***TASK*** the task is to summarize an input biomedical literature in six sentences 
    ***INPUT*** the input is a biomedical literature 
    ***OUTPUT*** the output is the summary of an input biomedical literature in six sentences 
    ***DOCUMENTATION*** 
    ***EXAMPLES*** 
    Input: AIMS AND OBJECTIVES To detect problems when classifying pressure ulcers and to examine whether an e-learning program is able to increase the classification skills of qualified nurses and nursing students . BACKGROUND Both the distinction between pressure ulcer grade s and the differentiation between moisture lesions is difficult . Misclassification and incorrect identification of the lesions results in inadequate preventive and therapeutic measures . Education and training are important for spreading evidence -based insights about this topic . DESIGN Repeated measure design , consisting of one pretest and three posttests . METHODS The experimental intervention consisted of a one-hour session during which the participants independently went over an e-learning program . The control intervention consisted of a one-hour lecture . Both interventions had the same learning contents . A convenience sample of 212 qualified nurses and 214 final-year nursing students was r and omly assigned to an experimental- and a control group . RESULTS In the pretest , the classification skills were low . After the intervention , these skills improved significantly in both groups . The nursing students achieved better results when using the e-learning program . Among the qualified nurses , there was no difference between the learning methods . Although the classification skills decreased in the posttests , they did not drop under the level of the pretest . CONCLUSION The actual classification system does not provide the necessary information about the severity of a pressure ulcer . The differential diagnosis between a moisture lesion was complicated . The classification skills of the qualified nurses and nursing students increased by both learning methods . Repetition remains , however , necessary . RELEVANCE TO CLINICAL PRACTICE Both instruction methods are adequate to acquire the knowledge about the differences between moisture lesions and pressure ulcers .  E-learning allows study ing in one 's own time and place , and could therefore be very suitable for repetition of the training . How to organise this training could be a subject for further research BACKGROUND Pressure ulcers ( PUs ) are a problem in health care . Staff competency is paramount to PU prevention . Education is essential to increase skills in pressure ulcer classification and risk assessment . Currently , no pressure ulcer learning programs are available in Norwegian . OBJECTIVES Develop and test an e-learning program for assessment of pressure ulcer risk and pressure ulcer classification . METHODS DESIGN , PARTICIPANTS AND SETTING Forty-four nurses working in acute care hospital wards or nursing homes participated and were assigned r and omly into two groups : an e-learning program group ( intervention ) and a traditional classroom lecture group ( control ) . Data was collected immediately before and after training , and again after three months . The study was conducted at one nursing home and two hospitals between May and December 2012 .  ANALYSIS Accuracy of risk assessment ( five patient cases ) and pressure ulcer classification ( 40 photos [ normal skin , pressure ulcer categories I-IV ] split in two sets ) were measured by comparing nurse evaluations in each of the two groups to a pre-established st and ard based on ratings by experts in pressure ulcer classification and risk assessment . Inter-rater reliability was measured by exact percent agreement and multi-rater Fleiss kappa . A Mann-Whitney U test was used for continuous sum score variables . RESULTS An e-learning program did not improve Braden subscale scoring . For pressure ulcer classification , however , the intervention group scored significantly higher than the control group on several of the categories in post-test immediately after training . However , after three months there were no significant differences in classification skills between the groups . CONCLUSION An e-learning program appears to have a greater effect on the accuracy of pressure ulcer classification than classroom teaching in the short term . For proficiency in Braden scoring , no significant effect of educational methods on learning results was detected The Braden Scale for Predicting  Pressure Sore  Risk was developed to foster early identification of patients at risk for forming pressure sores . The scale is composed of six subscales that reflect sensory perception , skin moisture , activity , mobility , friction and shear , and nutritional status . Content and construct validity were established by expert opinion and empirical testing . Three studies of reliability are reported here , using raters who varied in level of educational preparation and geographic region . Two prospect i ve studies of predictive validity were completed to determine the scale 's sensitivity and specificity . Reliability ranged from r = .83 to r = .94 for nurses ' aides and licensed practical nurses ; when used by registered nurses , the reliability increased to r = .99 . Predictive validity was calculated for each cut-off point of the scale . Using a cutoff point of 16 , sensitivity was 100 % in both studies . Specificity ranged from 64 % to 90 % . This instrument has highly satisfactory reliability when used by RNs , and greater sensitivity and specificity than instruments previously reported Abstract Background / Objective : To describe characteristics of recurrent pressure ulcers ( PrUs )  in veterans with spinal cord injury ( SCI ) . Design : Descriptive , cohort study . Setting s and Participants : Twenty-four veterans with SCI from 6 SCI centers in the Department of Veterans Affairs . Methods : Data from a prospect i ve study evaluating PrUs were analyzed for 24 veterans with 29 recurrent PrUs during 9 months . Additional retrospective medical record data were analyzed for 15 veterans who received inpatient treatment .  Results : Participants were male , 50 % non-Hispanic white , with paraplegia ( 63 % ) , complete SCI ( 83 % ) , a mean age of 56 years , and mean time since SCI of 21 years . Most PrUs recurred ( 63 % , n = 15 patients ) in the same location as the most recent ulcer and at the ischial tuberosities ( 63 % ) . Mean time to recurrence was 16.6 weeks . PrUs were stage III ( 28 % , n = 8) or IV ( 45 % , n = 13 ) with undermining ( 48 % ) , necrotic slough ( 50 % ) , and minimal exu date . One third were ( n = 9 ) larger than 16 cm2 . Mean Bates-Jensen Wound Assessment Tool Score was 33.63 . Inpatient medical record data ( n = 15 ) showed 73 % with documentation indicating infection treated with antibiotics ( 53 % , n = 8 patients ) , osteomyelitis ( 47 % , n = 7 ) , and /or cellulitis ( 1 3 % , n = 2 ) noted . Plastic surgery consultation was obtained for 67 % with surgery as an option for 73 % ( 1 without consultation ) . Scheduled repositioning was documented for 21 % . Conclusions : Most PrUs were severe , located at the same anatomic site , and recurred within 4 months , suggesting that the recurrent ulcers were more likely incomplete healing of the initial PrUs . This sample of veterans with SCI provides early data on recurrent PrU characteristics OBJECTIVE : This article assesses the comparative prevention-effectiveness and economic implication s of a Pressure Ulcer Prevention Program ( PUPP ) against st and ard practice of prevention using Agency for Health Care Policy and Research ( now the Agency for Healthcare Research and Quality [ AHRQ ] ) guidelines and a mixture of commercial products . DESIGN : The study is a r and omized , controlled , prospect i ve cohort study with an accompanying economic evaluation . The economic evaluation is performed from the perspective of the nursing and rehabilitation centers . SETTING S : Two nursing and rehabilitation centers under the same quality and safety support organization . Both institutions are experiencing high nursing staff turnover and incidence of pressure ulcers ( PrUs ) . PARTICIPANTS : 133 residents at risk of developing PrUs ( EQUIP-for- Quality Risk Score Moderate to Very High [ MVH ] ) . All are Medicare-eligible residents with Minimum Data Set ( MDS ) 2.0 evaluations . INTERVENTIONS : The PUPP includes a strategic product bundle and decision algorithms driven by MDS 2.0 Resident Assessment Scores to assist in reducing or preventing PrUs and incontinence-associated skin conditions . The control group utilizes a different br and and assortment of commercial skin care products , briefs , pads , and mattresses , but without use of the decision algorithms driven by MDS 2.0 Resident Assessment Scores . Pressure ulcer prevention education was done for all nurses by a nurse certified in the PUPP program at the beginning and ad libitum by trained senior nursing staff at the end of the study . MAIN OUTCOME MEASURES : Comparative reduction in the incidence of nosocomial PrUs and average 6-month net cost savings per MVH-risk resident . METHODS : Residents were assessed for PrU risk using EQUIP-for- Quality risk assessment algorithm based on data from their Minimum Data Set ( MDS 2.0 ) , then assigned to either the PUPP program or control group ( st and ard practice following AHRQ guidelines ) . Residents were followed until discharge , death , development of PrU , or a maximum time period of 6 months . Direct medical costs of prevention and PrU treatment were recorded using a modified activity-based costing method . A decision model was used to estimate the net cost savings attributed to the PUPP program over a 6-month period . RESULTS : A 67 % reduction in the incidence of nosocomial pressure ulcers is attributable to the PUPP strategy over a 6-month period for MVH residents . The average 6-month cost for a MVH Medicare resident is $ 1928 and $ 1130 for the control group and PUPP group respectively . Mean difference ( net cost savings per resident at risk of pressure ulceration ) is $ 798 per resident for PUPP . CONCLUSIONS : PUPP assisted in reducing the incidence of PrUs by 67 % in a 6-month period in nursing home facilities . The estimated annual net cost savings attributed to PUPP for 300 MVH residents is estimated at approximately $ PURPOSE The purpose of the study was to determine if simply providing nursing facilities with comparative quality performance information and education about quality improvement would improve clinical practice s and subsequently improve resident outcomes , or if a stronger intervention , expert clinical consultation with nursing facility staff , is needed . DESIGN AND METHODS Nursing facilities ( n = 113 ) were r and omly assigned to one of three groups : workshop and feedback reports only , workshop and feedback reports with clinical consultation , and control . Minimum Data Set ( MDS ) Quality Indicator ( QI ) feedback reports were prepared and sent quarterly to each facility in intervention groups for a year . Clinical consultation by a gerontological clinical nurse specialist ( GCNS ) was offered to those in the second group . RESULTS With the exception of MDS QI 27 ( little or no activity ) , no significant differences in resident assessment measures were detected between the groups of facilities . However , outcomes of residents in nursing homes that actually took advantage of the clinical consultation of the GCNS demonstrated trends in improvements in QIs measuring falls , behavioral symptoms , little or no activity , and pressure ulcers ( overall and for low-risk residents ) . IMPLICATION S Simply providing comparative performance feedback is not enough to improve resident outcomes . It appears that only those nursing homes that sought the additional intensive support of the GCNS were able to effect enough change in clinical practice to improve resident outcomes significantly OBJECTIVE To identify the independent effect of pressure ulcers on excess length of stay and control for all observable factors that may also contribute to excess length of stay . Hospitalized patients who develop a pressure ulcer during their hospital stay are at a greater risk for increased length of stay as compared with patients who do not . DESIGN Cross-sectional , observational study . SETTING Tertiary-care referral and teaching hospital in Australia . PATIENTS Two thous and hospitalized patients 18 years and older who had a minimum stay in the hospital of 1 night and admission to selected clinical units . METHODS Two thous and participants were r and omly selected from 4,500 patients enrolled in a prospect i ve survey conducted between October 2002 and January 2003 .  Quantile median robust regression was used to assess risk factors for excess length of hospital stay . RESULTS Having a pressure ulcer result ed in a median excess length of stay of 4.31 days . Twenty other variables were statistically significant at the 5 % level in the final model . CONCLUSIONS Pressure ulcers make a significant independent contribution to excess length of hospitalization beyond what might be expected based on admission diagnosis . However , our estimates were substantially lower than those currently used to make predictions of the economic costs of pressure ulcers ; existing estimates may overstate the true economic cost BACKGROUND Patients in hospitals and nursing homes are at risk for the development of often preventable adverse events . Guidelines for the prevention of many types of adverse events are available , however compliance with these guidelines appears to be lacking . As a result many patients do not receive appropriate care . We developed a patient safety program that allows organisations to implement multiple guidelines simultaneously and therefore facilitates guideline use to improve patient safety . This program was developed for three frequently occurring nursing care related adverse events : pressure ulcers , urinary tract infections and falls . For the implementation of this program we developed educational activities for nurses as a main implementation strategy . OBJECTIVES The aim of this study is to describe the effect of interactive and tailored education on the knowledge levels of nurses .  DESIGN A cluster r and omised trial was conducted between September 2006 and July 2008 . SETTING S Ten hospital wards and ten nursing home wards participated in this study . Prior to baseline , r and omisation of the wards to an intervention or control group was stratified for centre and type of ward . PARTICIPANTS All nurses from participating wards . METHODS A knowledge test measured  nurses ' knowledge on the prevention of pressure ulcers , urinary tract infections and falls , during baseline en follow-up . The results were analysed for hospitals and nursing homes separately . RESULTS After correction for baseline , the mean difference between the intervention and the control group on  hospital nurses ' knowledge on the prevention of the three adverse events was 0.19 points 
    Output:
    
None of the included studies explored our other primary outcome : change in health professionals ' clinical behaviour .
We are uncertain whether educating healthcare professionals about pressure ulcer prevention makes any difference to pressure ulcer incidence , or to nurses ' knowledge of pressure ulcer prevention .