Education on Etiology and Pressure Ulcer Prevention

Pressure ulcers are common in geriatric patients who have lost mobility and who often need assistance in order to move. A pressure ulcer is a localized injury to the skin that is characterized by alteration in skin integrity (Bates-Jensen, 2009). The altered skin is formed from ischemic damage, which is caused by poor circulation to an area of the body (2009). Further, the underlying tissue around the pressure point of bony prominences of the body is the common site where the skin breaks down (2009). While the breakdown sites differ between men and women, the most common breakdown sites include the hip, knee, elbow, shoulder, Scapulae, buttocks, and heels (2009). In severe cases, the breakdown of the body can compromise the oxygen supply in the blood and interfere with circulation (2009). Research has identified many preventative measures that can be utilized to prevent the development of pressure ulcers in geriatric patients.

This report will address how educating healthcare professionals on researched methods of preventing pressure ulcers can improve outcomes for patients. Prevention strategies that will be discussed include using overly mattresses to decrease the incidents of skin break, ensuring adequate nutrition and hydration, and repositioning patients to prevent ischemic damage to the skin. By developing an evaluation program that educates professionals and trains them to adopt these preventative measures, organizational changes can be adopted to systematically care for patients at risk of developing pressure ulcers.

Contribution to the Future of Healthcare

As the research will demonstrate, pressure ulcers are costly to the healthcare system yet highly preventable with the right preventative measures in place. However, it is important to educate healthcare professionals so that they can make use of procedures that will prevent the occurrence of pressure ulcers. This report will contribute to the healthcare profession by outlining best practices based on research that can be implemented in a systemic effort to lower the cases of pressure ulcer formation among patients in geriatric care.

The key stakeholders include the nurses, the medical and psychiatric physicians, the chief executives, the clinical directors, the educators, and the families who will be part of the process of implementing the change. Additionally, geriatric patients are stakeholders who will be most impacted by the changes enacted.

Change Model Overview

In the change model presented by Rosswurn and Larrabee (1999), six steps to change are outlined in order to develop and implement evidence-based practices in healthcare. This model will guide nursing professionals and other healthcare workers through the use of a systemic change process that 1) assesses the need for change, 2) links the problem with interventions and outcomes, 2) aids in synthesizing the best evidence, 3) designs the change that will fit into the targeted population, 4) designs the practice change, 5) implements and evaluates the change in practice, 5) implements and evaluates the change in practice, and 6) integrates and maintains the change in practice. These steps will be used to implement pressure ulcer prevention methods that are established by research.

Step 1: Assess the Need for Change

According to the research conducted by Barker et al. (2013), the implementation of best practices and guideline recommendations can help in preventing pressure ulcer formation. As the researchers note, there are currently no set policies or procedures for risk assessment of patients, yet the risk of developing pressure ulcers is increasing in the geriatric population daily (2013). According to Primiano et al. (2011), approximately 1.6 billion patients in the United States develop pressure ulcers, which impose a total treatment cost of $3.6 billion (p. 556). Further, the detrimental effects of pressure ulcers include increased length of stay at a hospital, further infections, pain, and increased risk of mortality (2011, p. 556). Up to 66 percent of patients who have undergone surgical procedures are especially at risk of developing a pressure ulcer within 72 hours of surgery (2011, p. 556). Because of the high costs and negative health consequences caused by pressure ulcers, there is a need for change in practices to help prevent increases in skin breakdown that occur among limited mobility patients in a geriatric unit.

Step 2: Link the problem, interventions, and outcome

The current problem is that there is a lack of routine inspection that is applied to detect symptoms of pressure ulcers. Educating healthcare professionals on uniform assessment methods can greatly reduce the number of patients who develop pressure ulcers. Upon admission and readmission to a geriatric facility, it is important that patients who are debilitated, in a wheelchair, or bedridden undergo a skin assessment. Facilities should utilize the Braden scale in order to make this assessment. As Chan, Pang, & Knowg (2009) noted, the Braden scale is used to determine the patients at risk of pressure ulcer development. This scale measures the clinical determinants of prolonged pressure, including activity, mobility, sensory, nutrition, moisture, and dry skin that can cause friction and tear (2009, p. 1565). Under the protocols established by the Braden scale, nurses will inspect the patient’s skin daily and record any changes in skin color, nutritional deficiencies, and changes in skin turgor (2009, p. 1565). When the assessment is implemented, nurses will utilize prevention checklist tools in order to implement prevention and care planning methods that enable them to detect and treat pressure ulcer formations (Barker et al., 2013). These interventions will apply the best practices established by the Braden scale to prevent pressure ulcers in vulnerable patients.

Step 3: Synthesize the Best Evidence

Along with assessing the skin condition of patients during intake, literature provides additional measures that should be utilized routinely to reduce the risk of pressure ulcers in geriatric patients. For managers, there is a financial incentive to purchase technologies and implement practices that will reduce the incidents of pressure ulcers. As an analysis of the cost of treating pressure ulcers reveals, acts of negligence in treating pressure ulcers cause the denial of payment by insurance companies, preventing facilities from collecting payment (Daniel et al., 2012). However, as Buttery and Phillips (2009) determined, research-based improvement can be utilized to enact effective improvements in care for patients vulnerable to developing pressure ulcers. Thus, administers can cut costs by adopting evidence-based changes that improve outcomes for geriatric patients.

First, management can improve outcomes for patients by changing the mattresses within the units under their charge. According to research by Manzano et al. (2013), alternating pressure air mattresses were more effective than overlays in preventing the development of pressure ulcers in patients (p. 2104). Additionally, management can consider the role of nutrition in reducing the risks faced by patients. According to the research, the risk of pressure wounds in malnourished patients can be reduced by providing them with 30-35 kcal per kg in weight (6. Prevention of Pressure Injuries, 2012, p. 21). Management can implement these two recommendations in order to greatly improve the well being of immobilized geriatric patients.

Next, healthcare practitioners can implement changes in their daily care for patients that will reduce the risks of pressure ulcer formation. As previously discussed, health care professionals who interact with patients upon check-in must consistently assess a patient for skin damage and other symptoms. Further, Krapfl and Gray (2008) determine that regular repositioning of patients reduces the prolonged exposure to pressure that contributes to the formation of a pressure ulcer (p. 571). Further, they determine from clinical trials and quasi-experimental studies that repositioning a patient between every 2 and 4 hours is an effective method of redistributing pressure and preserving the integrity of the skin (2008, p. 576). As Moore et al. (2013) determine repositioning is also a cost-effective method of reducing the prevalence of pressure ulcers in a geriatric hospital setting.

In order for staff to implement these best practices, they must receive the support they need to implement these changes across the organization. Implementing an education program that instructs medical personnel on the importance of pressure ulcer prevention and the best practices in pressure ulcer prevention is the critical first step to enacting change. As Guy (2013) asserted, “Pressure ulcer is prevented when all measures are implemented and evaluated (p. S4). Yet evaluation is only possible when the caregivers are adequately educated on the preventative measures and expected outcome of care. Thus, all evidence is measurable by the decrease in pressure ulcers in patients.

Step 4: Design Practice Change

The change will be designed based on the collaboration of all medical personnel that has direct contact with at-risk patients. This includes physicians, nurses, recovery assistance, certified nursing assistants, physical therapists, and occupational therapists. Family involvement is also very important in monitoring the condition of the patient. The stakeholders will be provided with the information that is needed to enable them to recognize the dynamics of skin changes and detect degradations in skin integrity. This change will be initiated in the geriatric unit of the medical facility as a trial program and implemented by a team of healthcare workers that are trained in applying the findings of literature to the developed treatment programs.

For all medical personnel, there will be a quarterly review in order to monitor training in the geriatric unit. The review will monitor the efficacy of the training in enhancing the ability of staff to assess patient risk, prevent the formation of pressure ulcers, and treat existing pressure ulcers. To enhance the education process, there will be a credited Certified Nursing Education system that will be awarded on the basis of program hours completed. Additionally, monthly progress checks will be utilized to ensure that the expected outcome of the program is being met.

Step 5: Implement and Evaluate the Change in Practice

There will be a six-month evaluation of the implementation approaches to ensure the change outcomes are being met. In order to aid with this monitoring, the implementation of daily skin assessment should be included in all shift reports. The recovery assistance and staff nurses will follow up with the assessment record of baths and document any unusual developments of skin redness noted in the skin log. The success of the plan will be measured by the increased use of risk assessments and the decreased incidents of the formation of skin ulcers among geriatric patients. Further, the number of nursing staff who successfully completes the credited Certified Nursing Education system will reflect the success of education efforts.

Step 6: Integrate and Maintain the Change in Practice

Continual monitoring will ensure that the change is maintained. The quality assurance performance insurance (QAPI) will help in assessing the efficacy of education in the next six months. Further, annual staff education will be provided to ensure that staff members remain current on evidence-based practices. To enhance the outcomes, the facility will promote staff to obtain in-depth knowledge of the prevention of pressure ulcers. Additionally, quality assurance nurses will help evaluate the impact of the education programs to ensure that they are effectively disseminating knowledge to the staff.

Implementation & Evaluation Plan

Education and the adoption of best practices are the core component of the change that will be implemented. In order to enact measures that will be effective in empowering staff members to care for vulnerable patients, it is important to adopt a health promotion and education program that alerts all stakeholders of their role in prevention and treatment. First, all stakeholders, regardless of their level of interaction with patients, must learn about the impact that pressure ulcers have on both the patients and the healthcare system as a whole. Second, management will be responsible for making necessary expenditures to enact the changes recommended by research. Third, management will work with an independent consultant to develop an education program for staff that trains them in assessing and treating patients with pressure ulcers. Fourth, experts should be made available during staff meetings to answer staff questions or provide in-depth information for personnel. Finally, family members of patients will be distributed literature to alert them to the dangers of pressure ulcers and to provide them with symptoms to look for on their visits.

Additionally, management must establish a protocol for data collection in order to evaluate the efficacy of the prevention and treatment measures. Management will utilize coding in the daily report so that all personnel can quickly note their interaction with patients and the result of their assessment of the patients. The coding will also enable personnel to access a quick checklist of the symptoms that they are to detect. Further, management is in charge of evaluating the efficacy of the program. They will monitor data to determine the frequency of assessments that are made on patients, the number of new cases of pressure ulcers, and the status of patients presently diagnosed with pressure ulcers.

Steps to Maintain Change

In order to ensure that the changes are being consistently adopted, management will conduct continual monitoring. Within six months, all personnel must demonstrate that they have satisfactorily completed training; further, management must ensure that newly hired staff members are provided with updated training. Additionally, management must check the daily reports to ensure that staff is correctly documenting their inspections of high-risk patients. Also, management will evaluate collected data from the daily reports in order to determine whether staff is appropriately utilizing assessment tools and providing recommended treatments for patients who have already developed pressure ulcers.

Conclusion

Despite the advancements in research on diagnosis, pressure ulcer remains a major threat to patients with impaired mobility and sensation. Nursing professionals and healthcare practitioners who work with geriatric patients can especially benefit from utilizing research-based methods of preventing pressure ulcer formation. To achieve the outlined six steps to implementing this change, the model of change presented by Rosswurm and Larrabee was referenced. Adopting the best practices established by research will benefit both the healthcare system as a whole and patients by reducing increased healthcare costs imposed by pressure ulcer diagnoses and by improving patient outcomes through effective preventative methods.

References

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Guy, H., Downie, F., McIntyre, L., & Peters, J. (2013, June 26). Pressure ulcer prevention: Making a difference across a health authority? British Journal of Nursing, 22(12), S4-S13. Retrieved from http://www.britishjournalofnursing.com

Krapfl, L.A., & Gray, M. (2008). Does regular repositioning prevent pressure ulcers? Journal of Wound, Ostomy and Continence Nursing, 35(6), 571-577. Retrieved from http://www.nursingcenter.com

Manzano, F., Perez, A., Colmenero, M., Aguilar, M., Sanchez-Cantalejo, E., et al. (2013). Comparison of alternating pressure mattresses and overlays for prevention of pressure ulcers in ventilated intensive care patients: A quasi-experimental study. Journal of Advanced Nursing, 69 (9), 2099-2106. Retrieved from http://www.proquest.com

Primiano, M., Friend, M., McClure, C., Nardi, S., Fix, L., Schafer, M., & McNett, M. (2011). Pressure ulcer prevalence and risk factors during prolonged surgical procedures. Association of Operating Room Nurses, AORN Journal, 94(6), 555-66. doi:http://dx.doi.org/10.1016/j.aorn.2011.03.014

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