Creating a Pressure Ulcer Prevention Algorithm: Systematic Review and Face Validation

Abstract

  Pressure ulcer (PU) prevention is a care imperative supported by substantive evidence, but translating that knowledge into clinical decision-making at the point of care remains challenging. The purpose of this study was to create a succinct, evidence-based algorithm for inclusion in an existing industry-sponsored, evidence-based wound care program that will: 1) help clinicians assess and document overall patient PU risk; 2) help clinicians assess and address modifiable PU risk factors; and 3) guide clinicians toward an evidence-based protocol of care for patients with impaired skin integrity.

First, using a systematic literature review and the Strength of Recommendation Taxonomy (SORT), a one-page algorithm containing 26 distinct decision points/steps was developed with study quality ratings for all publications identified. Second, based on the quality-of-evidence ratings, the strength of each recommendation was obtained for each decision point/step. Lastly, face validation and subsequent instrument revision based on analytic input occurred. Twelve (12) wound care experts were asked to review each decision step and rate its appropriateness/relevance on a 4-point Likert scale, where 1 = not relevant/appropriate and 4 = very relevant and appropriate. Average scores and a content validity index (CVI) were calculated for the algorithm and each individual component. Two components, the use of high-quality foam and medical grade sheepskin for at-risk patients, had sufficient evidence to receive an A strength of recommendation. However, the latter had a very low CVI (0.18). One other step, frequency of assessment for current or recent history of limited mobility (B strength of recommendation), had a low CVI (0.7). The overall literature-based level of evidence was good, but overall evidence gaps remain. The overall mean score was 3.6 (SD 0.8) with a CVI of 0.89 (out of 1). Both scores indicate strong face validity. This is the first PU prevention algorithm based on systematic literature review and face validation. Future content and construct validation is needed to refine the algorithm.

 Potential Conflicts of Interest: This study was supported by a research grant from ConvaTec Inc, Skillman, NJ. The study was conducted, the data analyzed, and the manuscript written by the authors, who are responsible for the content of this publication. The authors do not have any financial interest in any products discussed in this publication.

Introduction

  Pressure ulcer (PU) prevention has become a litigious and fiscal imperative in contemporary healthcare. Considered a quality indicator that greatly impacts quality of life and cost of care,¹ PU development can be interpreted as poor quality of care or even as a “medical error.”²

  Knowledge about PU prevention has increased substantially in recent decades,³ and multiple guidelines targeting their prevention and treatment are available.^4,5 However, research suggests that translating available knowledge into bedside clinical decision-making is complicated by many factors, including difficulties implementing lengthy, time-consuming care guidelines; faulty communication; limited education; and poor standardization.^6,7 Devices or instruments that can help encapsulate larger amounts of information into a more usable process may assist with the transfer of research into clinical practice.⁸ Cognitive forcing strategies such as checklists and algorithms can aid optimal clinical decision making and actions, thus expediting safe patient care.^9-11 The imperative for multicomponent PU prevention programs has become so strong that multiple publications have targeted it as a patient safety strategy that should be implemented immediately.^12,13

  The overall purpose of this work was to create a PU prevention algorithm for adults to be included in an existing industry-sponsored, evidence-based wound care program that will: 1) help clinicians assess and document overall patient PU risk, 2) help clinicians assess and address modifiable PU risk factors, and 3) guide clinicians toward an evidence-based protocol of care for patients with impaired skin integrity. To that end, the first purpose of this study was to create an evidence-based PU prevention algorithm for adults; the second, to identify the strength of recommendation of each decision step based on currently available evidence; and the third, to obtain face validation of the algorithm and revise the instrument based on analytic input.

Background

  ConvaTec’s Solutions® program (ConvaTec, Skillman, NJ), developed in the 1990s, consists of a set of eight wound algorithms and a Pressure Ulcer Prevention Algorithm. The former have since been content- and construct-validated, are available in a digital format,^14-16 and are currently included in the Agency for Healthcare Research and Quality (AHRQ) Guidelines Clearinghouse.¹⁷ The prevention algorithm has not been updated to reflect current standards of care and has not been formally tested, even though available evidence suggests implementation of the entire program reduces PU prevalence rates.^18,19

Methods

  Algorithm development.
  Literature review. The algorithm development and literature review process was guided by recently published recommendations for guideline development.²⁰ The project commenced in the fall of 2011 with a general review of the literature and development of a literature search strategy to capture both PU risk assessment and prevention intervention publications. A systematic review of the English literature on PU prevention published since 2007 and starting with highest level of evidence databases (meta-analysis) was conducted between January 2012 and May 2013 using the following databases: Medline® (US National Library of Medicine®, Bethesda, MD), CINAHL® (Western Adventist Health Services, Glendale, CA), JBI COnNECT+ (Joanna Briggs Institute Clinical Online Network of Evidence for Care and Therapeutics), The COCHRANE Library (The Cochrane Collaboration), and ProQuest Dissertation Abstracts. The search yielded 623 publications (see Table 1). First, all publications were reviewed for applicability. Because similar search terms were used in the different databases, a substantial number of citations were duplicates. After excluding duplicate, nonPU-related (other chronic wounds), preclinical studies as well as general opinion-based reviews, a total of 117 publications remained. Most salient publications were obtained from the Medline and CINAHL databases. Finally, using the same search terms, the PubMed (US National Library of Medicine), Clinical Trials.gov, and the Agency for Healthcare Research and Quality National Guideline Clearinghouse websites¹⁷ were reviewed and the most recent evidence based and/or content-validated PU clinical practice guidelines posted on guidelines.gov were retrieved.^4,5 Because the Association for the Advancement of Wound Care Pressure Ulcer Guideline4 includes previously published guidelines, such as the European Pressure Ulcer Advisory Panel and the National Pressure Ulcer Advisory Panel (EPUAP/NPUAP) Pressure Ulcer Guidelines,²¹ it was not included separately in order to prevent skewing evidence levels.

  Abstraction and study quality ratings. The initial literature review (n =117) yielded three major themes in PU prevention practice: 1) screening, diagnosis, and PU risk assessment; 2) PU prevention interventions; and 3) education related to all aspects of care. All publications were abstracted and entered into Excel® (Microsoft, Seattle, WA) spreadsheets based on these themes. In addition to publication information, the following variables were entered: publication type, study design and variables, intervention(s), contraindication(s), sample size, patient care setting, and study results or outcomes. With respect to risk assessment and screening instrument study results, emphasis was placed on modifiable PU risk factors. The quality of each individual study was rated using the Strength of Recommendation Taxonomy (SORT).²² The SORT meets the Institute of Medicine’s criteria for systematic reviews and guideline development²⁰ and is based on patient-centered, not interim, outcomes. With respect to the PU prevention literature, the SORT was found to be most useful because it includes clear criteria for rating diagnostic studies, treatment, prevention, and screening studies, as well as studies related to prognosis. It also has been used in previous wound algorithm validation work.^23,24

  Algorithm development. All available evidence, including other validated and reliable instruments such as the Braden Scale for Predicting Pressure Sore Risk© (originally developed by Barbara Braden and Nancy Bergstrom), was organized and put into a flowchart format for algorithm development. Color schemes were included to bring users’ attention to critical steps in the process (see Figure 1). Users enter the algorithm at the point of patient assessment for evident risk or history of recent PU; if appropriate, users then are re-directed to either prevention interventions for the at-risk patient or reassessment for the patient with intact skin and/or low risk. If, for example, the person is an obstetrics patient or healthy ambulatory surgery patient, the algorithm is not appropriate or necessary. Because staff, caregiver, and patient education are an important component of all aspects of patient assessment, screening, and intervention, this step undergirds the entire algorithm. If the patient develops or already has skin breakdown, the clinician is directed to obtain a differential diagnosis (eg, PU versus incontinence-associated dermatitis) and implement an appropriate validated wound care algorithm set (eg, Solutions® Algorithms, ConvaTec, Skillman, NJ).

  Literature-based evidence algorithm components. Each segment and step within the algorithm was described and the available abstracted evidence was grouped for each step to obtain an overall strength of recommendation where A = consistent, good quality patient level evidence; B = inconsistent or limited quality patient level evidence; and C = consensus, usual practice, opinion, disease-oriented evidence, or case series for studies of diagnosis, treatment, prevention, or screening.^20,22 For the final strength of recommendations, studies with a study quality (SORT) rating of 3 (lowest level) were included only for steps with limited Level 1 or 2 quality studies, leaving a total of 55 publications upon which the algorithm strength of recommendations were based (see Table 2 and Addendum). Because some evidence-based reviews, meta-analyses, or practice guidelines contained evidence to support multiple algorithm components/steps,^4,25 the Quality (SORT) rating of the study for the purpose of developing literature-based strength of recommendations was based on the strength of recommendation/level of evidence for the specific algorithm decision statement/step contained within that guideline.

  Face validation.
  Instrumentation. In order to obtain face validation for the newly constructed algorithm, a data collection instrument was developed by the researchers containing 17 questions regarding basic demographic data (age, gender, education, wound care experience) and the 26 items representing each segment/step previously developed for the literature-based evidence table. Using a process described by Lynn²⁶ and Waltz and Bausell,²⁷ participants were asked to review each decision statement/step and rate it according to the following scale: 1 = not relevant/appropriate, 2 = unable to assess relevance without revision, 3 = relevant but needs minor alteration, and 4 = very relevant and appropriate.

  Processes. Before surveying participants, the Institutional Review Board of La Salle University (Philadelphia, PA) reviewed the proposed project in 2012 and deemed it exempt status due to its low risk level and educational focus; however, ethical considerations were fully addressed. Specifically, all participants received an explanatory cover letter and were asked to provide written informed consent. A multidisciplinary group of clinicians (N = 23) was contacted via telephone or email and asked to participate in the study. After agreeing to participate and providing informed consent, participants received a professionally produced copy of the Pressure Ulcer Prevention Algorithm and the researcher-designed data collection instrument. The cover sheet provided background information, described the objectives of the PU prevention algorithms, and described the participant’s role in helping validate the newly constructed algorithm. Specifically, it was emphasized that being a member of the review panel did not constitute authorship or endorsement of the algorithm. Twelve (12) of the 23 invited experts agreed to participate, a response rate of 52%.

  Data analysis. Data analysis was conducted using Excel® version 2010 (Microsoft, Seattle, WA). Data were coded and entered into the database by an assistant. Summary statistics were calculated for demographic data (eg, mean age and frequencies).

  Ratings of all 26 algorithm decision statements/steps were entered and mean scores were calculated. The Content Validity Index (CVI) also was calculated using processes described by Lynn²⁶ and Waltz and Bausell²⁷ and clarified by Polit and Beck²⁸ and Polit et al.²⁹

  Qualitative comments regarding individual decision statements/steps and overall processes were transcribed and thematically analyzed using qualitative data reduction techniques. The “find” mechanism of Microsoft© Word assisted with thematic analysis.

Results

  Literature-based strength of recommendations. The number of level 1 and level 2 quality studies was substantial for the majority of the 26 steps (n = 18, 69%). Two of the decisions/steps had sufficient evidence to receive an A strength of recommendation; only eight had a C strength of recommendation. Most of the recommendations with lower level evidence pertained to common interventions related to skin protection and care (see Table 2).

  Face validation.
  Demographics. The majority (n = 9, 75%) of participants are female and Advanced Practice Nurses, Nurse Practitioners, or Clinical Nurse Specialists (n = 6, 50%) with an average age of 47.5 years (median 52). Five participants are Registered Nurses and one is a Medical Doctor (MD). All had received formal wound care education, were currently wound care-certified (certified wound, ostomy, continence nurse [CWOCN]/certified wound continence nurse [CWCN]: n = 10, 84%; certified wound specialist [CWS] or other: n = 2, 16%); and had a Baccalaureate (n = 4, 33%), Master’s (n = 6, 50%), or doctoral degree (n = 2, 17%). All had received their healthcare education in the US. Eleven out of 12 had 10 or more years of clinical experience, including four (33%) with more than 30 years experience. Several participants practice in more than one patient care setting, including acute care (n = 10, 83%), subacute care (n = 3, 25%), home care (n = 2, 17%) or long-term care (n = 2, 17%). Geographically, participants were widely dispersed. The most common practice areas (n = >1 per state) were Illinois (n = 2), Pennsylvania (n = 2), and Virginia (n = 2). Most (n = 9, 75%) indicated they encountered >200 wounds per year in their practice, with 11 (92%) indicating that PUs were the wounds they encountered most frequently. Respondents also managed patients with lower extremity wounds (n = 9), diabetic foot ulcers (n = 5), and surgical wounds (n = 3).

   Quantitative analysis. The overall mean score of all algorithm decision statements/steps was 3.5 (SD 0.8), interpreted as meaning the components were very relevant to relevant and needed only minor alteration. Without the lowest score step — provide medical grade sheepskin — the mean score was 3.6 (SD 0.8). The CVI of the entire PU prevention algorithm was 0.89, well above the minimum of 0.7 or 0.80 suggested by researchers as minimally acceptable.^26,28,29 A CVI of 0.89 suggests that participants viewed the overall content of the algorithm as strongly appropriate. Two steps questionable to reviewers and that received a less-than-acceptable CVI were following admission assessment if not at risk and with intact skin, assess for current or recent history of limited mobility (CVI 0.7) and provide medical grade sheepskin for bed and chair (CVI 0.18) (see Table 2). Table 2 displays the components’ evidence levels— ie, how each component or step of the algorithm was rated for CVI, mean score, and the study quality and strength of recommendation (patient-centered) based on available abstracted literature. In general, most steps were strongly rated except for those noted above.

 Qualitative analysis. Respondents’ comments reflected concern about time issues (Does it have to be every 24 hours or less?), the use of medical grade sheepskins (issues with infection control and incontinence), and the appropriateness of using medical grade sheepskin. In the US, synthetic sheepskins are used, and study participants expressed concern about hygiene and the effect of these sheepskins on pressure.

  Qualitative analysis generated themes regarding individual decision statements/steps: issues with timing, specifying the content of pertinent education, defining limited mobility, appearance of the algorithm (strengths and weaknesses), wording, and specification of products. Qualitative analysis of overall comments identified the following themes: terminology, specificity versus generality, expert versus nonexpert perspectives, litigation, and algorithm flow and appearance (see Table 3 and Table 4). In addition, one participant was confused about the entry step targeting risk versus nonrisk. Because most reviewers did not have this response, no changes were made to the language or format. Future content validation testing with a larger sample may help delineate needed changes.

  Following a careful review of these results, minor modifications were made to algorithm wording for the two most frequently questioned and lower CVI-rated steps. In addition, concerns about the flow of information prompted slight revisions in the layout for the purpose of reducing text redundancy.

Discussion

  An evidence-based PU prevention algorithm for adults was created for inclusion in an existing evidence-based wound care program. The systematic literature review identified more than 600 publications, but many were duplicates, did not pertain to PUs, or were nonclinical studies or nonevidence-based reviews. However, the remaining 117 publications used in the creation of the algorithm and the 55 publications used to populate the evidence table yielded a reasonably good strength of recommendation (level B) for the majority of the 26 decision points/steps. The majority of the available studies utilized for each choice were quality Level 2 (limited quality clinical trials or retrospective cohort studies or studies with inconsistent results).²² Occasionally a high-quality, Level 1 study was available to support an algorithm step.

  The CVI of the one-page algorithm for PU prevention in adults was strong (0.89 out of 1.0) with an overall mean of 3.50 (out of 1 to 4), suggesting the components were very appropriate to the purpose of the instrument. Although most validation average scores were >3.0, a few were not, yielding some observations that require further study or exploration. The strongest level of evidence available was for the use of medical grade sheepskin. Although used internationally and tested with good quality clinical trials (see Table 2), its use was not viewed positively by the experts, who cited current use of synthetic sheepskin. Most often, reference was made to problems with infection control and incontinence.

  Another decision item with a relatively good strength of recommendation and an acceptable but low CVI was the need to evaluate for a current or recent history of immobility in patients not considered at risk according to the Braden Scale. Although the Braden Scale subscores include patient mobility and activity, there are concerns about that instrument’s ability to capture recent episodes of immobility due to lengthy surgical procedures, emergency room stays, or following trauma.^4,30-33

  On the other hand, several steps (interventions) with the lowest quality studies and level of evidence (C strength of recommendation) had the highest CVI. Specifically, most interventions related to skin care and preventing skin exposure to moisture, as well as the need to provide a differential diagnosis if an alteration in skin integrity is observed, had a CVI >0.9. Clearly, these interventions are considered important by clinicians but lack good quality evidence. Recently, two studies^34,35 about the role of specialized fabrics that help manage moisture have been published, which may help increase evidence levels in this area.

  Strong evidence supports the use of a high-quality support surface to redistribute pressure,³⁶ but the exact nature of what surface is “best” is still to be determined; panel members expressed an interest in more specific directions for this step. Similarly, periodic reassessment of risk also is supported in the literature and received a high CVI, but the exact frequency of reassessment in various patient care environments remains vague. Although the expert panel considered more specific details about interventions to be beneficial, there was also concern about steps that were unambiguous. For example, although the literature generally supports assessment and reassessment within 24 hours and the CVI for that recommendation was high (0.9), some clinicians who participated in this study were concerned about the potential legal implications of timeframes. Use of a validated nutritional assessment tool also is well supported in the literature, but less evidence is available regarding how best to correct nutritional deficiencies. Finally, adequate quality evidence supports the use of valid, reliable instruments to assess PU risk, and the importance of staff, caregiver, and patient education about PU risk and prevention has relatively strong support.³⁷ At the same time, there is little consensus in the literature on how to achieve these educational requirements. Current study participants identified a need for more specific guidelines on this topic.

  The development and validation of the PU prevention algorithm was a challenging task but somewhat easier than previous algorithms developed, such as those for negative pressure wound therapy (NPWT).^23,24 The level of available evidence was generally stronger for PU but not as high level as would be desirable for optimal evidence-based practice.

  The great strength of the algorithm is that it captures much research evidence on various patient risk factors that are routinely collected and modifiable and places them in one succinct visual aid. Algorithms like the PU prevention algorithm can assist with promoting patient safety in a fast-paced clinical environment.^9-11

Study Limitations

  The current algorithm was designed to focus on adult care only and cannot be guaranteed appropriate or effective for neonatal and/or pediatric populations. Related to this focus is the phenomenon of device-related PUs. Because pediatrics was not incorporated, device-related skin damage was not abstracted because this etiology is a major issue in pediatric skin protection. Another phenomenon, deep tissue injury, was not incorporated specifically because the research evidence base underlying cause and prevention is only beginning to emerge, and the PU algorithm focuses on prevention, not PU assessment or treatment strategies.

  Although not strictly a limitation of the study, the issue of validation of algorithms, protocols, and guidelines is important. If skin integrity is altered, the PU prevention algorithm suggests obtaining a differential diagnosis and guides the user to a specific protocol of care. The PU prevention algorithm possibly could be used with other wound care protocols, but if those other algorithms, protocols, or decision trees are not research-based for content or construct validity, the evidence support for PU treatment potentially becomes weakened.

  To ensure information is current, the literature review was conducted for the years 2007 to 2013. Earlier work was not included purposely, but pertinent earlier work was included in the evidence-based guidelines and meta-analysis used for the creation of the algorithm. Finally, face validation with expert review is not commensurate with full content validation. It is only a “step one” activity. Full content validation is needed for best evidentiary support and further algorithm refinement.

Conclusion

  Following a systematic review of the literature, a one-page PU prevention algorithm was developed and face validated. More than 60% of the 26 decisions/steps contained in the algorithm had at least a B strength of recommendation. The average score for the algorithm was very good, but the individual CVI of two steps was <0.7, suggesting they need to be modified. To the authors’ knowledge, this is the first PU prevention algorithm based on a systematic literature review and face validation. Future research should target content and construct validation with a larger multidisciplinary group of wound care clinicians.

Acknowledgment

  The valuable contributions of the following Pressure Ulcer Prevention Algorithm Face Validation Panel members are gratefully acknowledged:
  Anita Thurman, MSN,FNP-C, CWOC-AP, Coordinator, Inpatient Wound Care, Southeastern Regional Medical Center, Lumberton, NC; Richard Schneider, MBA, RN, CWON, Department of Wound, Ostomy, and Continence Nursing, University of Virginia Health System, Charlottesville, VA; Deborah L. Gray, DNP, CRNP, Geriatric and Extended Service, James E. Van Zandt Veterans Administration Medical Center, Altoona, PA; Catherine T. Milne, APRN, MSN, BC-ANP/CSS, CWOCN, Connecticut Clinical Nursing Associates, LLC. Bristol, CT; Janet Johnson Prince, RN, BSN, CWOCN, Manager, Wound Care Services, St. Joseph Hospital, Nashua, NH; Anne Scheurich, BS, RN, CWOCN, Vice President of Clinical Operations, Telemedicine Solutions LLC, Schaumburg, IL; and Shawna Philbin, RN, BSN, CWOCN, WOC Department, Health First Palm Bay Hospital, Palm Bay, FL.

 Ms. van Rijswijk is an Instructor, Holy Family University, School of Nursing and Allied Health Professions, Philadelphia, PA; and Clinical Editor, Ostomy Wound Management. Dr. Beitz is a Professor of Nursing, School of Nursing – Camden, Rutgers University, Camden, NJ. Please address correspondence to Lia van Rijswijk, MSN, RN, CWCN, Holy Family University, 9801 Frankford Avenue, Philadelphia, PA 19114-2009; email: lvanrijswijk@holyfamily.edu.

1. Levine JM, Ayello EA, Zulkowski KM, Fogel J. Pressure ulcer knowledge in medical residents: an opportunity for improvement. Adv Skin Wound Care. 2012;25(3):115–117.

2. Peterson AM. Guest editorial: Pressure ulcer prevention, management, and outcome. J Legal Nurs Consult. 2012;23(1):3.

3. Niederhauser A, Van Deussen Lukas C, Parker V, Ayello EA, Zulkowski K, Berlowitz P. Comprehensive programs for preventing pressure ulcers: a review of the literature. Adv Skin Wound Care. 2012;25(4):167–188.

4. Association for the Advancement of Wound Care (AAWC). Association for the Advancement of Wound Care Guideline of Pressure Ulcer Guidelines. Malvern, PA: Association for the Advancement of Wound Care;2010.

5. Wound Ostomy Continence Nurses Society. Guidelines for Prevention and Management of Pressure Ulcers. Mt. Laurel, NJ: WOCN Society;2010.

6. Jankowski IM, Nadzam DM. Identifying gaps, barriers, and solutions in implementing pressure ulcer prevention programs. Jt Comm J Qual Patient Saf. 2011;37(6):253–264.

7. Soban LM, Hempel S, Munjas BA, Miles J, Rubenstein LV. Preventing pressure ulcers in hospitals: a systematic review of nurse-focused quality improved interventions. Jt Comm J Qual Patient Saf. 2011;37(6):245–252.

8. Beitz JM. Why are we still seeing pressure ulcers? Ostomy Wound Manage. 2013;59(2):56–57.

9. Croskerry P. Cognitive forcing strategies in clinical decision making. Ann Emerg Med. 2003;41(1):110–120.

10. Hales BM, Pronovost PJ. The checklist – a tool for error management and performance improvement. J Crit Care. 2006;21(3):231–235.

11. Sherbino J, Yip S, Dore KL, Siu E, Norman GR. The effectiveness of cognitive forcing strategies to decrease diagnostic error: an explanatory study. Teach Learn Med. 2011;23(1):78–84.

12. Shekelle PG, Pronovost PJ, Wachter RM, McDonald KM, Schoelles K, Dy SM, et al. The top ten patient safety strategies that can be encouraged for adoption now. Ann Intern Med. 2013;158(5 Pt 2):365–368.

13. Sullivan N, Schoelles KM. Preventing in-facility pressure ulcers as a patient safety strategy. Ann Intern Med. 2013;158(5 Pt 2):410–416.

14. Beitz JM, van Rijswijk L. Using wound care algorithms: a content validation study. J Wound Ostomy Continence Nurs. 1999;26(5):238–249.

15. Beitz JM, van Rijswijk L. A cross-sectional study to validate wound care algorithms for use by registered nurses. Ostomy Wound Manage. 2010;56(4):46–59.

16. Beitz JM, van Rijswijk L. Development and validation of an online interactive multimedia wound care algorithm program. J Wound Ostomy Continence Nurs. 2012;39(1):23–34.

17. United States Department of Health and Human Services. Agency for Healthcare Research and Quality; National Guideline Clearinghouse. Available at: http://guideline.gov. Accessed July 7, 2013.

18. Ohura T, Sanada H, Mino Y. Clinical activity-based cost effectiveness of traditional versus modern wound management in patients with pressure ulcers. WOUNDS. 2004;16(5):157–163.

19. Lyder C, Shannon R, Empleo-Frazier O, McGehee D, White C. A comprehensive program to prevent pressure ulcers in long-term care: exploring costs and outcomes. Ostomy Wound Manage. 2002;48:52–62.

20. Institute of Medicine. Clinical Practice Guidelines We Can Trust. Washington, DC: The National Academies Press;2011.

21. European Pressure Ulcer Advisory Panel and National Pressure Ulcer Advisory Panel. Prevention and Treatment of Pressure Ulcers: Quick Reference Guide. Washington, DC: NPUAP;2009.

22. Ebell MH, Siwek J, Weiss BD, Woolf SH, Susman J, Ewigman B, et al. Strength of recommendation taxonomy (SORT) a patient-centered approach to grading evidence in the literature. Am Fam Physician. 2004;69(3):548–556.

23. Beitz J, van Rijswijk L. Development of evidence-based algorithms for negative pressure wound therapy in adults with acute and chronic wounds: literature and expert-based face validation results. Ostomy Wound Manage. 2012;58(4):50–69.

24. Beitz J, van Rijswijk L. Content validation of algorithms for negative pressure wound therapy in adults with acute or chronic wounds: a cross-sectional study. Ostomy Wound Manage. 2012;58(9):32–40.

25. Stechmiller JK, Cowan L, Whitney JD, Phillips L, Aslam R, Barbul A, et al. Guidelines for the prevention of pressure ulcers. Wound Repair Regener. 2008;16(2):151–168.

26. Lynn MR. Determination and quantification of content validity. Nurs Res. 1986;35(6):382–385.

27. Waltz CW, Bausell RB. Nursing Research: Design, Statistics, and Computer Analysis. Philadelphia, PA: FA Davis;1981.

28. Polit DF, Beck CJ. The content validity index: are you sure you know what’s being reported? Critique and recommendations. Res Nurs Health. 2006;29(5):489–497.

29. Polit DF, Beck CT, Owen SV. Is the CVI an acceptable indicator of content validity? Appraisal and recommendations. Res Nurs Health. 2007;30(4):459–467.

30. Gallagher P, Barry P, Hartigan I, McCluskey P, O’Connor K, O’Connor M. Prevalence of pressure ulcers in three university teaching hospitals in Ireland. J Tissue Viability. 2008;17(4):103–109.

31. Lahmann NA., Kottner J, Dassen T, Tannen A. Higher pressure ulcer risk on intensive care? Comparison between general wards and intensive care units. J Clin Nurs. 2011;21(3-4):354–361.

32. Munro CA. The development of a pressure ulcer risk-assessment scale for perioperative patients. AORN J. 2010;92(3):272–287.

33. Page KN, Barker AL, Kamar J. Development and validation of a pressure ulcer risk assessment tool for acute hospital patients. Wound Repair Regen. 2011;19(1):31–37.

34. Coladonato J, Smith A, Watson N, Brown AT, McNichol L, Clegg A, et al. Prospective, non-randomized controlled trials to compare the effect of a silk-like fabric to standard hospital linens on the rate of hospital-acquired pressure ulcers. Ostomy Wound Manage. 2012;58(10):14–31.

35. Twersky J, Montgomery T, Sloane R, Weiner M, Doyle S, Mathur K, et al. A randomized controlled study to assess the effect of silk-like textiles and high absorbency adult incontinence briefs on pressure ulcer prevention. Ostomy Wound Manage. 2012;58(12):18–24.

36. McGinnis E, Stubbs N. Pressure-relieving devices for treating heel pressure ulcers. Cochrane Database Syst Rev. 2011;9:CD005485.

37. Shannon RJ, Brown L, Chakravarthy D. Pressure ulcer prevention program study: a randomized controlled prospective comparative value evaluation of two pressure ulcer prevention strategies in nursing and rehabilitation centers. Adv Skin Wound Care. 2012;25(10):450–464.

Addendum: Reviewed/Abstracted Publications References

Ackerman CL. ‘Not on my watch:’ treating and preventing pressure ulcers. Medsurg Nurs. 2011;20(2):86–93.

Alderden J, Whitney JD, Taylor SM, Zaratkiewicz S. Risk profile characteristics associated with outcomes of hospital-acquired pressure ulcers: a retrospective review. Crit Care Nurse. 2011;31(4):30–43.

Al-Samarrai NR, Uman GC, Al-Samarrai T, Alessi CA. Introducing a new incontinence management system for nursing home residents. J Am Med Dir Assoc. 2007;8(4):253–261.

Association for the Advancement of Wound Care (AAWC). 2010 Association for the Advancement of Wound Care Guideline of Pressure Ulcer Guidelines. Available at: www.guideline.gov.

Baharestani MM, Black JM, Carville K, Clark M, Cuddigan JE, Dealey C, et al. Dilemmas in measuring and using pressure ulcer prevalence and incidence: an international consensus. Int Wnd J. 2009;6(2):104.

Bales I. A comparison between the use of intravenous bags and heel lift suspension boot to prevent pressure ulcers in orthopedic patients. Adv Skin Wound Care. 2012;25(3):125–131.

Beeckman D, Schoonhoven L, Fletcher J, Furtado K, Gunningberg L, Heyman H, et al. EPUAP classification system for pressure ulcers: European reliability study. J Adv Nurs. 2007;60(6):682–691.

Beeckman D, Schoonhoven L, Fletcher J, Furtado K, Heyman H, Paquay L, et al. Pressure ulcers and incontinence-associated dermatitis: effectiveness of the pressure ulcer classification education tool on classification by nurses. Qual Saf Health Care. 2010;19(5):e3.

Beeckman D, DeFloor T, Verhaeghe S, Vanderwee K, Demarre L, Schoonhoven L. What is the most effective method of preventing and treating incontinence associated dermatitis? Nurs Times. 2010;106(38):22–25.

Beeckman D, Clays E, VanHecke A, Vanderwee K, Schoonhoven L, Verhaeghe S. A multi-faceted tailored strategy to implement an electronic clinical decision support system for pressure ulcer prevention in nursing homes: a two-armed randomized controlled clinical trial. Int J Nurs Stud. 2013;50(4):475–486.

Beitz JM, van Rijswijk L. Using wound care algorithms: a content validation study. J Wound Ostomy Continence Nurs. 1999;26(5):238–249.

Beitz JM, van Rijswijk L. Development and validation of an on-line interactive multimedia wound care algorithm program: outcomes of a pilot study. J Wound Ostomy Continence Nurs. 2012;39(1):23–34.

Beitz JM, van Rijswijk L. A cross-sectional study to validate wound care algorithms for us by registered nurses. Ostomy Wound Manage. 2010;56(4):46–59.

Berthe JV, Bustillo A, Melot C, de Fontaine S. Does a foamy-block mattress system prevent pressure sores? A prospective randomized clinical trial in 1729 patients. Acta Chir Belg. 2007;107(2):155–161.

Black JM, Edsberg LE, Baharestani MM, Langemo D, Goldberg M, McNichol L, et al. Pressure ulcers: avoidable or unavoidable? Results of the National Pressure Ulcer Advisor Panel Consensus Conference. Ostomy Wound Manage. 2011;57(2):24–37.

Bloemen-Vrencken JH, de Witte LP, Post MW, Pons C, van Asbeck FWA, van der Woude LH, et al. Comparison of two Dutch follow-up care models for spinal cord-injured patients and their impact on health problems, re-admissions and quality of care. Clin Rehab. 2007;21(111):997–1006.

Bolton LB, Donaldson NE, Rutledge DN, Bennett C, Brown DS. The impact of nursing interventions: overview of effective interventions, outcomes, measures, and priorities for future research. Med Care Research Rev. 2007;64(2):123S–143S.

Bosch M, Halfens RJ, van der Weijden T, Wensing M, Akkermans R, Grol R. Organizational culture, team climate, and quality management in an important patient safety issue: Nosocomial pressure ulcers. Worldviews Evid Based Nurs. 2011;8(1):4–14.

Brace JA. Deep tissue injury pressure ulcers among elderly patients. Doctoral Dissertation. University of Virginia. 2010. Available at: ProQuest LLC, UMI: 3435914. Accessed May 12, 2012.

Brace JA, Schubart JR. A prospective evaluation of a pressure ulcer prevention and management e-learning program for adults with spinal cord injury. Ostomy Wound Manage. 2010;56(8):24–34.

Brienza D, Kelsey S, Karg P, Allegretti A, Olson M, Schmeler M, et al. A randomized clinical trial on preventing pressure ulcers with wheelchair seat cushions. JAGS. 2010;58(12):2308–2314.

Butler M, Collins R, Drennan J, Halligan P, O’Mathuna DP, Schultz TJ, et al. Hospital nurse staffing models and patient and staff-related outcomes. The Cochrane Library. 2011;(7):CD007019.

Buttery J, Phillips L. Pressure ulcer audit highlights important gaps in the delivery of preventative care in England and Wales 2005-2008. EWMA J. 2009;9(3):27–31.

Campbell KE. Heel pressure ulcers in the orthopedic population: incidence and prevention. Thesis. University of Western Ontario. 2009. Available at: Library and Archives Canada; ISBN: 978-0-494-50204-4.

Carr D, Benoit R. The role of interventional patient hygiene in improving clinical and economic outcomes. Adv Skin Wound Care. 2009;22(2):74–78.

Catania K, Huang C, James P, Madison M, Moran M, Ohr M. PUPPI: the pressure ulcer prevention protocol interventions. Am J Nurs. 2007;107(4):44–52.

Cavicchioli A, Carella G. Clinical effectiveness of a low-tech versus high-tech pressure-redistributing mattress. J Wound Care. 2007;16(7):285–289.

Chamanga E. Wound management: Improving pressure ulcer care. J Comm Nurs. 2011;25(4):16–21.

Charrier L, Allochis MC, Cavallo MR, Gregori D, Cavallo F, Zotti CM. Integrated audit as a means to implement unit protocols: a randomized and controlled study. J Eval Clin Pract. 2008;14(5):847–853.

Comfort EH. Reducing pressure ulcer incidence through Braden Scale risk assessment and support surface use. Adv Skin Wound Care. 2008;21(7):330–334.

Cowan LJ, Stechmiller JK, Rowe M, Kairalla JA. Enhancing Braden pressure ulcer risk assessment in acutely ill adult veterans. Wound Rep Regen. 2012;20(2):137–148.

Dealey C. Skin care and pressure ulcers. Adv Skin Wound Care. 2009;22(9):421–428.

Dean E. Standardized care and innovation helps slash pressure ulcer rates. Nurs Standard. 2011;26(5):8.

Demarre L, Katrien V, Dimitri B, Defloor T. The effectiveness of a multistage low-pressure air mattress in pressure ulcer prevention: an RCT. J Clin Nurs. 2010;19 (suppl. 1):41.

Demarre L, Vanderwee K, Defloor T, Verhaeghe S, Schoonhoven L, Beeckman D. Pressure ulcers: knowledge and attitude of nurses and nursing assistants in Belgian nursing homes. J Clin Nurs. 2012;21(9-10):1425–1434.

Demarre L, Beeckman D, Vanderwee K, Deflorr T, Grypdonck M, Verhaeghe S. Multi-stage versus single-stage inflation and deflation cycle for alternating low-pressure air mattresses to prevent pressure ulcers in hospitalized patients: a randomized-controlled clinical trial. Int J Nurs Stud. 2012;49(4):416–426.

Denby A, Rowlands A. Stop them at the door: should a pressure ulcer prevention protocol be implemented in the emergency department. J Wound Ostomy Continence Nurs. 2013;37(1):35–38.

Dibsie LG. Implementing evidence-based practice to prevent skin breakdown. Crit Care Nurs Q. 2008;31(2):140–149.

Donnelly J, Winder J, Kernohan WG, Stevenson M. An RCT to determine the effect of a heel elevation device in pressure ulcer prevention post-hip fracture. J Wound Care. 2011;20(7):309–318.

Dorner B, Posthauer ME, Thomas D, National Pressure Ulcer Advisory Panel. The role of nutrition in pressure ulcer prevention and treatment: National Pressure Ulcer Advisory Panel white paper. Adv Skin Wound Care. 2009;22(5):212–221.

Duimel-Peeters IG, J G Halfens R, Ambergen AW, Houwing RH, P F Berger M, Snoeckx LH. The effectiveness of massage with and without dimethyl sulfoxide in preventing pressure ulcers: a randomized, double-blind cross-over trial in patients prone to pressure ulcers. Int J Nurs Stud. 2007;44(8):1285–1295.

Forni C, Loro L, Tremosini M, Mini S, Pignotti E, Bigoni O, et al. Use of polyurethane foam inside plaster casts to prevent the onset of heel sores in the population at risk. A controlled clinical study. J Clin Nurs. 2011;20(5-6):675–680.

Funkesson KH, Anbacken EM, Ek AC. Nurses’ reasoning process during care planning taking pressure ulcer prevention as an example. A think-aloud study. Int J Nurs Stud. 2007;44(7):1109–1119.

Gallagher P, Barry P, Hartigan I, McCluskey P, O’Connor K, O’Connor M. Prevalence of pressure ulcers in three university teaching hospitals in Ireland. J Tissue Viability. 2008;17(4):103–109.

Giesbrecht EM, Ethans KD, Staley D. Measuring the effect of incremental angles of wheelchair tilt on interface pressure among individuals with spinal cord injury. Spinal Cord. 2011;49(7):827–831.

Gray M. Incontinence-related skin damage: essential knowledge. Ostomy Wound Manage. 2007;53(12):28–32.

Groah SL, Ramella-Roman J, Libin A, Maitland Schladen M, Lichy A. Skin microvascular and metabolic response to sitting and pressure relief maneuvers in people with spinal cord injury. Topics Spinal Cord Inj Rehab. 2011;16(3):33–45.

Grubbs S, Ludwig M, McHale E, Meck J, Nayar E, Rice A, et al. The effect of high frequency ultrasound on the prevention of pressure ulcers in long-term care patients. Int J Acad Phys Assoc. 2009;7(1):1–17.

Guihan M, Garber SL, Bombardier CH, Durazo-Arizu R, Goldstein B, Holmes SA. Lessons learned while conducting research on prevention of pressure ulcers in veterans with spinal cord injury. Arch Phys Med Rehab. 2007;88(7):858–861.

He W, Liu P, Chen HL. The Bradel Scale cannot be used alone for assessing pressure ulcer risk in surgical patients: a meta-analysis. Ostomy Wound Manage. 2012;58(2):34–40.

Heyneman A, Vanderwee K, Grypdonck M, Defloor T. Effectiveness of two cushions in the prevention of heel pressure ulcers. Worldviews Evid Based Nurs. 2009;6(2):114–120.

Holm B, Mesch L, Hellzen O. Importance of nutrition for elderly persons with pressure ulcers or a vulnerability for pressure ulcers: a systematic literature review. Austr J Adv Nurs. 2005;25(1):77–84.

Howe L. Education and empowerment of the nursing assistant: validating their important role in skin care and pressure ulcer prevention, and demonstrating productivity enhancement and cost savings. Adv Skin Wound Care. 2008;21(6):275–281.

Huber J, Reddy R, Pitham T, Huber D. Increasing heel skin perfusion by elevation. Adv Skin Wound Care. 2008;21(1):37–41.

Jackson M, McKenney T, Drumm J, Merrick B, LeMaster T, VanGilder C. Pressure ulcer prevention in high-risk postoperative cardiovascular patients. Crit Care Nurse. 2011;31(4):44-53.

Jackson S.S. The impact of implementing the Braden Scale on pressure ulcer incidence, level of severity, and patient length of stay. Dissertation from University of Virginia. 2010. Available at: Proquest, LLC, UMI 3435915.

Joanna Briggs Institute. 2010. Pressure area care: turning an older person in bed. Available at: The Joanna Briggs Institute: Access Number: JBI2308.

Joanna Briggs Institute. 2011. Pressure area care. Available at: The Joanna Briggs Institute Recommended Practices; Access Number JBI1111.

Joanna Briggs Institute. Pressure ulcers — prevention of pressure related damage. Best Practice. 2008;12(2):1–4. Jones KR. Identifying best practices for pressure ulcer management. JCOM. 2009;16(8):375–381.

Junkin J, Gray M. Are pressure redistribution surfaces or heel protection devices effective for preventing heel pressure ulcers? J Wound Ostomy Continence Nurs. 2009;36(6):602–608.

Kim J, Ho CH, Wang X, Bogie K. The use of sensory electrical stimulation for pressure ulcer prevention. Physiother Theory Pract. 2010;26(8):528–536.

Kwong EW, Lau AT, Lee RL, Kwan RY. A pressure ulcer prevention programme specially designed for nursing homes: does it work? J Clin Nurs. 2011;20(19-20):2777–2786.

Lahmann NA, Kottner J, Dassen T, Tannen A. Higher pressure ulcer risk on intensive care? – Comparison between general wards and intensive care units. J Clin Nurs. 2011;21(3-4):354–361.

Langer G, Schloemer G, Knerr A, Kuss O, Behrens J. Nutritional interventions for preventing and treating pressure ulcers. Cochrane Database Syst Rev. 2003;(4):CD003216.

Large J. A cost-effective pressure damage prevention strategy. Br J Nurs. 2011;20(6):S22–S25.

Lavrencic L. A review of the literature to determine the recommended nursing interventions aimed at decreasing the risk of pressure ulcer development in patients with spinal cord injury. Wound Pract Res. 2011;19(1):6–13.

Lindbloom EJ, Brandt J, Hough LD, Meadows SE. Elder mistreatment in the nursing home: a systematic review. J Am Med Dir Assoc. 2007;8(9):610–616.

Liu Z, Cascioli V, Heusch AI, McCarthy PW. Studying thermal characteristics of seating materials by recording temperature from 3 positions at the seat-subject interface. J Tissue Viability. 2011;20(3):73–80.

Malbrain M, Hendriks B, Wijnands P, Denie D, Jans A, Vanpellicom J, De Keulenaer B. A pilot randomized controlled trial comparing reactive air and active alternating pressure mattresses in the prevention and treatment of pressure ulcers among medical ICU patients. J Tissue Viability. 2010;19(1):7–15.

Manzano F, Navarro MJ, Roldan D, Moral MA, Leyva I, Guerrero C, et al. Pressure ulcer incidence and risk factors in ventilated intensive care patients. J Crit Care. 2010;25(3):469–476.

McGinnis E, Stubbs N. Pressure-relieving devices for treating heel pressure ulcers. Cochrane Database Syst Rev. 2011;(9):DOI:CD005485.

McInnes E, Jammali-Blasi A, Bell-Syer SE, Dumville JC, Cullum N. Support surfaces for pressure ulcer prevention. Cochrane Database Syst Rev. 2011;(4):CD001735.

McInnes E, Jammali-Blasi A, Bell-Syer S, Dumville J, Cullum N. Preventing pressure ulcers — are pressure redistributing support surfaces effective? A Cochrane systematic review and meta-analysis. Int J Nurs Stud. 2012;49(3):345–359.

Messer MS. Pressure ulcer risk in ancillary services patients. J Wound Ostomy Continence Nurs. 2010;37(2):153–160.

Meyers TR. Preventing heel pressure ulcers and plantar flexion contractures in high-risk sedated patients. J Wound Ostomy Continence Nurs. 2010;37(4):372–378.

Michael SM, Porte D, Pountney TE. Tilted seat position for non-ambulant individuals with neurological and neuromuscular impairment: a systematic review. Clin Rehabil. 2007;21(12):1063–1074.

Mistiaen P, Achterberg W, Ament A, Halfens R, Huizinga J, Montgomery K, et al. Cost-effectiveness of the Australian Medical Sheepskin for the prevention of pressure ulcers in somatic nursing home patients: Study protocol for a prospective multi-centre randomised controlled trial. BMC Health Serv Res. 2008;8(4):1–12.

Mistiaen PJ, Jolley DJ, McGowan S, Hickey MB, Spreeuwenberg P, Francke AL. A multilevel analysis of three randomized controlled trials of the Australian Medical Sheepskin in the prevention of sacral pressure ulcers. Med J Aust. 2010;193(11-12):638–641.

Moore ZE, Cowman S. (2010) Risk assessment tools for the prevention of pressure ulcers (Review). Cochrane Database Syst Rev. 2008;(3):CD006471

Moore Z, Cowman S, Conroy RM. A randomized controlled clinical trial of repositioning, using the 30˚ tilt, for the prevention of pressure ulcers. J Clin Nurs. 2011;20(17-18):2633–2644.

Nakagami G, Sanada H, Konya C, Kitagawa A, Tadaka E, Matsuyama Y. Evaluation of a new pressure ulcer preventive dressing containing ceramide 2 with low frictional outer layer. J Adv Nurs. 2007;59(5):520–529.

Neuman MD, Archan S, Karlawish JH, Schwartz JS, Fleisher LA. The relationship between short-term mortality and quality of care for hip fracture: a meta-analysis of clinical pathways for hip fracture. J Am Ger Soc. 2009;57(11):2046–2054.

Nicosia G, Gliatta AE, Woodbury MG, Houghton PE. The effect of pressure-relieving surfaces on the prevention of heel ulcers in a variety of settings: a meta-analysis. Int Wound J. 2007;4(3):197–207.

Nijs N, Toppets A, Defloor T, Bernaerts K, Milisen K, Van Den Berghe G. Incidence and risk factors for pressure ulcers in the intensive care unit. J Clin Nurs. 2009;18(9):1258–1266.

Norton L, Coutts P, Sibbald RG. Beds: practical pressure management for surfaces/mattresses. Adv Skin Wound Care. 2011;24(7):324–332.

Page KN, Barker AL, Kamar J. Development and validation of a pressure ulcer risk assessment tool for acute hospital patients. Wound Repair Regen. 2011;19(1):31–37.

Paquay L, Wouters R, Defloor T, Buntinx F, Debaillie R, Geys L. Adherence to pressure ulcer prevention guidelines in home care: a survey of current practice. J Clin Nurs. 2008;17(5):627–636.

Pieper B, Langemo D, Cuddigan J. Pressure ulcer pain: a systematic literature review and National Pressure Ulcer Advisory Panel white paper. Ostomy Wound Manage. 2009;55(2):16–22.

Racco M, Phillips B. Developing a protocol for intensive care patients at high risk for pressure ulcers. Crit Care Nurse. 2010;30(3):77–80.

Rafte L. Evaluation of patient outcomes: Pressure ulcer prevention mattresses. Br J Nurs. 2011;20(11):S32–S38.

Reenalda J, Jannink M, Nederhand M, Ijzerman M. Clinical use of interface pressure to predict pressure ulcer development: a systematic review. Assist Technol. 2009;21(2):76–85.

Regan MA, Teasell RW, Wolfe DL, Keast D, Mortenson WB, Aubut JA. A systematic review of therapeutic interventions for pressure ulcers after spinal cord injury. Arch Phys Med Rehabil. 2009;90(2):213–231.

Rintala DH, Garber SL, Friedman JD, Holmes SA. Preventing recurrent pressure ulcers in veterans with spinal cord injury: impact of a structured education and follow-up intervention. Arch Phys Med Rehab. 2008;89(8):1429–1441.

Schweinberger MH, Roukis TS. Effectiveness of instituting a specific bed protocol in reducing complications associated with bed rest. J Foot Ankle Surg. 2010;49(4):340–347.

Sibbald RG, Coutts P, Woo KY. Reduction of bacterial burden and pain in chronic wounds using a new polyhexamethylene biguanide antimicrobial foam dressing — clinical trial results. Adv Skin Wound Care. 2011;24(2):78–84.

Slowikowski GC, Funk M. Factors associated with pressure ulcers in patients in a surgical intensive care unit. J Wound Ostomy Continence Nurs. 2010;37(6):619–626.

Smith BM, Guihan M, LaVela SL, Garber SL. Factors predicting pressure ulcers in veterans with spinal cord injuries. Am J Phys Med Rehabil. 2008;87(9):750–757.

Soban LM, Hempel S, Munjas BA, Miles J, Rubenstein LV. Preventing pressure ulcers in hospitals: a systematic review of nurse-focused quality improvement interventions. Jt Comm J Qual Patient Saf. 2011;37(6):245–252.

Stechmiller JK, Cowan L, Whitney JD, Phillips L, Aslam R, Barbul A, et al. Guidelines for the prevention of pressure ulcers. Wound Rep Regen. 2008;16(2):151–168.

Stockton L, Gebhardt KS, Clark M. Seating and pressure ulcers: clinical practice guideline. J Tissue Viability. 2009;18(4):98–108.

Stotts NA, Hopf HW, Kayser-Jones J, Chertow GM, Cooper BA, Wu HS. Increased fluid intake does not augment capacity to lay down new collagen in nursing home residents at risk for pressure ulcers: a randomized, controlled clinical trial. Wound Rep Regen. 2009;17(6):780–788.

Sving E, Gunningberg L, Hogman M, Mamhidir AG. Registered nurses attention to and perceptions of pressure ulcer prevention in hospital settings. J Clin Nurs. 2012;21(9-10):1293–1303.

Tescher AN, Branda ME, Bryne TJ, Naessens JM. All at-risk patients are not created equal: analysis of Braden pressure ulcer risk scores to identify specific risks. J Wound Ostomy Continence Nurs. 2012;39(3):1–10.

Tschannen D, Bates O, Talsma A, Guo Y. Patient-specific and surgical characteristics in the development of pressure ulcers. Am J Crit Care. 2012;21(2):116–124.

Tzen YT, Brienza DM, Karg P, Loughlin P. Effects of local cooling on sacral skin perfusion response to pressure: Implications for pressure ulcer prevention. J Tissue Viability. 2010;19(3):86–97.

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(2):325–335.

Vanderwee K, Grypdonck MH, De Bacquer D, Defloor T. Effectiveness of turning with unequal time intervals on the incidence of pressure ulcer lesions. J Adv Nurs. 2007;57(1):59–68.

Van Herck P, Sermeus W, Jylha V, Michiels D, Van den Heede K. Using hospital administrative data to evaluate the knowledge-to-action gap in pressure ulcer preventive care. J Eval Clin Pract. 2009;15(2):375–382.

van Leen M, Hovius S, Neyens J, Halfens R, Schols J. Pressure relief, cold foam or static air? A single center, prospective, controlled randomized clinical trial in a Dutch nursing home. J Tissue Viability. 2011;20(1):30–34.

Verbelen J. Use of polarized light as a method of pressure ulcer prevention in an adult intensive care unit. J Wound Care. 2007;16(4):145–150.

Verbunt M, Bartneck C. Sensing senses: tactile feedback for the prevention of decubitus ulcers. Appl Psychophysiol Biofeedback. 2010;35(3):243–250.

Walker Sewill DK, Van Sell S, Kindred C. Pressure ulcer prevention: utilizing unlicensed assistive personnel. Crit Care Nurs Q. 2010;33(4):348–355.

Webster J, Coleman K, Mudge A, Marquart L, Gardner G, Stankiewicz M, et al. Pressure ulcers: effectiveness of risk-assessment tools. A randomized controlled trial (the ULCER trial). BMJ Qual Saf. 2011;20(4):297–306.

Wound Ostomy Continence Nurses Society. Guidelines for prevention and management of pressure ulcers. 2010. Available at: www.guidelines.gov.

Yap TL, Kennerly SM. A nurse-led approach to preventing pressure ulcers. Rehabil Nurs. 2011;36(3):106–110.

Zaratkiewicz S, Whitney JD, Lowe JR, Taylor S, O’Donnell F, Minton-Foltz P. Development and implantation of a hospital-acquired pressure ulcer incidence tracking system and algorithm. J Healthcare Qual. 2010;32(6):44–51.