Ahead of this post- this is an expansion on a paper I wrote for my masters program. I chose this post today because tomorrow is Florence Nightingale's birthday and the cumulation of nurses week. Hopefully next week I'll post more about safe staffing.
Problem Statement and Literature Support
Pressure
ulcers are considered an easily preventable nursing error caused by
poor quality nursing care. The Agency for Healthcare Research and
Quality (AHRQ) states that pressure ulcers affect 2.5 million patients
per year (Agency for Healthcare Research and Quality [AHRQ], n.d.,
figure 1.1). In Minnesota there were 104 pressure ulcers reported via
centralized reporting in 2015 (Tingle, 2016, p. 274). A United Kingdom
study by Collier (2015) found that in 2014 there were 610 hospital
acquired pressure ulcers (HAPU) reported in the Lincolnshire Hospital
reporting tool (table 1). The Lincolnshire Hospital Trust in the United
Kingdom and Minnesota in the United States are some of the few places
requiring reporting of HAPUs. Ma and Park (2015) demonstrated that
increased quality of care provided by nurses as demonstrated by
achieving and maintaining the Magnet Status designation, reduced the
number of pressure ulcers that patients received while hospitalized. (p.
566). Literature exploring the cause of HAPUs in retrospective studies
as well as those examining prevention innovations and methods is
considerably limited. A brief search of CINAHL (Cumulative Index of
Nursing and Allied Health Literature) using the term pressure ulcer
retrieved over 5,000 results. When the term hospital acquired was added
to the search, either prior or after the phrase pressure ulcer, the
search returned no results.
Further and of significant concern to
this nurse, was the lack of long-term randomized control trials into the
routine of turning and repositioning a patient every two hours. Even
the Cochrane database, considered the gold standard for instituting
evidenced based practice changes, has very few reviews of the basic
nursing behavior. Using the search term "pressure ulcer" resulted in 65
overall reviews, and of those five looked at interventions not directly
related to treatments (i.e. wet to dry dressing, honey, etc), rather
organizational support and other staffing needs to provide safe and
appropriate patient care.
There is a secondary concern with the
lack of long term research into the turning cycle used by nursing
staff. During a patient's awake time repositioning every two hourse is
easy on the nursing staff and makes logical sense when a shift is an
even number of hours long. However, sleep cycles have been demonstrated
to be 90 minutes long, and restful sleep, specifically the delta,
non-dreaming deep sleep phase, has been demonstrated for tissue healing.
If the nursing staff continues to reposition patients every two hours
without regard to the patient's sleep cycle, are we, as nurses, actually
contributing to the problem.
Rational
Much
of the research done on pressure ulcer reduction and prevention has
been done at the single acute care hospital setting with few studies
resulting in interventions that can be easily implemented in other
facilities. Additionally, those studies that examine more general views
on preventing HAPUs and empirically examine HAPUs are primarily done in
Europe and Asia. A study done in one hospital demonstrated that most of
the hospital staff involved with pressure ulcer prevention have an
average level of knowledge about general pressure ulcer prevention
practices and a negative viewpoint towards pressure ulcer prevention
(Kaddourah, Abu-Shaheen, & Al-Tannir, 2016). Chaboyer, Gillepsie et.
al. (2014) found that there are limited randomized controlled trials
for best practice for pressure ulcers internationally, which limits the
implementation of best practices. Even the current best practice,
turning and repositioning every two (2) hours, which is considered
practical, has not been tested with randomized controlled trials. Two
well designed studies specifically focused on reduction of healthcare
acquired pressure ulcers (HAPU) in their facilities. The first study
focused on HAPU reduction in the hospital’s intensive care unit,
achieving a 69% reduction in HAPUs in the hospital’s intensive care unit
during that time frame (Swafford, Culpepper, & Dunn, 2016, p. 152).
The second study was hospital wide and focused on nurse led
interventions. This facility achieved an 80% reduction in their
incidence of HAPU since the introduction on the interventions
(Fabbruzo-Cota et al., 2016, p. 110). Both of those studies would be
difficult to expand to other health facilities, but what is learned can
be applied in the design of future hospital specific programs.
Plan Design
The
initial stages of a plan to decrease HAPUs in the hospital involve (1)
data collection of the rates of HAPUs within the organization (2)
educational assessment of the staff and (3) equipment assessment. The
next stage would include researching and discussing means of improvement
and reduction rates with staff. The third stage is implementing a plan,
followed by evaluation. If the plan does not result in reduction of
pressure ulcers, the process will start again at educational assessment.
If the plan does result in a reduction, the evaluation should continue
and modifications should be made as additional information about the
development and prevention of HAPU’s become available to ensure that
best practices continue. Godlock, Christensen, and Feider (2016)
recommend the FOCUS-PDCA model for instituting any systemic change.
FOCUS-PDCA consists of nine steps:
- Find a process to improve
- Organize a team
- Clarify the current process
- Understand variations in the current process
- Select process improvement
- Plan the improvement
- Do the improvement
- Check for improvement
- Act to hold gains
If
the nursing staff is not on board with a change, as many know, change
cannot be implemented even if the current methodology is fragmented and
is likely to cause patients or staff harm. In using a method such as
the FOCUS-PDCA method, there is room for staff involvement, and this
will make change smoother.
In implementing a HAPU reduction
program that would be scalable to other facilities and even across a
hospital, there are a few considerations. First, is the issue of
culture, including the nurse’s thoughts about pressure ulcers and
staffing should be considered. Staff with excellent knowledge as to
pressure ulcer formation and prevention can result in significant
decline in pressure ulcers. Swafford, Culpepper, and Dunn (2016)
achieved a sixty-nine percent (69%) decline in pressure ulcer formation
in the presence of an approximately twenty-two percent (22%) in
admissions in that same time period (p. 152). Swafford, Culpepper and
Dunn (2016) credit some of the reduction to education of the staff. (p.
152). Additionally, in a whole hospital implementation of a HAPU
reduction program education showed to contribute to an eighty percent
(80%) decline in HAPUs (Fabbruzo-Cota et al., 2016, p. 110). Both
studies emphasized the importance of education through the process,
including the education in the use and importance of the tools.
Additionally both the small ICU only study and the larger hospital study
demonstrated that providing their staff with adequate and appropriate
equipment and management support encouraged staff to use the equipment
and work towards best practices in their own personal practice.
Other
concerns that need to be addressed in terms of HAPU improvement
includes staffing levels. Many nurses in active practice whom I have
spoken with state their primary barrier to pressure ulcer prevention-
even current practice- is staffing levels. The nurses state that they
do not have time to do comprehensive head to toe assessments or ensure
that those with continence issues are clean and dry more than once or
twice a shift. In a twelve hour shift, those with positioning issues,
and continence issues should be checked and repositioned a minimum of 6
times by assorted staff members.
It would be simple to say that
adding more nurses and more support staff will solve the problem, a
complete HAPU reduction plan will include appropriate staffing,
education of the staff, and equipment to prevent staff and patient
injury. None of this is cheap, but the long run savings in prevented
pressure ulcers, as well as increased reimbursement from Medicare and
Medicaid would offset any losses suffered by the hospital in not only
the initial cost of implementing such a program but maintaining the
program.
Based on the general success of previously implemented
best practices within a single unit as well as whole hospital settings,
it can be expected that a well instated HAPU reduction program should
see a reduction in HAPUs of fifty percent (50%) or better over a one
year period. Godbold et. al. (2016) emphasized the importance of
continued ongoing monitoring (A- Act to hold gains) as key in making
sure that the reduction holds. If the hospital wants to continue to
reduce HAPUs or maintain the decreased risk of HAPUs in their
facilities, then the hospital cannot start to reverse what has been
done. This includes not decreasing staffing levels, keeping equipment in
good repair, and ensuring that their nursing staff has access to and
participate in an evidence based practice system.
References
Agency
for Healthcare Research and Quality. (n.d.). Preventing pressure ulcers
in hospitals: Are we ready to change. Retrieved from
http://www.ahrq.gov/professionals/systems/hospital/pressureulcertoolkit/putool1.http://www.ahrq.gov/professionals/systems/hospital/pressureulcertoolkit/putool1.html
Chaboyer,
W., Gillespie, B., McInnes, E., Kent, B., Whitty, J., & Thalib, L.
(2014, April 3). Repositioning for pressure ulcer prevention in adults.
Cochrane Database for Systemic Reviews. http://dx.doi.org/10.1002/14651858.CD009958.pub2
Collier,
M. (2015, October). The development and benefits of 10 year’s
experience with an elctronic monitoring tool (PUNT) in a UK hospital
trust.
European Wound Management Association, 15(2), 15-20.
Retrieved from
http://survey.hshsl.umaryland.edu/?url=http://search.ebscohost.com.proxy-hs.researchport.umd.edu/login.aspx?direct=true&db=c8h&AN=110787594&site=ehost-live
Fabbruzo-Cota,
C., Frecea, M., Kozell, K., Pere, K., Thomspon, T., Thomas, J. T.,
& Wong, A. (2016). A clinical nurse specialist-led interprofessional
quality improvement project to reduce hospital-aquired pressure ulcers.
Clincal Nurse Specialist, 110-116. http://dx.doi.org/10.1097/NUR.0000000000000191
Godlock,
G., Christiansen, M., & Feider, L. (2016, January/February ).
Implementation of an evidence-based patient safety team to prevent falls
in inpatient medical units.
MedSurg Nursing,
25(1), 17-23.
Kaddourah,
B., Abu-Shaheen, A. K., & Al-Tannir, M. (2016, February 24).
Knowledge and attitudes of health professionals towards pressure ulcers
at a rehabiliation hospital: a cross-sectional study .
Biomed Central Nursing ,
15(17). http://dx.doi.org/10.1186/s12912-016-0138-6
Ma, C., & Park, S. H. (2015). Hosptial magnet status, unit work enviornment, and pressure ulcers.
Journal of Nursing Scholarship,
47, 565-573. http://dx.doi.org/10.1111/jnu.12173
Swafford,
K., Culpepper, R., & Dunn, C. (2016). Use of a comprehensive
program to reduce the incidence of hospital aquired pressure ulcers in
an intensive care unit.
American Journal of Critical Care,
25(2), 152-155. http://dx.doi.org/10.4037/ajcc2016963
Tingle, J. (2016). Patient safety perspectives from other countries: the Minnesota system.
British Journal of Nursing ,
25(5),
274-275. Retrieved from
http://eds.b.ebscohost.com/ehost/pdfviewer/pdfviewer?sid=ce6c281a-f5d9-4cdb-9dba-83a2b3582523%40sessionmgr102&vid=0&hid=111
