Evidence-informed best practices are based on quality evidence and should be implemented into practice to optimize outcomes.10 Listed below you will find best practices graded according to the type of evidence. To view a description of the types of evidence, click here.
To help you move from best evidence to best practice, click on the + button next to each best practice to find details on how to implement, as well as change ideas to test using a PDSA approach.
Change ideas are specific and practical changes informed by experience and research that focus on improving specific aspects of a system, process or behaviour. To learn more about change ideas see the QI: Getting Started tab.
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Evidence-Informed |
How To Implement |
Toolbox |
| Early identification of Stage 1 pressure ulcers (Assessment) |
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Early identification of Stage 1 pressure ulcers
Type of Evidence: I (High)
References:
Systematic Reviews
Marchione FG, Araújo LM, Araújo LV. Approaches that use software to support the prevention of pressure ulcer: A systematic review. Int J Med Inform. 2015 Oct;84(10):725-36. Abstract available at: http://www.ncbi.nlm.nih.gov/pubmed/26116169
Moore ZE, Cowman S. Risk assessment tools for the prevention of pressure ulcers. Cochrane Database Syst Rev. 2014 Feb 5;2:CD006471. Full-text available at: http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD006471.pub3/full
Niederhauser A, VanDeusen Lukas C, Parker V, Ayello EA, Zulkowski K, Berlowitz D. Comprehensive programs for preventing pressure ulcers: A review of the literature. Adv Skin Wound Care. 2012;25(4):167-88. Available from: http://www.ncbi.nlm.nih.gov/pubmed/22441049
Supporting Research
Bergstrom, N, Horn SD, Rapp MP, Stern A, Barrett R, Watkiss M. Preventing pressure ulcers: a multi-site RCT in nursing homes. June 2011. Available at: http://lgdata.s3-website-us-east-1.amazonaws.com/docs/3744/896380/TR_2012.1_TURN_Clinical_Report_15Jun2012_FINAL_Revised_on_Feb_28_2013.pdf
Park SH, Choi YK, Kang CB. Predictive validity of the Braden Scale for pressure ulcer risk in hospitalized patients. J Tissue Viability. 2015 Aug;24(3):102-13. Abstract available at: http://www.ncbi.nlm.nih.gov/pubmed/26050532
Webster J, Coleman K, Mudge A, Marquart L, Gardner G, Stankiewicz, M., McClymont, A. Pressure ulcers: Effectiveness of risk-assessment tools. A randomised controlled trial (the ULCER trial). BMJ Qual Saf. 2011;20(4):297-306. Available from: http://www.ncbi.nlm.nih.gov/pubmed/21262791
Qaseem A, Mir TP, Starkey M, Denberg TD, Clinical Guidelines Committee of the American College of Physicians. Risk assessment and prevention of pressure ulcers: a clinical practice guideline from the American College of Physicians. Ann Intern Med. 2015 Mar 3;162(5):359-69. Full-text available at: http://annals.org/article.aspx?articleid=2173505
Qaseem A, Humphrey LL, Forciea MA, Starkey M, Denberg TD, Clinical Guidelines Committee of the American College of Physicians. Treatment of pressure ulcers: a clinical practice guideline from the American College of Physicians. Ann Intern Med. 2015 Mar 3;162(5):370-9. Full-text available at: http://annals.org/article.aspx?articleid=2173506
NICE. Pressure ulcers: prevention and management. April 2014. Available at: https://www.nice.org.uk/guidance/CG179/chapter/about-this-guideline#about-this-guideline
Health Quality Ontario. Management of chronic pressure ulcers: an evidence-based analysis. Toronto: Ontario Health Technology Assessment Series. 2009;9(3). Available from: http://www.health.gov.on.ca/english/providers/program/mas/tech/reviews/pdf/rev_pup_20090701.pdf
Ontario Health Technology Advisory Committee. OHTAC Recommendation Prevention and Treatment of Pressure Ulcers. Toronto: Ontario Health Technology Advisory Committee; 2009 Oct. Available from: http://www.health.gov.on.ca/english/providers/program/ohtac/tech/recommend/rec_pup_20091020.pdf
Registered Nurses’ Association of Ontario. Risk assessment and prevention of pressure ulcers. Toronto: Registered Nurses’ Association of Ontario; Revised 2011.Available from: http://rnao.ca/bpg/guidelines/risk-assessment-and-prevention-pressure-ulcers
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Evidence-Informed |
How To Implement |
Toolbox |
| Ongoing assessment of pressure ulcers (Assessment) |
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Ongoing Assessment of Pressure Ulcers
Type of Evidence: IV (Expert Opinion)
References:
Supporting Research
Qaseem A, Mir TP, Starkey M, Denberg TD, Clinical Guidelines Committee of the American College of Physicians. Risk assessment and prevention of pressure ulcers: a clinical practice guideline from the American College of Physicians. Ann Intern Med. 2015 Mar 3;162(5):359-69. Full-text available at: http://annals.org/article.aspx?articleid=2173505
Qaseem A, Humphrey LL, Forciea MA, Starkey M, Denberg TD, Clinical Guidelines Committee of the American College of Physicians. Treatment of pressure ulcers: a clinical practice guideline from the American College of Physicians. Ann Intern Med. 2015 Mar 3;162(5):370-9. Full-text available at: http://annals.org/article.aspx?articleid=2173506
NICE. Pressure ulcers: prevention and management. April 2014. Available at: https://www.nice.org.uk/guidance/CG179/chapter/about-this-guideline#about-this-guideline
Bergstrom, N, Horn SD, Rapp MP, Stern A, Barrett R, Watkiss M. Preventing pressure ulcers: a multi-site RCT in nursing homes. June 2011. Available at: http://lgdata.s3-website-us-east-1.amazonaws.com/docs/3744/896380/TR_2012.1_TURN_Clinical_Report_15Jun2012_FINAL_Revised_on_Feb_28_2013.pdf
Registered Nurses’ Association of Ontario. Risk assessment and prevention of pressure ulcers. Toronto: Registered Nurses’ Association of Ontario; Revised 2011.Available from: http://rnao.ca/bpg/guidelines/risk-assessment-and-prevention-pressure-ulcers
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Evidence-Informed |
How To Implement |
Toolbox |
| Identify contributing factors to pressure ulcer development to prevent recurrence (Prevention) |
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Identify Contributing Factors to Pressure Ulcer Development to Prevent Recurrence
Type of Evidence: IV (Expert Opinion)
References:
Supporting Research
Qaseem A, Mir TP, Starkey M, Denberg TD, Clinical Guidelines Committee of the American College of Physicians. Risk assessment and prevention of pressure ulcers: a clinical practice guideline from the American College of Physicians. Ann Intern Med. 2015 Mar 3;162(5):359-69. Full-text available at: http://annals.org/article.aspx?articleid=2173505
Qaseem A, Humphrey LL, Forciea MA, Starkey M, Denberg TD, Clinical Guidelines Committee of the American College of Physicians. Treatment of pressure ulcers: a clinical practice guideline from the American College of Physicians. Ann Intern Med. 2015 Mar 3;162(5):370-9. Full-text available at: http://annals.org/article.aspx?articleid=2173506
NICE. Pressure ulcers: prevention and management. April 2014. Available at: https://www.nice.org.uk/guidance/CG179/chapter/about-this-guideline#about-this-guideline
Bergstrom, N, Horn SD, Rapp MP, Stern A, Barrett R, Watkiss M. Preventing pressure ulcers: a multi-site RCT in nursing homes. June 2011. Available at: http://lgdata.s3-website-us-east-1.amazonaws.com/docs/3744/896380/TR_2012.1_TURN_Clinical_Report_15Jun2012_FINAL_Revised_on_Feb_28_2013.pdf
Health Quality Ontario. Management of chronic pressure ulcers: an evidence-based analysis. Toronto: Ontario Health Technology Assessment Series. 2009;9(3). Available from: http://www.health.gov.on.ca/english/providers/program/mas/tech/reviews/pdf/rev_pup_20090701.pdf
Ontario Health Technology Advisory Committee. OHTAC Recommendation Prevention and Treatment of Pressure Ulcers. Toronto: Ontario Health Technology Advisory Committee; 2009 Oct. Available from: http://www.health.gov.on.ca/english/providers/program/ohtac/tech/recommend/rec_pup_20091020.pdf
Registered Nurses’ Association of Ontario. Risk assessment and prevention of pressure ulcers. Toronto: Registered Nurses’ Association of Ontario; Revised 2011.Available from: http://rnao.ca/bpg/guidelines/risk-assessment-and-prevention-pressure-ulcers
Sibbald RG, Goodman L, Norton L, Krasner DL, Ayello EA. Prevention and Treatment of Pressure Ulcers. Skin Therapy Lett. 2012;17(8):4-7. Available from: http://www.ncbi.nlm.nih.gov/pubmed/22949132
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Evidence-Informed |
How To Implement |
Toolbox |
| Establish a regular turning schedule for high-risk residents (Prevention) |
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Establish a Regular Turning Schedule for High Risk Residents
Type of Evidence: I (High)
References:
Systematic Reviews
Moore ZE, Cowman S. Repositioning for treating pressure ulcers. Cochrane Database Syst Rev. 2015 Jan 5;1:CD006898. Abstract available at: http://www.ncbi.nlm.nih.gov/pubmed/25561248
Gillespie BM, Chaboyer WP, McInnes E, Kent B, Whitty JA, Thalib L. Repositioning for pressure ulcer prevention in adults. Cochrane Database Syst Rev. 2014 Apr 3;4:CD009958. Full-text available at: http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD009958.pub2/full
Supporting Research
Paulden M, Bergstrom N, Horn SD, Rapp MP, Barrett R, Watkiss M, Pham B, Krahn M. Turning for ulcer reduction (TURN) study: an economic analysis. October 2014. Available at: www.hqontario.ca/Portals/0/Documents/eds/ohtas/economic-analysis-turn-1410-en.pdf
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. Available from: http://www.ncbi.nlm.nih.gov/pubmed/21242997
Moore Z, Cowman S, Conroy RM. A randomised controlled clinical trial of repositioning, using the 30 degrees tilt, for the prevention of pressure ulcers. J Clin Nurs. 2011;20(17-18):2633-2644. Available from: http://www.ncbi.nlm.nih.gov/pubmed/21702861
Rafter L. Evaluation of patient outcomes: Pressure ulcer prevention mattresses. Br J Nurs. 2011;20(11):S32-S34-8. Available from: http://www.ncbi.nlm.nih.gov/pubmed/21727848
Qaseem A, Mir TP, Starkey M, Denberg TD, Clinical Guidelines Committee of the American College of Physicians. Risk assessment and prevention of pressure ulcers: a clinical practice guideline from the American College of Physicians. Ann Intern Med. 2015 Mar 3;162(5):359-69. Full-text available at: http://annals.org/article.aspx?articleid=2173505
Qaseem A, Humphrey LL, Forciea MA, Starkey M, Denberg TD, Clinical Guidelines Committee of the American College of Physicians. Treatment of pressure ulcers: a clinical practice guideline from the American College of Physicians. Ann Intern Med. 2015 Mar 3;162(5):370-9. Full-text available at: http://annals.org/article.aspx?articleid=2173506
NICE. Pressure ulcers: prevention and management. April 2014. Available at: https://www.nice.org.uk/guidance/CG179/chapter/about-this-guideline#about-this-guideline
Bergstrom, N, Horn SD, Rapp MP, Stern A, Barrett R, Watkiss M. Preventing pressure ulcers: a multi-site RCT in nursing homes. June 2011. Available at: http://lgdata.s3-website-us-east-1.amazonaws.com/docs/3744/896380/TR_2012.1_TURN_Clinical_Report_15Jun2012_FINAL_Revised_on_Feb_28_2013.pdf
Ontario Health Technology Advisory Committee. OHTAC Recommendation Prevention and Treatment of Pressure Ulcers. Toronto: Ontario Health Technology Advisory Committee; 2009 Oct. Available from: http://www.health.gov.on.ca/english/providers/program/ohtac/tech/recommend/rec_pup_20091020.pdf
Registered Nurses’ Association of Ontario. Risk assessment and prevention of pressure ulcers. Toronto: Registered Nurses’ Association of Ontario; Revised 2011.Available from: http://rnao.ca/bpg/guidelines/risk-assessment-and-prevention-pressure-ulcers
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Evidence-Informed |
How To Implement |
Toolbox |
| Use pressure relieving mattresses and pressure relieving padding |
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Use Pressure Relieving Mattresses and Pressure Relieving Padding to Prevent Pressure Ulcers
Type of Evidence: I (High)
References:
Systematic Reviews
Tricco AC, Antony J, Vafaei A, Khan PA, Harrington A, Cogo E, Wilson C, Perrier L, Hui W, Straus SE. Seeking effective interventions to treat complex wounds: an overview of systematic reviews. BMC Med. 2015 Apr 22;13:89. Full-text available at: http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD009958.pub2/full
McInnes E, Jammali-Blasi A, Bell-Syer SE, Dumville JC, Cullum N. Support surfaces for pressure ulcer prevention. Cochrane Database Syst Rev. 2011;(4). Available from: http://www.ncbi.nlm.nih.gov/pubmed/21491384
Supporting Research
Tasker LH, Shapcott NG, Watkins AJ, Holland PM. The effect of seat shape on the risk of pressure ulcers using discomfort and interface pressure measurements. Prosthet Orthot Int. 2014 Feb;38(1):46-53. Full-text available at:http://poi.sagepub.com/content/38/1/46.long
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. Available from: http://www.ncbi.nlm.nih.gov/pubmed/22104042
Reddy M. Pressure ulcers. Clin Evid (Online). 2011 Apr 28;2011:1901. Available from: http://www.ncbi.nlm.nih.gov/pubmed/21524319
Bain D. Laboratory performance of alternating pressure air mattresses component and sequelae. Br J Nurs. 2011;20(20):S29-34. Available from: http://www.ncbi.nlm.nih.gov/pubmed/22067933
Brienza D, Kelsey S, Karg P, et al. A randomized clinical trial on preventing pressure ulcers with wheelchair seat cushions. J Am Geriatr Soc. 2010;58(12):2308-2314. Available from: http://www.ncbi.nlm.nih.gov/pubmed/21070197
Rafter L. Evaluation of patient outcomes: Pressure ulcer prevention mattresses. Br J Nurs. 2011;20(11):S32, S34-8. Available from: http://www.ncbi.nlm.nih.gov/pubmed/21727848
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. Available from: http://www.ncbi.nlm.nih.gov/pubmed/20510611
Wu T, Wang ST, Lin PC, Liu CL, Chao YF. Effects of using a high-density foam pad versus a viscoelastic polymer pad on the incidence of pressure ulcer development during spinal surgery. Biol Res Nurs. 2011;13(4):419-424. Available from: http://www.ncbi.nlm.nih.gov/pubmed/21196422
Qaseem A, Mir TP, Starkey M, Denberg TD, Clinical Guidelines Committee of the American College of Physicians. Risk assessment and prevention of pressure ulcers: a clinical practice guideline from the American College of Physicians. Ann Intern Med. 2015 Mar 3;162(5):359-69. Full-text available at: http://annals.org/article.aspx?articleid=2173505
Qaseem A, Humphrey LL, Forciea MA, Starkey M, Denberg TD, Clinical Guidelines Committee of the American College of Physicians. Treatment of pressure ulcers: a clinical practice guideline from the American College of Physicians. Ann Intern Med. 2015 Mar 3;162(5):370-9. Full-text available at: http://annals.org/article.aspx?articleid=2173506
NICE. Pressure ulcers: prevention and management. April 2014. Available at: https://www.nice.org.uk/guidance/CG179/chapter/about-this-guideline#about-this-guideline
Bergstrom, N, Horn SD, Rapp MP, Stern A, Barrett R, Watkiss M. Preventing pressure ulcers: a multi-site RCT in nursing homes. June 2011. Available at: http://lgdata.s3-website-us-east-1.amazonaws.com/docs/3744/896380/TR_2012.1_TURN_Clinical_Report_15Jun2012_FINAL_Revised_on_Feb_28_2013.pdf
Institute for Healthcare Improvement. Pressure Ulcer Prevention [Internet]. Institute for Healthcare Improvement. Available from: http://app.ihi.org/imap/tool/#Process=cbe9c419-f6ae-49ed-8bb5-5d17844796e2
Ontario Health Technology Advisory Committee. OHTAC Recommendation Prevention and Treatment of Pressure Ulcers. Toronto: Ontario Health Technology Advisory Committee; 2009 Oct. Available from: http://www.health.gov.on.ca/english/providers/program/ohtac/tech/recommend/rec_pup_20091020.pdf
Orsted HL, Ohura T, Harding K. Pressure, Shear, Friction, and Microclimate in Context. London (UK): Wounds International; 2010. Available from: http://www.woundsinternational.com/pdf/content_8925.pdf
Registered Nurses’ Association of Ontario. Risk assessment and prevention of pressure ulcers. Toronto: Registered Nurses’ Association of Ontario; 2002. Revised 2011. Available from: http://rnao.ca/bpg/guidelines/risk-assessment-and-prevention-pressure-ulcers
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Evidence-Informed |
How To Implement |
Toolbox |
| Minimize use of restraints (Prevention) |
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Type of Evidence: III (Low)
References:
Supporting Research
Castle NG, Engberg J. The health consequences of using physical restraints in nursing homes. Med Care. 2009;47(11):1164-73. Available from: http://www.ncbi.nlm.nih.gov/pubmed/19786918
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Evidence-Informed |
How To Implement |
Toolbox |
Minimize shearing forces (Prevention) |
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Type of Evidence: II (Medium)
References:
Systematic Reviews
McGinnis E, Stubbs N. Pressure-relieving devices for treating heel pressure ulcers. Cochrane Database Syst Rev. 2011 Sep 7;(9):CD005485. Full-text available at: http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD005485.pub3/full
Supporting Research
Bales I. A comparison between the use of intravenous bags and the Heelift suspension boot to prevent pressure ulcers in orthopedic patients. Adv Skin Wound Care. 2012;25(3):125-131. Available from: http://www.ncbi.nlm.nih.gov/pubmed/22343600.
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. Available from: http://www.ncbi.nlm.nih.gov/pubmed/21242997
Moore Z, Cowman S, Conroy RM. A randomised controlled clinical trial of repositioning, using the 30 degrees tilt, for the prevention of pressure ulcers. J Clin Nurs. 2011;20(17-18):2633-2644. Available from: http://www.ncbi.nlm.nih.gov/pubmed/21702861
Orsted HL, Ohura T, Harding K. Pressure, Shear, Friction, and Microclimate in Context. London (UK): Wounds International; 2010. Available from: http://www.woundsinternational.com/pdf/content_8925.pdf
Qaseem A, Mir TP, Starkey M, Denberg TD, Clinical Guidelines Committee of the American College of Physicians. Risk assessment and prevention of pressure ulcers: a clinical practice guideline from the American College of Physicians. Ann Intern Med. 2015 Mar 3;162(5):359-69. Full-text available at: http://annals.org/article.aspx?articleid=2173505
Qaseem A, Humphrey LL, Forciea MA, Starkey M, Denberg TD, Clinical Guidelines Committee of the American College of Physicians. Treatment of pressure ulcers: a clinical practice guideline from the American College of Physicians. Ann Intern Med. 2015 Mar 3;162(5):370-9. Full-text available at: http://annals.org/article.aspx?articleid=2173506
NICE. Pressure ulcers: prevention and management. April 2014. Available at: https://www.nice.org.uk/guidance/CG179/chapter/about-this-guideline#about-this-guideline
Bergstrom, N, Horn SD, Rapp MP, Stern A, Barrett R, Watkiss M. Preventing pressure ulcers: a multi-site RCT in nursing homes. June 2011. Available at: http://lgdata.s3-website-us-east-1.amazonaws.com/docs/3744/896380/TR_2012.1_TURN_Clinical_Report_15Jun2012_FINAL_Revised_on_Feb_28_2013.pdf
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Evidence-Informed |
How To Implement |
Toolbox |
| Use pressure relieving mattresses and pressure relieving padding (Treatment) |
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Use Pressure Relieving Mattresses and Pressure Relieving Devices
Type of Evidence: I (High)
References:
Systematic Reviews
Tricco AC, Antony J, Vafaei A, Khan PA, Harrington A, Cogo E, Wilson C, Perrier L, Hui W, Straus SE. Seeking effective interventions to treat complex wounds: an overview of systematic reviews. BMC Med. 2015 Apr 22;13:89. Full-text available at: http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD009958.pub2/full
McInnes E, Jammali-Blasi A, Bell-Syer SE, Dumville JC, Cullum N. Support surfaces for pressure ulcer prevention. Cochrane Database Syst Rev. 2011;(4). Available from: http://www.ncbi.nlm.nih.gov/pubmed/21491384
Supporting Research
Tasker LH, Shapcott NG, Watkins AJ, Holland PM. The effect of seat shape on the risk of pressure ulcers using discomfort and interface pressure measurements. Prosthet Orthot Int. 2014 Feb;38(1):46-53. Full-text available at:http://poi.sagepub.com/content/38/1/46.long
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. Available from: http://www.ncbi.nlm.nih.gov/pubmed/22104042
Reddy M. Pressure ulcers. Clin Evid (Online). 2011 Apr 28;2011:1901. Available from: http://www.ncbi.nlm.nih.gov/pubmed/21524319
Bain D. Laboratory performance of alternating pressure air mattresses component and sequelae. Br J Nurs. 2011;20(20):S29-34. Available from: http://www.ncbi.nlm.nih.gov/pubmed/22067933
Brienza D, Kelsey S, Karg P, et al. A randomized clinical trial on preventing pressure ulcers with wheelchair seat cushions. J Am Geriatr Soc. 2010;58(12):2308-2314. Available from: http://www.ncbi.nlm.nih.gov/pubmed/21070197
Rafter L. Evaluation of patient outcomes: Pressure ulcer prevention mattresses. Br J Nurs. 2011;20(11):S32, S34-8. Available from: http://www.ncbi.nlm.nih.gov/pubmed/21727848
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. Available from: http://www.ncbi.nlm.nih.gov/pubmed/20510611
Wu T, Wang ST, Lin PC, Liu CL, Chao YF. Effects of using a high-density foam pad versus a viscoelastic polymer pad on the incidence of pressure ulcer development during spinal surgery. Biol Res Nurs. 2011;13(4):419-424. Available from: http://www.ncbi.nlm.nih.gov/pubmed/21196422
Institute for Healthcare Improvement. Pressure Ulcer Prevention [Internet]. Institute for Healthcare Improvement. Available from: http://app.ihi.org/imap/tool/#Process=cbe9c419-f6ae-49ed-8bb5-5d17844796e2
Ontario Health Technology Advisory Committee. OHTAC Recommendation Prevention and Treatment of Pressure Ulcers. Toronto: Ontario Health Technology Advisory Committee; 2009 Oct. Available from: http://www.health.gov.on.ca/english/providers/program/ohtac/tech/recommend/rec_pup_20091020.pdf
Orsted HL, Ohura T, Harding K. Pressure, Shear, Friction, and Microclimate in Context. London (UK): Wounds International; 2010. Available from: http://www.woundsinternational.com/pdf/content_8925.pdf
Qaseem A, Mir TP, Starkey M, Denberg TD, Clinical Guidelines Committee of the American College of Physicians. Risk assessment and prevention of pressure ulcers: a clinical practice guideline from the American College of Physicians. Ann Intern Med. 2015 Mar 3;162(5):359-69. Full-text available at: http://annals.org/article.aspx?articleid=2173505
Qaseem A, Humphrey LL, Forciea MA, Starkey M, Denberg TD, Clinical Guidelines Committee of the American College of Physicians. Treatment of pressure ulcers: a clinical practice guideline from the American College of Physicians. Ann Intern Med. 2015 Mar 3;162(5):370-9. Full-text available at: http://annals.org/article.aspx?articleid=2173506
NICE. Pressure ulcers: prevention and management. April 2014. Available at: https://www.nice.org.uk/guidance/CG179/chapter/about-this-guideline#about-this-guideline
Bergstrom, N, Horn SD, Rapp MP, Stern A, Barrett R, Watkiss M. Preventing pressure ulcers: a multi-site RCT in nursing homes. June 2011. Available at: http://lgdata.s3-website-us-east-1.amazonaws.com/docs/3744/896380/TR_2012.1_TURN_Clinical_Report_15Jun2012_FINAL_Revised_on_Feb_28_2013.pdf
Registered Nurses’ Association of Ontario. Risk assessment and prevention of pressure ulcers. Toronto: Registered Nurses’ Association of Ontario; 2002. Revised 2011. Available from: http://rnao.ca/bpg/guidelines/risk-assessment-and-prevention-pressure-ulcers
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Evidence-Informed |
How To Implement |
Toolbox |
Establish standardized treatment for each pressure ulcer stage (Treatment) |
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Establish Standardized Treatment for each Pressure Ulcer Stage
Type of Evidence: IV (Expert Opinion)
References:
Supporting Research
Qaseem A, Mir TP, Starkey M, Denberg TD, Clinical Guidelines Committee of the American College of Physicians. Risk assessment and prevention of pressure ulcers: a clinical practice guideline from the American College of Physicians. Ann Intern Med. 2015 Mar 3;162(5):359-69. Full-text available at: http://annals.org/article.aspx?articleid=2173505
Qaseem A, Humphrey LL, Forciea MA, Starkey M, Denberg TD, Clinical Guidelines Committee of the American College of Physicians. Treatment of pressure ulcers: a clinical practice guideline from the American College of Physicians. Ann Intern Med. 2015 Mar 3;162(5):370-9. Full-text available at: http://annals.org/article.aspx?articleid=2173506
NICE. Pressure ulcers: prevention and management. April 2014. Available at: https://www.nice.org.uk/guidance/CG179/chapter/about-this-guideline#about-this-guideline
Bergstrom, N, Horn SD, Rapp MP, Stern A, Barrett R, Watkiss M. Preventing pressure ulcers: a multi-site RCT in nursing homes. June 2011. Available at: http://lgdata.s3-website-us-east-1.amazonaws.com/docs/3744/896380/TR_2012.1_TURN_Clinical_Report_15Jun2012_FINAL_Revised_on_Feb_28_2013.pdf
Registered Nurses’ Association of Ontario. Risk assessment and prevention of pressure ulcers. Toronto: Registered Nurses’ Association of Ontario; 2002. Revised 2011. Available from: http://rnao.ca/bpg/guidelines/risk-assessment-and-prevention-pressure-ulcers
Sibbald RG, Goodman L, Norton L, Krasner DL, Ayello EA. Prevention and Treatment of Pressure Ulcers. Skin Therapy Lett. 2012;17(8):4-7. Available from: http://www.ncbi.nlm.nih.gov/pubmed/22949132
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Evidence-Informed |
How To Implement |
Toolbox |
| Protect and promote skin integrity from excessive moisture and incontinence (Treatment) |
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Protect and Promote Skin Integrity from Excessive Moisture and Incontinence
Type of Evidence: IV (Expert Opinion)
References:
Systematic Reviews
Beeckman D, Van Lancker A, Van Hecke A, Verhaeghe S. A systematic review and meta-analysis of incontinence-associated dermatitis, incontinence, and moisture as risk factors for pressure ulcer development. Res Nurs Health. 2014 Jun;37(3):204-18. Abstract available at: http://www.ncbi.nlm.nih.gov/pubmed/24700170
Supporting Research
Institute for Healthcare Improvement. Pressure Ulcer Prevention [Internet]. Institute for Healthcare Improvement. Available from: http://app.ihi.org/imap/tool/#Process=cbe9c419-f6ae-49ed-8bb5-5d17844796e2
Qaseem A, Mir TP, Starkey M, Denberg TD, Clinical Guidelines Committee of the American College of Physicians. Risk assessment and prevention of pressure ulcers: a clinical practice guideline from the American College of Physicians. Ann Intern Med. 2015 Mar 3;162(5):359-69. Full-text available at: http://annals.org/article.aspx?articleid=2173505
Qaseem A, Humphrey LL, Forciea MA, Starkey M, Denberg TD, Clinical Guidelines Committee of the American College of Physicians. Treatment of pressure ulcers: a clinical practice guideline from the American College of Physicians. Ann Intern Med. 2015 Mar 3;162(5):370-9. Full-text available at: http://annals.org/article.aspx?articleid=2173506
NICE. Pressure ulcers: prevention and management. April 2014. Available at: https://www.nice.org.uk/guidance/CG179/chapter/about-this-guideline#about-this-guideline
Bergstrom, N, Horn SD, Rapp MP, Stern A, Barrett R, Watkiss M. Preventing pressure ulcers: a multi-site RCT in nursing homes. June 2011. Available at: http://lgdata.s3-website-us-east-1.amazonaws.com/docs/3744/896380/TR_2012.1_TURN_Clinical_Report_15Jun2012_FINAL_Revised_on_Feb_28_2013.pdf
Registered Nurses’ Association of Ontario. Risk assessment and prevention of pressure ulcers. Toronto: Registered Nurses’ Association of Ontario; 2002. Revised 2011. Available from: http://rnao.ca/bpg/guidelines/risk-assessment-and-prevention-pressure-ulcers
|
Evidence-Informed |
How To Implement |
Toolbox |
| Minimize pain (Treatment) |
|
|
Minimize Pain
Type of Evidence: IV (Expert Opinion)
References:
Supporting Research
Sibbald RG, Goodman L, Norton L, Krasner DL, Ayello EA. Prevention and Treatment of Pressure Ulcers. Skin Therapy Lett. 2012;17(8):4-7. Available from: http://www.ncbi.nlm.nih.gov/pubmed/22949132
Guidelines
Qaseem A, Mir TP, Starkey M, Denberg TD, Clinical Guidelines Committee of the American College of Physicians. Risk assessment and prevention of pressure ulcers: a clinical practice guideline from the American College of Physicians. Ann Intern Med. 2015 Mar 3;162(5):359-69. Full-text available at: http://annals.org/article.aspx?articleid=2173505
Qaseem A, Humphrey LL, Forciea MA, Starkey M, Denberg TD, Clinical Guidelines Committee of the American College of Physicians. Treatment of pressure ulcers: a clinical practice guideline from the American College of Physicians. Ann Intern Med. 2015 Mar 3;162(5):370-9. Full-text available at: http://annals.org/article.aspx?articleid=2173506
NICE. Pressure ulcers: prevention and management. April 2014. Available at: https://www.nice.org.uk/guidance/CG179/chapter/about-this-guideline#about-this-guideline
Bergstrom, N, Horn SD, Rapp MP, Stern A, Barrett R, Watkiss M. Preventing pressure ulcers: a multi-site RCT in nursing homes. June 2011. Available at: http://lgdata.s3-website-us-east-1.amazonaws.com/docs/3744/896380/TR_2012.1_TURN_Clinical_Report_15Jun2012_FINAL_Revised_on_Feb_28_2013.pdf
Registered Nurses’ Association of Ontario. Risk assessment and prevention of pressure ulcers. Toronto: Registered Nurses’ Association of Ontario; 2002. Revised 2011. Available from: http://rnao.ca/bpg/guidelines/risk-assessment-and-prevention-pressure-ulcers
|
Evidence-Informed |
How To Implement |
Toolbox |
| Ensure optimal nutrition (Treatment) |
|
|
Type of Evidence: IV (Expert Opinion)
References:
Systematic Reviews
Langer G, Fink A. Nutritional interventions for preventing and treating pressure ulcers. Cochrane Database Syst Rev. 2014 Jun 12;6:CD003216. Full-text available at: http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD003216.pub2/full
Supporting Research
Cereda E, Klersy C, Serioli M, Crespi A, D'Andrea F; OligoElement Sore Trial Study Group. A nutritional formula enriched with arginine, zinc, and antioxidants for the healing of pressure ulcers: a randomized trial. Ann Intern Med. 2015 Feb 3;162(3):167-74. Abstract available at: http://www.ncbi.nlm.nih.gov/pubmed/25643304
Institute for Healthcare Improvement. Pressure Ulcer Prevention [Internet]. Institute for Healthcare Improvement. Available from: http://app.ihi.org/imap/tool/#Process=cbe9c419-f6ae-49ed-8bb5-5d17844796e2
Ontario Health Technology Advisory Committee. OHTAC Recommendation Prevention and Treatment of Pressure Ulcers. Toronto: Ontario Health Technology Advisory Committee; 2009 Oct. Available from: http://www.health.gov.on.ca/english/providers/program/ohtac/tech/recommend/rec_pup_20091020.pdf
Qaseem A, Mir TP, Starkey M, Denberg TD, Clinical Guidelines Committee of the American College of Physicians. Risk assessment and prevention of pressure ulcers: a clinical practice guideline from the American College of Physicians. Ann Intern Med. 2015 Mar 3;162(5):359-69. Full-text available at: http://annals.org/article.aspx?articleid=2173505
Qaseem A, Humphrey LL, Forciea MA, Starkey M, Denberg TD, Clinical Guidelines Committee of the American College of Physicians. Treatment of pressure ulcers: a clinical practice guideline from the American College of Physicians. Ann Intern Med. 2015 Mar 3;162(5):370-9. Full-text available at: http://annals.org/article.aspx?articleid=2173506
NICE. Pressure ulcers: prevention and management. April 2014. Available at: https://www.nice.org.uk/guidance/CG179/chapter/about-this-guideline#about-this-guideline
Bergstrom, N, Horn SD, Rapp MP, Stern A, Barrett R, Watkiss M. Preventing pressure ulcers: a multi-site RCT in nursing homes. June 2011. Available at: http://lgdata.s3-website-us-east-1.amazonaws.com/docs/3744/896380/TR_2012.1_TURN_Clinical_Report_15Jun2012_FINAL_Revised_on_Feb_28_2013.pdf
Registered Nurses’ Association of Ontario. Risk assessment and prevention of pressure ulcers. Toronto: Registered Nurses’ Association of Ontario; 2002. Revised 2011. Available from: http://rnao.ca/bpg/guidelines/risk-assessment-and-prevention-pressure-ulcers
|
Evidence-Informed |
How To Implement |
Toolbox |
| Employ best practices for bed ridden residents (Treatment) |
|
|
Employ Best Practices for Bed Ridden Residents
Type of Evidence: IV (Expert Opinion)
References:
Supporting Research
Qaseem A, Mir TP, Starkey M, Denberg TD, Clinical Guidelines Committee of the American College of Physicians. Risk assessment and prevention of pressure ulcers: a clinical practice guideline from the American College of Physicians. Ann Intern Med. 2015 Mar 3;162(5):359-69. Full-text available at: http://annals.org/article.aspx?articleid=2173505
Qaseem A, Humphrey LL, Forciea MA, Starkey M, Denberg TD, Clinical Guidelines Committee of the American College of Physicians. Treatment of pressure ulcers: a clinical practice guideline from the American College of Physicians. Ann Intern Med. 2015 Mar 3;162(5):370-9. Full-text available at: http://annals.org/article.aspx?articleid=2173506
NICE. Pressure ulcers: prevention and management. April 2014. Available at: https://www.nice.org.uk/guidance/CG179/chapter/about-this-guideline#about-this-guideline
Bergstrom, N, Horn SD, Rapp MP, Stern A, Barrett R, Watkiss M. Preventing pressure ulcers: a multi-site RCT in nursing homes. June 2011. Available at: http://lgdata.s3-website-us-east-1.amazonaws.com/docs/3744/896380/TR_2012.1_TURN_Clinical_Report_15Jun2012_FINAL_Revised_on_Feb_28_2013.pdf
Registered Nurses’ Association of Ontario. Risk assessment and prevention of pressure ulcers. Toronto: Registered Nurses’ Association of Ontario; 2002. Revised 2011. Available from: http://rnao.ca/bpg/guidelines/risk-assessment-and-prevention-pressure-ulcers
Lancet. 2003 Oct 11;362(9391):1225-30.
Available from: http://www.ncbi.nlm.nih.gov/pubmed/14568747
How will we know if a change is an improvement? Measurement is one of the critical steps in a quality improvement (QI) initiative that assesses the impact of your tests of change. Quality indicators are used to measure how well something is performing. There are three types of quality indicators used to measure your QI efforts: outcome (indicators that capture clinical outcomes and or system performance), process (indicators that track the processes that measure whether the system is working as planned), and balancing indicators (indicators that ensure that changing one part of the system does not cause new problems in other parts of the system).
| Type of Indicator | Indicator of Quality Improvement | How to Calculate: numerator __________ denominator |
Targets/ Benchmarks | How is This Indicator Used? |
|---|---|---|---|---|
| Outcome | Percentage of Residents Whose Stage 2 to 4 Pressure Ulcer Worsened |
Residents who have a pressure ulcer at stage 2 to 4 on their target assessment and for whom the stage of pressure ulcer is greater on their target assessment than on their prior assessment Residents with valid assessments |
Targets: As low as possible (set by individual homes) Provincial benchmarks: 1% |
Quality improvement QIP indicator Publicly reported by HQO |
Collected measures can be presented graphically by plugging the monthly results into run chart.
For a more comprehensive list of tools and resources, visit the following links on our HQO website:
A pressure ulcer, also referred to as a pressure sore, bedsore and decubitus ulcer, is defined as a localized injury to the skin and/or underlying tissue occurring most often over a bony prominence and caused by pressure, shearing, or friction, alone or in combination.1 Pressure ulcers are graded or staged along a 4-point classification system denoting severity. Stage I (1) represents the beginnings of a pressure ulcer and stage IV (4), the severest grade, consists of tissue loss with exposed bone, tendon, and or muscle.1
While the causes of pressure ulcers can vary, early assessment, prevention and treatment are all essential if pressure ulcers incidence is to be reduced. The Long-Term Care Homes Act, 2007, requires all homes in Ontario to have a wound care program to promote skin integrity, prevent the development of wounds and pressure ulcers, and provide effective skin and wound care interventions.2 To support your quality improvement efforts, this site includes pressure ulcer evidence informed best practices and change ideas for long-term care homes who aim to improve the incidence and prevalence of pressure ulcers.
Pressure ulcers can be painful and undermine function, mobility, and quality of life.3 As well, the interventions to treat them are a significant financial burden to the health care system.3 More importantly, pressure ulcers are avoidable with a greater focus on prevention. In 2012, 2.6% of LTC residents experienced a new pressure ulcer (stage 2 or higher) and 3% had a pressure ulcer that recently got worse.5
Ontario is the first jurisdiction that publicly reports quality indicators for long-term care homes. Measuring and monitoring efforts is essential in quality improvement. The tools and information provided in this resource focus on the process of quality improvement for long-term care homes however, the ultimate goal is to provide residents with the best possible care.
Toronto: Ontario Health Technology Advisory Committee; October 2009.
Available from: http://www.hqontario.ca/english/providers/program/ohtac/tech/recommend/rec_pup_20091020.pdf
2010 Mar 10
Available from: http://www.ontario.ca/laws/regulation/r10079
Toronto: Canadian Institute of Health Information; 2013.
Available from: https://secure.cihi.ca/free_products/AiB_Compromised_Wounds_EN.pdf
Toronto: Health Quality Ontario; 2012.
Available from: http://www.hqontario.ca/portals/0/Documents/pr/qmonitor-full-report-2011-en.pdf
Worsened Pressure Ulcer in Long-Term Care details for Ontario. 2015.
Available from: http://yourhealthsystem.cihi.ca/hsp/indepth?lang=en#/indicator/052/2/C5001/