A programme to reduce acquired pressure ulcers in care homes Trish Morris Thompson and Di Marks-Maran


Prevention of pressure ulcers is a major health concern, especially for older people. Much of the literature related to prevention of pressure ulcers focuses on hospital-acquired pressure ulcers. There is less literature related to prevention of pressure ulcers in care homes. This article presents a review of the literature related to prevention of pressure ulcers in care homes and an ambitious project undertaken by one care home provider to raise awareness of pressure ulcers, provide training in prevention and monitor and evaluate pressure ulcers in over 200 care home across the UK. Known as MI SKIN, the project involves ongoing training to all levels of care staff, a robust system of monitoring pressure ulcers and a mechanism to investigate and learn from any incident of pressure ulcer using root cause analysis. ■

Skin care

Patient safety


Trish Morris Thompson, Director of Quality and Clinical Governance, Barchester Healthcare, Di Marks Maran, Honorary Professor of Nursing, Kingston and St George’s University of London


The literature related to pressure ulcers takes into account issues related to incidence, prevalence and costs of pressure ulcers, as well as quality of life for older people in both hospital and care/nursing homes.

Pressure ulcers in hospitals

revention of pressure ulcers is an important goal for the NHS in the UK (Department of Health, 2011; National Institute of Health and Care Excellence, 2014) as well as for private healthcare providers. In the public healthcare sector in the UK, the National Safety Express programme was created by the Department of Health as a workstream within the Quality, Innovation, Productivity and Prevention (QIPP) programme (QIPP, 2011). The QIPP programme was designed to improve health outcomes and provide quality care with reduced costs associated with four patient harms; pressure ulcers, patient falls, urinary tract infection in patients with catheters, and venous thrombosis (QIPP, 2011). Important initiatives are being created in both the public and private sector to reduce avoidable harm in patients as a result of pressure ulcers, for example Harrison et al (2013). Harrison and colleagues created a strategy in one NHS trust to reduce the incidence of pressure ulcers through a combination of a comprehensive database, intensive monitoring using root cause analysis (RCA) and staff training. Although guidelines for prevention

Accepted for publication: May 2015

Background and literature review

Pressure ulcer risk has been studied for several decades (Norton et al, 1962; Bergstrom et al, 1995; Waterlow, 2005). The incidence and prevalence of pressure ulcers globally have also been researched. For example, in a review of epidemiological studies of pressure ulcer prevalence in the US, Landrigan et al (2010) found that incidence was found to be 6% in one study and 7% in a second study. Bales and Duvendack (2011) identified the detrimental effect on the health and wellbeing of patients, as well as the economic burden to the healthcare service, estimating the cost to hospitals in the US to be $11  billion per year, a figure considered to be unsustainable in economic terms. Vanderwee et al (2006) found that the prevalence of pressure ulcers across Europe is 18.1%. However, in a more recent study of nearly 20 000 patients in Belgium, Vanderwee et al (2011) found that pressure ulcer prevalence for categories 1–4 was 12.1%. Similar studies demonstrated variance in prevalence of pressure ulcers ranging from 4.4% in community settings (Hallett,1996) to 15.8% in a study of pressure ulcers in community and hospital (Hanson, 1997). However, some suggest that incidence studies of pressure ulcers provide more relevant data than prevalence studies (The Tissue Viability Society, 2012). Incidence refers to the number of new cases of pressure ulcers during a specified period of time, while prevalence is the number of people within a population with a pressure ulcer divided by the number of people in the total population at a given point in time. There is little in the way of studies of incidence and

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Key words: Pressure ulcers ■ Root cause analysis

and management of pressure ulcers were developed by the European Pressure Ulcer Advisory Panel (EPUAP) in collaboration with the National Pressure Ulcer Advisory Panel (NPUAP) (EPUAP and NPUAP, 2014), pressure ulcers remain an issue in health care. Much of the literature related to pressure ulcer prevention and management is related to hospital-acquired pressure ulcers. However, prevention and management is a goal for care homes as well. This article presents the creation of a programme to prevent and reduce incidence of pressure ulceration across a group of care homes in the UK.

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PRESSURE ULCERS prevalence of pressure ulcers in care homes. In the UK, different studies report differing costs to the NHS of treating pressure ulcers. Bennett et al (2004), for example, found that this cost varied from £1064 (grade 1) to £10 551 (grade 4) and the total cost in the UK was estimated at £1.4–£2.1  billion annually (Bennett et al, 2004). This represents approximately 2% of the NHS healthcare budget (Whitehead and Trueman, 2010). Chambers (2009) suggested slightly higher costs to the NHS and a more recent study by Dealey et al (2012) found that the treating a pressure ulcer can cost between £1214 (grade 1) to £14 108 (grade 4), although Posnett and Franks (2007) estimated the cost of treating a grade 4 pressure ulcer at between £40 000 and £50 000 per year. Based on a study by Ross (2009) that examined costs of different grades of pressure ulcer, a 50% reduction in grade 2 pressure ulcers alone would save over £300 000 per year, based on an incidence of 82 patients with this grade of pressure ulcer. A reduction in grade 3 and 4 pressure ulcers of one third would save the NHS approximately £240 000 each year (Chambers, 2009). Although similar figures are unavailable nationally for pressure ulcers in the private care home sector, there is a strong move to tackle the incidence and prevalence of pressure ulcers in care homes. However, it is clear that in the hospital sector, prevention of pressure ulcers is influenced by staffing levels (Meesterberends et al, 2011).

Pressure Damage Safety Cross

No New Case Identified

7 15

Admitted with New Home Acquired

8 16

9 17



3 5 10 18 23 25 27 29

4 6 11 19 24 26 28 30

MONTH/YEAR : 12 20

13 21

14 22


Figure 1. The Safety Cross

Pressure ulcers in care homes and nursing homes The literature related to pressure ulcers in residents in care homes and nursing homes tends to focus on who is at risk, risk factors, prevention and pressure ulcer management and treatment practices. For example, de Souza et al (2010), in a study of pressure ulcers in residents in a long-term care facility explored the predicative validity of a particular scale (The Braden Scale) for assessing pressure ulcer risk. Using skin examination and calculation of risk on the Braden scale every 2 days for 3 months, the residents (n=233) were assessed.The Braden Scale was found to have good predictive validity in assessing elderly residents. Kwong et al (2009) undertook a prospective cohort study of 246 residents aged 65 or older in four private nursing

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Box 1. What MI SKIN means = MOVEMENT (How might a change in movement affect a person’s risk of getting pressure damage?) ■ I = ILLNESS (What type of illness might affect a person’s risk of getting pressure damage?) ■ S = SORE (How would you know that a person was getting sore?) ■ K = KEEP MONITORING (Have you felt that you need to keep a closer eye on a person today? Have family/ friends raised any concerns about the person?) ■ I = INCONTINENCE (Has the person been incontinent today when they are not usually? Has the person been passing more or less urine than usual today?) ■ N = NUTRITION (Has the person not been eating and/or drinking as well as they usually do?) ■ M


the quality improvement methods and recommendations can reduce the incidence of grade 3-4 pressure ulcers. The findings from all of these US studies are not dissimilar to those from the UK, indicating that pressure ulcer prevalence, prevention and management are global issues. In summary, the literature suggests that care homes and nursing homes need to adopt a range of measures to ensure that clear guidelines for pressure ulcer management are available, that staff are appropriately trained and educated in pressure ulcer prevention, that regular assessment of skin and risk assessment of residents is undertaken and that multidisciplinary documentation systems are in place for staff to record the skin condition of residents and their risk for pressure ulcers that can be communicated to all involved in the care of residents.

The ‘MI SKIN Matters’ campaign MI SKIN was launched in 2012 as an awareness and education campaign across Barchester care homes. MI SKIN is an acronym for: ■■ M = movement ■■ I = illness ■■ S = sore ■■ K = keep monitoring ■■ I = incontinence ■■ N = nutrition. A detailed explanation of how the above acronym provides a framework for assessing residents’ risk of pressure ulcers can be found in Box 1. These six factors form the basis for the assessment, management and recording of the condition of each resident’s skin and risk of pressure ulcers. This approach is more than a risk assessment for pressure ulcers because it combines risk assessment with provision of resources and training for staff, developing new systems for pressure ulcer prevention and management in the homes and promoting a proactive attitude towards pressure ulcer assessment and management. Before the introduction of the MI SKIN project, data related to home-acquired pressure ulcers (HAPUs) were patchy across the care homes with a perceived underreporting of the incidence of pressure ulcers. The MI SKIN campaign was designed to reduce HAPUs through providing care home staff with training and education in pressure ulcer prevention, support and helpful resources, and through developing new and robust systems for reporting, recording and investigating HAPUs.

Staff training for MI SKIN Regional workshops were held in the summer of 2012 for care home staff. A company-wide tissue viability strategy was written and circulated to all staff before the workshop. In addition, a poster advertising the MI SKIN campaign was printed to be placed in prominent positions in all care homes. The poster was also used as a reminder of the meaning of the acronym MI SKIN. During the workshops, staff explored the tissue viability strategy and how the MI SKIN acronym can guide the way assessment for pressure ulcer risk can be carried out. Recording of the incidence of pressure ulcers across each

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homes in Hong Kong. Following an initial skin assessment on all residents, additional skin assessments were carried out every 2 days for 4 weeks to detect any pressure ulcers that were developing. After 4 weeks, 25 residents (16%) developed signs of pressure ulcers. Their findings suggest that this pattern of skin assessment was the most reliable way of predicting pressure ulcer development. Bedbound/ chairbound residents, especially those with comorbidities such a renal disease or stroke, were at highest risk especially if they lived in nursing homes where there were nursing assistants and few or no qualified nurses. As with the hospital sector, pressure ulcer prevention in nursing homes is influenced by staffing numbers. Over a 10-year period in the Netherlands, prevalence of pressure ulcers in Dutch nursing homes was found to be high (Meesterberends et al, 2011). Meesterberends and colleagues studied the impact on prevalence of pressure ulcers in Dutch nursing homes of developing and using pressure ulcer guidelines. Through semi-structured interviews nurses in eight nursing homes were interviewed (n=8). Their findings showed that in some homes, there were no pressure guidelines, in others, risk assessment scales were non-existent or not used and there was an absence of policies for repositioning elderly residents. Meesterberends et al (2011) found that pressure ulcer guidelines are necessary in nursing homes but barriers to their implementation and use need to be addressed.The relationship between incidence of pressure ulcers and the education and knowledge of staff was also reported by Bangova (2013). Horn et al (2010) found a 62% reduction in the incidence of new pressure ulcers in a care home was achieved where there was a strong multidisciplinary commitment to changing attitudes to pressure ulcer prevention and the implementation of a comprehensive data collection system to record pressure ulcer information on each resident. Improvement in information sharing encouraged personnel to take personal responsibility and improved their motivation. This is supported by a more recent study in the US by Dellafield and Magnabosco (2014). In the US, Lynn et al (2007) created a set of quality improvement methods and recommended practices were drawn up by a panel of experts and implemented in the participating nursing homes across 39 states. Findings showed that for some categories of pressure ulcer, healing times, prevalence and incidence remained unchanged, and for other there was marked improvement. Nursing homes using

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in relation to compliance with policy and action plans for the unit or care home. It therefore enables individual-, unit- and care-home-wide learning to take place. An RCA is triggered by the unit or care home when a pressure ulcer at grade 3 or above is identified and an investigation is then undertaken in conjunction with the staff involved in the care of the resident. The RCA investigation culminates in an action plan to prevent further incidence of pressure ulcers from occurring. The process of RCA was discussed at the workshop. Finally, additional resources were made available to all staff including a tissue viability workbook (made available via the company intranet) and internet links to grading damage assessment, the EPUAP (2014) guidelines and the National Institute of Health and Care Excellence (NICE) guidelines (NICE, 2014). Following the workshop all participants were asked to complete an action plan about what they personally will do to help reduce the number of home-acquired pressure ulcers. All staff received a MI SKIN workbook to complete within the following 2 weeks. The workshop was well evaluated by participants. Examples of feedback at the workshop evaluation include:






April – June 13

July – Sept 13

Oct – Dec 13

Jan – Mar 14

April – June 14

Quarter Figure 2. Percentage of new HAPUs (April 2013 – June 2014)

‘It will increase my knowledge in this area, improve my confidence when liaising with other healthcare professionals regarding pressure ulcers, develop my role in educating other staff and ensure I am more vigilant regarding pressure areas’. (Senior carer)

40 35

Percentage (%)

30 25

‘The importance of reporting pressure damage when it begins - grade 1. I like the idea of the Safety Cross as a highlighted visual aid and the mattress algorithm as a tool for choosing the appropriate pressure relieving aid.’ (Manager)

20 15 10

MI SKIN in action

5 0

End of life

Resident non compliant



April – June 14

Causative Factor Figure 3. Root Cause Analysis (January – June 2013)

unit within a care home was to be through the Safety Cross (See Figure 1), which was also explored during the workshop. Participants in the workshop were also introduced to ways of selecting the appropriate mattress for residents depending upon the assessment of the skin and risk of pressure ulcer. A MI SKIN workbook was written to support the training sessions, which staff completed within 2 weeks of undertaking the training workshop. The workshop culminated in all participants writing a personal action plan for what they will do to help reduce the incidence of pressure ulcers. Finally, at the workshop participants learned about RCA, which was a part of the strategy for pressure ulcers, to be used whenever a new HAPU was identified. RCA is an efficient way of finding out how an incidence of pressure ulceration has occurred and highlights what could have been done differently to prevent it. RCA looks at the care that was given


Each resident is assessed at least daily using the MI SKIN acronym and a handover sheet is used to communicate information about the assessment. An ongoing record of incidence of pressure ulcers, known as the safety cross, is posted in all units. The Safety Cross (often referred to in the literature as the Safety Calendar) is a visual way to record incidence of pressure ulcers in that unit. It is completed each day at a set time by a named person. Each day, one box is coloured to represent the absence or presence of a pressure ulcer; the box for the day is coloured in either green (if there have been no instances of pressure damage in that day), amber (if there has been someone admitted to the Home with pressure damage), or red (if someone has sustained pressure damage in the home on that day). The Safety Cross is kept on the wall in each nurse’s station so that it can be easily seen by all staff, helping keep MI SKIN in their minds.The Safety Cross is also taken by the nursing staff to the daily meeting with the home manager and other heads of departments to ensure that managers are kept up to date with any tissue viability issues in the home on a daily basis. Additionally, the patients found to have a pressure ulcer on any day is recorded on the Safety Cross. There are a number of purposes for the Safety Cross. First,

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Percentage (%)


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Evaluation of MI SKIN on home-acquired pressure ulcers

Percentage (%)

50 40 30 20 10 0

End of life

Resident non compliant



April – June 14

Causative Factor Figure 4. Root Cause Analysis (January – June 2014)

the data can be used to raise awareness within the team regarding how many pressure ulcers are acquired in the care home. Second, it can improve patient safety and promote good practice, for example, the number of days where there were no new pressure ulcers can also be recorded. Third, it provides real-time data about incidence. Finally, it provides an opportunity to link the data to an overall improvement aim. The Safety Cross does not replace individual data recorded for residents; instead it allows a unit or care home to keep a month by month tally of incidence of pressure ulcers over time. Where risk of pressure ulcers is found, an assessment is undertaken to determine the appropriate mattress to be used for that resident using the mattress algorithm. If any HAPU of grade 3 or above is reported, an RCA investigation is started. The RCA is led by the clinical lead within the home and involves all members of the care team. The process consists of a reflective examination of the care before the pressure damage occurring, identifying any changes to the individual’s condition and any actions taken at that time.The outcome from the RCA is the ability to answer the question “Was there anything that could have been done to prevent this occurrence?’ and if the answer is ‘yes’, to ensure that systems and processes are put in place to prevent the occurrence in future.

KEY POINTS n Prevention of pressure ulcers is a major health concern, especially for older people n The literature related to prevention of pressure ulcers primarily addresses hospital-acquired pressure ulcers n The MI SKIN matters project was initiated in a group of care homes to raise awareness of pressure ulcers and provide training to staff in prevention n MI SKIN includes a system for monitoring and evaluating pressure ulcers in over 200 care homes across the UK, including the use or root cause analysis n Since MI SKIN began there has been a decrease in care-home-acquired pressure ulcers, especially in terms of use of appropriate equipment and number of preventable pressure ulcers


MI SKIN commenced in April 2012. Data about the incidence of HAPUs is recorded regularly to plot the extent to which the MI SKIN project is making a difference. Figure 2 shows the incidence of reported HAPUs since MI SKIN commenced. It is impossible to compare this data with that from before April 2013 as previous data was unreliable and it was perceived that there was a good deal of under-reporting. Since April 2013, the 10 homes with the highest number of HAPUs have been evaluated bi-monthly. Data shows that in these 10 homes, fewer than 50% of the staff have undertaken the MI SKIN training. As a result MI SKIN training is now including as mandatory, and statistics are kept about attendance at the training sessions. This has made MI SKIN training visible across the company and has led to a reduction in HAPUs. As stated earlier, all homes were required to carry out RCA of any home-acquired pressure ulcer of a grade 3 or above. In September 2013 the care specialist team examined all HAPUs in the previous 6 months and carried out RCAs to identify cause and any ulcers that may have been preventable. Figure 3 shows the results of these RCAs Figure 3 demonstrates that 28% of the HAPUs that underwent RCA between January and June 2013 were identified as being preventable/avoidable. Avoidable pressure ulcers are defined as when the person receiving care developed a one because the care provider omitted to evaluate the patient and identify a risk, or did not plan/ implement interventions that match the patient’s need, or did not monitor or evaluate the impact of interventions, or did not revise their interventions appropriately (NPUAP, 2010). Unavoidable pressure ulcers are those that develop even though the person providing care did all of the above and the patient still developed a pressure ulcers, or, the patient refused to comply with or adhere to the strategies put in place to prevent pressure ulcers (NPUAP, 2010). The RCA activity was replicated in September 2014 and the findings of these are shown in Figure 4. A comparison of Figure 3 and Figure 4 shows that the greatest incidence of pressure ulcers is in people near to the end of life. Noncompliance from residents (unavoidable/preventable pressure ulcers) fell in 2014 and use of inappropriate equipment fell significantly in 2014. In addition, there was a decrease in the number of preventable/avoidable pressure ulcers in 2014. The authors conclude that raising awareness of skin care/ pressure ulcers, together with regular monitoring of risk, robust systems and staff training, is leading to a decrease in preventable/avoidable pressure ulcers in older people in these care homes.

Conclusion Pressure ulcers are harmful to patients and are costly to treat and heal. The literature suggests the need for care and nursing homes to provide clear guidelines for pressure ulcer management, appropriate training for staff in pressure ulcer prevention, regular pressure ulcer risk assessment of residents and multidisciplinary documentation systems for staff to record the skin condition of residents and incidence of

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pressure ulcers. Barchester Healthcare has attempted to do all of these through the development, implementation and BJN evaluation of the MI SKIN programme. Conflict of interest: none Bales I, Duvendack T (2011) Reaching for the moon: achieving zero pressure ulcer prevalence, an update. J Wound Care 20(8): 374, 376–7. doi: 10.12968/ jowc.2011.20.8.374 Bangova A (2013) Prevention of pressure ulcers in nursing home residents. Nurs Stand 27(24): 54, 56, 58–61. doi: 10.7748/ns2013. Bennett G, Dealey C, Posnett J (2004) The cost of pressure ulcers in the UK. Age Ageing 33(3): 230–5. doi: 10.1093/ageing/afh086 Bergstrom N, Braden B, Boynton P, Bruch S (1995) Using a research-based assessment scale in clinical practice. Nurs Clin North Am 30(3): 539–51 Chambers T (2009) Using patient safety investigations to reduce pressure ulcer incidence. London, NHS Institute for Improvement and Innovation. http:// tinyurl.com/7x93xn4 (accessed 11 June 2015) Dealey C, Posnett J, Walker A (2012) The cost of pressure ulcers in the United Kingdom. J Wound Care 21(6): 261–2, 264, 266. doi: 10.12968/ jowc.2012.21.6.261 Dellefield ME, Magnabosco JL (2014) Pressure ulcer prevention in nursing homes: nurse descriptions of individual and organization level factors. Geriatr Nurs 35(2): 97–104. doi: 10.1016/j.gerinurse.2013.10.010 Department of Health (2011) Defining Avoidable and Unavoidable Pressure Ulcers. http://tinyurl.com/cprcnn6 (accessed 12 June 2015) De Souza DMST, Santos VLC de G, Iri HK, Sadasue Oguri MY (2010) Predictive validity of the Braden Scale for Pressure Ulcer Risk in elderly residents of long-term care facilities. Geriatr Nurs 31(2): 95–104. doi: 10.1016/j.gerinurse.2009.11.010 European Pressure Ulcer Advisory Panel and National Pressure Ulcer Advisory Panel (2014) NEW 2014 Prevention and Treatment of Pressure Ulcers: Clinical Practice Guideline. http://tinyurl.com/q98e9q2 (accessed 15 June 2015) Hallett A (1996) Managing pressure sores in the community. J Wound Care 5(3): 105–7 Hanson R (1997) Sore points sorted. Nurs Times 93(7): 66–72 Harrison T, Kindred J, Marks-Maran D (2013) Reducing avoidable harm caused by pressure ulcers. Br J Nurs 22(6): S4-14. doi: 10.12968/ bjon.2013.22.Sup4.S4 Horn SD, Sharkey SS, Hudak S, Gassaway J, James R, Spector W (2010) Pressure ulcer prevention in long-term-care facilities: a pilot study implementing standardized nurse aide documentation and feedback reports. Adv Skin

Wound Care 23(3): 120–31. doi: 10.1097/01.ASW.0000363516.47512.67 Kwong EW, Pang SM, Aboo GH, Law SS (2009) Pressure ulcer development in older residents in nursing homes: influencing factors. J Adv Nurs 65(12): 2608–20. doi: 10.1111/j.1365-2648.2009.05117.x Landrigan CP, Parry GJ, Bones CB, Hackbarth AD, Goldmann DA, Sharek PJ (2010) Temporal trends in rates of patient harm resulting from medical care. N Engl J Med 363(22): 2124–34. doi: 10.1056/NEJMsa1004404 Lynn J, West J, Hausmann S et al (2007) Collaborative clinical quality improvement for pressure ulcers in nursing homes. J Am Geriatr Soc 55(10): 1663–9. doi: 10.1111/j.1532-5415.2007.01380.x Meesterberends E, Halfens RJG, Lohrmann C, Schols JMGA, de Wit R (2011) Evaluation of the dissemination and implementation of pressure ulcer guidelines in Dutch nursing homes. J Eval Clin Pract 17(4): 705–12. doi: 10.1111/j.1365-2753.2010.01487.x National Institute for Health and Care Excellence (2014) Pressure ulcers: prevention and management of pressure ulcers. (Clinical guidance 179). NICE, London. https://www.nice.org.uk/guidance/cg179 (accessed 15 June 2015) National Pressure Ulcer Advisory Panel (2007) NPUAP Pressure Ulcer Stages/ Categories. http://tinyurl.com/cejgpfg (accessed 11 June 2015) National Pressure Ulcer Advisory Panel (2010) Not All Pressure Ulcers are Avoidable. http://tinyurl.com/ogt7txl (accessed 11 June 2015) Norton D, McLaren R, Exton-Smith AN (1962) An investigation of geriatric nursing problems in hospital. Churchill Livingstone, London Posnett J, Franks P (2007) The costs of skin breakdown and ulceration in the UK. In: Pownall M. Skin Breakdown: The Silent Epidemic. Smith & Nephew Foundation, Hul/ QIPP (2011) Safety Express: Guide to Programme Delivery. http://tinyurl. com/5vypgj8 (accessed 11 June 2015) Ross J (2009) Root cause analysis (RCA) of pressure ulcer development. http://tinyurl.com/342jxoy (accessed 11 June 2015) Tissue Viability Society (2012) Achieving consensus in pressure ulcer reporting. http://tinyurl.com/qye4csl (accessed 11 June 2015) Vanderwee K, Clark M, Dealey C, Gunningberg L, Defloor T (2007) Pressure ulcer prevalence in Europe: a pilot study. J Eval Clin Pract 13(2): 227–35. doi: 10.1111/j.1365-2753.2006.00684.x Vanderwee K, Defloor T, Beeckman D et al (2011) Assessing the adequacy of pressure ulcer prevention in hospitals: a nationwide prevalence survey. BMJ Qual Saf 20(3): 260–7. doi: 10.1136/bmjqs.2010.043125 Waterlow J (2005) Pressure Ulcer Prevention Manual. Taunton Whitehead SJ,Trueman P (2010) To what extent can pressure relieving surfaces help reduce the costs of pressure ulcers? Nurs Times 106(30): 10-2)

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A programme to reduce acquired pressure ulcers in care homes.

Prevention of pressure ulcers is a major health concern, especially for older people. Much of the literature related to prevention of pressure ulcers ...
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