. 2015;12(4): Ohura N, et al. J Wound Care. 2005;14(9): Growing Evidence for Prevention Dressings Growing Evidence for Prevention Dressings (cont) Quasi-experimental, convenience sample of 90 critical-care patients to compare pressure injury development Participants were allocated randomly to 1 of 3 groups Repositioning of routine management Hydrocolloid dressing Foam dressing Repositioning of routine management group had the highest incidence rate of pressure injuries followed by the hydrocolloid-dressing group Foam-dressing group recorded no pressure injuries Conclusions Patients in high-risk groups in clinical settings should adopt strategies Repositioning Regular visual skin examinations Hydrocolloid or foam dressings may be used as appropriate to prevent sacral pressure ulcers Tsao WY, et al. Hu Li Za Zhi. 2013;60(4): Randomized controlled trial to investigate the effectiveness of multi-layered soft silicone foam dressings in preventing ICU pressure ulcers when applied in the emergency department to 440 trauma and critically ill patients Significantly fewer patients with pressure injuries in the intervention group (foam dressing) compared with the control group (usual care) (5 vs 20, P=.001) Overall, there were fewer sacral (2 vs 8, P=.05) and heel pressure ulcers (5 vs 19, P=. 002) and pressure injuries (7 vs 27, P=.002) in intervention groups than in the control group Conclusion Multi-layered soft silicone foam dressings are effective in preventing pressure ulcers in critically ill patients when applied in the emergency department prior to ICU transfer ICU = intensive care unit. Santamaria N, et al. J Wound Care. 2015;24(8): Growing Evidence for Prevention Dressings (cont) Prospective, randomized controlled trial in the ICU at a 569-bed, level II trauma hospital to compare the difference in incidence rates of HAPUs in 366 critically ill patients treated with Usual preventive care and 5-layered soft silicone foam dressing (intervention group) Usual care (control group) Incidence rate of HAPUs less in the intervention group (foam dressing) compared with that in the control group (usual care) (0.7% vs 5.9%, P=.01) Conclusions Use of soft silicone foam dressing combined with preventive care yielded statistically and clinically significant benefit in reducing incidence rate and severity of HAPUs in ICU patients This novel, cost-effective method can reduce the incidence of HAPUs in ICU patients Kalowes P, et al. Am J Crit Care. 2016;25(6):e108-e119. Growing Evidence for Prevention Dressings: Summary Based on a systematic review; a single high-quality RCT; a growing number of cohort, weak RCTs; and case series, the introduction of a dressing to prevent pressure injuries may help reduce the incidence of pressure injuries associated with medical devices, especially in patients in the immobile ICU There is no firm clinical evidence at this time to suggest that one dressing type is more effective than other dressing types AHRQ clinical guidelines, including the use of prophylactic/prevention dressings WOCN 2016 guideline for the prevention and management of pressure injuries European Pressure Ulcer Advisory Panel 2014 clinical practice guideline National Pressure Ulcer Advisory Panel Pan Pacific Pressure Injury Alliance WOCN = Wound, Ostomy and Continence Nurses Society. Black J, et al. Int Wound J. 2015;12(4): WOCN -Accredited Professional Education Programs. J Wound Ostomy Continence Nurs. 2016;43(6): Wound Ostomy and Continence Nurses Society (WOCN) [Web site]. Prevention-and-Management-of-Pressure-Ulcers-Injuries---Now-Available.htm NPUAP [Web site]. New 2014 prevention and treatment of pressure ulcers: clinical practice guideline. Accessed March 10, 2017.

6 Prevention Dressings: Summary When selecting a prevention dressing, consider: Ability of the dressing to manage moisture and microclimate Ease of application and removal of dressing Ability to remove the dressing to reassess skin Thickness of the dressing under medical devices Pressure Injury: Treatment Components of pressure injury treatment include: Accurate diagnosis and classification Assessment and monitoring of healing Pain assessment and treatment Wound bed preparation Assessment and treatment of infection and biofilms Use of biophysical agents Surgery National Pressure Ulcer Advisory Panel and European Pressure Ulcer Advisory Panel [Web site]. New 2014 Prevention and treatment of pressure ulcers: clinical practice guideline. Accessed March 16, National Pressure Ulcer Advisory Panel and European Pressure Ulcer Advisory Panel [Web site]. New 2014 Prevention and treatment of pressure ulcers: clinical practice guideline. Accessed March 16, Pressure Injury: Treatment (cont) Accurate diagnosis and classification Determine if wound is pressure related Differentiate pressure-related injuries from other types of wounds Moisture-associated skin damage most commonly confused with pressure injuries Recommend using NPUAP pressure injury classification Each stage clarified based on recent research and expert clinical consensus Improving the accuracy of pressure injury staging Clarifying deep tissue pressure injuries New system will allow healthcare providers to identify and treat pressure injuries earlier and more accurately Classify (stage) pressure injuries caused by medical devices Do not stage pressure injuries on mucous membranes Edsberg L, et al. J Wound Ostomy Continence Nurs. 2016;43(6): NPUAP in Collaboration with CMS: 2016 Pressure Injury Staging System Collaborative discussion between CMS and NPUAP included the NPUAP s 2016 staging system Each stage clarified based on recent research and expert clinical consensus Improving the accuracy of pressure injury staging Clarifying deep tissue pressure injuries New system will allow healthcare providers to identify and treat pressure injuries earlier and more accurately 2016 updated staging system includes Stage 1: Non-blanchable erythema of intact skin Stage 2: Partial-thickness skin loss with exposed dermis Stage 3: Full-thickness skin loss Stage 4: Full-thickness skin and tissue loss Unstageable: Obscured full-thickness skin and tissue loss Deep tissue: Persistent non-blanchable deep red, maroon, or purple discoloration National Pressure Ulcer Advisory Panel [Web site]. NPUAP pressure injury stages. Accessed March 10, National Pressure Ulcer Advisory Panel [Web site]. National pressure ulcer advisory panel meets with CMS to discuss identification and treatment of pressure injuries [press release]. January 30, Accessed March 10, Pressure Injury: Treatment Pressure Injury: Treatment (cont) Assessment and monitoring of healing Complete a comprehensive initial assessment Reassess individual, pressure injury, and plan of care if injury does not show healing as expected Assessment of pressure injury should be at least weekly Darkly pigmented skin assessment should include Skin heat Skin tenderness Change in tissue consistency Change in pain Pain assessment and treatment Complete a pain assessment on adults and children using a valid/reliable scale Incorporate equipment, positioning, and postures to minimize pain Select wound dressings to minimize pain Foam dressings with silicone borders to minimize medical adhesive related skin injury (MARSI) Consider non-pharmacologic and pharmacologic strategies Reduce procedural pain Topical Systemic Manage chronic pain Educate individuals and families in strategies

7 Pressure Injury: Treatment (cont) Types of Prevention/Treatment Dressings Wound bed preparation Wound bed preparation is characterized by On-going debridement Reduction of bacteria burden Management of exudate Tissue management: Cleansing and debridement Infection and inflammation control: Contamination, colonization, critical colonization, local infection, systemic infection, sepsis Consider use of topical antiseptic cleansers, topical antibiotics, antimicrobial dressings, and treatment of osteomyelitis as appropriate Moisture balance: Choose an appropriate dressing to best manage exudate Hydrocolloid Gauze Transparent film Silicone Hydrogel Collagen matrix Alginate Composite Foam Biologic Silver-impregnated Growth factors (platelet-derived growth factors) Honey-impregnated Prophylactic Cadexomer iodine Negative-pressure wound therapy 2016 National Pressure Ulcer Advisory Panel. Handouts pdf. Focus on Foam Dressings Conclusions International pressure injury guidelines recommend considering foam dressings for use on exudative stage 2 and shallow stage 3 pressure injuries Avoid using single small pieces of foam in exudating cavity ulcers Consider using gelling foam in highly exuding pressure injuries Used on full-thickness wounds (eg, stage 3 or 4 ulcers) with moderate to heavy exudate Dressing change up to 3 times per week Foam wound fillers up to once per day Can be used as secondary dressings to absorptive primary dressings (alginate, collagen, fiber gelling/hydrofiber) to enhance absorption of wound exudate 2016 National Pressure Ulcer Advisory Panel pdf. NPUAP, EPUAP, Pan Pacific Pressure Injury Alliance: Prevention and Treatment of Pressure Ulcers: Clinical Practice Guideline. In: Haesler E, ed. Perth, Australia: Cambridge Media, An effective and sustainable PIP program can be developed using the four Magnet Model domains of: 1. Transformational leadership 2. Structural empowerment 3. Exemplary professional practice 4. New knowledge: Innovation and improvement Components of pressure injury treatment include: 1. Accurate diagnosis and classification 2. Assessment and monitoring of healing 3. Pain assessment and treatment 4. Wound bed preparation Triple Aim to: 1. Improve health 2. Improve patient care (experience) 3. Contain costs Successful implementation of these elements yields measurable, positive outcomes References References (cont) Agency for Healthcare Research and Quality (AHRQ). (2011 July). AHRQ toolkit helps to prevent hospital-acquired pressure ulcers: Research Activities. Rockville, MD: AHRQ. Aoi, et al. Ultrasound assessment of deep tissue injury in pressure ulcers: possible prediction of pressure ulcer progression. Plast Reconstruct Surg. 2009;124(2): Berwick DM, Calkins DR, McCannon CJ, Hackbarth AD. The 100,000 lives campaign: setting a goal and a deadline for improving care quality. JAMA. 2006;295(3): Black JM. National Pressure Ulcer Advisory Panel: Moving toward consensus on deep tissue injury and pressure ulcer staging. Adv Skin Wound Care. 2005;18:415. Centers for Medicare and Medicaid Services (CMS). Overview of hospital-acquired conditions (present on admission indicator). Accessed March 13, Clark ML. The Magnet Recognition Program and evidence-based practice. J Perianesth Nurs. 2006;21(3): Creehan S, Cuddigan J, Gonzales D, Nix D, Padula W, Pittman J, Pontieri-Lewis V, Walden C, Wells B, Wheeler R. The VCU Pressure Ulcer Summit-Developing Centers for Pressure Ulcer Prevention Excellence: A Framework for Sustainability. J Wound Ostomy Continence Nurs. 2016;43(2): Donabedian A. Quality assurance. Structure, process and outcome. Nurs Stand. 1992;7(11 Suppl QA):4-5. Duncan K. Preventing Pressure Ulcers: The Goal is Zero. The Joint Commission Journal on Quality and Patient Safety. 2007;33(10). Edsberg L, Black J, Goldberg M., McNichol L, Moore L, Sieggreen M. Revised National Pressure Ulcer Advisory Panel Pressure Injury Staging System. J Wound Ostomy Continence Nurs. 2016;43(6): Jagannathan N, Tucker-Kellogg L. Membrane permeability during pressure ulcer formation: A computational model of dynamic competition between cytoskeletal damage and repair. J Biomechanics. 2016;29: Kelleher AD, Moorer A, Makic MF. Peer-to-peer nursing rounds and hospital-acquired pressure ulcer prevalence in a surgical intensive care unit: a quality improvement project. J Wound Ostomy Continence Nurs. 2012;39(2): doi: /won.0b013e LeMaster K. Reducing Incidence and Prevalence of Hospital-Acquired Pressure Ulcers at Genesis Medical. The Joint Commission Journal on Quality and Patient Safety. 2007;33(10). Lyder CH, Grady J, Mathur D, Petrillo MK, Meehan TP. Preventing pressure ulcers in Connecticut hospitals by using the plan-do-studyact model of quality improvement. Jt Comm J Qual Safe. 2004;30(4): Morton A, Mengersen K, Waterhouse M, Steiner S. Analysis of aggregated hospital infection data for accountability. J Hosp Infection. 2010;76(4): National Pressure Ulcer Advisory Panel and European Pressure Ulcer Advisory Panel. Prevention and treatment of pressure ulcers: clinical practice guideline. Washington DC: National Pressure Ulcer Advisory Panel; NPUAP, EPUAP and Pacific Pressure Injury Alliance. Prevention and Treatment of Pressure Ulcers: Clinical Practice Guideline Padula WV, Mishra MK, Makic MB, Sullivan PW. Improving the Quality of Pressure Ulcer Care with Prevention: a cost-effectiveness analysis. Med Care. 2011;49(4): Padula WV, Mishra MK, Makic MB, Valuck RJ. A Framework of Quality Improvement Interventions to Implement Evidence-Based Practices for Pressure Ulcer Prevention. Adv Skin Wound Care Padula WV, Mishra MK, Weaver CD, Yilmaz T, Splaine ME. Building Information for Systematic Improvement of the Prevention of Hospital-acquired Pressure Ulcers with Statistical Process Control Charts and Regression. BMJ Quality & Safety. 2012;21(6): Padula WV, Wald HM, Makic HM. Pressure ulcer risk assessment and prevention. Ann Intern Med. 2013;159(10):718. doi: / Pappas S. The Cost of Nurse-Sensitive Adverse Events. JONA. 2008;38(5): Qaseem A, Mir T, Starkey M, Denberg T. Risk assessment and prevention of pressure ulcers: A clinical practice guideline for the American College of Physicians. Ann Intern Med. 2015;162: doi: /M Ratliff CR, Bryant DE. Guideline for prevention and management of pressure ulcers. WOCN Clinical Practice Guideline. 2003;2(2):52. Glenview, IL: Wound, Ostomy, and Continence Nurses Society (WOCN). Ratliff CR, Tomaselli N. WOCN update on evidence-based guideline for pressure ulcers. J Wound Ostomy Continence Nurs. 2010;37(5): doi: /WON.0b013e3181f17cae.