Pressure ulcers remain a major cause of avoidable patient harm and cost across healthcare systems, yet emergency departments (EDs) — where vulnerable patients may lay for many hours before admission — rarely have prevention protocols in place.
Evidence shows that a small but significant proportion of patients develop new pressure injuries during their time in the ED, and that malnourished patients can sustain damage within hours of arrival. Despite this, preventive care is typically deferred until admission to an inpatient unit, by which time irreversible tissue damage may already have occurred.
The Prevention Emergency Project (PEP) is a quality improvement initiative undertaken in the ED at Karolinska University Hospital (KUH) in Huddinge, one of Europe’s largest emergency departments. A 2017 hospital-wide audit revealed a pressure ulcer incidence of 10.1%, and the ED — where patients could remain for up to 24 hours awaiting an inpatient bed — had no systematic approach to identifying or managing at-risk patients.
Drawing on a literature review, expert consultation, US study visits and extensive nurse engagement through interviews and workshops, the PEP team identified and implemented four evidence-based changes. First, an abridged version of the Norton risk assessment scale was introduced at triage, supported by a 45-second instructional video for paramedics at the ED entrance. Second, at-risk patients were immediately placed on a Tortoise Turning and Positioning System, which redistributes pressure through positive air displacement and reduces the physical burden on nurses during repositioning. Third, intentional rounding every two hours — triggered by alarms in the electronic medical record — ensured regular checks on positioning, skin integrity, nutrition, hydration, pain and comfort. Fourth, “PEP toolboxes” containing prophylactic heel and sacral dressings and incontinence pads were placed at the point of care.
Critically, the project prioritised nurse engagement throughout. Early workshops revealed that the cultural identity of ED nursing — fast-paced and adrenaline-driven — sometimes worked against systematic, person-centred care processes. By integrating PEP activities into the existing ED workflow and addressing staff concerns such as repositioning-related back injuries, the team minimised resistance to change. Project ambassadors, shift-start training videos and EMR integration further embedded the new practices.
Annual audit data showed documented prevention activities rising from 30% of patients in 2013–14 to 66% by 2019. A survey of 60 ED nurses found that those reporting they “always” or “often” provided appropriate pressure ulcer prevention care increased from 12% to 58% following implementation.
Stanberry B, Lahti N, Kevin C, Delin J. Preventing pressure ulcers in emergency departments: four simple and effective nurse-led changes. Emerg Nurse. 2022 Mar 1; 30(2): 20-25. DOI: 10.7748/en.2021.e2119.
