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Abstracts for Review

Ricci, E., Roberto, C., Ippolito, A., Bianco, A., & Scalise, M. (2013). A new pressurerelieving mattress overlay. EWMA Journal, 13(1), 27-32.
Aim: This is a two-arm prospective study with random assignment to assess the efficacy of Aiartex, a new CEmarked three-dimensional anti-decubitus mattress overlay made from flame retardant Polyester compared with Akton a commercially available viscoelastic mattress overlay for the prevention of pressure ulcers development in aged patients at moderate/high risk. Methods Fifty patients (aged 65 years or older) admitted in long-term units, who were at moderate/high risk (Braden scale score 8-14) or medium-high risk (Norton 1 scale score 6-12) of developing pressure ulcers, were randomly assigned to either three-dimensional (study group) or viscoelastic (control group) mattress. The observational period was 4 weeks. Results Neither patients using three-dimensional nor those using the control overlay developed a pressure ulcer during the entire study. Both overlays were well tolerated, and no patient experienced adverse events or allergic reactions. No patient experienced skin maceration or cutaneous irritation. Conclusions The results obtained with three dimensional were comparable to those obtained with the control mattress overlay. This suggests that a new comfortable, easy-to-use, and safe mattress overlay can be used for the prevention of pressure ulcers.

Moore, Z., Cowman, S., & Conroy, R. (2011). A randomised controlled clinical trial of repositioning, using the 30 tilt, for the prevention of pressure ulcers. Journal of Clinical Nursing, 20(17/18), 2633-2644.
Background. Pressure ulcers are common, costly and impact negatively on individuals. Pressure is the prime cause, and immobility is the factor that exposes individuals to pressure. International guidelines advocate repositioning; however, there is confusion surrounding the best method and frequency required. Design. A pragmatic, multi-centre, open label, prospective, cluster-randomised controlled trial was conducted to compare the incidence of pressure ulcers among older persons nursed using two different repositioning regimens. Method. Ethical approval was received. Study sites (n = 12) were allocated to study arm using cluster randomisation. The experimental group (n = 99) were repositioned three hourly at night, using the 30 degree tilt; the control group (n = 114) received routine prevention (six-hourly repositioning, using 90 degree lateral rotation). Data analysis was by intention to treat; follow-up was for four weeks. Results. All participants (n = 213) were Irish and white, among them 77% were women and 65% aged 80 years or older. Three patients (3%) in the experimental group and 13 patients (11%) in the control group developed a pressure ulcer (p = 0.035; 95% CI 0.0310.038; ICC = 0.001). All pressure ulcers were grade 1 (44%) or grade 2 (56%). Mobility and activity were the highest predictors of pressure ulcer development ( = -0.246, 95% CI = -0.319 to-0.066; p = 0.003); ( = 0.227, 95% CI = 0.041 0.246; p = 0.006). Conclusion. Repositioning older persons at risk of pressure ulcers every three hours at night, using the 30_ tilt, reduces the incidence of pressure ulcers compared with usual care. The study supports the recommendations of the 2009 international pressure ulcer prevention guidelines. Relevance to clinical practice. An effective method of pressure ulcer prevention has been identified; in the light of the problem of pressures ulcers, current prevention strategies should be reviewed. It is important to implement appropriate prevention strategies, of which repositioning is one.

Thoroddsen, A., Sigurjnsdttir, G., Ehnfors, M., & Ehrenberg, A. (2013). Accuracy, completeness and comprehensiveness of information on pressure ulcers recorded in the patient record. Scandinavian Journal of Caring Sciences, 27(1), 84-91.
Aim: To describe the accuracy, completeness and comprehensiveness of information on pressure ulcers documented in patient records. Design and setting: A cross-sectional descriptive study performed in 29 wards at a university hospital in Iceland. The study included skin assessment of patients and retrospective audits of records of patients identified with pressure ulcers. Participants: A sample of 219 patients was inspected for signs of pressure ulcers on 1 day in 2008. Records of patients identified with pressure ulcers were audited (n = 45) retrospectively. Results: The prevalence of pressure ulcers was 21%. Information in patient records lacked accuracy, completeness and comprehensiveness. Only 60% of the identified pressure ulcers were documented in the patient records. The lack of accuracy was most prevalent for stage I pressure ulcers. Conclusions: The purpose of documentation to record, communicate and support the flow of information in the patient record was not met. The patient records lacked

accuracy, completeness and comprehensiveness, which can jeopardise patient safety, continuity and quality of care. The information on pressure ulcers in patient records was found not to be a reliable source for the evaluation of quality in health care. To improve accuracy, completeness and comprehensiveness of data in the patient record, a systematic risk assessment for pressure ulcers and assessment and treatment of existing pressure ulcers based on evidence-based guidelines need to be implemented and recorded in clinical practice. Health information technology, including the electronic health record with decision support, has shown promising results to facilitate and improve documentation of pressure ulcers. Subjects: Pressure Ulcer; Pressure Ulcer; Wound Care; Medical Records; Middle Aged: 45-64 years; Aged: 65+ years; Aged, 80 and over; Male; Female

Barker, A., Kamar, J., Tyndall, T., White, L., Hutchinson, A., Klopfer, N., & Weller, C. (2013). Implementation of pressure ulcer prevention best practice recommendations in acute care: an observational study. International Wound Journal, 10(3), 313-320.
Pressure ulcers are a common but preventable problem in hospitals. Implementation of best practice guideline recommendations can prevent ulcers from occurring. This 9-year cohort study reports prevalence data from point prevalence surveys during the observation period, and three practice metrics to assess implementation of best practice guideline recommendations: (i) nurse compliance with use of a validated pressure ulcer risk assessment and intervention checklist; (ii) accuracy of risk assessment scoring in usual-care nurses and experienced injury prevention nurses; and (iii) use of pressure ulcer prevention strategies. The prevalence of hospital-acquired pressure ulcers decreased following implementation of an evidence-based prevention programme from 126% (2 years preprogramme implementation) to 26% (6 years postprogramme implementation) ( P < 0001). Audits between 2003 and 2011 of 4368 patient medical records identified compliance with pressure ulcer prevention documentation according to best practice guidelines was high (>84%). A sample of 270 patients formed the sample for the study of risk assessment scoring accuracy and use of prevention strategies. It was found usual-care nurses under-estimated patients' risk of pressure ulcer development and under-utilised prevention strategies compared with experienced injury prevention nurses. Despite a significant reduction in prevalence of hospital-acquired pressure ulcers and high documentation compliance, use of prevention strategies could further be improved to achieve better patient outcomes. Barriers to the use of prevention strategies by nurses in the acute hospital setting require further examination. This study provides important insights into the knowledge translation of pressure ulcer prevention best practice guideline recommendations at The Northern Hospital. Subjects: Pressure Ulcer; Acute Care; Risk Assessment

Cong, L., Yu, J., & Lui, Y. (2012). Implementing a Continuous Quality Improvement Program for Reducing Pressure Prevalence in a Teaching Hospital in China. Journal of Wound, Ostomy & Continence Nursing, 39(5), 509-513.
PURPOSE: The purpose of this study was to determine whether a continuous quality improvement program would reduce pressure ulcer prevalence. SUBJECTS AND SETTING: The study sample comprised 2913 patients who were used as a baseline comparison group and 3019 patients who acted as the intervention group. The research setting was a 3000-bed teaching hospital with 61 nursing units located in Wuhan, China. DESIGN: This prospective study compared pressure ulcer prevalence of patients admitted to hospital before and after implementation of a continuous quality improvement program designed to reduce the incidence of hospital-acquired pressure ulcers. The program was implemented after baseline data were collected in April and the comparison prevalence survey was completed in October of the same year. Pressure ulcer prevalence data were collected on a single day. RESULTS: The overall pressure ulcer prevalence (combining ulcers that were hospital acquired and present on admission) was 1.8% at baseline as compared to 1.4% following implementation of the quality improvement program. The prevalence of hospital-acquired pressure ulcers was 1.5% at baseline; it was 1.1% following the intervention. Excluding stage 1 pressure ulcers, the prevalence was 0.8% and 0.6%, respectively. No stage 4 pressure ulcers were identified when prevalence was measured after initiation of the prevention project. CONCLUSION: Pressure ulcer prevalence, which was low at baseline measurement, did not statistically significantly decrease, despite a comprehensive quality improvement program. Subjects: Pressure Ulcer; Pressure Ulcer; Program Implementation; Quality Improvement

Fred, C., Ford, S., Wagner, D., & Vanbrackle, L. (2012). Intraoperatively acquired pressure ulcers and perioperative normothermia: a look at relationships. AORN Journal, 96(3), 251-260.
The risk of developing an intraoperatively acquired pressure ulcer (IAPU), which is recognized as a significant complication of deep tissue injury occurrence, is associated with duration of surgery and patient positioning. There is a strong association between hypothermia, tissue viability, and surgical site infections; however, the relationship between hypothermia and pressure ulcers has not been fully explored. We examined the incidence of pressure ulcers in surgical patients and determined that there is a relationship between maintaining perioperative normothermia and a reduction in IAPU development. We used a retrospective, explanatory, nonexperimental design, and we fit a binary logistic model to the data. This study shows that patients at higher risk for developing an IAPU include those who are critically ill, have a low Braden Scale skin assessment score, are thin, and are male with at least a 1 F (1.8 C) drop in temperature. These are important risks for perioperative nurses to take into account during care of surgical patients. More perioperative research is needed to identify ways to reduce risk, provide close assessment of high-risk patients, and implement the identified risk-reduction strategies.

Beeckman, D., Defloor, T., Schoonhoven, L., & Vanderwee, K. (2011). Knowledge and Attitudes of Nurses on Pressure Ulcer Prevention: A Cross-Sectional Multicenter Study in Belgian Hospitals. Worldviews On Evidence-Based Nursing, 8(3), 166-176.
Background: Evidence-based guidelines for pressure ulcer prevention have been developed and promoted by authoritative organizations. However, nonadherence to these guidelines is frequently reported. Negative attitudes and lack of knowledge may act as barriers to using guidelines in clinical practice. Aims: To study the knowledge and attitudes of nurses about pressure ulcer prevention in Belgian hospitals and to explore the correlation between knowledge, attitudes, and the application of adequate prevention. Methods: A cross-sectional multicenter study was performed in a random sample of 14 Belgian hospitals, representing 207 wards. Out of that group, 94 wards were randomly selected (2105 patients). Clinical observations were performed to assess the adequacy of pressure ulcer prevention and pressure ulcer prevalence. From each participating ward, a random selection of at least five nurses completed an extensively validated knowledge and attitude instrument. In total, 553 nurses participated. A logistic regression analysis was performed to evaluate the correlation between knowledge, attitudes, and the application of adequate prevention. Results: Pressure ulcer prevalence (Category I-IV) was 13.5% (284/2105). Approximately 30% (625/2105) of the patients were at risk (Bradenscore <17 and/or presence of pressure ulcer). Only 13.9% (87/625) of these patients received fully adequate prevention whilst in bed and when seated. The mean knowledge and attitude scores were 49.7% and 71.3%, respectively. The application of adequate prevention on a nursing ward was significantly correlated with the attitudes of the nurses (OR = 3.07, p = .05). No independent correlation was found between knowledge and the application of adequate prevention (OR = 0.75, p = .71). Conclusions: Knowledge of nurses in Belgian hospitals about the prevention of pressure ulcers is inadequate. The attitudes of nurses toward pressure ulcers are significantly correlated with the application of adequate prevention. No correlation was found between knowledge and the application of adequate prevention.

Joseph, J., & Davies Clifton, ,. (2013). Nurses' knowledge of pressure ulcer risk assessment. Nursing Standard, 27(33), 54-60.
Pressure ulcers are a largely avoidable, but serious health problem in the UK. Nurses should be knowledgeable of the signs and symptoms of pressure ulcers, and preventive strategies to reduce their incidence. This article explores the literature on nurses' understanding and use of risk assessment tools to identify patients at increased risk of developing pressure ulcers and how, if at all, this contributes to fewer pressure ulcers in the healthcare setting.

Bosch, M., G., Trudy, Wensing, M., Akkermans, R., & Grol, R. (2011). Organizational culture, team climate, and quality management in an important patient safety issue: nosocomial pressure ulcers. Worldviews On Evidence-Based Nursing, 8(1), 4-14.
Background: Increasingly, policy reform in health care is discussed in terms of changing organizational culture, creating practice teams, and organizational quality management. Yet, the evidence for these suggested determinants of high-quality care is inconsistent. Aims: To determine if the type of organizational culture (Competing Values Framework), team climate (Team Climate Inventory), and preventive pressure ulcer quality management at ward level were related to the prevalence of pressure ulcers. Also, we wanted to determine if the type of organizational culture, team climate, or the institutional quality management related to preventive quality management at the ward level. Methods: In this cross-sectional observational study multivariate (logistic) regression analyses were performed, adjusting for potential confounders and institution-level clustering. Data from 1,274 patients and 460 health care professionals in 37 general hospital wards and 67 nursing home wards in the Netherlands were analyzed. The main outcome measures were nosocomial pressure ulcers in patients at risk for pressure ulcers (Braden score 18) and preventive quality management at ward level. Results: No associations were found between organizational culture, team climate, or preventive quality management at the ward level and the prevalence of nosocomial pressure ulcers. Institutional quality management was positively correlated with preventive quality management at ward level (adj. 0.32; p < 0.001). Conclusions and Implications: Although the prevalence of nosocomial pressure ulcers varied considerably across wards, it did not relate to organizational culture, team climate, or preventive quality management at the ward level. These results would therefore not subscribe the widely suggested importance of these factors in improving health care. However, different designs and research methods (that go beyond the cross-sectional design) may be more informative in studying relations between such complex factors and outcomes in a more meaningful way. KEYWORDS organizational culture, pressure ulcer, prevalence, quality of health care, institutional policies, team climate

Sullivan, N., & Schoelles, K. (2013). Preventing in-facility pressure ulcers as a patient safety strategy: a systematic review. Annals of Internal Medicine, 158(5 Pt 2), 410-416.
Complications from hospital-acquired pressure ulcers cause 60 000 deaths and significant morbidity annually in the United States. The objective of this systematic review is to review evidence regarding multicomponent strategies for preventing pressure ulcers and to examine the importance of contextual aspects of programs that aim to reduce facility-acquired pressure ulcers. CINAHL, the Cochrane Library, EMBASE, MEDLINE, and Pre MEDLINE were searched for articles published from 2000 to 2012. Studies (any design) that implemented multicomponent initiatives to prevent pressure ulcers in adults in U.S. acute and long-term care settings and that reported pressure ulcer rates at least 6 months after implementation were selected. Two reviewers extracted study data and rated quality of evidence. Findings from 26 implementation studies (moderate strength of evidence) suggested that the integration of several core components improved processes of care and reduced pressure ulcer rates. Key components included the simplification and standardization of pressure ulcer specific interventions and documentation, involvement of multidisciplinary teams and leadership, use of designated skin champions, ongoing staff education, and sustained audit and feedback.

McInnes, E., Jammali-Blasi, A., Bell-Syer, S., Dumville, J., & Cullum, N. (2012). Preventing pressure ulcersAre pressure-redistributing support surfaces effective? A Cochrane systematic review and metaanalysis. International Journal of Nursing Studies, 49(3), 345-359.
Abstract: Background:; Pressure ulcers (also known as bedsores, pressure sores, decubitus ulcers) are areas of localised damage to the skin and underlying tissue due to pressure, shear or friction.They are common in the elderly and immobile and costly in financial and human terms. Pressure-relieving beds, mattresses and seat cushions are widely used as aids to prevention in both institutional and non-institutional settings.; Objectives:; This systematic review seeks to answer the following questions: (1) to what extent do pressure-relieving cushions, beds, mattress overlays and mattress replacements reduce the incidence of pressure ulcers compared with standard support

surfaces? (2) how effective are different pressure-relieving surfaces in preventing pressure ulcers, compared to one another?; Search strategy:; For this second update the Cochrane Wounds Group Specialised Register was searched (28/2/08), The Cochrane Central Register of Controlled Trials (CENTRAL)(2008 Issue 1), Ovid MEDLINE (1950 to February Week 3 2008), Ovid EMBASE (1980 to 2008 Week 08) and Ovid CINAHL (1982 to February Week 3 2008). The reference sections of included studies were searched for further trials.; Selection criteria:; Randomised controlled trials (RCTs), published or unpublished, which assessed the effectiveness of beds, mattresses, mattress overlays, and seating cushions for the prevention of pressure ulcers, in any patient group, in any setting.Study selection was undertaken by at least two authors independently with a third author resolving uncertainty. RCTs were eligible for inclusion if they reported an objective, clinical outcome measure such as incidence and severity of new of pressure ulcers developed. Studies which only reported proxy outcome measures such as interface pressure were excluded.; Data collection and analysis:; Trial data were extracted by one researcher and checked by a second.The results from each study are presented as relative risk for dichotomous variables. Where deemed appropriate, similar studies were pooled in a meta analysis.; Main results:; For this second update 11 trials met the inclusion criteria bringing the total number of RCTs included in the review to 52.; Foam alternatives to the standard hospital foam mattress can reduce the incidence of pressure ulcers in people at risk.The relative merits of alternating and constant low pressure devices are unclear. There is one high quality trial comparing the different alternating pressure devices for pressure ulcer prevention which suggests that alternating pressure mattresses may be more cost effective than alternating pressure overlays.; Pressure-relieving overlays on the operating table have been shown to reduce postoperative pressure ulcer incidence, although two studies indicated that foam overlays resulted in adverse skin changes. Two trials indicated that Australian standard medical sheepskins prevented pressure ulcers.There is insufficient evidence to draw conclusions on the value of seat cushions, limb protectors and various constant low pressure devices as pressure ulcer prevention strategies.; A study of Accident and Emergency trolley overlays did not identify a reduction in pressure ulcer incidence.There are tentative indications that foot waffle heel elevators, a particular low air loss hydrotherapy mattress and two types of operating theatre overlays are harmful.; Authors' conclusions:; In people at high risk of pressure ulcer development higher specification foam mattresses rather than standard hospital foam mattresses should be used. The relative merits of higher-tech constant low pressure and alternating pressure for prevention are unclear but alternating pressure mattresses may be more cost effective than alternating pressure overlays. Medical grade sheepskins are associated with a decrease in pressure ulcer development. Organisations might consider the use of some forms of pressure relief for high risk patients in the operating theatre. Seat cushions and overlays designed for use in Accident and Emergency settings have not been adequately evaluated.; [CINAHL Note: The Cochrane Collaboration systematic reviews contain interactive software that allows various calculations in the MetaView.] Subjects: Beds and Mattresses; Pillows and Cushions; Pressure Ulcer; Pressure Ulcer

Evans, A. M., Barklam, D., Hone, K., Ellis, G., & Whitlock, J. (2013). Reducing pressure damage: care bundles and collaborative learning. British Journal of Nursing, S32-8.
Reduction of hospital-acquired pressure ulcers is a patient and nursing priority. Although evidence-based interventions to prevent such ulcers are well known, reducing this healthcare burden has proven consistently difficult. Via case studies, this article describes how a bundle approach to pressure ulcer prevention may be adapted for use within different clinical areas. It illustrates how collaborative learning may facilitate the spread of improvement work across a health board and build improvement skills within nursing.

Galvin, P., & Q. (2012). The Braden Q+P: a pediatric perioperative pressure ulcer risk assessment and intervention tool. AORN Journal, 96(3), 261-270.
Pressure ulcers continue to be a personally and financially expensive complication of surgery and hospitalization. The effects of anesthesia, immobilization during surgery, and use of multiple medical devices all place the surgical patient at high risk for pressure-related skin injury. As part of a comprehensive pressure ulcer prevention initiative, nurses in the cardiac and main ORs at Childrens Hospital Boston, Massachusetts, became concerned that current pressure ulcer risk assessment tools did not adequately capture the intense but short-term risk posed in the operating and procedural suites. A team, formed to investigate this matter, developed a tool to guide nursing assessment of patient risk and to plan nursing interventions to prevent pressure ulcers. Results after implementation of the Braden Q+P tool appear to show improvement in preventing pressure ulcers. Increased awareness of pressure ulcer prevention, a hospital focus on skin care, and nursing education about pressure ulcers supported this improvement .