Pressure Ulcer Issue in Evidence-Based Medicine

Problem or Issue

Pressure ulcers (PUs), especially hospital-acquired ones, are an important issue associated with the clinical management of patients. A PU can be defined as a “localized injury to the skin and/or underlying tissue, usually over a bony prominence, as a result of pressure alone or in combination with shear” (Qaseem, Mir, Starkey, & Denberg, 2015, p. 359). According to different estimates, the prevalence of the issue differs for various settings from 0.4% to 38% (Qaseem et al., 2015, p. 359).

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Hospital-acquired PUs are viewed as an essential quality indicator because they represent a preventable issue with significant negative consequences (Padula et al., 2015). Indeed, PUs result in increased morbidity and mortality (Qaseem et al., 2015). The treatment of PUs, especially severe ones, is also associated with expenses (Demarré et al., 2015; Qaseem et al., 2015). As a result, the prevention and effective management of PUs are a significant healthcare concern.

Patient Cohort

PUs appear in various groups of patients, but given the specifics of the described issue, the patients with hospital-acquired PUs are of interest to the present paper. Due to the heterogeneity of this group, various subgroups of the cohort run different risks of acquiring PUs. PUs are caused by friction and shear force, which are often experienced because of the contact with bedding (Park, Lee, & Kwon, 2015). Consequently, patients with reduced mobility are at risk of developing PUs (Anderson et al., 2015).

Moreover, aging processes affect the skin, making older patients more prone to PUs (Park et al., 2015). Other risk factors can include moisture, insufficient nutrition, and hemodynamic instability; the latter is associated with various illnesses, for instance, heart conditions (Anderson et al., 2015; Qaseem et al., 2015; Tayyib, Coyer, & Lewis, 2015). All the mentioned factors can become confounding variables that should be considered in a study of PUs with the chosen population.

Potential Solution

An appropriate approach to resolving the issue is comprehensive interventions or so-called pressure ulcer care bundles. The term refers to the complex interventions which incorporate multiple components that are evidenced to be able to address the problem of PUs and that result in positive outcomes for patients (Tayyib et al., 2015). The bundles can include training, tools, and guidelines meant for risk assessment, patient monitoring, skincare, the use of support surfaces, nutrition, repositioning, and other activities that are shown to reduce PU incidence, prevalence, and severity (Anderson et al., 2015; Tayyib et al., 2015).

Bundles may also incorporate instructions for patients; for example, the INTACT program encourages patients to participate in PU prevention efforts (Roberts et al., 2016). The choice of a specific bundle should be guided by the needs of any particular unit; the present paper has found little evidence concerning the comparative effectiveness of different bundles.

PU care bundles have been receiving notable coverage in recent literature that focuses on varied settings and patients. For instance, Tayyib et al. (2015) launched a randomized controlled trial that showed the positive outcomes of a bundle developed specifically for critically ill patients. The findings demonstrated improvements related to PU incidence, prevalence, and severity. On the other hand, universal bundles also exist; Anderson et al. (2015) studied one of them with the help of a quasi-experimental design and proved that it significantly decreases PU incidence. Loudet et al. (2015) presented the results of a quasi-experimental study which found a significant reduction in PU incidence as a result of the adoption of a multifaceted intervention.

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Also, the INTACT program, which is a care bundle with a focus on the activities of both nurses and patients, was studied by Chaboyer et al. (2016) in a randomized trial. The findings incorporated some evidence that could prove the effectiveness of the intervention, especially with respect to PU incidence. All the mentioned studies appear to have sound designs and relatively large samples (the smallest of them had more than 120 patients), which implies that high-quality evidence on the topic suggests that care bundles are effective. However, the studies of the comparative effectiveness of bundles are difficult to find.

For instance, a quasi-experiment by Padula et al. (2015) compared the PU-related quality improvement interventions that were employed in 53 hospitals, but the authors focused on individual activities. Therefore, the results of the study can be used to develop a bundle, but in general, more research devoted to the comparative effectiveness of this type of PU intervention is required.

Potential Clinical Outcome

The main clinical outcome of the proposed intervention is the improvement of the PU-related performance of a studied hospital. Said performance consists of the incidence and prevalence of hospital-acquired PUs and their severity. Some evidence indicates that different PU care bundles can reduce the incidence and prevalence of PUs in varied settings and with diverse patient groups (Chaboyer et al., 2016; Mallah, Nassar, & Kurdahi Badr, 2015; Tayyib et al., 2015).

The statement is true for hospital-acquired PUs (Anderson et al., 2015; Padula et al., 2015). Also, bundles promote PU healing, which, among other things, is associated with fewer cases of severe PUs (Loudet et al., 2015; Tayyib et al., 2015). The measurement of the chosen parameters depends on the means of detecting and assessing the severity of PUs, and PU categories are typically used to this end. They include the first, second, third, and fourth categories, which indicate increasing severity, and the unstageable category, in which slough or eschar prevent accurate assessment (Tayyib et al., 2015).

The rest of the components require the recording and processing of relevant data. PU incidence can be measured by determining the number of new cases for a given period of time (for instance, monthly incidence), and prevalence would be best presented by demonstrating the percentage of patients experiencing the issue (Stanhope & Lancaster, 2015). This way, the PU-related performance of a hospital can be measured.

References List

Anderson, M., Finch Guthrie, P., Kraft, W., Reicks, P., Skay, C., & Beal, A. (2015). Universal pressure ulcer prevention bundle with WOC nurse support. Journal of Wound, Ostomy and Continence Nursing, 42(3), 217-225. Web.

Chaboyer, W., Bucknall, T., Webster, J., McInnes, E., Gillespie, B. M., Banks, M.,… Cullum, N. (2016).The effect of a patient centred care bundle intervention on pressure ulcer incidence (INTACT): A cluster randomised trial. International Journal of Nursing Studies, 64, 63-71. Web.

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Demarré, L., Van Lancker, A., Van Hecke, A., Verhaeghe, S., Grypdonck, M., Lemey, J.,… Beeckman, D. (2015) The cost of prevention and treatment of pressure ulcers: A systematic review. International Journal of Nursing Studies, 52(11), 1754-1774. Web.

Loudet, C. I., Marchena, M. C., Maradeo, R., Fernández, S., Romero, V., Valenzuela, G.,… Reina, R. (2015). Impact of a multifaceted intervention on the incidence of pressure ulcers in a medical−surgical ICU. A before-after study. Intensive Care Medicine Experimental, 3(Suppl 1), A926. Web.

Mallah, Z., Nassar, N., & Kurdahi Badr, L. (2015). The effectiveness of a pressure ulcer intervention program on the prevalence of hospital acquired pressure ulcers: Controlled before and after study. Applied Nursing Research, 28(2), 106-113. Web.

Padula, W., Makic, M., Mishra, M., Campbell, J., Nair, K., Wald, H., & Valuck, R. (2015). Comparative effectiveness of quality improvement interventions for pressure ulcer prevention in academic medical centers in the United States. The Joint Commission Journal on Quality and Patient Safety, 41(6), 246-AP5. Web.

Park, S., Lee, Y., & Kwon, Y. (2015). Predictive validity of pressure ulcer risk assessment tools for elderly. Western Journal of Nursing Research, 38(4), 459-483. Web.

Qaseem, A., Mir, T., Starkey, M., & Denberg, T. (2015). Risk assessment and prevention of pressure ulcers: A clinical practice guideline from the American College of Physicians. Annals of Internal Medicine, 162(5), 359- 369. Web.

Roberts, S., McInnes, E., Wallis, M., Bucknall, T., Banks, M., & Chaboyer, W. (2016). Nurses’ perceptions of a pressure ulcer prevention care bundle: A qualitative descriptive study. BMC Nursing, 15(1). Web.

Stanhope, M., & Lancaster, J. (2015). Public health nursing. New York, NY: Elsevier.

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Tayyib, N., Coyer, F., & Lewis, P. (2015). A two-arm cluster randomized control trial to determine the effectiveness of a pressure ulcer prevention bundle for critically ill patients. Journal of Nursing Scholarship, 47(3), 237-247. Web.

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