Pressure mapping to prevent pressure ulcers in a hospital setting: A pragmatic randomised controlled trial

Pressure ulcers (PUs) cause suffering to patients (Gorecki et al., 2009) and costs to society (Demarré et al., 2015). The prevalence of PUs is used as a quality indicator worldwide and studies from hospital settings in different countries report prevalences from 0% to 46% (National Pressure Ulcer Advisory Panel [NPUAP], European Pressure Ulcer Advisory Panel, and Pan-Pacific Pressure Injury Alliance, 2014). Evidence-based international guidelines (NPUAP, 2014) were recently revised and are available to clinicians. A systematic review of 26 implementation studies suggests that key issues for success in PU prevention were the simplification and standardisation of PU-specific interventions and documentation, the involvement of multidisciplinary teams and leadership, designated skin champions, ongoing staff education, and sustained audit and feedback (Sullivan and Schoelles, 2013).

In 2007, a national patient safety initiative was launched by the Swedish Association of Local Authorities and Regions (SALAR). Preventing PUs is a prioritised area and Swedish national prevalence studies have been conducted annually since 2011. National goals are set, public reporting and benchmarking are available, and evidence-based guidelines have been disseminated free of charge to hospitals and nursing homes. Furthermore, a performance-based remuneration model was provided by the government to inspire hospitals to participate in the patient safety work in 2011–2015. Despite great effort on the national level to encourage the prevention of PUs, their prevalence remains high. In Swedish hospitals, the prevalence was 16.6% in 2011 and 13.4% in 2016 (Gunningberg et al., 2013a, SALAR, 2016).

Pressure relief through repositioning and the use of pressure-reducing mattresses, chair cushions, and heel cushions, for example, are the mainstay of preventive interventions (NPUAP, 2014; McInnes et al., 2015). International guidelines (NPUAP, 2014) do not recommend a specific time interval for repositioning. Instead, repositioning frequency should be individually determined with attention to the patient’s tissue tolerance, level of activity and mobility, general medical condition, overall treatment objectives, skin condition, and comfort. The most common locations for PUs are the sacrum and heels (Bredesen et al., 2015, Gunningberg et al., 2013a). Reducing the pressure at the interface between the patient’s body and the support surface is a valid clinical intervention for reducing the risk of pressure ulcer development (NPUAP, 2014). However, studies have revealed that both knowledge of how to reduce pressure and shear (Beeckman et al., 2011, Gunningberg et al., 2013b) and preventive interventions (repositioning and pressure-reducing equipment) are still lacking (Bredesen et al., 2015, Bååth et al., 2014).