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?
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 2010. 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.
Twenty-four articles were identified describing comprehensive PrU prevention programs. Twenty studies described single-site 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 Pprocesses when aggregated across the participating sites.29,30>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 one17 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.29–32
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 members9–13,15–28 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
Preparations. Twelve of the reviewed studies specified a set of activities completed prior to developing and implementing their initiatives.10–13,15,16,18,20,22,24,27,31 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-air loss 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 studies13,16,23,30 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.
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
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 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
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.9–28 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 studies14,16 and 3 long-term-care-facility studies.29–31 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 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.
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.
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; 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 al35 found that also changing to an electronic medical record at the same time as their PrU prevention program decreased gains previously seen. Virani et al36 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.
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