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ObjectivesThis continuing nursing educational (CNE) activity is designed for nurses and other health care providers who care for and educate patients and their families regarding pressure ulcers. For those wishing to obtain CNE credit, an evaluation follows. After studying the information presented in this article, the nurse will be able to:1. Describe the history of pressure ulcer staging.2. Discuss problems with staging systems.3. Define deep tissue injury as an etiology and the need to update the pressure ulcer staging system.4. Explain the updated pressure ulcer staging system. [ABSTRACT FROM AUTHOR]

You can remove dead tissue from a wound in many ways. Find out your options -- and how to choose which one to use. [ABSTRACT FROM AUTHOR]

To assess all published studies which describe what happens to the delivery of pressure ulcer/injury (PI/PU) care pathways as a result of detecting raised sub-epidermal moisture (SEM) delta (∆ ≥ 0.6). We undertook a systematic review of the literature, and included original research studies using either a prospective or retrospective study design that report the impact that assessment using SEM assessments have on healthcare practitioners' delivery of PI/PU care pathways in adults at risk of developing PI/PUs. The review protocol was registered on PROSPERO (CRD42023416975). A literature search was conducted in May 2023, using PubMed, CINAHL, Scopus, Cochrane, EMBASE, Web of Science and Science Direct databases. Data were extracted using a data extraction tool including elements such as country, setting, sample size, intervention, control and quality appraisal was undertaken using the Evidence-based Librarianship. We identified nine papers published between 2017 and 2022. The majority of these studies were conducted in England (n = 6; 67%). The systematic review included studies conducted across multiple care settings including acute care, medical-surgical units, and palliative care, highlighting the importance of PI/PU prevention and management across diverse patient populations. The PI/PU care pathways implemented in the studies varied, but commonly included elements such as the application or increased use of pressure-redistributing mattresses/cushions, implementation of repositioning plans, management of incontinence and moisture, regular skin inspection, and assessment of patient mobility. Out of the nine studies identified, seven reported PI/PU incidence. A meta-analysis of seven studies (N = 18 451) demonstrated a statistically significant reduction in visual PI/PU development in favour of SEM-guided care pathways compared to usual care (the odds ratio = 0.36 [95% confidence interval: 0.24-0.53, p < 0.00001]). This systematic review provides evidence that implementing SEM assessments in patients at risk of developing PI/PUs prompts anatomy-specific clinical actions. The subsequent implementation of enhanced and targeted skin care interventions leads to consistent and sustained reductions in hospital-acquired PU incidence. The findings emphasise the importance of incorporating SEM assessments as part of comprehensive PI/PU prevention strategies in all care settings and patient populations. This systematic review is limited by the predominance of observational studies and variable study quality. Future research should focus on randomised trials in different care settings that monitor the efficacy of preventive interventions and their impact in reducing PI/PU incidence when implemented based on SEM assessments., (© 2024 The Author(s). International Wound Journal published by Medicalhelplines.com Inc and John Wiley & Sons Ltd.)

Abstract: The National Pressure Injury Advisory Panel, European Pressure Ulcer Advisory Panel, and the Pan Pacific Pressure Injury Alliance are commencing a new (fourth) edition of the Prevention and Treatment of Pressure Ulcers/Injuries: Clinical Practice Guideline . The fourth edition of the International Pressure Injury (PI) Guideline will be developed using GRADE methods to ensure a rigorous process consistent with evolving international standards. Clinical questions will address prevention and treatment of PIs, identification of individuals at risk of PIs, assessment of skin and tissues, and PI assessment. Implementation considerations supporting application of the guidance in clinical practice will be developed. The guideline development process will be overseen by a guideline governance group and methodologist; the guideline development team will include health professionals, educators, researchers, individuals with or at risk of PIs, and informal carers.This article presents the project structure and processes to be used to undertake a systematic literature search, appraise risk of bias of the evidence, and aggregate research findings. The methods detail how certainty of evidence will be evaluated; presentation of relative benefits, risks, feasibility, acceptability, and resource requirements; and how recommendations will be made and graded. The methods outline transparent processes of development that combine scientific research with best clinical practice. Strong involvement from health professionals, educators, individuals with PIs, and informal carers will enhance the guideline's relevance and facilitate uptake. This update builds on previous editions to ensure consistency and comparability, with methodology changes improving the guideline's quality and clarity., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

General Purpose: To present a study conducting objective biomechanical testing of medical devices known to cause medical device-related pressure injuries (MDRPIs) in critically ill adults and comparing those results with clinical outcomes associated with each device., Target Audience: This continuing education activity is intended for physicians, physician assistants, nurse practitioners, and nurses with an interest in skin and wound care., Learning Objectives/outcomes: After participating in this educational activity, the participant will:1. Explain the results of the study of the relationships between objective biomechanical tests of medical devices and clinical outcomes that help inform clinicians using these devices.2. Synthesize the background information that informed the study., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

COVID-19 has infected millions of patients and impacted healthcare workers worldwide. Personal Protective Equipment (PPE) is a key component of protecting frontline clinicians against infection. The benefits of PPE far outweigh the risks, nonetheless, many clinicians are exhibiting skin injury caused by PPE worn incorrectly. These skin injuries, ranging from lesions to open wounds are concerning because they increase the susceptibility of viral infection and transmission to other individuals. Early into the COVID-19 pandemic (April 2020), the U. S. National Pressure Injury Advisory Panel (NPIAP) developed a series of position statements to improve wear-ability of PPE and protect healthcare professionals and their patients as safe from harm as possible under the circumstances. The NPIAP positions, which were formed by conducting a systematic review of what was known at the time, include: (a) Prepare skin before and after wearing PPE with skin sealants, barrier creams and moisturisers; (b) Frequent PPE offloading to relieve pressure and shear applied to skin; (c) treat visible skin injuries immediately caused by PPE to minimise future infection; (d) non-porous dressings may provide additional skin protection, but lack evidence; (e) health systems should take care to educate clinicians about placement and personal hygiene related to handling PPE. Throughout all of these practices, handwashing remains a top priority to handle PPE. These NPIAP positions provided early guidance to reduce the risk of skin injury caused by PPE based on available research regarding PPE injuries, a cautious application of evidence-based recommendations on prevention of device-related pressure injuries in patients and the expert opinion of the NPIAP Board of Directors. Clinicians who adhere to these recommendations reduce the prospects of skin damage and long-term effects (e.g. scarring). These simple steps to minimise the risk of skin injury and reduce the risk of coronavirus infection from PPE can help., (© 2021 John Wiley & Sons Ltd.)

Objective: After launching the 2019 International Pressure Ulcer/Injury Guideline, the National Pressure Injury Advisory Panel (NPIAP), the European Pressure Ulcer Advisory Panel (EPUAP) and the Pan Pacific Pressure Injury Alliance (PPPIA) collaborated with Sensorydata Corp., US, to develop a guideline app (InterPIP App). The app was designed to: present evidence-based guideline recommendations; incorporate search capacities and functionality to facilitate easy access to clinical guidance; provide accessibility in multiple languages; and to be available worldwide at a reasonable price, including opportunities for free access in low-resource countries. This paper describes the development, dissemination and formative evaluation of a mobile app providing evidence-based recommendations for pressure injury prevention, assessment/classification, and treatment at the point of care., Method: An evaluation tool was designed based on a framework developed by Nouri et al. and made available to all app subscribers., Results: The InterPIP App is currently available in 11 languages and had been downloaded 3616 times by February 2022 in 78 countries. A total of 62 individuals responded to the survey of end-users. In this formal evaluation of user experiences, the app was rated positively on criteria of: information/content; usability; design; functionality; ethics; and security/privacy (median=4 on a 1-5 Likert scale). Overall perceived value was ranked lower with a median of three. Users provided suggestions for ongoing app enhancement., Conclusion: The InterPIP App offers a unique opportunity to bring evidence-based guidance to the point of care. Formal evaluation of end-user experiences identified opportunities for quality improvement, and informed plans for future development and evaluation.

Objectives: Operating room-related pressure injuries (ORPI) are particularly challenging to examine for several reasons. Time in the OR is often a distinct event within the hospitalisation, and discovery of an ORPI may occur between several hours and up to 5 days postoperatively. The National Pressure Injury Advisory Panel (NPIAP) first developed a root cause analysis (RCA) toolkit in 2017 as a systematic strategy for investigating the root causes of facility-acquired pressure injury (PI). The purpose of this 2021 RCA toolkit update was to address an expanded investigation of medical device-related PIs (MDRPIs), both inside and outside the OR, as well as the specific PI prevention issues of the perioperative area., Methods: Clinicians have been using the 2017 toolkit as a basis for ongoing quality improvement tracking, since it provides more accurate information than data extractions from patient health records. A small working group consisting of NPIAP board and panel members developed investigative questions to identify the ORPI root causes and compliance with best practices for the entire perioperative experience., Results: Action items are linked to evidence-based recommendations from the NPIAP/European Pressure Ulcer Advisory Panel/Pan Pacific Pressure Injury Alliance 2019 International Guideline and the Association of PeriOperative Registered Nurses (AORN) Guidelines for Perioperative Practice. A multidisciplinary clinician guide was also developed to identify practice gaps and to compile the information into an action plan for staff education and/or process improvement., Conclusion: The updated NPIAP RCA toolkit provides mechanisms for investigating, compiling and trending data as a basis for data-driven quality improvement. Using the enhanced investigative tools, the root causes of both MDRPIs and ORPIs can be better understood to target efforts to reduce their occurrence.

In 2019, the third and updated edition of the Clinical Practice Guideline (CPG) on Prevention and Treatment of Pressure Ulcers/Injuries has been published. In addition to this most up-to-date evidence-based guidance for clinicians, related topics such as pressure ulcers (PUs)/pressure injuries (PIs) aetiology, classification, and future research needs were considered by the teams of experts. To elaborate on these topics, this is the third paper of a series of the CPG articles, which summarises the latest understanding of the aetiology of PUs/PIs with a special focus on the effects of soft tissue deformation. Sustained deformations of soft tissues cause initial cell death and tissue damage that ultimately may result in the formation of PUs/PIs. High tissue deformations result in cell damage on a microscopic level within just a few minutes, although it may take hours of sustained loading for the damage to become clinically visible. Superficial skin damage seems to be primarily caused by excessive shear strain/stress exposures, deeper PUs/PIs predominantly result from high pressures in combination with shear at the surface over bony prominences, or under stiff medical devices. Therefore, primary PU/PI prevention should aim for minimising deformations by either reducing the peak strain/stress values in tissues or decreasing the exposure time., (© 2021 The Authors. International Wound Journal published by Medicalhelplines.com Inc (3M) and John Wiley & Sons Ltd.)

Background: Consumer engagement is a requirement of high quality clinical guidelines. Developing strategies to engage consumers and incorporate the perspectives of individuals with or at risk of pressure ulcers/injuries and their informal caregivers was one priority in the recent update of the EPUAP/NPIAP/PPPIA's Prevention and Treatment of Pressure Ulcers/Injuries: Clinical Practice Guideline., Aims: The aims were to determine the goals of individuals and caregivers for pressure ulcer/injury care, priorities for pressure ulcer/injury education and biggest problems related to pressure ulcers/injuries., Methods: An online, anonymous, international 10-item survey, accessible in nine languages was provided to individuals and their caregivers from April to October 2018. Descriptive statistics were used for quantitative data and a thematic analysis approach was used to analyse qualitative data., Results: There were 1233 individuals from 27 countries who completed the survey. Overall, individuals and caregivers had similar goals of care. Reducing the size of pressure ulcer/injury was selected more often as a care goal than complete healing. Individuals, compared to caregivers, considered managing pain more important. Qualitative data analysis identified five themes including knowledge, attitudes, and skills; risk factors for pressure ulcer/injury; accessing pressure ulcer/injury care; quality of life for patients and caregivers; and the pressure ulcer/injury., Conclusions: The consumer survey provided consumer engagement and perspective that was incorporated into guideline development, including consideration during evaluation of the relevance and acceptability of recommendations, and assignment of recommendation strength ratings., (Copyright © 2021 Tissue Viability Society. Published by Elsevier Ltd. All rights reserved.)

BACKGROUND: When compared with all other health care professions, the psychiatric nursing profession has the highest prevalence of workplace violence. The effects of workplace violence can be psychologically and physically devastating. Supportive resources are not always available or fully utilized when available. Aims: The purpose of this study is to explore the true impact of workplace violence toward psychiatric mental health nurses, as well as their personal perspectives on the types of supportive resources necessary for future implementation. Additionally, this study strives to identify the facilitators and barriers to acquiring supportive resources. Methods: A qualitative descriptive study design was utilized. The theory of cognitive adaptation provided an underlying conceptual framework. Data were collected using REDCap software to identify the nature and extent of workplace violence in the study setting (Survey 1) and solicit detailed responses to focus group questions designed to address the study aims (Survey 2). RESULTS: Six pertinent themes were discovered: frequent exposure to workplace violence, attempt to understand workplace violence, the need for supportive means, barriers to accessing supportive means, increase administrative support, and workplace violence has a detrimental impact on various aspects of life. CONCLUSIONS: Although psychiatric mental health nurses express a desire for more psychological support postassault, the underlying meaning and cognitive adaptation following the workplace violence experience is not well understood, and there are barriers to the acquisition of services. The findings from this study are being used to inform a multifaceted program to effectively support psychiatric mental health nurses experiencing workplace violence.

In order to overcome inconsistencies in the reporting of outcomes in clinical trials, core outcome sets (COSs) have been developed in many clinical areas and the awareness of this concept is growing steadily. The Outcomes for Pressure Ulcer Trials (OUTPUTs) project aims to improve the quality of evidence from pressure ulcer prevention trials by developing a COS. As an initial step in the COS process we aimed to identify and classify both outcomes and concepts that represent potential outcomes for future trials that have been reported in pressure ulcer prevention research. A review was conducted in 12 major databases covering the literature indexed until 2016. Outcomes and relevant concepts reported in primary studies and/or reviews on pressure ulcer prevention in adult patients were extracted as presented in the articles, and afterwards inductively grouped into outcome domains. The domains were then categorized according to the outcome domain taxonomy recently proposed by the COMET group. In total 332 studies were included and 68 outcome domains were identified, covering multiple aspects of pressure ulcer prevention. Pressure ulcer occurrence was reported in 71% of all included studies, representing the most frequent outcome, followed by costs (22% of all studies) and acceptability of intervention and comfort (18% of all studies). A plethora of different outcomes are applied in pressure ulcer prevention research and substantial variations in definitions and reporting of similar outcomes were observed. A COS for pressure ulcer prevention trials is needed to overcome the noncomparability of outcomes., (© 2020 The Authors. British Journal of Dermatology published by John Wiley & Sons Ltd on behalf of British Association of Dermatologists.)

Purpose: The purpose of this study was to examine clinical characteristics and risk factors for critically ill patients who develop pressure injuries and identify the proportion of validated unavoidable pressure injuries associated with the proposed risk factors for acute skin failure (ASF)., Design: Retrospective case-control comparative study., Subjects and Setting: The sample comprised adult critically ill participants hospitalized in critical care units such as surgical, trauma, cardiovascular surgical, cardiac, neuro, and medical intensive care and corresponding progressive care units in 5 acute care hospitals within a large Midwestern academic/teaching healthcare system. Participants who developed hospital-acquired pressure injuries (HAPIs) and patients without HAPIs (controls) were included., Methods: A secondary analysis of data from a previous study with HAPIs and matching data for the control sample without HAPIs were obtained from the electronic health record. Descriptive and multivariate logistic regression analyses were conducted., Results: The sample comprised 475 participants; 165 experienced a HAPI and acted as cases, whereas the remaining 310 acted as controls. Acute Physiology and Chronic Health Evaluation (APACHE II) mean score (23.8, 8.7%; P < .001), mortality (n = 45, 27.3%; P = .002), history of liver disease (n = 28, 17%; P < .001), and unintentional loss of 10 lb or more in 1 month (n = 20, 12%; P = .002) were higher in the HAPI group. Multivariate logistic regression analysis identified participants with respiratory failure (odds ratio [OR] = 3.00; 95% confidence interval [CI], 1.27-7.08; P = .012), renal failure (OR = 7.48; 95% CI, 3.49-16.01; P < .001), cardiac failure (OR = 4.50; 95% CI, 1.76-11.51; P = .002), severe anemia (OR = 10.89; 95% CI, 3.59-33.00; P < .001), any type of sepsis (OR = 3.15; 95% CI, 1.44-6.90; P = .004), and moisture documentation (OR = 11.89; 95% CI, 5.27-26.81; P <.001) were more likely to develop a HAPI. No differences between unavoidable HAPI, avoidable HAPI, or the control group were identified based on the proposed ASF risk factors., Conclusion: This study provides important information regarding avoidable and unavoidable HAPIs and ASF. Key clinical characteristics and risk factors, such as patient acuity, organ failure, tissue perfusion, sepsis, and history of prior pressure injury, are associated with avoidable and unavoidable HAPI development. In addition, we were unable to support a relationship between unavoidable HAPIs and the proposed risk factors for ASF. Unavoidability of HAPIs rests with the documentation of appropriate interventions and not necessarily with the identification of clinical risk factors., Competing Interests: The authors have no relevant conflicts of interest to disclose., (Copyright © 2021 by the Wound, Ostomy and Continence Nurses Society.)

There has been an ongoing debate in the healthcare community about what pressure ulcers/injuries are, and how to name, define and classify them. The aim of this discussion paper is to provide a brief theoretical background about pressure ulcer/injury classification, to explain the approach the Guideline Governance Group has taken during the 2019 update of the International Guideline for 'Prevention and Treatment of Pressure Ulcers/Injuries' and to share views on how to best implement pressure ulcer/injury classification. First formal pressure ulcer/injury classifications were introduced in the 1950s and today various pressure ulcer/injury classification systems are used worldwide. Dissimilarities between commonly used classification systems may be considered a limitation that impedes clinical and scientific communication. However, the conceptual meaning of pressure ulcer/injury categories described within the various classification systems is comparable and the current evidence does not indicate that one classification is superior to another. Therefore, the Guideline Governance Group created a crosswalk of the major pressure ulcer/injury classifications in common use across different geographic regions. Clinicians are encouraged to use the classification system adopted by their healthcare setting in the most consistent way. The validity of pressure ulcer/injury classification is closely linked to its intended purpose. Studying measurement properties of pressure ulcer/injury classification systems must follow state-of-the-art methods. Structured educational interventions are helpful for improving diagnostic accuracy and reducing misclassification of pressure ulcers/injuries. Implementation of innovative skin and soft tissue assessments and revised pressure ulcer/injury classifications are only worth implementing, when the diagnostic information improves clinical care., Competing Interests: Declaration of competing interest All authors were part of the Guideline Governance Group overseeing the development of the International Guideline for ‘Prevention and Treatment of Pressure Ulcers/Injuries’ 2019., (Copyright © 2020 Tissue Viability Society. All rights reserved.)

Background: Despite prevention strategies, hospital-acquired pressure injuries (HAPIs) continue to occur, especially in critical care, raising the question whether some pressure injuries are unavoidable., Objectives: To determine the proportion of HAPIs among patients in critical and progressive care units that are unavoidable, and to identify risk factors that differentiate avoidable from unavoidable HAPIs., Methods: This study used a descriptive retrospective design. Data collected included demographic information, Braden Scale scores, clinical risk factors, and preventive interventions. The Pressure Ulcer Prevention Inventory was used to categorize HAPIs as avoidable or unavoidable., Results: A total of 165 patients participated in the study. Sixty-seven HAPIs (41%) were unavoidable. Participants who had congestive heart failure (odds ratio [OR], 0.22; 95% CI, 0.06-0.76; P = .02), were chemically sedated (OR, 0.38; 95% CI, 0.20-0.72; P = .003), had systolic blood pressure below 90 mm Hg (OR, 0.52; 95% CI, 0.27-0.99; P = .047), and received at least 1 vasopressor (OR, 0.44; 95% CI, 0.23-0.86; P = .01) were less likely to have an unavoidable HAPI. Those with bowel management devices were more likely to have an unavoidable HAPI (OR, 2.19; 95% CI, 1.02-4.71; P = .04). When length of stay was incorporated into the regression model, for each 1-day increase in stay, the odds of an unavoidable pressure injury developing increased by 4% (OR, 1.04; 95% CI, 1.002-1.08; P = .04). Participants who had a previous pressure injury were 5 times more likely to have an unavoidable HAPI (OR, 5.27; 95% CI, 1.20-23.15; P = .03)., Conclusions: Unavoidable HAPIs do occur; moreover, when preventive interventions are not documented and implemented appropriately, avoidable HAPIs occur., (©2019 American Association of Critical-Care Nurses.)

Background: Core outcome sets (COS) are being developed in many clinical areas to increase the quality and comparability of clinical trial results as well as to ensure their relevance for patients. A COS represents an agreed standardized set of outcomes that describes the minimum that should be consistently reported in all clinical trials of a defined area. It comprises a core domain set (defining what core outcomes should be measured) and a core measurement set (defining measurement/assessment instruments for each core domain). For pressure ulcer prevention trials a COS is lacking. The great heterogeneity of reported outcomes in this field indicates the need for a COS., Methods/design: The first part of this project aims to develop a core domain set by following established methods, which incorporates four steps: (1) definition of the scope, (2) conducting a scoping review, (3) organizing facilitated workshops with service users, (4) performing Delphi surveys and establishing consensus in a face-to-face meeting with different stakeholders., Discussion: After achieving consensus on the core domain set, further work will be undertaken to determine a corresponding core measurement set. This will lead to better pressure ulcer prevention research in the future. There are a number of methodological challenges in the field of COS development. To meet these challenges and to ensure a high-quality COS, the OUTPUTS project affiliates to current standards and works in close collaboration with international experts and with existing international service user groups., Trial Registration: The OUTPUTs project is registered in the COMET database: ( http://www.comet-initiative.org/studies/details/283 ). Registered on 2015.

Aim: The European Pressure Ulcer Advisory Panel, the Pan Pacific Pressure Injury Alliance, and the National Pressure Ulcer Advisory Panel are updating the 'Prevention and Treatment of Pressure Ulcers: Clinical Practice Guideline' (CPG) in 2019. The aim of this contribution is to summarize and to discuss the guideline development protocol for the 2019 update., Methods: A guideline governance group determines and monitors all steps of the CPG development. An international survey of consumers will be undertaken to establish consumer needs and interests. Systematic evidence searches in relevant electronic databases cover the period from July 2013 through August 2018. Risk of bias of included studies will be assessed by two reviewers using established checklists and an overall strength of evidence assigned to the cumulative body of evidence. Small working groups review the evidence available for each topic, review and/or draft the guideline chapters and recommendations and/or good practice statements. Finally, strength of recommendation grades are assigned. The recommendations are rated based on their importance and their potential to improve individual patient outcomes using an international formal consensus process., Discussion: Major methodological advantages of the current revision are a clear distinction between evidence-based recommendations and good practice statements and strong consumer involvement., Conclusion: The 2019 guideline update builds on the previous 2014 version to ensure consistency and comparability. Methodology changes will improve the guideline quality to increase clarity and to enhance implementation and compliance. The full guideline development protocol can be accessed from the guideline website (http://www.internationalguideline.com/)., (Copyright © 2019. Published by Elsevier Ltd.)

Aim: A discussion of the methodology used to develop the Prevention and Treatment of Pressure Ulcers: Clinical Practice Guideline. (2014)., Background: International experts representing National Pressure Ulcer Advisory Panel, European Pressure Ulcer Advisory Panel and Pan Pacific Pressure Injury Alliance developed the second edition of this clinical guideline., Design: Discussion paper - methodology., Data Sources: A comprehensive search for papers published up to July 2013 was conducted in 11 databases and identified 4286 studies. After critical appraisal, 356 studies were included and assigned a level of evidence., Implications for Nursing: Guideline recommendations provide guidance on best practice in pressure ulcer prevention and treatment. Understanding the development process of a guideline increases the meaningfulness of recommendations to clinicians., Findings: Five hundred and seventy five recommendations arose from the research and its interpretation. The body of evidence supporting each recommendation was assigned a strength of evidence. A strength of recommendation was assigned to recommendation statements using the GRADE system. Recommendations are primarily supported by a body of evidence rated as C (87% of recommendations), representing low quality and/or indirect evidence (30%) and expert opinion (57%). Two hundred and forty seven recommendations (43%) received a strong recommendation ('Do it')., Conclusion: Recommendations were developed with consideration to research of the highest methodological quality evidence and studies that add to clinical insight and provide guidance for areas of care where minimal research has been conducted. Recommendations in the guideline reflect best practice and should be implemented with consideration to local context and resources and the individual's preferences and needs., (© 2016 John Wiley & Sons Ltd.)

Hospital-acquired pressure ulcer occurrences have declined over the past decade as reimbursement policies have changed, evidence-based practice guidelines have been implemented, and quality improvement initiatives have been launched. However, the 2006-2008 Institute for Healthcare Improvement goal of zero pressure ulcers remains difficult to achieve and even more challenging to sustain. Magnet hospitals tend to have lower hospital-acquired pressure ulcer rates than non-Magnet hospitals, yet many non-Magnet hospitals also have robust pressure ulcer prevention programs. Successful programs share commonalities in structure, processes, and outcomes. A national summit of 55 pressure ulcer experts was convened at the Virginia Commonwealth University Medical Center in March 2014. The group was divided into 3 focus groups; each was assigned a task to develop a framework describing components of a proposed Magnet-designated Center of Pressure Ulcer Prevention Excellence. Systematic literature reviews, analysis of exemplars, and nominal group process techniques were used to create the framework. This article presents a framework describing the proposed Magnet-designated Centers of Pressure Ulcer Prevention Excellence. Critical attributes of Centers of Excellence are identified and organized according to the 4 domains of the ANCC model for the Magnet Recognition Program: transformational leadership; structural empowerment; exemplary professional practice; and new knowledge innovation and improvements. The structures, processes, and outcome measures necessary to become a proposed Center of Pressure Ulcer Prevention Excellence are discussed.

Aim: This paper discusses the critical determinants of pressure ulcer development and proposes a new pressure ulcer conceptual framework., Background: Recent work to develop and validate a new evidence-based pressure ulcer risk assessment framework was undertaken. This formed part of a Pressure UlceR Programme Of reSEarch (RP-PG-0407-10056), funded by the National Institute for Health Research. The foundation for the risk assessment component incorporated a systematic review and a consensus study that highlighted the need to propose a new conceptual framework., Design: Discussion Paper., Data Sources: The new conceptual framework links evidence from biomechanical, physiological and epidemiological evidence, through use of data from a systematic review (search conducted March 2010), a consensus study (conducted December 2010-2011) and an international expert group meeting (conducted December 2011)., Implications for Nursing: A new pressure ulcer conceptual framework incorporating key physiological and biomechanical components and their impact on internal strains, stresses and damage thresholds is proposed. Direct and key indirect causal factors suggested in a theoretical causal pathway are mapped to the physiological and biomechanical components of the framework. The new proposed conceptual framework provides the basis for understanding the critical determinants of pressure ulcer development and has the potential to influence risk assessment guidance and practice. It could also be used to underpin future research to explore the role of individual risk factors conceptually and operationally., Conclusion: By integrating existing knowledge from epidemiological, physiological and biomechanical evidence, a theoretical causal pathway and new conceptual framework are proposed with potential implications for practice and research., (© 2014 The Authors. Journal of Advanced Nursing Published by John Wiley & Sons Ltd.)

Aim: To agree a draft pressure ulcer risk factor Minimum Data Set to underpin the development of a new evidenced-based Risk Assessment Framework., Background: A recent systematic review identified the need for a pressure ulcer risk factor Minimum Data Set and development and validation of an evidenced-based pressure ulcer Risk Assessment Framework. This was undertaken through the Pressure UlceR Programme Of reSEarch (RP-PG-0407-10056), funded by the National Institute for Health Research and incorporates five phases. This article reports phase two, a consensus study., Design: Consensus study., Method: A modified nominal group technique based on the Research and Development/University of California at Los Angeles appropriateness method. This incorporated an expert group, review of the evidence and the views of a Patient and Public Involvement service user group. Data were collected December 2010-December 2011., Findings: The risk factors and assessment items of the Minimum Data Set (including immobility, pressure ulcer and skin status, perfusion, diabetes, skin moisture, sensory perception and nutrition) were agreed. In addition, a draft Risk Assessment Framework incorporating all Minimum Data Set items was developed, comprising a two stage assessment process (screening and detailed full assessment) and decision pathways., Conclusion: The draft Risk Assessment Framework will undergo further design and pre-testing with clinical nurses to assess and improve its usability. It will then be evaluated in clinical practice to assess its validity and reliability. The Minimum Data Set could be used in future for large scale risk factor studies informing refinement of the Risk Assessment Framework., (© 2014 The Authors. Journal of Advanced Nursing Published by John Wiley & Sons Ltd.)

Although pressure ulcer (PrU) development is now generally considered an indicator for quality of care, questions and concerns about situations in which they are unavoidable remain. Considering the importance of this issue and the lack of available research data, in 2010 the National Pressure Ulcer Advisory Panel (NPUAP) hosted a multidisciplinary conference to establish consensus on whether there are individuals in whom pressure ulcer development may be unavoidable and whether a difference exists between end-of-life skin changes and pressure ulcers. Thirty-four stakeholder organizations from various disciplines were identified and invited to send a voting representative. Of those, 24 accepted the invitation. Before the conference, existing literature was identified and shared via a webinar. A NPUAP task force developed standardized consensus questions for items with none or limited evidence and an interactive protocol was used to develop consensus among conference delegates and attendees. Consensus was established to be 80% agreement among conference delegates. Unanimous consensus was achieved for the following statements: most PrUs are avoidable; not all PrUs are avoidable; there are situations that render PrU development unavoidable, including hemodynamic instability that is worsened with physical movement and inability to maintain nutrition and hydration status and the presence of an advanced directive prohibiting artificial nutrition/hydration; pressure redistribution surfaces cannot replace turning and repositioning; and if enough pressure was removed from the external body the skin cannot always survive. Consensus was not obtained on the practicality or standard of turning patients every 2 hours nor on concerns surrounding the use of medical devices vis-à-vis their potential to cause skin damage. Research is needed to examine these issues, refine preventive practices in challenging situations, and identify the limits of prevention.

Pain is an ever-present problem in patients with pressure ulcers. As an advocate for persons with pressure ulcers, the National Pressure Ulcer Advisory Panel (NPUAP) is concerned about pain. To synthesize available pressure ulcer pain literature, a systematic review was performed of English language literature, specific to human research, 1992 to April 2008, using PubMed and the Cumulative Index in Nursing and Allied Health Literature. Fifteen relevant papers were found; they examined pain assessment tools, topical analgesia for pain management, and/or descriptions of persons with pressure ulcer pain. Studies had small sample sizes and included only adults. The literature established that 1) pressure ulcers cause pain; 2) pain assessment was typically found to be self-reported using different versions of the McGill Pain Questionnaire, Faces Rating Scale, or Visual Analog Scale; 3) pain assessment instruments should be appropriate to patient cognitive level and medical challenges; 4) in some cases, topical medications can ease pain and although information on systemic medication is limited, pain medications have been found to negatively affect appetite; and 5) wound treatment is painful, particularly dressing changes. Research gaps include the prevention and treatment of pressure ulcer pain, the impact of pain on nutrition, and pressure ulcer pain considerations for special groups (eg, children, end-of-life patients, and bariatric patients). The NPUAP presents this white paper as the current scientific know-ledge base on the topic. Research regarding the multidimensional aspects of pressure ulcer pain is strongly recommended.

Objective: To compare the clinical efficacy of 4 debridement alternatives in pressure ulcer management., Design: Nonexperimental design combining computer modeling and a decision analysis methodology. Data input into the model were derived from a literature review of the MEDLINE database for the years 1985 to 1995 (indexing terms: pressure ulcer, decubitus, economics, cost-effectiveness, and outcome) and a Delphi consensus process with an independent panel of 9 specialists in geriatric care., Setting: Long-term care., Patients: Hypothetical elderly female resident with a new full-thickness pressure ulcer (mild odor, minimal draining, no undermining, intact periulcer skin)., Interventions: The study patient underwent 1 month of therapy with each of 4 debridement methods: autolysis, wet-to-dry dressings, collagenase (Santyl) or fibrinolysin (Elase)., Main Outcome: Specific clinical outcomes (time to clean wound bed, risk of infection) and relative cost-effectiveness of each debridement method were calculated., Results: The likelihood of achieving a clean wound bed at 2 weeks was 70% for collagenase, 57% for fibrinolysin, 50% for autolysis, and 30% for wet-to-dry dressings. The total cost for 1 month of treatment was $610.96 for collagenase, $920.73 for autolysis, $986.38 for fibrinolysin, and $1,008.72 for wet-to-dry dressings., Conclusions: The study patient was most likely to have a clean wound bed after 2 and 4 weeks of treatment, less likely to need to switch debridement methods, and of equal or less likelihood of experiencing and infection and subsequent hospitalization when her wound was debrided with collagenase. Treatment with collagenase also resulted in the lowest total cost of treatment. Longer term, prospective studies using actual utilization data are needed to refine these estimates of the clinical and cost-effectiveness of each product.