Skip to main content
NCBI home page
Wiley Open Access Collection logoLink to Wiley Open Access Collection
. 2024 Jul 5;81(9):5315–5328. doi: 10.1111/jan.16309

Use of a risk‐based intervention bundle to prescribe and implement interventions to prevent pressure injury: An observational study

Paul Fulbrook 1,2,3,✉, Josephine Lovegrove 2,4,5, Saroeun Ven 1,2, Sarah Schnaak 6, Tracy Nowicki 6
PMCID: PMC12371779  PMID: 38969344

Abstract

Aim

To explore the relationship between the prescription and implementation of pressure injury preventative interventions following risk assessment combined with a risk‐stratified intervention bundle.

Design

Single‐centre, cross‐sectional, observational, prospective.

Methods

The charts and bedsides of 341 adult inpatients were examined. Data collection included pressure injury risk level, prescribed preventative interventions and evidence of intervention implementation.

Results

Most patients (68.6%) were at risk of pressure injury, and most interventions were prescribed according to their risk level. However, evidence from direct observation and/or documentation indicated intervention implementation rates were relatively poor. Of nine interventions mandated for all patients, compliance with three patient‐/carer‐focused interventions was particularly poor, with evidence indicating they had been implemented for 3%–10% of patients. Also, nutritional screening‐related interventions were implemented poorly. Clinically indicated implementation of heel‐elevation devices and bariatric equipment was low for at‐risk patients, and the implementation of interventions for patients with existing pressure injuries was suboptimal. Significant proportions of several interventions that were observed as having been implemented were not documented as such.

Conclusion

While most interventions were prescribed according to patient risk level, the overall implementation of interventions was poor. However, the results may in part be due to failure to document interventions as opposed to omitting them.

Implications for Patient Care

Documentation of interventions is crucial as it provides evidence of the care provided. An increased focus on documentation of pressure injury preventative interventions is required, with a clear distinction between prescription and implementation.

Impact

The results highlighted several deficiencies in care, particularly relating to evidence of implementation, patient involvement and nutritional screening. The results from this study will be used to inform and improve future pressure injury prevention practice within the study hospital and should be used to inform and benchmark pressure injury preventative practices in other hospitals.

Reporting Method

The study adheres to STROBE guidelines.

Patient or Public Contribution

None.

Keywords: acute care, adult nursing, assessment, documentation, patient safety, pressure injury, pressure ulcer, prevention, risk management, waterlow score

What does this paper contribute to the wider global clinical community?

  • Preventative intervention prescription and implementation have been suboptimal, underreported and less documented in practice, which has negative implications for patient safety and records of care quality.

  • This paper emphasizes the need for an increased focus on adequate documentation of the provision of care, including the prescription (planning) and implementation of pressure injury preventative interventions, with clear distinction between the two. A focus on improving patient involvement and nutritional screening is also required.

  • When monitoring pressure injury prevention practices, facilities should monitor preventative intervention use in addition to and relative to risk assessment, as risk assessment alone does not prevent pressure injury.

1. INTRODUCTION

Pressure injury is associated with serious consequences for individuals, including pain, decreased quality of life (Burston et al., 2023) and mortality (Song et al., 2019), while also increasing length of stay and health care costs (Nghiem et al., 2022; Padula & Delarmente, 2019). They are largely preventable with the provision of adequate care but remain a clinically significant problem within hospital settings (Li et al., 2020; Rodgers et al., 2021). Internationally, a systematic review found that the pooled hospital‐acquired pressure injury rate across over 1.8 million patients was 8.4% (Li et al., 2020). In Australian and New Zealand hospitals, a hospital‐acquired pressure injury prevalence of 7.9% was reported in another systematic review (Rodgers et al., 2021). A continued focus on improving prevention is therefore paramount, with the development of hospital‐acquired pressure injury considered an indicator of care quality (Van Dishoeck et al., 2016) and severe injury recognized as a high‐priority iatrogenic complication in Australia (Australian Commission on Safety and Quality in Health Care [ACSQHC], 2024).

2. BACKGROUND

In Australia, prevention and management of pressure injuries is monitored by the Australian Commission on Safety and Quality in Health Care. Standard 5 (Comprehensive Care) describes essential requirements for screening and assessment processes, skin inspection, the provision of information to patients, carers and families and the use of equipment, devices and products (National Safety and Quality Health Service Standards, 2021). Clinically, nursing practice follows the international guideline on pressure injury prevention and management (European Pressure Ulcer Advisory Panel [EPUAP] et al., 2019).

The first step in pressure injury prevention is a risk assessment, which should be structured and comprehensive (EPUAP et al., 2019). One method of structuring a pressure injury risk assessment is with the use of a risk assessment tool in combination with clinical judgement (EPUAP et al., 2019; Garcia‐Fernandez et al., 2014). Alternatively, clinical judgement alone may be comparable to tools and their various limitations (Papanikolaou et al., 2007; Webster et al., 2011), while there is emerging evidence exploring other approaches to augment risk assessment such as sub‐epidermal moisture measurement (Byrne et al., 2023; Chaboyer et al., 2023). However, despite their limitations, risk assessment tools provide structure and clinical reminders and prompt a focus on modifiable risk factors (EPUAP et al., 2019), particularly in the absence of adequate nursing experience and knowledge (Lovegrove et al., 2023). They are widely used in clinical practice, with commonly used tools including the Braden scale (Braden & Bergstrom, 1988; Braden & Maklebust, 2005), the Norton scale (Goldstone & Goldstone, 1982; Norton et al., 1962) and the Waterlow scale (Waterlow, 2005). Regardless, what is key is that the outcomes of a risk assessment are used to inform the prescription of preventative interventions (Lovegrove, Miles, et al., 2018). Prescription entails recognition of the identified risk and individual‐specific risk factors, as well as the selection and documentation of risk‐mitigating interventions (Lovegrove, Miles, et al., 2018). This should be followed by the implementation of the selected interventions, which is pivotal to risk mitigation (Latimer et al., 2016; Lovegrove, Miles, et al., 2018).

These three steps are interlinked, yet ongoing hospital‐acquired pressure injury occurrences (Li et al., 2020; Rodgers et al., 2021) suggest that this prevention process is not always adequately applied. Indeed, two systematic reviews have revealed that there are notable inadequacies in the linkage of pressure injury prevention steps from pressure injury risk assessment to intervention implementation internationally (Lovegrove et al., 2023; Lovegrove, Miles, et al., 2018). In the earlier review, many studies were found to not report on all steps of pressure injury prevention, with the clear definition and reporting of prescriptions particularly lacking. Of most concern, the review revealed a number of studies that reported that many patients assessed as being at risk of pressure injury did not have adequate pressure injury preventative interventions in place (e.g. Amir et al., 2017; Moore et al., 2015; Sving et al., 2014; Tubaishat & Aljezawi, 2013). Similarly, the most recent review indicated that risk status as assessed by both tools and clinical judgement was not well connected to intervention use (Lovegrove et al., 2023). Thus, further work examining the relationship between all three steps of pressure injury prevention has been recommended (Lovegrove, Miles, et al., 2018) and is required to improve prevention in clinical practice.

2.1. Pressure injury prevention in the study hospital

Based on the above recommendation, and the paucity of evidence linking pressure injury risk assessment to the prescription and implementation of interventions, two studies examining the prescription and implementation of pressure injury preventative interventions following risk assessment were previously undertaken in an Australian tertiary hospital (Lovegrove et al., 2020a; Lovegrove, Fulbrook, et al., 2018). In these studies, nurses' compliance with conducting pressure injury risk assessments was a significant focus of preventative care and auditing, but there was less emphasis on the subsequent prescription and implementation of preventative interventions. In both studies, four wards (cardiology, general medical, orthopaedic surgical, rehabilitation and stroke) were included, with each including 200 inpatients admitted within the previous 24 hours. Both studies demonstrated that compliance with pressure injury risk assessment was high, but the earlier study found that preventative intervention prescription following risk assessment was sub‐optimal (Lovegrove, Fulbrook, et al., 2018). While the number of preventative interventions increased as the pressure injury risk level increased, the rate of intervention prescription overall was inadequate. Some patients who were assessed as not at risk had interventions prescribed, while other patients that were at risk did not. Similarly, the later study reported that pressure injury preventative intervention prescription increased as risk level increased, but the rates of prescription and implementation were inadequate; significantly fewer interventions were implemented than were prescribed (Lovegrove et al., 2020a). Subsequently, in the study hospital, a risk‐stratified pressure injury prevention bundle was developed, which mandated a minimum set of pressure injury preventative interventions relative to the assessed pressure injury risk level. While evidence suggests that care bundles are effective in decreasing pressure injury incidence (Chaboyer et al., 2024; Gaspar et al., 2019; Lovegrove et al., 2021), the application of most is not informed by risk assessment. Thus, the authors conjected that the use of a risk‐stratified bundle would provide the most comprehensive and adequate prevention across degrees of individual risk (Lovegrove et al., 2020a).

The intervention bundle was combined with the Waterlow score (Waterlow, 2005), which was used as standard practice to assess pressure injury risk in the study setting. The hospital procedure required a risk assessment to be undertaken within 8 h of admission and weekly thereafter or following any patient condition change. The Waterlow score comprises a series of subscales which are scored numerically and includes a Malnutrition Screening Tool (MST) (Ferguson et al., 1999). Risk assessment is documented on a form comprising the hospital's Waterlow score and Pressure Injury Management Plan (see Appendix S1). A standardized set of preventative interventions is mandated within the management plan relative to the patient's assessed risk level. The number of required interventions increases relative to risk level; this includes nine baseline interventions for all patients regardless of risk level, one of which is based upon the MST score. There are also several optional interventions, with nurses expected to use clinical judgement to modify the interventions based on individual patient risk factors. Additional interventions are included for those with an existing pressure injury. Along with a formal risk assessment, a full skin inspection is required within 2 h of admission, with the assessment and pressure injury risk level documented on the hospital's Skin Integrity Assessment Form. Subsequent skin inspections are repeated at regular intervals based on the pressure injury risk level. Following consultation with hospital stakeholders, the intervention bundle was integrated into practice. However, it was unclear how implementation of the risk‐stratified bundle had impacted clinical practice, which required further examination.

3. THE STUDY

3.1. Aim

The aim of this study was to explore the relationship between nurses' prescription and implementation of pressure injury preventative interventions following risk assessment with the new risk‐stratified intervention bundle. The objectives were to:

  • identify which pressure injury preventative interventions were prescribed and implemented,

  • examine whether pressure injury preventative interventions were prescribed and implemented according to pressure injury risk level and

  • whether prescribed interventions were subsequently implemented.

4. METHODS

4.1. Study design

To address the aim and objectives, a single‐centre, prospective, cross‐sectional, observational study was conducted. It is reported in accordance with the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement (von Elm et al., 2007).

4.2. Study setting and sample

The study setting was a 633‐bed Australian tertiary hospital in southeast Queensland, which specializes in cardiovascular and pulmonary disease. The study was conducted in association with the hospital's Quality and Effectiveness Support Team (QuEST). The data were collected over 2 days in March 2023. The nursing and medical charts and bedside areas of eligible inpatients were examined. There was no deviation from standard clinical practice during the study. A convenience sample of all adult inpatients in occupied beds in sixteen acute wards (393 beds) on the two study days was included. If a patient was assessed on the first day and transferred to a different ward on the second day, their data were only included for the first day. Emergency, intensive, mental health and palliative care patients were excluded. On the data collection days, 341 patients occupied beds in the acute wards. The nursing and medical charts and bedside areas of all patients were examined in the study.

4.3. Data collection

A standardized data collection form was developed by the researchers and entered into the Research Data Capture (REDCap) data management system (Harris et al., 2009). A paper‐based version was tested a priori by members of QuEST in association with the research team, and minor modifications were made prior to finalization. The final data collection form was tested online in REDCap prior to data collection. All assessors (two research assistants and several nurses from QuEST) underwent a training workshop, led by a member of the research team, prior to data collection to familiarize themselves with the data collection tool and to ensure the fidelity of data inputs. The trainee assessors were nurses who were experts in assessing reported hospital‐acquired pressure injuries. The training programme focused on the REDCap data collection form, navigating the system, and testing the data collection form to ensure a correct understanding and interpretation of each question. The responses from each trainee were compared to the trainer's responses, and any discrepancies were discussed. The workshop was repeated three times, with the same participants, over several weeks, using new patient information to ensure assessors fully understood and were in total agreement.

On data collection days, acute inpatients were each assessed by two assessors working in pairs to cross‐check all observed evidence before data entry. Data were entered directly into the REDCap form in real‐time. Each inpatient was reviewed at the bedside to determine which pressure injury preventative interventions had been prescribed and were observed and/or documented as having been implemented. Some basic demographic data were also recorded. For most interventions, the only source of evidence that the intervention had been implemented was the nursing and/or medical notes. However, several interventions were observable (see Tables 3 and 6), which was considered the higher standard of evidence of implementation. For observable interventions, their documentation was also recorded. The list of interventions (with item reference numbers) that should be provided as standard care, according to each level of pressure injury risk, is shown in Table 3.

TABLE 3.

Prescribed and documented preventative interventions: All patients (n = 341).

Patient risk level Evidence source Item Intervention Prescribed n (%) Implemented n (%) Prescribed‐implemented significance p Prescribed and implemented n (%)
All patients WL A1 Complete Malnutrition Screening Tool 331 (97.1) 315 (92.4) <.001 315/331 (95.2)
MNR *A2 Refer to dietician for nutritional assessment if MST ≥2, BMI <18.5 or >40, or PI ≥stage 2 238 (69.8) 83 (24.3) <.001 83/238 (34.9)
WL A3 Complete PI risk assessment 329 (96.5) 309 (90.6) <.001 309/329 (93.9)
… and identify risk level 306 (89.7) <.001 306/329 (93.0)
DCP A4 Document PI risk on the daily patient care record 322 (94.4) 290 (85.0) <.001 290/322 (90.1)
SIAF A5 Document PI risk on Skin Integrity Assessment Form 320 (93.8) 173 (50.7) <.001 173/320 (54.1)
SIAF A6 Perform and document skin assessments on the Skin Integrity Assessment Form 320 (93.8) 227 (66.6) <.001 227/320 (70.9)
MNR A7 In partnership with patient/carer discuss PI risk factors 285/337 a (84.6) 29/337 a (8.6) <.001 29/285 (10.2)
MNR A8 In partnership with patient/carer develop PI management plan 266/338 b (78.7) 23/338 b (6.8) <.001 23/266 (8.6)
MNR A9 In partnership with patient/carer give patient/carer PI brochure 218/329 c (66.3) 6/329 c (1.8) <.001 6/218 (2.8)
PLUS: at‐risk OBS/MNR AR10 Select the appropriate mattress support surface 191 (56.0) 187 (54.81) .663 187/191 (97.9)
OBS/MNR *AR11 Provide heel elevation device (i.e. heel wedge, heel boot) if clinically indicated 129 (37.8) 36 (10.6) <.001 36/129 (27.9)
OBS/MNR *AR12 Contact Quality Effectiveness Support Team for bariatric pressure redistribution equipment 78 (22.9) 6 (1.8) <.001 6/78 (7.7)
PLUS: high‐risk OBS/MNR HR13 Revise seating options: use of a pressure redistribution chair 80 (23.5) 45 (13.2) <.001 45/80 (56.3)
OBS/MNR/PT HR14 Revise seating options: review seating positioning (minimum 2 hourly) 94 (27.6) 33 (9.7) <.001 33/94 (35.1)
MNR HR15 Review the repositioning schedule (minimum 4 hourly) 123 (36.1) 62 (18.2) <.001 62/123 (50.4)
MNR HR16 Review the patient's ability to increase mobility daily 119 (34.9) 55 (16.1) <.001 55/119 (46.2)
OBS HR17 Apply prophylactic sacral dressing 97 (28.4) 60 (17.6) <.001 60/97 (61.9)
PLUS: very high risk and patients with PI MNR VHR18 Manage continence: provide regular toileting 93 (27.3) 51 (15.0) <.001 51/93 (54.8)
OBS *VHR19 Manage continence: continence aids if incontinent 84 (24.6) 59 (17.3) .002 59/84 (70.2)
Optional interventions MNR OPT20 Refer to occupational therapist 25 (7.3) 16 (4.7) .062 16/25 (64.0)
OBS/MNR OPT21 Request seating cushion from occupational therapist 17 (5.0) 7 (2.1) .013 7/17 (41.1)
MNR OPT22 Refer to physiotherapist 23 (6.7) 19 (5.6) .390 19/23 (82.6)
OBS/MNR OPT23 Provide bed cradle 10 (2.9) 2 (0.6) .010 2/10 (20.0)
Open in a new tab

Abbreviations: DPCR, daily patient care record; MNR, medical and nursing records; OBS, observation; PI, pressure injury; PT, patient; SIAF, Skin Integrity Assessment Form; WC, wound chart; WL, Waterlow chart.

a

Not applicable n = 4.

b

Not applicable n = 3.

c

Not applicable n = 12.

*

Criterion‐related interventions.

TABLE 6.

Observed and documented interventions.

Item Intervention description Prescribed, n Observed, n (%) Documented, n (%) Observed‐documented significance, p
AR10 Select appropriate mattress support surface 191 186 (97.4) 48 (25.1) <.001
AR11 Provide heel elevation device (i.e. heel wedge, heel boot) if clinically indicated 129 33 (25.6) 16 (12.4) .001
AR12 Contact Quality Effectiveness Support Team for bariatric pressure redistribution equipment 78 6 (7.7) 1 (1.3) .034
HR13 Revise seating options: use of pressure redistribution chair 80 45 (56.3) 8 (10.0) <.001
HR14 Revise seating options: review seating positioning (minimum 2 hourly) 94 33 (35.1) 10 (10.6) <.001
HR15 Review repositioning schedule (minimum 4 hourly) 123 58 (47.2) 16 (13.0) <.001
HR17 Apply prophylactic sacral dressing 97 55 (56.7) 26 (26.8) <.001
VHR19 Manage continence: continence aids if incontinent 84 58 (69.0) 39 (46.4) <.001
OPT21 Request seating cushion from occupational therapist 17 7 (41.2) 4 (23.5) .139
OPT23 Provide bed cradle 10 2 (20.0) 1 (10.0) .429
Open in a new tab

4.4. Data analysis

Data were imported from REDCap into a Microsoft® Excel database, where they were checked and cleaned. Some missing demographic data, for example, body mass index (BMI), were retrieved from patient charts. When BMI was not recorded in the patient's chart, it was calculated retrospectively based on the patient's reported height and weight. The data were then imported into SPSS™ (version 28) for analysis. Categorical and ordinal variables are described using frequencies, proportions and medians (Md) with an interquartile range (IQR). Scale data are described using means (M) with a standard deviation (SD). Prevalence was calculated as follows: (numerator ÷ denominator) × 100%, where the numerator is the number of hospital inpatients assessed who had at least one pressure injury and the denominator is the total number of hospital inpatients assessed (Baharestani et al., 2009). A Chi‐square test for goodness‐of‐fit was used to compare prescribed intervention proportions with (expected) intervention implementation proportions.

4.5. Ethical considerations

Ethical approval was provided by the hospital's Human Research Ethics Committee (ref: LNR/2021/TPCH/74917). As there were no deviations from standard care during the study, patient consent was not required. All patient data were de‐identified, and only aggregate results are reported.

5. RESULTS

5.1. Sample characteristics

The characteristics of the 341 patients included in the sample are shown in Table 1. The Waterlow risk assessment was completed fully in most cases (71.6%, n = 244) but in 97 (28.4%) cases, one or more sections of the Waterlow score were incomplete, and the MST score was not completed in 17 (5.0%) cases. Two patients were documented as having a score of zero (minimum possible score is 2). The majority (98.5%, n = 336) of patients' risk levels were categorized correctly.

TABLE 1.

Sample characteristics (n = 341).

Mean age (SD, range) 70 (17, 20–99)
Male gender % (n) 50.1 (171)
Median days hospital length of stay (IQR, range) 5 (2–9, 0–72)
Body mass index % (n) Underweight Normal Overweight
23.5 (80) 33.1 (113) 22.9 (78)
Mobility level Independent Assistance required Restricted to bed
39.6n(135) 56.3 (192) 4.1 (14)
Median waterlow risk score (IQR, range) 13 (8.5–18, 0–35)
Waterlow risk category % (n) Not at risk At risk High risk Very high risk a
31.4 (107) 29.9 (102) 17.3 (59) 21.4 (73)
Median days since last risk assessment (IQR, range) 3 (1–5, 0–29)
Risk assessment completed within last 7 days % (n) 91.2 (311)
Risk assessment completed fully % (n) 71.6 (244)
Open in a new tab

Abbreviation: IQR, interquartile range.

a

Includes patients with current pressure injury.

5.2. Pressure injuries

At the time of data collection, 12 patients did not have the presence or absence of a pressure injury documented. Of these, most had been in the hospital for between 1 and 4 days; however, one patient had been in the hospital for 27 days. Of the remainder, 26 patients had at least one current pressure injury documented, giving an overall prevalence of 7.9%, but only 4 (1.2%) patients had hospital‐acquired pressure injuries (see Table 2). In total, 43 pressure injuries were documented, of which a quarter (25.6%, n = 11) were hospital‐acquired (see Table 2). One in ten patients (n = 26) had a previous history of pressure injury, although this was not documented in nearly a quarter of cases (24.9%, n = 85). Of the 26 patients with pressure injuries, 10 were documented as having had a previous pressure injury, but the patient's pressure injury history was not documented in 9 cases.

TABLE 2.

Pressure injury prevalence.

n Prevalence % (95% CI) Pressure injuries (n)
Stage 1 Stage 2 Stage 3 Stage 4 Unstageable Total
Any pressure injury 26/329 a 7.9 (5.2–11.4) 31 9 1 1 1 43
Any ≥Stage 2 pressure injury 9/329 a 2.7 (1.3–5.1)
Hospital‐acquired pressure injury 4/329 a 1.2 (0.3–3.1) 7 4 0 0 0 11
≥Stage 2 hospital‐acquired pressure injury 2/329 a 0.6 (0.1–2.1)
Present‐on‐admission pressure injury 22/329 a 6.7 (4.2–10.0) 24 5 1 1 1 32
≥Stage 2 present‐on‐admission pressure injury 7/329 a 2.1 (0.9–4.3)
Open in a new tab

Abbreviation: CI, confidence interval.

a

n = 12 missing.

The number of pressure injuries per patient ranged from 1 to 4. Of the present‐on‐admission pressure injuries (n = 32) that were identified in 22 patients, half were on the sacrum (50.0%, n = 16), of which two were Stage 2, one was Stage 3 and one was Stage 4. Only one other ≥Stage 1 pressure injury was found: a Stage 2 pressure injury on the patient's spine. Of the 11 hospital‐acquired pressure injuries present in 4 patients, 2 patients each had bilateral Stage 2 pressure injuries on their buttocks; 1 patient had 3 Stage 1 pressure injuries on their lower leg, heel and foot; and 1 patient had 4 Stage 1 pressure injuries on their coccyx, heel and bilateral ischial tuberosities. No suspected deep tissue or mucous membrane pressure injuries were documented.

5.3. Prescription and implementation of interventions

The prescription and documentation rates for all patients (n = 341), regardless of their risk level, are shown in Table 3. For all interventions, documentation rates were lower than prescription rates, and for all but three interventions (AR10: select appropriate mattress support surface, OPT20: occupational therapist referral, and OPT22: physiotherapist referral), the differences were significant.

5.3.1. Interventions for all patients

Nine interventions (A1–A9) are mandated for all patients regardless of risk level, although one intervention (*A2: dietician referral) is only mandated if the MST score is ≥2, the patient's BMI is <18.5 or ≥40, or the patient has a ≥Stage 2 pressure injury. As shown in Table 3, although all interventions were prescribed for most patients, implementation rates were lower. Notably, implementation rates for the three patient‐/carer‐focused interventions (A7–A9) were poor.

Completion of the MST is mandatory for all patients (and is completed and scored as part of the Waterlow score), whereas dietician referral is based on the three criteria described above. Although two‐thirds of patients (69.8%, n = 238) were prescribed referral to a dietician, this was documented as having occurred in only one‐third (34.9%, n = 83; p < .001). Furthermore, when the relationship between referral criteria and prescription and implementation rates was analysed further, rates were sub‐optimal (see Table 4). Of 331 patients for whom complete data were available, there were 150 patients that met at least one criterion for dietician referral, of which most (77.3%, n = 1164) had a referral prescribed; however, just over half (52.6%, n = 61) of these had a referral documented (p < .001).

TABLE 4.

Malnutrition screening and dietician referrals.

Intervention Prescribed n (%) Implemented n (%) Prescribed‐implemented significance p Prescribed and implemented n (%)
Complete MST 331/341 (97.1) 315/331 (95.2) <.001 315/315 (100)
a Dietician referral 238/341 (69.8) 83/341 (24.3) <.001 83/238 (34.9)
Dietician referral criteria Criterion met n (%)
MST score ≥2 90/341 (26.4) 73/341 (21.4) 46/341 (13.5) <.001 46/73 (63.0)
b BMI <18.5 or >40 89/331 (26.9) 67/331 (20.2) 30/331 (9.1) .004 30/67 (44.8)
Stage ≥2 PI 9/341 (2.6) 9/341 (2.6) 5/341 (1.5) .177 5/9 (55.6)
b Any criterion met 150/331 (45.3) 116/331 (35.1) 61/150 (18.4) <.001 61/116 (52.3)
b No criteria met 181/331 (54.7) 112/331 (33.8) 20/331 (6.0) <.001 20/112 (17.9)
Open in a new tab
a

Criterion‐based intervention.

b

BMI data missing n = 10.

It is mandatory for all patients to have a pressure injury risk assessment to identify their risk level and record it on the daily patient care record and skin integrity assessment form. Skin integrity assessment is mandatory for all patients and should be completed within 2 h of admission. The frequency of reassessment is based on risk score [<10 = weekly or when there is a change in the patient's condition; 11–14 = daily; 15–19 = twice daily (am, pm); ≥20 = every shift (am, pm, night)]. Reassessment should also be undertaken prior to transfer or discharge. Most patients (96.5%, n = 329) were prescribed completion of risk assessment and risk level. Of these, the risk assessment and risk level were documented in most cases (Table 3). Most patients (93.8%, n = 320) were prescribed skin integrity assessments, though significantly fewer (66.6%, n = 22) were documented as implemented (p < .001); see Table 3. In terms of the documented frequency of skin integrity assessments, the frequency was correct in just over half of patients (54.8%, n = 187) and was either incorrect (31.1%, n = 106) or not documented at all (14.1%, n = 48) in the remainder.

Three interventions are mandatory for all patients in partnership with the patient/carer (A7: discuss pressure injury risk factors; A8: develop a pressure injury management plan; and A9: give the patient/carer a pressure injury brochure). For a minority of patients, the assessors marked the interventions as ‘not applicable’ although reasons were not recorded. In general, these interventions were documented as prescribed in smaller proportions than other mandatory interventions and were documented as implemented in much smaller proportions (Table 3).

In addition to the nine mandatory interventions, nurses also prescribed between 3 and 25 additional interventions for patients not at risk (n = 107). However, the implementation rates were lower in all cases (see Figure 1a).

FIGURE 1.

FIGURE 1

Open in a new tab

Intervention prescription and documentation by risk level. Vertical lines indicate interventions required for each risk level.

5.3.2. Interventions for patients at risk of pressure injury

In addition to the nine mandatory interventions, all patients at risk (n = 105) should be prescribed three additional interventions (AR10–AR12) (see Figure 1b). However, only 65 (61.9%) patients were prescribed a specific mattress (AR10), although it was observed to have been implemented in the majority of these cases (96.9%, n = 63). A heel elevation device (AR11) or bariatric equipment (AR12) should only be prescribed if clinically indicated. Therefore, prescription rates for these two interventions were lower (n = 42 and n = 24, respectively), but implementation rates were much lower (n = 6, 14.3% and n = 1, 4.2%, respectively). Other interventions were also prescribed but implementation rates were again lower. All high‐risk patients (n = 67) should be prescribed five additional interventions (HR13–HR17) (see Figure 1c). Similarly, the prescription rates for these additional interventions were sub‐optimal, with implementation rates notably lower. For very high risk patients (n = 62), a further two interventions (VR18–VR19) should be prescribed (see Figure 1d). However, continence aids (VR19) should only be prescribed if clinically indicated. Prescription rates were sub‐optimal, and, apart from AR10 (provision of a specific mattress), implementation rates were lower. Notably, the implementation rates of AR11 (heel device) and AR12 (bariatric equipment) were very low (15/40; 37.5% and 3/24; 12.5%, respectively). Four optional interventions were prescribed for some very high risk patients with reasonable implementation rates (54.5%–84.6%); however, a bed cradle (OPT23) was prescribed for 6 patients but was implemented for none.

5.3.3. Interventions for patients with a pressure injury

For all patients with a pressure injury (n = 26), all interventions required for very high risk patients plus a further three interventions are mandated (PI24, PI25 and PI26). Also, a clinical incident report (PI27) is mandatory for all hospital‐acquired or ≥Stage 3 pressure injuries (n = 4). Referral to the wound management team (PI28) is required for all above ankle ≥Stage 3 pressure injuries (n = 2), and referral to the podiatry team (PI29) is required for all ankle and below pressure injuries (n = 1). Although in most cases, most interventions that were prescribed were also documented, as shown in Table 5, both prescription and documented implementation of interventions were sub‐optimal. Overall, interventions were frequently prescribed and implemented for patients over and above those required according to their risk level.

TABLE 5.

Prescription and documentation of interventions for patients with pressure injuries.

Evidence source Item Intervention Prescribed n (%) Implemented n (%) Prescribed‐implemented significance p Prescribed and implemented n (%)
Interventions for patients with pressure injury WC a PI24 Identify PI category and commence wound chart 9/26 (34.6) 9/26 (34.6) 1 9/9 (100)
MNR a PI25 Document on purple PI notification sticker 8/26 (30.8) 4/26 (15.4) .089 4/8 (50.0)
MNR a PI26 Document PI on alerts page in medical record 6/26 (23.1) 5/26 (19.2) .641 5/6 (83.3)
MNR a PI27 If hospital‐acquired or ≥Stage 3 PI: Complete incident report 4/7 (57.1) 3/7 (42.9) .445 3/4 (75.0)
MNR a PI28 If ≥Stage 3 PI and PI above ankle: Refer to wound and stoma management service 1/2 (50.0) 1/2 (50.0) 1 1/1 (100)
MNR a PI29 If ankle or below PI: Refer to podiatry service 0/1 (0) 0/1 1 0/0 (0)
Open in a new tab

Abbreviations: MNR, medical and nursing records; PI, pressure injury; WC, wound chart.

a

Criterion‐related or optional interventions.

5.3.4. Observed and documented interventions

Several interventions were directly observable as having been implemented (see Table 6); these should also have been documented as such. A specific mattress had been prescribed (AR10) for 191 patients and was observed as having been implemented in most cases (97.4%), but was documented in only a quarter of cases (25.1%). For all other interventions, observed implementation was sub‐optimal, ranging from 7.7% to 69.0%. For all interventions, documentation was poor (range 1.3%–46.4%), and the proportional differences between observed and documented interventions were statistically significant in most cases.

6. DISCUSSION

The results from this study will be used to inform and improve future pressure injury prevention practices within the study hospital and may be used to inform and benchmark pressure injury preventative practices in other hospitals. In this study, hospital‐acquired pressure injury prevalence was low (1.2%), which compares favourably with the statewide prevalence of 2.1% (95% CI 1.5%–2.4%) (Fulbrook et al., 2023) reported in the 5 years preceding implementation of the risk‐stratified intervention bundle in 2019. However, inferences about the difference in prevalence cannot be drawn from this study, and our results highlighted several areas of sub‐optimal practice. Overall, there was reasonable adherence to the pressure injury preventative intervention bundle, with most interventions prescribed according to patient risk level but at lower rates than required. However, based on observation and documentation, the evidence indicates that the implementation of interventions was sub‐optimal at all risk levels. While the bundle was integrated into practice using several implementation strategies, including stakeholder consultation, clinician education, auditing and feedback, it was not underpinned by a specific implementation framework such as the original and integrated Promoting Action on Research Implementation in Health Services (PARIHS; Harvey & Kitson, 2015; Rycroft‐Malone, 2004) and the Consolidated Framework for Implementation Research (CFIR; Damschroder et al., 2009) frameworks. This may have been a contributing factor to the incomplete compliance with bundle interventions in our study, and it is recommended that future projects employ a relevant quality improvement or implementation framework. For example, hospital‐acquired pressure injuries were significantly decreased in another Australian health service through the system‐wide translation of prevention evidence into practice using the PARiHS framework, which was found to enhance translational effectiveness in this context (Barakat‐Johnson et al., 2020).

In terms of the nine interventions that are mandatory for all inpatients, compliance with three interventions that focused on patient/carer involvement in pressure injury prevention was particularly poor. While these interventions were prescribed for 64% to 84% of patients, the evidence indicated that they had been implemented for only 3% to 10%. This is of concern given that person‐centred care, including engagement and involvement, is the gold standard approach within healthcare (Australian Commission on Safety and Quality in Health Care (ACSQHC), 2023), which enhances quality of care and outcomes (Bombard et al., 2018; Marzban et al., 2022). Nurses who have participated in pressure injury prevention programmes involving patient participation have previously emphasized the importance of patient involvement, indicating that a patient‐centric approach improves patient communication and satisfaction while decreasing clinician workload (Wan et al., 2023). This nursing support for patient involvement was identified across several studies by a recent mixed‐methods systematic review of barriers and facilitators to implementing pressure injury prevention guidelines (Wan et al., 2023), yet such support was not evident in our results. Increased efforts to involve patients as representatives in their own pressure injury preventative care are required and may also lead to a decrease in pressure injury incidence. Indeed, a cluster randomized controlled trial reported that implementation of a patient‐involvement pressure injury prevention bundle notably reduced the hazard of pressure injury, although the effect was not significant (Chaboyer et al., 2016). Complementing intervention‐based bundles with increased patient involvement aspects such as those included in the Chaboyer et al. (2016) bundle may be a crucial step towards improving pressure injury prevention holistically.

Overall, documentation of the implementation of interventions was poor. For most interventions, the only evidence available to confirm that an intervention had indeed been implemented was via nursing or medical records. In some cases, the lack of evidence of implementation may have been attributable to failure to document as opposed to failure to implement. There is some evidence in our data to support this possibility. For example, of the nine interventions shown in Table 6 that were observed as having been implemented, the documentation rates were significantly lower in all cases. Poor quality nursing documentation has been noted elsewhere, including divergence from the nursing process, which reflects decision‐making from assessment, nursing diagnosis, planning and implementation to evaluation (De Groot et al., 2019). Reasons for lacking documentation include time constraints and competing priorities, resource and workload issues, a lack of clear guidance for documentation completion, ambivalence towards documentation and institutional bureaucracy and policies (Blair & Smith, 2012). However, it is unclear why the documentation was incomplete in our study. This is an area that requires further research into contemporary barriers and facilitators in the context of pressure injury prevention, particularly given that documentation provides highly important evidence of the care provided (Gibelli et al., 2022). Without documentary evidence to the contrary, it may be (incorrectly) assumed that the quality of care was poor or that mandated interventions were omitted altogether. The lack of documentation may have significant implications in the future, perhaps when a patient or family member is claiming negligent care or even in a court case where an adverse event such as pressure injury has occurred (Brown, 2019; Gibelli et al., 2022).

In contrast, for one of the interventions that was relatively easy to observe (A9: pressure injury brochure), there was only observable evidence of implementation in 3% of cases. Of the other interventions for all patients, there were inconsistencies regarding the criterion‐based intervention for referral to a dietician (A2). Most patients (70%) were deemed by nurses to require referral; however, less than half (44%) specifically met at least one of the three criteria for referral. And, when each criterion was analysed separately, the prescription and implementation of patients meeting either the MST or BMI criteria were sub‐optimal. In part, this may be due to confusion about the multiple criteria for referral, particularly the BMI referral criteria. In many cases, the patient's BMI was not recorded by nurses on the Waterlow score, although the BMI category was recorded in all cases. In multiple cases, this information needed to be retrieved from the patients' medical records after the study was completed, and in ten cases, either the patient's height and/or their weight were not reported in the medical records to enable the calculation of BMI. This is of concern because nutritional decline is experienced in up to 65% of hospitalized patients (Cass & Charlton, 2022). Malnutrition has been identified as a pressure injury risk factor (Wang et al., 2024) and is recognized as a high‐priority hospital‐acquired complication in Australia (ACSQHC, 2024). Nutrition plays a key role in pressure injury healing (Munoz & Posthauer, 2022), further emphasizing the need for improved nutritional screening practices. Notably, the mixed methods review of Wan et al. (2023) also identified nutrition as an area of concern, and in two studies, nurses were unaware of how to use nutritional screening tools and prompt dietician referrals. Inadequate nutritional screening and care during hospital admission have also been reported in other studies (Bonnetti et al., 2017; Tervo‐Heikkinen et al., 2023). There is a need to support clinicians in recognizing malnutrition as a risk factor for not only pressure injury but other complications, including increased morbidity and mortality (Barker et al., 2011), and translating this into improved efforts to assess and respond to malnutrition in acute patients.

Beyond the nine interventions mandated for all patients, it was evident that the prescription and implementation of additional interventions required according to the three risk levels were sub‐optimal. Although prescription rates were lower, as they were based on clinical need, two interventions were implemented poorly at all risk levels: provision of a heel elevation device and provision of bariatric equipment. For patients that were prescribed these two interventions, they were implemented for only 27.9% (n = 36/129) and 7.7% (n = 6/78), respectively. These implementation rates are of concern, especially for patients assessed to be at risk of pressure injury. The final area of concern from our results is related to patients with an existing pressure injury. Although this was a relatively small proportion of patients (8%), the required interventions were implemented in 50% or less of all cases. This has the potential to delay pressure injury healing, which is significant given the prolonged impacts of pressure injury for individuals (Burston et al., 2023).

Overall, there is emerging evidence to support the effectiveness of pressure injury prevention care bundles internationally, but few are underpinned by the outcome of a risk assessment (Lovegrove et al., 2020b; Lovegrove, Fulbrook, et al., 2018). While pressure injury prevention should be individualized to the patient and their specific risk factors, there has been recognition of the need to provide support for clinical decision‐making in relation to pressure injury prevention planning (Li et al., 2024). Standardization of pressure injury preventative interventions based on risk, which can subsequently be tailored to the individual, is one approach to addressing this need and ensuring that a minimum standard of pressure injury preventative care is in place (Lovegrove et al., 2020b; Lovegrove, Fulbrook, et al., 2018). This is particularly relevant given that research suggests pressure injury prevention knowledge and practice in acute care is deficient globally, with a myriad of barriers impacting care processes (Liang et al., 2023; Lovegrove, Miles, et al., 2018; Tervo‐Heikkinen et al., 2023; Wan et al., 2023). However, while studies suggest that care bundles are effective for pressure injury prevention in hospitals, systematic reviews of hospital‐acquired pressure injury prevention indicate the evidence for prevention bundles is heterogeneous and of limited quality (Gaspar et al., 2019; Lovegrove et al., 2021), and hospital prevention bundles specifically (Chaboyer et al., 2024), indicate the evidence is heterogeneous and of limited quality.

6.1. Limitations

A structured data collection tool was used, and assessors worked in pairs; however, the interrater reliability of the tool was not assessed formally. This would be beneficial for future studies. For many interventions, evidence of intervention implementation relied on document interpretation, rather than direct observation. However, this provided important evidence demonstrating the need for improving documentation in practice. As this study was undertaken after implementation of the bundle, with no comparative before‐period, direct inferences of differences in practice and pressure injury prevalence cannot be made. Although there were significant differences between prescription and implementation rates for most interventions, the reasons for these differences were not investigated. Only a small number of independent variables were recorded, and there were multiple outcome variables (documentation and implementation rates). Future studies could record a greater number of independent (predictor) variables, such as nursing experience and qualifications and patient factors, that would enable multivariate analyses. As well, future qualitative studies would help to identify influencing factors, which could provide information for practice changes that may result in improved implementation and documentation rates. As this study was conducted at a single site, the results are not generalizable.

6.2. Implications for practice

Our results highlight the importance of documentation of clinical practices, especially when there is no other observable evidence to indicate that a clinical event has occurred. As such, there is a need to ensure that the documentation of intervention prescription is clearly associated with the documentation of intervention implementation. Our findings indicate some key aspects of pressure injury preventative care, including patient engagement and nutritional screening, as well as interventions for patients with an existing pressure injury where significant improvements could be made. While our results were found at a single site, they may indicate areas in which to focus improvements in other settings. Pressure injury prevention care bundles should be implemented for all patients all of the time, unless contraindicated. When patients are deemed to be at risk of pressure injury, compliance with preventative interventions will help to ensure that at least a minimum standard (or set) of interventions is implemented and that adverse events do not occur. However, it is important that nurses do not use a ‘tick and flick’ approach to the prescription and implementation of interventions, and that clinical judgement is used alongside to individualize risk factor assessments and tailor interventions according to each patient's needs. Our results will be used to help improve pressure injury prevention practices within the study hospital and may be used to inform and benchmark nursing care in other acute hospital settings.

6.3. Implications for further research

The risk‐stratified pressure injury preventative intervention bundle may be an approach that will better individualize and target pressure injury prevention and improve resourcing, but this was not examined in this study, and further work is needed in this area. Similarly, the effect of the implementation of the bundle on pressure injury incidence and prevalence was not examined directly. In this context, future research could be undertaken to compare outcomes associated with risk‐stratified care bundles with other non‐stratified bundles or with other models of pressure injury prevention. As noted in the limitations, the reasons for the differences in rates of prescription and implementation were not investigated in this study. Therefore, future qualitative studies would be beneficial to help understand these discrepancies and the barriers to implementation and documentation. Further research is also suggested in the areas of patient and carer involvement and nutritional assessment practices in pressure injury prevention and how they impact clinical outcomes, to investigate the barriers and facilitators to clinical documentation and to inform future behaviour change efforts.

7. CONCLUSION

Overall, most interventions were prescribed according to patient risk level and thus adhered to the intervention bundle, but observable and documentary evidence indicate that implementation was sub‐optimal. However, this may in part be due to limitations in the documentation of the implementation of pressure injury preventative interventions. Improvements to practice and further research, as recommended by this paper, are needed to improve patient outcomes and prevent the consequences of pressure injury development. Future improvement efforts should be underpinned by a relevant quality improvement or implementation framework.

AUTHOR CONTRIBUTIONS

Paul Fulbrook: Conceptualization, Data curation, Formal analysis, Funding acquisition, Investigation, Methodology, Project administration, Validation, Writing – original draft, Writing – review and editing. Josephine Lovegrove: Conceptualization, Investigation, Methodology, Writing – original draft, Writing – review and editing. Saroeun Ven: Data curation, Methodology, Project administration, Writing – original draft, Writing – review and editing. Sarah Schnaak: Data curation, Methodology, Writing – review and editing. Tracy Nowicki: Data curation, Methodology, Writing – review and editing. The authors have checked to make sure that this article conforms to the journal's statistical guidelines and the statistics were checked prior to submission by an expert statistician: Dr Michael Steele, Senior Lecturer in Biostatistics, Faculty of Health Sciences, Australian Catholic University. E‐mail: michael.steele@acu.edu.au. The authors affirm that the methods used in the data analyses are suitably applied to their data within their study design and context, and the statistical findings have been implemented and interpreted correctly. The authors agree to take responsibility that the choice of statistical approach was appropriate and was conducted and interpreted correctly.

FUNDING INFORMATION

This study was unfunded.

CONFLICT OF INTEREST STATEMENT

No conflict of interest has been declared by the authors.

PEER REVIEW

The peer review history for this article is available at https://www.webofscience.com/api/gateway/wos/peer‐review/10.1111/jan.16309.

Supporting information

Appendix S1

JAN-81-5315-s001.docx (145.1KB, docx)

Appendix S2

JAN-81-5315-s002.doc (95.5KB, doc)

ACKNOWLEDGEMENTS

The authors acknowledge the contribution of Dr Sandra Miles towards conceptualization. The authors also acknowledge and sincerely thank the QuEST nurse assessors and Jacob Butterworth (Nursing Research and Practice Development Centre, The Prince Charles Hospital) who conducted data collection. Dr Josephine Lovegrove's salary was part‐funded by the NHMRC Centre of Research Excellence in Wiser Wound Care (APP1196436). Open access publishing facilitated by Australian Catholic University, as part of the Wiley ‐ Australian Catholic University agreement via the Council of Australian University Librarians.

Fulbrook, P. , Lovegrove, J. , Ven, S. , Schnaak, S. , & Nowicki, T. (2025). Use of a risk‐based intervention bundle to prescribe and implement interventions to prevent pressure injury: An observational study. Journal of Advanced Nursing, 81, 5315–5328. 10.1111/jan.16309

DATA AVAILABILITY STATEMENT

The data that support the findings of this study are available on request from the corresponding author. The data are not publicly available due to privacy or ethical restrictions.

REFERENCES

  1. Amir, Y. , Tan, F. E. S. , Halfens, R. , Lohrmann, C. , & Schols, J. (2017). Pressure ulcer prevalence and care in Indonesian hospitals: A multicentre, cross‐sectional evaluation using an extended donabedian model. Ostomy/Wound Management, 63(2), 8–23. [PubMed] [Google Scholar]
  2. Australian Commission on Safety and Quality in Health Care . (2021). National safety and quality health service standards. 2nd ed. – version 2. ACSQHC. https://www.safetyandquality.gov.au/sites/default/files/2021‐05/national_safety_and_quality_health_service_nsqhs_standards_second_edition_‐_updated_may_2021.pdf [Google Scholar]
  3. Australian Commission on Safety and Quality in Health Care [ACSQHC] . (2023). Partnering with patients in their own care . https://www.safetyandquality.gov.au/standards/nsqhs‐standards/partnering‐consumers‐standard/partnering‐patients‐their‐own‐care
  4. Australian Commission on Safety and Quality in Health Care [ACSQHC] . (2024). Hospital‐acquired complications (HACs) . https://www.safetyandquality.gov.au/our‐work/indicators/hospital‐acquired‐complications
  5. Baharestani, M. , Black, J. , Carville, K. , Clark, M. , Cuddigan, J. , Dealey, C. , Defloor, T. , Harding, K. , Lahmann, N. , Lubbers, M. , Lyder, C. , Ohura, T. , Orsted, H. , Reger, S. , Romanelli, M. , & Sanada, H. (2009). International guidelines. Pressure ulcer prevention: Prevalence and incidence in context. A consensus document. MEP Ltd. [DOI] [PMC free article] [PubMed] [Google Scholar]
  6. Barakat‐Johnson, M. , Lai, M. , Wand, T. , Coyer, F. , & White, K. (2020). Systemwide practice change program to combat hospital‐acquired pressure injuryies: Translating knowledge into practice. Journal of Nursing Care Quality, 35(1), 51–57. 10.1097/NCQ.0000000000000395 [DOI] [PubMed] [Google Scholar]
  7. Barker, L. A. , Gout, B. S. , & Crowe, T. C. (2011). Hospital malnutrition: Prevalence, identification and impact on patients and the healthcare system. International Journal of Environmental Research & Public Health, 8(2), 514–527. 10.3390/ijerph8020514 [DOI] [PMC free article] [PubMed] [Google Scholar]
  8. Blair, W. , & Smith, B. (2012). Nursing documentation: Frameworks and barriers. Contemporary Nurse, 41(2), 160–168. 10.5172/conu.2012.41.2.160 [DOI] [PubMed] [Google Scholar]
  9. Bombard, Y. , Baker, G. R. , Orlando, E. , Fancott, C. , Bhatia, P. , Casalino, S. , Onate, K. , Denis, J. , & Pomey, M. (2018). Engaging patients to improve quality of care: A systematic review. Implementation Science, 13, 98. 10.1186/s13012-018-0784-z [DOI] [PMC free article] [PubMed] [Google Scholar]
  10. Bonnetti, L. , Terzoni, S. , Lusignani, M. , Negri, M. , Froldi, M. , & Destrebecq, A. (2017). Prevalence of malnutrition among older people in medical and surgical wards in hospital and quality of nutritional care: A multicenter, cross‐sectional study. Journal of Clinical Nursing, 26(23–24), 5082–5092. 10.1111/jocn.14051 [DOI] [PubMed] [Google Scholar]
  11. Braden, B. , & Bergstrom, N. (1988). Braden scale for predicting pressure sore risk . http://bradenscale.com/images/bradenscale.pdf [PubMed]
  12. Braden, B. J. , & Maklebust, J. (2005). Preventing pressure ulcers with the Braden scale. The American Journal of Nursing, 105(6), 70–72. [DOI] [PubMed] [Google Scholar]
  13. Brown, A. (2019). Legal implications of pressure injuries: Experience of a tissue viability nurse expert. Nursing Standard, 34(2), 69–74. 10.7748/ns.2019.e11301 [DOI] [PubMed] [Google Scholar]
  14. Burston, A. , Miles, S. J. , & Fulbrook, P. (2023). Patient and carer experience of living with a pressure injury: A meta‐synthesis of qualitative studies. Journal of Clinical Nursing, 32(13–14), 3233–3247. 10.1111/jocn.16431 [DOI] [PubMed] [Google Scholar]
  15. Byrne, S. , Patton, D. , Avsar, P. , Strapp, H. , Budri, A. , O'Conner, T. , Nugent, L. , & Moore, Z. (2023). Sub epidermal moisture measurement and targeted SSKIN bundle interventions, a winning combination for the treatment of early pressure ulcer development. International Wound Journal, 20(6), 1987–1999. 10.1111/iwj.14061 [DOI] [PMC free article] [PubMed] [Google Scholar]
  16. Cass, A. R. , & Charlton, K. E. (2022). Prevalence of hospital‐acquired malnutrition and modifiable determinants of nutritional deterioration during inpatient admissions: A systematic review of the evidence. Journal of Human Nutrition and Dietetics, 35(6), 1043–1058. 10.1111/jhn.13009 [DOI] [PMC free article] [PubMed] [Google Scholar]
  17. Chaboyer, W. , Bucknall, T. , Webster, J. , McInnes, E. , Gillespie, B. M. , Banks, M. , Whitty, J. A. , Thalib, L. , Roberts, S. , Tallott, M. , Cullum, N. , & Wallis, M. (2016). The effect of a patient centred care bundle intervention on pressure ulcer incidence (INTACT): A cluster ranomised trial. International Journal of Nursing Studies, 64, 63–71. 10.1016/j.ijnurstu.2016.09.015 [DOI] [PubMed] [Google Scholar]
  18. Chaboyer, W. , Harbeck, E. L. , Walker, R. M. , Latimer, S. , Deakin, J. , Probert, R. , & Gillespie, B. M. (2023). Variations in sacral sub‐epidermal moisture measurements in hospitalized medical and surgical patients: A longitudinal observational sub‐study. International Journal of Nursing Studies, 145, 104545. 10.1016/j.ijnurstu.2023.104545 [DOI] [PubMed] [Google Scholar]
  19. Chaboyer, W. , Latimer, S. , Priyadarshani, U. , Harbeck, E. , Patton, D. , Sim, J. , Moore, Z. , Deakin, J. , Carlini, J. , Lovegrove, J. , Jahandideh, S. , & Gillespie, B. M. (2024). The effect of pressure injury prevention care bundles on pressure injuries in hospital patients: A complex intervention systematic review and meta‐analysis. International Journal of Nursing Studies, 155, 104768. 10.1016/j.ijnurstu.2024.104768 [DOI] [PubMed] [Google Scholar]
  20. Damschroder, L. J. , Aron, D. C. , Keith, R. E. , Kirsh, S. R. , Alexander, J. A. , & Lowery, J. C. (2009). Fostering implementation of health services research findings into practice: A consolidated framework for advancing implementation science. Implementation Science, 4(50), 1–15. 10.1186/1748-5908-4-50 [DOI] [PMC free article] [PubMed] [Google Scholar]
  21. De Groot, K. , Triemstra, M. , Paans, W. , & Francke, A. L. (2019). Quality criteria, instruments, and requirements for nursing documentation: A systematic review of systematic reviews. Journal of Advanced Nursing, 75(7), 1379–1393. 10.1111/jan.13919 [DOI] [PubMed] [Google Scholar]
  22. European Pressure Ulcer Advisory Panel [EPUAP] , National Pressure Injury Advisory Panel [NPIAP] , Pan Pacific Pressure Injury Alliance [PPPIA] , & Haesler E. (Ed.). (2019). Prevention and treatment of pressure injuries/ulcers: Clinical practice guideline. EPUAP, NPIAP & PPPIA. [Google Scholar]
  23. Ferguson, M. , Capra, S. , Bauer, J. , & Banks, M. (1999). Development of a valid and reliable malnutrition screening tool for adult acute hospital patients. Nutrition, 15(6), 458–464. 10.1016/s0899-9007(99)00084-2 [DOI] [PubMed] [Google Scholar]
  24. Fulbrook, P. , Lovegrove, J. , Hay, K. , & Coyer, F. (2023). State‐wide prevalence of pressure injury in intensive care versus acute general patients: A five‐year analysis. Journal of Clinical Nursing, 32(15–16), 4947–4961. 10.1111/jocn.16687 [DOI] [PubMed] [Google Scholar]
  25. Garcia‐Fernandez, F. P. , Pancorbo‐Hidalgo, P. L. , & Agreda, J. J. S. (2014). Predictive capacity of risk assessment scales and clinical judgement for pressure ulcers: A meta‐analysis. Journal of Wound, Ostomy, and Continence Nursing, 41(1), 24–34. 10.1097/01.WON.0000438014.90734.a2 [DOI] [PubMed] [Google Scholar]
  26. Gaspar, S. , Peralta, M. , Marques, A. , Budri, A. , & Gaspar de Matos, M. (2019). Effectiveness of hospital‐acquired pressure ulcers prevention: A systematic review. International Wound Journal, 16(5), 1087–1102. 10.1111/iwj.13147 [DOI] [PMC free article] [PubMed] [Google Scholar]
  27. Gibelli, F. , Bailo, P. , Sirignano, A. , & Ricci, G. (2022). Pressure ulcers from the medico‐legal perspective: A case report and literature review. Healthcare, 10(8), 1426. 10.3390/healthcare10081426 [DOI] [PMC free article] [PubMed] [Google Scholar]
  28. Goldstone, L. A. , & Goldstone, J. (1982). The Norton score: An early warning of pressure sores? Journal of Advanced Nursing, 7(5), 419–426. 10.1111/j.1365-2648.1982.tb00258.x [DOI] [PubMed] [Google Scholar]
  29. Harris, P. A. , Taylor, R. , Payne, J. , Gonzalez, N. , & Conde, J. G. (2009). Research electronic data capture (REDCap) – A meta‐driven methodology and workflow process for providing translational research informatics support. Journal of Biomedical Informatics, 42(2), 377–381. 10.1016/j.jbi.2008.08.010 [DOI] [PMC free article] [PubMed] [Google Scholar]
  30. Harvey, G. , & Kitson, A. (2015). PARIHS revisited: From heuristic to integrated framework for the successful implementation of knowledge into practice. Implementation Science, 11, 33. 10.1186/s13012-016-0398-2 [DOI] [PMC free article] [PubMed] [Google Scholar]
  31. Latimer, S. , Chaboyer, W. , & Gillespie, B. (2016). Pressure injury prevention strategies in acute medical inpatients: An observational study. Contemporary Nurse, 52(2/3), 326–340. 10.1080/10376178.2016.1190657 [DOI] [PubMed] [Google Scholar]
  32. Li, J. , Li, Z. , & Wu, X. (2024). The practice and facilitators of, and barriers to, implementing individualized repositioning frequency: A national cross‐sectional survey of critical care nurses. Journal of Tissue Viability, 33, 89–95. 10.1016/j.jtv.2024.01.002 [DOI] [PubMed] [Google Scholar]
  33. Li, Z. , Lin, F. , Thalib, L. , & Chaboyer, W. (2020). Global prevalence and incidence of pressure injuries in hospitalised adult patients: A systematic review and meta‐analysis. International Journal of Nursing Studies, 105, 103546. 10.1016/j.ijnurstu.2020.103546 [DOI] [PubMed] [Google Scholar]
  34. Liang, H. , Hu, H. , Feng, L. , Wei, H. , Ying, Y. , & Liu, Y. (2023). The knowledge and attitudes on the prevention of pressure ulcers in Chinese nurses: A cross‐sectional study in 93 tertiary and secondary hospitals. International Wound Journal, 21, e14593. 10.1111/iwj.14593 [DOI] [PMC free article] [PubMed] [Google Scholar]
  35. Lovegrove, J. , Fulbrook, P. , & Miles, S. (2018). Prescription of pressure injury preventative interventions following risk assessment: An exploratory, descriptive study. International Wound Journal, 15(6), 985–992. 10.1111/iwj.12965 [DOI] [PMC free article] [PubMed] [Google Scholar]
  36. Lovegrove, J. , Fulbrook, P. , & Miles, S. (2020a). Relationship between prescription and documentation of pressure injury prevention interventions and their implementation: An exploratory, descriptive study. Worldviews on Evidence‐Based Nursing, 17(6), 465–475. 10.1111/wvn.12473 [DOI] [PubMed] [Google Scholar]
  37. Lovegrove, J. , Fulbrook, P. , & Miles, S. (2020b). International consensus on pressure injury preventative interventions by risk level for critically ill patients: A modified Delphi study. International Wound Journal, 17(5), 1112–1127. 10.1111/iwj.13461 [DOI] [PMC free article] [PubMed] [Google Scholar]
  38. Lovegrove, J. , Fulbrook, P. , Miles, S. J. , & Steele, M. (2021). Effectiveness of interventions to prevent pressure injury in adults admitted to acute hospital settings: A systematic review and meta‐analysis of randomised controlled trials. International Journal of Nursing Studies, 122, 104027. 10.1016/j.ijnurstu.2021.104027 [DOI] [PubMed] [Google Scholar]
  39. Lovegrove, J. , Miles, S. , & Fulbrook, P. (2018). The relationship between pressure ulcer risk assessment and preventative interventions: A systematic review. Journal of Wound Care, 27(12), 862–875. 10.12968/jowc.2018.27.12.862 [DOI] [PubMed] [Google Scholar]
  40. Lovegrove, J. , Ven, S. , Miles, S. J. , & Fulbrook, P. (2023). Comparison of pressure injury risk assessment outcomes using a structured assessment tool versus clinical judgement: A systematic review. Journal of Clinical Nursing, 32(9–10), 1674–1690. 10.1111/jocn.16154 [DOI] [PubMed] [Google Scholar]
  41. Marzban, S. , Najafi, M. , Agolli, A. , & Ashrafi, E. (2022). Impact of patient engagement on healthcare quality: A scoping review. Journal of Patient Experience, 9, 23743735221125439. 10.1177/23743735221125439 [DOI] [PMC free article] [PubMed] [Google Scholar]
  42. Moore, Z. , Johansen, E. , van Etten, M. , Strapp, H. , Solbakken, T. , Eskerud Smith, B. , & Faulstich, J. (2015). Pressure ulcer prevalence and prevention practices: A cross‐sectional comparative survey in Norway and Ireland. Journal of Wound Care, 24(8), 333–339. 10.12968/jowc.2015.24.8.333 [DOI] [PubMed] [Google Scholar]
  43. Munoz, N. , & Posthauer, M. E. (2022). Nutrition strategies for pressure injury management: Implementing the 2019 international clinical practice guideline. Nutrition in Clinical Practice, 37(3), 567–582. 10.1002/ncp.10762 [DOI] [PubMed] [Google Scholar]
  44. Nghiem, S. , Campbell, J. , Walker, R. M. , Bynes, J. , & Chaboyer, W. (2022). Pressure injuries in Australian public hospitals: A cost of illness study. International Journal of Nursing Studies, 130, 104191. 10.1016/j.ijnurstu.2022.104191 [DOI] [PubMed] [Google Scholar]
  45. Norton, D. , McLaren, R. , & Exton‐Smith, A. N. (1962). An investigation of geriatric nursing problems in hospital. National Corporation for the Care of Old People. [Google Scholar]
  46. Padula, W. V. , & Delarmente, B. A. (2019). The national cost of hospital‐acquired pressure injuries in the United States. International Wound Journal, 16(3), 634–640. 10.1111/iwj.13071 [DOI] [PMC free article] [PubMed] [Google Scholar]
  47. Papanikolaou, P. , Lyne, P. , & Anthony, D. (2007). Risk assessment scales for pressure ulcers: A methodological review. International Journal of Nursing Studies, 44(2), 285–296. 10.1016/j.ijnurstu.2006.01.015 [DOI] [PubMed] [Google Scholar]
  48. Rodgers, K. , Sim, J. , & Clifton, R. (2021). Systematic review of pressure injury prevalence in Australian and New Zealand hospitals. Collegian, 28(3), 310–323. 10.1016/j.colegn.2020.08.012 [DOI] [Google Scholar]
  49. Rycroft‐Malone, J. (2004). The PARIHS framework – A framework for guiding the implementation of evidence‐based practice. Nursing Care Quality, 19(4), 297–304. 10.1097/00001786-200410000-00002 [DOI] [PubMed] [Google Scholar]
  50. Song, Y. , Shen, H. , Cai, J. , Zha, M. , & Chen, H. (2019). The relationship between pressure injury complication and mortality risk of older patients in follow‐up: A systematic review and meta‐analysis. International Wound Journal, 16(6), 1533–1544. 10.1111/iwj.13243 [DOI] [PMC free article] [PubMed] [Google Scholar]
  51. Sving, E. , Idval, E. , Högberg, H. , & Gunningberg, L. (2014). Factors contributing to evidence‐based pressure ulcer prevention. A cross‐sectional study. International Journal of Nursing Studies, 51(5), 717–725. 10.1016/j.ijnurstu.2013.09.007 [DOI] [PubMed] [Google Scholar]
  52. Tervo‐Heikkinen, T. , Heikkilä, A. , Koivunen, M. , Kortteisto, T. , Peltokoski, J. , & Salmela, S. (2023). Nursing interventions in preventing pressure injuries in acute inpatient care: A cross‐sectional national study. BMC Nursing, 22, 198. 10.1186/s12912-023-01369-8 [DOI] [PMC free article] [PubMed] [Google Scholar]
  53. Tubaishat, A. , & Aljezawi, M. (2013). The prevalence of pressure ulceration among Jordanian hospitalised patients. Journal of Wound Care, 22(6), 305–310. 10.12968/jowc.2013.22.6.305 [DOI] [PubMed] [Google Scholar]
  54. Van Dishoeck, A. , Looman, C. W. N. , Steyerberg, E. W. , Halfens, R. J. G. , & Mackenbach, J. P. (2016). Performance indicators; the association between the quality of preventative care and the prevalence of hospital‐acquired skin lesions in adult hospital patients. Journal of Advanced Nursing, 72(11), 2818–2830. 10.1111/jan.13044 [DOI] [PubMed] [Google Scholar]
  55. von Elm, E. , Altman, D. G. , Egger, M. , Pocock, S. J. , Gøtzsche, P. C. , & Vandenbroucke, J. P. (2007). Strengthening the reporting of observational studies in epidemiology (STROBE) statement: Guidelines for the reporting of observational studies. BMJ, 335, 806. 10.1136/bmj.39335.541782.AD [DOI] [PMC free article] [PubMed] [Google Scholar]
  56. Wan, C. W. , Cheng, H. , Musgrave‐Takeda, M. , Liu, M. G. , Tobiano, G. , McMahon, J. , & McInnes, E. (2023). Barriers and facilitators to implementing pressure injury prevention and management guidelines in acute care: A mixed‐methods systematic review. International Journal of Nursing Studies, 145, 104557. 10.1016/j.ijnurstu.2023.104557 [DOI] [PubMed] [Google Scholar]
  57. Wang, I. , Walker, R. M. , Gillespie, B. , Scott, I. , Sugathapala, R. D. U. , & Chaboyer, W. (2024). Risk factors predicting hospital‐acquired pressure injury in adult patients: An overview of reviews. International Journal of Nursing Studies, 150, 104642. 10.1016/j.ijnurstu.2023.104642 [DOI] [PubMed] [Google Scholar]
  58. Waterlow, J. (2005). Waterlow score card . http://www.judy‐waterlow.co.uk/the‐waterlow‐score‐card.htm
  59. Webster, J. , Coleman, K. , Mudge, A. , Marquart, L. , Gardner, G. , Stankiewicz, M. , Kirby, J. , Vellacott, C. , Horton‐Breshears, M. , & McClymont, A. (2011). Pressure ulcers: effectiveness of risk‐assessment tools: A randomised controlled trial (the ULCER trial). BMJ Quality & Safety, 20(4), 297–306. 10.1136/bmjqs.2010.043109 [DOI] [PubMed] [Google Scholar]

Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Supplementary Materials

Appendix S1

JAN-81-5315-s001.docx (145.1KB, docx)

Appendix S2

JAN-81-5315-s002.doc (95.5KB, doc)

Data Availability Statement

The data that support the findings of this study are available on request from the corresponding author. The data are not publicly available due to privacy or ethical restrictions.

Articles from Journal of Advanced Nursing are provided here courtesy of Wiley

RESOURCES