Nursing 114 Journal

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Pressure Injury Prevention in Patients with Prolonged ED Stays Prior to Admission

Hospital-acquired pressure injuries often begin in the ED.

Pressure injuries (PIs) are painful and put patients at risk for serious infection; there- fore, they require greater use of costly health

care services and are potentially devastating to patients’ overall health. Hospital-acquired PIs (HAPIs) are preventable adverse events that can result in increased length of stay and greater hos- pital costs; the Agency for Healthcare Research and Quality considers them “never events.”1 Despite efforts to reduce PIs, approximately 2.5 million Americans in acute care facilities develop them each year,2 and an estimate often cited over the past 15 years is that 60,000 patients die every year from complications related to PIs.3 Regard- ing costs, Bauer and colleagues analyzed all inpa- tient PIs recorded in the U.S. Nationwide Inpatient Sample database from 2008 to 2012 and found that the median total cost was $36,500 (mean, $72,000; SD, $122,900).4

The setting for this evidence-based practice (EBP) project was a tertiary academic medical center where approximately 75% of patients admitted to

the hospital enter via the ED. Historically, ED care and culture have focused on acute life-threatening problems rather than chronic conditions in geriatric patients. The focus on emergent conditions often distracts ED staff from addressing and evaluating risk factors that contribute to skin compromise.5, 6

Changes in the ED population. There have been significant changes in the types of patients presenting to the ED over the past 10 to 15 years.7 Today, adult patients presenting to EDs are gener- ally older and have more comorbid conditions on admission. Therefore, the emergency nurse holds a key position in HAPI prevention. However, not all patients cared for in the ED are admitted to the hospital, and once the decision is made to admit a patient, there may be delays until a bed on an acute care unit becomes available. Sometimes the lack of an available bed can lead to prolonged stays in the ED. This waiting period between the writing of an admission order and transfer of the patient to an inpatient unit is known as boarding time.

ABSTRACT Purpose: The purpose of this project was to examine whether initiating a standardized pressure injury (PI) assessment and prevention protocol early in adult patients’ ED stay reduces hospital-acquired PIs (HAPIs) in those patients admitted from the ED to acute care inpatient medical units.

Methods: A nurse-led evidence-based practice team studied the problem of increasing HAPIs on four acute care inpatient units and found that, among patients who had been admitted to inpatient care from the ED, longer ED boarding times correlated with a higher rate of HAPIs. ED staff and acute care unit nurses collaborated to develop new protocols to prevent HAPIs in the ED, including staff education and standard- ized assessments and prevention care for at-risk patients. Data collection was performed at three time pe- riods over approximately two and a half years: baseline, intervention, and postintervention.

Results: The incidence rate for HAPIs decreased from 3.56 per 1,000 patient-days at baseline to 1.31 per 1,000 patient-days during the intervention period. This reduction was sustained over the next five months, during which the HAPI incidence rate was 1.53 per 1,000 patient-days.

Implications: At a time when ED length of stay is difficult to manage and continues to increase, the use of evidence-based interventions and protocols can reduce the rate of PIs in high-risk patients waiting for hospital admission, leading to a reduction in PI rates and overall hospital costs.

Keywords: evidence-based practice, hospital-acquired pressure injury, pressure injury, pressure ulcer, prevention, skin assessment

CULTIVATING QUALITY

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By Amanda Edwards, BSN, RN, CBCN, Novi Sitanggang, BSN, RN, Kelly Wolff, BSN, RN, Jewel Role, BSN, RN, Trisha Cardona, BSN, RN, Myra Sanchez, and Patricia Radovich, PhD, CNS, FCCM

Environmental factors in the ED. The ED is one of the most common entry points in hospital admis- sion, and patients admitted through the ED can be exposed to prolonged positioning on hard surfaces such as backboards, stretchers, and radiology tables. Additionally these patients may be trans- ferred between a stretcher and other surfaces both in the ED and during their hospital stay.6, 8 These factors increase the likelihood that PIs will develop in at-risk patients.9

Two studies we reviewed found that patients were experiencing prolonged stays (two hours or more) in the ED.10, 11 HAPIs can occur in as little as two hours of unrelieved pressure, and a significant number of patients have much longer ED stays. Bjorklund and colleagues determined PI prevention was feasible in the ED, noting risk assessment was vital in early prevention.8

An international meta-analysis that examined Australian, French, Canadian, and U.S. studies of PI development in the ED found that even in short stays, PIs are a common complication.11 The researchers included six studies with eight cohorts and sample sizes ranging from 152 to 32,664 and found ED PI incidence ranging from 0.38% to 19.1%. A recent study by Fullbrook and colleagues supports the findings of the meta-analysis, with PIs identified in 11 of 212 participants, a prevalence of 5.2% at presentation.12 The researchers found that a significant number of these patients were admit- ted to the hospital, a prevalence of 7.8% at this entry point. The study supports the finding that patients with HAPIs have spent longer periods of time in the ambulance and the ED.

HAPI prevention. McInnes and colleagues’ 2011 systematic review of 59 randomized clinical trials found that high-tech foam alternatives to standard hospital foam mattresses, such as viscoelastic and other polymer-based foams, reduced the incidence of PIs in at-risk patients (risk ratio, 0.40; 95% CI, 0.21-0.74); however, they didn’t find a clear differ- ence in the benefits derived from alternating versus constant low-pressure devices.13 Kalowes and col- leagues’ 2016 study found that use of a soft silicone foam dressing combined with preventive care yielded a statistically and clinically significant bene- fit in reducing the incidence rate and severity of HAPIs in ICU patients.14 Cubit and colleagues also noted bilayer foam dressings are particularly helpful when used in the ED.15

According to the Joint Commission’s ethics/equal standard of care provision (standard LD.04.03.07), “Patients with comparable needs receive the same standard of care, treatment, and services through- out the hospital.”16 Therefore, patients who receive

admission orders while physically in the ED and waiting for a bed are to receive the same standard of care as inpatients, and implementing best prac- tices in PI prevention in the ED is necessary before admission to an inpatient unit.

DESCRIPTION OF THE PROBLEM A group of nurses, one from each of four acute care medical units, formed an EBP team in February 2015, adding a patient care assistant (PCA) who also worked in acute care. In March and April, the team members received training in EBP using the Johns Hopkins Nursing Evidence-Based Practice Model,17 and in June, they began to identify prob- lems in their practice area that might be addressed with an EBP approach.

Increase in HAPIs. By July 2015, the EBP team became concerned that HAPIs were increasing on their units and decided to monitor the situation. The team learned that the only supplies used in the ED to prevent HAPIs were pillows, sheets, gauze, diapers, and lotions. Other useful supplies, such as

ED patients often spend hours on hard surfaces such as back- boards and stretchers. Photo by Jonathan Torgovnik / Getty Images News.

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barrier creams, multilayer foam dressings, wound rulers, and cameras, were not readily available in the ED. To address this need, the team recruited a float nurse who served as a supply manager. The team performed an assessment to determine what supplies were available and accessible to the ED staff. With the collaboration of the supply manager and advice from the hospital’s wound and ostomy care nurse, most of these supplies, including barrier creams, multilayer foam dressings, and wound rul- ers, were acquired and placed in specific locations close to patient care areas in the ED.

In September 2015, the team determined that they needed to expand and conduct a root cause analysis of 25 HAPIs that had occurred on the four acute care units between May and August. In addi- tion to the float nurse, two additional RNs, from the ED and wound care department, joined the team.

To investigate whether other factors arising along the continuum of care might have contributed to HAPI development, the root cause analysis wasn’t limited to the acute care units. The acute care nurses identified patients who had been admitted from the ED as those who had developed HAPIs. Further, they identified ED boarding time as a potential fac- tor in the increasing number of HAPIs. The team decided to explore the problem and the literature in depth. They found that the average ED boarding time among patients who developed HAPIs after being admitted to acute care was 13.11 hours, a duration similar to those found in the literature. (A separate Lean Six Sigma initiative, begun in June 2016, to reduce boarding times and improve throughput in the hospital, serves as an illustration of the difficulty in achieving positive results in this area: despite the initiative, the range of ED boarding times increased from six to 12 hours before the ini- tiative to 16 to 55 hours by January 2017.)

In addition to the root cause analysis, in Septem- ber and October 2015, the team conducted a retro- spective chart review of patients who had developed HAPIs. Many of the patients admitted to acute care units weren’t able to move independently or had conditions that hindered their awareness of the need to change position. The EBP team saw, based on the lack of documentation of skin assessment and provision of interventions, that the preventive skin care in the ED was highly variable.

Purpose of the project. The aim of this EBP proj- ect was to determine whether initiating a standard- ized PI assessment and prevention protocol early in adult patients’ ED stay would reduce HAPIs in those admitted from the ED to acute care inpatient medi- cal units.

METHODS The setting for this EBP project was four 26-bed acute care units with a complex patient population; prevalent diagnoses included various cancers, acute kidney injury, chronic kidney disease, liver failure, stroke, HIV–AIDS, uncontrolled diabetes, nonheal- ing wounds, coronary artery disease, sepsis, gall- bladder disease, acute respiratory failure, drug and/ or alcohol overdose, and myocardial infarction. The acute care units had an established process for initi- ation of PI prevention upon patient admission. This process included a head-to-toe skin assessment con- ducted simultaneously by two clinical nurses, docu- mentation of all wounds or areas of skin injury or both, the application of foam dressings to bony prominences, and frequent adjustments to the patient’s position to reduce pressure on high-pressure areas (off-loading).

Baseline data collection. To obtain a baseline measure of the incidence of HAPIs, the EBP team conducted a retrospective review to identify all PIs found between ED transfer to the four acute care units and hospital discharge from May through August 2015. The team also reviewed notes entered into patients’ electronic health records (EHRs) in the ED and the four acute care units for data spe- cific to skin assessment and for patient scores on the Braden Scale for Predicting Pressure Sore Risk (www.bradenscale.com). We found documented skin assessments of very few ED patients, with few documented interventions. The incidence rate of HAPIs over these four months was 3.56 per 1,000 patient days. Because the literature indicated that prolonged ED stays (two hours or more) are a factor in HAPI development, the EBP team also collected data on how much time patients spent in the ED prior to transfer. We documented which patients received preventive interventions from ED staff, including skin assessment, toileting, skin care, off-loading of pressure from bony prominences with pillows or wedges, and frequent turning in bed. Based on this information, the EBP team deter- mined that a standardized evidence-based approach to PI prevention needed to be initiated in the ED and continued in the acute care setting to increase the assessment rate and prevention of skin break- down.

Prevention protocol development. The EBP team used the Johns Hopkins model to develop the HAPI prevention protocol.17 The model comprises a three-step process known as PET—practice ques- tion, evidence, and translation—meant to ensure that the latest research findings and best practices are quickly and appropriately incorporated into patient care. The EBP team conducted a literature

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review using the Academic Search Premier, CINAHL, and PubMed databases. The keywords used in the search, singly and in combination, were pressure injury, pressure, skin breakdown, injury, emergency department, chronic conditions, preven- tion, nursing, and interventions. Thirty-one articles were identified, and 12 were excluded because of lack of relevance or low-quality evidence. The team rated the remaining 19 articles, which included ran- domized controlled trials, systematic reviews, and quasi-experimental and exploratory descriptive research, and found they were of good to high qual- ity (in the range of I to III on the Johns Hopkins Evidence Level and Quality Guide18), with sufficient sample sizes and consistently generalizable results.

The EBP team assessed these articles as relevant to the purpose of the initiative and used them in devel- oping this evidence-based project.

PI prevention protocol. First, the EBP team col- laborated with wound care and ED nurses and emergency technicians to understand current care practices in the ED. Second, the EBP team devel- oped educational tools for the nursing staff in the ED and acute care areas. Third, based on the literature, the team developed two standardized PI prevention bundles to use for risk assessment and initiation of preventive measures in the ED and on the four acute care units.

In the ED, the bundle included the identification of necessary skin prevention supplies, staff education

Table 1. Standardized Nursing Processes for HAPI Prevention in the ED and on Acute Care Units

Nursing Process

Responsible Staff A: ED RN B: Acute care unit RN C: ED technician/PCA Details

Documentation of Braden subscales

A, B Use Braden subscales in assessment, including two- RN skin checks on admission and on every shift in high-risk patients with a Braden score of 14 or less.

Photo documentation of wounds

A, B Document wounds on admission and/or upon dis- covery, upon transfer from ED to acute care unit, at a change in staging, and at discharge.

Initiation of specific skin care interventions (based on Braden subscale score)

A, B, C Initiate prevention interventions using Braden sub- scale scoring in high-risk patients. Increase communi- cation between RN and technician/PCA regarding prevention plan.

Two-RN skin check A, B Initiate skin assessment using two-RN evaluation at the bedside on admission and on every shift for patients with a Braden score of 14 or less.

High-risk patient care A, B, C Use patient mobility devices and 2 to 4 persons to perform turning on schedule.

Early notification of change in patient status

C Notify RN of presence of redness, wounds, or prob- lems or changes in transfer ability or mobility. Per- form ongoing moisture control and interventions. Maintain interventions based on RN assessment of Braden score.

Monitor nutritional intake A, B, C Encourage nutritional intake; address NPO status of more than 8 hours with provider.

RN handoff A, B Include skin assessment, concerns, and interventions in handoff.

Education A, B, C Using PowerPoint, educate staff on Braden assess- ment, documentation, and interventions targeting at-risk ED patients, including data points from the EBP project.

EBP = evidence-based practice; HAPI = hospital-acquired pressure injury; NPO = nil per os, or nothing by mouth; PCA = patient care assistant.

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on how to use those supplies, and designation of easily accessible supply storage areas; staff educa- tion on detailed skin assessment,8 including specific risk factors for PI,3, 8 such as a Braden Scale score of less than 14, an altered level of consciousness, impaired mobility, impaired ability to communi- cate, skin moisture, continence problems, problems with nutritional intake, prolonged time in one posi- tion,13 extended time in transport, and more than six hours spent in the ED; and staff education on documentation of assessments in the EHR and the risks of injury associated with time in the ED of more than six hours.

On the acute care units, initial skin assessments by two RNs was considered the standard of care, but the initiation and documentation of these assessments was variable. The acute care unit bun- dle included explicit reinforcement of the need for the two-RN assessment, plus education on the necessity of conducting it within four hours of transfer to the acute care unit (a previously estab- lished organizational policy); education on the assessment of factors that increase the risk of HAPI development (as specified above); reinforcement of the use of preventive interventions (preventive foam dressings, turning frequency, reassessment needs)6, 13; and instructing PCAs to look out for any redness when turning, incontinence, or self-care problems or changes, and to notify the RN if any of those occurred. As part of the new protocol, RNs part- nered with PCAs to ensure ongoing assessments throughout the shift. The PCAs were also educated on the need to monitor a patient’s nutritional intake; to monitor the amount of time a patient spent on a bedpan, sitting up in a chair, or being transported via wheelchair for diagnostic testing; and to notify their RN partners of any changes or new problems as they arose.

At the same time as we began our project, the hospital restructured ED staffing, adding float nurses to care for patients who had long boarding times. Therefore, we included the ED float nurses in our educational efforts.

Implementation. After the EBP team developed the HAPI prevention bundles, these were estab- lished as protocols and were implemented from August through October 2016.

Equipment and supplies. The EBP team identi- fied areas in the ED for storing prevention sup- plies, including foaming cleanser, barrier creams, and multilayer foam dressings, and arranged to allocate such supplies for easier accessibility. The availability of air mattress overlays was extended to the ED for off-loading pressure in at-risk patients.

Standardizing nursing processes. The EBP team standardized nursing processes in the ED and extended these processes to the four acute care units to enhance consistency through care transitions and to streamline assessment and interventions for PIs (see Table 1). These processes were added to the EHR documentation as part of the institution’s standard core measures.

Education. As noted above, the EBP team had determined that the ED nursing staff weren’t sure how to assess the skin of patients for PI prevention and staging. To ameliorate the knowledge deficit, the team offered educational resources, including a PowerPoint presentation with real wound examples and the hospital’s internal wound care website, to the float nurse and the ED educators and managers who, in turn, educated staff members in staff meet- ings and in-service sessions. Most education ses- sions and practice changes occurred in the ED set- ting. Education on HAPI prevention was extended to other members of the health care team, including ED technicians and ED and acute care unit PCAs. Technicians and PCAs provided direct patient care, which included assistance with activities of daily liv- ing such as bathing, dressing, and grooming, as well as continued observation according to nursing assessment guidelines. These roles made them valu- able in the observation of any changes in a patient’s skin integrity. Educational updates were also pro- vided to the inpatient nursing staff during staff meetings.

It should be noted that the institution does not require EBP projects to be evaluated by the univer- sity’s institutional review board.

Data analysis was conducted using SPSS soft- ware, version 21. Pertinent clinical data including the incidence of HAPIs and the number of hours patients spent in the ED were summarized using descriptive statistics. Pearson correlation was calcu- lated to analyze the association between ED board- ing times and the occurrence of HAPI. One-way analysis of variance (ANOVA) was used to compare the mean ED boarding times, in hours, of the base- line and intervention groups. The α level was set at = 0.05 for all inferential analyses; therefore, P < 0.05 was considered significant.

RESULTS Correlation between HAPI incidence and ED boarding time in the baseline group (May to August 2015) was significant (P = 0.013), prompting fur- ther examination of the data. In the baseline group (N = 25), the mean boarding time was 13.11 hours (median, 11.5; range, 3 to 29; SD, 7.7). In the inter- vention group (N = 7), between June and August

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2016, the mean boarding time was 18.14 hours (median, 16; range, 8 to 30; SD, 7.19). Analysis of intervention group data found that the incidence rate for HAPIs decreased to 1.31 per 1,000 patient- days from 3.56 per 1,000 patient-days in the base- line period. There was a 72% reduction in HAPIs from the 25 in the baseline group to the seven in the intervention group.

The EBP team then conducted a postintervention review from October 2016 to January 2017 to eval- uate the effects of the intervention. In the postinter- vention period, HAPIs occurred at an incidence rate of 1.53 per 1,000 patient-days, demonstrating a sustained reduction from baseline. The mean board- ing time in the postintervention group (N = 8) remained elevated at 20.11 hours (median, 20.2; range, 7 to 31; SD, 11.32). See Figure 1.

DISCUSSION Patients who are immobile, incontinent, unable to voice their needs, or any combination of these, are at higher risk for HAPIs, regardless of the hospital department in which they’re located. Because HAPIs can be prevented by assessing patients early in their hospital stay and implementing preventive interventions, preventive care must begin in the ED. Prior to this project, HAPI prevention began when patients were admitted to an acute care unit, which was often too late, as injuries had already occurred. Given the added expense of caring for patients who have acquired PIs, the reduction in HAPI incidence solely as a result of implementing prevention strate- gies, as demonstrated in this EBP project, represents a potentially enormous fiscal saving achieved at rel- atively little expense.

Before we began this EBP project, ED nursing staff had a large volume of patients who were at various levels of acuity, making skin assessment and HAPI prevention difficult. This resulted in a high rate of variability in skin assessment, hygiene, docu- mentation, and prevention care. We determined that in our baseline population there was an increased risk of HAPI development among those who experienced an ED boarding time of more than six hours.

The lack of easily accessible skin care supplies was another factor in PI incidence. In their system- atic review, McInnes and colleagues discussed the use of PI prevention supplies, such as low-pressure mattresses and overlays (“high-tech devices”), and Kalowes and colleagues discussed foam dressings (“low-tech devices”) that helped significantly reduce the rate of HAPIs.13, 14 These discussions in the liter- ature prompted us to make prevention supplies more accessible to ED nursing staff.

Figure 1. ED Boarding Times in the Baseline, Intervention, and Postintervention Groups

In the first phase of this project, the importance of a good handoff was captured by having the acute care unit nurses ask the ED staff about their patient’s skin integrity after transfer from the ED. To supplement the ED staffing and implement simi- lar prevention strategies, float nurses dedicated to caring for patients with admission orders were taught to provide complete assessments using the Braden Scale, with increased attention to the tool’s subscales, and to implement PI prevention for those patients deemed high risk. Skin care interventions included repositioning the patient every two hours, frequent perineal care and attention to excess mois- ture, applying skin barrier protectant, use of foam bilayer dressings, documentation and monitoring of PIs present prior to ED admission, and the continu- ation of wound care treatments after transfer to the

HR = incidence rate of hospital-acquired pressure injuries.

0 Baseline Group,

N = 25 May–Aug 2015

HR: 3.56

Intervention Group, N = 7

Jun–Aug 2016 HR: 1.31

Postintervention Group, N = 8

Oct 2016–Jan 2017 HR: 1.53

2

4

6

8

10 N

um be

r o f P

at ie

nt s

Hours Spent in ED

12

< 6 hours 6–12 hours 13–24 hours > 24 hours14

16

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acute care units. The presence of the float nurse team affected the project positively in other ways; their presence created extra support for the ED staff and patients and fostered a sense of collaboration with the ED’s regularly scheduled staff.

Limitations. This EBP project was conducted on a small number of units in a single organization. While our organization’s medical patients are com- plex, with a wide range of comorbidities, other populations that include trauma patients or those with neurological conditions may also benefit from a wider perspective on caring for patients at risk for PI and HAPI development. Such facilities and oth- ers with different processes or populations may not have the same outcomes.

Implications. ED clients have more complexity and higher acuity than ever before. Although nurses and others are working to improve patient flow throughout their organizations, it is imperative that skin care and PI prevention begin in the ED, at the point of admission, and continue to be part of long- term goals for patients at high risk for PIs. These patients require assessment and prevention at all points in the continuum of care. The ideal solution for decreasing the incidence of HAPIs is to improve the knowledge and understanding of nursing staff who care for high-risk patients. The success of this EBP project depended largely on the willingness of patient care staff to participate in education and change initiatives relating to HAPI prevention and on empowering staff to care for this population and accept accountability for any increase in the inci- dence of skin injury.

Standardizing the assessment process and giving ED nurses easy access to the tools and supplies required for adequate assessment early in patients’ hospital stay can make frontline prevention of skin injury a reality. The use of additional acute care nurses with experience and expertise in HAPI pre- vention is essential. Protocols regarding positioning, skin and wound care, and the use of protective dressings can be easily implemented in high-risk patients by educating and motivating existing staff, thus making prevention initiatives cost effective. Further research addressing interventions in the ED should be performed and disseminated among ED providers, promoting among organizations the sharing of knowledge and strategies that enhance the safety and security of patients. ▼

Amanda Edwards is a nurse navigator at Loma Linda University Medical Center in Loma Linda, CA, where Novi Sitanggang is an interim patient care director, Kelly Wolff and Jewel Role are clin- ical nurses, Myra Sanchez is a patient care assistant, and Patricia Radovich is director of nursing research. Trisha Cardona is a clin- ical nurse at Community Hospital of the Monterey Peninsula in

Monterey, CA. Contact author: Amanda Edwards, akedwards@ llu.edu. The authors have disclosed no potential conflicts of inter- est, financial or otherwise.

REFERENCES 1. Patient Safety Network. Patient safety primer. Never events.

2019. https://psnet.ahrq.gov/primer/never-events. 2. Berlowitz D, et al. Preventing pressure ulcers in hospitals: a

toolkit for improving quality of care. Rockville, MD: Agency for Healthcare Research and Quality; 2014 Oct. Publication: 11-0053-EF. https://www.ahrq.gov/sites/default/files/publications/ files/putoolkit.pdf.

3. Denby A, Rowlands A. Stop them at the door: should a pressure ulcer prevention protocol be implemented in the emergency department? J Wound Ostomy Continence Nurs 2010;37(1):35-8.

4. Bauer K, et al. Pressure ulcers in the United States’ inpatient population from 2008 to 2012: results of a retrospective nationwide study. Ostomy Wound Manage 2016;62(11):30-8.

5. Faulkner S, et al. The emergency department’s response to pressure ulcer crisis. Wounds UK 2015;11(2):20-5.

6. Santamaria N, et al. Preventing pressure injuries in the Emergency Department: current evidence and practice con- siderations. Int Wound J 2019;16(3):746-52.

7. Muntlin Athlin Å, et al. Heel pressure ulcer, prevention and predictors during the care delivery chain—when and where to take action? A descriptive and explorative study. Scand J Trauma Resusc Emerg Med 2016;24(1):134.

8. Bjorklund L, et al. The pressure is on! An innovative approach to address pressure ulcers in the ED setting. J Emerg Nurs 2012;38(2):159-64.

9. European Pressure Ulcer Advisory Panel (EPUAP), National Pressure Injury Advisory Panel (NPIAP), and the Pan Pacific Pressure Injury Alliance (PPPIA), editor. Prevention and treat- ment of pressure ulcers/injuries: clinical practice guideline. 3rd ed; 2019.

10. Dugaret E, et al. Prevalence and incidence rates of pressure ulcers in an Emergency Department. Int Wound J 2014; 11(4):386-91.

11. Liu P, et al. The incidence of pressure ulcers in the emer- gency department: a metaanalysis. Wounds 2017;29(1):14-9.

12. Fulbrook P, et al. Prevalence of pressure injury in adults presenting to the emergency department by ambulance. Aust Crit Care 2019;32(6):509-14.

13. McInnes E, et al. Preventing pressure ulcers—are pressure- redistributing support surfaces effective? A Cochrane sys- tematic review and meta-analysis. Int J Nurs Stud 2012; 49(3):345-59.

14. Kalowes P, et al. Five-layered soft silicone foam dressing to prevent pressure ulcers in the intensive care unit. Am J Crit Care 2016;25(6):e108-e119.

15. Cubit K, et al. Taking the pressure off in the emergency department: evaluation of the prophylactic application of a low shear, soft silicon sacral dressing on high risk medical patients. Int Wound J 2013;10(5):579-84.

16. Joint Commission, Division of Standards and Survey Methods. The Joint Commission 2009 requirements related to the provision of culturally competent patient-centered care hospital accreditation program (HAP). Oakbrook Terrace, IL; 2009. https://www.jointcommission.org/-/media/deprecated- unorganized/imported-assets/tjc/system-folders/assetmanager/ 2009_clasrelatedstandardshappdf.pdf.

17. Johns Hopkins Medicine, Center for Evidence-Based Practice. Johns Hopkins nursing evidence-based practice model. 2017. https://www.hopkinsmedicine.org/evidence- based-practice/ijhn_2017_ebp.html.

18. Johns Hopkins Medicine, Center for Evidence-Based Practice. Johns Hopkins nursing evidence-based practice. Appendix C: evidence level and quality guide. Baltimore, MD; 2017. https://www.hopkinsmedicine.org/evidence-based- practice/_docs/appendix_c_evidence_level_quality_guide.pdf.