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Clinical Guidelines |3 March 2015

Risk Assessment and Prevention of Pressure Ulcers: A Clinical Practice Guideline From the American College of Physicians Free

Amir Qaseem, MD, PhD, MHA; Tanveer P. Mir, MD; Melissa Starkey, PhD; Thomas D. Denberg, MD, PhD; for the Clinical Guidelines Committee of the American College of Physicians *

Amir Qaseem, MD, PhD, MHA
From the American College of Physicians, Philadelphia, Pennsylvania; New York University Clinical Cancer Center, New York, New York; and Carilion Clinic, Roanoke, Virginia.

Tanveer P. Mir, MD
From the American College of Physicians, Philadelphia, Pennsylvania; New York University Clinical Cancer Center, New York, New York; and Carilion Clinic, Roanoke, Virginia.

Melissa Starkey, PhD
From the American College of Physicians, Philadelphia, Pennsylvania; New York University Clinical Cancer Center, New York, New York; and Carilion Clinic, Roanoke, Virginia.

Thomas D. Denberg, MD, PhD
From the American College of Physicians, Philadelphia, Pennsylvania; New York University Clinical Cancer Center, New York, New York; and Carilion Clinic, Roanoke, Virginia.

for the Clinical Guidelines Committee of the American College of Physicians

Article, Author, and Disclosure Information
Author, Article, and Disclosure Information
* This paper, written by Amir Qaseem, MD, PhD, MHA; Tanveer P. Mir, MD; Melissa Starkey, PhD; and Thomas D. Denberg, MD, PhD, was developed for the Clinical Guidelines Committee of the American College of Physicians. Individuals who served on the Clinical Guidelines Committee from initiation of the project until its approval were Thomas D. Denberg, MD, PhD (Chair); Michael J. Barry, MD; Molly Cooke, MD; Paul Dallas, MD; Nick Fitterman, MD; Mary Ann Forciea, MD; Russell P. Harris, MD, MPH; Linda L. Humphrey, MD, MPH; Tanveer P. Mir, MD; Holger J. Schünemann, MD, PhD; J. Sanford Schwartz, MD; Paul Shekelle, MD, PhD; and Timothy Wilt, MD, MPH. Approved by the ACP Board of Regents on 26 July 2014.
  • From the American College of Physicians, Philadelphia, Pennsylvania; New York University Clinical Cancer Center, New York, New York; and Carilion Clinic, Roanoke, Virginia.

    Note: Clinical practice guidelines are “guides” only and may not apply to all patients and all clinical situations. Thus, they are not intended to override clinicians' judgment. All ACP clinical practice guidelines are considered automatically withdrawn or invalid 5 years after publication or once an update has been issued.

    Disclaimer: The authors of this article are responsible for its contents, including any clinical or treatment recommendations.

    Acknowledgment: The authors thank Dr. Roger Chou for updating the evidence from the original systematic review for the development of this guideline.

    Financial Support: Financial support for the development of this guideline comes exclusively from the ACP operating budget.

    Disclosures: Authors followed the policy regarding conflicts of interest described at www.annals.org/article.aspx?articleid=745942. Disclosures can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M14-1567. A record of conflicts of interest is kept for each Clinical Guidelines Committee meeting and conference call and can be viewed at www.acponline.org/clinical_information/guidelines/guidelines/conflicts_cgc.htm.

    Requests for Single Reprints: Amir Qaseem, MD, PhD, MHA, American College of Physicians, 190 N. Independence Mall West, Philadelphia, PA 19106; e-mail, aqaseem@acponline.org.

    Current Author Addresses: Drs. Qaseem and Starkey: American College of Physicians, 190 N. Independence Mall West, Philadelphia, PA 19106.

    Dr. Mir: New York University Clinical Cancer Center, 160 East 34th Street, New York, NY 10016.

    Dr. Denberg: Carilion Clinic, PO Box 13727, Roanoke, VA 24036.

    Author Contributions: Conception and design: A. Qaseem, T.P. Mir.

    Analysis and interpretation of the data: A. Qaseem, M. Starkey, T.D. Denberg.

    Drafting of the article: A. Qaseem, T.P. Mir, M. Starkey, T.D. Denberg.

    Critical revision of the article for important intellectual content: A. Qaseem, M. Starkey, T.D. Denberg.

    Final approval of the article: A. Qaseem, T.P. Mir, T.D. Denberg.

    Statistical expertise: A. Qaseem.

    Administrative, technical, or logistic support: A. Qaseem, M. Starkey, T.D. Denberg.

    Collection and assembly of data: A. Qaseem, M. Starkey.

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    • Abstract
    • Methods
    • Comparative Effectiveness of Risk Assessment Tools for Reducing the Incidence or Severity of Pressure Ulcers
    • Comparative Diagnostic Accuracy of Risk Assessment Tools for Predicting the Incidence of Pressure Ulcers
    • Evidence Related to Individual Interventions
    • Interventions to Facilitate Implementation of Pressure Ulcer Prevention Protocols or Guidelines
    • Evidence Related to Multicomponent Interventions
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Abstract

Description:

The American College of Physicians (ACP) developed this guideline to present the evidence and provide clinical recommendations based on the comparative effectiveness of risk assessment scales and preventive interventions for pressure ulcers.

Methods:

This guideline is based on published literature on this topic that was identified by using MEDLINE (1946 through February 2014), CINAHL (1998 through February 2014), the Cochrane Library, clinical trials registries, and reference lists. Searches were limited to English-language publications. The outcomes evaluated for this guideline include pressure ulcer incidence and severity, resource use, diagnostic accuracy, measures of risk, and harms. This guideline grades the quality of evidence and strength of recommendations by using ACP's clinical practice guidelines grading system. The target audience for this guideline includes all clinicians, and the target patient population is patients at risk for pressure ulcers.

Recommendation 1:

ACP recommends that clinicians should perform a risk assessment to identify patients who are at risk of developing pressure ulcers. (Grade: weak recommendation, low-quality evidence)

Recommendation 2:

ACP recommends that clinicians should choose advanced static mattresses or advanced static overlays in patients who are at an increased risk of developing pressure ulcers. (Grade: strong recommendation, moderate-quality evidence)

Recommendation 3:

ACP recommends against using alternating-air mattresses or alternating-air overlays in patients who are at an increased risk of developing pressure ulcers. (Grade: weak recommendation, moderate-quality evidence)

Pressure ulcers are defined as localized injury to the skin and/or underlying tissue, usually over a bony prominence, as a result of pressure alone or in combination with shear (1). They commonly occur in patients with limited mobility, such as those in hospitals or long-term care settings. It is estimated that up to 3 million adults in the United States are affected by pressure ulcers (2). The prevalence in the United States is estimated to range from 0.4% to 38% in acute care hospitals, 2% to 24% in long-term care nursing facilities, and 0% to 17% in home care settings (2–4). Between 1990 and 2001, pressure ulcers were reported as a cause of death in nearly 115 000 persons and were listed as the underlying cause of death in more than 21 000 (5). The estimated cost of treating each case of pressure ulcers ranges from $37 800 to $70 000, and up to $11 billion is spent annually in the United States to treat pressure ulcers (2, 6, 7). A growing industry has developed to market various products for pressure ulcer prevention.
Risk factors for pressure ulcers include older age; black race or Hispanic ethnicity; lower body weight; cognitive impairment; physical impairments; and other comorbid conditions that affect soft tissue integrity and healing, such as urinary or fecal incontinence, diabetes, edema, impaired microcirculation, hypoalbuminemia, and malnutrition (8–11). Various risk assessment instruments have been developed, including the Braden, Cubbin and Jackson, Norton, Ramstadius, and Waterlow scales.
Prevention strategies for pressure ulcers begin with identification of high-risk persons. Many interventions designed to prevent pressure ulcers and reduce friction and shear are available, and categories include various support surfaces (such as mattresses, integrated bed systems, overlays, and cushions), repositioning, nutritional supplementation, skin care (for example, dressing and management of incontinence), and topical creams (Table 1). Studies have suggested that prevention of hospital-acquired pressure ulcers is more effective than standard care (12). Although this guideline focuses on a comparative effectiveness review of individual interventions, we understand that care teams often implement multicomponent interventions or bundled approaches to preventing pressure ulcers and that pressure ulcer care involves physicians, nurses, and other members of the care team.

Table 1. Pressure Ulcer Preventive Interventions

Table 1. Pressure Ulcer Preventive Interventions
The purpose of this American College of Physicians (ACP) guideline is to present the available evidence on the comparative effectiveness of various risk assessment instruments and benefits and harms of strategies to prevent pressure ulcers. The target audience for this guideline is all clinicians, including physicians, nurses, dieticians, and physical therapists. The target patient population comprises all adults at risk for pressure ulcers. For recommendations on the treatment of pressure ulcers, please refer to the accompanying ACP guideline (13).

Methods

This guideline is based on a systematic evidence review (14), an update of the literature (Supplement), and an evidence report sponsored by the Agency for Healthcare Research and Quality (AHRQ) (17) that addressed the following key questions:
1. Is the use of risk assessment tools effective in reducing the incidence or severity of pressure ulcers, and how does effectiveness vary according to setting and patient characteristics?
2. How do various risk assessment tools compare with one another in their ability to predict the incidence of pressure ulcers?
3. In patients at increased risk for pressure ulcers, what is the effectiveness and comparative effectiveness of preventive interventions in reducing the incidence or severity of pressure ulcers, and how does effectiveness vary according to assessed risk level, setting, or patient characteristics?
4. What are the harms of interventions for preventing pressure ulcers? Do harms differ according to the type of intervention, setting, or patient characteristics?
We searched MEDLINE (1946 through February 2014), CINAHL (1998 through February 2014), the Cochrane Library, clinical trials registries, and reference lists to identify trials published in English. The outcomes evaluated for this guideline include pressure ulcer incidence and severity; resource use (including duration of hospital stay or cost); diagnostic accuracy (sensitivity, specificity, and positive and negative likelihood ratios); measures of risk (hazard ratios, odds ratios, and relative risks); discrimination (area under the receiver-operating characteristic curve); and harms, such as dermatologic reactions, discomfort, and infection.
We also supplemented the AHRQ evidence review with another systematic evidence review of multicomponent strategies for preventing pressure ulcers that examined the importance of contextual aspects of programs that aim to reduce facility-acquired pressure ulcers (16). This review included implementation studies (from 2000 to September 2012) of multicomponent initiatives to prevent pressure ulcers in adults in U.S. acute and long-term care settings. Studies were limited to those that reported pressure ulcer rates at least 6 months after implementation of the intervention.
Further details about the methods and inclusion and exclusion criteria applied in the evidence review are available in the full AHRQ report (15) and the Supplement. This guideline rates the quality of evidence and strength of recommendations by using ACP's guideline grading system (Table 2). Details of the ACP guideline development process can be found in ACP's methods paper (17).

Table 2. The American College of Physicians' Guideline Grading System

Table 2. The American College of Physicians' Guideline Grading System

Comparative Effectiveness of Risk Assessment Tools for Reducing the Incidence or Severity of Pressure Ulcers

Low-quality evidence from 1 good-quality study showed no difference among the Waterlow scale, the Ramstadius tool (an unvalidated combination risk assessment and intervention protocol), and nurses' clinical judgment alone in reducing the risk for pressure ulcers or length of stay in patients (18). A recent Cochrane review supported this conclusion, citing lack of evidence to conclusively show a difference between the risk assessment tools and clinical judgment in reducing pressure ulcer incidence (19). No study evaluated the effectiveness of risk assessment tools across care settings or patient subgroups.

Comparative Diagnostic Accuracy of Risk Assessment Tools for Predicting the Incidence of Pressure Ulcers

Moderate-quality evidence showed that the Braden, Cubbin and Jackson, Norton, and Waterlow scales had low sensitivity and specificity to identify patients at risk for pressure ulcers. In addition, moderate-quality evidence showed that diagnostic accuracy did not differ substantially among the scales (15). Low-quality evidence showed no clear differences in diagnostic accuracy of the Braden scale according to patient characteristics or settings, with lower optimal cutoffs for surgical or acute care patients. Moderate-quality evidence showed no clear differences in diagnostic accuracy of the Braden scale according to baseline pressure ulcer risk. Although the Cubbin and Jackson scale was initially developed for patients in intensive care units, low-quality evidence showed that it had a similar diagnostic accuracy to the Braden and Waterlow scales in this setting (20, 21). Tables 3 and 4 provide descriptions of the scales as well as sensitivities and specificities; more details are available in the full evidence report (15).

Table 3. Descriptions of Commonly Used Pressure Ulcer Risk Assessment Tools

Table 3. Descriptions of Commonly Used Pressure Ulcer Risk Assessment Tools

Table 4. Evidence for Pressure Ulcer Risk Assessment Tools

Table 4. Evidence for Pressure Ulcer Risk Assessment Tools

Evidence Related to Individual Interventions

Effectiveness and Comparative Effectiveness of Preventive Interventions to Reduce the Incidence or Severity of Pressure Ulcers

Many interventions were studied by only 1 trial each, and pooling of studies was not practical because of methodological limitations and clinical diversity of the studies. Table 5 summarizes the evidence for the various preventive interventions. Static (moderate-quality evidence) (55–59) and alternating-air (low-quality evidence) (74–76) mattresses or overlays reduced pressure ulcer incidence compared with standard hospital mattresses. Evidence was mixed or showed no statistically significant difference for comparisons of other support surfaces (61–69, 71–83). Low-quality evidence showed no difference in risk for pressure ulcers or mixed results for heel supports or boots (84, 85), different wheelchair cushions (86–89), nutritional supplementation (90–95), various dressings (101, 102), intraoperative warming (103), and various repositioning intervals (low- to moderate-quality evidence) (96–100, 108, 109). Low-quality evidence showed that a skin cream containing fatty acid and a skin cleanser other than soap decreased risk for pressure ulcers (60, 110, 111).

Table 5. Evidence for Interventions to Reduce Incidence and Severity of Pressure Ulcers

Table 5. Evidence for Interventions to Reduce Incidence and Severity of Pressure Ulcers

Harms of Interventions to Prevent Pressure Ulcers

A total of 16 trials reported harms for interventions to prevent pressure ulcers. Although details on specific harms were sparse, no serious treatment-related harms were reported. In summary, evidence was insufficient to determine how harms of preventive interventions vary according to the type of intervention, care setting, or patient characteristics.

Mattresses, Overlays, and Other Support Systems

Low-quality evidence from 9 studies of support surfaces reported harms. Heat-related discomfort was reported in 3 trials of sheepskin overlays, which also led to withdrawals (56, 57, 60). One trial reported differences in pain and sleep disturbances between different dynamic mattresses (110). A study comparing a multicell pulsating dynamic mattress with a static gel overlay found no differences in risk for adverse events (111). One study reported no increased risk for adverse events with the Heelift Suspension Boot (DM Systems) compared with standard care (84). One study reported an increased risk for withdrawal due to discomfort with the Jay cushion compared with standard wheelchair cushions (88).

Nutritional Supplementation

Low-quality evidence from 1 study reported that tube feeds were poorly tolerated (54% removed within 1 week and 67% removed within 2 weeks) (93).

Repositioning

Low-quality evidence from 2 studies reported increased nonadherence due to intolerability of repositioning at a 30-degree tilt position compared with standard positioning (108, 109).

Dressings

Low-quality evidence from 1 study showed that application of the Remois Pad (Alcare) resulted in pruritus in 1 patient out of 37 total (112).

Creams, Lotions, and Cleansers

Low-quality evidence from 3 studies reported harms for lotions or creams. Two studies reported 1 case each of a wet sore or rash, and 1 study showed no differences in rash between various creams studied (106, 113, 114).

Interventions to Facilitate Implementation of Pressure Ulcer Prevention Protocols or Guidelines

Low-quality evidence from 1 study showed no difference in incident stage 2 to 4 ulcers between a multicomponent electronic clinical decision-support system or provision of guidelines (1.8% vs. 2.1%; relative risk, 0.85 [95% CI, 0.23 to 3.10]) (107). Evidence from 1 poor-quality study showed that immediate implementation of musical cues was associated with lower risk for incident ulcers in nursing home residents (6.0% vs. 9.4%; relative risk, 0.64 [CI, 0.45 to 0.90]) (115).

Evidence Related to Multicomponent Interventions

Multicomponent interventions are increasingly becoming the standard of care for prevention of pressure ulcers. Bundling care practices and organizing a team approach to care have been shown to be effective at improving patient outcomes.

Benefits

Moderate-quality evidence from a review of 26 implementation studies showed that multicomponent interventions can improve skin care and reduce pressure ulcer rates in both acute and long-term care settings (16). The review found that key components of successful interventions include simplification and standardization of pressure ulcer–specific interventions and documentation, involvement of multidisciplinary teams and leadership (including ostomy, continence, and other nurses and personnel), designated skin champions who educate staff about skin care and ulcer prevention, ongoing staff education (including team meetings and motivational campaigns), and sustained audit and feedback (including weekly prevalence reports, formal and informal feedback, and all-facility meetings) (16). Successful interventions also incorporated evidence-based guidelines into their practices.

Harms

The systematic review found no harms reported for the multicomponent strategies that were used to prevent pressure ulcers (16).

Costs

The systematic review identified 4 studies (116–120) that reported significant cost savings with the multicomponent approach. In 2008, a 2-hospital system (548 beds in Naples, Florida) estimated annual cost savings of approximately $11.5 million as a result of statistically significant reductions in pressure ulcer prevalence (117).

Summary

Low-quality evidence showed that risk assessment tools (the Waterlow and Ramstadius scales) were equivalent to clinical judgment alone for reducing pressure ulcer incidence. Evidence on the diagnostic accuracy of the commonly used risk assessment instruments showed that these tools can help in the identification of patients who are at an increased risk for pressure ulcers, although the sensitivities and specificities were low. Diagnostic accuracy did not differ substantially among the various risk assessment instruments, and studies of direct comparisons were limited.
Most of the evidence on preventive interventions came from studies assessing support surfaces. Moderate-quality evidence showed that advanced static mattresses and overlays were associated with a lower risk for pressure ulcers compared with standard mattresses in higher-risk patients. Evidence on other preventive interventions, including nutritional supplementation, lotions, cleansers, and dressings, was limited and inconclusive because most were assessed by few studies.
Little evidence was available on harms of preventive interventions, although no serious harms were reported. Evidence was also insufficient to draw a conclusion about harms based on the type of intervention, care setting, or patient characteristics.
All of the preventive interventions reviewed in this guideline were assessed individually, but they can be bundled to provide optimum care. Evidence shows that multicomponent strategies can improve clinical outcomes. Key components of successful implementation efforts include simplification and standardization of pressure ulcer–specific interventions and documentation, involvement of multidisciplinary teams and leadership, designated skin champions, ongoing staff education, and sustained audit and feedback. The Figure summarizes the recommendations and clinical considerations.
Figure.

Summary of the American College of Physicians guideline on risk assessment and prevention of pressure ulcers.

Recommendations

Recommendation 1: ACP recommends that clinicians should perform a risk assessment to identify patients who are at risk of developing pressure ulcers. (Grade: weak recommendation, low-quality evidence)
Risk assessment is often part of bundled care and multicomponent interventions for preventing pressure ulcers. Risk factors for pressure ulcers include older age; black race or Hispanic ethnicity; lower body weight; cognitive impairment; physical impairments; and other comorbid conditions that affect soft tissue integrity and healing, such as urinary or fecal incontinence, diabetes, edema, impaired microcirculation, hypoalbuminemia, and malnutrition. Clinicians should make individualized decisions based on risk assessment on whether to use a single or multicomponent intervention to prevent pressure ulcers in patients.
The current evidence does not conclusively show a difference between clinical judgment and risk assessment scales in reducing pressure ulcer incidence. However, tools may be especially useful for clinicians without expert gestalt. Moderate-quality evidence showed that the Braden, Cubbin and Jackson, Norton, and Waterlow scales can predict which patients are more likely to develop a pressure ulcer, and all of these instruments have low sensitivity and specificity. In addition, moderate-quality evidence showed that the diagnostic accuracies of the scales do not differ substantially. No study evaluated the effectiveness of risk assessment tools across care settings or patient subgroups.
Recommendation 2: ACP recommends that clinicians should choose advanced static mattresses or advanced static overlays in patients who are at an increased risk of developing pressure ulcers. (Grade: strong recommendation, moderate-quality evidence)
Moderate-quality evidence showed that the use of advanced static mattresses or overlays was associated with a lower risk for pressure ulcers compared with standard hospital mattresses, and no brand was shown to be superior. Advanced static mattresses and overlays are also less expensive than alternating-air or low–air-loss mattresses and can be used as part of a multicomponent approach to pressure ulcer prevention.
Recommendation 3: ACP recommends against using alternating-air mattresses or alternating-air overlays in patients who are at an increased risk of developing pressure ulcers. (Grade: weak recommendation, moderate-quality evidence)
The current evidence does not show a clear benefit for pressure ulcer prevention using alternating-air beds and overlays compared with static mattresses and overlays, and alternating-air beds and overlays are associated with significantly higher costs. Lower-cost support surfaces should be the preferred approach to care.

Inconclusive Areas of Evidence

Evidence is insufficient to compare various preventive interventions, such as different types of repositioning and leg elevations, relative to various kinds of usual care. Creams and lotions, dressings, repositioning, and nutritional support, in any combination, are generally regarded as usual care. Of note, the comparison group in many studies was standard care that often included repositioning, skin care, and/or nutrition. Therefore, any lack of evidence showing benefit relative to the comparison group of usual care does not mean that usual care should be abandoned.

Future Research

Data on the efficacy of many of the interventions came only from single studies, and further research into comparative effectiveness of pressure ulcer prevention strategies is warranted. In addition, more research is needed on the comparative efficacy of pressure ulcer risk assessment tools and their efficacy compared with clinical judgment.

High-Value Care

Prevention of pressure ulcers is the first important step, and advanced static mattresses and overlays were associated with a lower risk for pressure ulcers compared with standard mattresses in higher-risk patients. Many hospitals in the United States use alternating-air and low–air-loss mattresses and overlays despite the lack of evidence showing a potential benefit in the reduction of pressure ulcers in high-risk populations. Using these support systems is expensive and adds unnecessary burden on the health care system. Based on the review of the current evidence, lower-cost support services should be the preferred approach to care.

References

  1. European Pressure Ulcer Advisory Panel
    National Pressure Ulcer Advisory Panel
    Pan Pacific Pressure Injury Alliance
    Prevention and Treatment of Pressure Ulcers: Quick Reference Guide.
    Washington, DC
    National Pressure Ulcer Advisory Panel
    2009
  2. Lyder
    CH
    .  
    Pressure ulcer prevention and management.
    JAMA
    2003
    289
    223
    6
     PubMed
    CrossRef
     PubMed
  3. Pressure ulcers in America: prevalence, incidence, and implications for the future.
    An executive summary of the National Pressure Ulcer Advisory Panel monograph. Adv Skin Wound Care
    2001
    14
    208
    15
     PubMed
  4. VanGilder
    C
    ,  
    Amlung
    S
    ,  
    Harrison
    P
    ,  
    Meyer
    S
    .  
    Results of the 2008–2009 International Pressure Ulcer Prevalence Survey and a 3-year, acute care, unit-specific analysis.
    Ostomy Wound Manage
    2009
    55
    39
    45
     PubMed
     PubMed
  5. Redelings
    MD
    ,  
    Lee
    NE
    ,  
    Sorvillo
    F
    .  
    Pressure ulcers: more lethal than we thought?
    Adv Skin Wound Care
    2005
    18
    367
    72
     PubMed
    CrossRef
     PubMed
  6. Kuhn
    BA
    ,  
    Coulter
    SJ
    .  
    Balancing the pressure ulcer cost and quality equation.
    Nurs Econ
    1992
    10
    353
    9
     PubMed
     PubMed
  7. Russo
    CA
    ,  
    Steiner
    C
    ,  
    Spector
    W
    .  
    Hospitalizations Related to Pressure Ulcers Among Adults 18 Years and Older, 2006. HCUP statistical brief no. 64.
    Rockville, MD
    Agency for Healthcare Research and Quality
    2008
  8. Fogerty
    MD
    ,  
    Abumrad
    NN
    ,  
    Nanney
    L
    ,  
    Arbogast
    PG
    ,  
    Poulose
    B
    ,  
    Barbul
    A
    .  
    Risk factors for pressure ulcers in acute care hospitals.
    Wound Repair Regen
    2008
    16
    11
    8
     PubMed
    CrossRef
     PubMed
  9. Lyder
    C
    ,  
    Ayello
    E
    .  
    Patient Safety and Quality: An Evidence-Based Handbook for Nurses. AHRQ publication no. 08-0043.
    Rockville, MD
    Agency for Healthcare Research and Quality
    2008
    1
    33
  10. Lyder
    CH
    ,  
    Yu
    C
    ,  
    Emerling
    J
    ,  
    Mangat
    R
    ,  
    Stevenson
    D
    ,  
    Empleo-Frazier
    O
    ,  
    et al
    The Braden Scale for pressure ulcer risk: evaluating the predictive validity in Black and Latino/Hispanic elders.
    Appl Nurs Res
    1999
    12
    60
    8
     PubMed
    CrossRef
     PubMed
  11. Baumgarten
    M
    ,  
    Margolis
    DJ
    ,  
    Localio
    AR
    ,  
    Kagan
    SH
    ,  
    Lowe
    RA
    ,  
    Kinosian
    B
    ,  
    et al
    Pressure ulcers among elderly patients early in the hospital stay.
    J Gerontol A Biol Sci Med Sci
    2006
    61
    749
    54
     PubMed
    CrossRef
     PubMed
  12. Padula
    WV
    ,  
    Mishra
    MK
    ,  
    Makic
    MB
    ,  
    Sullivan
    PW
    .  
    Improving the quality of pressure ulcer care with prevention: a cost-effectiveness analysis.
    Med Care
    2011
    49
    385
    92
     PubMed
     PubMed
  13. 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
    162
    370
    9
  14. Chou
    R
    ,  
    Dana
    T
    ,  
    Bougatsos
    C
    ,  
    Blazina
    I
    ,  
    Starmer
    AJ
    ,  
    Reitel
    K
    ,  
    et al
    Pressure ulcer risk assessment and prevention: a systematic comparative effectiveness review.
    Ann Intern Med
    2013
    159
    28
    38
    CrossRef
     PubMed
  15. Chou R, Dana T, Bougatsos C, Blazina I, Starmer A, Reitel K, et al. Pressure Ulcer Risk Assessment and Prevention: Comparative Effectiveness. Comparative effectiveness review no. 87. (Prepared by Oregon Evidence-based Practice Center under contract no. 290-2007-10057-I.) AHRQ publication no. 12(13)-EHC148-EF. Rockville, MD: Agency for Healthcare Research and Quality; 2013. Accessed at www.effectivehealthcare.ahrq.gov/ehc/products/309/1490/pressure-ulcer-prevention-executive-130508.pdf on 5 January 2015.
  16. Sullivan
    N
    ,  
    Schoelles
    KM
    .  
    Preventing in-facility pressure ulcers as a patient safety strategy: a systematic review.
    Ann Intern Med
    2013
    158
    410
    6
    CrossRef
     PubMed
  17. Qaseem
    A
    ,  
    Snow
    V
    ,  
    Owens
    DK
    ,  
    Shekelle
    P
    .  
    Clinical Guidelines Committee of the American College of Physicians
    The development of clinical practice guidelines and guidance statements of the American College of Physicians: summary of methods.
    Ann Intern Med
    2010
    153
    194
    9
    CrossRef
     PubMed
  18. Webster
    J
    ,  
    Coleman
    K
    ,  
    Mudge
    A
    ,  
    Marquart
    L
    ,  
    Gardner
    G
    ,  
    Stankiewicz
    M
    ,  
    et al
    Pressure ulcers: effectiveness of risk-assessment tools. A randomised controlled trial (the ULCER trial).
    BMJ Qual Saf
    2011
    20
    297
    306
     PubMed
    CrossRef
     PubMed
  19. Moore
    ZE
    ,  
    Cowman
    S
    .  
    Risk assessment tools for the prevention of pressure ulcers.
    Cochrane Database Syst Rev
    2014
    2
    CD006471
     PubMed
     PubMed
  20. Boyle
    M
    ,  
    Green
    M
    .  
    Pressure sores in intensive care: defining their incidence and associated factors and assessing the utility of two pressure sore risk assessment tools.
    Aust Crit Care
    2001
    14
    24
    30
     PubMed
    CrossRef
     PubMed
  21. Jun Seongsook
    RN
    ,  
    Jeong Ihnsook
    RN
    ,  
    Lee Younghee
    RN
    .  
    Validity of pressure ulcer risk assessment scales; Cubbin and Jackson, Braden, and Douglas scale.
    Int J Nurs Stud
    2004
    41
    199
    204
     PubMed
    CrossRef
     PubMed
  22. Bergstrom
    N
    ,  
    Braden
    B
    ,  
    Kemp
    M
    ,  
    Champagne
    M
    ,  
    Ruby
    E
    .  
    Predicting pressure ulcer risk: a multisite study of the predictive validity of the Braden Scale.
    Nurs Res
    1998
    47
    261
    9
     PubMed
    CrossRef
     PubMed
  23. Bergstrom
    N
    ,  
    Braden
    BJ
    ,  
    Laguzza
    A
    ,  
    Holman
    V
    .  
    The Braden Scale for predicting pressure sore risk.
    Nurs Res
    1987
    36
    205
    10
     PubMed
    CrossRef
     PubMed
  24. Bergstrom
    N
    ,  
    Demuth
    PJ
    ,  
    Braden
    BJ
    .  
    A clinical trial of the Braden Scale for predicting pressure sore risk.
    Nurs Clin North Am
    1987
    22
    417
    28
     PubMed
     PubMed
  25. Braden
    BJ
    ,  
    Bergstrom
    N
    .  
    Predictive validity of the Braden Scale for pressure sore risk in a nursing home population.
    Res Nurs Health
    1994
    17
    459
    70
     PubMed
    CrossRef
     PubMed
  26. Capobianco
    ML
    ,  
    McDonald
    DD
    .  
    Factors affecting the predictive validity of the Braden Scale.
    Adv Wound Care
    1996
    9
    32
    6
     PubMed
     PubMed
  27. Defloor
    T
    ,  
    Grypdonck
    MF
    .  
    Pressure ulcers: validation of two risk assessment scales.
    J Clin Nurs
    2005
    14
    373
    82
     PubMed
    CrossRef
     PubMed
  28. Goodridge
    DM
    ,  
    Sloan
    JA
    ,  
    LeDoyen
    YM
    ,  
    McKenzie
    JA
    ,  
    Knight
    WE
    ,  
    Gayari
    M
    .  
    Risk-assessment scores, prevention strategies, and the incidence of pressure ulcers among the elderly in four Canadian health-care facilities.
    Can J Nurs Res
    1998
    30
    23
    44
     PubMed
     PubMed
  29. Halfens
    RJ
    ,  
    Van Achterberg
    T
    ,  
    Bal
    RM
    .  
    Validity and reliability of the Braden Scale and the influence of other risk factors: a multi-centre prospective study.
    Int J Nurs Stud
    2000
    37
    313
    9
     PubMed
    CrossRef
     PubMed
  30. Langemo
    DK
    ,  
    Olson
    B
    ,  
    Hunter
    S
    ,  
    Hanson
    D
    ,  
    Burd
    C
    ,  
    Cathcart-Silberberg
    T
    .  
    Incidence and prediction of pressure ulcers in five patient care settings.
    Decubitus
    1991
    4
    25
    6
     PubMed
     PubMed
  31. Lewicki
    LJ
    ,  
    Mion
    LC
    ,  
    Secic
    M
    .  
    Sensitivity and specificity of the Braden Scale in the cardiac surgical population.
    J Wound Ostomy Continence Nurs
    2000
    27
    36
    41
     PubMed
     PubMed
  32. Lyder
    CH
    ,  
    Yu
    C
    ,  
    Emerling
    J
    ,  
    Mangat
    R
    ,  
    Stevenson
    D
    ,  
    Empleo-Frazier
    O
    ,  
    et al
    The Braden Scale for pressure ulcer risk: evaluating the predictive validity in Black and Latino/Hispanic elders.
    Appl Nurs Res
    1999
    12
    60
    8
     PubMed
    CrossRef
     PubMed
  33. Olson
    K
    ,  
    Tkachuk
    L
    ,  
    Hanson
    J
    .  
    Preventing pressure sores in oncology patients.
    Clin Nurs Res
    1998
    7
    207
    24
     PubMed
    CrossRef
     PubMed
  34. Pang
    SM
    ,  
    Wong
    TK
    .  
    Predicting pressure sore risk with the Norton, Braden, and Waterlow scales in a Hong Kong rehabilitation hospital.
    Nurs Res
    1998
    47
    147
    53
     PubMed
    CrossRef
     PubMed
  35. Ramundo
    JM
    .  
    Reliability and validity of the Braden Scale in the home care setting.
    J Wound Ostomy Continence Nurs
    1995
    22
    128
    34
     PubMed
    CrossRef
     PubMed
  36. Salvadalena
    GD
    ,  
    Snyder
    ML
    ,  
    Brogdon
    KE
    .  
    Clinical trial of the Braden Scale on an acute care medical unit.
    J ET Nurs
    1992
    19
    160
    5
     PubMed
     PubMed
  37. Schoonhoven
    L
    ,  
    Haalboom
    JR
    ,  
    Bousema
    MT
    ,  
    Algra
    A
    ,  
    Grobbee
    DE
    ,  
    Grypdonck
    MH
    ,  
    et al
    prePURSE study group
    The prevention and pressure ulcer risk score evaluation study. Prospective cohort study of routine use of risk assessment scales for prediction of pressure ulcers.
    BMJ
    2002
    325
    797
     PubMed
    CrossRef
     PubMed
  38. Baldwin
    KM
    ,  
    Ziegler
    SM
    .  
    Pressure ulcer risk following critical traumatic injury.
    Adv Wound Care
    1998
    11
    168
    73
     PubMed
     PubMed
  39. Barnes
    D
    ,  
    Payton
    RG
    .  
    Clinical application of the Braden Scale in the acute-care setting.
    Dermatol Nurs
    1993
    5
    386
    8
     PubMed
     PubMed
  40. Chan
    EY
    ,  
    Tan
    SL
    ,  
    Lee
    CK
    ,  
    Lee
    JY
    .  
    Prevalence, incidence and predictors of pressure ulcers in a tertiary hospital in Singapore.
    J Wound Care
    2005
    14
    383
    4
     PubMed
    CrossRef
     PubMed
  41. Feuchtinger
    J
    ,  
    Halfens
    R
    ,  
    Dassen
    T
    .  
    Pressure ulcer risk assessment immediately after cardiac surgery—does it make a difference? A comparison of three pressure ulcer risk assessment instruments within a cardiac surgery population.
    Nurs Crit Care
    2007
    12
    42
    9
     PubMed
    CrossRef
     PubMed
  42. Hagisawa
    S
    ,  
    Barbenel
    J
    .  
    The limits of pressure sore prevention.
    J R Soc Med
    1999
    92
    576
    8
     PubMed
     PubMed
  43. Jalali
    R
    ,  
    Rezaie
    M
    .  
    Predicting pressure ulcer risk: comparing the predictive validity of 4 scales.
    Adv Skin Wound Care
    2005
    18
    92
    7
     PubMed
    CrossRef
     PubMed
  44. Kim
    E
    ,  
    Lee
    S
    ,  
    Lee
    E
    ,  
    Eom
    M
    .  
    Comparison of the predictive validity among pressure ulcer risk assessment scales for surgical ICU patients.
    Aust J Adv Nurs
    2009
    26
    87
    94
  45. Kwong
    E
    ,  
    Pang
    S
    ,  
    Wong
    T
    ,  
    Ho
    J
    ,  
    Shao-ling
    X
    ,  
    Li-jun
    T
    .  
    Predicting pressure ulcer risk with the modified Braden, Braden, and Norton scales in acute care hospitals in Mainland China.
    Appl Nurs Res
    2005
    18
    122
    8
     PubMed
    CrossRef
     PubMed
  46. Lyder
    CH
    ,  
    Yu
    C
    ,  
    Stevenson
    D
    ,  
    Mangat
    R
    ,  
    Empleo-Frazier
    O
    ,  
    Emerling
    J
    ,  
    et al
    Validating the Braden Scale for the prediction of pressure ulcer risk in blacks and Latino/Hispanic elders: a pilot study.
    Ostomy Wound Manage
    1998
    44
    42S
    49S
     PubMed
     PubMed
  47. Serpa
    LF
    ,  
    Santos
    VL
    ,  
    Campanili
    TC
    ,  
    Queiroz
    M
    .  
    Predictive validity of the Braden scale for pressure ulcer risk in critical care patients.
    Rev Lat Am Enfermagem
    2011
    19
    50
    7
     PubMed
    CrossRef
     PubMed
  48. Tourtual
    DM
    ,  
    Riesenberg
    LA
    ,  
    Korutz
    CJ
    ,  
    Semo
    AH
    ,  
    Asef
    A
    ,  
    Talati
    K
    ,  
    et al
    Predictors of hospital acquired heel pressure ulcers.
    Ostomy Wound Manage
    1997
    43
    24
    8
     PubMed
     PubMed
  49. VandenBosch
    T
    ,  
    Montoye
    C
    ,  
    Satwicz
    M
    ,  
    Durkee-Leonard
    K
    ,  
    Boylan-Lewis
    B
    .  
    Predictive validity of the Braden Scale and nurse perception in identifying pressure ulcer risk.
    Appl Nurs Res
    1996
    9
    80
    6
     PubMed
    CrossRef
     PubMed
  50. Bergstrom
    N
    ,  
    Braden
    BJ
    .  
    Predictive validity of the Braden Scale among Black and White subjects.
    Nurs Res
    2002
    51
    398
    403
     PubMed
    CrossRef
     PubMed
  51. Lincoln
    R
    ,  
    Roberts
    R
    ,  
    Maddox
    A
    ,  
    Levine
    S
    ,  
    Patterson
    C
    .  
    Use of the Norton Pressure Sore Risk Assessment Scoring System with elderly patients in acute care.
    J Enterostomal Ther
    1986
    13
    132
    8
     PubMed
     PubMed
  52. Stotts
    NA
    .  
    Predicting pressure ulcer development in surgical patients.
    Heart Lung
    1988
    17
    641
    7
     PubMed
     PubMed
  53. Chan
    WH
    ,  
    Chow
    KW
    ,  
    French
    P
    ,  
    Lai
    YS
    ,  
    Tse
    LK
    .  
    Which pressure sore risk calculator?
    A study of the effectiveness of the Norton scale in Hong Kong. Int J Nurs Stud
    1997
    34
    165
    9
     PubMed
  54. Perneger
    TV
    ,  
    Raë
    AC
    ,  
    Gaspoz
    JM
    ,  
    Borst
    F
    ,  
    Vitek
    O
    ,  
    Héliot
    C
    .  
    Screening for pressure ulcer risk in an acute care hospital: development of a brief bedside scale.
    J Clin Epidemiol
    2002
    55
    498
    504
     PubMed
    CrossRef
     PubMed
  55. Gray
    D
    ,  
    Campbell
    M
    .  
    A randomized clinical trial of two types of foam mattresses.
    J Tissue Viability
    1994
    4
    128
    32
    CrossRef
  56. Jolley
    DJ
    ,  
    Wright
    R
    ,  
    McGowan
    S
    ,  
    Hickey
    MB
    ,  
    Campbell
    DA
    ,  
    Sinclair
    RD
    ,  
    et al
    Preventing pressure ulcers with the Australian Medical Sheepskin: an open-label randomised controlled trial.
    Med J Aust
    2004
    180
    324
    7
     PubMed
     PubMed
  57. Mistiaen
    P
    ,  
    Achterberg
    W
    ,  
    Ament
    A
    ,  
    Halfens
    R
    ,  
    Huizinga
    J
    ,  
    Montgomery
    K
    ,  
    et al
    The effectiveness of the Australian Medical Sheepskin for the prevention of pressure ulcers in somatic nursing home patients: a prospective multicenter randomized-controlled trial (ISRCTN17553857).
    Wound Repair Regen
    2010
    18
    572
    9
     PubMed
    CrossRef
     PubMed
  58. Russell
    LJ
    ,  
    Reynolds
    TM
    ,  
    Park
    C
    ,  
    Rithalia
    S
    ,  
    Gonsalkorale
    M
    ,  
    Birch
    J
    ,  
    et al
    PPUS-1 Study Group
    Randomized clinical trial comparing 2 support surfaces: results of the Prevention of Pressure Ulcers Study.
    Adv Skin Wound Care
    2003
    16
    317
    27
     PubMed
    CrossRef
     PubMed
  59. 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
    30
    4
     PubMed
    CrossRef
     PubMed
  60. McGowan
    S
    ,  
    Montgomery
    K
    ,  
    Jolley
    D
    ,  
    Wright
    R
    .  
    The role of sheepskins in preventing pressure ulcers in elderly orthopaedic patients.
    Proceedings of the First World Wound Healing Congress, Melbourne, Australia, 10–13 September 2000. Primary Intention
    2000
    8
    127
    34
  61. Collier
    ME
    .  
    Pressure-reducing mattresses.
    J Wound Care
    1996
    5
    207
    11
     PubMed
     PubMed
  62. Cooper
    PJ
    ,  
    Gray
    DG
    ,  
    Mollison
    J
    .  
    A randomised controlled trial of two pressure-reducing surfaces.
    J Wound Care
    1998
    7
    374
    6
     PubMed
     PubMed
  63. Gray
    DG
    ,  
    Smith
    M
    .  
    Comparison of a new foam mattress with the standard hospital mattress.
    J Wound Care
    2000
    9
    29
    31
     PubMed
    CrossRef
     PubMed
  64. Hampton
    S
    .  
    Efficacy and cost-effectiveness of the Thermo contour mattress.
    Br J Nurs
    1999
    8
    990
    6
     PubMed
    CrossRef
     PubMed
  65. Kemp
    MG
    ,  
    Kopanke
    D
    ,  
    Tordecilla
    L
    ,  
    Fogg
    L
    ,  
    Shott
    S
    ,  
    Matthiesen
    V
    ,  
    et al
    The role of support surfaces and patient attributes in preventing pressure ulcers in elderly patients.
    Res Nurs Health
    1993
    16
    89
    96
     PubMed
    CrossRef
     PubMed
  66. Lazzara
    DJ
    ,  
    Buschmann
    MT
    .  
    Prevention of pressure ulcers in elderly nursing home residents: are special support surfaces the answer?
    Decubitus
    1991
    4
    42
    4
     PubMed
     PubMed
  67. Lim
    R
    ,  
    Sirett
    R
    ,  
    Conine
    TA
    ,  
    Daechsel
    D
    .  
    Clinical trial of foam cushions in the prevention of decubitis ulcers in elderly patients.
    J Rehabil Res Dev
    1988
    25
    19
    26
     PubMed
     PubMed
  68. Sideranko
    S
    ,  
    Quinn
    A
    ,  
    Burns
    K
    ,  
    Froman
    RD
    .  
    Effects of position and mattress overlay on sacral and heel pressures in a clinical population.
    Res Nurs Health
    1992
    15
    245
    51
     PubMed
    CrossRef
     PubMed
  69. Stapleton
    M
    .  
    Preventing pressure sores—an evaluation of three products.
    Geriatr Nurs (Lond)
    1986
    6
    23
    5
     PubMed
     PubMed
  70. Vyhlidal
    SK
    ,  
    Moxness
    D
    ,  
    Bosak
    KS
    ,  
    Van Meter
    FG
    ,  
    Bergstrom
    N
    .  
    Mattress replacement or foam overlay? A prospective study on the incidence of pressure ulcers.
    Appl Nurs Res
    1997
    10
    111
    20
     PubMed
    CrossRef
     PubMed
  71. Inman
    KJ
    ,  
    Sibbald
    WJ
    ,  
    Rutledge
    FS
    ,  
    Clark
    BJ
    .  
    Clinical utility and cost-effectiveness of an air suspension bed in the prevention of pressure ulcers.
    JAMA
    1993
    269
    1139
    43
     PubMed
    CrossRef
     PubMed
  72. Jesurum
    J
    ,  
    Joseph
    K
    ,  
    Davis
    JM
    ,  
    Suki
    R
    .  
    Balloons, beds, and breakdown. Effects of low-air loss therapy on the development of pressure ulcers in cardiovascular surgical patients with intra-aortic balloon pump support.
    Crit Care Nurs Clin North Am
    1996
    8
    423
    40
     PubMed
     PubMed
  73. Theaker
    C
    ,  
    Kuper
    M
    ,  
    Soni
    N
    .  
    Pressure ulcer prevention in intensive care—a randomised control trial of two pressure-relieving devices.
    Anaesthesia
    2005
    60
    395
    9
     PubMed
    CrossRef
     PubMed
  74. Andersen
    KE
    ,  
    Jensen
    O
    ,  
    Kvorning
    SA
    ,  
    Bach
    E
    .  
    Decubitus prophylaxis: a prospective trial on the efficiency of alternating-pressure air-mattresses and water-mattresses.
    Acta Derm Venereol
    1983
    63
    227
    30
     PubMed
     PubMed
  75. Cavicchioli
    A
    ,  
    Carella
    G
    .  
    Clinical effectiveness of a low-tech versus high-tech pressure-redistributing mattress.
    J Wound Care
    2007
    16
    285
    9
     PubMed
    CrossRef
     PubMed
  76. Sanada
    H
    ,  
    Sugama
    J
    ,  
    Matsui
    Y
    ,  
    Konya
    C
    ,  
    Kitagawa
    A
    ,  
    Okuwa
    M
    ,  
    et al
    Randomised controlled trial to evaluate a new double-layer air-cell overlay for elderly patients requiring head elevation.
    J Tissue Viability
    2003
    13
    112
    4
     PubMed
    CrossRef
     PubMed
  77. Conine
    TA
    ,  
    Daechsel
    D
    ,  
    Lau
    MS
    .  
    The role of alternating air and Silicore overlays in preventing decubitus ulcers.
    Int J Rehabil Res
    1990
    13
    57
    65
     PubMed
    CrossRef
     PubMed
  78. Daechsel
    D
    ,  
    Conine
    TA
    .  
    Special mattresses: effectiveness in preventing decubitus ulcers in chronic neurologic patients.
    Arch Phys Med Rehabil
    1985
    66
    246
    8
     PubMed
    CrossRef
     PubMed
  79. Vanderwee
    K
    ,  
    Grypdonck
    MH
    ,  
    Defloor
    T
    .  
    Effectiveness of an alternating pressure air mattress for the prevention of pressure ulcers.
    Age Ageing
    2005
    34
    261
    7
     PubMed
    CrossRef
     PubMed
  80. Demarré
    L
    ,  
    Beeckman
    D
    ,  
    Vanderwee
    K
    ,  
    Defloor
    T
    ,  
    Grypdonck
    M
    ,  
    Verhaeghe
    S
    .  
    Multi-stage versus single-stage inflation and deflation cycle for alternating low pressure air mattresses to prevent pressure ulcers in hospitalised patients: a randomised-controlled clinical trial.
    Int J Nurs Stud
    2012
    49
    416
    26
     PubMed
    CrossRef
     PubMed
  81. Nixon
    J
    ,  
    Cranny
    G
    ,  
    Iglesias
    C
    ,  
    Nelson
    EA
    ,  
    Hawkins
    K
    ,  
    Phillips
    A
    ,  
    et al
    Randomised, controlled trial of alternating pressure mattresses compared with alternating pressure overlays for the prevention of pressure ulcers: PRESSURE (Pressure Relieving Support Surfaces) trial.
    BMJ
    2006
    332
    1413
     PubMed
    CrossRef
     PubMed
  82. Nixon
    J
    ,  
    Nelson
    EA
    ,  
    Cranny
    G
    ,  
    Iglesias
    CP
    ,  
    Hawkins
    K
    ,  
    Cullum
    NA
    ,  
    et al
    PRESSURE Trial Group
    Pressure relieving support surfaces: a randomised evaluation.
    Health Technol Assess
    2006
    10
    1
    163
     PubMed
    CrossRef
  83. Taylor
    L
    .  
    Evaluating the Pegasus Trinova: a data hierarchy approach.
    Br J Nurs
    1999
    8
    771
    4
     PubMed
    CrossRef
     PubMed
  84. Donnelly
    J
    ,  
    Winder
    J
    ,  
    Kernohan
    WG
    ,  
    Stevenson
    M
    .  
    An RCT to determine the effect of a heel elevation device in pressure ulcer prevention post-hip fracture.
    J Wound Care
    2011
    20
    309
    12
     PubMed
    CrossRef
     PubMed
  85. Tymec
    AC
    ,  
    Pieper
    B
    ,  
    Vollman
    K
    .  
    A comparison of two pressure-relieving devices on the prevention of heel pressure ulcers.
    Adv Wound Care
    1997
    10
    39
    44
     PubMed
     PubMed
  86. Brienza
    D
    ,  
    Kelsey
    S
    ,  
    Karg
    P
    ,  
    Allegretti
    A
    ,  
    Olson
    M
    ,  
    Schmeler
    M
    ,  
    et al
    A randomized clinical trial on preventing pressure ulcers with wheelchair seat cushions.
    J Am Geriatr Soc
    2010
    58
    2308
    14
     PubMed
    CrossRef
     PubMed
  87. Conine
    TA
    ,  
    Daechsel
    D
    ,  
    Hershler
    C
    .  
    Pressure sore prophylaxis in elderly patients using slab foam or customized contoured foam wheelchair cushions.
    OTJR (Thorofare N J)
    1993
    13
    101
    16
  88. Conine
    TA
    ,  
    Hershler
    C
    ,  
    Daechsel
    D
    ,  
    Peel
    C
    ,  
    Pearson
    A
    .  
    Pressure ulcer prophylaxis in elderly patients using polyurethane foam or Jay wheelchair cushions.
    Int J Rehabil Res
    1994
    17
    123
    37
     PubMed
    CrossRef
     PubMed
  89. Geyer
    MJ
    ,  
    Brienza
    DM
    ,  
    Karg
    P
    ,  
    Trefler
    E
    ,  
    Kelsey
    S
    .  
    A randomized control trial to evaluate pressure-reducing seat cushions for elderly wheelchair users.
    Adv Skin Wound Care
    2001
    14
    120
    9
     PubMed
    CrossRef
     PubMed
  90. Bourdel-Marchasson
    I
    ,  
    Barateau
    M
    ,  
    Rondeau
    V
    ,  
    Dequae-Merchadou
    L
    ,  
    Salles-Montaudon
    N
    ,  
    Emeriau
    JP
    ,  
    et al
    A multi-center trial of the effects of oral nutritional supplementation in critically ill older inpatients. GAGE Group. Groupe Aquitain Geriatrique d'Evaluation.
    Nutrition
    2000
    16
    1
    5
     PubMed
    CrossRef
     PubMed
  91. Delmi
    M
    ,  
    Rapin
    CH
    ,  
    Bengoa
    JM
    ,  
    Delmas
    PD
    ,  
    Vasey
    H
    ,  
    Bonjour
    JP
    .  
    Dietary supplementation in elderly patients with fractured neck of the femur.
    Lancet
    1990
    335
    1013
    6
     PubMed
    CrossRef
     PubMed
  92. Ek
    AC
    ,  
    Unosson
    M
    ,  
    Larsson
    J
    ,  
    Von Schenck
    H
    ,  
    Bjurulf
    P
    .  
    The development and healing of pressure sores related to the nutritional state.
    Clin Nutr
    1991
    10
    245
    50
     PubMed
    CrossRef
     PubMed
  93. Hartgrink
    HH
    ,  
    Wille
    J
    ,  
    König
    P
    ,  
    Hermans
    J
    ,  
    Breslau
    PJ
    .  
    Pressure sores and tube feeding in patients with a fracture of the hip: a randomized clinical trial.
    Clin Nutr
    1998
    17
    287
    92
     PubMed
    CrossRef
     PubMed
  94. Houwing
    RH
    ,  
    Rozendaal
    M
    ,  
    Wouters-Wesseling
    W
    ,  
    Beulens
    JW
    ,  
    Buskens
    E
    ,  
    Haalboom
    JR
    .  
    A randomised, double-blind assessment of the effect of nutritional supplementation on the prevention of pressure ulcers in hip-fracture patients.
    Clin Nutr
    2003
    22
    401
    5
     PubMed
    CrossRef
     PubMed
  95. Theilla
    M
    ,  
    Singer
    P
    ,  
    Cohen
    J
    ,  
    Dekeyser
    F
    .  
    A diet enriched in eicosapentanoic acid, gamma-linolenic acid and antioxidants in the prevention of new pressure ulcer formation in critically ill patients with acute lung injury: a randomized, prospective, controlled study.
    Clin Nutr
    2007
    26
    752
    7
     PubMed
    CrossRef
     PubMed
  96. Moore
    Z
    ,  
    Cowman
    S
    ,  
    Conroy
    RM
    .  
    A randomised controlled clinical trial of repositioning, using the 30° tilt, for the prevention of pressure ulcers.
    J Clin Nurs
    2011
    20
    2633
    44
     PubMed
    CrossRef
     PubMed
  97. Bergstrom
    N
    ,  
    Horn
    SD
    ,  
    Rapp
    MP
    ,  
    Stern
    A
    ,  
    Barrett
    R
    ,  
    Watkiss
    M
    .  
    Turning for Ulcer ReductioN: a multisite randomized clinical trial in nursing homes.
    J Am Geriatr Soc
    2013
    61
    1705
    13
     PubMed
     PubMed
  98. Vanderwee
    K
    ,  
    Grypdonck
    MH
    ,  
    De Bacquer
    D
    ,  
    Defloor
    T
    .  
    Effectiveness of turning with unequal time intervals on the incidence of pressure ulcer lesions.
    J Adv Nurs
    2007
    57
    59
    68
     PubMed
    CrossRef
     PubMed
  99. Brown
    MM
    ,  
    Cornwell
    J
    ,  
    Weist
    JK
    .  
    Reducing the risks to the institutionalized elderly: part I. Depersonalization, negative relocation effects, and medical care deficiencies. Part II. Fire, food poisoning, decubitus ulcer and drug abuse.
    J Gerontol Nurs
    1981
    7
    401
    7
     PubMed
    CrossRef
     PubMed
  100. Smith
    AM
    ,  
    Malone
    JA
    .  
    Preventing pressure ulcers in institutionalized elders: assessing the effects of small, unscheduled shifts in body position.
    Decubitus
    1990
    3
    20
    4
     PubMed
     PubMed
  101. Brindle
    CT
    ,  
    Wegelin
    JA
    .  
    Prophylactic dressing application to reduce pressure ulcer formation in cardiac surgery patients.
    J Wound Ostomy Continence Nurs
    2012
    39
    133
    42
     PubMed
    CrossRef
     PubMed
  102. Fader
    M
    ,  
    Clarke-O'Neill
    S
    ,  
    Cook
    D
    ,  
    Dean
    G
    ,  
    Brooks
    R
    ,  
    Cottenden
    A
    ,  
    et al
    Management of night-time urinary incontinence in residential settings for older people: an investigation into the effects of different pad changing regimes on skin health.
    J Clin Nurs
    2003
    12
    374
    86
     PubMed
    CrossRef
     PubMed
  103. Scott
    EM
    ,  
    Leaper
    DJ
    ,  
    Clark
    M
    ,  
    Kelly
    PJ
    .  
    Effects of warming therapy on pressure ulcers—a randomized trial.
    AORN J
    2001
    73
    921
    7
     PubMed
    CrossRef
     PubMed
  104. Torra i Bou
    JE
    ,  
    Segovia Gómez
    T
    ,  
    Verdú Soriano
    J
    ,  
    Nolasco Bonmatí
    A
    ,  
    Rueda López
    J
    ,  
    Arboix i Perejamo
    M
    .  
    The effectiveness of a hyperoxygenated fatty acid compound in preventing pressure ulcers.
    J Wound Care
    2005
    14
    117
    21
     PubMed
    CrossRef
     PubMed
  105. Declair
    V
    .  
    The usefulness of topical application of essential fatty acids (EFA) to prevent pressure ulcers.
    Ostomy Wound Manage
    1997
    43
    48
    52
     PubMed
     PubMed
  106. Cooper
    P
    ,  
    Gray
    D
    .  
    Comparison of two skin care regimes for incontinence.
    Br J Nurs
    2001
    10
    S6
     PubMed
    CrossRef
     PubMed
  107. Beeckman
    D
    ,  
    Clays
    E
    ,  
    Van Hecke
    A
    ,  
    Vanderwee
    K
    ,  
    Schoonhoven
    L
    ,  
    Verhaeghe
    S
    .  
    A multi-faceted tailored strategy to implement an electronic clinical decision support system for pressure ulcer prevention in nursing homes: a two-armed randomized controlled trial.
    Int J Nurs Stud
    2013
    50
    475
    86
     PubMed
    CrossRef
     PubMed
  108. Defloor
    T
    ,  
    De Bacquer
    D
    ,  
    Grypdonck
    MH
    .  
    The effect of various combinations of turning and pressure reducing devices on the incidence of pressure ulcers.
    Int J Nurs Stud
    2005
    42
    37
    46
     PubMed
    CrossRef
     PubMed
  109. Young
    T
    .  
    The 30 degree tilt position vs the 90 degree lateral and supine positions in reducing the incidence of non-blanching erythema in a hospital inpatient population: a randomised controlled trial.
    J Tissue Viability
    2004
    14
    88
     PubMed
    CrossRef
     PubMed
  110. Pring
    J
    ,  
    Millman
    P
    .  
    Evaluating pressure-relieving mattresses.
    J Wound Care
    1998
    7
    177
    9
     PubMed
     PubMed
  111. Russell
    L
    ,  
    Reynolds
    TM
    ,  
    Carr
    J
    ,  
    Evans
    A
    ,  
    Holmes
    M
    .  
    Randomised controlled trial of two pressure-relieving systems.
    J Wound Care
    2000
    9
    52
    5
     PubMed
    CrossRef
     PubMed
  112. Nakagami
    G
    ,  
    Sanada
    H
    ,  
    Konya
    C
    ,  
    Kitagawa
    A
    ,  
    Tadaka
    E
    ,  
    Matsuyama
    Y
    .  
    Evaluation of a new pressure ulcer preventive dressing containing ceramide 2 with low frictional outer layer.
    J Adv Nurs
    2007
    59
    520
    9
     PubMed
    CrossRef
     PubMed
  113. Smith
    RG
    ,  
    Everett
    E
    ,  
    Tucker
    L
    .  
    A double blind trial of silicone barrier cream in the prevention of pressure sores in elderly patients.
    Journal of Clinical & Experimental Gerontology
    1986
    7
    337
    46
  114. van der Cammen
    TJ
    ,  
    O'Callaghan
    U
    ,  
    Whitefield
    M
    .  
    Prevention of pressure sores. A comparison of new and old pressure sore treatments.
    Br J Clin Pract
    1987
    41
    1009
    11
     PubMed
  115. Yap
    TL
    ,  
    Kennerly
    SM
    ,  
    Simmons
    MR
    ,  
    Buncher
    CR
    ,  
    Miller
    E
    ,  
    Kim
    J
    ,  
    et al
    Multidimensional team-based intervention using musical cues to reduce odds of facility-acquired pressure ulcers in long-term care: a paired randomized intervention study.
    J Am Geriatr Soc
    2013
    61
    1552
    9
     PubMed
  116. Courtney
    BA
    ,  
    Ruppman
    JB
    ,  
    Cooper
    HM
    .  
    Save our skin: initiative cuts pressure ulcer incidence in half.
    Nurs Manage
    2006
    37
    36
     PubMed
  117. McInerney
    JA
    .  
    Reducing hospital-acquired pressure ulcer prevalence through a focused prevention program.
    Adv Skin Wound Care
    2008
    21
    75
    8
     PubMed
  118. Rosen
    J
    ,  
    Mittal
    V
    ,  
    Degenholtz
    H
    ,  
    Castle
    N
    ,  
    Mulsant
    BH
    ,  
    Hulland
    S
    ,  
    et al
    Ability, incentives, and management feedback: organizational change to reduce pressure ulcers in a nursing home.
    J Am Med Dir Assoc
    2006
    7
    141
    6
     PubMed
  119. Tippet
    AW
    .  
    Reducing the incidence of pressure ulcers in nursing home residents: a prospective 6-year evaluation.
    Ostomy Wound Manage
    2009
    55
    52
    8
     PubMed
  120. Xakellis
    GC
    ,  
    Frantz
    R
    .  
    The cost of healing pressure ulcers across multiple health care settings.
    Adv Wound Care
    1996
    9
    18
    22
     PubMed
Figure.

Summary of the American College of Physicians guideline on risk assessment and prevention of pressure ulcers.

Table 1. Pressure Ulcer Preventive Interventions

Table 1. Pressure Ulcer Preventive Interventions

Table 2. The American College of Physicians' Guideline Grading System

Table 2. The American College of Physicians' Guideline Grading System

Table 3. Descriptions of Commonly Used Pressure Ulcer Risk Assessment Tools

Table 3. Descriptions of Commonly Used Pressure Ulcer Risk Assessment Tools

Table 4. Evidence for Pressure Ulcer Risk Assessment Tools

Table 4. Evidence for Pressure Ulcer Risk Assessment Tools

Table 5. Evidence for Interventions to Reduce Incidence and Severity of Pressure Ulcers

Table 5. Evidence for Interventions to Reduce Incidence and Severity of Pressure Ulcers
PDF Supplemental Content
Supplement. Pressure Ulcer Risk Assessment and Prevention: Update to a Comparative Effectiveness Review

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Risk Assessment and Prevention of Pressure Ulcers

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4 Comments

William V. Padula Ph.D. M.S., C. Tod Brindle R.N. M.S.N. C.W.O.C.N, Mary Beth F. Makic Ph.D. R.N.

WVP: Fellow, Department of Medicine, University of Chicago, Chicago, IL; CTB: Wound Ostomy Continence Nurse, Virginia Commonwealth University Health System, Richmond, VA; MBFM: Associate Professor, Co

March 26, 2015

In Reply: Risk Assessment and Prevention of Pressure Ulcers

TO THE EDITOR: The ACP guidelines by Qaseem and colleagues effectively summarize the strength of evidence supporting pressure ulcer (PrU) prevention, which is only weak to moderate in most cases.(1) We agree with their recommendation that clinicians should risk-assess all hospitalized patients to identify those at-risk for PrUs.(1) How this first step is implemented is important in order to initiate other components of evidence-based practices (EBPs) as indicated by the Wound, Ostomy and Continence Nurses Society (WOCN) as well as the National Pressure Ulcer Advisory Panel (NPUAP), European Pressure Ulcer Advisory Panel (EPUAP), and Pan Pacific Pressure Injury Alliance (PPPIA) in the 2014 International Guidelines for PrU prevention.(2,3)

Qaseem et al. reviewed several risk-assessment instruments, including the Braden, Cubbin and Jackson, Norton, Ramstadius and Waterlow scales, and found that the Braden and Norton scales possessed good quality evidence for prognosis of risk.(1) However, these instruments lacked subscales that would differentiate patient risk on the basis of socio-demographics or clinical setting.

In addition, a recent meta-analysis by Garcia-Fernandez and colleagues found that the Braden Scale has the most validation studies and shows high-capacity to predict PrUs.(3) Good predictive capacity was found for the Norton scale as well.(3) In fact, this meta-analysis of four studies with a pooled sample of 1500 patients determined that clinical judgment alone achieved inadequate PrU risk-assessment.

While current evidence is inconclusive about the direct association between risk-assessment and PrU reductions, the evidence does support the use of validated PrU risk-assessment tools such as Braden or Norton scales in conjunction with clinical judgement.(2-4) The ACP guidelines should not deter any providers from using these instruments, even those with “expert gestalt.” Staff nurses, for instance, should become comfortable using the best-available structured instruments to carry out risk-assessment. Likewise, those with clinical expertise who are revered by others of less experience should strive to establish a benchmark for best-practices in quality improvement by synergizing their judgment with the strengths of risk-assessment instruments.(5)

Clinical practice guidelines such as these preventive recommendations from the ACP need to align providers with national best-practices and the use of structured instruments even when the science to support their use is continuing to grow and strengthen. As the field of nursing continues to investigate improved population-based risk-assessment instruments as part of EBPs, training providers to use structured instruments as opposed to clinical judgment will make a transition to modern instruments more seamless.

REFERENCES

1. 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.

2. National Pressure Ulcer Advisory Panel (NPUAP), European Pressure Ulcer Advisory Panel (EPUAP) and Pan Pacific Pressure Injury Alliance (PPPIA). Prevention and Treatment of Pressure Ulcers: Clinical Practice Guideline. Emily Haesler (Ed.). Cambridge Media: Perth, Australia; 2014.

3. Ratliff CR, Tomaselli N. WOCN update on evidence-based guideline for pressure ulcers. J Wound Ostomy Continence Nurs. 2010; 37(5):459-60.

4. Garcia-Fernandez FP, Pancorbo-Hidalgo PL, Agreda JS. Predictive capacity of risk assessment scales and clinical judgement for pressure ulcers: a meta-analysis. J Wound Ostomy Continence Nurs. 2014; 41(1): 24-34.

5. Padula WV, Mishra MK, Makic MB, Valuck RJ. A framework of quality improvement interventions to implement evidence-based practices for pressure ulcer prevention. Adv Skin Wound Care. 2014 Jun; 27(6): 280-284.

Jill Monfre PhD RN CWOCN, Justin Endo MD

Dr. Endo: Assistant Professor, Department of Dermatology, University of Wisconsin; Dr. Monfre: Clinical Nurse Specialist, University of Wisconsin Hospital and Clinics

April 2, 2015

In Reply: Risk Assessment

The American College of Physicians (ACP) has improved physician awareness with their pressure ulcer (PrU) guidelines. We agree with the comments from Padula et al. in response to the ACP guidelines. The collaboratively published guideline by the European Pressure Ulcer Advisory Panel (EPUAP), National Pressure Ulcer Advisory Panel (NPUAP), and the Pan Pacific Pressure Injury Alliance (PPPIA) is an excellent, comprehensive and updated reference. (1)
While we await further research, what should our role as internists be in PrU management, and what can the ACP do to help us implement best practice based on limited evidence?
In a study by Cox et al., two-thirds of surveyed physicians believed that their role was important in preventing PrU, but less than half reported feeling adequately trained during residency. (2) Less than 40% ever attended a continuing education program or lecture about PrU. Over 80% of physicians did not understand the purpose of a pressure redistribution mattresses. This survey suggests that physicians might benefit from receiving general background information about PrU in addition to the granular recommendations of published clinical guidelines. We hope that ACP continues to work to fill this practical knowledge gap, which, in turn, might help physicians co-manage PrU and communicate with interdisciplinary wound care teams.

References
1. European Pressure Ulcer Advisory Panel NPUAP, Pan Pacific Pressure Injury Alliance, 2014;Pages. Accessed at Cambridge Media at http://www.npuap.org/wp-content/uploads/2014/08/Updated-10-16-14-Quick-Reference-Guide-DIGITAL-NPUAP-EPUAP-PPPIA-16Oct2014.pdf.
2. Cox J, Roche S, Gandhi N. Critical care physicians: attitudes, beliefs, and knowledge about pressure ulcers. Adv Skin Wound Care. 2013;26(4):168-76.

Todd J. Kowalski, MD, Michelle L. Tilson, CWOCN, Sonya A. Brickner, CWOCN, CFCN

Gundersen Health System

April 9, 2015

In Reply: Risk assessment and prevention of pressure ulcers: a clinical practice guideline from the American College of Physicians

TO THE EDITOR: The American College of Physicians clinical practice guidelines for prevention, assessment, and treatment of pressure ulcers (1, 2) highlight the dearth of evidence available to guide clinicians and health systems. This is salient because pressure ulcers have been coined “never events.” Since 2008 Centers for Medicare & Medicaid Services (CMS) has withheld reimbursement for treatment of hospital-acquired stage III and IV pressure ulcers, but—in contrast to other disease states for which evidence strongly suggests that better processes yield better outcomes—pressure ulcer rates have not improved (3). Furthermore, 100% of expert voting attendees at a recent National Pressure Ulcer Advisory Panel (NPUAP) consensus conference believe that patient situations may render pressure ulcers unavoidable (4).
More surprising is the tenuous evidence upon which the staging system used for pressure ulcers is based, in particular the NPUAP pressure ulcer stage of “Suspected Deep Tissue Injury (DTI)–depth unknown.” In 2007, the NPUAP added the DTI stage in order to engender more aggressive treatment interventions. At that time not a single published study validated the definition or outlined the prognostic significance of the newly defined entity. Since then, research suggests that < 1% of skin lesions labeled “DTI” by certified wound nurses may progress to stage III ulcers (5). Expert wound diagnosticians attending a 2007 NPUAP consensus conference achieved only 60% accuracy when classifying pressure ulcers and associated dermal lesions using the new definitions. Documentation and diagnosis of DTI is further obscured because no ICD-9 nor ICD-10 codes are specific to DTI. The NPUAP recommends that DTI be coded as “pressure ulcer, unstageable”; however, the Agency for Healthcare Research and Quality considers hospital-acquired unstageable pressure ulcers a Patient Safety Indicator (PSI)—a reflection of quality of care. In turn, PSI data are used by the CMS Value-Based Purchasing program to determine whether to pay or withhold payment for services. Thus, DTI documentation not only conveys uncertain clinical ramifications but also may result in adverse quality and fiscal metrics for hospital systems. Overall, these findings highlight that pressure ulcers ought not be utilized as hospital-based quality measures until evidence-based interventions that yield improved outcomes are available, particularly when public reporting and financial sanctions may be tied to them. We recommend that DTI undergo rigorous study before it is considered a distinct clinical entity and that the condition not be associated with any quality or reimbursement metrics.

Todd J. Kowalski, MD
Michelle L. Tilson, CWOCN
Sonya A. Brickner. CWOCN, CFCN
Gundersen Health System
La Crosse, WI 54601

References
1. 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;162(5):359-69. [PMID: 25732278]
2. 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;162(5):370-9. [PMID: 25732279]
3. Waters TM, Daniels MJ, Bazzoli GJ, Perencevich E, Dunton N, Staggs VS, et al. Effect of Medicare's nonpayment for hospital-acquired conditions: lessons for future policy. JAMA Intern Med. 2015;175(3):347-54. [PMID: 25559166]
4. Black JM, Edsberg LE, Baharestani MM, Langemo D, Goldberg M, McNichol L, et al. Pressure ulcers: avoidable or unavoidable? Results of the National Pressure Ulcer Advisory Panel Consensus Conference. Ostomy Wound Manage. 2011;57(2):24-37. [PMID: 21350270]
5. Sullivan R. A two-year retrospective review of suspected deep tissue injury evolution in adult acute care patients. Ostomy Wound Manage. 2013;59(9):30-9. [PMID: 24018390]


Amir Qaseem, MD, PhD, Mary Ann Forciea, MD, Linda Humphrey, MD, MPH

ACP, Univeristy of Pennsylvania, Oregon Health and Science University

August 12, 2015

Author's Response

As Dr. Padula rightfully pointed out, the evidence is inconclusive to link specific pressure ulcer risk assessment tools with outcomes such as reduced pressure ulcers. We also found insufficient evidence to determine the superiority of any one tool over the others or over clinical gestalt for predicting the development of pressure ulcers. The ACP guideline does not recommend against using pressure ulcer risk assessment tools, nor is the intent to discourage this practice. However, in the absence of evidence, we cannot promote the use of these tools over clinical judgment and leave the decision of risk assessment up to the care provider.

Dr. Kowalski brings up the important point that developing performance measures for many chronic conditions, such as preventing pressure ulcers, is challenging. We agree that performance measures should be based on robust scientific evidence in the areas that shows clinical benefit rather than on statistical data or expert opinion.


Mary Ann Forciea, MD, FACP
University of Pennsylvania Health System, Philadelphia, PA

Linda L. Humphrey, MD, MPH, MACP
Oregon Health and Science University, Portland, OR

Amir Qaseem, MD, PhD, MHA, FACP
American College of Physicians, Philadelphia, PA

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Qaseem A, Mir TP, Starkey M, et al, for the 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;162:359–369. doi: https://doi.org/10.7326/M14-1567

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Published: Ann Intern Med. 2015;162(5):359-369.

DOI: 10.7326/M14-1567

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