LR8 / Reduction in the incidence of health care acquired pressure ulcers


Type of Patient Safety Practice
Clinical Practice (CP)
Related practices from PaSQ database
"Best fit" category of the reported practice
Decubitus ulcers
Patient safety theme the SCP/clinical risk management practice is aimed at
Reduction in the incidence of health care acquired pressure ulcers
Objective of the CRM practice
Pressure Ulcers can be avoided with the right knowledge and use of appropriate prevention measures by health care staff [19]. Pressure ulcers endure a cost to the health care systems across Europe, as high as 25 billion € a year which equates to almost one sixth’ [17 %] of the total EU budget [4]. It is now more important than ever to adopt interventions that are not only effective in delivering high quality of care, but are also cost-effective. The EU can play a significant role in sharing best practices for pressure ulcer prevention and treatment in health care settings particularly through the Joint Action on Patient Safety and Quality of Care. Different wounds require different treatment and although evidence-based guidelines for healthcare professionals are available for treatment, they are often not implemented in many healthcare settings [1, 20, 21]. None the less, the incidence of wounds can be considerably reduced in every Member States by following basic clinical guidelines [18].
Short description of the CRM practice, including any references for further information
Risk assessment is the first step in planning pressure ulcer prevention strategies [7]. The purpose of risk assessment is to identify those at risk of pressure ulcer development, by identifying key factors considered important [7]. Following this assessment, effective prevention interventions may be planned and implemented [8]. Pressure ulcer prevention involves a range of interventions, such as nutritional care [9], skin care [8], use of pressure redistribution surfaces [10], and repositioning [11]
Innovator of the SCP, country of origin
United States of America, Ireland, the Netherlands, Wales and England.
Involved health care staff
Pressure ulcers are not related to a specific health care group. However, care givers, such as nurses, are relevant involved professionals.
Tested in which countries/health care systems, health care context(s) and/or clinical specialty/specialties, including references
The “skin bundle” has been/are currently tested in Wales and England as well as Denmark. Please find information above.
Summary of evidence for effectiveness, including references
Pressure ulcers are largely a preventable problem, yet despite the advances in technology, preventative aids and increased financial expenditure, they remain a common and debilitating concern [1]. The presence of a pressure ulcer is considered to be an indicator of quality of care [2] and incidence figures reduce society’s confidence in the health service’s ability to deliver care that is timely, appropriate and effective [3]. Pressure ulcers impose a significant financial burden on health care systems, with current estimates suggesting that approximately 4% of health care budgets is spent on pressure ulcer management [4]. The literature clearly articulates the impact of pressure ulcers on the individual’s quality of life, noting that the emotional, physical, mental and social domains of life are all profoundly affected [5]. It is of concern that pressure ulcers are also associated with increased mortality. Indeed, evidence suggests a higher incidence of death among those with pressure ulcers when compared to their matched counterparts without pressure ulcers [6].

Indeed, studies have shown that with effective preventative strategies, a reduction of up to 73 % of the pressure ulcer incidence is possible. Indeed, a recent study [11] demonstrated that use of an alternate method of repositioning reduced the incidence of pressure ulceration by 8 per 100 patients [11%-3%]. The study reiterated that repositioning individuals at risk of pressure ulcer development [one component of pressure ulcer prevention strategies] makes both economic and clinical sense, thereby supporting the EPUAP/NPUAP 2009 guidelines [8]. In addition, the Institute of Health Improvement in the USA ahs transferred its patient safety ‘Skin Bundles’ to Europe, with Wales and parts of England adopting this. Early results demonstrate hundreds of ‘pressure ulcer free’ days (National Leadership and Innovation for Health, 2009).

Despite evidence demonstrating the efficacy of pressure ulcer prevention strategies in reducing pressure ulcer incidence figures, there is a corresponding evidence base suggesting a lack of integration of best practice within clinical practice. For example, from a European perspective the mean use of pressure redistribution devices is varies from 28% [12] to 97.3% [13]. Whereas, the mean use of repositioning for pressure ulcer prevention varies from 0% [14] to 37% [15].
Summary of evidence for transferability (transferability across health care systems or health care contexts or clinical specialties), including references
In 2009 the European Pressure Ulcer Advisory Panel and the National Pressure Ulcer Advisory Panel, USA, developed international guidelines for the prevention and management of pressure ulcers [8]. These guidelines reflect the diversity of clinical settings where pressure ulcers occur, for example, primary and secondary care, older person services and acute medical specialities. Furthermore, the guidelines are based on best evidence which has been systematically searched, retrieved, appraised and outlined within the document. In addition, the work has been subject to peer review to ensure that the contents provide appropriate guidance for practice. Dissemination does not necessarily imply implementation [16]. For example, despite the presence of guidelines in the Netherlands since 1991, knowledge about pressure ulcer prevention had improved little over the subsequent 12 years [17]. Conversely, other clinical settings have shown significantly improved outcomes with systematic implementation and evaluation of guidelines [18].
Summary of available information on feasibility, including references
limitations in staff education and training; lack of physician involvement; limited involvement of unlicensed nursing staff; lack of plan for communicating at-risk status; and limited quality improvement evaluations of bedside practices [22, 23].

Methods for overcoming barriers:
Use of a multifaceted dissemination and implementation strategy increases the likelihood of uptake in practice [24]

Diffusion of innovation theory [25]

Transtheoretical model of behaviour change [26]

Health education theory [24]

Social influence theory [27]

Social ecology [28]
Existing implementation tools, including references
EPUAP-NPUAP Guidelines [8]
SSKIN bundle:

Selected risk assessment tools: Braden and Norton
Potential for/description of patient involvement in the CRM practice, including references
Patients should be afforded more say in decisions about their care and treatment, more opportunity to make choices with information and support as a means of securing better care and better outcomes [29]
Bibliography (for each reference: author(s), year, title, journal/internet link, page(s))
[1] Moore Z, Cowman S. Pressure ulcer prevalence and prevention practices in care of the older person in the Republic of Ireland. J Clin Nurs. 2012;21[3-4]:362-71.

[2] OECD. Health Care Quality Indicators Project. In: OECD, editor. Paris: OECD; 2002.

[3] McLoughlin V, Millar J, Mattke S, Franca M, Jonsson PM, Somekh D, et al. Selecting indicators for patient safety at the health system level in OECD countries. International Journal for Quality in Health Care. 2006;18[suppl 1]:14-20.

[4] Posnett J, Gottrup F, Lundgren H, Saal G. The resource impact of wounds on health-care providers in Europe. Journal of Wound Care. 2009;18[4]:154-61.

[5] Gorecki C, Brown JM, Nelson EA, Briggs M, Schoonhoven L, Dealey C, et al. Impact of pressure ulcers on quality of life in older patients: a systematic review. Journal of the American Geriatrics Society. 2009;57[7]:1175-83.

[6] Thomas DR, Goode PS, Tarquine PH, Allman RM. Hospital-acquired pressure ulcers and risk of death. Journal of the American Geriatrics Society. 1996;44[12]:1435-76.

[7] Risk assessment tools for the prevention of pressure ulcers [database on the Internet]. 2010.

[8] European Pressure Ulcer Advisory Panel, National Pressure Ulcer Advisory Panel. Prevention and treatment of pressure ulcers: quick reference guide. Washington DC: National Pressure Ulcer Advisory Panel, 2009.

[9] Nutritional interventions for preventing and treating pressure ulcers [database on the Internet]. Wiley. 2003.

[10] McInnes E, Jammali-Blasi A, Bell-Syer SEM, Dumville JC, Cullum N. Support surfaces for pressure ulcer prevention. Cochrane Database of Systematic Reviews. 2011[Issue 4: Art. No.: CD001735. DOI: 10.1002/14651858.CD001735.pub4.].

[11] Moore Z, Cowman S, Conroy RM. A randomised controlled clinical trial of repositioning, using the 30° tilt, for the prevention of pressure ulcers. J Clin Nurs. 2011;20[17-18]:2633-44.

[12] Gunningberg L, Lindholm C, Carlsson M, Sjödén PO. Effect of visco-elastic foam mattresses on the development of pressure ulcers in patients with hip fractures. Journal of Wound Care. 2000;9[10]:455-60.

[13] Strand T, Lindgren M. Knowledge, attitudes and barriers towards prevention of pressure ulcers in intensive care units: a descriptive cross-sectional study. Intensive and Critical Care Nursing. 2010;26[6]:335-42.

[14] Bjoro K, Ribu L. Pilotstudie av trykksarprevalens i et norsk sykehus. Sykepleien Forskning. 2009;4[4]:298-305.

[15] Abildgaard AU, Daugaard K. Tryksar. En praevalensundersogelse. Ugeskr Laeger. 1979;141[46]:3147-51.

[16] Jorgensen S, Nygaard R. Evidence based guidelines -- how to channel relevant knowledge into the hands of nurses and carers who are treating patients in daily life. EWMA Journal. 2010;10[2]:23-6.

[17] Hulsenboom MA, Bours GJJW, Halfens RJG. Knowledge of pressure ulcer prevention: a cross-sectional and comparative study among nurses. BMC Nursing 2007;6[2: doi:10.1186/1472-6955-6-2].

[18] Gibbons W, Shanks HT, Kleinhelter P, Jones P. Eliminating facility-acquired pressure ulcers at Ascension Health. Joint Commission Journal on Quality and Patient Safety. 2006;32[9]:488-96.

[19] Moore Z, Price PE. Nurses’ attitudes, behaviours and perceived barriers towards pressure ulcer prevention. Journal of Clinical Nursing. 2004;13:942-51.

[20] Gunningberg L, Lindholm C, Carlsson M, Sjödén PO. Risk, prevention and treatment of pressure ulcers--nursing staff knowledge and documentation. Scandinavian Journal of Caring Sciences. 2001;15[3]:257-63.

[21] Jordan O Brien J, Cowman S. An exploration of nursing documentation of pressure ulcer care in an acute setting in Ireland. J Wound Care. 2011;20[5]:197-8, 200, 2-3.

[22] Jankowski IM, Nadzam DM. Identifying gaps, barriers, and solutions in implementing pressure ulcer prevention programs. Joint Commision Journal on Quality and Patient Safety. 2011;37[6]:253-64.

[23] De Laat EH, Schoonhoven L, Pickkers P, L VA, Van Achterberg T. Implementation of a new policy results in a decrease of pressure ulcer frequency. Int J Qual Health Care. 2006;18[2]:107-12.

[24] Moulding NT, Silagy CA, Weller DP. A framework for effective management of change in clinical practice: dissemination and implementation of clinical practice guidelines. Qual Health Care. 1999;8:177-83.

[25] Wejnert B. Annual Review of Sociology [Annual Reviews]. Integrating Models of Diffusion of Innovations: A Conceptual Framework. 2002;28:297-306.

[26] Prochaska JO, DiClemente CC. Stages and processes of self-change of smoking: Toward an integrative model of change. Journal of Consulting and Clinical Psychology. 1983;51:390-5.

[27] Kelman H. Compliance, identification, and internalization: Three processes of attitude change. Journal of Conflict Resolution. 1958;1:51-60.

[28] Stokols D. Translating social ecological theory into guidelines for community health promotion. American Journal of Health Promotion. 1996;10[4]:282-98.

[29] Department of Health UK. Liberating the NHS: No decision about me, without me - further consultation on proposals to secure shared decision-making2012. Available from:

[30] NLIAH 2009,

[31] Bale S. Preventing skin damage: a Welsh perspective. Wounds UK 2012, Vol 8, No 3

[32] Pancorbo-Hidalgo P L, Garcia-Fernandez F P, Lopez-Medina I M, Alvarez-Nieto C. Risk assessment scales for pressure ulcer prevention: a systematic review. Available from:

[33] Bergstrom, Nancy; Braden, Barbara; Kemp, Mildred; Champagne, Mary; Ruby, Elizabeth. Predicting Pressure Ulcer Risk: A Multisite Study of the Predictive Validity of the Braden Scale. Nursing Research: September/October 1998 - Volume 47 - Issue 5 - pp 261-269.
[34] Lisette Schoonhoven, Jeen R E Haalboom, Mente T Bousema, Ale Algra, Diederick E Grobbee, Maria H Grypdonck, Erik Buskens. Prospective cohort study of routine use of risk assessment scales for prediction of pressure ulcers
Journal of Advanced Nursing. Volume 54, Issue 1, pages 94–110, April 2006
[35] Tom Defloor, Maria FH Grypdonck. Pressure ulcers: validation of two risk assessment scales. Journal of Clinical Nursing. Volume 14, Issue 3, pages 373–382, March 2005
Dr. Zena Moore
Any additional information on the CRM (e.g. implementation barriers and drivers)