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Background  Hazardous healthcare settings, for example acute care, need to focus more on preventing adverse events and preventive actions across the care delivery chain (i.e pre-hospital and emergency care, and further at the hospital ward) should be more studied. Pressure ulcer prevalence is still at unreasonably high levels, causing increased healthcare costs and suffering for patients. Recent biomedical research reveals that the first signs of cell damage could arise within minutes. However, few studies have investigated optimal pressure ulcer prevention in the initial stage of the care process, e.g. in the ambulance care or at the emergency department. The aim of the study was to describe heel pressure ulcer prevalence and nursing actions in relation to pressure ulcer prevention during the care delivery chain, for older patients with neurological symptoms or reduced general condition. Another aim was to investigate early predictors for the development of heel pressure ulcer during the care delivery chain.    Methods  Existing data collected from a multi-centre randomized controlled trial investigating the effect of using a heel prevention boot to reduce the incidence of heel pressure ulcer across the care delivery chain was used. Totally 183 patients participated. The settings for the study were five ambulance stations, two emergency departments and 16 wards at two hospitals in Sweden.    Results  A total of 39 individual patients (21 %) developed heel pressure ulcer at different stages across the care delivery chain. Findings revealed that 47–64 % of the patients were assessed as being at risk for developing heel pressure ulcer. Preventive action was taken. However, all patients who developed pressure ulcer during the care delivery chain did not receive adequate pressure ulcer prevention actions during their hospital stay.    Discussion and Conclusions  In the ambulance and at the emergency department, skin inspection seems to be appropriate for preventing pressure ulcer. However, carrying out risk assessment with a validated instrument is of significant importance at the ward level. This would also be an appropriate level of resource use. Context-specific actions for pressure ulcer prevention should be incorporated into the care of the patient from the very beginning of the care delivery chain.    Trial registration    ISRCTN85296908 .    Electronic supplementary material  The online version of this article (doi:10.1186/s13049-016-0326-0) contains supplementary material, which is available to authorized users.

Heel pressure ulcer, prevention and predictors during the care delivery chain – when and where to take action? A descriptive and explorative study