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While looking up statistics, I was surprised to find that the prevalence rate of pressure ulcers is fairly high in US hospitals at 15% of in-patients (Courtney et al, 2006). The incidence rate is between 7 and 10%. Hospital-acquired pressure ulcers have caused the death of 60,000 in-patients in the US. Annual direct treatment costs for the hospital have exceeded $400,000 (Courtney et al, 2006). These statistics could be simulated in my hospital.
Traditional standards of care like patient repositioning have been overlooked for modern technology. Moreover the idea that such ulcers are inevitable may have influenced the health care personnel. However the picture is already changing for the better with the implementation of revised guidelines for the prevention and treatment of the ulcers and the need for change being identified.
In our hospital, our patients are subjected to a nursing assessment every 12 hours. A pressure sore risk assessment using the Braden scale and a skin assessment are made in the current practice. Patients who needed repositioning are noted and the information transferred to the next duty nurse through the shift-to-shift report. The primary nurse takes the responsibility of turning the patient every two hours through the left, prone and right positions and then reversing the order. In my observation, I realize that timely repositioning of patients is compromised thereby reducing the quality of service being rendered.
Need for change
The article by Courtney et al (2006), which I obtained through a search of EbscoHost, supports my suggestions for using a timer and turning signs on the patient’s door for reminding the duty nurses. Among the five solutions that helped reduce pressure ulcers in the Saint Francis Medical Center, the second had the highest evidence (Courtney et al, 2006).
It consisted of revising the Skin Breakdown Prevention Protocol to a user-friendly one by playing music through the in-house paging system to remind the nurses and placing signs outside the respective patients’ doors. A change is essential in order to improve on the statistics regarding patient satisfaction and quality of life. This provided me an idea as to how quality improvement of service may be rendered through finding some way to remind and help the nurses keep to the two-hour repositioning.
Initially I scrutinized the problems in the procedure adopted in our hospital for the management of pressure ulcers in the ward (Courtney, 2006). Utilizing the Six Sigma procedure of problem-solving methodology which has been proven to be beneficial in Saint Francis Medical Center, I attempted to elicit the details of the problem (Courtney, 2006). The problem could be defined as the failure of nurses to keep to the two-hour schedule for repositioning within their hectic schedule. In the race to do their best to accomplish everything that needs to be done for all the assigned patients, they forgo some duties and keep them for later.
The priority goes for the provision of medicines or management of some immediate emergency. I myself have behaved similarly and postponed the repositioning not realizing the hidden but far-reaching consequences. The patients’ requirements should have always come first and foremost. Failing to reposition in two hours denies them the opportunity to live longer with a good quality of life. In exploring and analyzing the reasons for the appearance and progression of pressure sores and the poor timing, I realized that among the many factors involved, there was something that could be implemented immediately in the ward: timely repositioning.
The steps to the initiation of change should result in the timely repositioning of patients no matter what other duties the nurses have and measures must ensure long- term control of the situation. The nurses may be provided alarm timers which warn them of the next repositioning and the turning signs vigilantly placed on the patients’ doors.
The need for change has been expressed in the guidelines by the Registered Nurses Association of Ontario (2005). Change is to be instituted according to environment and practice setting. Guidelines for evidence-based practice are only to be used as resource tools and the adaptation of user-friendly techniques is recommended (Nursing Best Practice Guidelines, 2005). The Saint Francis Medical Center has reported a significant improvement in patient satisfaction, outcome, costs, awareness of the staff, and risk management following the change in evidence- based practice (Courtney et al, 2006). The protocol by which the health care team evaluates patient risk for developing pressure sores is also recommended by the Institute for Clinical Systems Improvement (Healthcare Protocol, 2007).
Identification of the problem
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)?
Relevant data
The patients who have been provided the advantage of timely repositioning during a period of three months are compared to a similar group of patients who did not have this advantage in the same period. Quality improvement data may be assessed in the two groups by checking on patient satisfaction and patient outcome (by noting the number who acquired the pressure sores in hospital). Patient satisfaction could be verified by asking them to reply to questions in a prepared proforma requiring ‘yes’ or ‘no’ answers and the procedure implemented by statisticians so that the answers are not biased or influenced by familiar faces. Hospital statistics would reveal the cost incurred for the two groups of patients.
Conclusion
Awareness of skin integrity would inevitably increase and positive efforts on the part of the nurses would improve patient satisfaction and patient outcome. The implementation of the novel evidence-based practice would improve the quality of stay of patients prone to pressure ulcers, shorten their stay, and thereby reduce hospital costs. The morale of the nursing staff would be boosted thereby keeping the situation handled on a long term basis. Risk management would show an improvement. My burning clinical question should produce a long-lasting solution with the alarm timer and turning signs.
References
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.
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