International Journal for Quality in Health Care Advance Access originally published online on April 6, 2008
International Journal for Quality in Health Care 2008 20(4):246-253; doi:10.1093/intqhc/mzn009
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Tracking quality over time: what do pressure ulcer data show?
1 Leader of Nursing Research and Development, Surgery Division, Uppsala University Hospital, and Assistant Professor, Department of Surgery, Uppsala University, Uppsala, Sweden
2 Professor, School of Nursing, University of California, San Francisco, and Associate Director of the John A. Hartford Center of Geriatric Nursing Excellence.
Address reprint requests to: Lena Gunningberg, Tel: +46 18 611 3194; Fax: +46 18 611 3689; E-mail: lena.gunningberg{at}akademiska.se
 |
Abstract |
|---|
 Top Abstract IntroductionMethodResultsDiscussionConclusionFundingAcknowledgementsReferences |
|---|
Objective. To compare the prevalence of pressure ulcers and prevention before and after a quality improvement program; determine whether patient characteristics differed for those who did and did not develop pressure ulcers; identify pressure ulcer prevention implemented at admission and whether prevention and risk factors varied by pressure ulcer severity.
Design. Descriptive comparative study based on two cross-sectional pressure ulcer surveys conducted in 2002 and 2006, complemented with a retrospective audit of the electronic health record and administrative system for patients identified with pressure ulcers.
Setting. 1100-bed Swedish university hospital.
Participants. 612 hospitalized patients in 2002 and 632 in 2006.
Main outcome measures. Prevalence of pressure ulcers and prevention (pressure-reducing mattresses; planned repositioning; chair, heel and 30° lateral positioning cushions).
Results. Pressure ulcer prevalence was 23.9% in 2002 and 22.9% in 2006. When non-blanchable erythema was excluded, the prevalence was 8.0 and 12.0%, respectively. The use of pressure-reducing mattresses increased while planned repositioning decreased. Those who developed ulcers were older, at-risk for ulcers, incontinent and had longer length of stay. Little prevention was documented at admission. Some prevention strategies and risk factors were related to severity of ulcers.
Conclusions. Pressure ulcer prevalence did not decrease, despite a comprehensive quality improvement program. Special attention is needed to provide prevention to older patients with acute admission. Skin and risk assessment, as well as prevention, should start early in the hospitalization. Identifying those persons with community-acquired versus hospital-acquired ulcers will strengthen pressure ulcers as an accurate marker of quality of care for hospitalized patients. If possible, data should be reported by ward level for comparison over time.
Keywords: hospitals, pressure ulcer, prevention, quality indicators, risk assessment
|
Introduction |
|---|
|
TopAbstractIntroductionMethodResultsDiscussionConclusionFundingAcknowledgementsReferences |
|---|
Patient safety and quality of care are high on the healthcare agenda [1]. Pressure ulcers have long been used as a quality indicator of nursing care. Pressure ulcer prevalence studies are being currently used in many institutions around the world to monitor quality of care [2, 3]. The prevalence of pressure ulcers is high in hospitalized patients. In the United States, large datasets (n = 17 510 to n = 31 969) show a pressure ulcer prevalence between 14 and 17% [4]. A Canadian study reports a prevalence of 25.1% in acute care (n = 4831) [5] and across European settings (Belgium, Italy, Portugal, UK and Sweden), the prevalence is 18.1% in hospitals (n = 5947) [6]. Pressure ulcers are a problem because they cause suffering [7, 8] and increase healthcare costs [9, 10]. Efficient comprehensive improvement work is needed to reduce the prevalence of pressure ulcers in hospitalized patients [10].
In Sweden, pressure ulcers have not routinely been a hospital-level quality indicator. However, pressure ulcer prevalence was evaluated in 2002 in a Swedish university hospital using the European Pressure Ulcer Advisory Panel methodology [6]. Of the patients surveyed (n = 612), 23.9% had pressure ulcers [11]. A comprehensive hospital-wide quality improvement plan was developed and undertaken that addressed pivotal aspects of pressure ulcer prevention (Table 1). The prevalence was subsequently reevaluated in 2006. This paper provides a snapshot of the pressure ulcer status prior to and after the quality improvement program and provides insights into factors that contribute to the post-implementation pressure ulcer status.
|
The aims of the study were to:
- compare pressure ulcer prevalence and prevention in a university hospital before and after implementation of a pressure ulcer quality improvement program,
- determine whether the patient characteristics differed for those who did and did not develop pressure ulcers,
- identify pressure ulcer prevention implemented at admission, and
- determine whether prevention and risk factors varied by pressure ulcer severity.
|
Method |
|---|
|
TopAbstractIntroductionMethodResultsDiscussionConclusionFundingAcknowledgementsReferences |
|---|
Design
The data for this descriptive comparative study come from two cross-sectional pressure ulcer surveys conducted in 2002 and 2006. Both datasets were utilized to address the first study aim. The 2006 survey data were used to examine the remaining study aims, complemented with a retrospective audit of the electronic health record and the administrative system for patients identified with pressure ulcers.
Sample
The sample included all patients, 18 years and older, admitted to a 1100-bed university hospital before midnight the day of the survey. All inpatient areas were surveyed except psychiatry, day care, maternity and hospice. In addition, 120 eligible patients (16.4%) in 2002 and 92 patients (12.7%) in 2006 were not included because they were not available for inspection in the ward or they refused to participate.
Measures/instruments
Prevalence was defined as the number of persons with pressure ulcers detected by physical examination on the survey day. The EPUAP prevalence methodology was used for the physical examination [6]. Pressure ulcers were defined using the EPUAP criteria [6].
- Grade 1: non-blanchable erythema of intact skin;
- Grade 2: partial-thickness skin loss involving epidermis, or dermis, or both;
- Grade 3: full-thickness skin loss involving damage to or necrosis of subcutaneous tissue that may extend down to, but not through, underlying fascia; and
- Grade 4: full-thickness skin loss with extensive destruction, tissue necrosis, or damage to muscle, bone or supporting structures. Necrotic ulcers are classified as Grade 4 [6].
Prevention was defined as the use of pressure-reducing mattresses, chair cushions and planned repositioning in bed and chair observed at the time of the physical examination. In the 2006 survey, cushions for 30° lateral positioning and heel cushions were added. In the retrospective audit of records, documented information regarding prevention was used.
Pressure ulcer risk was assessed with the Braden Scale and the incontinence subscale of the Norton scale [6]. A total Braden score <17 was defined as at risk for pressure ulcer development. In the audit of records, risk assessment was defined as either documentation of clinical judgment ‘at-risk’ or findings of risk using a validated risk assessment tool.
Patient characteristics in the survey included age, gender, expected length of stay and department. In the retrospective audit, information was abstracted from the administrative system on primary and secondary diagnoses, admitted from home or not, acute or elective admission (acute admission was through the emergency department), not cared for in usual ward, surgery, length of stay in the hospital, and whether the patient died within 7 months. Data were obtained from the electronic health record on the hemoglobin, blood pressure (BP) and time in the emergency department. For documentation of pressure ulcer, notes from all professionals were searched with the key word ‘Skin’, ‘Pressure Ulcer’ or ‘Ulcer’.
A standardized data-collection form was utilized in the survey [6]. An additional one-page data-collection form was developed for the retrospective audit of the electronic health record and the administrative system.
Procedure
Permission for the study was obtained from the medical director at the hospital. The patients received verbal and written information about the study and gave verbal consent. All data were treated confidentially. Participants were free to withdraw at any time. Approval was obtained from the Research Ethics Committee of the Faculty of Medicine at Uppsala University (No. 01-502).
For both prevalence studies, each patient was visited by a team of two registered nurses, i.e. a specially trained data collector (non-ward nurse) and a staff nurse (ward nurse). The patient's skin was assessed, the Braden scale was completed, and preventive strategies were recorded. If there was a disagreement about the pressure ulcer grade, the decision was made by the non-ward nurse.
Prior to each survey day, all nurses participating in the prevalence survey attended a half-day training on the survey procedure. Each nurse graded 10 color photos of pressure ulcers. Inter-rater reliability examined with Cohen's kappa was 0.82 (n = 22) in 2002 and 0.78 (n = 52) in 2006, which was judged to be excellent agreement [12]. After the inter-rater reliability was tested, additional education was provided by reviewing each photograph and discussing the criteria for its pressure ulcer grading.
For the 2006 survey, two experienced Quality Coordinators, prior head nurses with special training in the electronic record use and the administrative system, conducted the retrospective audit for patients identified with pressure ulcers.
Data analyses
Study data were analyzed using SPSS (version 14.0) and were explored descriptively. To compare groups, Student's t-test was used for continuous variables, Mann–Whitney U-test for ordinal scale variables, and Chi-square for dichotomous variables. A P-value of <0.05 was considered statistically significant.
|
Results |
|---|
|
TopAbstractIntroductionMethodResultsDiscussionConclusionFundingAcknowledgementsReferences |
|---|
Comparison of pressure ulcer prevalence and prevention: 2002 and 2006
Over 600 patients were included in each prevalence study (n = 612 in 2002; n = 632 in 2006). There were no significant differences between the groups in gender, age, type of unit or risk status (Braden subscales or total score). Expected length of stay was significantly shorter in 2006 (P = 0.002) (Table 2).
|
The prevalence of all pressure ulcers (Grade 1–4) was 23.9% in 2002 and 22.9% in 2006. When Grade 1 pressure ulcers were excluded, the prevalence rates were 8.0 and 12.0%, respectively (Table 3), which reveals a significant increase (P = 0.018) from baseline to the second survey. On the other hand, the mean number of ulcers per patient decreased significantly from 1.9 in 2002 to 1.6 in 2006 (P = 0.02). In both years, the sacrum and heels were the most common locations. However, in 2006, ‘other locations’, e.g. elbows, ears and feet, have increased (P = 0.02). The use of pressure-reducing mattresses increased significantly (P < 0.001) from 25.3% in 2002 to 41.1% in 2006. Planned repositioning in the bed or chair as well as the use of a pressure-reducing cushion in the chair were used sparsely in both years and decreased significantly over time, i.e. repositioning in bed (P = 0.02), chair (P = 0.01) and pressure-reducing cushions (P = 0.02).
|
Characteristics of those who did and did not develop pressure ulcers in 2006
Patients with pressure ulcers (n = 145) were compared with those without ulcers (n = 487). Patients with pressure ulcers were significantly older (mean age 77 versus 66 years; P < 0.001), had lower scores on all Braden subscales (P < 0.001), total Braden score (P < 0.001), and more incontinence (P < 0.001) than patients without pressure ulcers. They also had significantly longer hospital stay prior to the survey (mean number of days 16 versus 10 days on that specific ward; P < 0.001). Patients with a pressure ulcer received pressure-reducing mattresses (P < 0.001) and planned repositioning (P < 0.001) more frequently than patients without pressure ulcers.
Most of the patients (77.2%) with pressure ulcers had an acute admission and were admitted from home. One-third of the patients in the emergency department and in the operating room stayed there more than 4 h. Although the majority of patients were older (75.2%, >70 years), 25% of the patients with pressure ulcers were younger. Patients with pressure ulcers were present on all of the wards. Twenty-eight patients (20.5%) died within 7 months after the survey. At hospital admission, mean systolic BP was 132.7 (SD 28.6), mean diastolic BP was 73.8 mmHg (SD 13.7) and mean hemoglobin was 124.6 mg/l (SD 19.4).
Patients with pressure ulcers were admitted for varied reasons. Most common were admission for rehabilitation (n = 27), neurological conditions (n = 21), fractures (n = 17), circulatory conditions (n = 14), infection (n = 12) and malignancy (n = 11). Only two patients were admitted primarily for pressure ulcer treatment. Many patients had multiple secondary diagnoses (range 1–10), with the mean and median being 4.0.
Pressure ulcer prevention implemented at admission: 2006
Of the 145 patients with pressure ulcers, 136 records were audited. In nine cases, patients' identity numbers were not correct, and it was not possible to find the records. Skin inspection was recorded in the admission note on 56 patients (41.2%). Twenty patients (3.2%) were identified with pressure ulcers, but only three were described in sufficient detail that pressure ulcer grade could be determined (two Grade 1 and one Grade 3). Risk assessment was documented for a fourth of the patients and only a few used a validated instrument. Only one patient received a pressure-reducing mattress, another 30° lateral positioning cushion, three had a heel cushion, and five had planned repositioning.
During hospitalization and prior to the survey, 18 patients were identified with a new pressure ulcer, thus 38 patients (6.0%) had pressure ulcers when they arrived on the ward where the survey was conducted. On the survey day, 145 (22.9%) had ulcers.
Prevention and risk factors by pressure ulcer severity: 2006
When prevention of those with Grade 1 ulcers was compared with that for more severe ulcers (Grades 2, 3 and 4), those with more severe ulcers had significantly more pressure-reducing mattresses (P < 0.001), cushions for 30° lateral positioning (P = 0.001), and heel cushions (P = 0.01). Interventions rarely used and that did not differ significantly by severity were planned repositioning in bed, chair cushions and repositioning in chair. Seat cushions were used mainly in the geriatric department.
The total Braden scores showed that 80 of 145 patients (55.2%) with pressure ulcers were at risk (Table 4). However, 91 patients (62.8%) were bed or chair fast, 65 (44.8%) had very limited mobility or were completely immobile, and 42 (29.0%) required moderate to maximum help with bed or chair repositioning. Patients with more severe ulcers experienced greater moisture (P = 0.003), were more often bed or chair fast (P < 0.001), immobile (P < 0.001), and had issues of friction and shear (P = 0.001).
|
|
Discussion |
|---|
|
TopAbstractIntroductionMethodResultsDiscussionConclusionFundingAcknowledgementsReferences |
|---|
Pressure ulcers across time were present in about 1 in 4.5 patients, and the prevalence did not decrease despite a comprehensive quality improvement program. When grade 1 ulcers were excluded, the prevalence of ulcers remained high (8% in 2002 and 12% in 2006), although less than that seen in other studies [4]. It is disappointing that the quality improvement program did not result in a decreased prevalence of pressure ulcers. The methodology recommended by the European Pressure Ulcer Advisory Panel is a point prevalence survey and does not gather data for the origins of any pressure ulcers. Thus, these findings may reflect only the nature of patients admitted to the hospital, and not necessarily the care provided during hospitalization. This raises the question of whether prevalence is a good measure of quality of care [10, 13]. Furthermore, the retrospective audit of the electronic health record revealed a lack of documentation of skin assessment on admission to the hospital, thus it was impossible to decide whether the pressure ulcers were hospital-acquired or not. It is crucial to have a methodology that is both reliable and relatively easy to conduct for regular feedback to the clinicians.
A similar study from a 900-bed hospital in the Netherlands found a significant decrease in Grade 1–4 hospital-acquired pressure ulcers from 18 to 11% (P < 0.001) after implementing a hospital guideline for pressure ulcer care including a visco-elastic foam mattresses [14]. However, their sample was younger than ours and skin assessment was only performed on patients ‘at-risk’, which could mean an underestimation of ulcers due to lack of detection. Several quality improvement reports show examples of success, but often they do not report pressure ulcer grades, reliability of the data collection or patient demographics [10, 13].
Successful implementation of change can be explained by the relationship among evidence, context and facilitation [15]. The organizational context, including leadership and culture, is highlighted as it influences priorities and investments [16]. In the hospital studied, the focus for the last few years has been on two issues: major reorganization of departments and nursing leadership and implementation of the electronic health record. Educational priorities were on facilitating documentation by all professionals in the computerized system, limiting time and energy for substantive focus on pressure ulcer prevention. Another possible explanation for our findings is that improvements in one department were offset in another. A parallel study shows that the incidence of pressure ulcers in our orthopedic ward decreased from 55% in 1997 to 18% in 2006, after stepwise introduction of risk and skin assessment, pressure- reducing mattresses, education and nutritional guidelines [17] (A.-K. Westerlund et al., submitted). Because of the reorganization, it was not possible to compare data at the ward level.
When analyzing the patients with pressure ulcers in detail, it is evident that more than 75% were 70 or older, had acute admissions, were admitted from home, and over 40% had surgery during their hospital stay. These findings are confirmed by others [18, 19]. Patient with pressure ulcers spent more days in the hospital had multiple co-morbidities and a high post-survey death rate. This suggests that patients were frail, lacked biological reserves, required complex medical treatment, and were at risk of pressure ulcers as an iatrogenic consequence of hospitalization [20]. Most (77%) had acute admission, and yet only 41% had admission skin assessment. Very few patients received prevention from the start of their hospitalization.
When care at admission was compared with that on the survey day, more prevention was provided on the survey day. However, it was not possible to identify the timing of mattress use (prior to or following ulcer identification). Over the 4-year period, the mean number of ulcer per patient decreased, but the existing ulcers were slightly deeper. This might be explained by a decrease in planned repositioning and use of chair cushions, although the use of pressure-reducing mattresses significantly increased. These findings show that it is important to emphasize to staff that regular repositioning and heel-protection is needed, even when the patient lies on a pressure-reducing mattress. Findings from this study are consistent with those of De Laat et al. [14], who found that despite implementing a hospital guideline for pressure ulcer prevention, repositioning did not increase. Repositioning is central to prevention [21], yet the issue is how to translate science into practice. A recent systematic review revealed that little is known about how to increase research use in nursing [22].
The Institute for Healthcare Improvement in the United States recommends an ‘all-or-none’ format, meaning that all of the following should be performed: risk assessment, inspect skin daily, moisture management, optimal nutrition, repositioning and use of pressure-relieving surfaces [10]. However, Table 4 shows that patients with pressure ulcers have different risk factors. As expected, our data also show that patients with ulcers received pressure-reducing mattresses and planned repositioning more often that those without ulcers. Individual plans must be tailored to the patient's specific risk factors. Resources for care also need to be considered. Patient and family participation is pivotal in the development and implementation of a prevention plan, yet their role has not been addressed. Studies are needed that document positive outcomes, regardless of whether individual or bundles of interventions are utilized.
The issue of when to initiate prevention remains. Vanderwee et al. [23] found no significant difference in the prevalence of pressure ulcers when prevention was initiated by a Braden score <17 or when a Grade 1 pressure ulcer appeared. Further research is needed to determine what the trigger should be for prevention.
It is important to realize that while the bedside care of turning and positioning patients is primarily a nursing responsibility, pressure ulcer prevention extends beyond nursing and includes the multidisciplinary team. Each profession has a responsibility, e.g. dieticians for assessing nutritional need, physiotherapists for complex mobility issues, physicians for medical issues, etc. [24].
Methodological strengths and limitations
The prevalence methodology used in this study is widely used in Europe and similar to that used in pressure ulcer prevalence studies across the globe. The data collectors were educated in the methodology, and the inter-rater reliability of the pressure ulcer grading was excellent prior to the study. Data were based on the examination of the patient by two registered nurses, which strengthen the validity and reliability of the observations. However, this prevalence study methodology does not provide a way to determine the incidence of pressure ulcers. Thus, effects of prevention cannot be fully known.
The data on prevention on admission were based on retrospective audit of the electronic health records, and it is possible that more prevention was provided than documented. Data from records are limited by the fact that they are self-reports; however, they are also legal documents and are expected to accurately reflect care provided.
|
Conclusion |
|---|
|
TopAbstractIntroductionMethodResultsDiscussionConclusionFundingAcknowledgementsReferences |
|---|
Pressure ulcer prevalence did not decrease, despite a comprehensive quality improvement program. Those who developed ulcers were older, at risk of ulcers, incontinent and had longer length of stay. Increased use of pressure-reducing mattresses during the 4-year period reflected the adoption of evidence-based practice [21]. Risk factors for those with more severe ulcers were increased moisture, decreased activity, limited mobility and problems with friction. Major reorganization and implementation of an electronic health record may have negatively influenced the quality improvement program; further research on this is needed.
Data show that special attention is needed to provide prevention to older patients with acute admission. Thus, skin and risk assessment, as well as prevention, should start early in the hospital stay. Increasing the data collection to identify those patients with community-acquired versus hospital-acquired ulcers will strengthen pressure ulcers as an accurate marker of quality of care for hospitalized patients. If possible, data should be reported on ward level for comparison over time.
|
Funding |
|---|
|
TopAbstractIntroductionMethodResultsDiscussionConclusionFundingAcknowledgementsReferences |
|---|
This study was supported by a grant from Uppsala University Hospital.
|
Acknowledgements |
|---|
|
TopAbstractIntroductionMethodResultsDiscussionConclusionFundingAcknowledgementsReferences |
|---|
We thank all the nurses greatly for participating in the prevalence surveys. We also thank Lisa Jonsson and Ulla-Britt Söderström for auditing the electronic health record and the administrative system, and Åsa Boström for her participation in the design of the audit and in the data collection.
|
References |
|---|
|
TopAbstractIntroductionMethodResultsDiscussionConclusionFundingAcknowledgementsReferences |
|---|
- Blegen MA. Patient safety in hospital acute care units. Annu Rev Nurs Res (2006) 24:103–25.[Medline]
- Aydin CE, Bolton LB, Donaldson N, et al. Creating and analyzing a statewide nursing quality measurement database. J Nurs Scholarsh (2004) 36:371–78.[CrossRef][Web of Science][Medline]
- Bours GJ, Halfens RJ, Candel MJ, et al. A pressure ulcer audit and feedback project across multi-hospital settings in the Netherlands. Int J Qual Health Care (2004) 16:211–18.
[Abstract/Free Full Text] - Whittington KT, Briones R. National Prevalence and Incidence Study: 6-year sequential acute care data. Adv Skin Wound Care (2004) 17:490–94.[Medline]
- Woodbury MG, Houghton PE. Prevalence of pressure ulcers in Canadian healthcare settings. Ostomy Wound Manage (2004) 50:22–4. 26, 28, 30, 32, 34, 36–8.[Medline]
- Vanderwee K, Clark M, Dealey C, et al. Pressure ulcer prevalence in Europe: a pilot study. J Eval Clin Pract (2007) 13:227–35.[CrossRef][Web of Science][Medline]
- Spilsbury K, Nelson A, Cullum N, et al. Pressure ulcers and their treatment and effects on quality of life: hospital inpatient perspectives. J Adv Nurs (2007) 57:494–504.[CrossRef][Web of Science][Medline]
- Hopkins A, Dealey C, Bale S, et al. Patient stories of living with a pressure ulcer. J Adv Nurs (2006) 56:345–53.[CrossRef][Web of Science][Medline]
- Beckrich K, Aronovitch SA. Hospital-acquired pressure ulcers: a comparison of costs in medical vs. surgical patients. Nurs Econ (1999) 17:263–71.[Medline]
- Institute of Healthcare Improvement (IHI). Protecting 5 million lives from harm. Getting started kit: prevent pressure ulcers. http://www.ihi.org/IHI/Program/Campaign (December 2006, date last accessed).
- Gunningberg L. Risk, prevalence and prevention of pressure ulcers in three Swedish health-care settings. J Wound Care (2004) 13:286–90.[Medline]
- Fleiss JL, Chilton NW. The measurement of interexaminer agreement on periodontal disease. J Periondontal Res (1983) 18:601–16.[CrossRef]
- Catania K, Huang C, James P, et al. PUPPI: the pressure ulcer prevention protocol interventions. Am J Nurs (2007) 107:44–53.[Web of Science][Medline]
- De Laat EH, Schoonhoven L, Pickkers P, et al. Implementation of a new policy results in a decrease of pressure ulcer frequency. Int J Qual Health Care (2006) 18:107–12.
[Abstract/Free Full Text] - Rycroft-Malone J, Kitson A, Harvey G, et al. Ingredients for change: revisiting a conceptual framework. Qual Saf Health Care (2002) 11:174–80.
[Abstract/Free Full Text] - Rycroft-Malone J, Harvey G, Seers K, et al. An exploration of the factors that influence the implementation of evidence into practice. J Clin Nurs (2004) 13:913–24.[CrossRef][Web of Science][Medline]
- Gunningberg L, Lindholm C, Carlsson M, et al. Reduced incidence of pressure ulcers in patients with hip fractures. A two-year follow-up of quality indicators. Int J Qual Health Care (2001) 13:399–407.
[Abstract/Free Full Text] - Baumgarten M, Margolis D, Localio R, et al. Pressure ulcers among elderly patients early in the hospital stay. J Gerontol (2006) 61A:749–54.[Web of Science]
- Nixon J, Cranny G, Iglesias C, et al. Randomised, controlled trial of alternating pressure mattresses compared with alternating pressure overlays for the prevention of pressure ulcers: PRESSURE (pressure relieving support surfaces) trial. BMJ (2006) 332:1413–15.
[Abstract/Free Full Text] - Abate M, Di Iorio A, Di Renzo D, et al. Frailty in the elderly: the physical dimension. Eura Medicophys (2006) 42:1–9.[Medline]
- Cullum N, McInnes E, Bell-Syer Se, et al. Support surfaces for pressure ulcer prevention. Cochrane Database Syst Rev (2004) (3): CD001735 (review).
- Thompson D, Estabrooks C, Scott-Findlay S, et al. Interventions aimed at increasing research use in nursing: a systematic review. Implement Sci (2007) 2. http://www.implementationscience.com/content/2/1/15 (July 2007, date last accessed).
- Vanderwee K, Grypdonck M, Defloor T. Non-blanchable erythema as an indicator for the need for pressure ulcer prevention: a randomized-controlled trial. J Clin Nurs (2007) 16:325–35.[Web of Science][Medline]
- Dolynchuk K, Keast D, Campbell K, et al. Best practices for the prevention and treatment of pressure ulcers. Ostomy Wound Manage (2000) 46:38–52.[Medline]
- Beckman D, Schoonhoven L, Fletcher J, et al. European study of the reliability of the EPUAP classification system for pressure ulcers. J Adv Nurs (2007) 60:682–91.[CrossRef][Web of Science][Medline]
- Gunningberg L, Ehrenberg A. Accuracy and quality in the nursing documentation of pressure ulcers. A comparison of record content and patient examination. J Wound Ostomy Continence Nurs (2004) 31:328–35.[Medline]
- Gunningberg L, Fogelberg-Dahm M, Ehrenberg A. Nurses' perceptions of feed-back from the electronic patient record for the quality on pressure ulcer care. Stud Health Technol Inform (2006) 122:850.[Medline]
- Gunningberg L. EPUAP pressure ulcer prevalence survey in Sweden. A two-year follow-up of quality indicators. J Wound Ostomy Continence Nurs (2006) 33:258–66.[Web of Science][Medline]
CiteULike 
Connotea 
Del.icio.us What's this?
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||