|Type of Patient Safety Practice
|Clinical Practice (CP)
Related practices from PaSQ database
|"Best fit" category of the reported practice
|Patient safety theme the SCP/clinical risk management practice is aimed at
|Prevention and treatment of pressure ulcers in at risk patients, through electro-mechanically powered/ assisted pulsed air-flow cyclic pressure-relieving, anti-sores support surfaces
|Objective of the CRM practice
|After reviewing the literature, several studies point towards a reduction in pressure ulcers. As it may be seen from the variety from intervention no particular intervention is superior to another.
There are benefits to several interventions, which reduce pressure ulcers incidence in at risk patient. The clearest conclusion one can draw is that standard hospital mattresses have been consistently outperformed by a range of foam-based, low pressure mattresses and overlays, and also by “higher-tech” pressure relieving beds and mattresses in the prevention of PU (what is standard varies by hospital, country and over time) [p. 13, 8]
|Short description of the CRM practice, including any references for further information
|The different interventions to prevent pressure ulcers are for example: “Alternative foam mattresses and low-air-loss beds, whereas bed over layers were not considered as that promising [1, 4].
|Innovator of the SCP, country of origin
|Spain , UK [1,11, 15], the Netherlands , USA (Washington, Chicago, Los Angeles) [5, 12, 7], USA, Canda  and Europe in gerneral, France , Germany , Australia 
|Involved health care staff
|Nurses as main type of health care professional involved, however other care givers, physicians and even the patient him / herself would need to be involved, depending on which intervention is chosen.
|Tested in which countries/health care systems, health care context(s) and/or clinical specialty/specialties, including references
|1. Health care context: (university) hospitals, [p.5, 11],
2. Specialty: Intensive Care units [p. 14, 10], surgical unit [p.57, 2], tertiary referral facility for (heart surgery and liver transplantation) [p.3, 3], acute care facilities [p. 268, 4], cardiological and surgical intensive care [p. 413 –abstract, 6], nephrological intensive care, vascular, orthopedic, medical, or care of elderly people wards 
|Summary of evidence for effectiveness, including references
|After reviewing the literature, several studies point towards prevention methods aimed to pressure ulcers in at risk patients. There is a variety of types of interventions. When compared, several interventions seem to prove relative effectiveness. However, some interventions reduce pressure ulcers incidence in at risk patients more effectively than others.
The clearest conclusion one can draw is that standard hospital mattresses have been consistently outperformed by a range of foam-based, low pressure mattresses and overlays, and also by “higher-tech” pressure relieving beds and mattresses in the prevention of PU (what is standard varies by hospital, country and over time) [p. 13, 8].
A systematic review was carried out to define what are the effects of preventive interventions in people at risk of developing pressure ulcers and what are the effects of treatments in people with pressure ulcers [p.1, 1].
Unrelieved pressure or friction of the skin, particularly over bony prominences, can lead to pressure ulcers in up to a third of people in hospitals or community care, and a fifth of nursing home residents [p. 2, 1].
The following interventions, were compared for their effectiveness and safety:
1. Higher-category pressure redistribution mattresses are considered a critical component of a pressure ulcer prevention program [p.55, 2]
2. “Alternative foam mattresses (such as viscoelastic foam) reduce the incidence of pressure ulcers in people at risk compared with standard hospital foam mattresses, although we don’t know which is the best alternative to use.” [p. 2, 1]. “Foam alternatives may be more effective at 10-14 days at reducing the incidence of pressure ulcers in people at high risk of developing pressure ulcers“ [p.3, 1] “Compared with each other foam mattresses consisting of five sections may be more effective than a 4-inch thick dimpled foam mattresses at reducing the risk of pressure ulcers [p.3, 1].
3. “Low-air-loss beds may reduce the risk of pressure ulcers compared with standard intensive-care beds, but we don’t know whether pressure-relieving overlays on operating tables are also beneficial compared with other pressure-relieving surfaces” [p. 2, 1].
4. “Medical sheepskin overlays may reduce the risk of pressure ulcers compared with standard care” [p. 2, 1].
5. “Hydrocellular heel supports may decrease the risk of pressure ulcers compared with orthopedic wool padding, but air-filled vinyl boots with foot cradles and low-air-loss hydrotherapy beds may increase the risk of ulcers compared with other pressure-relieving surfaces” [p. 2, 1].
6. “air-fluidised supports may improve healing compared with standard care, although they can make it harder for people to get in and out of bed independently” [p. 2, 1]. 7. “Compared with each other pressure-reducing cushions, foam seat cushions and foam-and-gel seat cushions seems equally effective” [p.6, 1].
7.1 “In prevention, a structured foam mattress is more efficient than a standard hospital mattress” [pp. 7, 14].
8. Higher-category pressure redistribution mattresses are considered a critical component of a pressure ulcer prevention program [p.55, 2]
8.1 A prospective, comparative cohort study monitored the prevalence of Hospital-acquired pressure ulcers (HAPU) in hospitals and compared rates of matched medical-surgical units with and without low-air-loss beds. [p.55, 2]
9. Researchers reported that low-air-loss beds significantly decreased the incidence of PU when compared to a standard hospital bed although the characteristics of the standard bed were not well described. [p.56, 2]
9.1 “low-air-loss beds did not lead to significantly lower HAPU prevalence rates across paired units with shared staff. Low-air-loss mattresses are designed to reduce PU risk by removing excess heat and moisture from the skin surface and continuously redistributing body weight” [p.59, 2]
Our findings underscore the need for nurses caring for patients to continue all appropriate PU preventive measures for individual patients, even where they are placed on higher category pressure redistribution surfaces such as low-air-loss beds. [p.60, 2]
A prospective quasi-experimental study was conducted among patients in the medical-surgery intensive care unit to compare the effectiveness of alternating pressure air mattresses vs. overlays to prevent pressure ulcers. [p, 1, 3]
for patients with in need of a longer type of mechanical ventilation,
10. Alternative pressure air mattresses were more effective than alternating pressure air overlays in preventing pressure ulcers in mechanically ventilated critical care patients. (p.7) - [pp.6, 7, 3]
10.1 an alternating pressure mattress is more effective than a visco-elastic mattress limiting the occurrence heel pressure ulcers [p. 7, 14] 11. Critically ill subjects placed on low air loss beds with microclimate management in surgical ICUs had a lower pressure ulcer incidence than those placed on integrated powered air pressure redistribution beds [p. 267 – abstract, 4]
12. In acute care facilities in Holland, de Laat and associates reported that the incidence density of grades II to IV PUs decreased from 54 per 1000 patient days at baseline to 32 peer 1000 days 12 months after implementation. [p. 268, 4] 12.1 The implementation of the 2009 International Pressure Ulcer Prevention and Treatment guidelines for pressure ulcer care resulted in a significant and sustained decrease in the development of grade II-IV pressure ulcers in critically ill patients. [p. 817, 5]
12.2 the median pressure ulcer-free time increased from 12 days to 19 days [p. 818, 5] the number of preventive transfers to special mattresses was the strongest indicator for the decreased risk of pressure ulcers. [p. 815 – abstract]
12.3 the number needed to treat to prevent one pressure ulcer during the first 9 days was 6. [p. 818, 5]
12.4 Both the decrease in pressure ulcer incidence and the increase in the pressure ulcer-free time were associated and could therefore be attributed to the increased frequency of preventive patient transfers to a specific pressure-reducing mattress. [p. 819, 5]
12.5 Timely transfer to a specific mattress (i.e., transfer before the occurrence of a pressure ulcer) was the main indicator for a decrease in pressure ulcer development. [p. 815. abstract, 5] - an indicator of increased adherence to the guideline and increased quality of care that accounted for the observed reduction in pressure ulcer incidence [p. 819, 5]
12.6 Some preventive measures, such as foam mattresses and alternating air pressure mattresses, probably have a positive effect on preventing pressure ulcers among intensive care patients as well. [p 420, 6]
13. Faster healing and better function indicate that treatment using the generic total contact seat is superior to low air loss bed therapy, which is standard care for advanced pressure ulcers. [p. 1733 – abstract, 7]
13.1 The studies reported effects on healing with subjects spending time in the more physiologically beneficial position of upright sitting, as opposed to being restricted to bed. [p. 1742, 7]
13.2 The researchers’ hypothesis were that the healing rates of stage II and IV pressure ulcers for subjects on the generic total contact seat would be at least as good as the rates for patients on low air loss bed surface, and that subjects using the generic total contact seat would be more functional than those lying on a low air loss bed surface [p. 1733 – abstract, 7]
14. A randomized controlled study conducted at the Schwab Rehabilitation Hospital in Chicago concluded that the individualized cyclic pressure relief may have substantial benefits in accelerating the healing process in wheelchair users with existing PUs, while maintaining the mobility of individuals with SCI during the PU treatment. [p. 514, 12]
15. Active therapy system mattress have seen a consistent reduction on both the number and the severity of […] pressure ulcers within the ICU
|Summary of evidence for transferability (transferability across health care systems or health care contexts or clinical specialties), including references
|The literature seems to indicate that the different interventions to prevent pressure ulcers are transferable across health care systems (Spain, England,. Chicago, Germany) and clinical specialities (nurses, carers, physicians). Below, there are excerpts attesting to transferability from different articles.
1. A prospective quasi-experimental study was conducted among patients in the medical-surgery intensive care unit of a university hospital on mechanical ventilation ?24 hours during two time periods (2001 and 2006). [p.1, 3]
2. In in de Laat and associates studied the effect of implementing a PU guideline that included placing patients on specialty mattresses.
3. A guideline for pressure ulcer care was implemented on all intensive care units [p. 815, 5]
4. Incidence studies concerning pressure ulcers in intensive care units in Germany can be transferred to other countries’ care units since pressure ulcer incidences are a common problem in various countries such as the Netherlands. [p. 414, 6]
5. Over 1 separate 18-months period, subjects with PU were recruited by contacting staff from long term care facilities at UCLA, community nursing homes and the Greater Los Angeles Veterans Administration Medical Center (VAMC) [p. 1733 – abstract, 7], which can indicate a certain degree of transferability given also the diversity of recruitment settings, as well as the RCT which compared altering pressure mattresses with alternative pressure overlays was performed in 11 hospitals in six NHS trusts [pp.1, 15]
6. Another randomized controlled study was conducted at the Schwab Rehabilitation Hospital in Chicago [p. 515, 12]
|Summary of available information on feasibility, including references
|1. Based prevention guidelines, Medicare regulations that lowered payment for care related to stage III and IV HAPUs went into effect in 2008 [p.55, 2]
2. “findings underscore the need for nurses caring for patients to continue all appropriate PU preventive measures for individual patients, even were they are placed on higher category pressure redistribution surfaces.” [p.60, 2] 3. This quasi-experiment study that alternative pressure air mattresses were more effective than alternating pressure air overlays in preventing pressure ulcers in mechanically ventilated critical care patients [p.6, 3]
4. Need of and supporting innovators (contact nurses) and investing in nurses who were enthusiastic about improving pressure ulcer care, the so-called early adopters [p. 818-819, 5]
Important characteristics for a feasible intervention:
1. Regular visits (twice a week) to the ICUs, positive feedback during the study period, and organization of meetings on topics concerning pressure ulcer prevention for contact nurses after the implementation of the guideline [p. 819, 5]
2. Conscious of costs since pressure ulcers have been described as one of the most costly and physically debilitating complications in the 20th century [p 414, 6, p. 1733, 7, p.1 –abstract, 8, p.5, 13], since e.g. bed replacement and foam over layers may cost between 100 and L30,000 [p. 3, 8]
2.1. There is a higher probability (64%) that alternating mattress replacements are cost-saving; they were associated with lower overall costs (74.50 pounds sterling per patient on average, mainly due to reduced length of stay) and greater benefits (a delay in time to ulceration of 10.63 days on average). (p. 58)
2.2. One trial showed that low air-loss beds were more cost-effective at decreasing the incidence of pressure ulcers in critically ill patients than a standard ICU bed (Inman 1993) [p. 12, 8]
2.3. France: some financial outlays are reimbursed by national health insurance [p. 2, 14]
3. Identification of people at high risk and use of prevention strategies (pressure-relieving equipment) in order to provide best available evidence
|Existing implementation tools, including references
|1. Braden Scale for Pressure Sore Risk [p. 6, 1, p.269, 4, p 413 – abstract, 6, p. 9, 8, p. 3, 11]
1.1. 6 subscales, sensory-perception, moisture, mobility, activity, nutrition, and friction and shear, used to describe PU risk [p.269, 4]
2.International Pressure Ulcer Guideline
3. The National Institute for Health and Clinical Excellence guidelines [p.55, 2]
4. Waterloo Pressure Sore Risk [p.269, 4, p. 9, 8]
5. Royal College of Nursing Clinical Practice Guideline on pressure ulcer risk assessment and prevention
5.1.Rrisk assessment tools should only be used as an aide-memoire and should not replace clinical judgment [p. 3, 11]
6. Scale of Norton (Norton1996) [p.269, 4, p. 9, 8]
7. Acute Chronic Health Evaluation (APACHE) III score (Knaus et al. 1991),
8. individual and total sequential organ failure assessment (SOFA) scores [p. 3, 3]
9. In PUSH (Pressure Ulcer Scale for Healing) [p. 514, 12]
10. Gosnell guideline. [p. 9, 8]
11. Grading of Recommendation Assessment, Development, and Evaluation (GRADE) system [p. 5, 13]
|Potential for/description of patient involvement in the CRM practice, including references
|1. “In people with pressure ulcers, air-fluidised supports may improve healing compared with standard care, although they can make it harder for people to get in and out of bed independently” [p.2, 1].
2. Interaction while seating and moving [1733, 7]
2.1. Subjects were placed on the generic total contact seat for 1 session a day for as log as tolerated, but never for more than 4 hours.
2.2. After each session, subjects were returned to their hospital beds and were turned every 2 hours.
2.3. Subjects from the 2 nd group were placed on an overlay atop a standard hospital bed and were turned every 2 hours.
2.4. Subjects from the third group were placed on a low air loss bed preset for body weight, height, girth, and optimum air flow.
2.5. (subjects assigned to low air loss bed do not need to be turned, but in practice for this study, they were turned every 2 hours because that was standard nursing procedure) [p. 1737, 7]
3. Group used wheelchairs equipped with an individually adjusted automated seat that provided cyclic pressure relief, [...] sat in wheelchairs for a minimum of 4 hours per day for 30 days during their PrU treatment. [p. 514, 12]
|Bibliography (for each reference: author(s), year, title, journal/internet link, page(s))
| Cullum N, Petherick E. (2008): Pressure ulcers. In: SourceDepartment of Health Sciences, University of York, York, UK. pii: 1901. Clinical Evidence (Online). 2008: 1901.
 Johnson J, Peterson D, Campbell B, Richardson R, Rutledge D. (2011): Hospital-acquired pressure ulcer prevalence - evaluating low-air-loss beds. In: J Wound Ostomy Continence Nurs. 38(1):55-60. Erratum in: J Wound Ostomy Continence Nurs. 2011 38(4):347
 Manzano F, Pérez AM, Colmenero M, Aguilar MM, Sánchez-Cantalejo E, Reche AM, Talavera J, López F, Barco SF, Fernández-Mondejar E. (2013): Comparison of alternating pressure mattresses and overlays for prevention of pressure ulcers in ventilated intensive care patients: a quasi-experimental study. In: SourceICU, HU Virgen de las Nieves, Granada, Spain. © 2013 Blackwell Publishing Ltd. In: Journal of Advanced Nursing
 Black J, Berke C, Urzendowski G. (2012): Pressure ulcer incidence and progression in critically ill subjects: influence of low air loss mattress versus a powered air pressure redistribution mattress. In: J Wound Ostomy Continence Nurs. 39(3):267-73.
 de Laat EH, Pickkers P, Schoonhoven L, Verbeek AL, Feuth T, van Achterberg T. (2007): Guideline implementation results in a decrease of pressure ulcer incidence in critically ill patients. In: Critical Care Medicine 35(3):815-20.
 Shahin ES, Dassen T, Halfens RJ. (2009): Incidence, prevention and treatment of pressure ulcers in intensive care patients: a longitudinal study. In: Int J Nurs Stud. 46(4):413-21. doi: 10.1016/j.ijnurstu.2008.02.011. Epub 2008 Apr 18.
 Rosenthal MJ, Felton RM, Nastasi AE, Naliboff BD, Harker J, Navach JH. (2003): Healing of advanced pressure ulcers by a generic total contact seat: 2 randomized comparisons with low air loss bed treatments. Arch Phys Med Rehabil. 84(12):1733-42.
 Cullum N, McInnes E, Bell-Syer SE, Legood R. (2004): Support surfaces for pressure ulcer prevention. Cochrane Database of Systematic Review (3):CD001735. Update in Cochrane Database of Systematic Review. 2008;(4):CD001735.
 McInnes E, Dumville JC, Jammali-Blasi A, Bell-Syer SE. (2011): Support surfaces for treating pressure ulcers. Cochrane Database Systematic Review (12):CD009490.
 Nixon J, Nelson EA, Cranny G, Iglesias CP, Hawkins K, Cullum NA, Phillips A, Spilsbury K, Torgerson DJ, Mason S; PRESSURE Trial Group. (2006): Pressure relieving support surfaces: a randomised evaluation. In: Health Technol Assess.10(22):iii-iv, ix-x, 1-163.
 Malbrain M, Hendriks B, Wijnands P, Denie D, Jans A, Vanpellicom J, De Keulenaer B. (2010): A pilot randomised controlled trial comparing reactive air and active alternating pressure mattresses in the prevention and treatment of pressure ulcers among medical ICU patients. In: J Tissue Viability.19 (1):7-15.
 Makhsous M, Lin F, Knaus E, Zeigler M, Rowles DM, Gittler M, Bankard J, Chen D. (2009): Promote pressure ulcer healing in individuals with spinal cord injury using an individualized cyclic pressure-relief protocol. In: Departments of Physical Therapy and Human Movement Sciences, Physical Medicine and Rehabilitation, Orthopaedic Surgery, Northwestern University, Chicago, Illinois, USA. 22(11):514-21.
 Health Quality Ontario. (2009): Pressure ulcer prevention: an evidence-based analysis. In: Ont Health Technol Assess Ser. 9(2):1-104.
 Colin D, Rochet JM, Ribinik P, Barrois B, Passadori Y, Michel JM. (2012): What is the best support surface in prevention and treatment, as of 2012, for a patient at risk and/or suffering from pressure ulcer sore? Developing French guidelines for clinical practice. In: Annals of Physical and Rehabilitation Medicine. 55(7):466-81.
 Nixon J., Cranny G., Iglesias C., and al. (2006): Randomized, controlled trial of alternating pressure mattresses compared with alternating pressure overlays for the prevention of pessure ulcers: PRESSURE (pressure relieving support surfaces) trial. In: British Medical Journal 332: 1413-1415
 Phillips L. BSc. RN & McLeod PhD, Huntleigh Healthcare, UK. (2005): The use of Dynamic Alternating Pressure Seat Cushions for the prevention and Treatment of Pressure Ulcers. In: Revue l`Escarre 25:39-41
|1. Prof Dr Gelu Onose
2. Univ Assist Monica Haras, MD PHD
3. Simone Mohrs, CPME Public Health Intern, Masstricht University
4. Cristina Popescu, MD, Postgrad
5. Aura Spanu, MD Postgrad
|Any additional information on the CRM (e.g. implementation barriers and drivers)