Creation and implementation of a pressure ulcer prevention bundle improves patient outcomes

An Evidence-Based Approach to Protecting Our Biggest Organ: Implementation of a Skin, Surface, Keep Moving, Incontinence/Moisture, and Nutrition/Hydration (SSKIN) Care Bundle

Background: The skin, surface, keep moving, incontinence/moisture, and nutrition/hydration (SSKIN) bundle is a resource to aid in care planning when at risk of pressure injuries. The bundle uses best practices to minimize variations in care. Objectives: The objectives of this quality improvement (QI) pilot project were as follows: (a) increase nurses' knowledge of pressure injury prevention, (b) increase nurses' knowledge of the use of the SSKIN bundle, and (c) to pilot the use of an SSKIN bundle in the clinical setting designed to standardize nursing interventions and documentation. Methods: Nurses completed a module on pressure injury prevention that included a pre- and posttest to determine knowledge. Education on the use of the SSKIN bundle was provided, followed by a posttest to establish understanding and knowledge gained. The bundle was utilized in the acute inpatient rehabilitation unit for 4 weeks, and compliance was assessed using the "all-or-none" approach (100% compliance). At the conclusion of the pilot project, staff nurses completed a post-survey created by the QI leader (Likert scale format). The survey included topics on the ease of learning to use the bundle, improved knowledge, perceived reduction in variation of care, perceived facilitation of discussion on skin, opinions on whether the bundle should be instituted hospital-wide, and incorporation of the bundle into the electronic health record (EHR). Results: There was an increase in pressure injury prevention knowledge from an average score of 88.89% on the pretest to 98.15% on the posttest. The mean score on the SSKIN bundle posttest was 93.75%. The bundle ran for 4 weeks and was initiated for ten patients during 74 shifts. Compliance with all components of the bundle was 77%. Conclusion: A pressure injury prevention initiative, such as the SSKIN bundle, can be a useful tool to help standardize nursing interventions and documentation. Implications for Nursing: Results revealed Nutrition as the component with the highest degree of noncompliance. Practice recommendations include documenting every patients nutrition information, regardless of Braden score.

Effectiveness of a Pressure Injury Prevention Care Bundle; Prospective Interventional Study in Intensive Care Units

PURPOSE

The purpose of this study was to assess the effectiveness of a pressure injury prevention care bundle.

DESIGN

Prospective interventional study.

SUBJECTS AND SETTING

Participants were 13 nurses and 104 patients cared for in the intensive care unit for at least 24 hours in a university hospital in Ankara, Turkey.

METHODS

The study was conducted in 2 stages: the pre-care and post-care bundle stages. In the pre-care bundle stage, the pressure injury incidence of the patients was followed by the nurses. At the end of the third month, the researcher held a 1-day training program for the nurses about the care bundle use to promote correct implementation. In the post-care bundle stage, the nurses provided care according to the bundle. Compliance with the care bundle was assessed. Pressure injury incidence rates in the pre- and post-care bundle stages were compared.

RESULTS

The incidence of stage 1 pressure injury was 15.11 (1000 patient-days) in the pre-care bundle stage and 6.79 (1000 patient-days) in the post-care bundle stage; this reduction was not statistically significant.

CONCLUSIONS

A pressure injury prevention bundle was implemented in an intensive care unit, resulting in a decline in stage 1 pressure injuries.

Impact of a Swiss pressure ulcer prevention breakthrough collaborative

RATIONALE, AIMS AND OBJECTIVES

Pressure ulcers may have severe impacts on the quality of life of patients, including pain, low mood and restrictions in performing daily life and social life activities. In Switzerland, 4% of patients develop hospital-acquired pressure ulcers. Six hospitals teamed up with the Vaud Hospital Federation (Switzerland) in a Breakthrough Collaborative, with the goal of reducing hospital-acquired pressure ulcers by 50%. The aim of this study was to assess the actual reduction.

METHODS

A multimodal set of interventions was deployed in all wards except obstetrics and gynaecology, over 18 months starting in October 2016, including systematic risk assessment, use of a prevention bundle, education through e-learning, measurement and feedback, patient engagement and promotion of a safety culture. All six hospitals monitored compliance with the use of the risk assessment, bundle application and patient involvement aspects. A safety calendar was implemented in all wards, for recording and visually displaying the numbers of new patients with pressure ulcers, as well as the presence of such ulcers upon admission and their category.

RESULTS

Compliance with performing Braden risk assessments rose from 39% at baseline to 61% by the end of the collaborative (P < .001), prevention bundle compliance from 2% to 30% (P < .001%) and documented patient engagement from 2% to 21% (P < .001%). The percentage of days where one or more patient was reported as having developed one or more pressure ulcers in the ward decreased from 8.21% to 4.18%, a 49% reduction (P < .001) which amounts to preventing 1124 new patients from developing one or more pressure ulcers during the collaborative.

CONCLUSIONS

The Breakthrough Collaborative using a multimodal improvement approach combined with measurement and feedback was associated with a statistically and clinically significant improvement in compliance to best practice and with a reduction of hospital-acquired pressure ulcers by half.

Preventing pressure injury in nursing homes: developing a care bundle using the Behaviour Change Wheel

OBJECTIVE

To develop, with nurse specialists and nursing home care staff, a theory and evidence-informed pressure injury prevention care bundle for use in nursing home settings.

DESIGN

The development of a care bundle.

METHODS

We undertook a detailed, multistaged and theoretically driven development process. First, we identified evidence-informed pressure injury prevention practices: these formed an initial set of possible target behaviours to be considered for inclusion in the bundle. During a 4-hour workshop and supplemental email consultation with a total of 13 healthcare workers, we agreed the key target behaviours for the care bundle. We explored with staff the barriers and facilitators to prevention activity and defined intervention functions and behaviour change practices using the Behaviour Change Wheel.

SETTING

North West England.

RESULTS

The target behaviours consisted of three elements: support surfaces, skin inspection and repositioning. We identified capability, opportunity and reflective motivation as influencing the pressure injury prevention behaviours of nursing home care staff. The intervention functions (education, training, modelling) and behaviour change techniques (information about social and environmental consequences, information on health consequences, feedback on behaviour, feedback on the outcome of behaviour, prompts/cues, instruction on how to perform the behaviour, demonstration of behaviour) were incorporated into the care bundle.

CONCLUSION

This is the first description of a pressure injury prevention care bundle for nursing homes developed using the Behaviour Change Wheel. Key stakeholders identified and prioritised the appropriate target behaviours to aid pressure injury prevention in a nursing home setting.

Prescription of pressure injury preventative interventions following risk assessment: An exploratory, descriptive study

This exploratory, descriptive study aimed to identify and describe the pressure injury preventative interventions prescribed by nurses following the assessment of a patient's pressure injury risk and to compare the prescribed interventions relative to the assessed risk level. A total of 200 inpatients in a tertiary Australian hospital were included. Patients' charts were audited within 24 hours of admission. Data collected included patient characteristics, pressure injury risk assessment score and level, and preventative interventions prescribed. Most patients were assessed as not being at risk, with the largest group of at-risk patients assessed as being at high risk. Some not-at-risk patients were prescribed interventions intended for those at risk, while prescription rates of preventative interventions recommended for those at any level of risk were variable (6%-64%). Significant associations were found between assessed pressure injury risk and preventative intervention prescription. Preventative intervention prescription was inadequate, potentially exposing some patients to pressure injury. However, the association between intervention prescription and risk level suggests that nurses are prescribing interventions relative to risk. A more structured approach to intervention prescription according to risk level, such as a care bundle, may help to improve nurses' preventative intervention prescription and ensure that all at-risk patients receive appropriate preventative interventions.

Healthy Skin Wins: A Glowing Pressure Ulcer Prevention Program That Can Guide Evidence-Based Practice

BACKGROUND

In 2013, an observational survey was conducted among 242 in-patients in a community hospital with a pressure ulcer (PU) prevalence of 34.3%. An evidence-based pressure ulcer prevention program (PUPP) was then implemented including a staff awareness campaign entitled "Healthy Skin Wins" with an online tutorial about PU prevention.

AIMS

To determine the effectiveness of the PUPP in reducing the prevalence of PUs, to determine the effectiveness of the online tutorial in increasing hospital staff's knowledge level about PU prevention, and to explore frontline staff's perspectives of the PUPP.

METHODS

This was a mixed methods study. A repeat observational survey discerned if the PUPP reduced PU prevalence. A pre-test post-test design was used to determine whether hospital staff's knowledge of PU prevention was enhanced by the online tutorial. Qualitative interviews were conducted with nurses, allied health professionals, and health care aides to explore staff's perspectives of the PUPP.

RESULTS

A comparison of initial and repeat observational surveys (n = 239) identified a statistically significant reduction in the prevalence of PU to 7.53% (p < .001). The online tutorial enhanced staff knowledge level with a statistically significantly higher mean post-test score (n = 80). Thirty-five frontline staff shared their perspectives of the PUPP with "it's definitely a combination of everything" and "there's a disconnect between what's needed and what's available" as the main themes.

CONCLUSIONS

Incorporating evidence-based PU prevention into clinical practice greatly reduced the prevalence of PUs among hospital in-patients. Due to the small sample size for the pre-test post-test component, the effectiveness of the online tutorial in improving the knowledge level of PU prevention among hospital staff requires further research.

LINKING EVIDENCE TO ACTION

Evidence-based PU prevention strategies are facilitated by using a multidisciplinary approach. Educational tools about PU prevention must target all members of the healthcare team including healthcare aides, patients and families.

Universal Pressure Ulcer Prevention Bundle With WOC Nurse Support

PURPOSE

This study examined the effectiveness of a universal pressure ulcer prevention bundle (UPUPB) applied to intensive care unit (ICU) patients combined with proactive, semiweekly WOC nurse rounds. The UPUBP was compared to a standard guideline with referral-based WOC nurse involvement measuring adherence to 5 evidence-based prevention interventions and incidence of pressure ulcers.

DESIGN

The study used a quasi-experimental, pre-, and postintervention design in which each phase included different subjects. Descriptive methods assisted in exploring the content of WOC nurse rounds.

SUBJECT AND SETTING

One hundred eighty-one pre- and 146 postintervention subjects who met inclusion criteria and were admitted to ICU for more than 24 hours participated in the study. The research setting was 3 ICUs located at North Memorial Medical Center in Minneapolis, Minnesota.

METHODS

Data collection included admission/discharge skin assessments, chart reviews for 5 evidence-based interventions and patient characteristics, and WOC nurse rounding logs. Study subjects with intact skin on admission identified with an initial skin assessment were enrolled in which prephase subjects received standard care and postphase subjects received the UPUPB. Skin assessments on ICU discharge and chart reviews throughout the stay determined the presence of unit-acquired pressure ulcers and skin care received. Analysis included description of WOC nurse rounds, t-tests for guideline adherence, and multivariate analysis for intervention effect on pressure ulcer incidence. Unit assignment, Braden Scale score, and ICU length of stay were covariates for a multivariate model based on bivariate logistic regression screening.

RESULTS

The incidence of unit-acquired pressure ulcers decreased from 15.5% to 2.1%. WOC nurses logged 204 rounds over 6 months, focusing primarily on early detection of pressure sources. Data analysis revealed significantly increased adherence to heel elevation (t = -3.905, df = 325, P < .001) and repositioning (t = -2.441, df = 325, P < .015). Multivariate logistic regression modeling showed a significant reduction in unit-acquired pressure ulcers (P < .001). The intervention increased the Nagelkerke R-Square value by 0.099 (P < .001) more than 0.297 (P < .001) when including only covariates, for a final model value of 0.396 (P < .001).

CONCLUSION

The UPUPB with WOC nurse rounds resulted in a statistically significant and clinically relevant reduction in the incidence of pressure ulcers.

The effect of a patient centred care bundle intervention on pressure ulcer incidence (INTACT): A cluster randomised trial

BACKGROUND

Hospital-acquired pressure ulcers are a serious patient safety concern, associated with poor patient outcomes and high healthcare costs. They are also viewed as an indicator of nursing care quality.

OBJECTIVE

To evaluate the effectiveness of a pressure ulcer prevention care bundle in preventing hospital-acquired pressure ulcers among at risk patients.

DESIGN

Pragmatic cluster randomised trial.

SETTING

Eight tertiary referral hospitals with >200 beds each in three Australian states.

PARTICIPANTS

1600 patients (200/hospital) were recruited. Patients were eligible if they were: ≥18 years old; at risk of pressure ulcer because of limited mobility; expected to stay in hospital ≥48h and able to read English.

METHODS

Hospitals (clusters) were stratified in two groups by recent pressure ulcer rates and randomised within strata to either a pressure ulcer prevention care bundle or standard care. The care bundle was theoretically and empirically based on patient participation and clinical practice guidelines. It was multi-component, with three messages for patients' participation in pressure ulcer prevention care: keep moving; look after your skin; and eat a healthy diet. Training aids for patients included a DVD, brochure and poster. Nurses in intervention hospitals were trained in partnering with patients in their pressure ulcer prevention care. The statistician, recruiters, and outcome assessors were blinded to group allocation and interventionists blinded to the study hypotheses, tested at both the cluster and patient level. The primary outcome, incidence of hospital-acquired pressure ulcers, which applied to both the cluster and individual participant level, was measured by daily skin inspection.

RESULTS

Four clusters were randomised to each group and 799 patients per group analysed. The intraclass correlation coefficient was 0.035. After adjusting for clustering and pre-specified covariates (age, pressure ulcer present at baseline, body mass index, reason for admission, residence and number of comorbidities on admission), the hazard ratio for new pressure ulcers developed (pressure ulcer prevention care bundle relative to standard care) was 0.58 (95% CI: 0.25, 1.33; p=0.198). No adverse events or harms were reported.

CONCLUSIONS

Although the pressure ulcer prevention care bundle was associated with a large reduction in the hazard of ulceration, there was a high degree of uncertainty around this estimate and the difference was not statistically significant. Possible explanations for this non-significant finding include that the pressure ulcer prevention care bundle was effective but the sample size too small to detect this.

Using conformational positioning to reduce hospital-acquired pressure ulcers

Prevention of pressure ulcers is an ongoing concern. This article reports on the evaluation and usage of a new positioning device that adapts to the contours of the body and led to a decrease in the incidence of nosocomial pressure ulcers in a cardiothoracic intensive care unit.

INTroducing A Care bundle To prevent pressure injury (INTACT) in at-risk patients: A protocol for a cluster randomised trial

BACKGROUND

Pressure injuries are a significant clinical and economic issue, affecting both patients and the health care system. Many pressure injuries in hospitals are facility acquired, and are largely preventable. Despite growing evidence and directives for pressure injury prevention, implementation of preventative strategies is suboptimal, and pressure injuries remain a serious problem in hospitals.

OBJECTIVES

This study will test the effectiveness and cost-effectiveness of a patient-centred pressure injury prevention care bundle on the development of hospital acquired pressure injury in at-risk patients.

DESIGN

This is a multi-site, parallel group cluster randomised trial. The hospital is the unit of randomisation.

METHODS

Adult medical and surgical patients admitted to the study wards of eight hospitals who are (a) deemed to be at risk of pressure injury (i.e. have reduced mobility), (b) expected to stay in hospital for ≥48h, (c) admitted to hospital in the past 36h; and (d) able to provide informed consent will be eligible to participate. Consenting patients will receive either the pressure injury prevention care bundle or standard care. The care bundle contains three main messages: (1) keep moving; (2) look after your skin; and (3) eat a healthy diet. Nurses will receive education about the intervention. Patients will exit the study upon development of a pressure injury, hospital discharge or 28 days, whichever comes first; transfer to another hospital or transfer to critical care and mechanically ventilated. The primary outcome is incidence of hospital acquired pressure injury. Secondary outcomes are pressure injury stage, patient participation in care and health care costs. A health economic sub-study and a process evaluation will be undertaken alongside the trial. Data will be analysed at the cluster (hospital) and patient level. Estimates of hospital acquired pressure injury incidence in each group, group differences and 95% confidence interval and p values will be reported.

DISCUSSION

To our knowledge, this is the first trial of an intervention to incorporate a number of pressure injury prevention strategies into a care bundle focusing on patient participation and nurse-patient partnership. The results of this study will provide important information on the effectiveness and cost-effectiveness of this intervention in preventing pressure injuries in at-risk patients. If the results confirm the utility of the developed care bundle, it could have a significant impact on clinical practice worldwide.

TRIAL REGISTRATION

This trial is registered with the Australian New Zealand Clinical Trials Registry, ACTRN12613001343796.

Translating knowledge into best practice care bundles: a pragmatic strategy for EBP implementation via moving postprocedural pain management nursing guidelines into clinical practice

AIMS AND OBJECTIVES

To describe quantitative and qualitative best evidence as sources for practical interventions usable in daily care delivery in order to integrate best evidence into clinical decision-making at local practice settings. To illustrate the development, implementation and evaluation of a pain management nursing care bundle based on a clinical practice guideline via a real-world clinical exemplar.

BACKGROUND

Successful implementation of evidence-based practice requires consistent integration of best evidence into daily clinical decision-making. Best evidence comprises high-quality knowledge summarised in systematic reviews and translated into guidelines. However, consistent integration of guidelines into care delivery remains challenging, partly due to guidelines not being in a usable form for daily practice or relevant for the local context.

DESIGN

A position paper with a clinical exemplar of a nurse-led, evidence-based quality improvement project to design, implement and evaluate a pain management care bundle translated from a national nursing guideline.

METHODS

A pragmatic approach to integrating guidelines into daily practice is presented. Best evidence from a national nursing guideline was translated into a pain management care bundle and integrated into daily practice in 15 medical-surgical (med-surg) units of nine hospitals of a large university hospital system in Finland.

CONCLUSIONS

Translation of best evidence from guidelines into usable form as care bundles adapted to the local setting may increase implementation and uptake of guidelines and improve quality and consistency of care delivery.

RELEVANCE TO CLINICAL PRACTICE

A pragmatic approach to translating a nursing guideline into a pain management care bundle to incorporate best evidence into daily practice may help achieve more consistent and equitable integration of guidelines into care delivery, and better quality of pain management and patient outcomes.

Healthcare innovation barriers: results of a survey of certified professional healthcare risk managers

Medical errors cause significant patient injuries, including deaths. Innovations designed to improve quality and reduce risk are numerous, as are the barriers that prevent innovation implementation. The purpose of this research was to analyze the relationships, if any, between the independent variables of hospital bed size and organizational structure, and the dependent variable barriers to three innovations: implementing a surgical safety checklist, preventing catheter-associated urinary tract infections, and adopting patient- and family-centered care. The findings strengthen and expand existing research and serve as the foundation for understanding barriers to implementation of three healthcare innovations. Future research should focus on organizational culture instead of innovation-specific barriers and should incorporate other independent variables, such as organizational profitability.

Comprehensive programs for preventing pressure ulcers: a review of the literature

OBJECTIVE

The objective of this study was to examine the evidence supporting the combined use of interventions to prevent pressure ulcers (PrUs) in acute care and long-term-care facilities.

DESIGN

A systematic review of the literature describing multifaceted PrU prevention programs was performed. Articles were included if they described an intervention implemented in acute care settings or long-term-care facilities, incorporated more than 1 intervention component, involved a multidisciplinary team, and included information about outcomes related to the intervention.

MAIN RESULTS

Twenty-four studies were identified. Recurring components used in the development and implementation of PrU prevention programs included preparations prior to the start of a program, PrU prevention best practices, staff education, clinical monitoring and feedback, skin care champions, and cues to action. Ten studies reported PrU prevalence rates; 9 of them reported decreased prevalence rates at the end of their programs. Of the 6 studies reporting PrU incidence rates, 5 reported a decrease in incidence rates. Four studies measured care processes: 1 study reported an overall improvement; 2 studies reported improvement on some, but not all, measures; and 1 study reported no change.

CONCLUSIONS

There is a growing literature describing multipronged, multidisciplinary interventions to prevent PrUs in acute care settings and long-term-care facilities. Outcomes reported in these studies suggest that such programs can be successful in reducing PrU prevalence or incidence rates. However, to strengthen the level of evidence, sites should be encouraged to rigorously evaluate their programs and to publish their results.

Making sense of skin color in clinical care

The background of this article is that assessment and quantification of skin color is important to health care; color is one indicator of overall health and is linked to oxygenation, tissue perfusion, nutritional status, and injury. The purpose is to describe how skin color varies across racial/ethnic groups so that the information can be applied to clinical practice. The method used is cross-sectional, descriptive design (n = 257). We recorded self-defined race/ethnicity and used a spectrophotometer to measure skin color at two anatomic sites. Skin color variables included L* (light/dark), a* (red/green), and b* (yellow/blue). As regards results, we found significant differences in L*, a*, and b* values by site and race/ethnicity in White, Asian, and Biracial participants. L*: F(3, 233) = 139.04, p < .01 and F(3, 233) = 118.47, p < .01. Black participants had significantly lower mean L* values and wider ranges of L*, a*, and b* as compared with other groups. In regard to application, these findings suggest that clinicians and researchers should plan and provide care based on skin color, rather than race/ethnicity.

Use of an intervention bundle to eliminate pressure ulcers in critical care

Nursing staff chose to eliminate hospital-acquired pressure ulcers in their intensive care unit through implementation of an intervention bundle. A bundle of 7 interventions (pressure ulcer bundle, PUB) was developed through review of current evidence. After implementation, quarterly hospital-acquired pressure ulcer rates decreased and continued to remain below 1% throughout the year, and the goal of no pressure ulcers was met for 2 months. The PUB interventions have potential for use in a variety of settings where there are bed-bound patients.

Implementation of best practice in the prevention of heel pressure ulcers in the acute orthopedic population

To implement and evaluate a heel pressure ulcer prevention program (HPUPP) for orthopaedic patients. Program development of HPUPP involved input from administrators, staff and adult patients on an orthopaedic service in an academic tertiary care facility, located in a small urban centre in Canada. Prospective evaluation was conducted. Consensus exercises with clinical staff and administrators (Delphi and Nominal group) were used to, evaluate current practices, select a heel protective device, and develop key aspects of the HPUPP. HPUPP involved an individualised, bedside, staff education program, a team approach to improve patient mobility and use of a heel protective device. A 2-inch foam wedge covered in washable vinyl was placed at the foot of all beds on the orthopedic service. After the program was implemented, the incidence of heel pressure ulcers was 0%, which was a significant reduction compared with pre-implementation levels [13.8% (95% confidence interval 8-18%)]. Key components of the program success were initial and ongoing support from administration and surgeons, incorporation of feedback from clinical staff and patients, and keeping the program simple. Heel PU can be prevented in most orthopaedic patients using a universal heel PU prevention program.

Wound healing in older adults

Chronic wounds affect a substantial number of individuals throughout the world, and impose a significant psychological, physical and economic burden. As the population ages, the incidence of chronic wounds is also expected to rise. Clinicians struggle to find the optimal approaches to prevention and treatment of these nonhealing or slow-healing wounds. This review discusses current best practices and evidence-based recommendations for preventing and managing chronic wounds in general, as well as pressure ulcers, diabetic foot ulcers and venous leg ulcers specifically. This review highlights the significant gaps and inconsistencies in the current evidence base for chronic wound care, which have hindered making substantial progress in improving wound healing rates. It concludes with recommendations for improving the research and clinical knowledge base related to optimal wound-care practices.

Skin integrity in critically ill obese patients

Almost one-third of intensive care unit (ICU) patients are obese. Obese patients pose a unique challenge for preventing skin breakdown, healing wounds, and preventing complications of surgery and prolonged immobility. Yet little research to date has been done to study the effects of obesity on skin integrity and wound healing in this patient population. This article discusses common skin conditions and wound complications associated with obese patients and general treatment guidelines as they pertain to the critically ill patient.