Experimental randomised controlled trials (RCTs), non-randomised controlled trials (CTs), cohort studies, time series and controlled or uncontrolled pre-post studies of quality improvement interventions for changing routine methods of pressure ulcer prevention in a hospital setting were eligible for inclusion. Quality improvement interventions were defined in the review as interventions that addressed structure and/or process changes as defined in the Donabedian framework. Studies were required to report at least one nursing process- or patient-related outcome. Studies of solely educational interventions, wound-care or site-specific pressure ulcers were excluded.
Most studies were set in single hospitals with multiple units. Participants included adults and children with a wide variety of clinical conditions. Most studies used multiple intervention strategies, including pressure-ulcer-specific measures combined with quality improvement strategies. The most commonly used strategies were protocol-based care, staff education, pressure-ulcer risk assessment tools, performance monitoring and assembling a new team to plan the intervention. Methods of delivery ranged from simple one-off events to complex ongoing activities. Only half of the studies that used performance monitoring also provided feedback to staff. Most studies reported patient-related outcomes and few reported nursing process measures. Measures of pressure ulcer incidence were inconsistent across studies (with respect to pressure ulcer stage, units of measurement). Process of care measures differed widely. The final assessment was conducted between six and 60 months after completion of the intervention (where reported). Most studies took place in USA.
Two reviewers independently selected the studies. Disagreements were resolved by discussion.