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Review the limitations of the study of the researchers’ conclusions regarding the effectiveness of the dressing in preventing pressure ulcers. Would you, as a nurse manager, implement this particular dressing on a nursing unit with assurance that it would help prevent pressure ulcers? Why or why not?

Journal Club #3: Appraisal Worksheet

Student Names:


What sampling method used? What measures did the researchers take to reduce bias in their sampling method? Were their measures sufficient? Why or why not?

2. What extraneous variables did the exclusion criteria control for? Did this reduce bias in the sample? Why or why not?

3. How many people were in the sample? How many people were in the final data analysis? What explanation did the authors give for loss of numbers in the sample? Was this explanation sufficient?

©2016 American Association of Critical-Care Nurses

Pressure Ulcer Management

Background Patients in intensive care units are likely to
have limited mobility owing to hemodynamic instability
and activity orders for bed rest. Bed rest is indicated
because of the severity of the disease process, which
often involves intubation, sedation, paralysis, surgical
procedures, poor nutrition, low flow states, and poor cir-
culation. These patients are predisposed to the develop-
ment and/or the progression of pressure ulcers not only
because of their underlying diseases, but also because
of limited mobility and deconditioned states of health.
Objective To assess whether treating high-risk patients
with a prophylactic sacral dressing decreases the inci-
dence of unit-acquired sacral pressure ulcers.
Methods An evidence-based tool for identifying patients
at high risk for pressure ulcers was used in 3 intensive
care units at an urban tertiary care hospital and academic
medical center. Those patients deemed at high risk had
a prophylactic sacral dressing applied. Incidence rates
were collected and compared for the 7 months preced-
ing use of the dressings and for 7 months during the
trial period when the dressing was used.
Results After the sacral dressing began being used, the
number of unit-acquired sacral pressure ulcers decreased
by 3.4 to 7.6 per 1000 patient days depending on the unit.
Conclusions A prophylactic sacral dressing may help
prevent unit-acquired sacral pressure ulcers. Implemen-
tation of an involved care team with heightened aware-
ness and increased education along with a prophylactic
sacral dressing in patients deemed high risk for skin
breakdown are all essential for success. (American Jour-
nal of Critical Care. 2016;25:228-234)

By Jaime Byrne, RN, MSN, CCRN, Patricia Nichols, RN, MSN, CCRN, Marzena
Sroczynski, RN, BSN, CWOCN, Laurie Stelmaski, RN, BSN, CWON, Molly Stetzer,
RN, BSN, CWOCN, Cynthia Line, PhD, and Kristen Carlin, MPH


atients in intensive care units (ICUs) are predisposed to pressure ulcers because of

limited mobility and the severity of their disease processes. Pressure ulcers result

from pressure or a combination of pressure and shear, usually over bony promi-

nences, and cause localized injury to the skin and underlying tissues.1 The prevalence

of pressure ulcers in acute care settings is estimated at 12% to 19.7%, of which 20%

occur on the sacrum or coccyx.2 In ICUs, pressure ulcers rates can occur in 14% to 42% of

patients.3 For patients, pressure ulcers can be painful, embarrassing, isolating, and, in some

cases, life-threatening.4

The standard of care to prevent pressure ulcers

includes routine repositioning to offload pressure

points, moisture management, use of support sur-

faces, and assessment of nutritional requirements by

registered dietitians. Despite these practices designed

to mitigate risk, pressure ulcers continue to develop
in many high-risk ICU patients. In practice, pressure
ulcers are indicators of quality of care.5 The Joint
Commission considers prevention of health care–
associated pressure ulcers a National Patient Safety
Goal.6 The Institute for Healthcare Improvement
included pressure ulcer prevention in its 5 Million
Lives Campaign.7 More recently, the federal govern-
ment identified pressure ulcers as one of the hospi-
tal-acquired conditions included in the Agency for
Healthcare Research and Quality composite mea-
sure PSI-90.8 Hospital-acquired conditions are
included in 2 pay-for-performance programs under
the Patient Protection and Affordable Care Act that
have great implications for hospital finances: pen-
alties for hospital-acquired conditions and val-
ue-based purchasing incentives.9

Treatment of pressure ulcers is expensive, with
estimates of the cost at a mean of $1200 to $1600
per day.10 The Centers for Medicare and Medicaid
Services no longer reimburses facilities for pressure
ulcer care when the ulcers are acquired in the hospi-
tal.11 Starting in 2015, hospitals that rank among

the worst 25% for hospital-acquired conditions,

including pressure ulcers, will see their reimburse-

ment rates decline.12 Reducing the incidence of

pressure ulcers would not only reduce the negative

physical and psychological impact on patients and

improve patients’ outcomes, it might also reduce
costs and increase reim-
bursement for hospitals.
Yet, despite the widespread
recognition of the need to
prevent pressure ulcers in
critical care patients, chal-
lenges remain in the ability
to prevent them. Recent
studies indicate that silicone dressings may hold
promise for prevention of pressure ulcers. ICU
patients who received a soft silicone multilayered
foam dressing on the sacrum showed significantly
fewer pressure ulcers.13-



This study sought to evaluate the effects of a
prophylactic silicone adhesive hydrocellular sacral
foam dressing on incidence of sacral pressure ulcers
among high-risk ICU patients. The product for the
trial was chosen because the facility already used
Allevyn (Smith & Nephew) dressings of various sizes
and shapes for care of skin tears with good results
and the nurses were already familiar with this type
of product. The particular dressing used in this trial

is specifically designed for use on the difficult-to-fit
coccyx area.


This study was conducted in an urban tertiary
care academic medical center that is also a level I

trauma center with 951 licensed acute care beds.
Three ICUs at the institution participated in the

study: the surgical coronary care unit (SCCU), a
9-bed surgical cardiac ICU; the medical coronary

care unit (MCCU), a 9-bed medical cardiac ICU;
and a 25-bed medical ICU (MICU). The SCCU

generally provides care for patients after coronary

artery bypass surgery, valve replacement or repair,

About the Authors
Jaime Byrne is an intensive care clinical nurse specialist,
Marzena Sroczynski is a certified wound ostomy conti-
nence nurse specialist, and Laurie Stelmaski is a certified
wound ostomy nurse at Thomas Jefferson University
Hospital, Philadelphia, Pennsylvania. Patricia Nichols is
director of nursing education at Aria Health, Philadelphia,
Pennsylvania. Molly Stetzer is a certified wound ostomy
continence nurse specialist, Children’s Hospital of Phila-
delphia, Philadelphia, Pennsylvania. Cynthia Line is a proj-
ect manager and Kristen Carlin is a biostatistician, Office
of Nursing Research, Thomas Jefferson University Hospital.

Corresponding author: Jaime Byrne, RN, MSN, CCRN,
Thomas Jefferson University Hospital, 111 South 11th Street,
Philadelphia, PA 19107 (e-mail: AJCC AMERICAN JOURNAL OF CRITICAL CARE, May 2016, Volume 25, No. 3 229

In practice, pressure
ulcers are often
perceived as quality
of care indicators.


implantation of a ventricular assist device, heart

transplant, or extracorporeal membrane oxygenation

cannulation. The MCCU provides care for patients

who had a recent ST-segment elevation myocardial

infarction, cardiogenic shock, or heart failure with

decompensation and for patients who require opti-

mization before cardiothoracic surgery. The MICU

generally provides care for patients with liver failure,

respiratory failure requiring intubation and mechani-

cal ventilation, pulmonary hypertension, septic shock,

multisystem organ failure, and acute respiratory dis-

tress syndrome. The hospital’s standard mattress in

all 3 of these ICUs was the AtmosAir 9000 (KCI).

The study was approved by the institutional

review board and granted a waiver of consent. All
adults, aged 18 years and older, and admitted to
any of these ICUs were screened for inclusion in
the trial on the basis of their risk factors for skin
breakdown. Patients assessed as having any 1 of
the following criteria were included in the study:
surgery longer than 4 hours or cumulative surgeries
longer than 6 hours; cardiac arrest during this
admission; vasopressor use for more than 48 hours;
shock; sepsis; or multiorgan dysfunction syndrome.

If patients did not meet the afore-
mentioned singular criteria, they
were evaluated for the following:
age more than 65 years old; bed
rest; traction; diabetes; liver fail-
ure; hemodynamic instability;
body mass index (calculated as
weight in kilograms divided by
height in meters squared) less than
18.5 (underweight) or greater than
40 (morbid obesity); malnutri-
tion (prealbumin < 20 mg/dL, albumin < 2.5 g/dL, nothing by

mouth > 3 days); spinal cord injury (quadriplegia/

paraplegia); sedation/paralysis for more than 48

hours; history of pressure ulcers; mechanical venti-
lation for more than 48 hours; nitric oxide ventila-
tion; drive lines (left or right ventricular assist

device balloon pump, extracorporeal membrane

oxygenation); history of vascular disease; expected
length of stay greater than 5 days; intermittent
hemodialysis/continuous venovenous hemodialysis;

Braden score 12 or less; or orthopedic injuries. Any

patient who screened positive for 5 or more of these
conditions was included in the study.

Patients with any of the following conditions
were excluded from the study: urinary or fecal incon-

tinence not managed with a urinary catheter or fecal

management system, weeping edema or anasarca,
diaphoresis in sacral area, or preexisting sacral

pressure ulcer. Patients who were excluded from

the study could still receive the study dressing if a

wound ostomy and continence nurse (WOCN) rec-

ommended it, but those patients were not included

in the evaluation.

A prospective, nonrandomized, quasi-experimental

observational study was conducted to compare ICU-

acquired sacral pressure ulcers in patients assessed

at high risk for development of pressure ulcers before

and after implementing prophylactic use of silicone

adhesive hydrocellular sacral foam dressings. Base-

line data on the daily incidence of pressure ulcers

on the sacrum, buttocks, and coccyx were collected

for the 7 months before implementation of the

dressings, from October 2011 to April 2012. During
this 7-month period, a screening tool to determine
which patients were at high risk for pressure ulcer
development on the sacrum, buttocks, and coccyx
was developed after an extensive literature review.
This tool was validated by the 3 WOCNs employed
by the facility. In preparation for intervention data
collection, in February 2012, each participating ICU
conducted an informal evaluation of the screening
criteria for risk of pressure ulcers and the applica-
tion of the sacral dressing as prophylaxis. Registered
nurses were asked to assess patients using the screen-
ing criteria and apply the dressing as pressure ulcer
prophylaxis in patients who met screening criteria.
The nurses were also asked to evaluate the dressing
for ease of application, removal, wear time, patient
comfort, ease of repositioning,

and patient safety.

Overall, the nurses rated the aspects of the sacral
dressing positively. During this study preparation,
fewer than 10% of patients had clear fluid-filled
blisters related to moisture develop under the sacral
dressing. Following the review of these patients by
the WOCN, the screening criteria and follow-up

assessment criteria were clarified to minimize the risk
for blistering under the dressing during the interven-
tion phase. Before the intervention phase, staff in

all 3 units and the cardiothoracic operating room,

where patients had dressings applied before their
procedure, received education regarding the dressing
criteria tool, dressing application (Table 1), the data

collection tool (Figure 1), and dressing removal.

The intervention phase of this study occurred
from May through November 2012. During the trial
period, each adult patient who was admitted to any

of the 3 ICUs was assessed by a registered nurse upon

arrival to the unit and screened for study eligibility.
Patients who met inclusion criteria received a

prophylactic sacral dressing. The dressing used in
this study was the Allevyn Gentle Border Sacrum

Dressing manufactured by Smith & Nephew. Data

Nurses evaluated
the dressing for

ease of application,
removal, wear time,

patient comfort,
ease of repositioning,

and patient safety. AJCC AMERICAN JOURNAL OF CRITICAL CARE, May 2016, Volume 25, No. 3 231

on ICU-acquired pressure ulcers were collected

daily by clinical nurse specialists and registered

nurses for each unit.

Once the sacral dressing was applied to a patient,

an assessment was performed by the primary nurse

every shift (minimum every 12 hours) and docu-

mented on the data collection tool and in the

electronic medical record. Skin assessments were

completed per the hospital’s standard of nursing

care and included peeling back the sacral dressing

to perform a full skin inspection underneath. Also

documented on the data collection tool were assess-

ments of the skin condition under the dressing,

whether the dressing was reapplied or changed, and

the end date of the patient’s participation either

because the dressing was removed or because the

patient was transferred out of a participating ICU.
Each patient had a data collection tool for each
shift. Completed data collection tools were col-
lected weekly by each unit’s clinical nurse specialist.

To ensure appropriate assessment and clinical
care for patients with the sacral dressing, a mark
was placed next to the patient’s name on the unit’s
patient assignment board in the nurses’ break room.
The sacral dressing was changed every 3 days while
the patient remained in the study. Any patients who
had exclusion criteria develop after application of
the sacral dressing during this study had the dress-
ing removed. The removal date was noted on the
data collection tool as the end date of the patient’s
participation. If, during the study, any skin changes
occurred under the dressing, the dressing was removed
unless continued use was recommended by a WOCN.
Each event that required dressing removal was inves-
tigated by a WOCN, and if any further treatment
was recommended, it was implemented promptly.
In addition, because the study included patients at
very high risk for skin breakdown, any skin break-
down or redness was noted and a WOCN evaluated

further use of sacral dressing treatment.

Statistical Analysis
Data were entered into an Excel (Microsoft

Corp) spreadsheet and imported into IBM SPSS

Statistics 19 (IBM SPSS) for analysis. Descriptive

statistics were used to characterize the dressing use.
Pressure ulcer rates were calculated by using the
industry’s standardized rate per 1000 patient days.

Differences in pressure ulcer rates were obtained

by calculating incidence rate ratios and confidence
intervals. P values were calculated by using a 2 test.

Data from all 3 units (SCCU, MCCU, and MICU)

were combined for analysis. Of the 584 patients
assessed for inclusion, 243 (41.6%) had a sacral

dressing applied but completed data were received
on only 200 of those patients (Figure 2). Among
the 243 who had a sacral dressing applied, surgery
longer than 4 hours or cumulative surgeries longer
than 6 hours (32.5%, n = 79) and
sepsis (23.5%, n = 57) were the

most common singular inclusion
criteria (Figure 3). Table 2 lists the
characteristics for the 132 patients

who met inclusion criteria for 5

or more factors and had a sacral
dressing applied. The mean dura-
tion for a patient to have a dress-

ing in place was 3.26 days (SD,

3.17, n = 200), with a range of 0 to 24 days. In all,
71.5% (n = 143) of patients had a dressing applied
for 3 or fewer days.

Depending on the unit, implementation of the

sacral dressing reduced unit-acquired sacral pressure
ulcers anywhere from 3.4 to 7.6 per 1000 patient days.

The SCCU had the most dramatic reduction at 7.6
per 1000 patient days, the MCCU had a reduction

of 3.4/1000 patient-days, and the MICU reduced

rates by 3.6 per 1000 patient days (Table 3).

Table 1
Quick tips and daily expectations for
use of dressings

Quick tips

Key reminders
Refer to criteria checklist to iden-

tify proper patient
Place preventatively on clean dry

intact skin
Apply dressing before applying

any emollients (skin prep, pro-
tectants, wipes)

Check under dressing every 12
hours and document skin

Peel right or left top corner
quarter way to view skin

Place dressing back and trace
over with warm hand

If dressing slightly soiled, clean
from inside out

Change every 3 days
Remove if patient transfers out of

If dressing stays on < 24 hours

because of multiple incontinence
episodes, discontinue use

Dressing Application
Remove center backing of dressing

and start with center in gluteal

Point/tail of dressing covers coccyx
Start in center and work up and out
Don’t stretch wings when removing

remaining backing
Once dressing is in place, hold warm

hand on dressing for 30 seconds

Apply as directed and mark dress-
ing with date and time of appli-

Peel back every shift for skin
assessment, reseal existing
dressing after assessing

Document any new findings,
report changes to clinical nurse
specialist, wound ostomy conti-
nence nurse, or both

Remove and discard dressing
every 3 days

Reapply as long as patient meets
the inclusion criteria

If dressing exterior is soiled but
remains intact, it does not need
to be changed; wipe clean and
change on third day

If dressing does not stay intact
more than 24 hours because of
incontinence, discontinue
dressing and use barrier cream
or alternative management

Daily expectations

Use of the sacral
dressing reduced
pressure ulcers by
3.4 to 7.6 per 1000
patient days.



Figure 1 Data collection tool.

Abbreviations: DTI, deep tissue injury; PU, pressure ulcer; WOCN, wound ostomy continence nurse.

ALLEVYN Sacral Gentle Border for Pressure Reduction—Data Collection

***Consult Wound Care on Each Patient***

Room #:_______________

ICU admission date: ____/______/____

Evaluation period: Date dressing originally applied: ____/______/____

End date (either date dressing permanently removed or when patient transferred out of the ICU): ____/_____/____

Did the patient die? Please circle. Yes / No


ADD additional sheets as needed. Once completed, place in allotted bin in the unit for collection.

Date Time Skin condition Dressing

AM Intact
Nonblanchable erythema or color different from skin tone/stage I PU
Partial thickness/stage II PU
Full thickness/stage III or IV PU/unstageable PU
Evidence of DTI
Exclusion criteria met
Other (describe):

Permanently removed

WOCN consulted

PM Intact
Nonblanchable erythema or color different from skin tone/stage I PU
Partial thickness/stage II PU
Full thickness/stage III or IV PU/unstageable PU
Evidence of DTI
Exclusion criteria met
Other (describe):

Permanently removed
WOCN consulted

AM Intact
Nonblanchable erythema or color different from skin tone/stage I PU
Partial thickness/stage II PU
Full thickness/stage III or IV PU/unstageable PU
Evidence of DTI
Exclusion criteria met
Other (describe):

Permanently removed
WOCN consulted

PM Intact
Nonblanchable erythema or color different from skin tone/stage I PU
Partial thickness/stage II PU
Full thickness/stage III or IV PU/unstageable PU
Evidence of DTI
Exclusion criteria met
Other (describe):

Permanently removed
WOCN consulted

Figure 2 Flow chart shows how study’s sample size was deter-

Total number of patients assessed for inclusion in the study

Number of patients who had a sacral dressing applied

Number of patients who had a sacral dressing applied
and had complete data




Five patients experienced unanticipated skin
issues during the trial. Two patients had a deep

tissue injury (DTI) develop, 1 had a stage I pressure
ulcer develop, and 1 had a blister develop on the

sacrum. In all of these cases, the dressing was imme-
diately removed upon discovery of the skin changes,

a WOCN was consulted, and further treatment was
implemented, if recommended by the WOCN. The

fifth case was a DTI located on the patient’s left
buttock that resulted from pressure caused by the

patient lying on a partially dislodged sacral dress-
ing. Upon discovery of the altered dressing integ-

rity, this patient was treated appropriately with a

wound care consultation and the application of a
mild topical vasodilator, and the DTI resolved. AJCC AMERICAN JOURNAL OF CRITICAL CARE, May 2016, Volume 25, No. 3 233

Minimizing pressure ulcers is an important

issue for the management of critically ill patients.

The intention of the study was to see if the use of

a new product on the market would improve out-

comes in our patients at high risk for pressure ulcers.

Study findings revealed that during the 7-month trial,

use of the dressing led to decreases in the incidence

of pressure ulcers on the sacral, coccyx, and buttock

area in all 3 ICUs. These findings suggested that the

dressing could decrease cost for institutions and

improve patient care, contributing to the body of

knowledge about interventions to minimize the risk

of pressure ulcers. Our results were similar to those

of Santamaria et al,13 Chaiken,15 and Walsh et al.14

Education and reminders to the bedside staff on

exactly how to apply and use the dressing are imper-
ative to the prevention of pressure ulcers in patients.

Limitations and Strengths
Because of the nature of the prospective study

design, demographic information was not collected.
This lack of demographic data prevented a direct
comparison between the pretrial population and
the population during the trial. Other risk factors
for pressure ulcers, not related to the prophylactic
dressing, may have differed between these 2 popula-
tions, thus biasing the results of this trial. Addition-
ally, the study sample was nonrandomized; it was a
convenience sample that looked only at feasibility.
Interrater reliability could not be assessed because
repositioning of patients was not monitored. Docu-
mentation was incomplete in 43 of the patients who
had the dressing applied, making it impossible to
track the reason for application and wear time in
those patients. Multiple initiatives were taking place
during this time frame that also focused on preven-
tion of pressure ulcers. A multidisciplinary hospital-

acquired pressure ulcer committee was developed in
September 2011 that evaluated wound care practices,
policies, and products and implemented changes,

all with the common goal of decreasing the incidence

of pressure ulcers. Dermal defense champions were
chosen in February 2012, and their focus was to
receive monthly education on pressure ulcer preven-

tion and then relay that information at the unit level

to staff nurses. The units had increased education
and awareness during this period, which caused
more active participation. The decrease in pressure

ulcer incidence during the intervention phase

improved patients’ outcomes.

The results of this study indicated that a pro-

phylactic sacral dressing may prevent ICU-acquired

sacral pressure ulcers. Future studies could evaluate

the effects of prophylactic dressings in conjunction
with a critical care bundle for prevention of pres-

sure ulcers that addresses nutritional status and

frequent repositioning. Conducting a randomized
controlled trial would be beneficial for further

Figure 3 Frequencies of conditions that led to automatic inclusion
in the study among patients who had the dressing applied.
Abbreviations: MODS, multiorgan dysfunction syndrome.


















MODSShockSepsisSurgery Vasopressor


Table 2
Nonautomatic inclusion factors of 243
patients who had Allevyn dressing applied:
5 or more factors required for inclusion

Bed rest

Expected stay > 5 days

Age > 65 years

Hemodynamic instability


Mechanical ventilation


Braden score > 12

History of vascular disease


Body mass index

Liver failure

Intermittent hemodialysis

Drive lines

History of pressure ulcers

Orthopedic injuries

Spinal cord

Nitric oxide ventilation


159 (65.4)

104 (42.8)

101 (41.6)

97 (39.9)

51 (21.0)

50 (20.6)

48 (19.8)

44 (18.1)

34 (14.0)

24 (9.9)

22 (9.1)

18 (7.4)

16 (6.6)

15 (6.2)

7 (2.9)

4 (1.6)

3 (1.2)

1 (0.4)

0 (0.0)

No. (%) of patients



Table 3
Improvements seen in each unit in the study during the Allevyn trial period

Surgical coronary care

Medical coronary care

Medical intensive care



















P95% ClIncidence rate ratio
Rate difference

(per 1000 patient days)

Pressure ulcer incidence
(per 1000 patient days)

During trialBefore trial

analysis of the effects of the dressing itself. It would

be useful to study the cost-effectiveness of such

interventions. Also, it would be useful to study

prophylactic dressings on other body areas prone

to pressure damage, such as around devices or

specialty equipment.

Some of the Allevyn dressings were donated by the man-
ufacturer, Smith & Nephew (120 dressings comprising
approximately 50% of 1 month’s supply). However, this
donation covered only a portion of necessary supplies.
Additional supplies were provided by Thomas Jefferson
University Hospital. Smith & Nephew played no role in
the design of the research study or the collection of data
and was not considered a contributing partner or coauthor.

Now that you’ve read the article, create or contribute to an
online discussion on this topic. Visit
and click “Submit a response” in either the full-text or PDF
view of the article.

For more about preventing pressure ulcers, visit the
Critical Care Nurse Web site,, and
read the article by Cooper, et al, “Against All Odds:
Preventing Pressure Ulcers in High-Risk Cardiac Surgery
Patients” (October 2015).

1. European Pressure Ulcer Advisory Panel and National

Pressure Ulcer Advisory Panel. Prevention and Treatment
of Pressure Ulcers: Clinical Practice Guidelines. Washing-
ton, DC: National Pressure Ulcer Advisory Panel; 2009.

2. Jenkins ML, O’Neal E. Pressure ulcer prevalence and inci-
dence in acute care. Adv Skin Wound Care. 2010;23:556-559.

3. Cox J. Pressure ulcer development and vasopressor agents
in adult critical care patients: a literature review. Ostomy
Wound Manage. 2013;59(4):50-54, 56-60.

4. Langemo DK, Melland H, Hanson D, Olson B, Hunter S.
The lived experience of having a pressure ulcer: a qualita-
tive analysis. Adv Skin Wound Care. 2000;13:225-235.

5. Gallant C, Morin D, St-Germain D, Dallaire D. Prevention and
treatment of pressure ulcers in a university hospital center:
a correlational study examining nurses’ knowledge and best
practice. Int J Nurs Pract. 2010;16:183-187.

6. The Joint Commission. 2011 Joint Commission national patient
safety goals. /2011Nation-
alPatientSafety . 2011. Accessed February 22, 2016.

7. Institute for Healthcare Improvement. 5 Million lives cam-
cInitiatives/5MillionLivesCampaign/Pages/default.aspx. 2008.
Accessed February 22, 2016.

8. Agency for Healthcare Research and Quality: US Department
of Health and Human Services. Quality indicator user guide:
patient safety indicators (psi) composite measures version
ules/PSI/V43/Composite_User_Technical _Specification_
PSI_4.3 . Accessed February 22, 2016.

9. American Hospital Association. Quality reporting and
pay-for-performance. April 15, 2014.
/content/14/ip-qualreport . Accessed February 22, 2016.

10. Russo CA, Steiner C, Spector W. Hospitalizations related to
pressure ulcers among adults 18 years and older, 2006. Sta-
tistical brief #64, AHRQ Healthcare Cost and Utilization Proj-
ect. .
December 2008. Accessed February 22, 2016.

11. Centers for Medicare & Medicaid Services. Hospital-acquired
Service-Payment/HospitalAcqCond/Hospital-Acquired _Con-
ditions.html. Accessed February 22, 2016.

12. Medicare website. Linking quality to payment. http://www payment
.html?AspxAutoDetectCookieSupport=1. Accessed February
22, 2016.

13. Santamaria N, Gerdtz M, Sage S, et al. A randomized con-
trolled trial of the effectiveness of soft silicone multi- layered
foam dressing in the prevention of sacral and heel pressure
ulcers in trauma and critically ill patients: the border trial.
Int Wound J. 2015;12(3):302-308.

14. Walsh NS, Blanck AW, Smith L, Cross M, Andersson L, Polito
C. Use of a sacral silicone border foam dressing as one
component of a pressure ulcer prevention program in an
intensive care unit setting. J Wound Ostomy Continence
Nurs. 2012;39(2):146-149.

15. Chaiken N. Reduction of sacral pressure ulcers in the inten-
sive care unit using a silicone border foam dressing. J Wound
Ostomy Continence Nurs. 2012;39(2):143-145.

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