Reducing Pressure Ulcer Prevalence Rates in the Long-Term Acute Care Setting
Abstract: Information about pressure ulcer prevalence, prevention, and optimal management strategies in the long-term acute care hospital (LTACH) setting is sparse. Although care processes in other patient care settings have been reported to affect pressure ulcer prevalence rates, the effect of such programs in the LTACH is unknown. To reduce perceived above-average pressure ulcer prevalence rates and improve care processes, a 108-bed LTACH used a failure mode and effects analysis to identify and address high-priority areas for improvement. Areas in need of improvement included a lack of 1) wound care professionals, 2) methods to consistently document prevention and wound data, and 3) an interdisciplinary wound care team approach, as well as a faulty electronic medical record. While prevalence data were collected, policies and procedures based on several published guidelines were developed and incorporated into the pressure ulcer plan of care by the newly established wound care team. Improved assessment and documentation methods, enhanced staff education, revised electronic records, wound care product reviews, and a facility-wide commitment to improved care resulted in a reduction of facility-acquired pressure ulcer prevalence from 41% at baseline to an average of 4.2% during the following 12 months as well as fewer missing electronic record data (<1% of charts had missing data). These study results suggest that staff education, better documentation, and a dedicated wound care team improves care practices and reduces pressure ulcer prevalence in the LTACH. Studies to increase knowledge about the LTACH patient population and their unique needs and risk profiles are needed.
Wound prevention and management are provided across the healthcare continuum in outpatient clinics, provider offices, home health, and acute, subacute, and long-term care facilities. A long-term acute care hospital (LTACH), a vital part of the healthcare continuum, is a federally recognized healthcare setting with its own reimbursement rules and regulations.
LTACHs provide specialized acute care for medically complex patients who no longer require the extensive diagnostic testing available at acute care hospitals but still need extended hospitalization.1 To be considered for admission to an LTACH, the individual must require 24-hour, onsite medical care by a physician along with frequent evaluation and management of multiple comorbidities with the potential need for immediate diagnostic imaging, laboratory services, ventilation management, cardiac monitoring, or complex treatment modality changes. Some patients are admitted to receive intravenous therapy services not available in other non-acute care settings. Like acute care, specialized consultation is available. LTACHs differ from chronic care settings in that they focus on comprehensive treatment of critically ill or high-acuity patients using specialized programs geared to the patient’s illness. The goal is medical recovery and return to home and family.2 Unlike rehabilitation centers, qualification for admission does not include patient ability to participate in 3 hours of rehabilitation therapies per day. LTACH reimbursement, like acute care, functions under a diagnosis-related group (DRG) reimbursement system. LTACHs participate in the Joint Commission on the Accreditation of Hospital Organizations (JCAHO) review process and must comply with federal and applicable state rules and regulations regarding patient care. Medicare is one of the predominant payors for LTACH care. Some LTACHs have a specialized rehabilitation component that may be accredited by the Commission on Accreditation of Rehabilitation Facilities (CARF).
Gaylord Hospital is a not-for-profit, 108-bed LTACH located in south central Connecticut. The facility specializes in medically complex populations including patients with stroke, spinal cord, brain, and traumatic injuries and bariatric-related issues; postsurgical patients with complex wounds or fistulas; and patients with cardiac or respiratory issues including ventilation dependency, sleep apnea, and neuromuscular disorders. The hospital is staffed and organized to manage the specific needs of acutely ill individuals with severe medical conditions who require 24-hour medical and nursing supervision as well as chronically disabled patients who require hospital-level care. Gaylord Hospital is able to treat patients needing rehabilitation for illness or injuries related to the brain and nervous system, as well as bone, joint, lung, heart, and skin conditions.
Although facility data suggested above-average pressure ulcer prevalence in the institution, no comparative benchmark or reports of process improvement initiatives in the LTACH setting was found in the literature. The purpose of the initiative described herein was to improve care processes to prevent and treat pressure ulcers.
Reported incidence and prevalence data have been the subject of controversy. Incidence is defined as the number of cases that develop in a population over time. Prevalence is defined as the number of existing cases in a population at one point in time.3 Pressure ulcer prevalence rates may fluctuate because variables such as increased patient acuity, seasonal occurrences,4 nurse staffing,5 or Braden Score variations in the population affect pressure ulcer development rates. In the United States and Europe, interpreting data reported in the literature and obtaining true incidence rates is difficult because the terms incidence and prevalence often are used interchangeably.3,6
To determine benchmarks of prevalence in LTACH, a literature review was conducted using PubMed from 1990 to 2005. MeSH search terms pressure ulcer, decubitus ulcer, skin ulcer, prevalence, quality circles, quality assurance, and continuous quality management were used. No MeSH terms exist for long-term acute care. In addition, a manual search of journals and textbooks associated with long-term care, subacute care, LTACH, rehabilitation settings, and wound management was performed and the Association for Acute Long Term Hospital Association (ALTHA) was contacted. A voluntary anonymous member survey conducted by ALTHA (unpublished data, 2005) with a 17.6% response rate from members in 300 hospitals reported an average prevalence rate of 15.2%. The survey did not differentiate between facility-acquired versus pre-admission-acquired pressure ulcers.
VanGilder et al,7 assessing a LTACH-specific data subset of the International Pressure Prevalence™ survey, reported participation of 38 LTACHs, with a total of 1,983 patients. Survey teams in each LTACH received uniform data collection and training. A 27.3% overall prevalence — almost double the acute care or the long-term care settings rates — with a 7.0% facility-acquired prevalence rate was reported. Pressure ulcer prevalence was slightly lower (by 0.5%) than in acute care but 1.4% higher than in long-term care. The high overall prevalence rate is not surprising, given that many LTACH admissions are from critical care units in acute care hospitals.8 The majority of these admissions are complex, high-acuity patients who have had long stays in critical care, where risk for pressure ulcer development is higher3,9,10 as compared to other acute care hospitalized patients. The survey was limited by the inability to ascertain inter-rater reliability among LTACH survey teams and the inherent limitation of self-reported data. Uneven LTACH geographical participation also limited generalization: three mid-Atlantic states (NY, NJ, PA) represented almost one third (n = 648) of the data and the north central states (IA, KS, MN, MO, NE, ND, SD) reported on a total of 37 patients.
The literature reporting pressure ulcer outcomes related to process improvement initiatives in a variety of settings is more abundant but LTACH data are lacking. Reports from the New Jersey Acute Care initiative11,12 indicate that prevalence rates decreased 30%, (pre-implementation prevalence was 18% and post-implementation rate of 5%) among the 151 participating acute care facilities after implementation of a comprehensive quality improvement process program. The program spanned 24 months and included staff education, use of a clinical expert in wound prevention and treatment, and implementation of evidence-based protocols. A similar endeavor was undertaken in Minnesota13; outcomes have not yet been reported. Long et al14 recently reported results from a quality improvement process at an LTACH. Similar to acute care improvement initiatives, the facility used staff education, established protocols, and consistent documentation in a “prevent, treat, and evaluate” wound care team framework to reduce pressure ulcer rates from 18.3% to 5.3% over a 1-year period of time. Publications of LTACH pressure ulcer initiatives or individual facility reports of process improvement projects in these settings were not found in the peer-reviewed literature.
Connecticut Clinical Nursing Associates (CCNA), LLC, an advanced practice nurse wound management clinical practice specializing in direct care, education, and care process improvement initiatives to facilitate the development of a state-of-the-art wound care program, was hired initially to conduct an organizational assessment of the facility with an identified advanced practice nurse (she became the wound care coordinator). After the initial evaluation and report, CCNA used this organization’s theoretical method, the failure mode and effects analysis (FMEA) developed by the US military,15 to facilitate change, including a processes of care improvement strategy to reduce the risk of pressure ulcers in this LTACH. FMEA is a systematic process for identifying potential design process failures before they occur with the intent to eliminate them or minimize risk.15 Basic steps are followed when conducting a healthcare FMEA (see Table 1).
Identifying potential failure modes. Pressure ulcer prevention and management was selected a high-priority area to improve clinical practice and patient outcomes. At one time, the facility had a certified wound specialist (CWS) nurse employed as a night shift registered nurse supervisor. No formal, centrally organized wound, skin, or pressure ulcer prevention and management program was in place. When the CWS resigned to seek other opportunities, the LTACH was left only with policies and procedures published by a rehabilitation organization.16 The LTACH retained the consultant services of CCNA who facilitated CWS role modeling opportunities to the newly formed wound care team and institutional staff while overseeing the care improvement efforts.
The lack of both facility and published LTACH prevalence data to measure the impact of practice improvement initiatives was the first challenge identified. Initial data were sorely needed. Weekly for 4 weeks, the consultants, along with one advanced practice nurse and one staff registered nurse, examined every patient for the presence of pressure ulcers. The Braden Scale Score was used to calculate risk and compare assessment results to the current medical record score, if available. The medical record of each patient also was reviewed for risk assessment indicators, interventions initiated to prevent pressure ulcers, and clinical documentation of the presence or absence of pressure ulcers. If a pressure ulcer was documented, the quality of the documentation was assessed via pre-defined standards from the literature.17-20 Both nursing and medical staff documentation were reviewed; if the patient was considered at risk by Braden subset scores in the nutrition or mobility categories, physical therapy and nutrition notes also were reviewed.
Based on these findings, initial facility-acquired and overall prevalence data were determined. Retrospective and ongoing concurrent chart reviews and rounds with different healthcare providers (including physicians, nurse practitioners, physician assistants, staff nurses, dieticians, and physical therapists) were initiated and revealed several opportunities to improve practice and patient outcomes (see Table 2).
A wound care team was formed. The lack of an interdisciplinary wound care team was identified as a contributing factor of a failure mode. An interdisciplinary wound care team was formed that included an advanced practice nurse (APRN), dieticians, physical therapists, staff nurses, occupational therapists, a unit manager, offshift supervisors, the director of nursing, an infection control nurse, a clinical educator, and a clinical manager information specialist. The role of each member of the skin care team was defined.
Key team members obtained certification and roles were defined. The APRN and offshift nursing supervisor became certified by the Wound Education Institute as Wound Care Certified (WCC). The advanced practice nurse was appointed wound care coordinator. The team reported directly to the Vice President for Clinical Services and the Director of Medical Affairs. Team clinicians were trained in prevalence data collection. Prevalence studies to establish facility-acquired and overall pressure ulcer rates, initially done weekly, were decreased approximately to every other week approximately 3 months into the program and then to monthly 5 months into the program as rates improved.
Documentation was improved. Team clinicians examined every hospital patient who provided permission on the day of data collection. Anatomical location and type of wound were identified on a data collection form. The daily census was obtained in order to calculate the prevalence rate. The clinical record also was reviewed by CCNA, who in turn trained the wound care coordinator and wound care team members to determine accuracy of clinical findings as compared to documentation for each patient. Following the FMEA framework, the team met weekly to review identified failure modes and their contributing factors and to develop a plan to improve care process and define expected results.
New policies and procedures were introduced. Policies and procedures were developed after the wound care team critically reviewed a number of clinical practice guidelines, including those published by the Wound, Ostomy Continence Nurses Society,17 Paralyzed Veterans Association,18 American Medical Directors Association,19 Agency for Healthcare Research and Quality,20 and National Pressure Ulcer Advisory Panel.21 Actual bedside practice was compared to these guidelines through team member observation and record review to identify gaps in practice and design additional interventions to narrow the gaps. Concurrent reviews of the medical record revealed a lack of thorough documentation for pressure ulcer assessment, risk, and initiation of preventative measures by bedside clinicians.
The EMR was scrutinized and revised. Although the wound team intuitively believed staff education was necessary, the infrastructure with which the bedside clinicians documented wound assessment and treatment modalities was assessed to determine other process flaws. Before undertaking medical, nursing, physical, and occupational therapy staff education, the wound team made a thorough review of the electronic medical record (EMR) system and found an electronic format not ideally suited for documenting a full scope of skin impairment, risk assessment, pressure ulcer prevention interventions, and individualized care planning. Data reported between clinicians using the system were inconsistent and in some cases absent. The institution’s Clinical Information Management Specialist was added to the team to revise the EMR and implement a complete yet easy process for risk assessment; wound prevention, assessment and treatment documentation; and nurse care planning. The PUSH Tool22 was added to the electronic record so wound progress could be monitored and measured.
Staff education was enhanced. Subsequently, staff education commenced, incorporating adult learning principles of active participation, role-modeling, and immediate feedback. These principles were facilitated through formal clinical rounds and interactive didactic sessions as well as impromptu wound care coordinator-initiated, one-on-one teaching sessions at the bedside. Newly identified wounds in the facility required immediate assessment by a member of the wound care team; available unit clinicians were encouraged to participate. The wound care coordinator for the medical staff and supervisors of physical and occupational therapy, dietary, and nursing staff performed EMR review of individual documentation in conjunction with patient clinical assessments to determine accuracy. Constructive feedback was given to correct any inconsistencies between clinical presentation and documentation. Wound care products were reviewed. All wound care-related products were reviewed to develop prevention and treatment algorithms. This included pressure redistribution surfaces for bed and seat surfaces, topical moisture balance dressings, topical antimicrobial agents, adjunctive therapies, debridement methods, and nutritional and moisture management interventions. Pressure ulcer prevention was emphasized. The nursing standards committee and the medical staff approved the algorithms developed by the wound care team. Although the algorithms were not validated, they were based on the clinical practice guidelines the team had previously reviewed. The program was formalized in July 2005 and implemented facility-wide by October 2005.
Data collection. Rates regarding etiology and pressure ulcer staging data were collected by the wound care team, determined by agreement, and reported as percentages. Chart reviews by three wound care team members with concurrent clinical evaluations by the entire wound team were performed to compare clinical documentation with observation of the patient to determine accuracy of documentation and also tabulate percentages (pencil and paper). Prevalence rates were calculated as the number of persons with a pressure ulcer divided by the number of persons in the facility at a particular point in time multiplied by 100.3 Prevalence rates per unit also were calculated and reviewed.
At study baseline, the facility-acquired pressure ulcer prevalence was 41% and subsequent facility-acquired prevalence rates before process improvement implementation ranged from 33% to 58.3%. The per-unit rate review showed that on a pulmonary-focused unit, 25% of patients had ear/scalp junction pressure ulcers. The majority of patients received oxygen via nasal cannula concomitantly with oral or parenteral steroids. This trend was not identified on other units. A focused quality care improvement initiative on this unit regarding interventions included adapting the nasal cannula to prevent pressure in this area. Increased monitoring and inspection of the areas of concern on this unit reduced pressure ulcers in this body location to <3% within 2 months.
On the nursing unit where spinal cord injury and trauma patients were hospitalized, pressure ulcers were noted on the sacrum and heels due to immobility and sensory deficit. After increased diligence involving heel offloading and use of pressure redistribution support surfaces and proper positioning, pressure ulcer rates dropped from a baseline of 33.8% to 2.9%.
CCNA needed to validate that the wound team assessments were consistent among members before they began to validate and monitor clinical care. After reviewing 45 patients and their charts, wound team consistency in determining the wound etiology and pressure ulcer staging was found to be >90%. Each case was reviewed by the team during rounds and each member offered individual assessment of etiology and staging. When the entire group did not agree, clinical discussion was initiated using anatomical principles and evidence-based guidelines as a basis to make a clinical diagnosis. Over the 4-month period, staff education via structured inservices, role modeling behaviors, and feedback from wound team members along with infrastructure improvements in the EMR to facilitate proper documentation resulted in marked improvements. Less than 1% of charts reviewed (n = 396) had absent data. Clinical exam and documentation had >92.5% agreement between wound care team findings and the routine bedside staff. Facility-acquired pressure ulcer rate was reduced by 37% within 1 year of facility-wide implementation. Ongoing monthly monitoring via prevalence studies demonstrate that the overall facility-acquired rate has ranged from 3.1% to 8.2% for the 12 month period following system-wide implementation, with a mean rate of 4.2% (see Figure 1).
Incidental findings have noted an increased collaboration among disciplines with regard to wound prevention and treatment as well as a tendency for early intervention when wounds are newly discovered. Two WCC staff members sought further education and now hold CWCN certification from the Wound, Ostomy, Continence Nurse Certification Board; use of a CWOCN consultant and subsequent CWCN certification of employees of the facility seemed to be key to successful outcomes of this project, providing in-house expertise. The wound care team functions within a fluid interdisciplinary program.
Additionally, monthly review of documentation and the presence of multiple pressure ulcer prevention interventions observed on the units reinforce Gaylord’s wound team confidence that bedside clinician knowledge has been enhanced, making rounds and clinical documentation review more fulfilling for staff. The administration is cognizant that commitment to quality care requires ongoing support. As consumerism in healthcare increases, such measures could shape the long-term financial health of an institution.
Although LTACH care process improvement initiatives have not been reported in the literature, Long’s14 early descriptive report of one institution’s quality improvement initiative suggests that focused programs in this setting can reduce prevalence rates in the LTACH arena. A 71.1% reduction in pressure ulcer prevalence was achieved using methods similar to the current endeavor (ie, development of a wound team, updating policies and procedures to meet current standards of care, staff education, formulary, and algorithms). Gaylord was able to reduce the monthly pressure ulcer prevalence rate, on average, by 37%. It is unknown if these rates are superior or serve as benchmarks in the LTACH setting due to the sparseness of benchmark data for this setting. The mean facility-acquired pressure ulcer prevalence rates of 4.2% are below the reported LTACH rates of 7.0%7 after interventions were fully implemented with the exception of 1 month during which rates were higher. This suggests that ongoing care process monitoring and intervention are imperative because rates will fluctuate upward without intensive attention from the organization (see Figure 1). When vigilance at Gaylord was reduced from weekly to monthly for 1 month, rates started to climb. With increased presence on the units, chart monitoring, feedback to staff, and biweekly prevalence rounds, lower rates were maintained.
This study supports the improved outcomes in a pressure ulcer prevention program relative to a comprehensive, integrated multifaceted initiative that combines clinical expertise, a multidisciplinary wound team, staff education, and policies and procedures that translate clinical practice standards into practice. The study also supports information found in the literature23 as well as findings of Granick and Ladin,24 who reported a 15% reduction in pressure ulcer prevalence rates when an interdisciplinary wound team was initiated in an acute care facility. In a descriptive study of a medically complex outpatient population with wounds, Gottrup et al25 was able to demonstrate improved outcomes in both prevention and treatment of wounds when a multidisciplinary team model was implemented.
Clearly, more research is warranted in the LTACH setting. A number of gaps in the LTACH literature regarding pressure ulcer prevention remain. Further reports of care process improvement activities in the LTACH setting are still needed. Questions for consideration include: 1) Are certain interventions more successful than others in reducing facility acquired pressure ulcers? 2) Which risk factors predispose the patient to pressure ulcers while in a LTACH? 3) What are the optimal risk assessment tool and risk assessment timeframe in this setting? Also, because LTACH patients may have a higher acuity than those admitted to home health or subacute centers and these facilities tend to lack an in-house dedicated critical unit, is this population equivocal in risk to acute care critical care patients or those on step-down units?
After assessing potential design failures in its approach to pressure ulcer prevention and care and responding by addressing flaws in the EMR and creating a more interdisciplinary approach to care, an LTACH found maintaining low facility-acquired pressure ulcer rates can be accomplished by ongoing emphasis on implementation of evidenced-based practices, especially in times of current regulatory pressures for patient safety. By bundling interventions, establishing an infrastructure to prevent and manage pressure ulcers, and securing administrative support for quality, this facility is well-positioned to face continuing challenges with regard to preventing, staging, and monitoring pressure ulcers.
Ms. Milne is an Advanced Practice Nurse and co-owner, Connecticut Clinical Nursing Associates, LLC, Bristol, CT. Ms. Triglia is an Advanced Practice Nurse and Wound Care Coordinator, Gaylord Hospital, Wallingford, CT. Ms. Houle is an Advanced Practice Nurse and co-owner, Connecticut Clinical Nursing Associates, LLC. Ms. DeLong is a Nurse Supervisor and Wound Care Team member and Dr. Rosenblum is a Staff Physician and Wound Care Team Medical Advisor, Gaylord Hospital. Please address correspondence to: Catherine T. Milne, APRN, MSN, BC, CWOCN, P.O. Box 1535, Bristol, CT 06011-1535; email: firstname.lastname@example.org
1. Gage B, Pilkauskas N, Dalton K, et al. Long Term Care (LTACH) Payment System Monitoring and Evaluation PHASE II REPORT. Available at: www.cms.hhs.gov/LongTermCareHospitalPPS/Downloads/RTI_LTCHPPS_Final_Rpt. pdf. Accessed September 13, 2008.
2. Dematte D’Amico JE, Donnelly H, Mutlu G, Feinglass J, Jovanovic B, Ndukwu I. Risk assessment for inpatient survival in the long-term acute care setting after prolonged critical illness. Chest. 2003;124(3):1039–1045.
3. National Pressure Ulcer Advisory Panel Board of Directors. Cuddigan J, Berlowitz DR, Ayello, EA (eds). Pressure ulcers in America: prevalence, incidence, and implications for the future. An executive summary of the National Pressure Ulcer Advisory Panel Monograph. Adv Skin Wound Care. 2001;4(4):208–215.
4. Schwien T, Gilbert J, Lang C. Pressure ulcer prevalence and the role of negative pressure wound therapy in home health quality outcomes. Ostomy Wound Manage. 2005;51(9):47–60.
5. Bostick J. Relationship of nursing personnel and nursing home care quality. J Nurs Care Qual. 2004;19(2):130–136.
6. European Pressure Ulcer Advisory Panel. DeFloor T, Bours G, Schoonhoven L, Clark M. Draft EPUAP Statement on Prevalence and Incidence Monitoring. Available at: www.epuap.org/review4_1/ page6html. Accessed November 30, 2007.
7. Van Gilder C, Macfarlane GD, Meyer S. Results of Nine International Pressure Ulcer Prevalence Surveys: 1989 to 2005. Ostomy Wound Manage. 2008;54(2):40–54.
8. Eskildsen MA. Long-term acute care: a review of the literature. J Am Geriatr Soc. 2007;55(5):775–759.
9. Whittington K, Briones R. National prevalence and incidence study: 6-year sequential acute care data. Adv Skin Wound Care. 2004;17(9):490–494.
10. Vollman K. Ventilator-associated pneumonia and pressure ulcer prevention as targets for quality improvement in the ICU. Crit Care Nurs Clin North Am. 2006;18(4):453–467.
11. Holmes AM, Ayello EA, Zulkowski K, Edelstein T. A Collaborative Statewide Multi-Facility Initiative Reduces Pressure Ulcers. Poster Presented at the WOCN Society 39th Annual Conference. Salt Lake City, Utah. June 9–13, 2007.
12. Holmes A, Edelstein T. Envisioning a world without pressure ulcers. Extended Care Product News. 2007;122(8):24–29.
13. Minnesota Hospital Association. Safe skin call to action. Available at: www.mnhospitals.org/index/tools-app/tool.353?view=detail. Accessed November 15, 2007.
14. Long MA, Reed L. Practice Innovation: Development of a Wound Care Team in a Long Term Acute Care (LTAC) Facility. Poster Presented at the WOCN Society 39th Annual Conference. Salt Lake City, Utah. June 9–13, 2007.
15. American Society for Quality. Failure modes and effects analysis. Available at: www.asq.org/learn-about-quality/process-analy.sis-tools/overview/fmea.html. Accessed October 27, 2007.
16. Alexander T, Hiduke R, Stevens K. Rehabilitation Nursing Procedures Manual, 2nd ed. Columbus, Ohio: McGraw-Hill;1999.
17. Wound, Ostomy, and Continence Nurses Society (WOCN). Guideline for prevention and management of pressure ulcers. Glenview (IL): Wound, Ostomy, and Continence Nurses Society (WOCN); 2003.Available through www.wocn.org.
18. Paralyzed Veterans of America. Pressure ulcer prevention and treatment following spinal cord injury: a clinical practice guideline for health care professionals. Washington (DC): Paralyzed Veterans of America; 2000. Available through www.pva.org.
19. American Medical Directors Association (AMDA). Pressure ulcers in the long-term care setting. Columbia (MD): American Medical Directors Association (AMDA); 1996. Available through www.amda.com.
20. Agency for Health Care Policy and Research (AHCPR). Pressure ulcers in adults prediction and prevention. Rockville, Md: U.S. Department of Health and Human Services, Public Health Service, AHCPR; May 1992.
21. National Pressure Ulcer Advisory Panel. Management of tissue load: an excerpt from the third NPUAP slide set. National Pressure Ulcer Advisory Panel. Adv Wound Skin Care. 1997;10(6):35–38.
22. Thomas DR, Rodeheaver GT, Bartolucci AA. Pressure ulcer scale for healing: derivation and validation of the PUSH Tool. Adv Wound Care. 1997;10(5):96–101.
23. Hiser B, Rochette J, Philbin S, Lowerhouse N, TerBurgh C, Pietsch C. Implementing a pressure ulcer prevention program and enhancing the role of the CWOCN: impact on outcomes. Ostomy Wound Manage. 2006;52(2):48–59.
24. Granick M, Ladin D. The multidisciplinary in-hospital wound care team: two models. Adv Wound Care. 1998;11(21):80–83.
25. Gottrup F, Holstein P, Jorgensen B, Lohmann M, Karlsmar, T. A new concept of a multidisciplinary wound healing center and a national expert function of wound healing. Arch Surg. 2001;136(7):765–772.