Comprehensive Programs for Preventing Pressure Ulcers: A Review of the Literature

Transcription

1 APRIL 2012 Comprehensive Programs for Preventing Pressure Ulcers: A Review of the Literature C M E CATEGORY 1 1 Credit ANCC 2.9 Contact Hours Andrea Niederhauser, MPH & Program Manager & Boston University School of Public Health & Boston, Massachusetts Carol VanDeusen Lukas, EdD & Senior Investigator & Center for Organization, Leadership, and Management Research & Veterans Health Administration & Boston Healthcare System & Clinical Associate Professor & Boston University School of Public Health & Boston, Massachusetts Victoria Parker, DBA & Associate Professor & Health Policy and Management & Boston University School of Public Health & Boston, Massachusetts Elizabeth A. Ayello, PhD, RN, ACNS-BC, CWON, MAPWCA & FAAN & Faculty & Excelsior College of Nursing & Albany, New York & Senior Advisor & The John A. Hartford Institute for Geriatric Nursing & New York, New York & President & Ayello, Harris & Associates & New York, New York & Clinical Editor & Advances in Skin & Wound Care & Ambler, Pennsylvania Karen Zulkowski, DNS, RN &Associate Professor & Montana State University-Bozeman & Bozeman, Montana Dan Berlowitz, MD, MPH & Director & Center for Health Quality, Outcomes and Economic Research & Bedford Veterans Affairs Hospital & Professor & Boston University School of Public Health & Boston, Massachusetts All staff, authors, and planners, including spouses/partners (if any), in any position to control the content of this CME activity have disclosed that they have no financial relationships with, or financial interests in, any commercial companies pertaining to this educational activity. To earn CME credit, you must read the CME article and complete the quiz and evaluation on the enclosed answer form, answering at least 12 of the 17 questions correctly. This continuing educational activity will expire for physicians on April 30, PURPOSE: To enhance the learner s competence in pressure ulcer (PrU) prevention through a literature review of comprehensive programs. TARGET AUDIENCE: This continuing education activity is intended for physicians and nurses with an interest in skin and wound care. OBJECTIVES: After participating in this educational activity, the participant should be better able to: 1. Analyze the findings of the PrU prevention program studies found in the literature review. 2. Apply research findings to clinical practice ADVANCES IN SKIN & WOUND CARE & APRIL 2012

2 ABSTRACT OBJECTIVE: The objective of this study was to examine the evidence supporting the combined use of interventions to prevent pressure ulcers (PrUs) in acute care and long-term-care facilities. DESIGN: A systematic review of the literature describing multifaceted PrU prevention programs was performed. Articles were included if they described an intervention implemented in acute care settings or long-term-care facilities, incorporated more than 1 intervention component, involved a multidisciplinary team, and included information about outcomes related to the intervention. MAIN RESULTS: Twenty-four studies were identified. Recurring components used in the development and implementation of PrU prevention programs included preparations prior to the start of a program, PrU prevention best practices, staff education, clinical monitoring and feedback, skin care champions, and cues to action. Ten studies reported PrU prevalence rates; 9 of them reported decreased prevalence rates at the end of their programs. Of the 6 studies reporting PrU incidence rates, 5 reported a decrease in incidence rates. Four studies measured care processes: 1 study reported an overall improvement; 2 studies reported improvement on some, but not all, measures; and 1 study reported no change. CONCLUSIONS: There is a growing literature describing multipronged, multidisciplinary interventions to prevent PrUs in acute care settings and long-term-care facilities. Outcomes reported in these studies suggest that such programs can be successful in reducing PrU prevalence or incidence rates. However, to strengthen the level of evidence, sites should be encouraged to rigorously evaluate their programs and to publish their results. KEYWORDS: preventing pressure ulcers, multidisciplinary interventions to prevent pressure ulcers, reducing incidence of pressure ulcers ADV SKIN WOUND CARE 2012;25:167-88; quiz SCOPE OF THE PROBLEM Pressure ulcers (PrUs) remain a national priority in American healthcare. Every year, tens of thousands of patients develop these skin lesions. Although rates vary widely among different care settings, a 2009 survey among self-selected sites in the United States found an overall PrU prevalence rate of 11.9% and a facility-acquired rate of 5.0% in acute care facilities. 1 Along with pain and the risk for serious infections, PrUs result in increased healthcare utilization and costs. A survey using Medicare inpatient data found that, between 2005 and 2007, PrUs accounted for up to $2.41 billion in excess healthcare costs. 2 Some PrUs may be avoidable, and in the past decade, the prevention of PrUs has gained increased emphasis in clinical practice. In the quest to reduce harm to patients from serious preventable events, institutions such as the National Quality Forum, the Agency for Healthcare Quality and Research, and the Joint Commission, among others, selected PrUs as indicators for patient safety and quality of hospital care. In similar efforts, the 5 Million Lives Campaign, led by the Institute for Healthcare Improvement, brought additional attention to the importance of preventing PrUs in healthcare facilities. Furthermore, in 2008, the Centers for Medicare & Medicaid Services implemented new payment rules that included PrUs on the list of never events and stopped reimbursement to hospitals for the costs of care resulting from facility-acquired Stages III and IV PrUs. 3 This article will help clinicians identify best practice evidence supporting the combined use of interventions to prevent PrUs in acute care and long-term-care facilities. PRESSURE ULCER BEST PRACTICES In the United States, best practices to prevent PrUs have been identified in randomized controlled trials and have been widely disseminated through clinical practice guidelines. A number of systematic studies have evaluated the efficiency of individual best practices, such as the use of special support surfaces or standardized tools to assess risk for PrU development. 4,5 However, the systematic implementation of best practices one at a time in the standard care environment has been shown to be a challenge for many facilities. Studies have found low adherence rates to best practices for PrU prevention in different care settings. For example, 1 study found that although hospitalized older adults were assessed for PrU risks, only 15% had a supportive device in place by day 3 of hospitalization. 6 Another study found that, of 2425 hospitalized Medicare beneficiaries from across the nation, only 23% of immobile patients were documented as being at risk within 48 hours of admission, 66% were repositioned every 2 hours, and 8% received a pressure-reducing device. 7 A third study surveyed medical records of 834 residents in Veterans Health Administration long-term-care facilities and found that overall adherence to 6 critical best-care practices (such as standardized risk assessment and regular repositioning) was only 50%. 8 Rather than implementing single best practices, care facilities have increasingly begun to bundle best practices together and implement them as part of comprehensive programs in their facilities. The aim of this review was to examine the evidence supporting the combined use of multiple interventions to prevent PrUs in acute care and long-term-care facilities. Two questions guided the analysis of the literature: & Are there any specific components that have consistently been included in multifaceted programs? & Is there evidence that these comprehensive programs reduce PrU incidence and/or prevalence? ADVANCES IN SKIN & WOUND CARE & VOL. 25 NO

3 METHODS For this review, Ovid MEDLINE and Ovid CINAHL were searched using combinations of the following search terms: pressure ulcer, bed sore, decubitus ulcer, prevention, protocol, best practice, quality assurance, and tool. In addition, reference lists were reviewed, and clinical experts were contacted to identify further relevant studies. The search was limited to articles published in English between January 1995 and December To be included, the studies needed to describe a program to prevent PrUs that & was implemented in an acute care or long-term-care facility, & consisted of more than 1 intervention component, & was not limited to site-specific PrUs (such as heel ulcers), & was delivered through multidisciplinary efforts, and & measured and reported PrU prevalence or incidence rates before and after implementation of the program. RESULTS Twenty-four articles were identified describing comprehensive PrU prevention programs. Twenty studies described singlesite interventions and four described multisite interventions. All of the reviewed studies used a longitudinal 1-group pretest-posttest design. No randomized controlled trials were reported. An in-depth review of the studies was performed, and each study was analyzed for the following elements: setting and scope of the program, implementation team and preparations prior to program implementation, intervention components, methods of data collection, and results. The different intervention components were categorized into the following groups: PrU prevention best practices, staff education, clinical monitoring and evaluation, skin care champions, other campaign elements, and strategies to ensure sustainability. The findings of this review are shown in Table 1 and are summarized in the following sections. Setting and Scope Of the 20 programs reviewed in acute care settings, 9 28 all but one 17 were rolled out on multiple units or hospital-wide. Two studies reported spreading the program throughout the system after testing it on a small number of pilot units. 18,22 Long-term-care facility initiatives included between 1 and 20 participating facilities Team The individuals who initiated and led the improvement efforts were not specified in any of the reviewed articles. However, a distinction was found between programs that were initiated and led internally by staff members 9 13,15 28 and programs that were designed by external experts and implemented in collaboration with the facility in question. 14,29 32 Once the need for change was identified, several facilities chose to establish a team responsible for the design and/or implementation of the intervention. Teams responsible for designing and implementing the programs were generally multidisciplinary and, if specified, included combinations of nurses and nursing aides, wound experts, dietitians, pharmacists, physical therapists, physicians, clinical researchers, educators, information technology staff, managers, and directors. 10,11,15,18,20 25,27 Program Components Preparations. Twelve of the reviewed studies specified a set of activities completed prior to developing and implementing their initiatives ,15,16,18,20,22,24,27,31 Preparations included literature reviews of best practices for prevention and treatment of PrUs; baseline prevalence and incidence surveys; assessments of current state of staff knowledge, existing policies, and care processes; and the testing, evaluation, and selection of pressure relief equipment or skin care products. Pressure Ulcer Prevention Best Practices. Consistent with existing clinical practice guidelines, studies that described their PrU prevention protocol most commonly reported the use of standardized tools for assessing risk for PrUs; regular skin (re)assessment; an individualized care plan for patients at risk for PrUs; the use of pressure relief equipment, such as low-airloss mattresses and heel lifts; nutritional assessment and consultation for at-risk patients; frequent turning and repositioning; and the use of skin care products and moisture barrier creams. Staff Education. All but 4 studies 13,16,23,30 described some form of education or training to increase staff knowledge. Generally, education was targeted at nursing staff and included instructions on PrU treatment and prevention practices, presentations of new or existing facility guidelines and policies, and training on the use of skin care products and support surfaces. Two studies reported educational programs for physicians. 20,28 Most of the studies reported formal staff educational activities, such as unit in-service sessions and workshops, computerized educational modules, educational packages for staff, skin fairs, and wound conferences. 9 12,14,15,18 22,24 29,31,32 Three studies furthermore reported the integration of PrU prevention and treatment into their orientation of new hires. 18,20,21 In addition to formal activities, several studies described more informal ways of teaching PrU prevention. 9,11,17,22,27,31 One-on-one mentoring, consultation, and support at the bedside through certified nursing staff, training provided in preparation of PrU data collection, and individual case reviews of hospital-acquired PrUs were among the opportunities seized to provide ongoing training ADVANCES IN SKIN & WOUND CARE & APRIL 2012

4 Clinical Monitoring and Feedback. Ongoing clinical monitoring was frequently used to encourage behavior change and ensure compliance with the PrU prevention practices. Staff compliance with existing protocols was monitored through daily, weekly, or monthly rounding of the wound nurses or other nursing staff; regular chart audits; and PrU tracking forms and compliance monitoring tools. 9 13,15,18,21,22,24,26 28,30,31 Additional strategies for continuous improvement included preventability or root-cause analyses when a patient developed a PrU and the development of action plans when results of the surveys were unsatisfactory. 13,18,26 Table 1. STUDIES DESCRIBING MULTIFACETED PRESSURE ULCER PREVENTION PROGRAMS (LISTED IN ALPHABETICAL ORDER) Reference Authors Setting and Scope Team Preparations Best Practices Staff Education Acute care setting 9 Baldelli and Paciella, 2008 Hospital intensive care unit (ICU) medical-surgical Task force (not specified) Risk assessment Skin assessment Head of bed <30 degrees Presentation (at launch) Bedside education (ongoing) Incontinence skin care Turning, positioning Heel elevation Nutritional assessment Pressure relief 10 Bales and Padwojski, 2009 Hospital-wide Wound committee: CWOCN wound champions CWOCN hours increased to full time Analysis of care processes and PrU protocols Literature review on evidencebased practice interventions Computer tool for PrU assessment and initial care, including skin tear protocol Pressure relief surfaces evaluated and purchased PrU prevention algorithm for surgical patients Mandatory education sessions 11 Catania et al, 2007 All 5 inpatient units at hospital (Cancer hospital; USA) Multidisciplinary QI team: Clinical nurse specialist (CNS) Nursing director ET registered nurse (RN) quality manager Staff development specialist Initial intervention: chart audits by CNS Second intervention: assessment of state of practice Risk assessment Skin assessment Individualized care plan based on Braden subscores and linked to products/services available at the facility Initial intervention: Unit in-service sessions Second intervention: Information packets (at launch) CNS available to assist and mentor staff ADVANCES IN SKIN & WOUND CARE & VOL. 25 NO

5 Providing feedback on the quality improvement process and sharing PrU rates with the staff at all levels was a priority reported in the majority of studies. Eight of the 24 studies highlighted the importance of sharing the results from their surveys with the staff by posting the PrU rates on unit billboards; publishing them in unit newsletters; distributing them to unit managers, directors, and senior leadership; or discussing them at staff meetings. 9,12,17,18,20,21,30,32 Skin Care Champions. Seven of the acute care studies created the role of a skin care champion as part of their PrU prevention Clinical Monitoring/Feedback Skin Care Champions Other Elements Sustainability Pressure Ulcer (PrU) Rates Care Process Measures Compliance monitoring: daily unit audits Posting of rates on units and discussion during meetings Continuous support from ET team Turn clocks Theme: Check, Rock & Roll Around the Clock Continued data collection Annual 2-d prevalence/ incidence study For project: monthly prevalence/incidence study Unit-specific action plans if needed 2006: Overall prevalence: 15% Overall incidence: 7% (decreased from year before) Monthly studies: below national benchmark, downward trend Weekly audits on each unit Event forms for each HAPU Daily review of documentation and skin assessments for patients with Braden scores <19 Unit-based wound champions Theme song Two campaigns to maintain staff motivation Quarterly prevalence studies Monthly incidence rates based on event forms for every HAPU Baseline August 2007 Overall prevalence: 9.5% Post December 2008 Overall prevalence: 5.66% HAPU Prevalence: 0% Second intervention: weekly chart audits Continued data collection Quarterly prevalence studies RN: completed protocol PCA: audits chart 3 d later Baseline: May 2003 All: 19.47% HAPUs: 12.39% Post: December 2004 All: 4.11% HAPUs: 2.05% Weekly monitoring of at-risk patients and staff compliance with protocol ADVANCES IN SKIN & WOUND CARE & APRIL 2012

6 Table 1. STUDIES DESCRIBING MULTIFACETED PRESSURE ULCER PREVENTION PROGRAMS (LISTED IN ALPHABETICAL ORDER), CONTINUED Reference Authors 12 Chicano and Drolshagen, 2009 Setting and Scope Team Preparations Best Practices Staff Education 25-bed intermediatecare unit Quality council members (not specified) Assessed staff knowledge Assessed current practices Reviewed existing tools and standards of practice Risk assessment Skin assessment Repositioning schedule Electronic documentation system Revised practice standards for the use of TED stockings and SCDs Updated wound assessment guidelines Staff education 13 Courtney et al, 2006 Hospital-wide Assessment of performance in regard to PrU Assessment of potential gaps/ problems Risk and skin assessment in OR Revised skin breakdown prevention protocol Support equipment 14 De Laat et al, 2006 Hospital-wide (the Nether lands) Hospital guideline for PrU care Pressure-reducing mattresses Introduction of new guidelines during staff meetings or clinical lesson ADVANCES IN SKIN & WOUND CARE & VOL. 25 NO

7 Clinical Monitoring/Feedback Skin Care Champions Other Elements Sustainability Pressure Ulcer (PrU) Rates Care Process Measures Chart audits Staff adherence to guidelines reported during staff meetings Stop skin sign alerts placed on patient charts Quarterly prevalence studies HAPU Incidence: 2005: 6 occurrences within 12 mo 2006: 5 occurrences within 12 mo 2007: 0 occurrences within 12 mo Prevent ability analysis Chart audits Outcome improvement plans SOS champion on each unit PrU pocket guide Theme song Stickers on patient charts Redefinition of roles and responsibilities of process owners Ongoing monitoring of process measures Baseline prevalence/ incidence study 2001 Overall prevalence: 13% 2001 HAPU incidence: 9.4% 2005 HAPU incidence: 1.8% One contact nurse on every unit Continued data collection Baseline HAPU rate: 18% 4-mo Post HAPU rate: 13% 11-mo Post: HAPU rate: 11% Baseline Inadequate preventive measures: 19% Inadequate treatment: 60% Adequate repositioning: 7% 4-mo Post inadequate preventive measure: 4% Inadequate treatment: 31% Adequate repos: 10% 11-mo Post: inadequate preventive measures: 6% Inadequate treatment: 31% ADVANCES IN SKIN & WOUND CARE & APRIL 2012

8 Table 1. STUDIES DESCRIBING MULTIFACETED PRESSURE ULCER PREVENTION PROGRAMS (LISTED IN ALPHABETICAL ORDER), CONTINUED Reference Authors 15 Dibsie, 2008 Hospital-wide Setting and Scope Team Preparations Best Practices Staff Education Multidisciplinary team (not specified) Assessed current practices Standardization of products Organization of supply carts on each unit In-service education 16 Elliott 2010 Three acute-care sites (United Kingdom) Review of previous and current prevention activities to identify areas for improvement Risk assessment Positioning and repositioning documentation Focus on heel ulcer prevention Purchased 350 dynamic mattresses for high-risk patients 17 Elliott et al, bed adult ICU (Australia) One-on-one training (at launch) 18 Gibbons et al, 2006 Hospital-wide Three pilot units Staggered rollout Leadership team (SKIN team): CNO Nurse manager Educator Pharmacist Dietitian 2 staff RNs 2 WOCN Nurse in performance improvement Long-term-care nursing educator Assessed current practices Literature review Expert meeting Initial chart review SKIN bundle Surfaces Keep patients turning Incontinence Nutrition Initial education (at launch) Ongoing education for continuing and new staff Self-study modules ADVANCES IN SKIN & WOUND CARE & VOL. 25 NO

9 Clinical Monitoring/Feedback Skin Care Champions Other Elements Sustainability Pressure Ulcer (PrU) Rates Care Process Measures Weekly rounding and documentation wounds Skin champions representing all areas of the hospital Newsletter Quarterly prevalence studies Baseline: All: 15% HAPUs: 9% Post: HAPU in 2007: 3% (stage 2 and higher) Tissue viability support workers at each site Not reported Project has identified areas in need for continued improvement efforts Annual prevalence study Baseline: February 2009: 15.5% Post: February 2010: 13.4% Documentation of repositioning regimen increased from 6% to 13% Documented evidence for repositioning decreased from 11% to 10% Patients nursed on appropriate mattress increased from 79% to 88% Use of heel protectants increased from 33% to 36% Presentation of data Reminders (not specified) Monthly newsletter Monthly prevalence studies Baseline: 2003 Prevalence: 50% Post: 2005 Prevalence: 8% Compliance monitoring tool (not specified) Root-cause analysis Review results at weekly skin operations meetings SKIN risk reminders placed on nursing clipboards Newsletters Poster Pocket reference cards Continued data collection Identification of other opportunities for PrU prevention Quarterly prevalence studies Annual incidence study HAPU baseline prevalence: 5.7% Incidence: 2004: >2% 2006: <1% No Stage III and IV PrUs between 2004 and ADVANCES IN SKIN & WOUND CARE & APRIL 2012

10 Table 1. STUDIES DESCRIBING MULTIFACETED PRESSURE ULCER PREVENTION PROGRAMS (LISTED IN ALPHABETICAL ORDER), CONTINUED Reference Authors Setting and Scope Team Preparations Best Practices Staff Education 19 Gunningberg and Stotts, 2008 Hospital-wide (Sweden) Development of clinical guidelines (not specified) Education for nurses and nurse assistants Mandatory use of documentation templates Web-based program 20 Hiser et al, 2006 Five participating units (not specified) Wound care team: WOCN ARNP Department manager RNs Physical therapists Dietitians Skin resource team Lit review Assessed policies Assessed knowledge Care planning linked to Braden score PrU prevention protocol PrU/skin tear physician orders Risk assessment with Braden Scale Dietary consults Ostomy supplies updated Annual wound conference Physician education New staff orientation Skills fairs 6 times a year Support surfaces evaluated and changed List of skin care products standardized ADVANCES IN SKIN & WOUND CARE & VOL. 25 NO

11 Clinical Monitoring/Feedback Skin Care Champions Other Elements Sustainability Pressure Ulcer (PrU) Rates Care Process Measures SKIN reminders on patient chart Weekly SKIN operations meeting Medical staff approved standing order for dietitians Cross-sectional prevalence studies 2002 Baseline: 23.9% (all stages) 8% (Stages II-IV) 2006 Post: 22.9% (all stages) 2006: Retrospective chart audit Skin inspection recorded: 41.2% Risk assessment documented 25% 12% (Stages II-IV) No statistically significant decrease Timely feedback to staff Redefinition of role of WOCN Skin resource team Newsletter Resource book Quarterly Prevalencestudies 2002 HAPU Prevalence: 9.2% 2004 HAPU Prevalence: 6.6% ADVANCES IN SKIN & WOUND CARE & APRIL 2012

12 Table 1. STUDIES DESCRIBING MULTIFACETED PRESSURE ULCER PREVENTION PROGRAMS (LISTED IN ALPHABETICAL ORDER), CONTINUED Reference Authors 21 Hopkins et al, 2000 Setting and Scope Team Preparations Best Practices Medical-surgical unit (United States) PrU team (planned the surveys): nurse researcher, skin care clinical nurse specialists, nurse educator, staff nurse, QI representative After each annual survey, implementation of new practices Use of Braden scale AHRQ guidelines for protocols Use of specialty equipment Revise/update protocol Staff Education Continuing education activities Nursing orientation PrU program 22 LeMaster, 2007 Pulmonary and oncology units CNS Group Analyzed HAPU data to identify trends and areas for improvement Baseline knowledge assessment Standard intervention TOE: Turn, Overlay, Elevate Education at regular staff meeting (at launch) Direct consultation services to bedside staff 23 McInerney, 2008 Hospital-wide Heel intervention: task force: critical care physician, podiatrist, risk manager, 2 WOCNs, CMO, CNO, clinical informatics analyst, manager of central distribution, education OR and CC After 18 mo: Review of literature and inspection of heel pressurerelieving devices First intervention Risk assessment Static air overlay for patients with score <16 After 18 mo: Heelift boots Powered air beds for critical care Pressure-reducing mattresses 24 Sacharok and Drew, 1998 Adult medical, surgical, and critical care units Skin care team: RNs, nursing administration, unit manager, WOCN, clinical specialist Rear admirals (skin care resource person, nursing unit representative) Literature review Knowledge and care-delivery patterns assessment Retrospective chart review of PrU incidence Gap analysis PrU protocol developed and approved for use hospital-wide Pressure-reducing mattresses tested and purchased Skin care products evaluated Braden scale on admission and weekly Education at staff meetings Mandatory annual equipment fairs Skin care fair ADVANCES IN SKIN & WOUND CARE & VOL. 25 NO

13 Clinical Monitoring/Feedback Skin Care Champions Other Elements Sustainability Pressure Ulcer (PrU) Rates Care Process Measures Display study results/ present at meetings and conferences Monitor documentation and usage of specialty beds (not specified) Unit skin resource nurse Quick reference of protocols HAPU Prevalence 1996: 18% 1997: 10% 1998: 9% Daily rounding for 6 wk TOE acronym placed on top of turn sheets and algorithms Internal resources manual Implementation of additional cues to help with maintaining practice Quarterly prevalence studies Prevalence rate decreased to zero after implementation First intervention Second WOCN hired Continued data collection Semiannual HAPU prevalence study February 2002: HAPU prevalence: 12.8% July 2003: HAPU prevalence: 5.1% July 2005: HAPU prevalence: 2% July 2006: HAPU prevalence: 2.4% Monthly prevalence rounds by rear admirals Poster on units Pocket reference guide Continued data collection Identification of other opportunities for PrU prevention 1994: Monthly prevalence studies : Quarterly prevalence studies 1994: HAPU prevalence: 19% 1997: HAPU prevalence: 3% Retrospective chart review 1995: HAPU incidence rate 43% lower than in ADVANCES IN SKIN & WOUND CARE & APRIL 2012

14 Table 1. STUDIES DESCRIBING MULTIFACETED PRESSURE ULCER PREVENTION PROGRAMS (LISTED IN ALPHABETICAL ORDER), CONTINUED Reference Authors Setting and Scope Team Preparations Best Practices Staff Education Multidisciplinary consultations (nutrition, physical therapy, ET) Nursing care flow sheet redesign Standardization of products 25 Stausberg et al, 2006 and 2009 Hospital-wide (Germany) Interdisciplinary team: Nurses Physicians Information technology specialists and researchers PrU prevention guidelines Risk assessment and derivation of preventive measures Optimization of pressure system supply Introduction of special foam mattresses Staff training 26 Stoelting et al, 2007 Hospital-wide Wound ostomy management team (not specified) Braden Scale for risk assessment PrU prevention protocol Staff education 27 Young et al, 2010 Hospital-wide Clinician-led task force Literature review Assessment of stakeholders and environmental readiness for change Revised and updated skin care policy New support surfaces evaluated and selected Standardized patient turning schedule Education of nurses through mandatory continuing educational sessions Monthly updates from unit champions New skin care products 28 Young et al, 2003 Acute care, rehabilitation center, and skilled nursing unit (United States) 2 ET nurses (not specified) Braden scale Weekly/biweekly assessment of patients at risk Standard protocol with interventions In-service Hospital-wide conferences Physician education ADVANCES IN SKIN & WOUND CARE & VOL. 25 NO

15 Clinical Monitoring/Feedback Skin Care Champions Other Elements Sustainability Pressure Ulcer (PrU) Rates Care Process Measures Retrospective analysis of electronic hospital data Point prevalence rates increased significantly from 1.44% in year 1 to 1.77% in year 4 Incidence rate increased from 0.56% to 0.65% PrU tracking form Individual case reviews and plans of actions Wound ostomy unit champion Red Dot initiative (not specified) Continued data collection Prevalence study Second inspection of patients 4 d later Incidence rate dropped from 7% to 4% Monthly chart audits Unit champions Save Our Skin logo Prevalence and incidence study: Laminated copy of Braden scale placed at each patient s bedside Fall 2006: HAPU incidence Campus 1: 12.5% Campus 2: 8.7% Campus 3: 0% Spring 2007: HAPU incidence Campus 1: 9.1% Campus 2: 2.8% Campus 3: 0% Weekly prevention assessment rounds Expanded role of ET nurse from treatment to prevention Increased from 1 to 2 full-time equivalent ET Identification of other opportunities for PrU prevention Quarterly prevalence walks (results not reported) Incidence measured : 55% decrease in PrU incidence Compliance with skin assessment on admission: increased to 97% ADVANCES IN SKIN & WOUND CARE & APRIL 2012

16 Table 1. STUDIES DESCRIBING MULTIFACETED PRESSURE ULCER PREVENTION PROGRAMS (LISTED IN ALPHABETICAL ORDER), CONTINUED Reference Authors Setting and Scope Team Preparations Best Practices Staff Education Highlighted in patient chart Individual turn schedules ET nurse PrU consult sheets Evaluation/ monitoring of specialty products Long-term-care setting 29 Abel et al, long-termcare facilities QIO (not specified) Care planning tool Patient/family education tool Training for nursing home staff Communication form to physicians 30 Baier et al, long-termcare facilities QI teams at each site (not specified) Use of QI approach based on Plan-Study-Act, tailored to each facility 31 McKeeney, long-termcare facilities (United Kingdom) Tissue viability service (not specified) 1 wound nurse Audit tool completed to assess improvement areas Action plan based on outcomes of audit Two formal small group training sessions (at launch) Ongoing support, advice, and education of nursing staff ADVANCES IN SKIN & WOUND CARE & VOL. 25 NO

17 Clinical Monitoring/Feedback Skin Care Champions Other Elements Sustainability Pressure Ulcer (PrU) Rates Care Process Measures External facilitation: Periodic visits by QIO Reference cards Wound assessment guide Visual reminder of mobility needs Incidence rate (no significant decrease): Baseline: 13.6% Post: 10% Pre/Post dataabstracted from medical records to Measure 12 quality indicators Mixed results Improvement in 8 out of 12 measures Relationship between improved QI scores and incidence rates Audit and feedback External facilitation: Individual mentoring for each QI team Collaboration among nursing homes Guidebook for PrU prevention 12 process measures (data abstracted from records) Did not measure prevalence/incidence rates Measured at baseline and at follow-up after 1 y Mixed results:9of12 process measures showed significant improvement (aggregate across all facilities) Rounding of wound nurse Tissue viability link-nurse in each longterm-care facility Manual of pressure relieving equipment Audit tool: 9 care processes at baseline and after 8 wk Overall benchmark improved at all sites Action plan to work on problem areas identified through audit ADVANCES IN SKIN & WOUND CARE & APRIL 2012

18 Table 1. STUDIES DESCRIBING MULTIFACETED PRESSURE ULCER PREVENTION PROGRAMS (LISTED IN ALPHABETICAL ORDER), CONTINUED Reference Authors Setting and Scope Team Preparations Best Practices Staff Education through wound care sister 32 Rosen et al, 2006 Long-termcare facility Research team Interacting with administration (not specified) 4-wk training period prior to intervention (mandatory staff training) * 2011 Niederhauser, VanDeusen Lukas, Parker, Ayello, Zulkowski, Berlowitz. Abbreviations: ARNP, advanced registered nurse practitioner; CMO, Chief Medical Officer; CNO, Chief Nursing Officer; OR, operating room; CC, critical care; ET, enterostomal therapist; CWOCN, certified wound, ostomy and continence nurse; HAPU, hospital-acquired pressure ulcers; QI, quality improvement; QIO, quality improvement organization; TED, thrombo embolic deterrent (stockings); SCD, spinal cord disease; SOS, Save Our Skin (name of campaign). program. 10,13 15,21,26,27 The roles and responsibilities of skin care champions varied slightly from site to site. Generally, the staff members received additional training in PrU treatment and prevention, and their responsibilities included a combination of the following elements: to introduce the new policies and interventions on the unit, to serve as skin care resource and mentor to coworkers, to serve as liaison between the unit and other parties involved in the improvement efforts, and to participate in the data collection and ongoing process monitoring. Other Elements. To increase awareness and provide cues to action for consistent and correct implementation of the new clinical practices, several programs utilized audiovisual support and other isolated activities. 9,10,12,13,15,17,18,20 22,24,27,29 32 Examples of these support elements included use of turn clocks, stickers in the patient charts or outside patient rooms to identify patients with PrUs or at risk for developing one, PrU pocket guides and reference cards, theme songs played every 2 hours, penlights for skin assessments, weekly skin care newsletters, posters on the units, and manuals or guidebooks on skin care products, support equipment, or PrU prevention and treatment protocols. Another strategy to ensure continued awareness of the program was the development of acronyms and themes related to the program. The following themes were identified in the reviewed literature: Check, Rock & Roll Around the Clock 9 ; PUPPI (Pressure Ulcer Prevention Protocol Interventions) 11 ; Save Our Skin 13,27 ; SKIN (Surfaces, Keep the patients turning, Incontinence management, Nutrition) 18 ; and TOE (Turn, Overlay, Elevate). 22 Strategies to Sustain Efforts. It is not evident in the literature if initiatives were discontinued after completion of the project period, or whether all or certain intervention components were continued even after the formal study phase. A number of studies, however, suggested ongoing measurement and reporting of PrU rates as a strategy for ensuring continued awareness of PrU prevention. 9,11,13,14,18,23,24,26 Four studies reported identification of new practice issues as a way for sustaining the momentum of the prevention efforts. 16,18,24,28 Finally, 1 study noted that additional visual and auditory cues were introduced after completion of the study to ensure consistent adherence to PrU prevention protocols. 22 ADVANCES IN SKIN & WOUND CARE & VOL. 25 NO

19 Clinical Monitoring/Feedback Skin Care Champions Other Elements Sustainability Pressure Ulcer (PrU) Rates Care Process Measures Evaluation form for training sessions Weekly feedbacks on staff compliance with training Weekly reports by management to staff of PrU incidence Penlights for skin assessment Caregivers required to wear TAP card Monitored the incidence of PrUs during the 48-wk program Baseline HAPU incidence: 28.3% $75 if the incidence of PrUs was reduced below the goal $10 for completion of training program Intervention HAPU incidence: 9.3% Reduction of PrU incidence was highest during the 12-wk intervention phase; results were not sustained without the support of the research team Outcomes PrU Rates. The majority of studies reported positive outcomes from their PrU prevention initiatives; however, P values assessing statistical significance were rarely reported. Almost all of the reviewed studies measured PrU prevalence rates before and after implementation of their quality improvement projects Seven studies did not sufficiently describe the results of their prevalence surveys to draw meaningful conclusions. 12,13,18,22,26 28 Eleven studies saw a decrease in prevalence rates over the course of the study period, 9,10,11,14 17,20,21,23,24 whereas 2 programs reported no significant changes. 19,25 Ten studies reported PrU incidence rates. 9,12,13,18,24 29,32 Eight of these studies reported a decrease in rates between baseline and follow-up; 1 study reported that incidence rates increased between project year 1 and year 4 without statistical significance, 25 and 1 study noted that results could not be sustained during the postimplementation phase. 32 Care Processes. Process measures were reported by 2 acute care-setting studies 14,16, and 3 long-term-care-facility studies One acute care-setting study measured the use of a new mattress and implementation of a repositioning schedule and found no significant change in preventive behavior when the use of new support mattresses was not taken into account. 14 The other acute care study reported minimal improvements in some of the measured care processes. 16 Among the 3 multisite long-term-care facility programs, one reported an overall improvement of clinical practice benchmarks across all participating facilities after implementation of the 8-week program. 31 The other 2 multisite studies saw significant improvement in 8 of 12 and 9 of 12 care processes when aggregated across the participating sites. 29,30 Other Outcomes. Positive outcomes, such as increased staff awareness and knowledge, as well as change in attitudes toward PRESSURE ULCER TOOLKIT This literature review was performed as part of the process for developing a toolkit to reduce PrUs using a multifaceted quality improvement approach. The free toolkit is available on the Agency for Healthcare Research and Quality s website: ADVANCES IN SKIN & WOUND CARE & APRIL 2012

20 PrU prevention, were noted in several of the articles. However, reports of these outcomes were mostly anecdotal and were not validated by any formal evaluation. DISCUSSION This review showed that there is an array of studies describing the use of multipronged initiatives to prevent PrU development among patients in hospitals and long-term-care facilities. Moreover, many programs reported impressive improvements in PrU prevalence or incidence rates. These results suggest that multifaceted, multidisciplinary programs are effective in preventing PrUs. A number of approaches were widely used as components of the multipronged approach and are likely to contribute to its success. In preparation of implementation, literature reviews or assessment of the current state of PrU practice was often used to provide a baseline for the data collection and identify areas in need for improvement. Intervention components included the use of a bundle of best practices for PrU prevention, the reliance on a unit skin care champions, and an emphasis on staff education. Strategies to generate staff enthusiasm and increase awareness and adherence to the best practices, such as turning clocks or skin care newsletters, often were used. The involvement of frontline staff members in all stages of program design and implementation was considered to be essential by many studies to ensure staff engagement, ownership, and dedication. Providing frequent real-time data feedback and giving staff credit for improvement, celebrating success, and stimulating a healthy competition among the units were frequently described as ways of engaging the staff and providing them a sense of pride in their accomplishments. Finally, regular monitoring of charts, weekly or monthly rounding, and root-cause analysis to examine what went wrong when a PrU developed were also used successfully. Few studies commented on long-term sustainability of the intervention, and there was little in the literature to suggest how improvements could be maintained. Continuous monitoring of PrU rates, the presence of a wound care team or unit champions, and continued formal and informal education seemed to be some of the elements that could positively influence the maintenance of positive outcomes. Despite the number of studies showing benefit, results must be interpreted with caution. Foremost, the level of evidence is weak. Studies mostly consisted of a longitudinal 1-group pretest-posttest design. They have neither randomization to interventions nor control groups. Description of methods for data collection and analysis was often neglected in the publications. Only 5 studies reported process measures. This makes it difficult to determine whether the interventions contributed to increased staff compliance with new PrU prevention practices. In addition, some of the studies that measured care processes showed that albeit improved, adherence to certain best practices still remained low. One of the studies, for example, found that the proportion of residents with appropriate risk assessment completed within 2 days of admission increased from 2.2% to only 15.3%, whereas the proportion of residents with PrUs that receive weekly skin assessments increased from 12.6% to 32.8%. 29 Furthermore, the components of the multifaceted programs were not evaluated individually, and it is therefore not possible to determine the impact of each single component. There is also a high likelihood of publication bias. Nearly all published studies were positive in showing a benefit. Given the multitude of interventions, it is not plausible that all programs would work. More likely, those programs that showed a benefit were more likely to be written up and published. Finally, studies generally did not describe or analyze the processes by which the new programs were implemented, the challenges they faced, and how they did overcome them. However, organizational change requires attention not only to the content of the program, but also to the strategies needed to implement the program. CONCLUSION Improving PrU prevention remains an important issue for hospital patients. This literature review has identified many components that have consistently been included in successful multifaceted PrU interventions. A review of the studies supports previously reported exemplars of success in PrU reduction initiatives. This includes administrative support with active involvement of clinical staff at the patient care level, bundling of care practices and infusing them into routine care practice, creating systemwide change and communication that is individualized to the institution s culture, making visible the documentation of PrU prevention practices, and regular education of all levels of staff. 33 Prevention practices of risk assessment, pressure redistribution and repositioning, and attention to skin care are common bundle care elements. It appears that the more care practices are incorporated into usual care practices, the more staff are apt to perform them and not see them as another task to perform. For example, including skin inspection while taking vital signs and reporting a patient s PrU risk assessment status as part of the patient s handoff report are ways for staff to consistently perform suggested prevention interventions. The best outcomes are a result of PrU prevention bundle care practices performed consistently. Pressure ulcer quality improvement teams that are empowered within their institutions appear to have more success. No one composition of the team has been identified as being best; ADVANCES IN SKIN & WOUND CARE & VOL. 25 NO

21 each institution must decide what mix of the interdisciplinary team needs to be included in its oversight of PrU reduction initiatives. Pressure ulcer reduction initiatives should be customized and prioritized for the needs of professionals in that institution. 34 Making too many changes at one time may impact the sustainability of PrU prevention practices. Dahlstrom et al 35 found that also changing to an electronic medical record at the same time as their PrU prevention program decreased gains previously seen. Virani et al 36 have summarized factors that contribute to poor sustainability of evidence-based practices, including inadequate time for teaching new practices to staff, inadequate attention to barriers of acceptance of new practices, and organizational factors such as inadequate resources for equipment/supplies and infrastructure support. They recommend that sustainability of practice changes therefore requires systematic, thoughtful planning and action to ensure that the changes are embedded into the various knowledge reservoirs in the organization. 36 The authors agree with Virani et al, 36 who believe that a regular review of research literature and practice guidelines should be used to evaluate an institution s PrU practices. What did not work in one institution might work in another. Facilities that have implemented PrU programs, successfully or not, should be encouraged to rigorously evaluate their programs and publish their results to strengthen the level of evidence.& PRACTICE PEARLS & The review of the literature supports multi-disciplinary, bundled approaches to PrU prevention. & No one approach has been identified as being best; institutions should carefully plan and customize PrU prevention programs according to their needs and abilities. & PrU prevention programs require attention to content, as well as implementation and sustainability strategies. & Institutions having implemented PrU prevention programs are encouraged to share their strategies and results so that others can learn from the experience. REFERENCES 1. VanGilder C, Amlung S, Harrison P, Meyer S. Results of the International Pressure Ulcer Prevalence Survey and a 3-year, acute care, unit-specific analysis. Ostomy Wound Manage 2009;55(11): HealthGrades. The Sixth Annual HealthGrades Patient Safety in American Hospitals Study pdf. Last accessed 02/02/ Inpatient Prospective Payment System FY 2009 Final Rule (HAC Section begins on page 39) Last accessed January 25, Pancorbo-Hidalgo PL, Garcia-Fernandez FP, Lopez-Medina IM, Alvarez-Nieto C. Risk assessment scales for pressure ulcer prevention: a systematic review. J Adv Nurs 2006; 54(1): McInnes E, Bell-Syer SE, Dumville JC, Legood R, Cullum NA. Support surfaces for pressure ulcer prevention. Cochrane Database Syst Rev 2008;(4):CD Rich SE, Shardell, M, Margolis D, Baumgarten M. Pressure ulcer prevention device use among elderly patients early in the hospital stay. Nurs Res 2009;58: Lyder CH, Preston J, Grady JN, et al. Quality of care for hospitalized Medicare patients at risk for pressure ulcers. Arch Intern Med 2001;161: Saliba D, Rubenstein L, Simon B, et al. Adherence to pressure ulcer prevention guidelines: implications for nursing home quality. J Am Geriatr Soc 2003;51(1): Baldelli P, Paciella M. Creation and implementation of a pressure ulcer prevention bundle improves patient outcomes. Am J Med Qual 2008;23: Bales I, Padwojski A. Reaching for the moon: achieving zero pressure ulcer prevalence. J Wound Care. 2009;18: Catania K, Huang C, James P, Madison M, Moran M, Ohr M. Wound wise: PUPPI: the Pressure Ulcer Prevention Protocol Interventions. Am J Nurs 2007;107(4): Chicano SG, Drolshagen C. Reducing hospital-acquired pressure ulcers. J Wound Ostomy Continence Nurs 2009;36(1): Courtney BA, Ruppman JB, Cooper HM. Save our skin: initiative cuts pressure ulcer incidence in half. Nurs Manage 2006;37(4):36, 38, 40 passim. 14. De Laat EH, Schoonhoven L, Pickkers P, Verbeek AL, Van Achterberg T. Implementation of a new policy results in a decrease of pressure ulcer frequency. Int J Qual Health Care 2006;18: Dibsie LG. Implementing evidence-based practice to prevent skin breakdown. Crit Care Nurs Q 2008;31: Elliott J. Strategies to improve the prevention of pressure ulcers. Nurs Older People 2010; 22(9): Elliott R, McKinley S, Fox V. Quality improvement program to reduce the prevalence of pressure ulcers in an intensive care unit. Am J Crit Care 2008;17: Gibbons W, Shanks HT, Kleinhelter P, Jones P. Eliminating facility-acquired pressure ulcers at Ascension Health. Jt Comm J Qual Patient Saf 2006;32: Gunningberg L, Stotts NA. Tracking quality over time: what do pressure ulcer data show? Int J Qual Health Care 2008;20: Hiser B, Rochette J, Philbin S, Lowerhouse N, Terburgh C, Pietsch C. Implementing a pressure ulcer prevention program and enhancing the role of the CWOCN: impact on outcomes. Ostomy Wound Manage 2006;52(2): Hopkins B, Hanlon M, Yauk S, Sykes S, Rose T, Cleary A. Reducing nosocomial pressure ulcers in an acute care facility. J Nurs Care Qual 2000;14(3): LeMaster KM. Reducing incidence and prevalence of hospital-acquired pressure ulcers at Genesis Medical Center. Jt Comm J Qual Patient Saf 2007;33:611-6, McInerney JA. Reducing hospital-acquired pressure ulcer prevalence through a focused prevention program. Adv Skin Wound Care 2008;21: Sacharok C, Drew J. Use of a total quality management model to reduce pressure ulcer prevalence in the acute care setting. J Wound Ostomy Continence Nurs 1998;25: Stausberg J, Lehmann N, Kröger K, Maier I, Schneider H, Niebel W. Interdisciplinary decubitus project. Increasing pressure ulcer rates and changes in delivery of care: a retrospective analysis at a university clinic. J Clin Nurs 2010;19(11-12): Stoelting J, McKenna L, Taggart E, Mottar R, Jeffers BR, WendlerMC. Prevention ofnosocomial pressure ulcers: a process improvement project. J Wound Ostomy Continence Nurs 2007;34: Young J, Ernsting M, Kehoe A, Holmes K. Results of a clinician-led evidence-based task force initiative relating to pressure ulcer risk assessment and prevention. J Wound Ostomy Continence Nurs 2010;37: Young ZF, Evans A, Davis J. Nosocomial pressure ulcer prevention: a successful project. J Nurs Adm 2003;33: Abel RL, Warren K, Bean G, et al. Quality improvement in nursing homes in Texas: results from a pressure ulcer prevention project. J Am Med Dir Assoc 2005;6: Baier RR, Gifford DR, Lyder CH, et al. Quality improvement for pressure ulcer care in the nursing home setting: the Northeast Pressure Ulcer Project. J Am Med Dir Assoc 2003;4: ADVANCES IN SKIN & WOUND CARE & APRIL 2012