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The point prevalence study had a cross-sectional survey design. This was a level VI quantitative descriptive article. The research approach fit the purpose of the study. The rigorous methodology along the lines of the EPUAP increased the relevance of the study. This was the methodology adopted across Europe thereby allowing scope for comparison (Vanderwee et al, 2007). The aim was to examine the risk factors for pressure ulcers in acute care hospitals as previous studies had not investigated hospital-acquired pressure ulcers. This motivated the researcher to investigate the risk factors in patients in hospital with new pressure ulcers. The language and concepts were not consistent with the approach; the difficulty in obtaining consent from patients who mostly understood Swedish only created a problem.
Data collection and analysis appeared appropriate. Data collection was done using the services of nurses and two nursing educators who had the one-day training of pressure ulcer risk assessment. On that day they were also shown photographs of the skin conditions. This method was not totally right as these nurses could not have been familiar with the varying skin conditions. Their training could have helped but doubts about diagnosis were expected.
Nurses who had been posted for some time in the related departments and who were seeing pressure ulcers as they developed could have been the best data collectors. This was necessary as informed nurses could have differentiated already existing ulcers from newly appearing hospital-acquired ulcers. Data analysis techniques were good using the Mann Whitney U and the chi square tests and spss. Risk factors were assessed following the data analysis. The study was relevant to a certain extent and concluded fairly well.
The literature review revealed that pressure ulcers occurred in older citizens who were immobile. A doubt had been raised that pressure ulcers due to hospital stay were different from already existing ulcers. This point had been addressed in this study. At the time of admission the Braden scale was used to identify risks of ulcers and the Norton scale was used to identify incontinence which was a predictor of pressure ulcers and not included in the Braden scale.
The worst of the ulcers was classified according to the EPUAP classification (European Pressure Ulcer Advisory Panel). A body map indicated the sites of existing pressure ulcers. The number of days in hospital before the study was different for each case. Preventive measures used were recorded. The findings had just confirmed that pressure ulcers in acute care hospitals were still a problem and that preventive measures were insufficient. This finding was not a new discovery and made this just one more study among many which said the same thing. Staff training had been emphasized upon and this was considered a potential contribution to future research. The timely response of the staff towards turning the patients and using preventive measures to fight off ulcers was the inference gathered.
The sampling strategy was guided by the study needs. The study had clearly defined two groups of patients with pressure ulcers. Efforts were made to ensure that patients who entered the hospital did not have any ulcer risks at the time of admission. This separated the patients who already had ulcers from the patients with hospital-acquired pressure ulcers. The elimination guidelines had not been defined and patients were not selected with care. Selection of the sample was therefore not controlled. The sample composition and size reflected study needs. A large sample of 535 was more representative of the population.
Ethical considerations were provided to the patients and their families who were notified earlier. Participation was voluntary. Information obtained was confidential. Data collection procedures had not been clearly detailed. Researcher roles and activities had been explained. Data analysis had been detailed. The Braden cut-off score model decided the sampling end. Data management procedures were not evident.
Results were detailed as below. Regarding the pressure ulcers, the prevalence in the sample was 27%. The older age group was significantly associated with the pressure ulcers. They were mostly from the orthopedic and medical wards. A Braden score below 17 was another association. The higher age was also a risk factor. Limited activity of the patients was the only separate cause for hospital- acquired ulcers. Friction while repositioning and shear when the patient lies down can lead to pressure ulcers of both types. Preventive measures were less in all the patients.
Other articles to support BCQ
The Six Sigma methodology employed at St. Francis Medical Center used 5 steps for achieving optimum health care delivery (Courtney et al, 2006). It employed a 5-phased problem-solving process. The problem was initially defined. Then critical customer requirements (CCR) were determined. Measurement of the results of identified CCRs was then done. This was followed up by the investigation into the main causes of the issue.
The reason which produced the biggest effect was defined. A process by which the issue could be solved was started. Measures were taken to ensure long-term improvements. (Courtney et al, 2006). This study produced some good results. The pressure ulcer prevalence was low at 13%. Sixty-five percent of patients did not have a breakdown of ulcers. The sacrum was the commonest spot for the ulcers that started in the hospital. The coccyx and the heels which were in close proximity to the bed were other areas for these ulcers. One drawback noted was the laxity of the staff in implementation of prevention measures.
The allotment of beds was a confusing problem. Medical records also were not efficiently maintained. Room for improvement was still there. Among the five solutions that the St.Francis Center adopted, the introduction of music at timely intervals to remind the nurses of the need to turn the patient with ulcers was a successful procedure. Quality improvement of service was possible (Courtney et al, 2006). The Nursing Best Practice Guidelines indicated that resource tools in the form of evidence-based practice needed to be used and the adaptation of user-friendly techniques was recommended (Nursing Best Practice Guidelines, 2005). The Institute for Clinical Systems had decided a protocol where the health care team evaluated patient risk for development of pressure sores (Healthcare Protocol, 2007)
BCQ
In patients that require repositioning every two hours to prevent pressure ulcers (P), would the introduction of an alarm timer and required posting of turning signs on the patients room door (I), versus the current practice of no alarm timer and no required posting of turning signs(C), reduce the occurrence and risk of pressure ulcers in these patients (O), over a three month time frame (T)?
Clinical expertise
The work in the wards is heavy and time consuming. Though we are six in the ward, the item that we compromise upon is the timely turning over of the patients with pressure ulcer risks. Administration of medicines and injections and attention towards emergency problems take all our time in the wards. There being no system by which we are reminded about the time to turn the patients, we are mostly unable to keep to the schedule.
Considering the importance of the two hour time schedule, something has to be done immediately to change the situation. The significance of the above and other studies is that the staff is responsible for timely repositioning the patients. I would like to assert that a timer and posting signs on the doors of patients would help the staff to do this work in a timely manner. MY BCQ is to find out if this can be successfully implemented.
The staff is generally in favor of this “timer and signs” idea. None of the staff would choose to forget the timely repositioning of the patients. They would welcome the timer and the signs. Changing the policy in our station and studying the effects in the ward would decide whether the timer and signs work over a three month period. The costs involved in the purchase of timers and signs are negligible when compared to the benefits the patients have.
Summary
The best evidence from the articles discussed above indicated that pressure ulcers were a problem in acute care hospitals. The poor use of preventive measures added to the problem. The development of ulcer care guidelines was a necessity.
Cost-effective care and shorter hospital stays are the preferences now. Risk assessments and preventive measures must be started at the time of admission itself. Older patients need to improve their activity level to prevent ulcers, shear or friction. Staff must be trained well for recognizing the features of oncoming ulcers. Health professionals need to change their ideas about ulcers and go along with guidelines for prevention of ulcers. A special care plan and educational program must be easily accessible for the nurses. The quality of pressure ulcer care should not be compromised.
References
Wan Hansson C., Hagell, P., A. Willman. (2008). Risk factors and prevention among patients with hospital-acquired and pre-existing pressure ulcers in an acute care hospital. Journal of Clinical Nursing, Vol.17, 1718-1727 Blackwell Publishing.
Courtney, B.A.; Ruppman, J.B. and Cooper. H.M. 2006. Save our skin: Initiative cuts pressure ulcer incidence in half, Nurse Management.
Healthcare Protocol, 2007. Skin Safety Protocol: Risk assessment and prevention of pressure ulcers, Institute for Clinical Systems Improvement. Nurse Management. Web.
Nursing Best Practice Guidelines Program, 2005. Risk assessment and prevention of ulcers, Registered Nurses of Ontario. Web.
Vanderwee, K., Clark, M., Dealey, C. Gunningberg, L. and Defloor, T. (2007). Pressure ulcer prevalence in Europe: A pilot study. Journal of Evaluation in Clinical Practice. Vol. 13: 227-235.
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