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Overview

Updated on December 03, 2015

Issue

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. 

Call to Action

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.

  1. Ontario Health Technology Advisory Committee (OHTAC). OHTAC Recommendation: Prevention and Management of Pressure Ulcers.

    Toronto: Ontario Health Technology Advisory Committee; October 2009.
    Available from: http://www.hqontario.ca/english/providers/program/ohtac/tech/recommend/rec_pup_20091020.pdf

  2. Government of Ontario. Ontario Regulation 79/10, Long-Term Care Homes Act, 2007.

    2010 Mar 10
    Available from: http://www.ontario.ca/laws/regulation/r10079

  3. Canadian Institute of Health Information. Compromised Wounds in Canada. 2013.

    Toronto: Canadian Institute of Health Information; 2013.
    Available from: https://secure.cihi.ca/free_products/AiB_Compromised_Wounds_EN.pdf

  4. Health Quality Ontario. Quality Monitor 2012.

    Toronto: Health Quality Ontario; 2012.
    Available from: http://www.hqontario.ca/portals/0/Documents/pr/qmonitor-full-report-2011-en.pdf

  5. Canadian Institute of Health Information. Your Health System.

    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/

Best Practices

Updated on December 03, 2015

“Insanity is doing things the way we’ve always done them and expecting different results”
Albert Einstein

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.

  1. Grol R, Grimshaw J. From best evidence to best practice: effective implementation of change in patients' care.

    Lancet. 2003 Oct 11;362(9391):1225-30.
    Available from: http://www.ncbi.nlm.nih.gov/pubmed/14568747

Measurement

Updated on December 03, 2015

“Some is not a number, soon is not a time.”
Don Berwick, former President and CEO of IHI, December 2004, at launch of the 100,000 Lives Campaign

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


Run Charts

Collected measures can be presented graphically by plugging the monthly results into run chart.

Tools & Resources

Updated on December 03, 2015

“Knowledge derived from research and experience may be of little value unless it is put into practice.”
Dr. Judith Shamian, keynote address at the 11th International Nursing Infomatics Conference, in Montreal, 2011

Tools

Pressure Ulcers
QI Tools


For a more comprehensive list of tools and resources, visit the following links on our HQO website:


 


Resources

Pressure Ulcers
QI Resources