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Numerous interventions for pressure injury prevention have been developed, including care bundles. To systematically review the effectiveness of pressure injury prevention care bundles on pressure injury prevalence, incidence, and hospital-acquired pressure injury rate in hospitalised patients. The Medical Literature Analysis and Retrieval System Online (via PubMed), the Cumulative Index to Nursing and Allied Health Literature, EMBASE, Scopus, the Cochrane Library and two registries were searched (from 2009 to September 2023). Randomised controlled trials and non-randomised studies with a comparison group published in English after 2008 were included. Studies reporting on the frequency of pressure injuries where the number of patients was not the numerator or denominator, or where the denominator was not reported, and single subgroups of hospitalised patients were excluded. Educational programmes targeting healthcare professionals and bundles targeting specific types of pressure injuries were excluded. Bundles with ≥ 3 components directed towards patients and implemented in ≥ 2 hospital services were included. Screening, data extraction and risk of bias assessments were undertaken independently by two researchers. Random effects meta-analyses were conducted. The certainty of the body of evidence was assessed using Grading of Recommendations, Assessment, Development and Evaluation. Nine studies (seven non-randomised with historical controls; two randomised) conducted in eight countries were included. There were four to eight bundle components; most were core, and only a few were discretionary. Various strategies were used prior to (six studies), during (five studies) and after (two studies) implementation to embed the bundles. The pooled risk ratio for pressure injury prevalence (five non-randomised studies) was 0.55 (95 % confidence intervals 0.29–1.03), and for hospital-acquired pressure injury rate (five non-randomised studies) it was 0.31 (95 % confidence intervals 0.12–0.83). All non-randomised studies were at high risk of bias, with very low certainty of evidence. In the two randomised studies, the care bundles had non-significant effects on hospital-acquired pressure injury incidence density, but data could not be pooled. Whilst some studies showed decreases in pressure injuries, this evidence was very low certainty. The potential benefits of adding emerging evidence-based components to bundles should be considered. Future effectiveness studies should include contemporaneous controls and the development of a comprehensive, theory and evidence-informed implementation plan. PROSPERO CRD42023423058. Pressure injury prevention care bundles decrease hospital-acquired pressure injuries, but the certainty of this evidence is very low. [ABSTRACT FROM AUTHOR]

Hospital-acquired pressure injuries remain a significant patient safety threat. Current well-known pressure injury risk assessment tools have many limitations and therefore do not accurately predict the risk of pressure injury development over diverse populations. A contemporary understanding of the risk factors predicting pressure injury in adult hospitalised patients will inform pressure injury prevention and future researchers considering risk assessment tool development may benefit from our summary and synthesis of risk factors. To summarise and synthesise systematic reviews that identify risk factors for hospital-acquired pressure injury development in adult patients. An overview of systematic reviews. Cochrane and the Joanna Briggs Institute methodologies guided this overview. The Cochrane library, CINAHL, MEDLINE, and Embase databases were searched for relevant articles published in English from January 2008 to September 2022. Two researchers independently screened articles against the predefined inclusion and exclusion criteria, extracted data and assessed the quality of the included reviews using "a measurement tool to assess systematic reviews" (AMSTAR version 2). Data were categorised using an inductive approach and synthesised according to the recent pressure injury conceptual frameworks. From 11 eligible reviews, 37 risk factors were categorised inductively into 14 groups of risk factors. From these, six groups were classified into two domains: four to mechanical boundary conditions and two to susceptibility and tolerance of the individual. The remaining eight groups were evident across both domains. Four main risk factors, including diabetes, length of surgery or intensive care unit stay, vasopressor use, and low haemoglobin level were synthesised. The overall quality of the included reviews was low in five studies (45 %) and critically low in six studies (55 %). Our findings highlighted the limitations in the methodological quality of the included reviews that may have influenced our results regarding risk factors. Current risk assessment tools and conceptual frameworks do not fully explain the complex and changing interactions amongst risk factors. This may warrant the need for more high-quality research, such as cohort studies, focussing on predicting hospital-acquired pressure injury in adult patients, to reconsider these risk factors we synthesised. This overview was registered with the PROSPERO (CRD42022362218) on 27 September 2022. [ABSTRACT FROM AUTHOR]

Abstract Objective To review observational studies reporting medical device-related pressure injuries and to identify the medical devices commonly associated with pressure injuries. Design A systematic review of primary research was undertaken, according to the Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) guidelines. Data sources A comprehensive electronic literature search of AMED, CINAHL, MEDLINE, PsycINFO, Web of Science, British Nursing Database and Google Scholar was conducted from inception to 31st December 2018. Studies that reported the prevalence or incidence of medical device-related pressure injuries and published in English language were included in the review. Review methods The eligibility of studies was evaluated independently by three of the four authors and audited by an independent researcher. The titles and abstracts of all studies were screened to identify studies that met the inclusion criteria. Full-text articles of the remaining studies were obtained and screened against the inclusion criteria. Risk of bias was assessed using the Newcastle-Ottawa scale. Meta-analysis was conducted using the 'metaprop' routine, with estimates of medical device-related pressure injuries from the included studies pooled using DerSimonian-Laird random-effects model. Meta-regression analysis was also conducted to examine between-study heterogeneity. Results Twenty-nine studies (17 cross-sectional studies; 12 cohort studies) comprising data on 126,150 patients were eligible for inclusion in this review. The mean ages for patients were approximately 36.2 years (adults) and 5.9 years (children). The estimated pooled incidence and prevalence of medical device-related pressure injuries were 12% (95% CI 8–18) and 10% (95% CI 6–16) respectively. These results should be interpreted with caution given the high levels of heterogeneity observed between included studies. The commonly identified medical devices associated with the risk of developing medical device-related pressure injuries include respiratory devices, cervical collars, tubing devices, splints, and intravenous catheters. Conclusions Medical device-related pressure injuries are among key indicators of patient safety and nursing quality in healthcare facilities. This systematic review and meta-analysis provide up-to-date estimates of the extent and nature of medical device-related pressure injuries, and the findings suggest that device-related pressure injuries are a public health issue of significance, especially as these injuries affect patients' wellbeing and increase the cost of care for both patients and providers. Further research is required to inform strategies for increasing the reporting and risk assessment of medical device-related pressure injuries. [ABSTRACT FROM AUTHOR]

Pressure injuries are a fundamental safety concern in older people living in nursing homes. Recent studies report a disparate body of evidence on pressure injury prevalence and incidence in this population. To systematically quantify the prevalence and incidence of pressure injuries among older people living in nursing homes, and to identify the most frequently occurring PI stage(s) and anatomical location(s). Systematic review and meta-analysis. Nursing homes, aged care, or long-term care facilities. Older people, 60 years and older. Cross-sectional and cohort studies reporting on either prevalence or incidence of pressure injuries were included. Studies published in English from 2000 onwards were systematically searched in Medline, PubMed, Embase, Cochrane Library, CINAHL and ProQuest. Screening, data extraction and quality appraisal were undertaken independently by two or more authors and adjudicated by another. Outcomes included pressure injury point prevalence, cumulative incidence, and nursing home acquired pressure injury rate. In meta-analyses, Cochrane's Q test and the I2 statistic were used to explore heterogeneity. Random effects models were used in the presence of substantial heterogeneity. Sources of heterogeneity were investigated by subgroup analyses and meta-regression. 3384 abstracts were screened, and 47 full-text studies included. In 30 studies with 355,784 older people, the pooled pressure injury prevalence for any stage was 11.6 % (95 % CI 9.6–13.7 %). Fifteen studies with 5,421,798 older people reported the prevalence of pressure injury excluding stage I and the pooled estimate was 7.2 % (95 % CI 6.2–8.3 %). The pooled incidence for pressure injury of any stage in four studies with 10,645 older people was 14.3 % (95 % CI 5.5–26.2 %). Nursing home acquired pressure injury rate was reported in six studies with 79,998 older people and the pooled estimate was 8.5 % (95 % CI 4.4–13.5 %). Stage I and stage II pressure injuries were the most common stages reported. The heel (34.1 %), sacrum (27.2 %) and foot (18.4 %) were the three most reported locations of pressure injuries. Meta-regression results indicated a reduction in pressure injury prevalence over the years of data collection. The burden of pressure injuries among older people in nursing homes is similar to hospitalised patients and requires a targeted approach to prevention as is undertaken in hospitals. Future studies using robust methodologies focusing on epidemiology of pressure injury development in older people are needed to conduct as the first step of preventing pressure injuries. PROSPERO CRD42022328367. Pressure injury rates in nursing homes are comparable to hospital rates indicating the need for targeted programmes similar to those in hospitals. [ABSTRACT FROM AUTHOR]

Abstract Background Pressure injuries are localised areas of injury to the skin and/or underlying tissues. Objectives To assess foam dressings compared to other dressings in healing pressure injuries. Design Systematic review and meta-analysis Data sources The review team searched: the Cochrane Wounds Specialised Register; the Cochrane Central Register of Controlled Trials; Ovid MEDLINE; Ovid Embase; EBSCO CINAHL Plus and the NHS Economic Evaluation Database. Authors also searched clinical trials registries and scanned reference lists for reviews, meta-analyses and health technology reports. No restrictions were applied to language, publication date or study setting. Study eligibility criteria Published or unpublished randomised controlled trials and cluster- randomised controlled trials that examined the clinical or cost effectiveness of foam dressings for healing pressure injuries. Participants Patients of any age with a pressure injury of Stage II or above in any care setting. Interventions Use of any foam wound dressing for treating Stage II pressure injuries or above. Study appraisal and synthesis methods Full-text were assessed for eligibility using a priori criteria by two authors. Risk of bias was assessed using the Grading of Recommendations, Assessment, Development and Evaluation criteria, and Consolidated Health Economic Evaluation Reporting Standards. Risk ratio and mean difference with 95% confidence intervals were used to measure the effect. The review team used Review Manager 5 to enter narrative and qualitative data of included studies. Results Authors found nine studies published between 1994 and 2016 involving 483 participants with pressure injuries at Stage II or above. Included studies compared foam dressings with other types of dressings. However, it was unclear if the foam dressing affected healing (RR 1.00, 95% CI 0.78–1.28), time to complete healing (MD 5.67 days 95% CI-4.03–15.37), adverse events (RR 0.33, 95% CI 0.01–7.65), or reduction in pressure injury size (MD 0.30 cm2 per day, 95% CI −0.15 to 0.75), as the certainty of the evidence was very low. Limitations Using the Grading of Recommendations, Assessment, Development and Evaluation criteria, the certainty and completeness of evidence was low to very low, making it difficult to draw comparisons between foam and other dressings. Conclusions and implications It is uncertain whether foam dressings are more clinically effective, more acceptable to users, or more cost effective compared to alternative dressings in treating pressure injuries. [ABSTRACT FROM AUTHOR]

Aim The aim of this study was to assess student nurses’ knowledge of and attitudes towards pressure injury prevention evidence-based guidelines. Background Pressure injuries are a substantial problem in many healthcare settings causing major harm to patients, and generating major economic costs for health service providers. Nurses have a crucial role in the prevention of pressure injuries across all health care settings. Design A multi-centered, cross-sectional study was conducted using a paper-based questionnaire with undergraduate nursing students enrolled in seven universities with campuses across five Australian states (Queensland, New South Wales, Western Australia, Victoria and Tasmania). Methods Data were collected from nursing students using two validated instruments (Pressure Ulcer Knowledge Assessment Instrument and Attitude Toward Pressure Ulcer Prevention Instrument), to measure students’ pressure injury prevention knowledge and attitudes. Results Students reported relatively low pressure injury prevention knowledge scores (51%), and high attitude scores (78%). Critical issues in this study were nursing students’ lack of knowledge about preventative strategies to reduce the amount and duration of pressure/shear, and lower confidence in their capability to prevent pressure injury. Level of education and exposure to working in a greater number of different clinical units were significantly related to pressure injury prevention knowledge and attitude scores. Conclusion The study findings highlight the need to implement a comprehensive approach to increasing Australian nursing students’ pressure injury prevention and management knowledge, as well as ensuring that these students have adequate experiences in clinical units, with a high focus on pressure injury prevention to raise their personal capability. [ABSTRACT FROM AUTHOR]

Importance Though theoretically sound, studies have failed to demonstrate the benefit of routine repositioning of at-risk patients for the prevention of hospital acquired pressure injuries. Objective To assess the clinical effectiveness of a wearable patient sensor to improve care delivery and patient outcomes by increasing the total time with turning compliance and preventing pressure injuries in acutely ill patients. Design Pragmatic, investigator initiated, open label, single site, randomized clinical trial. Setting Two Intensive Care Units in a large Academic Medical Center in California. Participants Consecutive adult patients admitted to one of two Intensive Care Units between September 2015 to January 2016 were included (n = 1564). Of the eligible patients, 1312 underwent randomization. Intervention Patients received either turning care relying on traditional turn reminders and standard practices (control group, n = 653), or optimal turning practices, influenced by real-time data derived from a wearable patient sensor (treatment group, n = 659). Main outcome(s) and Measure(s) The primary and secondary outcomes of interest were occurrence of hospital acquired pressure injury and turning compliance. Sensitivity analysis was performed to compare intention-to-treat and per-protocol effects. Results The mean age was 60 years (SD, 17 years); 55% were male. We analyzed 103,000 h of monitoring data. Overall the intervention group had significantly fewer Hospital Acquired Pressure Injuries during Intensive Care Unit admission than the control group (5 patients [0.7%] vs. 15 patients [2.3%] ( OR   =  0.33, 95%CI [0.12, 0.90], p  = 0.031). The total time with turning compliance was significantly different in the intervention group vs. control group (67% vs 54%; difference 0.11, 95%CI [0.08, 0.13], p  < 0.001). Turning magnitude (21° , p   =  0.923) and adequate depressurization time (39%, p  = 0.145) were not statistically different between groups. Conclusions and Relevance Among acutely ill adult patients requiring Intensive Care Unit admission, the provision of optimal turning was greater with a wearable patient sensor, increasing the total time with turning compliance and demonstrated a statistically significant protective effect against the development of hospital acquired pressure injuries. These are the first quantitative data on turn quality in the Intensive Care Unit and highlight the need to reinforce optimal turning practices. Additional clinical trials leveraging technologies like wearable sensors are needed to establish the appropriate frequency and dosing of individualized turning protocols to prevent pressure injuries in at-risk hospitalized patients. [ABSTRACT FROM AUTHOR]

Objective To identify risk factors independently predictive of pressure injury (also known as pressure ulcer) development among critical-care patients. Design We undertook a systematic review of primary research based on standardized criteria set forth by the Institute of Medicine. Data sources We searched the following databases: CINAHL (EBSCOhost), the Cochrane Library (Wilson), Dissertations & Theses Global (ProQuest), PubMed (National Library of Medicine), and Scopus. There was no language restriction. Method A research librarian coordinated the search strategy. Articles that potentially met inclusion criteria were screened by two investigators. Among the articles that met selection criteria, one investigator extracted data and a second investigator reviewed the data for accuracy. Based on a literature search, we developed a tool for assessing study quality using a combination of currently available tools and expert input. We used the method developed by Coleman et al. in 2014 to generate evidence tables and a summary narrative synthesis by domain and subdomain. Results Of 1753 abstracts reviewed, 158 were identified as potentially eligible and 18 fulfilled eligibility criteria. Five studies were classified as high quality, two were moderate quality, nine were low quality, and two were of very low quality. Age, mobility/activity, perfusion, and vasopressor infusion emerged as important risk factors for pressure injury development, whereas results for risk categories that are theoretically important, including nutrition, and skin/pressure injury status, were mixed. Methodological limitations across studies limited the generalizability of the results, and future research is needed, particularly to evaluate risk conferred by altered nutrition and skin/pressure injury status, and to further elucidate the effects of perfusion-related variables. Conclusions Results underscore the importance of avoiding overinterpretation of a single study, and the importance of taking study quality into consideration when reviewing risk factors. Maximal pressure injury prevention efforts are particularly important among critical-care patients who are older, have altered mobility, experience poor perfusion, or who are receiving a vasopressor infusion. [ABSTRACT FROM AUTHOR]

Pressure injuries are a leading hospital adverse event, yet they are mostly preventable. Understanding their financial costs will help to appreciate the burden they place on the health system and assist in better planning and management of health expenditures to prevent pressure injuries. To estimate the cost of pressure injuries in Australian public hospitals in 2020 demonstrating its economic burden in a well–resourced health system. A cost of illness study with a 12-month time horizon was conducted. Resource use for the treatment of pressure injuries and productivity loss due to pressure injuries were derived using a bottom-up approach. Parameters of the cost estimates were obtained from secondary sources and literature syntheses. A simulation with 10,000 draws was used to generate statistical properties of the cost estimates. Based on a prevalence of 12.9%, the total cost of pressure injuries in Australian public hospitals was $9.11 billion [95% confidence intervals: 9.02, 9.21]. The two largest shares of costs were accounted for by the opportunity cost of excess length of stay of $3.60 billion [3.52, 3.68] and treatment costs of $3.59 billion [3.57, 3.60]. Productivity loss associated with pressure injuries amounts to $493 million [482, 504]. Hospital-acquired pressure injuries account for a total of $5.50 billion [5.44, 5.56], whereas pressure injuries present on admissions costed $3.71 billion [3.70, 3.72]. In terms of severity, Stage 2 pressure injuries contributed the most to total treatment costs, total excessive length of stay, and total loss of healthy life years. Australian society is willing to pay $1.43 billion [1.40, 1.45] to save 6,701 [6,595; 6,807] healthy life years lost by pressure injury. Reducing preventable pressure injuries and stopping the progression of Stage 1 pressure injuries will likely result in an immense cost-saving for Australia and will likely have similar benefits for other countries with comparable profiles. Australian public hospital study provides comprehensive analysis of the cost of pressure injury, including estimates of direct and indirect medical costs, and indirect non-medical costs - such as productivity and quality of life. [ABSTRACT FROM AUTHOR]

Hospital-acquired pressure injuries cause significant harm to afflicted individuals, and financially burden hospitals. Most pressure injuries are avoidable with the use of preventative interventions. However, within acute hospital settings the effectiveness of pressure injury preventative interventions, as demonstrated by high-level evidence, requires examination. Analyse the effectiveness of interventions to prevent pressure injury in adults admitted to acute hospital settings. Systematic review and meta-analysis of randomised controlled trials. CINAHL, MEDLINE, Scopus, Web of Science and Embase were searched in May/June 2019. In April 2020, searches were updated to the end of 2019. Randomised controlled trials which investigated the effectiveness of pressure injury preventative interventions on pressure injury incidence, within adults admitted to acute hospital settings, were included. Trials limited to pressure injury treatment or specialty areas, and non-English reports, were excluded. Screening, extraction and risk-of-bias assessment were undertaken independently by two reviewers, with a third as arbitrator. Included studies were grouped by intervention type. Studies were synthesised narratively, and meta-analysis was undertaken where study interventions were similar. Using a random-effects model, primary meta-analyses were undertaken using intention-to-treat data. Of 2000 records, 45 studies were included in the systematic review which investigated nine different intervention types: continence management, heel protection devices, medication, nutrition, positioning, prophylactic dressings, support surfaces, topical preparations and bundled interventions. All studies were judged to be at unclear or high risk-of-bias. Several meta-analyses were undertaken, pooled by intervention type. Most pooled samples were heterogeneous. Based on intention-to-treat data, only one intervention demonstrated a statistically significant effect: Australian medical sheepskin surfaces compared to other standard care surfaces (risk ratio 0.42, p = 0.006, I2 = 36%), but included studies were limited by bias and age. Following per protocol meta-analyses, only two intervention types demonstrated a significant effect: support surfaces (active versus other comparison [risk ratio = 0.54, p = 0.005, I2 = 43%] and standard surfaces [risk ratio = 0.31, p < 0.001, I2 = 0%]; and reactive versus other comparison surfaces [risk ratio = 0.53, p = 0.03, I2 = 64%]) and heel protection devices versus standard care (risk ratio = 0.38, p < 0.001, I2 = 36%). Only one intervention was supported by intention-to-treat meta-analysis. Significantly, all trials were at unclear or high risk-of-bias; and there were several limitations regarding heterogeneity across trials and trial outcomes. Further large-scale, high-quality trials testing pressure injury preventative interventions are required to establish effectiveness within acute hospital settings. Attention should be paid to true intention-to-treat analysis, and acute and intensive care settings should be reported separately. PROSPERO registration number : CRD42019129556. [ABSTRACT FROM AUTHOR]

Pressure injuries are one of the most frequently occurring, yet preventable hospital-acquired adverse events. Given there are many clinical practice guidelines available on the prevention and treatment of pressure injuries, it is useful to understand the quality of these guidelines and the clinical application of their recommendations. To critically evaluate the quality and applicability of the recommendations in pressure injury prevention and treatment clinical practice guidelines. Systematic review, reported using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. We systematically searched the literature published from 2005 to 2020 using MEDLINE, EMBASE, CINAHL, the Cochrane Library, ProQuest and PubMed electronic databases, and nine guideline repositories. We assessed overall quality using the validated Appraisal of Guidelines for Research and Evaluation II (AGREE II) and AGREE Recommendation Excellence (AGREE-REX) tools. Overall % mean scores across AGREE II and AGREE-REX domains were calculated for each guideline. Clinical practice guidelines were then ranked in tertiles based on "high", "moderate" or "low" quality. The review protocol was registered in the International Prospective Register of Systematic Reviews. Initial combined database and repository searches yielded 3247 documents. Of these,73 full text documents were reviewed. The final analysis included 12 complete guidelines and 14 related documents. Overall AGREE II scores ranged from 32% to 96% while AGREE-REX scores were generally lower ranging from 10% to 75%. Combined % mean scores across AGREE II and AGREE-REX criteria suggest that four guidelines were ranked as "high" (range 69% to 85%) and are recommended without modification. These included; the 2019 International Guideline, the 2016 Canadian Guideline, the 2014 NICE Guideline, and the 2013 Belgian Guideline. There is disparity in the quality of the included guidelines, however four high quality guidelines are available. These guidelines could ideally be implemented in daily practice and adapted to local policies. [ABSTRACT FROM AUTHOR]

Pressure injury is recognised as an adverse event occurring in healthcare settings. Patients in intensive care are at high risk of developing a pressure injury. Cardiac patients are also among those at higher risk. To systematically assess the incidence and prevalence of pressure injury in adult cardiac patients admitted to intensive care. Systematic review and meta-analysis of incidence and prevalence Articles published in English between 2009 and 2018, reporting pressure injury as a primary outcome were selected based on inclusion criteria. Two authors assessed study bias and extracted data, with a third reviewer as arbitrator. A random effects meta-analysis was conducted. Sub-group meta-analyses were conducted to investigate potential causes of heterogeneity. Fifteen studies met the criteria for inclusion in the systematic review, of which 14 were incidence studies. Heterogeneity was significant and there was large observed variance between studies. The 95% confidence interval of cumulative incidence across all 14 studies, with an overall sample size of 6371, was 9.8–25.6%. In 11 studies that included all-stage pressure injury the 95% confidence interval was 8.3–28.3%. In seven studies in which Stage 1 pressure injury was excluded, the 95% confidence interval was 5.8–22.7%. In the single prevalence study included, which excluded Stage 1 pressure injury, prevalence was 8.8%. The incidence of pressure injury in cardiac intensive care patients was similar to that found in general intensive care patients. However, our results suggest that the incidence may be significantly higher in cardiac surgical patients admitted to intensive care. There were significant differences across the various studies in the ways in which data were collected and reported. Further well-designed studies are required to better understand incidence in this population, using standardised methods of data collection and reporting. [ABSTRACT FROM AUTHOR]

Pressure ulcer rates are persistently high despite years of research and practice policies focused on prevention. Prior research found crosssectional associations between care interventions, hospital and nursing unit characteristics and pressure ulcer rates. Whether these associations persist over time is unknown. Finally, comparisons of quality measures across rural and urban location have mixed findings. Our study examined effects of care interventions on unit-acquired pressure ulcer rates over 4 years controlling for community, hospital, and nursing unit characteristics in rural and urban locations. Guided by contingency theory a longitudinal study was conducted to examine associations between context, staffing, care interventions, nurse outcomes, and pressure ulcer rates, using unit-level data from the National Database of Nursing Quality IndicatorsⓇ 2010–2013 (16 quarters) augmented with data on rural classifications and case mix index. Ulcer rates were measured as percentage of patients with a nursing unit-acquired pressure ulcer. The three care interventions were unit-percentage of patients receiving skin assessment on admission, receiving risk assessment on admission, and receiving any risk assessment before the pressure ulcer. Nursing unit characteristics were RN staffing, education, and experience. Nurse outcomes were job satisfaction and intent-to-stay. We included 5761 units (332 rural and 5429 urban) in 772 hospitals (89 rural and 683 urban) that reported ulcer rates in two or more quarters during the study period. Rural and urban units were examined separately using multilevel binomial regression in which within-unit changes in pressure ulcer rates were related to the within-unit changes in the explanatory variables, controlling for region, hospital size, unit type, case mix index, and percentage of patients at risk for pressure ulcers. An increase in the three care interventions, RN skill mix, and the two nurse outcomes were associated with a decrease in unit-acquired pressure ulcers. For example, in rural units a 10% increase in unit-percentage of any risk assessment and in urban units a 10% increase in skin assessment on admission were associated with a 21% and 5% decrease in the odds of developing an ulcer. A 10% increase in RN skill mix was associated with 17–18% and 5–6% decrease in ulcer rates in rural and urban units respectively. Hospitals aiming to improve pressure ulcer prevention should focus on organizational structures that support improved nurses work environments and workflow that will enhance nursing care interventions. Future studies should include both contextual and patient characteristics along with care interventions. [ABSTRACT FROM AUTHOR]