|Type of Patient Safety Practice|
|Clinical Practice (CP)|
|“Best fit” category of the reported practice|
|Patient safety theme the SCP/clinical risk management practice is aimed at|
|Prevention and treatment of pressure ulcers in at risk patients, through electro-mechanically powered/ assisted pulsed air-flow cyclic pressure-relieving, anti-sores support surfaces|
|Objective of the CRM practice|
|After reviewing the literature, several studies point towards a reduction in pressure ulcers. As it may be seen from the variety from intervention no particular intervention is superior to another.
There are benefits to several interventions, which reduce pressure ulcers incidence in at risk patient. The clearest conclusion one can draw is that standard hospital mattresses have been consistently outperformed by a range of foam-based, low pressure mattresses and overlays, and also by “higher-tech” pressure relieving beds and mattresses in the prevention of PU (what is standard varies by hospital, country and over time) [p. 13, 8]
|Short description of the CRM practice, including any references for further information|
|The different interventions to prevent pressure ulcers are for example: “Alternative foam mattresses and low-air-loss beds, whereas bed over layers were not considered as that promising [1, 4].|
|Innovator of the SCP, country of origin|
|Spain , UK [1,11, 15], the Netherlands , USA (Washington, Chicago, Los Angeles) [5, 12, 7], USA, Canda  and Europe in gerneral, France , Germany , Australia |
|Involved health care staff|
|Nurses as main type of health care professional involved, however other care givers, physicians and even the patient him / herself would need to be involved, depending on which intervention is chosen.|
|Tested in which countries/health care systems, health care context(s) and/or clinical specialty/specialties, including references|
|1. Health care context: (university) hospitals, [p.5, 11],
2. Specialty: Intensive Care units [p. 14, 10], surgical unit [p.57, 2], tertiary referral facility for (heart surgery and liver transplantation) [p.3, 3], acute care facilities [p. 268, 4], cardiological and surgical intensive care [p. 413 –abstract, 6], nephrological intensive care, vascular, orthopedic, medical, or care of elderly people wards 
|Summary of evidence for effectiveness, including references|
|After reviewing the literature, several studies point towards prevention methods aimed to pressure ulcers in at risk patients. There is a variety of types of interventions. When compared, several interventions seem to prove relative effectiveness. However, some interventions reduce pressure ulcers incidence in at risk patients more effectively than others.
The clearest conclusion one can draw is that standard hospital mattresses have been consistently outperformed by a range of foam-based, low pressure mattresses and overlays, and also by “higher-tech” pressure relieving beds and mattresses in the prevention of PU (what is standard varies by hospital, country and over time) [p. 13, 8].
A systematic review was carried out to define what are the effects of preventive interventions in people at risk of developing pressure ulcers and what are the effects of treatments in people with pressure ulcers [p.1, 1].
The following interventions, were compared for their effectiveness and safety:
|Summary of evidence for transferability (transferability across health care systems or health care contexts or clinical specialties), including references|
|The literature seems to indicate that the different interventions to prevent pressure ulcers are transferable across health care systems (Spain, England,. Chicago, Germany) and clinical specialities (nurses, carers, physicians). Below, there are excerpts attesting to transferability from different articles.
1. A prospective quasi-experimental study was conducted among patients in the medical-surgery intensive care unit of a university hospital on mechanical ventilation ?24 hours during two time periods (2001 and 2006). [p.1, 3]
|Summary of available information on feasibility, including references|
|1. Based prevention guidelines, Medicare regulations that lowered payment for care related to stage III and IV HAPUs went into effect in 2008 [p.55, 2]
2. “findings underscore the need for nurses caring for patients to continue all appropriate PU preventive measures for individual patients, even were they are placed on higher category pressure redistribution surfaces.” [p.60, 2] 3. This quasi-experiment study that alternative pressure air mattresses were more effective than alternating pressure air overlays in preventing pressure ulcers in mechanically ventilated critical care patients [p.6, 3]
4. Need of and supporting innovators (contact nurses) and investing in nurses who were enthusiastic about improving pressure ulcer care, the so-called early adopters [p. 818-819, 5]
Important characteristics for a feasible intervention:
1. Regular visits (twice a week) to the ICUs, positive feedback during the study period, and organization of meetings on topics concerning pressure ulcer prevention for contact nurses after the implementation of the guideline [p. 819, 5]
2. Conscious of costs since pressure ulcers have been described as one of the most costly and physically debilitating complications in the 20th century [p 414, 6, p. 1733, 7, p.1 –abstract, 8, p.5, 13], since e.g. bed replacement and foam over layers may cost between 100 and L30,000 [p. 3, 8]
2.1. There is a higher probability (64%) that alternating mattress replacements are cost-saving; they were associated with lower overall costs (74.50 pounds sterling per patient on average, mainly due to reduced length of stay) and greater benefits (a delay in time to ulceration of 10.63 days on average). (p. 58)
2.2. One trial showed that low air-loss beds were more cost-effective at decreasing the incidence of pressure ulcers in critically ill patients than a standard ICU bed (Inman 1993) [p. 12, 8]
2.3. France: some financial outlays are reimbursed by national health insurance [p. 2, 14]
3. Identification of people at high risk and use of prevention strategies (pressure-relieving equipment) in order to provide best available evidence
|Existing implementation tools, including references|
|1. Braden Scale for Pressure Sore Risk [p. 6, 1, p.269, 4, p 413 – abstract, 6, p. 9, 8, p. 3, 11]
1.1. 6 subscales, sensory-perception, moisture, mobility, activity, nutrition, and friction and shear, used to describe PU risk [p.269, 4]
2.International Pressure Ulcer Guideline
3. The National Institute for Health and Clinical Excellence guidelines [p.55, 2]
4. Waterloo Pressure Sore Risk [p.269, 4, p. 9, 8]
5. Royal College of Nursing Clinical Practice Guideline on pressure ulcer risk assessment and prevention
5.1.Rrisk assessment tools should only be used as an aide-memoire and should not replace clinical judgment [p. 3, 11]
6. Scale of Norton (Norton1996) [p.269, 4, p. 9, 8]
7. Acute Chronic Health Evaluation (APACHE) III score (Knaus et al. 1991),
8. individual and total sequential organ failure assessment (SOFA) scores [p. 3, 3]
9. In PUSH (Pressure Ulcer Scale for Healing) [p. 514, 12]
10. Gosnell guideline. [p. 9, 8]
11. Grading of Recommendation Assessment, Development, and Evaluation (GRADE) system [p. 5, 13]
|Potential for/description of patient involvement in the CRM practice, including references|
|1. “In people with pressure ulcers, air-fluidised supports may improve healing compared with standard care, although they can make it harder for people to get in and out of bed independently” [p.2, 1].
2. Interaction while seating and moving [1733, 7]
2.1. Subjects were placed on the generic total contact seat for 1 session a day for as log as tolerated, but never for more than 4 hours.
2.2. After each session, subjects were returned to their hospital beds and were turned every 2 hours.
2.3. Subjects from the 2 nd group were placed on an overlay atop a standard hospital bed and were turned every 2 hours.
2.4. Subjects from the third group were placed on a low air loss bed preset for body weight, height, girth, and optimum air flow.
2.5. (subjects assigned to low air loss bed do not need to be turned, but in practice for this study, they were turned every 2 hours because that was standard nursing procedure) [p. 1737, 7]
3. Group used wheelchairs equipped with an individually adjusted automated seat that provided cyclic pressure relief, […] sat in wheelchairs for a minimum of 4 hours per day for 30 days during their PrU treatment. [p. 514, 12]
|Bibliography (for each reference: author(s), year, title, journal/internet link, page(s))|
| Cullum N, Petherick E. (2008): Pressure ulcers. In: SourceDepartment of Health Sciences, University of York, York, UK. pii: 1901. Clinical Evidence (Online). 2008: 1901.
 Johnson J, Peterson D, Campbell B, Richardson R, Rutledge D. (2011): Hospital-acquired pressure ulcer prevalence – evaluating low-air-loss beds. In: J Wound Ostomy Continence Nurs. 38(1):55-60. Erratum in: J Wound Ostomy Continence Nurs. 2011 38(4):347
 Manzano F, Pérez AM, Colmenero M, Aguilar MM, Sánchez-Cantalejo E, Reche AM, Talavera J, López F, Barco SF, Fernández-Mondejar E. (2013): Comparison of alternating pressure mattresses and overlays for prevention of pressure ulcers in ventilated intensive care patients: a quasi-experimental study. In: SourceICU, HU Virgen de las Nieves, Granada, Spain. © 2013 Blackwell Publishing Ltd. In: Journal of Advanced Nursing
 Black J, Berke C, Urzendowski G. (2012): Pressure ulcer incidence and progression in critically ill subjects: influence of low air loss mattress versus a powered air pressure redistribution mattress. In: J Wound Ostomy Continence Nurs. 39(3):267-73.
 de Laat EH, Pickkers P, Schoonhoven L, Verbeek AL, Feuth T, van Achterberg T. (2007): Guideline implementation results in a decrease of pressure ulcer incidence in critically ill patients. In: Critical Care Medicine 35(3):815-20.
 Shahin ES, Dassen T, Halfens RJ. (2009): Incidence, prevention and treatment of pressure ulcers in intensive care patients: a longitudinal study. In: Int J Nurs Stud. 46(4):413-21. doi: 10.1016/j.ijnurstu.2008.02.011. Epub 2008 Apr 18.
 Rosenthal MJ, Felton RM, Nastasi AE, Naliboff BD, Harker J, Navach JH. (2003): Healing of advanced pressure ulcers by a generic total contact seat: 2 randomized comparisons with low air loss bed treatments. Arch Phys Med Rehabil. 84(12):1733-42.
 Cullum N, McInnes E, Bell-Syer SE, Legood R. (2004): Support surfaces for pressure ulcer prevention. Cochrane Database of Systematic Review (3):CD001735. Update in Cochrane Database of Systematic Review. 2008;(4):CD001735.
 McInnes E, Dumville JC, Jammali-Blasi A, Bell-Syer SE. (2011): Support surfaces for treating pressure ulcers. Cochrane Database Systematic Review (12):CD009490.
 Nixon J, Nelson EA, Cranny G, Iglesias CP, Hawkins K, Cullum NA, Phillips A, Spilsbury K, Torgerson DJ, Mason S; PRESSURE Trial Group. (2006): Pressure relieving support surfaces: a randomised evaluation. In: Health Technol Assess.10(22):iii-iv, ix-x, 1-163.
 Malbrain M, Hendriks B, Wijnands P, Denie D, Jans A, Vanpellicom J, De Keulenaer B. (2010): A pilot randomised controlled trial comparing reactive air and active alternating pressure mattresses in the prevention and treatment of pressure ulcers among medical ICU patients. In: J Tissue Viability.19 (1):7-15.
 Makhsous M, Lin F, Knaus E, Zeigler M, Rowles DM, Gittler M, Bankard J, Chen D. (2009): Promote pressure ulcer healing in individuals with spinal cord injury using an individualized cyclic pressure-relief protocol. In: Departments of Physical Therapy and Human Movement Sciences, Physical Medicine and Rehabilitation, Orthopaedic Surgery, Northwestern University, Chicago, Illinois, USA. 22(11):514-21.
 Health Quality Ontario. (2009): Pressure ulcer prevention: an evidence-based analysis. In: Ont Health Technol Assess Ser. 9(2):1-104.
 Colin D, Rochet JM, Ribinik P, Barrois B, Passadori Y, Michel JM. (2012): What is the best support surface in prevention and treatment, as of 2012, for a patient at risk and/or suffering from pressure ulcer sore? Developing French guidelines for clinical practice. In: Annals of Physical and Rehabilitation Medicine. 55(7):466-81.
 Nixon J., Cranny G., Iglesias C., and al. (2006): Randomized, controlled trial of alternating pressure mattresses compared with alternating pressure overlays for the prevention of pessure ulcers: PRESSURE (pressure relieving support surfaces) trial. In: British Medical Journal 332: 1413-1415
 Phillips L. BSc. RN & McLeod PhD, Huntleigh Healthcare, UK. (2005): The use of Dynamic Alternating Pressure Seat Cushions for the prevention and Treatment of Pressure Ulcers. In: Revue l`Escarre 25:39-41
|1. Prof Dr Gelu Onose
2. Univ Assist Monica Haras, MD PHD
3. Simone Mohrs, CPME Public Health Intern, Masstricht University
4. Cristina Popescu, MD, Postgrad
5. Aura Spanu, MD Postgrad
|Any additional information on the CRM (e.g. implementation barriers and drivers)|