Skip to main content

Pressure Ulcer Monitoring: A Process of Evidence-Based Practice, Quality, and Research

Buy Article:

$12.00 plus tax (Refund Policy)


Background: A number of settings in eastern Ontario, Canada, have collaborated on establishing a common pressure ulcer monitoring system. This work was undertaken in a proactive effort to implement practice guideline recommendations related to pressure ulcer prevention. The monitoring system was developed at The Ottawa Hospital (Ottawa, Ontario, Canada), an acute care teaching hospital, and then shared with multiple settings, which adopted it.

Methods: A work group was formed with clinical, quality, and research expertise. In a prospective (rather than retrospective) chart audit, 12-hour point prevalence surveys are conducted in which risk, occurrence, and interventions are tracked. Trained surveyors conduct a standard risk appraisal, head-to-toe skin assessment, and chart scan. Reporting mechanisms were developed at the organization, program, and unit levels.

Results: Between 2001 and 2007, despite an inpatient population of which usually more than 25% were at "high" risk, prevalence decreased from 18% to 14%.

Recommendations: Fifteen years' experience in pressure ulcer monitoring suggests the following recommendations: (1) create and enable skin care champions to monitor and develop unit-based solutions in response to survey findings; (2) embed monitoring in the quality and professional practice infrastructure of the organization; (3) use existing structures and processes such as unit councils or quality committees; quality processes and practice panels are ideal venues to situate pressure ulcer monitoring at both organizational and unit levels; and (4) create a data collection process that is as clinically sensible and feasible as possible.

Summary and Conclusions: Monitoring is the linchpin that formed the foundation for the long-term, systemwide undertaking of the prevention of pressure ulcers and that created the climate for change and continued momentum.

Document Type: Research Article

Publication date: 2008-06-01

More about this publication?
  • The Joint Commission Journal on Quality and Patient Safety will be published by Elsevier beginning in 2017! For readers who receive access to the journal through their institutions, the journal can now be found on ScienceDirect ( For librarians looking to subscribe to the journal for their institutions please contact your Elsevier Account Manager or visit for more information. All other readers, please visit to subscribe to the journal or to claim your access for an existing subscription.
  • Editorial Board
  • Information for Authors
  • Subscribe to this Title
  • Information for Advertisers
  • Reprints and Permissions
  • Index
  • Ingenta Connect is not responsible for the content or availability of external websites
  • Access Key
  • Free ContentFree content
  • Partial Free ContentPartial Free content
  • New ContentNew content
  • Open Access ContentOpen access content
  • Partial Open Access ContentPartial Open access content
  • Subscribed ContentSubscribed content
  • Partial Subscribed ContentPartial Subscribed content
  • Free Trial ContentFree trial content
Cookie Policy
Cookie Policy
Ingenta Connect website makes use of cookies so as to keep track of data that you have filled in. I am Happy with this Find out more