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The Use of Protocols for Pressure Ulcers in Emergency Departments


In the modern world, the development of pressure or decubitus ulcers is among the key skin problems faced by patients in different departments whose opportunities to stay physically active are limited. Many hospitals in the country develop their own guidelines and protocols to avoid PU complications, but their effectiveness remains a critical question. This project aims at summarizing the existing knowledge on PU protocols to design an intervention that can be successfully implemented in emergency departments.

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The Spirit of Enquiry Ignited

It is common knowledge that pressure ulcers have a variety of consequences such as dangerous infections or, if no treatment is provided, amputation in the United States, more than 2.5 million people have this disease, and it develops during hospitalization in about one-third of patients (Boyko, Longaker, & Yang, 2018). The range of strategies has been designed to develop a comprehensive approach to PU prevention. However, given that their effectiveness has not been widely discussed, modern hospitals use different approaches to PU treatment and prevention. This study is aimed at testing the effectiveness of the PU protocol for high-risk patients in the emergency department. This problem is usually observed among patients who have a low sensitivity to pain, poor circulation of blood, or are motionless, and these characteristics are used to form intervention and comparison groups.

The PICOT Question Formulated

In patients who are identified as high risk for developing a pressure ulcer (P), does the implementation of a pressure ulcer protocol initiated in the emergency department (I) as compared to patients who receive usual care (C) reduce the incidence of hospital-acquired pressure ulcers (O) on day 3 of hospitalization (T)?

Search Strategy Conducted

To understand state of the art in PU treatment and prevention, six professional databases (Cochrane, NGC, TRIP, CINAHL, PubMed, and EBSCOhost) were searched using the following combination of keywords: “pressure ulcer” and “protocols.” In terms of the preliminary search results, more than forty thousand articles were found in total. By utilizing advanced search options to identify the most relevant peer-reviewed works (search by publication type, study type, patient age, and MeSh terms), it was possible to reduce the number of search results significantly. With the help of the PubMed database, five open-access peer-reviewed articles devoted to the effectiveness of PU protocols for high-risk adult patients were chosen for further analysis. Finally, level III and IV evidence studies were used for evidence synthesis.

Critical Appraisal of the Evidence Performed

Critical appraisal tools such as evaluation tables were used to define the applicability of the chosen studies to the planned research. The studies turned out to be extremely different in terms of sample size and, therefore, the quality (the sample size ranged from 62 to 70000 adult participants). The chosen articles presented level III and IV evidence, and no appropriate systematic reviews were found in the search results. All articles focused on adults at high risk of PU, but no special attention was paid to ED patients.

The time aspect was not extremely significant, and only three studies used it (the period of time ranged from 1 day to 12 months). Tested interventions included improved PU protocols, the AHRQ program, and the HAPU prevention program, and the practical outcomes reported by the researchers were quite different. Thus, the studies testing standard PU prevention protocols demonstrated from medium to high effectiveness in PU rates reduction, whereas the outcomes heavily depended on the age of patients and hospital types (Bååth, Idvall, Gunningberg, & Hommel, 2014; Kwong, Hung, & Woo, 2016; Sving, Idvall, Högberg, & Gunningberg, 2014). At the same time, the implementation of both the AHRQ and HAPU prevention programs showed positive and statistically significant outcomes in PU rate reduction and even helped hospitals to reduce financial losses (Olsho et al., 2014; Swafford, Culpepper, & Dunn, 2016).

Having different titles, the interventions from the studies included basically the same components such as skincare rules, the use of special equipment (airflow mattresses), and repositioning practices. However, the results were rather heterogeneous, which supported the need for further research. The given study aims at contributing to the field by testing the effectiveness of the brief PU prevention protocol in the emergency department at my current workplace.

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Evidence Integrated with Clinical Expertise to Implement the Best Practice

The theoretical framework for the study was informed by the results reported by mentioned researchers. Thus, the plan for the project under discussion was to use the evidence from studies to create a series of PU prevention recommendations to be implemented in ED. Obviously, the most effective components of plans tested by the mentioned authors were included to produce positive outcomes. The combination of the PU prevention measures included the following: skin assessment every 5 hours, the use of pressure relief mattresses, repositioning every 2 hours, and staff education concerning approaches to PU prevention (2 sessions) (Olsho et al., 2014; Swafford et al., 2016). From accuracy considerations, skin assessment and staff education procedures were standardized.

The study design was a randomized controlled trial. All patients included in the sample (or, in some cases, their representatives) were to sign standard participation agreements. Thus, the researchers were allowed to use patients’ medical information and assessment results for statistical purposes, whereas all personal details remained confidential. The sample included 30 adult ED patients kept at the hospital where I work. In terms of the procedure, only high-risk patients with Braden score 10-13 became participants. The participants were randomly divided into two equal groups, and trained nurses used the above-mentioned PU prevention recommendations for the first group, whereas the second one was receiving usual care. On day 3 of hospitalization, all participants underwent a PU assessment procedure. The instruments used included the Braden scale and sample protocols for nurses.

Outcomes of Practice Change Evaluated

The purpose of the evaluation is to make a conclusion concerning the effectiveness of the intervention and, therefore, define its practical implications. The clinical question guiding the evaluation is the following: is the use of the PU prevention measures in ED more effective for reducing HAPU rates than usual care? A short period of time (3 days) is used, and the stakeholders are participants, their relatives, nurses, and hospital managers.

The outcomes indicate that patients from the intervention group were three times less likely to have pressure ulcers on day 3 of hospitalization than people in the comparison group (6,67% and 20% of cases). Importantly, the participants’ subjective experiences were not studied, only objective data was used for evaluation. Based on the results, the intervention under analysis is promising, and further studies may be required to improve it.

Project Dissemination

The project has not been presented at professional conferences yet, but its positive outcomes are acknowledged by the hospital management and patients. In case of repeated positive results, it will be possible to use the PU protocol on a regular basis. However, the issues related to the costs of special equipment and nurse workload will need to be addressed. As a result, patient outcomes will be significantly improved.


To sum it up, the discussed research project helps to attract more attention to the problem of pressure ulcers acquired in hospitals. The project outcomes justify the need for further research that would use larger samples. Thus, it will be possible to solidify knowledge on the effectiveness of PU protocols for high-risk patients. In terms of further studies, they should also analyze outcomes with reference to the age and weight status of patients in emergency departments.


Boyko, T. V., Longaker, M. T., & Yang, G. P. (2018). Review of the current management of pressure ulcers. Advances in Wound Care, 7(2), 57-67.

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Bååth, C., Idvall, E., Gunningberg, L., & Hommel, A. (2014). Pressure-reducing interventions among persons with pressure ulcers: Results from the first three national pressure ulcer prevalence surveys in Sweden. Journal of Evaluation in Clinical Practice, 20(1), 58-65.

Kwong, E. W., Hung, M. S., & Woo, K. (2016). Improvement of pressure ulcer prevention care in private for-profit residential care homes: An action research study. BMC Geriatrics, 16(1), 192-199.

Olsho, L. E., Spector, W. D., Williams, C. S., Rhodes, W., Fink, R. V., Limcangco, R., & Hurd, D. (2014). Evaluation of AHRQ’s on-time pressure ulcer prevention program: A facilitator-assisted clinical decision support intervention for nursing homes. Medical Care, 52(3), 258-266.

Sving, E., Idvall, E., Högberg, H., & Gunningberg, L. (2014). Factors contributing to evidence-based pressure ulcer prevention: A cross-sectional study. International Journal of Nursing Studies, 51(5), 717-725.

Swafford, K., Culpepper, R., & Dunn, C. (2016). Use of a comprehensive program to reduce the incidence of hospital-acquired pressure ulcers in an intensive care unit. American Journal of Critical Care, 25(2), 152-155.

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