Reduction of Pressure Ulcers by Risk Assessment and Prevention in Hospital

Setting
introduction
Pressure ulcers continue to be a distressing medical problem. Not only do patients
experience pain and discomfort but intensive wound care also incurs considerable costs to
both patients and hospitals. Therefore both health care professionals and patients should
consider the prevention of pressure ulcers of extreme importance. Hospital nursing teams
are especially concerned with the prevention of pressure ulcers that develop during
hospitalization, i.e. the nosocomial pressure ulcers.

The aim of this project is to improve pressure ulcer risk assessment and prevention
through the implementation of guideline recommendations, many of which related to
accurate and timely documentation of risk, adequate care planning and the provision and
review of appropriate equipment. To achieve this, clinical audit will be used. The clinical
areas audited provided care to patients identified anecdotally at higher risk of pressure
ulcer development due to their physical condition. A quantitative form of research is
applied in this project.

Literature Review
Pressure ulcer is most commonly known as bedsore. Other names for it include pressure
sore, decubitus ulcer and tropic ulcer. It is an ischemic necrosis and ulceration of tissues
overlying a bony prominence which has been subjected to prolonged pressure against an
external object like a bed, wheelchair, cast or splint for example (Beckley & Silage,
2003). The condition results to impaired skin integrity related to unrelieved, prolonged
pressure ( 2004).

Such a condition is seen most frequently in patients who have diminished or absent
sensation, or are debilitated, emaciated, paralyzed, or otherwise long bedridden. Any
patient experiencing decreased mobility, decreased sensory perception, fecal or urinary
incontinence and/or poor nutrition can therefore be at risk for pressure ulcer
development. Tissues over the sacrum, Ischia, greater trochanters, external malleoli, and
heels are especially susceptible but other sites may be involved, depending on the
patient’s position. Pressure ulcers can affect not only superficial tissues, but also muscle
and bone.

Both intrinsic and extrinsic factors precipitate pressure ulcers. Intrinsic factors include
loss of pain and pressure sensations that ordinarily prompt the patient to shift position and
relieve the pressure, and the thinness of fat and muscle padding between bony weight-
bearing prominences and the skin. Disuse atrophy, malnutrition, anemia, and infection
play contributory roles. The most important of the extrinsic factors is pressure. Its force
and duration directly determine the extent of the ulcer. Pressure severe enough to impair
local circulation can occur within hours of an immobilized patient, causing local tissue
anoxia that progresses, if unrelieved, to necrosis of the skin and subcutaneous tissues.

The best treatment for pressure ulcers is prevention. Pressure on sensitive areas must be
relieved. Unless a full-flotation bed such as a water bed is used, providing even
distribution of the patient’s weight. If the patient is using braces or plaster casts, a
protective padding at bony prominences should be used under braces or plaster casts, and
a window in the cast should be cut over potential pressure sites.

Skin inspection is also important. Pressure points should be checked for erythematic or
trauma at least once/day in an adequate light. Able patients, mobile or immobile, and
their families must be taught a routine of daily visual inspection and palpation of sites for
potential ulcer formation. Exquisite skin care for neurologically damaged parts is
necessary to prevent maceration and secondary infection. Maintaining cleanliness and
dryness helps to prevent maceration.

The prevention of pressure ulcers is a priority in caring for patients and is not limited to
patients with restrictions in mobility. Impaired skin integrity may not be a problem in
healthy, immobilized individuals but is a serious and potentially devastating problem in
ill or debilitated patients. Prompt identification of the high-risk patients and their risk
factors aids in prevention of pressure ulcers.

A well-balanced diet, high in protein, is important in the treatment of pressure ulcers.

Blood transfusions may be needed for anemia. Threatened pressure sores require
energetic use of all the above mentioned prophylactic measures to prevent tissue necrosis.
The area should be kept exposed, free from pressure, and dry.

The major problem in treating pressure ulcer is that the ulcer is like an iceberg, a small
visible surface with an extensive unknown base, and there is no good method of
determining the extent of tissue damage.

More advanced ulcers require surgical treatment. Surgical debridement and closure is
required for fat and muscle involvement. Affected bone tissue requires surgical removal;
disarticulation of joint may be needed. Necrotic tissue can promote pathogen growth and
delay healing, so it should be removed. An exception may be scharr or necrotic tissue on
a heel ulcer because an open heel wound can easily become infected and lead to
osteomyelitis. Several debridement methods are available; the choice depends on the
amount of necrotic tissue, absence or presence of infection, patient preferences, and
economic considerations (Baranoski, 2006).

Evidence-based pressure ulcer prevention and treatment

Evidence-based practice, which is often referred to as evidence-based nursing or

evidence-based medicine, is the conscientious, explicit, and judicious use of current best
evidence in making decisions about the care of individual patients. (1) It involves
integrating the individual clinical expertise of the physician or nurse with the best
available external clinical evidence from systematic research and individual patient
preferences. (2) Research shows that patients' outcomes are at least 28% better when
clinical care is based on evidence rather than tradition or common sense (Bryan-Brown,
2006). The following paragraphs would discuss health care practices and interventions on
pressure ulcers which are evidence-based and are widely used in health care settings
today.

A major aspect of nursing care is the maintenance of skin integrity. Consistent, planned
skin care interventions are critical to ensuring high quality of care (2004). Nurses
constantly observe their patient’s skin for breaks or impaired skin integrity. Impaired skin
integrity occurs from prolonged pressure, irritation of the skin, or immobility, leading to
the development of pressure ulcers. Nursing care interventions aimed at the prevention,
assessment and treatment of pressure ulcers should be based on research (Potter & Perry,
2004) or evidence-based practice.

There are several instruments for assessing patients who are at high risk for developing a
pressure ulcer. Patients with little risk for pressure ulcer development are spared the
unnecessary and sometimes costly preventive treatments and the related risk of
complications.

Prevention and treatment of pressure ulcers are major nursing priorities. The incidence of
pressure ulcers in a facility or agency is an important indicator of quality of care. There is
evidence that a program of prevention guided by risk assessment can simultaneously
reduce the institutional incidence of pressure ulcers by as much as 60% and bring down
the costs of prevention at the same time (2004).

Evidence-based practice shows that lack of documentation of patients at risk

demonstrates the need for hospitals to increase prediction and prevention strategies. Use
of a risk scale can provide triggers to plan care to decrease risk factors.

As a predictive measure, individuals should be assessed for risk of pressure ulcer

development upon admission to acute care and rehabilitation hospitals, nursing homes,
home care programs, and other health care facilities (2004). Pressure ulcer risk
assessment should be done systematically.

Evidence-based practice also shows that extended stays of over 7 days increase the risk of
pressure ulcer development (Lyder, et al, 2001). Nurses must therefore remain vigilant in
the prevention of pressure ulcers in patients with longer hospital stays.

Evidence-based practice shows that the use of care practices such as daily skin
assessment, use of pressure-relief surfaces and objective risk assessment measures, such
as the Braden scale, identified at risk patients and reduce evidence of pressure ulcers
(Lyder, et al, 2001). The Braden scale was developed based on risk factors in a nursing
home population. It is highly reliable when used to identify patients at greatest risk for
pressure ulcers. It is also the most commonly used assessment scale for pressure ulcer
( 2004).
Evidence-based practice also shows that the use of nutritional consultation was associated
with decreased incidence of pressure ulcers, suggesting a nutritional consultation may
sensitize the staff that the older adult is at risk for pressure ulcer development (Lyder, et
al, 2001).

Nursing interventions for reducing and treating pressure ulcers are evaluated by
determining the patient’s response to nursing therapies and by determining whether each
goal was achieved. To evaluate outcomes and responses to patient care, the nurse
measures the effectiveness of interventions. The optimal outcomes are to prevent injury
to the skin and tissues, reduce injury to the skin and underlying tissues, and restore skin
integrity (Potter & Perry, 2004). The care of a patient with a pressure ulcer requires a
multidisciplinary team approach.

There is a strong relationship between nutritional status and pressure ulcer development,
yet nutrition is an area often overlooked by clinicians in pressure ulcer care. Nutrition,
including adequate hydration, plays an important role in pressure ulcer prevention and
healing, and is critical in maintaining tissue integrity. Patients defined as malnourished at
hospital admission are twice as likely to develop pressure ulcers as well-nourished
patients. Therefore, nurses and dietitians should work together to assess the patient's
nutritional and hydration status and ensure that these factors are addressed in the patient's
care plan (Voss, 2000).

Pressure ulcers, regardless of their origin, represent negative outcomes for patients. These
negative outcomes may include pain, additional treatments and surgery, longer hospital
stays, disfigurement or scarring, increased morbidity; and increased costs. Although all
negative outcomes are of concern, a hospital-acquired pressure ulcer can result in
increased cost of treatment, patient dissatisfaction with care, and a potential litigious
situation (Schultz, 2005).

Statement of the problem

Are nurses and other health care staff implementing the right risk assessment and
prevention strategies for pressure ulcer?

Aims / Objectives
Aims:

? To review the research literature regarding the prevention of pressure ulcer

? To reflect the implementation of risk assessment in pressure ulcer prevention
? To improve pressure ulcer risk assessment and prevention to reflect the guideline
recommendations

Objectives:

? Develop a dissemination and implementation strategy to accompany the guideline

? Audit care in pressure ulcer risk assessment and prevention, using criteria based
on the guideline
? Make recommendations for practice and future research based on the findings of
the study.

Introduction

In keeping with the classical audit cycle this project seeks to identify current best practice
in prescribing, survey the actual practice, and then institute measures to improve
prescribing up to the identified standards. The audit tool will be used to collect data on
length of stay, mattresses and repositioning provided to patients in each of the following
hospital wards: medical, orthopedic or geriatric ward, groups considered to have a higher
risk of pressure ulcer development, recovery room for the postoperative stay until first
ambulation. This audit tool included demographic data as well as data on the modified
Norton scale for evaluation of a patient's risk of developing a pressure ulcer. A score of
16 or less indicates increased risk for developing a pressure ulcer.

The audit tool will also include data on accompanying medical conditions, i.e.
incontinence, diabetes, heart insufficiency and peripheral vascular diseases. Continence
means that a patient has full control on urine and feces. Inserting a Foley catheter into the
bladder can bypass the problem of urine incontinence. In case of urine incontinence,
continued contact between skin and urine weakens the cell wall and may alter the skin
pH, making it more susceptible to breakdown (2004).

methodology

As the project had a short timeframe, a decision was taken with the advisory panel that
four to six sites would provide sufficient patient numbers to allow improvement in
practice to be detected between the audits. Sites were included if they provided care to
medical, orthopedic or geriatrics, groups considered to have a higher risk of pressure
ulcer development. As this was an audit project, ethics committee approval will not be
required. However confirmation of this will be sought and obtained from all hospital sites
involved in the project.

The audit criterion is that a practitioner with 'appropriate and adequate training' should
undertake the initial risk assessment and document findings. For audit purposes, the grade
of the nurse or health care professional will be recorded.

Dissemination and implementation strategy

The dissemination and implementation strategy was informed by evidence and reflected
the advice of site link nurses and staff from the clinical areas on possible barriers to
change. This ensured the strategy reflected best evidence to bring about change, and
encouraged local ownership of the guideline. Dissemination comprised the identification
of a nurse from each clinical area who could support clinical staff involved in the project
and assist with the audits; circulating copies of the project proposal, quarterly newsletters
and summaries of the guideline recommendations to all relevant staff.
Implementation and Data Collection

Implementation focused on the development of an evidence-based resource pack by the

project team and provision of education sessions by the project manager. A resource pack
was given to each senior member of staff in the clinical area to be audited, the site link
nurses and directors of nursing, and included an implementation guide and copies of the
audit tools.

The project manager shall lead education sessions at each site, with the assistance of the
site link nurse, following audit 1. The sessions were to be attended by nursing staff from
the clinical areas to be audited, senior nurses and/or ward managers. The sessions focused
on a description of evidence-based practice and clinical guideline development; the
development and recommendations of the RUN guideline; an outline of the project; site
specific feedback and recommendations for practice from audit 1.

To ensure standardization of pressure ulcer grading for the audit, the PUPA tool was used
by the project team (Stephens, 2003). Reduction in pressure ulcer prevalence is not a
study outcome due to the time constraints and need to take account of potential
contributory factors. Nevertheless, it is considered important to assess prevalence to
enable audit findings to be more generalisability. Each site will be asked to identify
clinical areas that met inclusion criteria and arrange dates for the project manager to
undertake audit 1. Audit 2 will commence at each site five to six months later.

Development of Audit Tools

Two audit tools will be developed; one for the patient and one for the clinical area. The
tools are developed using recommendations for audit criteria proposed by Baker and
Fraser (1995), which included the following:
? Criteria should be based on evidence where possible.
? Criteria should be prioritized according to the strength of the evidence and effect
on patient outcome.
? Criteria should be measurable and appropriate to the clinical setting.

Audit criteria will then be derived from the guideline. This will be followed with a
consultation with the advisory panel where and agreement will take place on what the
audit would comprise.

Measurement and Analysis

On the first audit and data analysis, to be included are all patients admitted to the hospital
with no skin breakdown during a six-month period, but are at risk for pressure ulcer
development. The nurse will collect the data, using the audit tool. The information
sources are patients' records, interviews with patients and/or patients' families, and
nurses.

This is quantitative form of research wherein patient age range and mean will be
computed both in the first and second audit. Pressure ulcer risk was elicited using clinical
assessment and a tool to obtain a risk assessment score. Risk assessment scores for each
patient were verified by the auditors (Stephens, 2003).

Data from audit 2 will then be compared with audit 1. The Statistical product and Service
Solutions (SPAS) for Windows version 13 will be used. Statistical analysis of the
quantitative data generated from the audit will involve the use of descriptive statistics to
establish means, standard deviations, frequencies and distributions.

Data will be coded and entered onto an Excel spreadsheet, and results collated in an
anonyms form using simple descriptive statistics to enable comparative analysis to be
undertaken. Each site will then receive feedback comparing results from both audits by
clinical area in an anonyms form.

Significance of the study

Protect patients from developing pressure ulcer, it is important to improve pressure ulcer
risk assessment and prevention through the implementation of guideline
recommendations. Therefore, an intervention program will be prepared and implemented
based on the results of the project. The program will be prepared as an addition to the
basic health care practice that is common for bedridden patients and other patients at risk
for pressure ulcer development.

Conclusion

Patient safety should be the number one concern during hospital stay and also before,
during and after each hospital procedure performed. A detailed knowledge of the
epidemiology, based on adequate surveillance methodologies, is necessary to understand
the Pathophsiology and the rationale of preventive strategies that have been demonstrated
to be effective in preventing and treating pressure ulcers. The principles of general
preventive measures such as the implementation of standard and isolation precautions,
following guidelines, and the control of antibiotic use should be reviewed. Some patients
are more at risk for pressure ulcer development than others, and this should be taken into
account by health care professionals.

The necessity to audit is seen in the high prevalence of pressure ulcer development in
hospital stays despite established clinical guidelines. There is a need to improve pressure
ulcer risk assessment and prevention through the implementation of guideline
recommendations, many of which related to accurate and timely documentation of risk,
adequate care planning and the provision and review of appropriate equipment involved.
The success of the health care professional who practices pressure ulcer prevention and
control techniques is measured by determining whether the goals for reducing or
preventing infection are achieved. A comparison of the patients’ response with expected
outcomes determines the success of the health care interventions.