The Joint Commission Journal on Quality and Patient Safety

Adverse Events

Pressure Ulcers and Prevention Among Acute Care Hospitals

in the United States
Sandra Bergquist-Beringer, PhD, RN, CWCN; Lei Dong, MS; Jianghua He, PhD; Nancy Dunton, PhD, FAAN

H ospital-acquired pressure ulcers are a known problem in

acute care facilities and the focus of national policy
and patient safety initiatives within the United States. Pressure
Article-at-a-Glance
ulcers reduce patient quality of life,1 are associated with higher Background: Most pressure ulcers can be prevented with
in-hospital mortality,2,3 and contributed $1.99 billion in evidence-based practice. Many studies describe the imple-
excess health care costs for Medicare patients between 2007 and mentation of a pressure ulcer prevention program but few re-
2009.4 port the effect on outcomes across acute care facilities.
Efforts to prevent pressure ulcers have intensified during the Methods: Data on hospital-acquired pressure ulcers and
past decade through programs such as the Institute for Health- prevention from the National Database of Nursing Quality
care Improvement’s (IHI) 5 Million Lives Campaign to protect Indicators® 2010 Pressure Ulcer Surveys were linked to hos-
patients from harm5; the selection of pressure ulcers as a National pital characteristics and nurse staffing measures within the
Patient Safety Goal by The Joint Commission (for long term data set. The sample consisted of 1,419 hospitals from across
care)6; the implementation of the Centers for Medicare & Med- the United States and 710,626 patients who had been sur-
icaid (CMS) nonpayment policy for hospital-acquired condi- veyed for pressure ulcers in adult critical care, step-down,
tions, including stage III and IV pressure ulcers7; and the medical, surgical, and medical/surgical units. Hierarchical
inclusion of pressure ulcers in the Partnership for Patients initia- logistic regression analysis was performed to identify study
tive to improve the safety of hospital care.8 Updated clinical prac- variables associated with hospital-acquired pressure ulcers
tice guidelines on pressure ulcer prevention from the National among patients at risk for these ulcers.
Pressure Ulcer Advisory Panel (NPUAP)/European Pressure Results: The rate of hospital-acquired pressure ulcers was
Ulcer Advisory Panel and the Wound, Ostomy and Continence 3.6% across all surveyed patients and 7.9% among those at
Nurses Society were also published.9,10 These guidelines provide risk. Patients who received a skin and pressure ulcer risk as-
evidence-based recommendations for practice that include a skin sessment on admission were less likely to develop a pressure
and pressure ulcer risk assessment on admission, regular reassess- ulcer. Additional study variables associated with lower hos-
ment of pressure ulcer risk, and interventions to minimize pa- pital-acquired pressure ulcer rates included a recent reassess-
tient risk, such as regular skin assessment, support surface use, ment of pressure ulcer risk, higher Braden Scale scores, a
routine repositioning, nutritional support, and skin moisture recent skin assessment, routine repositioning, and Magnet
management. More recently, “Multicomponent interventions to or Magnet-applicant designation. Variables associated with
reduce pressure ulcers” was 1 of the 10 patient safety strategies a higher likelihood of hospital-acquired pressure ulcers in-
strongly encouraged, on the basis the evidence, “for adoption cluded nutritional support, moisture management, larger
now.”11 hospital size, and academic medical center status.
The literature contains myriad studies on pressure ulcer pre- Conclusions: Results provide empirical support for pres-
vention, many of which describe the implementation of inter- sure ulcer prevention guideline recommendations on skin
ventions to prevent pressure ulcers in acute care facilities. Three assessment, pressure ulcer risk assessment, and routine repo-
recent reviews found that the majority of these studies reported sitioning, but the 7.9% rate of hospital-acquired pressure ul-
a positive effect of the intervention(s) on pressure ulcer outcomes cers among at-risk patients suggests room for improvement
such as lower pressure ulcer incidence or nosocomial pressure in pressure ulcer prevention practice.
ulcer rates.12–14 However, most were single-hospital studies. Fur-

404 September 2013 Volume 39 Number 9

Copyright 2013 © The Joint Commission

 The Joint Commission Journal on Quality and Patient Safety

ther, the relationship between each intervention in a multifaceted pressure ulcers. The study also describes the rate of hospital-ac-
prevention program and the outcome were not examined.12 Few quired pressure ulcers for first through fourth quarters in 2010
of the studies measured the effect on care processes12–14 such as to extend our report of 2010 rates published in the NPUAP
the percentage of patients who received a skin assessment within 2012 monograph Pressure Ulcers: Prevalence, Incidence, and
24 hours of admission. Nor were these effects uniformly Implications for the Future,21 which was limited to the first and
reported,13 limiting comparison across studies. Moreover, nurse second quarters.
staffing and other organizational characteristics that might
influence the success of the prevention interventions were not Methods
evaluated.13 STUDY DESIGN
The National Database of Nursing Quality Indicators® This was a retrospective study using first- through fourth-
(NDNQI®) is the largest nursing quality registry in the United quarter 2010 data on patient pressure ulcers and prevention, hos-
States15 from which pressure ulcer prevention performance and pital characteristics, and nurse staffing from NDNQI–partici-
its influence on pressure ulcer outcomes can be examined.* The pating hospitals in the United States. The year 2010 was selected
database was established by the American Nurses Association in for analysis because this was the last year for which full data were
1998 with twin goals: (1) to provide participating hospitals with available at the time of extraction.
unit-based data and comparative information on patient out-
come indicators, including pressure ulcers, for use in quality im- DATA ON PRESSURE ULCERS
provement activities; and (2) to develop a data repository for NDNQI data on patient pressure ulcers included the number
research related to the impact of nurse staffing on these out- and category/stage of hospital-acquired pressure ulcers, assess-
comes.16,17 Participation in the NDNQI is voluntary and sup- ment of pressure ulcer risk, and interventions to prevent pressure
ported by membership fees. As of January 2013, the NDNQI ulcers. The data for these measures were gathered quarterly by
received data from 1,909 hospitals in the United States and 17 trained nursing staff located at each NDNQI hospital during a
hospitals outside the United States.18 For this study, only hospi- cross-sectional survey (NDNQI Pressure Ulcer Survey) that was
tals in the United States are considered. performed on a single day.
Development of the NDNQI was based on Donabedian’s Categorization and Staging of Identified Pressure Ulcers. The
quality framework,19 which posits that the structure and skin of patients on each participating unit was visually examined
processes of care influence patient outcomes.20 The NDNQI during the NDNQI Pressure Ulcer Survey. Pressure ulcers de-
began collecting data on pressure ulcer processes of care in tected were categorized/staged using NPUAP criteria,9 then clas-
2000–2001 with select items on pressure ulcer risk assessment. sified as hospital-acquired or community-acquired. A pressure
Additional process-of-care measures were added in 2003, 2007, ulcer was determined to be hospital-acquired when review of the
and 2009, and existing items were revised. The full set of process patient’s medical record revealed no documentation of the pres-
measures now includes eight items on pressure ulcer risk assess- sure ulcer on admission to the facility.
ment and six items on pressure ulcer prevention interventions. To improve the accuracy of data on hospital-acquired pres-
Importantly, the NDNQI database contains uniform informa- sure ulcers, NDNQI guidelines stipulate that nursing staff be
tion on patient pressure ulcer risk and prevention interventions trained in pressure ulcer identification and staging prior to sur-
from numerous nursing units, which can be linked to structural vey procedures.22 An educational program was developed by the
measures within the data set, such as hospital bed size and nurse NDNQI to facilitate this training and released online. Modules
staffing, and to pressure ulcer outcomes. within the educational program are updated routinely and freely
The purpose of this study was (1) to examine the frequency available to anyone for review.23 Reliability studies on NDNQI
of pressure ulcer risk assessment and prevention interventions pressure ulcer data found that nurses had moderate to near per-
among patients at risk for pressure ulcers in NDNQI–partici- fect reliability in pressure ulcer identification and staging.24,25 Par-
pating hospitals, and (2) to identify patient pressure ulcer risk as- ticipating hospitals are also encouraged to confirm acceptable
sessment and prevention interventions, hospital characteristics, interreliability of pressure ulcer identification and staging among
and nurse staffing measures associated with hospital-acquired their survey team members at least annually.
Pressure Ulcer Risk and Prevention. Specific measures of pres-
* The NDNQI is a program of the American Nurses Association’s (ANA) National
Center for Nursing Quality. The program is being administered on ANA’s behalf by
sure ulcer risk assessment included patient skin assessment on
the University of Kansas School of Nursing. admission (yes/no), patient pressure ulcer risk assessment on ad-

September 2013 Volume 39 Number 9 405

Copyright 2013 © The Joint Commission

 The Joint Commission Journal on Quality and Patient Safety

mission (yes/no), time since the last pressure ulcer risk assess- DATA ANALYSIS
ment, which is an estimate of the frequency of pressure ulcer risk The analysis of the first through fourth quarter 2010
reassessments, and the total Braden Scale26 score on last assess- NDNQI data on pressure ulcers, hospital characteristics, and
ment. These data were captured by chart review during the nurse staffing was limited to adult critical care, step-down, med-
NDNQI Pressure Ulcer Survey. Time since the last risk assess- ical, surgical, and medical/surgical units (the studied units) for
ment was dichotomized for the analysis (> 0 hours to 24 hours comparison with previous analysis.21 Most of the pressure ulcer
or > 24 hours to 1 week) on the basis of the IHI recommenda- data are submitted by these units, and at least 90% of the pa-
tion that hospitalized patients be reassessed for pressure ulcer tients on each unit receive the level of care appropriate to the
risk as least daily.5 Measures of prevention interventions con- unit type by definition in NDNQI guidelines for participation.22
sisted of daily skin assessment, pressure-redistribution surface Descriptive statistics were used to summarize the data on pa-
use, routine repositioning, nutritional support, and moisture tient pressure ulcer risk assessment and prevention interventions,
management. Routine repositioning was defined as the time inter- hospital characteristics, and nurse staffing. The rate of hospital-
val for patient repositioning/turning identified in the patient acquired pressure ulcers among all surveyed patients was defined
plan of care or in unit policy for at-risk patients. Nutritional sup- as the proportion of patients with a hospital-acquired pressure
port referred to the provision of oral, parenteral, or enteral nutri- ulcer in the studied units among all patients surveyed in these
tion as recommended by clinical practice guidelines for pressure units. The rate of hospital-acquired pressure ulcers among pa-
ulcer prevention.9,10 Moisture management was defined as actions tients at risk for pressure ulcers (at-risk patients) was defined as
performed to protect patient skin from excessive moisture or dry- the proportion of at-risk patients with a hospital-acquired pres-
ness. sure ulcer in the studied units among all at-risk patients surveyed
Intervention use during the 24-hour period before the in these units.
NDNQI Pressure Ulcer Survey was determined from review of Hierarchical logistic regression models were constructed with
documentation in the patient record. The response options for SAS 9.2 (SAS Institute, Inc., Cary, North Carolina) using the
these intervention measures are unique to the NDNQI and in- GLIMMIX procedure to estimate the odds ratio (OR), 95%
clude “yes” and “no,” as well as “documented contraindication,” confidence interval (CI), and statistical significance (p < .05) for
“unnecessary for patient,” and “patient refused,” which were a hospital-acquired pressure ulcer among at-risk patients (n =
added to improve the validity of the yes/no responses and quan- 282,500). Hierarchical logistic regression analysis takes into ac-
tify situations that may make the pressure ulcer unavoidable. count the nested nature of patients within units and units within
hospitals to generate inferences.28 Three models were constructed
DATA ON HOSPITAL CHARACTERISTICS AND NURSE so that each subsequent model added a set of measures to those
STAFFING included in the previous model, as follows:
Data on hospital characteristics and nurse staffing were stud- ■ Model 1 included patient-level data on pressure ulcer risk

ied because effective pressure ulcer prevention is influenced by assessment and prevention interventions.
the organizational culture and operational practices that pro- ■ Model 2 added hospital-level data on hospital size, Magnet

mote these practices.27 NDNQI data on hospital characteristics status, and teaching status.
included hospital size, which was defined as the total number of ■ Model 3 added unit-level data on nurse staffing.

staffed beds in the hospital; Magnet status; and teaching status. Both RN hours per patient-day and RN skill mix were centered
Magnet status recognizes hospitals that achieved Magnet desig- at their mean by unit type for the analysis to control for the pos-
nation by the American Nurses Credentialing Center relative to sible confounding between nurse staffing measures and unit
applicants for this designation and non-Magnet hospitals. Hos- type.
pitals self-classify as an academic medical center if the facility is
the primary clinical site for a school of medicine, a teaching hos- Results
pital if the facility has medical interns or residents, or a non- DESCRIPTION OF THE SAMPLE
teaching hospital.22 Measures of nurse staffing included registered Nearly one quarter of all hospitals in the United States29 partic-
nurse (RN) hours per patient day and RN skill mix, which was ipated in the NDNQI Pressure Ulcer Surveys during 2010 (N =
defined as the percentage of total nursing hours provided by 1,419 participating hospitals). Hospital distribution by size,
RNs. teaching status, and Magnet status (Table 1, page 407) was sim-
ilar to the first and second quarter 2010 results.21 Data from

406 September 2013 Volume 39 Number 9

Copyright 2013 © The Joint Commission

 The Joint Commission Journal on Quality and Patient Safety

Table 1. Hospital Characteristics and Nurse Staffing Measures*

Hospital Characteristics (N = 1,419 Hospitals) n Percentage of 1,419 Hospitals

Hospital Size (# of staffed beds)†
< 100 300 21.1
100–199 411 29.0
200–299 286 20.2
300–399 191 13.5
400–499 109 7.7
> 500 122 8.6
Type
Academic medical center 149 10.5
Teaching 482 34.0
Non-teaching 788 55.5
Magnet Status†
Magnet 326 23.0
Magnet-applicant 255 18.0
Non-Magnet 838 59.1
RN Hours per Patient Day RN Skill Mix
Nurse Staffing Measures (N = 10,261 Nurses) Mean (SD) Mean Percentage (SD)
All units 8.48 (4.37) 74.1 (13.3)
Critical care units 15.33 (2.73) 90.4 (7.1)
Step-down units 7.73 (1.96) 74.2 (9.9)
Medical units 5.84 (1.69) 66.7 (10.1)
Surgical units 6.09 (1.44) 68.3 (9.5)
Medical/Surgical units 5.94 (1.55) 67.6 (10.0)

* RN Skill Mix, percentage of all nursing hours supplied by registered nurses; SD, standard deviation.
† Because of rounding, percentages may total > 100%.

10,405 hospital units were analyzed. Nursing hours on these units (2.6%). Quarterly variations were also observed. The rate
units were largely supplied by RNs—up to 90.4% in critical care of hospital-acquired pressure ulcers was 4.0% in Quarter 1,
units. Mean RN hours per patient-day ranged from 5.84 in med- 3.6% in Quarter 2, 3.5% in Quarter 3, and 3.5% in Quarter 4.
ical units to 15.33 in critical care units. A total of 710,626 pa- The 25,928 patients with a hospital-acquired pressure ulcer had
tients were surveyed for pressure ulcers in the studied units. Like 36,758 pressure ulcers. The distribution of pressure ulcers by
our previous findings,21 52.0% of the patients were female, and category/stage is shown in Table 2 (page 408).
63 years old on average (standard deviation [SD] = 17.65).
RATE OF HOSPITAL-ACQUIRED PRESSURE ULCERS,
HOSPITAL-ACQUIRED PRESSURE ULCER RATES AMONG PRESSURE ULCER RISK ASSESSMENT, AND PREVENTION
ALL SURVEYED PATIENTS INTERVENTIONS AMONG PATIENTS AT RISK FOR
The rate of hospital-acquired pressure ulcers among all sur- PRESSURE ULCERS
veyed patients was 3.6% (n = 25,928 patients). Exclusion of Nearly 40% of the 710,626 patients surveyed were deter-
known pressure ulcers under nonremovable dressings that could mined to be at risk for pressure ulcers (n = 282,500 from 1,407
not be staged and mucosal pressure ulcers that should not be hospitals) on the basis of the last Braden Scale score (90.5%) or
staged30 reduced this proportion by another 0.1%. other clinical factors (9.5%). The overall rate of hospital-ac-
Hospital-acquired pressure ulcers rates were highest in criti- quired pressure ulcers among at-risk patients was 7.9%. When
cal care units (8.1%) relative to step-down units (3.7%), med- known pressure ulcers under nonremovable dressings that could
ical units (3.1%), surgical units (2.4%), and medical/surgical not be staged and mucosal pressure ulcers that should not be

September 2013 Volume 39 Number 9 407

Copyright 2013 © The Joint Commission

 The Joint Commission Journal on Quality and Patient Safety

Table 2. Distribution of Hospital-Acquired Pressure Ulcers by Category/Stage Among Patients in

NDNQI–Participating Hospitals During 2010*

All Surveyed Patients Patients at Pressure Ulcer Risk

Category/Stage (% of 36,758 Pressure Ulcers)† (% of 31,998 Pressure Ulcers)‡
Stage I 27.9 26.2
Stage II 41.8 42.2
Stage III 4.5 4.7
Stage IV 1.8 2.0
Unstageable 10.3 10.9
sDTI 12.1 12.4
Under nonremovable dressing, mucosal 1.6 1.6

* sDTI, suspected deep tissue injury.

† The 25,928 patients with a hospital-acquired pressure ulcer had 36,758 pressure ulcers.
‡ The 22,295 patients with a hospital-acquired pressure ulcer had 31,998 pressure ulcers.

staged30 were removed from this count, the rate of hospital-ac- tients. For 7,791 patients (2.8%), a pressure-redistribution sur-
quired pressure ulcers was 7.7%. The 22,295 patients with a hos- face was deemed unnecessary for the patient, implying that this
pital-acquired pressure ulcer had 31,998 pressure ulcers. Their intervention was considered for implementation but, on review
distribution by category/stage was similar to the distribution ob- of the patient’s risk factors, it was determined the intervention
served for all surveyed patients (Table 2). was not needed. Approximately 75% of at-risk patients (76.8%)
Most of the 282,500 patients who were at risk for pressure were routinely repositioned during the 24-hour period before
ulcers had received timely admission skin and pressure ulcer risk the NDNQI Pressure Ulcer Survey; however, activities to man-
assessments, suggesting that these evaluations have been inte- age moisture were performed for just 64.8% of these patients.
grated into usual routines and practices. Specifically, 92.9% of Only 56.3% of at-risk patients received nutritional support;
at-risk patients received a skin assessment, and 92.6% of at-risk 19.1% did not. The proportion of patients who refused one or
patients received a pressure ulcer risk assessment within 24 hours more of these interventions was very small (0.1%–0.4%).
of admission. A similar 94.2% were reassessed for pressure ulcer
risk during the 24-hour period before the NDNQI Pressure PRESSURE ULCER RISK ASSESSMENT AND PREVENTION
Ulcer Survey. The average Braden Scale score on last assessment INTERVENTIONS, HOSPITAL CHARACTERISTICS, AND
was 15.24 (n = 255,928 patients with Braden Scale scores; SD NURSE STAFFING MEASURES ASSOCIATED WITH
= 2.82); the median score was 16. When classified by Braden HOSPITAL-ACQUIRED PRESSURE ULCERS AMONG
Scale risk level,31 2.7% of the 255,928 patients in our study with AT-RISK PATIENTS
Braden Scale scores had a score of 9 or less, indicating that they Hierarchical regression modeling of pressure ulcer risk assess-
were at very high risk for pressure ulcers, 14.8% had a score of ment and prevention interventions associated with hospital-ac-
10 to 12 (high risk); 20.0% had a score of 13 to 14 (moderate quired pressure ulcers (Model 1) revealed that patients who
risk); 55.0% had a score of 15 to 18 (mild risk); and 7.5% had received a skin assessment on admission (OR = 0.73, CI = 0.65
a score of 19 to 23 (no risk). to 0.83) or a pressure ulcer risk assessment on admission (OR =
The frequency of interventions to prevent pressure ulcers var- 0.80, CI = 0.72 to 0.90), or were reassessed for pressure ulcer
ied among at-risk patients. More precisely, 89.6% of at-risk pa- risk during the 24 hours before the NDNQI Pressure Ulcer Sur-
tients received a skin assessment for pressure ulcers during the vey (OR = 0.85, CI = 0.80 to 0.90) were less likely to develop a
24-hour period before the NDNQI Pressure Ulcer Survey; 1.2% pressure ulcer (Table 4, page 410). The odds of a hospital-ac-
did not (Table 3, page 409). For 117 patients (0.04%), this in- quired pressure ulcer decreased 12% for each 1-point increase
tervention was not performed because of a documented con- in the total Braden Scale score (OR = 0.88, CI = 0.88 to 0.89).
traindication. However, contextual data to explain the Daily skin assessment (OR = 0.81, CI = 0.71 to 0.91) and rou-
contraindication were not available for study analysis. A pres- tine repositioning (OR = 0.85, CI = 0.81 to 0.90) were also as-
sure-redistribution surface was in use for 81.8% of at-risk pa- sociated with lower likelihood of hospital-acquired pressure

408 September 2013 Volume 39 Number 9

Copyright 2013 © The Joint Commission

 The Joint Commission Journal on Quality and Patient Safety

Table 3. Pressure Ulcer Prevention Interventions Among At-Risk Patients at Risk for Pressure Ulcers (N = 282,500)

Frequency by Response Option (%)

Documented Unnecessary Patient

Type of Prevention Intervention Yes No Contraindication for Patient Refused
Daily skin assessment* 253,045 (89.6) 3,527 (1.2) 117 (0.04)
Pressure-redistribution surface use† 231,209 (81.8) 22,690 (8.0) 272 (0.1) 7,791 (2.8) 292 (0.1)
Routine repositioning‡ 216,972 (76.8) 23,032 (8.2) 653 (0.2) 19,277 (6.8) 989 (0.4)
Nutritional support§ 159,033 (56.3) 53,979 (19.1) 3,983 (1.4) 31,524 (11.2) 521 (0.2)
Moisture management|| 183,154 (64.8) 28,457 (10.1) 316 (0.1) 32,367 (11.5) 181 (0.1)
* Missing data on 25,811 patients (9.1%).
† Missing data on 20,246 patients (7.2%).
‡ Missing data on 21,577 patients (7.6%).
§ Missing data on 33,460 patients (11.8%).
|| Missing data on 38,025 patients (13.5%).

ulcers. Interestingly, patients for whom pressure-redistribution sure ulcers for the first through fourth quarters in 2010 and the
surface use, routine repositioning, nutritional support, or mois- frequency of pressure ulcer risk assessment and prevention in-
ture management were deemed unnecessary had lower hospital- terventions in a large sample of NDNQI–participating hospi-
acquired pressure ulcer rates, suggesting that nurses appropriately tals from across the United States and examined their
identified needless interventions. relationships, including nurse staffing measures. Our reported
Prevention interventions significantly associated with higher hospital-acquired pressure ulcer rate of 3.6% among all surveyed
hospital-acquired pressure ulcer rates included nutritional sup- patients in adult critical care, step-down, medical, surgical, and
port (OR = 1.59, CI = 1.52 to 1.66) and moisture management medical/surgical units is lower than the 3.8% for the first and
(OR = 1.09, CI = 1.03 to 1.15). Patients for whom daily skin as- second quarters of 2010 and the 6.5% rate for 2006–2007
sessment was contraindicated (OR = 2.60, CI = 1.50 to 4.49) (fourth and first quarters) found in previous analysis of NDNQI
and those who refused repositioning (OR = 1.76, CI = 1.43 to data from these unit types.21 Seasonal variations in hospital-ac-
2.15) were also more likely to have a hospital-acquired pressure quired pressure ulcers with higher first-quarter rates were also
ulcer. observed and likely explain the difference between the 3.6% rate
The odds of a hospital-acquired pressure ulcer for pressure for all four quarters in 2010 and the 3.8% rate for the first and
ulcer risk assessment and prevention interventions remained re- second quarter only. Seasonality in hospital-acquired pressure
markably stable when hospital characteristics (Model 2) and ulcer rates was also reported by He et al.,32 with winter months
nurse staffing measures (Model 3) were added to the regression (January–March) being highest and summer months (July–Sep-
analysis. In the fully adjusted model (Model 3), the likelihood of tember) being lowest during 2004–2008. Although the magni-
pressure ulcer development was significantly higher among larger tude of these fluctuations diminished after 2008 as hospital-
hospitals (OR = 1.08, CI = 1.06 to 1.09) and academic medical acquired pressure ulcers decreased, the first-quarter rates during
centers relative to nonteaching hospitals (OR = 1.25, CI = 1.18 2009–2011 remained higher than the other quarters for reasons
to 1.31). In contrast, the likelihood of hospital-acquired pres- that have yet to be elucidated but may be related to seasonal vari-
sure ulcers was significantly lower in Magnet hospitals (OR = ations in patient volume and acuity relative to nurse staffing
0.68, CI = 0.65 to 0.71) and those applying for Magnet status levels.32
(OR = 0.73, CI = 0.70 to 0.77) when compared with non-Mag- The overall downward trend in facility-acquired pressure ul-
net hospitals. RN hours per patient-day and RN skill mix were cers since 2006–2007 was noted in other large database studies
not associated with hospital-acquired pressure ulcers after con- that compared these rates over time. Data from the 2006–2009
trolling for all other variables in the model. International Pressure Ulcer Prevalence Surveys showed that fa-
cility-acquired pressure ulcer rates among hospitals in the United
Discussion States decreased from 6.4% in 2006 and 2007 to 5.0% in
In this study, we investigated the rate of hospital-acquired pres- 2009.33,34 Among acute care facilities participating in the Collab-

September 2013 Volume 39 Number 9 409

Copyright 2013 © The Joint Commission

 The Joint Commission Journal on Quality and Patient Safety

Table 4. Pressure Ulcer Risk Assessment and Prevention Interventions, Hospital Measures, and Nurse Staffing Measures
Associated with Hospital-Acquired Pressure Ulcers Among At-Risk Patients in NDNQI–Participating Hospitals*

Model 3. Risk and Prevention

Model 1. Risk and Model 2. Risk and Prevention Interventions, Hospital
Prevention Interventions, and Characteristics, and
Interventions† Hospital Characteristics‡ Nurse Staffing§
Measures Odds 95% CI P Value|| Odds 95% CI P Value|| Odds 95% CI P Value||
Risk and Prevention Interventions
Skin assessment on admission 0.73 (0.65–0.83) < .001 0.75 (0.67–0.85) < .001 0.76 (0.67–0.87) < .001
Risk assessment on admission 0.80 (0.72–0.90) < .001 0.82 (0.73–0.91) < .001 0.82 (0.73–0.92) <. 001
Risk reassessment in last 24 hours 0.85 (0.80–0.90) < .001 0.88 (0.83–0.94) < .001 0.87 (0.81–0.92) < .001
Last Braden Scale score 0.88 (0.88–0.89) < .001 0.88 (0.88–0.89) < 001 0.88 (0.88–0.89) < .001
Daily skin assessment
Yes 0.81 (0.71–0.91) < .001 0.83 (0.73–0.94) .003 0.82 (0.72–0.94) .003
Documented contraindication 2.60 (1.50–4.49) < .001 2.68 (1.55–4.63) < .001 2.84 (1.64–4.95) < .001
Pressure-redistribution surface use
Yes 1.01 (0.95–1.07) .79 0.99 (0.93–1.05) .76 1.00 (0.94–1.07) . 97
Documented contraindication 0.91 (0.54–1.55) .74 0.87 (0.51–1.47) .59 0.87 (0.50–1.50) .61
Unnecessary for patient 0.48 (0.40–0.57) < .001 0.48 (0.40–0.57) < .001 0.46 (0.39–0.55) < .001
Patient refused 1.25 (0.81–1.93) .31 1.29 (0.84–1.98) .25 1.30 (0.82–2.06) .27
Routine repositioning
Yes 0.85 (0.81–0.90) < .001 0.87 (0.82–0.92) < .001 0.86 (0.81–0.92) <. 001
Documented contraindication 0.79 (0.57–1.08) .14 0.79 (0.57–1.09) .15 0.80 (0.57–1.11) .18
Unnecessary for patient 0.67 (0.60–0.74) < .001 0.67 (0.61–0.74) < .001 0.69 (0.62–0.77) < .001
Patient refused 1.76 (1.43–2.15) < .001 1.79 (1.46–2.19) < .001 1.78 (1.43–2.20) < .001
Nutritional support
Yes 1.59 (1.52–1.66) < .001 1.56 (1.50–1.64) < .001 1.58 (1.51–1.66) < .001
Documented contraindication 0.86 (0.75–1.00) .05 0.83 (0.72–0.95) .009 0.81 (0.70–0.95) .007
Unnecessary for patient 0.84 (0.78–0.91) < .001 0.84 (0.77–0.90) < .001 0.84 (0.78–0.91) < .001
Patient refused 1.04 (0.74–1.48) .81 1.04 (0.73–1.48) .83 1.15 (0.80–1.65) .45
Moisture management
Yes 1.09 (1.03–1.15) .004 1.07 (1.02–1.14) .01 1.06 (1.00–1.13) .04
Documented contraindication 0.86 (0.52–1.43) .57 0.85 (0.52–1.41) .54 0.97 (0.57–1.66) .91
Unnecessary for patient 0.72 (0.66–0.78) < .001 0.73 (0.67–0.79) < .001 0.73 (0.67–0.80) < .001
Patient refused 0.74 (0.39–1.41) .36 0.73 (0.38–1.39) .34 0.74 (0.38–1.46) .39
Hospital Characteristics
Bed size (no. of staffed beds) 1.07 (1.06–1.09) < .001 1.08 (1.06–1.09) < .001
Teaching status
Academic medical center 1.26 (1.20–1.33) < .001 1.25 (1.18–1.31) < .001
Teaching hospital 1.02 (0.98–1.06) .39 1.01 (0.97–1.05) .57
Magnet status
Magnet 0.69 (0.66–0.72) < .001 0.68 (0.65–0.71) < .001
Magnet-applicant 0.77 (0.74–0.80) < .001 0.73 (0.70–0.77) < .001
Nurse Staffing Measures
RN hours per patient-day 1.01 (0.99–1.02) .34
RN skill mix 1.21 (0.98–1.50) .08

* The National Database of Nursing Quality Indicators® (NDNQI®) CI, confidence interval; RN skill mix, percentage of all nursing hours supplied by registered nurses.
† n = 212,823 patients, 17,356 patients with a hospital-acquired pressure ulcer.
‡ n = 212,823 patients, 17,356 patients with a hospital-acquired pressure ulcer.

§
n = 192,109 patients, 15,487 patients with a hospital-acquired pressure ulcer.
|| p < .05 = statistical significance.

410 September 2013 Volume 39 Number 9

Copyright 2013 © The Joint Commission

 The Joint Commission Journal on Quality and Patient Safety

orative Alliance for Nursing Outcomes (CALNOC) data reg- pressure ulcer have multiple risk factors not captured in stan-
istry, hospital-acquired pressure ulcers decreased from 7.0% in dard assessment tools. Collectively, these findings suggest that
2006 and 6.2% in 2007 to 2.8% in 2009 and 1.8% in 2010.35 an evidenced-based program of pressure ulcer prevention tai-
More recent evidence suggests that hospital-acquired pressure lored to patient risk factors, identified through review of pressure
ulcers continue to decline.32,36 These findings likely reflect the ef- ulcer risk assessment tool subscale scores and other clinical fac-
fect of national initiatives to reduce pressure ulcer occurrence tors, should be promptly implemented for all hospitalized pa-
and the usefulness of routine monitoring for quality improve- tients determined to be at pressure ulcer risk.
ment purposes to lower these rates. The 1.8% rate of hospital- Only 56.3% to 89.6% of the at-risk patients received inter-
acquired pressure ulcers observed in CALNOC 2010 survey data ventions to prevent pressure ulcers recommended by clinical
was notably lower than the 3.6% rate for 2010 from NDNQI practice guidelines,9,10 during the 24-hour period before the
survey data and is probably due to differences in the participat- NDNQI Pressure Ulcer Survey. For another 2.8% to 11.5% of
ing hospitals. Most of the CALNOC study hospitals (97%) were these patients, the intervention was deemed unnecessary. The
located in California; only 14% were larger facilities with a daily 1.4% of at-risk patients with a documented contraindication to
census of 300 or more. In contrast, NDNQI–participating hos- nutritional support was lower than expected because food or flu-
pitals were from across the United States, and 29.8% had 300 ids are often withheld after midnight (NPO) in preparation for
staffed beds or higher. Significant regional variations in pressure surgery or diagnostic procedures in the morning. Results sug-
ulcer rates were reported by Lyder et al.,3 with the highest inci- gest room for improvement in pressure ulcer prevention but
dence in the northeastern United States. We found that larger should be interpreted with caution, given the 7.2% to 13.5% of
hospital size was associated with higher pressure ulcer rates. missing data across interventions. Strategies to improve survey
Most hospital-acquired pressure ulcers were stage I and stage completion of the prevention intervention items should be em-
II pressure ulcers. In contrast, stage III and stage IV pressure ul- ployed, including more detailed instructions for selecting nutri-
cers together accounted for 6.3% of all pressure ulcers; 22.4% of tional support response options.
the pressure ulcers were unstageable and suspected deep tissue in- Hierarchical regression modeling revealed that patients who
jury (sDTI). When totaled, the proportion of full-thickness pres- received a skin assessment on admission, a pressure ulcer risk as-
sure ulcers (stage III, stage IV, and unstageable ulcers) was sessment on admission, or a skin assessment within the 24-hour
16.6%, and the proportion of stage III and stage IV ulcers, un- period before the survey, or were reassessed for pressure ulcer risk
stageable ulcers, and sDTI (full thickness pressure ulcers/injuries) during this period, were less likely to acquire a pressure ulcer.
was 28.7%. These results suggest that adverse event reports that Findings support clinical practice recommendations for skin and
include only stage III and stage IV pressure ulcers underestimate pressure ulcer risk assessments to prevent pressure ulcers.5,9,10 As
the overall rate of full-thickness tissue loss/injury from pressure with previous studies,41,42 higher Braden Scale scores were asso-
by 62.0% to 78.0%. The 12.1% of sDTI was greater than the ciated with lower pressure ulcers rates.
7.0% to 10.9% previously reported21,37 and warrants further in- Routine repositioning reduced the odds for hospital-acquired
vestigation. pressure ulcers by 14%, and this study is one of only a few stud-
The rate of hospital-acquired pressure ulcers was substantially ies that have confirmed this association.43–46 The regression analy-
higher (7.9%) among patients at risk for pressure ulcers. By risk sis controlled for redistribution surface use, risk level (Braden
level, approximately one half of these patients were at mild risk Scale score), hospital characteristics, and nurse staffing measures,
(Braden Scale score, 15 to 18); another 20.0% were at moder- whereas previous investigations were smaller-sample studies that
ate risk (Braden Scale score, 13 to 14). Maklebust and Magnan38 may not have accounted for these factors. Because data on repo-
found that nurses had difficulty determining which preventive sitioning frequency were not available for our analysis, future re-
interventions should be deployed for patients with Braden Scale search should examine the relationship between the
scores of 13 to 18. Consequently, patients at mild risk or mod- repositioning interval and hospital-acquired pressure ulcer oc-
erate risk may be more vulnerable to pressure ulceration than currence. Although the number of at-risk patients who refused
their risk assessment indicates. Consideration of the individual routine repositioning was small, the positive association with
risk factors (subscales) within the Braden Scale and related sub- hospital-acquired pressure ulcers supports the need for patient
scale scores was recommended for pressure ulcer prevention and family education on pressure ulcer prevention and the con-
planning.39 Other studies, such as those conducted by Bry et al.40 sequences of noncompliance with the prevention program.47
and Lyder et al.,3 showed that patients with a hospital-acquired We found no significant association between pressure-redis-

September 2013 Volume 39 Number 9 411

Copyright 2013 © The Joint Commission

 The Joint Commission Journal on Quality and Patient Safety

tribution surface use and the rate of hospital-acquired pressure vious studies using NDNQI data on nurse staffing and pressure
ulcers among patients at risk for pressure ulcers in adult critical ulcer outcomes showed that an increase in RN hours per patient-
care, step-down, medical, surgical, and medical/surgical units. day was associated with higher hospital-acquired pressure ulcer
Although heterogeneity in the support surface used may have rates and that an increase in RN skill mix was associated with
confounded the relationship, Rich et al.48 reported similar results lower rates.32,58 Differences between study results may be related
for powered and nonpowered support surface use in older pa- to sampling and other methodological variations. Although our
tients with hip fracture. Among pediatric intensive care patients, analysis adjusted for Braden Scale scores, which estimate patient
however, and postoperative patients at high pressure ulcer risk, risk for pressure ulcers, the findings may also reflect uncontrolled
support surface use decreased pressure ulcer development.45,49 measures of patient acuity that attenuated the association to
Several previous studies that have described the implementation nonsignificance. Lake et al.59 showed that NDNQI hospitals
of interventions to prevent pressure ulcers reported equipping cared for more complex Medicare patients than the average
all beds in a unit or the hospital with pressure-redistribution hospital.
mattresses.50–53 If common practice, there may not have been
enough variability in pressure-redistribution surface use to detect LIMITATIONS
an association with hospital-acquired pressure ulcers. Research to replicate this study in non-NDNQI–participat-
The positive relationship between nutritional support and ing hospitals is needed, as the sample of hospitals were volunteer
hospital-acquired pressure ulcers and the positive relationship members of the NDNQI, and results may not generalize to all
between moisture management and hospital-acquired pressure hospitals in the United States. Also, hospital-acquired pressure
ulcers were not expected. These results likely reflect the cross- ulcers by state and United States region were not evaluated, lim-
sectional approach to data collection on prevention interven- iting comparison with studies that report these rates. Magnet
tions that limited temporal inferences and may indicate that hospitals were overrepresented relative to their national distri-
these interventions were implemented after the hospital-acquired bution, as were large hospitals, although the proportion of
pressure ulcer was discovered. Jankowski et al.52 found that timely smaller hospitals with less than 200 staffed beds participating in
access and appropriate use of barrier ointment, skin protection the NDNQI has grown over time.21 The regression analysis did
wipes, and moisturizers were persistent challenges to prevention not control for age, sex, or unit type, which are worthy variables
program initiatives. but were not included in the modeling because all hospitalized
The higher rate of pressure ulcers among at-risk patients in patients should be assessed for pressure ulcer risk and all at-risk
larger hospitals and academic medical centers likely reflects pa- patients should receive prevention interventions. Furthermore,
tient acuity within the institutions. Trauma and complexly ill study methods limited the report to discussion of associations
patients are often transferred or directly admitted to these types rather than causation.
of facilities because they are better equipped to care for sicker
patients. The odds of having a hospital-acquired pressure ulcer Conclusions
were 32% lower for at-risk patients in Magnet hospitals and 27% Findings from this study of NDNQI–participating hospitals in
lower for at-risk patients in Magnet-applicant hospitals relative the United States identified a 3.6% first through fourth quarter
to non-Magnet hospitals after adjusting for study covariates 2010 rate of hospital-acquired pressure ulcers among all surveyed
(Table 4, Model 3). These effect sizes are surprising large, con- patients in adult critical care, step-down, medical, surgical, and
sidering that previous studies reported lower hospital-acquired medical/surgical units, which was lower than the 6.5% rate for
pressure ulcer rates for only Magnet in-process hospitals (p < 2006–2007 (fourth and first quarter) previously reported. Al-
.05),54 modestly lower rates in Magnet hospitals (p < .10),55 or no though recent evidence suggests that hospital-acquired pressure
significant difference between Magnet and non-Magnet hospi- ulcers continue to decline, subsequent research should deter-
tals in pressure ulcer rates.32,56 Notably, the earlier evidence was mine if the downward trend in these rates can be sustained. To
from Magnet hospitals that predated 2007 revisions to the Mag- the authors’ best knowledge, this is the first study to examine
net model for greater focus on exemplary professional practice the association of pressure ulcer risk assessment and prevention
and the expectation for better patient outcomes.57 interventions with hospital-acquired pressure ulcers across acute
RN hours per patient-day and RN skill mix were not mean- care facilities in the United States. Results provide empirical ev-
ingfully associated with hospital-acquired pressure ulcers after idence for pressure ulcer prevention guideline recommendations
controlling for all other variables in the model. In contrast, pre- on skin assessment, pressure ulcer risk assessment, and routine

412 September 2013 Volume 39 Number 9

Copyright 2013 © The Joint Commission

 The Joint Commission Journal on Quality and Patient Safety

repositioning to reduce pressure ulcer occurrence among hospi- 8. Centers for Medicare & Medicaid Services. Partnership for Patients. Accessed
Jul 17, 2013. http://innovation.cms.gov/initiatives/Partnership-for-Patients/.
talized patients and support for Braden Scale use among these 9. National Pressure Ulcer Advisory Panel (NPUAP), European Pressure Ulcer
patients. Although the study’s results are encouraging, much Advisory Panel. Prevention and Treatment of Pressure Ulcers: Clinical Practice
work remains to reduce the rate of hospital-acquired pressure ul- Guideline. Washington, DC: NPUAP, 2009.
10. Ratliff CR, Tomaselli N; Guideline Task Force. Guideline for Prevention and
cers among at-risk patients, which was 7.9%. Strategies to im-
Management of Pressure Ulcers. Mount Laurel, NJ: Wound, Ostomy and Con-
prove the proportion of at-risk patients who receive pressure tinence Nurses Society, 2010.
ulcer prevention interventions should be employed to reduce 11. Shekelle PG, et al. The top patient safety strategies that can be encouraged
this rate. Future studies are needed to establish the temporal re- for adoption now. Ann Intern Med. 2013 Mar 5;158(5 Pt 2):365–368.
12. Niederhauser A, et al. Comprehensive programs for preventing pressure ul-
lationship between pressure ulcer prevention and hospital-ac- cers: A review of the literature. Adv Skin Wound Care. 2012;25(4):167–188.
quired pressure ulcers, with attention to individual intervention 13. Soban LM, et al. Preventing pressure ulcers in hospitals: A systematic review
use and the hospital characteristics and nurse staffing measures of nurse-focused quality improvement interventions. Jt Comm J Qual Patient
Saf. 2011;37(6):245–252.
that may influence these relationships. J
14. Sullivan N, Schoelles KM. Preventing in-facility pressure ulcers as a patient
safety strategy: A systematic review. Ann Intern Med. 2013 Mar 5;158(5 Pt
2):410–416.
Sandra Bergquist-Beringer, PhD, RN, CWCN, is Associate Profes-
15. American Nurses Association. The National Database. Accessed Jul 17,
sor and NDNQI Pressure Ulcer Consultant, School of Nursing, Univer-
2013. http://www.nursingworld.org/MainMenuCategories/ThePracticeofPro-
sity of Kansas Medical Center, Kansas City. Lei Dong, MS, is Senior
fessionalNursing/PatientSafetyQuality/Research-Measurement/The-National-
Research Analyst, Department of Biostatistics, and Data Manager,
Office of Scholarly, Academic & Research Mentoring, University of
Database.aspx.
Kansas Medical Center. Jianghua He, PhD, is Associate Professor, 16. Montalvo I. The National Database of Nursing Quality Indicators®
Department of Biostatistics, University of Kansas Medical Center. (NDNQI®). Online J Issues Nurs. 2007;12(3):2.
Nancy Dunton, PhD, FAAN, is Research Professor and NDNQI Prin- 17. Dunton NE. Take a cue from the NDNQI. Nurs Manage. 2008;39(4):20,
cipal Investigator, School of Nursing, University of Kansas Medical 22–23.
Center. Please address correspondence to Sandra Bergquist- 18. Montalvo I, Dunton N, Quigley P. Reducing patient falls & injuries: Drive
Beringer, sbergquist-beringer@kumc.edu. quality improvement with NDNQI® data. Web presentation at the meeting of
the Partnership for Patients®, Jan 14, 2013.
19. Donabedian A. The quality of care: How can it be assessed? JAMA. 1998
Sep 23–30;260(12):1743–1748.
References 20. Dunton N, et al. Nurse staffing and patient falls on acute care hospital units.
1. Gorecki C, et al. Impact of pressure ulcers on quality of life in older patients: Nurs Outlook. 2004;52(1):53–59.
A systematic review. J Am Geriatr Soc. 2009;57(7):1175–1183. 21. Bergquist-Beringer S, Gajewski BJ, Davidson J. Pressure ulcer prevalence
2. Agency for Healthcare Research and Quality, Healthcare Cost and Utilization and incidence: Report from the National Database of Nursing Quality Indica-
Project (HCUP). Hospitalizations related to pressure ulcers among adults 18 tors® (NDNQI®). In Pieper B, editor; National Pressure Ulcer Advisory Panel
years and older, 2006. Statistical Brief 64. Russo C, Steiner C, Spector W. Dec (NPUAP): Pressure Ulcers: Prevalence, Incidence, and Implications for the Future,
2008. Accessed Jul 17, 2013. http://www.hcup-us.ahrq.gov/reports 2nd ed. Washington, DC: NPUAP, 2012, 175–187.
/statbriefs/sb64.pdf 22. American Nurses Association, National Database of Nursing Quality Indi-
3. Lyder, CH et al. Hospital-acquired pressure ulcers: Results from the national cators®. NDNQI® Guidelines for Data Collection and Submission on Pressure
Medicare Patient Safety Monitoring System Study. J Am Geriatr Soc. Ulcers. 2012. Accessed Jul 17, 2013. https://www.nursingquality.org.
2012;60(9):1603–1608. 23. Bergquist-Beringer S, Davidson J. National Database of Nursing Quality In-
4. Reed K, May R. The Eighth Annual HealthGrades Patient Safety in American dicators: Pressure Ulcer Training. 2012. American Nurses Association. Accessed
Hospitals Study. Denver: Health Grades, Inc., Mar 2011. Accessed Jul 17, 2013. Jul 17, 2013. http://www.nursingquality.org/NDNQIPressureUlcerTraining/.
https://www.cpmhealthgrades.com/CPM/assets/File/HealthGradesPatient 24. Hart S, et al. Reliability testing of the National Database of Nursing Qual-
SafetyInAmericanHospitalsStudy2011.pdf. ity Indicators pressure ulcer indicator. J Nurs Care Qual. 2006;21(3):256–265.
5. Institute for Healthcare Improvement. Protecting 5 Million Lives from 25. Bergquist-Beringer S, et al. The reliability of the National Database of Nurs-
Harm: Overview. Accessed Jul 17, 2013. http://www.ihi.org/offerings/Initia- ing Quality Indicators pressure ulcer indicator: A triangulation approach. J Nurs
tives/PastStrategicInitiatives/5MillionLivesCampaign/Pages/default.aspx. Care Qual. 2011;26(4);292–301.
6. The Joint Commission. The Joint Commission announces the 2006 Na- 26. Bergstrom N, et al. The Braden Scale for predicting pressure sore risk. Nurs
tional Patient Safety Goals and requirements. Jt Comm Perspect. 2005;25(7): Res. 1987;36(4):205–210.
1–10. 27. Agency for Healthcare Research and Quality. Preventing Pressure Ulcers in
7. Centers for Medicare & Medicaid Services. Preventable Hospital-Acquired Hospitals: A Toolkit for Improving Quality of Care. Apr 2011. Accessed Jul 17,
Conditions (HACs), Including Infections. In Medicare Program; Changes to 2013. http://www.ahrq.gov/research/ltc/pressureulcertoolkit/.
the Hospital Inpatient Prospective Payment Systems for Acute Care Hospitals 28. Wong GY, Mason WM. The hierarchical logistic regression model for mul-
and Fiscal Year 2010 Rates; and Changes to the Long-Term Care Hospital tilevel analysis. Journal of the American Statistical Association. 1985;80(391):
Prospective Payment System and Rate Years 2010 and 2009 Rates. Fed Regist. 513–524.
2009 Aug 27;74(165):43782–43783. Accessed Jul 17, 2013. https://www 29. American Hospital Association. Fast Facts on US Hospitals. (Updated: Jan
.federalregister.gov/articles/2009/08/27/E9-18663/medicare-program-changes 3, 2013.) Accessed Jul 17, 2013. http://www.aha.org/research/rc/stat-studies
-to-the-hospital-inpatient-prospective-payment-systems-for-acute-care#p-837. /fast-facts.shtml.

September 2013 Volume 39 Number 9 413

Copyright 2013 © The Joint Commission

 The Joint Commission Journal on Quality and Patient Safety

30. National Pressure Ulcer Advisory Panel. Mucosal Pressure Ulcers: An prevention planning: What’s the connection. J Wound Ostomy Continence Nurs.
NPUAP Position Statement. 2009. Accessed Jul 17, 2013. 2009;36(6):622–634.
h t t p : / / w w w. n p u a p. o r g / w p - c o n t e n t / u p l o a d s / 2 0 1 2 / 0 3 / Mu c o s a l 40. Bry KE, Buescher D, Sandrik M. Never say never: A descriptive study of
_Pressure_Ulcer_Position_Statement_final.pdf hospital-acquired pressure ulcers in a hospital setting. J Wound Ostomy Conti-
31. Braden BJ, Maklebust J. Preventing pressure ulcers with the Braden Scale: nence Nurs. 2012;39(3):274–281.
An update on this easy-to-use tool that assesses a patient’s risk. Am J Nurs. 41. Bergstrom N, et al. Multi-site study of incidence of pressure ulcers and the
2005;105(6):70–72. relationship between risk level, demographic characteristics, diagnoses, and pre-
32. He J, et al. Unit-level time trends and seasonality in the rate of hospital-ac- scription of preventive interventions. J Am Geriatr Soc. 1996;44(1):22–30.
quired pressure ulcers in US acute care hospitals. Res Nurs Health. 2013;36(2): 42. Bergstrom N, et al. Predicting pressure ulcer risk: A multisite study of the
171–180. predictive validity of the Braden Scale. Nurs Res. 1998;47(5):261–269.
33. VanGilder C, et al. Body mass index, weight, and pressure ulcer prevalence: 43. Defloor T, De Bacquer D, Grypdonck MH. The effect of various combi-
An analysis of the 2006-2007 International Pressure Ulcer Prevalence Surveys. nations of turning and pressure reducing devices on the incidence of pressure
J Nurs Care Qual. 2009;24(2):127–135. ulcers. Int J Nurs Stud. 2005;42(1):37–46.
34. VanGilder C, et al. Results of the 2008-2009 International Pressure Ulcer 44. Kaitani T, et al. Risk factors related to the development of pressure ulcers
Prevalence Survey and a 3-year, acute care, unit-specific analysis. Ostomy Wound in the critical care setting. J Clin Nurs. 2010;19(3-4):414–421.
Manage. 2009 Nov 1;55(11):39–45. 45. Schindler CA, et al. Protecting fragile skin: Nursing interventions to de-
35. Stotts N, et al. Eliminating hospital-acquired pressure ulcers: Within our crease development of pressure ulcers in pediatric intensive care. Am J Crit Care.
reach. Adv Skin Wound Care. 2013;26(1):13–18. 2011;20(1):26–35.
36. VanGilder C et al. Overall results from the 2011 International Pressure 46. Moore Z, Cowman S, Conroy RM. A randomised controlled clinical trial
Ulcer Prevalence (IPUP) Survey [Abstract]. J Wound Ostomy Continence Nurs. of repositioning, using the 30° tilt for the prevention of pressure ulcers. J Clin
2012;39(3 Suppl):S3–4. Nurs. 2011;20(17–18):2633–2644.
37. VanGilder C, et al. The demographics of suspected deep tissue injury in 47. Black JM, et al. Pressure ulcers: Avoidable or unavoidable? Results of the Na-
the United States: An analysis of the International Pressure Ulcer Prevalence tional Pressure Ulcer Advisory Panel Consensus Conference. Ostomy Wound
Survey 2006-2009. Adv Skin Wound Care. 2010;23(6):254–261. Manag. 2011;57(2):24–37.
38. Maklebust J, Magnan MA. A quasi-experimental study to assess the effect 48. Rich SE, et al. Pressure-redistributing support surface use and pressure ulcer
of technology-assisted training on correct endorsement of pressure ulcer pre- incidence in elderly hip fracture patients. J Am Geriatr Soc. 2011;59(6):
ventive interventions. Ostomy Wound Manage. 2009;55(2):32–42. 1052–1059.
39. Magnan MA, Maklebust J. Braden Scale risk assessments and pressure ulcer 49. Huang HY, Chen HL, Xu XJ. Pressure-redistribution surfaces for preven-
tion of surgery-related pressure ulcers: A meta-analysis. Ostomy Wound Manag.
2013;59(4):36–38, 42, 44, 46, 48.
50. Bales I, Duvendack T. Reaching for the moon: Achieving zero pressure ulcer
prevalence, an update. J Wound Care. 2011;20(8):374, 376–377.
51. Gray-Siracusa K, Schrier L. Use of an intervention bundle to eliminate pres-
sure ulcers in critical care. J Nurs Care Qual. 2011;26(3):216–225.
52. Jankowski IM, Nadzam DM. Identifying gaps, barriers, and solutions in
implementing pressure ulcer prevention programs. Jt Comm J Qual Pat Saf.
2011;37(6):253–264.
53. McInerney JA. Reducing hospital-acquired pressure ulcer prevalence
through a focused prevention program. Adv Skin Wound Care.
2008;21(2):75–78.
54. Carlton T. Comparing hospital-acquired patient outcomes/complications in
magnet, non-magnet and magnet in-process hospitals (PhD diss.). University
of Colorado Health Sciences Center, 2009. Accessed Jul 17, 2013. http://grad-
works.umi.com/33/61/3361661.html.
55. Goode CJ, et al. Comparison of patient outcomes in Magnet® and non-
Magnet hospitals. J Nurs Admin. 2011;41(12):517–523.
56. Mills AC, Gillespie KN. Effect of Magnet hospital recognition on 2 patient
outcomes. J Nurs Care Qual. 2013;28(1):17–23.
57. American Nurses Credentialing Center (ANCC). The Magnet Model Com-
ponents and Sources of Evidence: Magnet Recognition Program®. Silver Spring,
MD: ANCC, 2011.
58. Dunton N, et al. The relationship of nursing workforce characteristics to pa-
tient outcomes. Online J Issues Nurs. 2007;12(3):3. Accessed Jul 17, 2013.
http://www.nursingworld.org/MainMenuCategories/ANAMarketplace/ANA
Periodicals/OJIN/TableofContents/Volume122007/No3Sept07/Nursing
WorkforceCharacteristics.aspx
59. Lake ET, et al. Patient falls: Association with hospital Magnet status and
nursing unit staffing. Res Nurs Health. 2010;33(5):413–425.

414 September 2013 Volume 39 Number 9

Copyright 2013 © The Joint Commission