Pressure Ulcer Prevention in Long-Term care /Rehabilitation Center
Background
Pressure ulcers have been a common occurrence in rehabilitation centers and hospital set-ups with the main risk factors considered prolonged skin contact with support devices, deficiency in skin calories, high moisture levels, and diseases such as arteriosclerosis. A pressure ulcer is a term that describes localized injuries that occur on the skin or underlying tissues on a bony body part where continued friction results in sores (Keelaghan et al., 2008). The development of the hospital-acquired pressure ulcers (HAPU) has been a matter of great concern in medical practice for several decades with increased focus from government other regulatory bodies coming to focus in recent years.
The costs of treating pressure ulcers is observed to be immense depending on the prevalence stage of the ulcer, hence, the need to invest more in preventing the ulcers than fighting for their cure (Cooper, 2013). Stage III and IV ulcers are extremely severe and to help ensure patients do not develop such severe pressure ulcers, hospitals are required to evaluate their patients to help discover the ulcers in time and put patients on medication. Statistically, the National Pressure Ulcer Advisory Panel (NPUAP) (2009) notes that 0.4% and 38% of pressure ulcers occur in hospital settings while 2.2% – 23.9% occur in skilled nursing facilities whereas 0-17% happen in home settings.
Problem Statement
The high prevalence of hospital-acquired pressure ulcers among patients across various healthcare settings puts immense financial costs on patients and their families as the ulcers are very difficult to cure especially in their advanced stages. Patients in rehabilitation centers are in critical conditions and require a lot of equipment support to guide their respiration, excretion and overall body support. The continued bodily exposure to these support equipment results in pressure increase on the skin epidermis leading to the creation of wounds that deteriorate to ulcers.
Due to the high costs involved in the treatment process of pressure ulcers, this study notes that there is some urgent need to develop efficient care and preventive mechanisms such that patients in rehabilitation centers and other healthcare settings do not suffer from pressure ulcers. The eradication of pressure ulcers may not be an easy task due to the severity of some patient conditions though improvement of the support devices to can help considerably reduce the risk factors. In rehabilitation centers where most of the patients are the elderly persons suffering from chronic conditions, morbidity is usually a problem, turning and repositioning of patients has not been an effective method of avoiding pressure ulcers. Thus, this prompts the proposal for use of pressure re-distribution mattresses to help reduce incidences of pressure ulcers.
Change Proposal Purpose
To help reduce the prevalence of HAPU in healthcare settings, the use of pressure re-distribution mattresses such as the visco-elastic form, high-density foams, and the cubed forms has been noted to be a highly effective method of mitigating the prevalence (Lyder & Ayello, 2008). According to Keelaghan et al. (2008), oral nutrition supplements such as the use of 2kcal/ml drinks help enhance the ability of body tissues in tolerating pressure before wearing out. The oral nutrition supplements are recognized as a highly cost-effective method of preventing the occurrence of pressure ulcers and additionally contribute to the overall body development in later years where it helps enhance body immunity and prevent against weight loss.
According to Cuddigan, Berlowitz, and Ayello (2001), dry skin is another risk factor that contributes to the occurrence of pressure ulcers, hence the proposition of skin emollient as a remedy move. Skin emollient helps hydrate dry skin and reduce the possibilities of skin damage and the combination of this practice and the use of pressure mattresses play a huge role in mitigating the prevalence of HAPU. The suggested change proposal for hospitalized patients will thus help reduce the costs spent on pressure ulcers in addition to helping prevent incidences of HAPU among high-risk and low-risk patients (Teague, 2009). According to Cooper (2013), low-air-loss mattresses also help reduce the moisture on the patient surfaces leading to a dry strong skin that is not easily vulnerable to pressure ulcers. Thus, the use of the proposed intervention method will largely help reduce the costs on HAPU through prevention in addition to helping prevent the emotional pains suffered in the process of treating the ulcers.
PICOT question
The PICOT question is: Is the use of pressure redistribution mattresses more effective than turning and repositioning of patients in the reduction of HAPU among elderly patients between the ages of 55-65 years, and who are paralyzed due to spinal code injuries?
PICO (T) Statement
P: The study populations in this case, will be elderly patients aging between 55-65 years with spinal cord injuries, who are paralyzed and admitted in rehabilitation centers. The patients with spinal cord injuries are at a very high risk of HAPU due to their state of immobility and as a result depend on nurses and physicians to turn them on the beds every 3-4 hours to help avoid the risk of contracting HAPU. The pressure of their bodies is more experienced on the body’s bony parts such as the shoulders, back and the hips (Levine, Sinno, Levine, & Saadeh, 2012).
I: For this evidence-based study involves the use of pressure mattresses such as the low air loss mattresses, lateral rotational mattresses, and fluidized mattresses that help enhance the patient pressure redistribution when compared to the ordinary standard mattresses, hence preventing the development of HAPU (Sarasua, J. G., et al., 2011). This study is anchored on Huang, Chen & Xu (2013)’s study that proved that patients placed on pressure re-distribution mattresses recorded a much lower need for pressure ulcer surgeries when compared to those on standard mattresses.
C: The comparison method relied upon to test the effectiveness of this intervention study is the use of turning and repositioning of patients every two hours on the standard beds.
O: The primary outcome anticipated in this evidence-based intervention study is the reduction and final elimination of HAPU among hospitalized patients in rehabilitation centers with spinal cord injuries (Thein, Gomes, Krahn, & Wodchis, 2010). The secondary outcome expected from this intervention is the realization of reduced costs of management of HAPU as it has been observed to cost the stated population highly (Keelaghan, Margolis, Zhan, & Baumgarten, 2008).
T: The most appropriate period for this evidence-based study will be 18 months during which elderly patients who will be admitted at the John Hopkins Hospital in Baltimore will be provided with pressure redistribution mattresses over their hospitalization period. The physicians will supply them with oral nutritional supplements that are useful for improving tissue tolerance to pressure (Lyder&Ayello, 2008). Their skins will also be kept moisturized using skin emollients to prevent HAPU from dry skin. The physicians will then observe the trends of HAPU development among these patients, as compared to patients who used normal standard mattresses, and were only turned and repositioned as a measure to prevent the occurrence of pressure ulcers.
Literature Search Strategy
The use of keywords was the type of search strategy embraced in this study as it helped expose the researcher to a wide range of scholarly work, from which a selection was done based on the most suitable and relevant literature. The key words were input into an online Google search engine and the results sieved according to the study demands and researcher preferences.
Literature Evaluation
The occurrence of pressure ulcers was observed to decrease considerably when patients are exposed to pressure re-distribution fluff mattresses (Perneger et al., 2002). The researcher further noted that the pressure re-distribution quality improvement technique was responsible for the reduction in costs of managing pressure ulcers through prevention. In their study, Baumgarten et al. (2006) evaluated unit-based quality reassurance interventions that recognize the efficiency of precautionary trials and consciousness of a patient’s risk for pressure ulcers and unit pride resulting to hugely efficient precautionary approaches.
Baumgarten et al. (2006) proposes that it is very important that patients understand the manufacturers recommendations about the appropriate use of equipment used to provide their care while hospitalized to help avoid instances of inappropriate use that can result in the development of HAPU. Additionally, the researchers propose that upon admission, a patient should undergo skin assessment and risk assessment, to ensure that existing wounds are documented and treatment interventions established. Pham et al. (2011) in a bid to establish the effectiveness of pressure redistribution mattresses in dealing with hospital-acquired pressure ulcers concluded that medical and fiscal proof bolsters pressure redistribution for every long-term care patient.
Utilization of Change Theory
This study utilizes Kurt Lewin’s Theory of change which involves the processes of unfreezing, moving and refreezing (Burnes, 2004). Based on this theory, I will propose the need for the new care mechanisms for patients in rehabilitation center that are capable of reducing pressure ulcers in addition to explaining why my propositions are better than the already operational methods of care and handling of patients suffering from spinal cord injuries at the facility. I will then implement my care policies which include careful reading of manufacturer instructions and using pressure distributing mattresses on patients in the experiment group. The process will continue throughout the eighteen-month intervention period.
Proposed Implementation Plan
In this study, admitted patients will be categorized into control and experimental groups where the experiment patients will be provided with pressure re-distribution mattresses whereas the nurses will care for the control groups through the turning and repositioning technique every 2 hours. The progress of the patients will be monitored through an eighteen-month period, after which an analysis will be conducted to help gauge the prevalence of HAPU in the two groups. The method with few or no reported cases of HAPU will be regarded the most effective evidence-based intervention method.
Potential Barriers
The main barrier anticipated in this study is ensuring that after exactly every two hours, patients in the control group are turned and repositioned to help ease the pressure on the affected body parts in a bid to avoid incidences of pressure ulcers. However, the use of reminder alarm clocks will be used to help remind the nurses to do the turning and repositioning in the scheduled time intervals.
Reference
Baumgarten M, Margolis DJ, Localio AR, (2006). Pressure ulcers among elderly patients early in the hospital stay. J Gerontol a Biol Sci Med Sci, 61(7), 749-754
Burnes, B. (2004). Kurt Lewin and planned approach to change: A re-appraisal. Journal of
Management Studies, 41(6), 0022-2380.
Cooper., K. L. (2013). Evidence-based prevention of pressure ulcers in the intensive care unit.
Critical Nurse Care, 33(6), 57-67. doi: http://dx.doi.org/10.4037/ccn2013985
Cuddigan, J., Berlowitz, D., &Ayello, E. (2001). Pressure ulcers in America: prevalence, incidence, and implications for the future. Reston VA: National Pressure Ulcer Advisory Panel.
Huang, H. Y., Chen, H. L., &Xu, X. J. (2013). Pressure-redistribution surfaces for prevention of surgery-related pressure ulcers: a meta-analysis. Ostomy Wound Manage, 59(4), 36-48.
Keelaghan, E., Margolis, D., Zhan, M., &Baumgarten, M. (2008). Prevalence of pressure ulcers on hospital admission among nursing home residents transferred to the hospital. Wound Repair and Regeneration: Official Publication of the Wound Healing Society [and] the European Tissue Repair Society, 16(3), 331–336. http://doi.org/10.1111/j.1524-475X.2008.00373.x
Levine, S. M., Sinno, S., Levine, J. P., &Saadeh, P. B. (2012). An evidenced-based approach to the surgical management of pressure ulcers. Ann PlastSurg, 69, 482–484.
Lyder, C., &Ayello, A. (2008). Pressure Ulcers: A Patient Safety Issue. In: Hughes RG, editor. Patient Safety and Quality: An Evidence-Based Handbook for Nurses. Rockville (MD): Agency for Healthcare Research and Quality (US); 2008 Apr. Chapter 12. Available from: http://www.ncbi.nlm.nih.gov/books/NBK2650
National Pressure Ulcer Advisory Panel, European Pressure Ulcer Advisory Panel. (2009). Prevention and Treatment of Pressure Ulcers: Clinical Practice Guideline. Washington, DC: National Pressure Ulcer Advisory Panel.
Perneger, T. V., Raë, A., Gaspoz, J., Borst, F., Vitek, O., & Héliot, C. (2002). Screening for pressure ulcer risk in an acute care hospital. Journal of Clinical Epidemiology, 55(5), 498-504. doi:10.1016/s0895-4356(01)00514-5
Pham, B. (2011). Preventing Pressure Ulcers in Long-term Care. Arch Intern Med Archives of Internal Medicine, 171(20), 1839. doi:10.1001/archinternmed.2011.473
Sarasua, J. G., et al. (2011). Treatment of pressure ulcers with autologous bone marrow nuclear cells in patients with spinal cord injury. J Spinal Cord Med, 34(3), 301–307.
Teague, L., et al., (2009). The Cost-Effectiveness of Pressure Redistribution Mattresses for Early Prevention of Pressure Ulcers in Patients Admitted to Hospitals via the Emergency Departments. Retrieved from http://www.hqontario.ca/Portals/0/Documents/evidence/special-reports/theta-pressure-ulcers-er-0912-en.pdf
Thein, H., Gomes, T., Krahn, M., & Wodchis, W. (2010). Health status utilities and the impact of pressure ulcers in long-term care residents in Ontario. Qual Life Res. 19(1), 81-89
