Pressure ulcer prevention strategies in the USA: a systematic review of the literature17th May 2013
Sullivan N, Schoelles KM (2013) Preventing in-facility pressure ulcers as a patient safety strategy. A systematic review. Ann Internal Med 158(2): 410–16
This article reviews the evidence for multi-component strategies to prevent hospital-acquired pressure ulcers in care settings in the USA from 2000–2012. It uses data from 26 articles and gives details of successful patient safety strategies. Inclusion criteria were that the study used multi-component strategies among adults at facilities in the USA and that pressure ulcer rates were recorded six months after implementation. Study quality was assessed using the 19-point Standards for Quality Improvement Reporting Excellence guidelines. Particular attention was paid to whether the study described the intervention so that it could be reproduced, provided data on changes in process and observed outcomes, reporting study limitations and reported differences between actual and expected outcome. High quality articles had 8–10 items, moderate 5–7 and low was fewer than 5.
Of the 26 studies, 18 were in acute settings and eight in long-term care. The authors found that nine components were associated with successful reduction in pressure ulcer formation. In most of the studies the following components were used in combination and 24 reported a reduction in pressure ulcer rates (11 had statistically significant reductions):
- Education/staff training
- Revised protocols and documentation
- Quality audits and feedback
- Risk assessment using the Braden scale.
There was an emphasis on repeating risk assessments and implementing specific interventions based on the assessments. Interventions included repositioning, using special support surfaces, attention to moisture, nutrition and hydration and off-loading. Some of the studies reported improvements in other areas such as streamlined documentation and improved identification of high-risk patients. Improved documentation tended to improve results.
The authors found that six of the 26 studies had a model or theory that guided implementation, e.g. a plan, do, study, act plan. They also looked at motivating factors for implementing changes and found that a great many of the studies were responding to changes from the US Centers for Medicare and Medicaid Services that would restrict payments to people with hospital-acquired pressure ulcers. Other motivating factors included commitments to improve patient outcomes and others wished to bring outcomes into line with other facilities.
Most of the studies have one key coordinator who was in charge of the healthcare team, but there was a general emphasis on teamwork.
Audit and feedback was key to 20 of the prevention strategies. Positive reinforcement, visible goals and competition between teams were all used as incentives. Novel educational strategies were also described in some of the studies.
The authors reported on the barriers to success in the studies, which included lack of motivation, staff resistance, lack of consistent staffing, data collection difficulties and technology failures. They also reported the ways these barriers were overcome through more frequent interactions with staff and increased training and assigning responsibility to team members. Standardising documentation also solved some problems.
Ways to sustain the prevention strategies included annual competency tests, monthly updates, publicising results and keeping tabs on prevalence figures. Other studies had financial incentives for staff who kept prevalence down, and others had a wound care committee in place.
Four of the studies that the authors reviewed reported cost-savings.
Sustainable interventions were specified in some of the studies under review. The interventions that were not reliant on staffing levels but that were institutional such as using risk assessment tools or specialised mattresses were easier to sustain. Other successful interventions were giving nurses control of the strategy and strong leadership.
The authors conclude that this review provides moderate-strength evidence that implementing a multi-component strategy for pressure ulcer prevention can lead to successful reductions in pressure ulcer formation. The important features of successful strategies were simplified, standardised interventions, multidisciplinary involvement (often nurse-led), designating skin champions, sustained education, audit and feedback.
The authors cite reviews based on more recent studies that have similar findings to theirs and call for further research into the effect of daily care processes on outcomes. They call for more research and more reporting of the results of strategies — even when they have not been successful. They also call for a greater focus on sustaining the momentum of prevention strategies.