Braden scale strengths and weaknesses

IMPLEMENTATION OF A PREVENTION PROGRAM v

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IMPLEMENTATION OF A PREVENTION PROGRAM TO REDUCE hospital acquired pressure ulcers

by

(name)

Evidence-based Practice Project

Submitted to the Faculty of NUR 49800 Capstone Course in Nursing

College of Nursing

of Purdue University Northwest,

Hammond, Indiana

in partial fulfillment of course requirements for the degree of

Bachelor of Science

September, 2017

© copyright

kristine de castro

2017

all rights reserved

table of contents

Section Page

table of contents iii

abstract iv

Sections

1. Introduction 1

2. Review of Literature and Synthesis of the Evidence 4

3. Plan for Implementation 18

4. Plan for Evaluation 27

5. Conclusions, Recommendations and Implications 34

references 36

List of tables

Table Page

Table 1 Summary of Reviewed Evidence 9

Table 2 Estimated Timetable Blueprint for Implementation 25

Table 3 EBP Evaluation Plan 30

ABSTRACT

Purpose: The purpose of this evidence based project is to determine if implementing a pressure ulcer prevention program, utilizing a multi-component pressure ulcer care bundle, will result in reducing the occurrence of hospital acquired pressure ulcers.

PICO question: “In hospitalized adult patients, what is the effectiveness of a pressure ulcer prevention program (or care bundle) compared to not having a pressure ulcer prevention program on reducing the occurrence of hospital acquired pressure ulcers?”

Significance of the problem: Hospital acquired pressure ulcers (HAPUs) are a serious and potentially preventable patient safety concern associated with negative patient outcomes including: pain, infection, increase hospital stays, and premature mortality. In addition to negative patient outcomes, hospital acquired pressure ulcers pose significant financial implications for healthcare facilities.

Synthesis of the evidence: A review of research and evidence suggests that an effective pressure ulcer prevention program should consist of a care bundle of nursing interventions related to: risk assessment, nutrition, repositioning/mobilization, skin care, support services/medical devices, and education. In addition, research studies have demonstrated a reduction in the occurrence of hospital acquired pressure ulcers as the result of an evidence based pressure ulcer prevention program.

Recommended implementation for practice change: Sufficient research supports that the implementation of a pressure ulcer prevention program will reduce the occurrence of hospital acquired pressure ulcers. Therefore, this knowledge should lead to the development and implementation of an evidence based pressure ulcer prevention program.

Conclusions/recommendations for practice: The recommendation is to pursue an evidence based pressure ulcer prevention program. Once developed, the prevention program should be piloted on a hospital unit with either high risk or high incidence of HAPUs. The pilot program outcomes will determine the feasibility of implementing the prevention program throughout the hospital.

Key words: hospital acquired pressure ulcer, pressure ulcer prevention program, pressure ulcer care bundle, pressure ulcer incidence

section 1

Implementation of a Prevention Program to Reduce Hospital Acquired Pressure Ulcers

Pressure ulcers, also known as pressure injuries or decubitus ulcers, can be defined as localized injury to skin and underlying tissue, usually over a bony prominence, due to unrelieved pressure, friction, or shearing forces. A hospital acquired pressure ulcer (HAPU) is any ulcer noted 24 hours or more after hospital admission (The Joint Commission, 2016). HAPUs are a serious and potentially preventable patient safety concern associated with negative patient outcomes and high healthcare costs. Pressures ulcers are a significant patient health issue and an organizational challenge addressed on a daily basis.

Purpose

The purpose of this evidence based project is to determine if implementing a pressure ulcer prevention program, utilizing a multi-component pressure ulcer care bundle, will result in reducing the occurrence of hospital acquired pressure ulcers.

Relevance

In United States acute care facilities, more than 2.5 million patients develop pressure ulcers annually, and approximately 60,000 patients die from pressure ulcer complications per year (Harmon, Grobbel, & Palleschi, 2016). High risk populations for the development of pressure injuries are individuals with reduced mobility and physical activity such as older adult, critically ill, and surgical patients. Pressure ulcers are assessed and classified from stage I (mild reddening) to stage IV (tissue loss) to determine the severity of the wound. The development of a stageable pressure ulcer can interfere with a patient’s functional recovery, cause pain and infection (e.g. cellulitis, osteomyelitis, and endocarditis), contribute to increased hospital stays, and result in premature mortality (The Joint Commission, 2016). Therefore, a pressure ulcer acquired during a hospital admission is typically considered an indicator of the quality of care delivered within the healthcare facility.

In addition to negative patient outcomes, hospital acquired pressure ulcers pose a significant financial burden on healthcare facilities resulting from additional treatment and staffing expenses. Since 2008, the Centers for Medicare and Medicaid Services announced that the additional costs incurred for HAPUs will no longer be reimbursed for those patients insured by either Medicare or Medicaid (Bauer, Rock, Nazzal, Jones, & Weikai, 2016). A hospital admission involving a pressure ulcer may incur additional annual charges of up to $700,000. It is estimated that the medical management of pressure ulcers costs the US health system $9.1 billion to $11.6 billion per year (Bauer et al., 2016).

Patient complications and financial implications related to hospital acquired pressure ulcers has resulted in an increased focus for Hospital A on prevention strategies to address this issue.

Potential Outcomes

Hospital A would like to evaluate the effectiveness of implementing a pressure ulcer prevention program (or care bundle). The potential outcome of such efforts is a reduction in the occurrence of HAPUs and ultimately, improvement in the quality and safety of patient care.

Clinical Question (PICO)

“In hospitalized adult patients, what is the effectiveness of a pressure ulcer prevention program (or care bundle) compared to not having a pressure ulcer prevention program on reducing the occurrence of hospital acquired pressure ulcers?”

Section 2

Review of Literature and Synthesis of Evidence

To address the clinical question (PICO), a review of literature was performed using the keywords: “hospital acquired pressure ulcer”, “pressure ulcer prevention program”, “pressure ulcer care bundle”, and “pressure ulcer incidence”. Five electronic databases (Joanna Briggs Institute, AHRQ National Guideline Clearinghouse, CINAHL, Cochrane Library-Cochrane Database of Systematic Reviews, and Google Scholar) were searched using database limits (when possible) of “English language”, "human subjects”, full text, and date range (year 2000 to present). The search revealed thirteen articles, studies, or clinical guidelines that provided relevant information regarding the significance of this issue and/or evidence to analyze the clinical question. The review of literature evaluated either: (1) the components/interventions of an effective pressure ulcer prevention program (or care bundle), or (2) the reduction in hospital acquired pressure ulcers due to implementing a multi-component pressure ulcer prevention program. In support of this project, nine articles were used to address the clinical PICO question: “In hospitalized adult patients, what is the effectiveness of a pressure ulcer prevention program (or care bundle) compared to not having a pressure ulcer prevention program on reducing the occurrence of hospital acquired pressure ulcers?”

Literature Common Themes

The analysis of the articles revealed the common topics of: a care bundle definition, effective components of a care bundle prevention program, and the impact on the occurrence of hospital acquired pressure ulcers.

Definition of care bundle. The literature discusses that an effective pressure ulcer prevention program consists of multiple nursing interventions or a care bundle. A care bundle is an evidence based practice protocol that groups several evidence-based practices together to address a specific procedure, symptom or treatment (Downie, Perrin, & Kiernan, 2013). Furthermore, the bundle should be constructed as a unit of care implemented for every patient, on every occasion. A care bundle that is consistently used as a cluster of treatments will have a greater effect on positive patient outcomes.

Components of care bundle prevention program. Evidence consistently demonstrates that there are various components to an effective care bundle designed to prevent pressure ulcer development. According to The Agency for Healthcare Research and Quality (2014), evidence based recommendations for the prevention of HAPUs would include nursing interventions for nutrition, repositioning/early mobilization, support services, and medical devices. The Joanna Briggs Institute (2008) outlines evidence based best practices for the prevention of pressure ulcers within the following categories of care: risk assessment, nutrition, repositioning, and support services. Additionally, the National Pressure Ulcer Advisory Panel (2016) has recently released a checklist entitled Pressure Ulcer Prevention Points which outlines key areas to address for prevention: risk assessment, nutrition, repositioning/mobilization, skin care, and education.

Reduction in hospital acquired pressure ulcers. Various studies provided consistent evidence on the effect of a multiple component pressure ulcer prevention program in the reduction of hospital acquired pressure ulcers. A systematic review of 39 hospitals worldwide that implemented such programs revealed that in 31 of the hospitals the overall PU incidence decreased with the introduction of the interventions (Soban, Hempel, Munjas, Miles, & Rubenstein, 2011). Another systematic review (involving 18 acute care settings and 8 long-term care settings) by Sullivan and Schoelles (2013), also resulted in a statistically signification reduction of pressure ulcer rates in 11 of the 26 reviewed hospital studies with a median pressure ulcer reduction rate of 67% to 100%. In addition, findings from a single study involving the implementation of a pressure ulcer prevention care bundle within 19 units of a Magnet hospital revealed a reduction in HAPUs. Specifically, prevalence of HAPUs was reduced from 6.63% (six months prior to the study) to 2.47% (six months after the study) (Mallah, Nassar, & Badr, 2015). Finally, in a study involving an intensive care unit within an Australian tertiary hospital, the incidence of pressures ulcers was less in the intervention group (18.1%) using a pressure ulcer prevention protocol as compared to the control group (30.4%) receiving standard skin care practices (Coyer et al., 2015).

An inconsistent finding did occur in a multi-hospital randomized control trial utilizing a patient centered pressure ulcer prevention program. A reduction in the number of HAPUs did occur between patients receiving the care bundle as compared to those who received standard care. However, once disease process factors and hospital grouping factors were analyzed at the patient level, no statistically significant effect of the prevention interventions on pressure ulcer incidence occurred. The authors believed this was potentially due to the small number of clusters used in the study (Chaboyer et al., 2016).

Existing Knowledge Gaps

When analyzing the various studies, some gaps in knowledge (or necessary research) were discussed. For example, future research should report strategies to continue the momentum of the prevention programs once started given the persistent significance in morbidity and mortality of pressure ulcers (Sullivan and Schoelles, 2013). Additionally, research should be performed on how nursing staffing levels influence a pressure ulcer prevention program and incidence of HAPUs (Soban et al., 2011). Lastly, more experimental rather than descriptive studies should be performed to strengthen the level of findings in these topic areas.

Findings

Given the review of literature, evidence suggests that an effective pressure ulcer prevention program should consist of a care bundle of nursing interventions. The care bundle interventions can be categorized by: risk assessment, nutrition, repositioning/mobilization, skin care, support services/medical devices, and education. Additionally, sufficient research supports that the implementation of a pressure ulcer prevention program does reduce the occurrence of hospital acquired pressure ulcers.

PICO Question: “In hospitalized adult patients, what is the effectiveness of a pressure ulcer prevention program (or care bundle) compared to not having a pressure ulcer prevention program on reducing the occurrence of hospital acquired pressure ulcers?”

Key words: hospital acquired pressure ulcer, pressure ulcer prevention program, pressure ulcer care bundle, pressure ulcer incidence

Databases Searched: CINAHL, Cochrane Library, Joanna Briggs Institute, AHRQ National Guideline Clearinghouse, Google Scholar

Table 1

Summary of Reviewed Evidence

Author(s) and Date of Publication ONLY

Design/ Setting/ Sample

Data Collection Tools

Findings/Results

Appraisal of Evidence: Worth to Practice (include Strengths, Weaknesses and Conclusions)

Level of Evidence (LOE)

Agency for Healthcare Research and Quality (2014)

Design:

Clinical practice guideline

Setting:

Various worldwide studies

Sample:

N=356 papers (newly included papers from 2008-2013 since the guideline builds on a previously published body of evidence)

Numerous databases were searched for pressure ulcer studies. Studies included in the analysis are: randomized control trials (RCTs), controlled clinical trials, quasi-experimental, cohort, cross-sectional, surveys prevalence/ incidence, case-control, and case

series.

The guideline outlines evidence based recommendations for the prevention (and treatment) of pressure ulcers within the following categories: nutrition, repositioning/early mobilization, support services, and medical devices.

Strengths:

Clinical practice guideline is the highest level of evidence.

Expert consensus is used to formulate the recommendation.

Strength of the evidence and the strength of the recommendations is provided.

Weaknesses:

HAPU incidence data (associated with interventions) is not provided. However, the guideline does indicate that a reduction in HAPU was a major outcome considered when evaluating the effectiveness of the intervention.

Conclusions:

The clinical guideline outlines recommended evidence based interventions that should be considered for inclusion in a pressure ulcer prevention program.

LOE:

Level I

(clinical practice guideline)

Chaboyer, W., Bucknall, T., Webster, J., McInnes, E., Gillespie, B., Banks, M., & . . . Wallis, M. (2016)

Design:

Cluster randomized controlled trial (RCT)

Setting:

Eight tertiary hospitals (with greater than 200 beds each) in three Australian states

Sample:

N=8 tertiary referral hospitals

(4 clusters allocated to intervention group and 4 clusters allocated to control group)

800 patients within each cluster consented to participate in the study.

Data was collected using tablet computers by two research assistant groups (RNs and other clinicians) at each hospital site.

Collected patient data included:

1. Baseline demographic and clinical data (including diagnosis and risk factors for pressure ulcers).

2. Daily patient skin status and pressure ulcer strategies including repositioning, nutrition, pressure relieving devices, and skin care products.

The intervention group received the pressure ulcer prevention care bundle (based on patient participation and clinical practice guidelines) and the control group received standard care.

1. 6.1% of patients in the intervention group developed a HAPU and 10.5% in the control group developed a HAPU.

2. However, once disease process factors and hospital grouping factors were analyzed at the patient level, no statistically significant effect of the prevention interventions on pressure ulcer incidence occurred.

3.There was a 52% reduction in the risk of a HAPU associated with the intervention group compared with standard care control group.

Strengths:

Multi-site RCT of patient centered pressure ulcer prevention care bundle targeting patient and staff behaviors.

Hospitals were randomized using a central randomization independent service to avoid selection bias.

Weaknesses:

Low statistical relevance due to the small number of clusters used in the study.

Conclusions:

No statistically significant effect of the pressure ulcer (patient centered) care bundle on pressure ulcer incidence once prognostic factors and clustering had been accounted for at the patient level. Therefore, uncertainty regarding if the intervention reduced HAPUs relative to usual care.

LOE:

Level II

(cluster randomized controlled trial

Coyer, F., Gardner, A., Doubrovsky, A., Cole, R., Ryan, F., Allen, C., & McNamara, G. (2015)

Design:

Controlled before and after study

Setting:

36 bed adult ICU in an Australian tertiary referral hospital

Sample:

N=207 ICU patients (102 control group patients receiving standard skin care practices and 105 intervention group receiving Inspire protocol)

Research nurses were employed and trained for data collection.

A data collection form was used to collect patient data including: demographic variables, skin assessment data, tools for staging ulcers, and process care interventions for pressure injury prevention using the Inspire protocol.

The Inspire protocol has interventions for: skin assessment, skin hygiene, repositioning, mobility, and nutrition)

1. Cumulative incidence of pressure injuries was significantly lower in the intervention group (18.1%) compared to the control group (30.4%) for skin injuries (x2=4.3; p-.04).

2. Significantly fewer pressure injuries developed over time in the intervention group.

Strengths:

The study has a control and intervention group.

Weaknesses:

Randomization did not occur when placing patients in the control or intervention group since the study was done in phases.

Conclusions:

Patients receiving the pressure ulcer prevention Inspire protocol had a lower incidence of pressure injuries.

LOE:

Level III

(controlled before and after study)

Mallah, Z., Nassar, N., & Badr, K. (2015)

Design:

Prospective

cohort study

Setting:

Data collected from 19 units (including medical, surgical, oncology, and ICUs) at a 300 bed Magnet hospital in Lebanon

Sample:

N=486 inpatients

Data was collected on participating units by 20 RN project champions, 2 wound specialists, & 2 RN quality improvement managers.

Collected patient data included:

1. Braden score on admission

2.Use of pressure ulcer preventative strategies (yes/no) (repositioning, skin care, nutritional support, pressure redistribution mattress) per the INTACT care bundle)

3. Patient demographics (age, gender, diagnosis, and length of stay)

1. Of the sample patients at risk for pressure ulcers, 81% had a documented prevention strategy, 76% had repositioning done, 78% had skin care, 87% had nutritional support, and 73% were placed on pressure redistribution mattresses.

2. Prevalence of HAPU was reduced from 6.63% (6 months prior to study) to 2.47% (6 months after the study).

3. Sensitivity of the Braden scale in predicting a HAPU was 92.3% (% of patient at risk for pressure ulcers and developed one) and specificity was 60.04% (% of patients not at risk for pressure ulcer and did not develop one).

4. Multiple logistical regression demonstrated skin care and Braden scores are two factors that significantly predict the development of a HAPU.

Strengths:

The study had a powered sample size with 486 patients (N=150 in similar studies).

Interventions were documented by well-trained RN champions.

The study followed the NDNQI (National Database of Nursing Quality Indicators) guidelines for preventative pressure ulcer interventions.

Weaknesses:

The design of the study was a descriptive design rather than experimental design (subjects were not randomized and no control group).

Study relied on nursing notes that preventative interventions were performed.

Conclusions:

The study applied a multi-modal program to prevent pressure ulcers. The interventions included a bundle of care performed by the nursing staff during routine care practice. The prevalence of HAPUs was reduced.

LOE:

Level IV

(prospective

cohort study)

National Pressure Ulcer Advisory Panel (NPUAP) (2016)

Design

Expert opinion

Setting

Not applicable

Sample

Not applicable

Information is not published as to the research and data collection process for the development of the guideline.

The Pressure Injury Prevention Points document created by the NPUAP recommends pressure ulcer prevention nursing interventions within the following areas: risk assessment, skin care, nutrition, repositioning/mobilization, and education.

Strengths:

The guideline is developed by the NPUAP which is a non-for profit professional organization composed of experts from different health care disciplines whom share a commitment to the prevention and management of pressure injuries.

The Joint Commission uses this guideline as the basis for their publication (Quick Safety) for strategies to prevent pressure ulcers.

Weaknesses:

Information is not provided as to the research studies used as the basis for the guideline.

Conclusions:

The NPUAP is a reputable organization, and the guideline provides valuable information for the components of a pressure ulcer prevention program.

LOE:

Level VII

(Guideline based on opinion of expert committee-NPUAP)

Soban, L., Hempel, S., Munjas, B., Miles, J., & Rubenstein, L. (2011)

Design:

Systematic review

Setting:

Hospital settings throughout the world

Sample:

N=39 studies representing 9 different countries

Six electronic databases were searched for publications from 1990-2009 to find studies using the following criteria: hospital setting, experimental design (e.g. RCTs, cohort, pre-post), testing of a quality improvement intervention to change pressure ulcer prevention care, and at least one outcome measure.

Selected studies were appraised of quality based on 8 criteria published by Center for Reviews and Dissemination.

1. 31 studies reported a patient outcome measure that reflected PU incidence. The pooled risk difference across studies was -.07 (95% confidence interval; p<.0001) indicating overall PU incidence decreases after the interventions

2.Majority of the studies used multiple intervention strategies in combination with educational and quality improvement strategies.

3. Most commonly reported pressure ulcer interventions were: implementation of protocol-based care, staff education, risk assessment, performance monitoring (collection of outcome data), assembly of new team for intervention, use of new equipment/process for beds/support surfaces, and new intervention based on published guidelines.

Strengths:

The quality of each study was assessed using 8 criteria published by the Center for Reviews and Dissemination.

Weaknesses:

Nearly all the studies included in the review were of lower level of evidence since they were a simple before and after study design without a control group/randomization.

Conclusions:

The findings suggest that multi-component prevention programs aimed at pressure ulcer reduction may improve patient outcomes by reducing the overall incidence of HAPU.

LOE:

Level IV

(systematic review of primarily non-experimental studies)

Sullivan, N., & Schoelles, K. (2013)

Design:

Systematic review

Setting:

Acute care settings within the United States (18 studies) and long-term care settings (8 studies)

Sample:

N=26 studies

Studies analyzed in the systematic review included: time series quasi-experimental (majority of the studies), RCTs, and controlled before/after.

1. In the 18 hospital studies, multiple patient care interventions were used to reduce patient risk for pressure ulcers. Initial and repeated risk assessments were preformed (e.g. Braden Scale) followed by tailored interventions based on risk category/factors. Interventions included: support surfaces, repositioning/mobility, skin management (e.g. care products, incontinence interventions), friction reduction (via mechanical means), and nutrition (assessment, interventions, and hydration).

2. 24 of the 26 studies report some improvement in pressure ulcer rates.

3. Statistically significant reductions in pressure ulcers rates were reported in 11 of the 26 studies with the median reduction of 82% (range: 67% to 100%).

Strengths:

Studies analyzed were assessed for quality using a the 19-item SQUIRE (Standards for Quality Improvement Reporting Excellence) guideline.

Weaknesses:

The systematic review is primarily of quasi-experimental studies (level III) rather than RCTs (level I).

Conclusions:

Evidence suggests that implementing multicomponent initiatives for pressure ulcer prevention in acute care settings can improve quality of patient care and reduce pressure ulcer rates.

LOE:

Level III

(systematic review of primarily quasi-experimental studies)

Tayyib, N., & Coyer, F. (2016)

Design:

Systematic Review

Setting:

Intensive Care Units (ICUs) throughout the world

Sample:

N=24 studies

Six electronic databases were searched for publications from 2000-2015 to identify studies involving the effectiveness of single interventions designed to reduce the incidence and prevalence of HAPUs in intensive care units

Study interventions were appraised of quality using the Joanna Briggs Institute Meta-Analysis of Statistics Assessment and Review Instrument.

1. Interventions reviewed across studies for pressure ulcer prevention interventions included: risk assessment, preventative skin care, emerging therapies (polarized light and dressings), nutrition, repositioning/early mobility, support surfaces, medical device impact, and education.

2. Research findings identified that the use of a silicon foam dressing intervention reduced the occurrence of HAPUs.

3. In individual studies addressing the use of one intervention (related to nutrition, skin-care regime, position/repositioning, support surfaces, or education), no statistically significant results lead to the prevention of HAPUs in the ICUs.

4. Further RCTs studies are needed with a standardized criterion for reporting on each pressure ulcer prevention intervention.

Strengths:

Study interventions were appraised of quality using the Joanna Briggs Institute Meta-Analysis of Statistics Assessment and Review Instrument.

Weaknesses:

There is uncertainty in the interpretation of many studies due to small underpowered sample sizes with wide confidence intervals.

Conclusions:

Research findings identified that the use of a silicon foam dressing intervention reduced the occurrence of HAPUs. Other single intervention studies did not demonstrate an impact on HAPU incidence. This systematic review supports the concept that HAPU prevention is more effective using multiple interventions within a care bundle.

LOE:

Level IV

(systematic review of RCTs, quasi-experimental, and comparative studies)

The Joanna Briggs Institute. (2008)

Design:

Clinical practice guideline

Setting:

Hospitals settings throughout the world

Sample:

N=4 systematic reviews (published between 2003-2006)

The 4 systematic reviews included in the bet practice sheet reviewed the effectiveness of risk assessment scales, repositioning, support surfaces, and nutritional supplements for pressure ulcer prevention.

The guideline outlines evidence based best practices for the prevention of pressure ulcers within the following categories: risk assessment, repositioning, support services, and nutrition.

Strengths:

Clinical practice guideline is the highest level of evidence.

Recommendations are graded based on effectiveness.

Weaknesses:

HAPU incidence data (associated with each intervention) is not provided.

Conclusions:

The guideline is recommended evidence based interventions that should be considered for inclusion in a pressure ulcer prevention program.

LOE:

Level I

(clinical practice guideline)

Section 3

Plan for Implementation

Hospital A has recently seen an increase in the occurrence of hospital acquired pressure ulcers. Furthermore, the Centers for Medicare and Medicaid Services (CMMS) will no longer reimburse additional medical expenses for Medicare or Medicaid patients that develop a pressure ulcer during their hospital stay. As a result, there is an intensified interest within the facility to implement an evidence-based approach to improve this quality indicator, eliminate the costs associated with HAPUs, and ultimately improved the quality and safety of patient care.

To implement evidence based practice (EBP), it is useful for the project team to follow a framework or proven model. Once such model is the PARIHS (Promoting Action on Research Implementation in Health Services) framework which is based on three categories (evidence, context, and facilitation) that are key to a successful EBP implementation (Rycroft-Malone, 2004). The first component, evidence, involves the project’s utilization of gathered research as well as clinical and patient experience. Given the preceding review of literature, evidence does appear to support the decrease in HAPUs through the implementation of a multi-component (or care bundle) prevention program. Additionally, clinical and patient experience will be considered in the following “Stakeholders” discussion. The second component in the PARIHS framework, context, is related to the environment or facility where the new practice will be implemented. Context dictates that the facility’s culture and leadership needs to be considered in the implementation plan; therefore, these aspects of the implementation will be addressed in the following discussion of “Organizational Fit” and “Barriers to Implementation”. Lastly, the facilitation component of the PARIHS model relates to assisting individuals in understanding the change required to implement EBP. This element will be addressed in the “Facilitation Strategies for EBP Implementation” and “Resources Needed” discussion.

Stakeholders

Hospital A’s target population for the project is all patients admitted to the medical center. The stakeholders for this project are those individuals who are affected by or influence the implementation of the pressure ulcer prevention program. In particular, the active stakeholders (those who have a critical role in making the project happen) will include: hospitalized patients, staff nurses/nurse assistants, physicians, unit nursing managers/directors, and clinical nurse educators. The passive stakeholders (not actively involved in project but promote its success) will include: nursing administration (including the Chief Nursing Officer), quality improvement management, and risk management.

A multidisciplinary PUP (pressure ulcer prevention) support team will be established which will consist of core individuals consistently working on the project to ensure its success. This team will be comprised of: a team lead, a EBP mentor (a nurse educator with an EBP certification), a group of volunteer PUP nurse champions, a wound care nurse, a physician representative, a registered dietician, a quality improvement representative, a risk management representative, a finance representative, a supplies management representative, and an information technology representative. The non-clinical members of the support team will be called upon as necessary to address aspects of the project associated with their respective departments.

To launch the project successfully, there are various hospital personnel that will need to be persuaded for support. This would include: nursing administration, physician administration, the wound care department, the finance department (e.g. financial analyst or financial controller), the quality improvement department, and risk management. Once there is initial approval to explore this EBP project at the nursing unit management level, then the next step would be to seek approval from the other indicated areas as soon as possible. The recommended strategy for informing these areas would be for one or more members of the PUP support team (e.g. PUP team lead and EBP mentor) to meet one-on-one with these respective areas to explain the recent increase in HAPUs, to describe the EBP project/potential outcomes, and to seek support. Once the necessary project approvals are gained, a PUP unit pilot is complete, and approval is received for hospital wide implementation, then all clinical hospital personnel will need to be informed of the project thru an email communication, unit meetings, and project support signage (e.g. professional posters and pamphlets).

Organizational Fit

The pressure ulcer prevention program is a hospital wide initiative; therefore, the project itself should correlate with Hospital A’s mission, vision, and values. The hospital’s mission statement is “to advocate the health of our communities by providing outstanding healthcare services”. One of the project outcomes of the EBP proposal is improvement in the quality of patient care. This outcome correlates directly with providing outstanding healthcare services within the community. The hospital’s vision statement is “to be a locally responsive, regionally relevant health system”. The creation of a pressure ulcer prevention program is in response to an increase in HAPUs. By addressing the issue via this project, the hospital is demonstrating local responsiveness by providing quality community healthcare services. Lastly, the values statement of the hospital follows the mnemonic: D.R.I.V.E. (determination, respect, integrity, vision, excellence, and nurturing). All of these values will be addressed thru this EBP project since the hospital will be demonstrating that it is: (1) determined to improve patient outcomes; (2) committed to respecting the patients need for quality care related to pressure ulcers, (3) persistent in their integrity by taking action to address the HAPU issue, (4) exhibiting vision to implement the latest evidence based pressure ulcer prevention care, (5) displaying excellence by continually focusing on patient-centered care, and (6) cultivating a nurturing environment through the utilization of evidence based prevention interventions that result in positive patient outcomes .

Hospital A has recently implemented a prevention program to prevent hospital acquired infections (HAIs). The project was evidence based and did result in a reduction in occurrence of HAIs. The PUP project will review this project’s overall outcomes, findings, and “lessons learned” to gain insight when planning the PUP implementation.

Barriers to EBP Implementation

One of the potential barriers to implementing the EBP project is the potential concern of clinical providers (specifically staff nurses and nurse assistants) that the pressure ulcer care bundle could result in an increase in their daily workloads. The care bundle will result in additional nursing interventions as compared with current standard practice. For the project to be successful, the unit nursing managers will need to be supportive of the project and be willing to work with the PUP support team to determine strategies to address this concern.

A second possible barrier is that some clinicians may be resistant to change, since they have been in the nursing industry for many years, and prefer routine care rather than new protocols based on evidence. PUP training will need to address this barrier as it will demonstrate the need for change to improve the quality and safety of patient care. Furthermore, nurse competency return demonstrations should also be part of the training program to ensure that all nurses understand the new care bundle and are comfortable in implementing the change into practice.

Facilitation Strategies for EBP Implementation

The PUP support team’s goal through facilitation is to enable the implementation of the program so that it is successful. One strategy in doing this is to have the support team’s “EBP mentor” role filled by a nursing clinical educator that has a certification in evidence based practice. This will allow a key team member to possess the knowledge and skills to aid an EBP project implementation.

Another facilitation strategy for the implementation is to solicit nurse champions on the PUP support team that already have experience with evidence based project implementations. For example, the evidenced based HAI prevention program was successfully implement at Hospital A. Therefore, if possible, the PUP support team should solicit nurses involved with that project’s support team to become a member of the PUP support team.

Another facilitation strategy is for the information technology representative (on the PUP support team) to work with PUP nurse champions to automate the pressure ulcer care bundle checklist and PUP care plan documentation into the electronic medical record (EMR). Upfront planning for this task will be essential so that the electronic documentation required for the new care bundle interventions is well developed, streamlined, and efficient for the nurses and nurse assistants.

Lastly, an additional and very important strategy for this project is to pilot the PUP program within a hospital unit that is either at high risk for pressure ulcer development or has a high incidence of HAPUs. The pilot program will allow the PUP support team: to test the new care bundle and implementation strategy; to gain project feedback; to review project outcomes; and to determine the feasibility of implementing the program hospital wide.

Resources Needed

Numerous resources will be required for the success of the pressure ulcer prevention program. Financial funding will be a critical resource required for this EBP project and will be needed for items such as: (1) education and training expenses (e.g. facility and printing expenses), (2) information technology modifications (e.g. addition of care bundle interventions/care plans into the EMR), and (3) new patient supplies (e.g. new foam dressings, mattress changes, mobility devices). Another required resource is the additional personnel time required for the project including: (1) non-clinical time for staff meetings to introduce/explain the project, (2) non-clinical time for training/education of staff members, (3) non-clinical time for PUP support team member project tasks, and (4) leadership time to monitor and support the team.

Approval for these resources will be required on a smaller scale initially (from nursing management and finance department) for the PUP unit pilot. Once the unit pilot is complete, the pilot outcome data and research evidence can be used to outline a cost/benefit analysis for senior hospital administration. This analysis will demonstrate if the overall patient care benefit and cost savings will make the PUP project feasible to implement hospital wide.

Table 2

Estimated Timetable Blueprint for Implementation

Task

Estimated Date

of Start

Estimated Date of Completion

Person/s Responsible

Gain approval from nursing management and Finance department for PUP project concept and pilot unit funding

9/25/17 (2 weeks)

10/6/17

· EBP Mentor

· Student

· Nursing Management

· Finance Department

Note: It is assumed in the remaining tasks that the “student” will be a part of the PUP support team as a volunteer nurse champion.

· Identify PUP support team roles and responsibilities

· Solicit PUP support team members

10/9/17 (2 weeks)

10/20/17

· PUP team lead

· EBP Mentor

Solicit approval for PUP project via one-on-one meetings with key departments needed for project support

10/23/17 (3 weeks)

11/10/17

· PUP Team Lead

· EBP Mentor

· Determine PUP pilot unit

· Solicit PUP nurse champions from the pilot unit

11/13/17 (1 week)

11/17/17

· PUP Team Lead

· EBP Mentor

· Nursing Management

Determine the evidence based nursing interventions that will be a part of the new PUP care bundle:

· Analyze current pressure ulcer prevention interventions

· Review evidence based pressure ulcer nursing interventions from literature/research review

· Finalize new PUP care bundle

· Solicit approval from Nursing Management

11/20/17 (8 weeks)

01/12/18

· PUP Team Lead

· EBP Mentor

· PUP Support Team

· Nursing Management (for approval)

· Determine EMR modifications required for the PUP care bundle

· Solicit approval from Nursing Management

· Design/Test EMR modifications

1/15/18

(6 weeks-concurrent task)

2/23/18

· PUP support team

· Nursing Management (for approval)

· Determine new/changes in patient supplies required for the PUP program

· Solicit approval from Nursing Management

· Procure new supplies

1/15/18

(6 weeks-concurrent task)

2/23/18

· PUP support team

· Nursing Management (for approval)

· Determine education and train materials for the pilot unit

· Solicit approval from Nursing Management

· Design/create education and training material

2/26/18 (3 weeks)

3/16/18

· PUP support team

· Nursing Management (for approval)

Meet with pilot unit to explain: HAPU issue, PUP project pilot, and project outcome measures

3/19/18 (1 week)

3/23/18

· PUP Team Lead

· EBP Mentor

Provide training to the PUP pilot active stakeholders on the new PUP care bundle and pilot rollout

3/26/18 (1 week)

3/30/18

· PUP Team Lead

· EBP Mentor

· PUP Support Team

Launch/implement 6-month PUP program in the pilot unit

4/2/18 (24 weeks)

9/28/18

· Pilot Unit

· PUP Team Lead

· EBP Mentor

· PUP Support Team

Measure/document pilot program outcomes

4/2/18

(24 weeks-concurrent task)

9/28/18

· PUP Team Lead

· PUP Support Team

Prepare and present to senior hospital management pilot program outcomes, research evidence, and cost/benefit analysis to determine feasibility of hospital wide PUP program implementation

10/01/18 (2 weeks)

10/12/18

· PUP Team Lead

· EBP Mentor

· Nursing Management

section 4

Plan for Evaluation

Research evidence does supports that an evidence based pressure ulcer prevention program will result in a decrease in the occurrence of hospital acquired pressure ulcers. The following discussion will provide information as to the baseline data and outcome indicators (Table 3) that will be used to evaluate the success of the proposed pressure ulcer prevention program.

Baseline Data

Base line data is important to collect for the PUP unit pilot as it demonstrates Hospital A’s performance data prior to implementing the pressure ulcer practice change. According to the Agency for Healthcare Research and Quality (2015), pressure ulcer rates are the most direct measure of how well a pressure ulcer prevention program is succeeding in averting pressure ulcers. Given this, the baseline data that will be collect for the pilot unit will include: (1) pressure ulcer incidence rate (the number or percentage of patients developing new pressure ulcers after admission), and (2) pressure ulcer prevalence rate (the number or percentage of people having a pressure ulcer on admission or after admission). Incidence rates provide the most direct evidence of the quality of a prevention program; however, prevalence rates can provide a useful snapshot of the pressure ulcer burden within a hospital and therefore should be collected as well (Agency for Healthcare Research and Quality, 2015).

At Hospital A, the pressure ulcer incidence and prevalence rates are currently being tracked manually by the staff nurses and nursing unit manager. When a staff nurse notes the development of a pressure ulcer for their patient, the information is noted within the assessment notes in the EMR (electronic medical record) and then the information is manually logged into the unit’s pressure ulcer incidence and prevalence log. The nursing unit manager then uses this manual log to notify (via an email) the risk management and quality management departments. The risk management department then uses the log data and enters the information into their risk management system so that a monthly report can be generated to track pressure ulcer incidence and prevalence data hospital wide.

For the PUP unit pilot baseline data, pressure ulcer incidence and prevalence data will be collected for six months prior to beginning the pilot. The staff nurses and nursing unit manager will continue their current processes of logging incidence/prevalence information. Additionally, PUP support team members (EBP team lead, Nursing Unit Manager, and Risk Management representative) will work together to gather and review the pilot unit’s baseline incidence and prevalence monthly reports from the risk management system.

Interpretation of Data

During the 6-month pilot implementation, monthly pressure ulcer incidence and prevalence rates will continue to be gathered and monitored by the PUP support team (see Table 3: EBP Evaluation Pan for a detailed explanation of the data collection process). After completion of the pilot, the baseline pre-implementation rates can be compared to the pilot post-implementation rates to determine if the pressure ulcer prevention program is effective in reducing hospital acquired pressure ulcers. Specifically, the project outcome indicators are as follows:

· Within 6 months of the pilot program implementation, the pressure ulcer (PU) incidence rate will decrease by 15% for the pilot unit. (The pressure ulcer incidence rate will provide the most direct evidence of the quality of a prevention program since it measures pressure ulcers after admission.)

· Within 6 months of the pilot program implementation, the pressure ulcer (PU) prevalence rate will decrease by 18% for the pilot unit. (This rate will measure pressure ulcers on admission and after admission. It is a useful measure since it will indicate if the PUP program is assisting in reducing/resolving the “on admission” pressure ulcers as well.)

· At the end of the 6-month pilot program, the return on investment for the unit pilot will be a minimum 20%. (This indicator is important for the PUP support team to demonstrate to senior hospital administration that the additional hospital expenses incurred from the PUP program will result in positive financial outcomes for the hospital.)

Table 3

EBP Evaluation Plan

Outcome(s)

Measurement

Data Collection Process/ Time of Collection/

Person Responsible

1. Pressure ulcer incidence rate

Within 6 months of the pilot program implementation, the pressure ulcer (PU) incidence rate will decrease by 15% for the pilot unit.

2. Pressure ulcer prevalence rate

Within 6 months of the pilot program implementation, the pressure ulcer (PU) prevalence rate will decrease by 18% for the pilot unit.

Measurement Definition:

Pressure ulcer incidence rate is the number or percent of patients (on the pilot unit) developing a new pressure ulcer since admission onto the unit.

For the pilot, the calculation is as follows:

PU incidence rate=

(No. of patients that developed a new pressure ulcer) / (No. of patients admitted on the unit for the same month) x 100

Measurement Definition:

Pressure ulcer prevalence rate is the number or percent of patients having a pressure ulcer on admission plus those acquired after admission.

For the pilot, the calculation is as follows:

PU prevalence rate = (No. of patients with any pressure ulcer for the month) / (No. of patients on the unit for the month) x 100

Baseline Incidence and Prevalence Measurement:

A 6-month audit of pressure ulcer incidence and prevalence data will be reviewed for the pilot unit prior to beginning the pilot. This information is currently being manually sent to the risk management department who then generates a monthly PU incidence report.

Outcome Incidence and Prevalence Data Measurement:

During the pressure ulcer prevention program pilot, a 6-month audit of monthly pressure ulcer incidence and prevalence data will be compiled based on the monthly PU incidence and prevalence report (see Data Collection Process).

The 6 months of baseline pre-implementation data will be compared to the 6 months of post implementation data through the creation of two bar charts (one for incidence data and one for prevalence data). The bar charts will then allow analysis to be performed to determine if the PU incidence and prevalence rates have decreased as a result of the new pressure ulcer prevention program. This information will be presented to senior hospital management and will be used to determine if the PUP program should be implemented hospital wide.

Data Collection Process:

The process to determine pressure ulcer data during the unit pilot is as follows:

1. Nurses will perform a new pressure ulcer patient assessment (as one component of the new PU prevention program) on admission to the unit and as part of their regular patient assessment each shift.

2. Nurses will enter the pressure ulcer assessment data into the modified EMR that will now contain pressure ulcer assessment data fields including indicator fields for: (1) “pressure ulcer exists on admission”, and (2) “new pressure ulcer after admission”.

3. These new indicator fields will send a patient pressure ulcer alert notification to the nursing unit manager. In addition, the indicator fields will also be linked (or interfaced) to the risk management system so that the total number of pressure ulcers will be maintained within a database.

4. A PU incidence/prevalence report will be generated monthly from the risk management system outlining the pressure ulcer data for the month.

Time of Collection:

· Patient pressure ulcer assessment data will be collected and entered into the EMR daily

· During the 6-month pilot (April 2018-October 2018), monthly reports will be generated from the risk management system indicating the pressure ulcer information

Person/s Responsible:

PUP support team members will be responsible for collecting and monitoring the PU incidence/prevalence data including:

· Nursing staff: will enter PU assessment data into the EMR

· Nursing management/EBP team lead: will monitor the PU alert notifications and work with the PUP support team/pilot unit to ensure the nursing staff understands and is following the new pressure ulcer prevention interventions

· Risk Management/Quality Improvement department representatives: will produce and monitor the monthly pressure ulcer incidence/prevalence reports

3. Return on Investment (ROI) for the PUP program

At the end of the 6-month pilot program, the return on investment for the unit pilot will be a minimum 20%.

Measurement Definition:

The return on investment is used to assess the financial return on implemented improvement projects.

For the pilot, the calculation is as follows :

ROI = (Pilot savings – pilot cost) / (pilot cost) x 100

1. Savings due to PUP program:

· Decrease in Hospital A’s costs associated with HAPUs (e.g. supplies, medication, personnel)

· Decrease in revenue loss from Medicare not reimbursing for HAPUs

2. Expenses of PUP program:

· New supplies costs

· Education/training costs

· Personnel labor costs

Baseline Data Measurement:

Baseline data is not calculated for a ROI outcome indicator.

Outcome Data Measurement:

After completion of the pilot, the ROI can be calculated by the finance department by running expense and savings reports from their system that tracks this data. This information will be used to calculate the ROI.

The ROI information outcome will be presented to senior hospital management and will be used to determine if the PUP program should be implemented hospital wide.

Data Collection Process:

During the 6-month pilot, the PUP support team members will provide the EBP team lead with expenses associated with pilot program. The EBP lead will enter the information into the finance department’s expense tracking system. In addition, the savings information will also be derived from data that is current being tracked in the same system.

Time of Collection:

Data will be collected/provided during the 6-month pilot program (April 2018-October 2018).

Person/s Responsible:

PUP support team members will collect the data:

· Finance representative: will calculate the ROI outcome based on savings/expense data provided by team members.

· EBP team lead: will enter expense information into tracking system

· Supplies Management representative: will provide new supplies cost

· Nurse Educator: will provide costs associated with education/training

· Human Resources department: will provide personnel time associated with the pilot program

section 5

Conclusions, Recommendations, and Implications

The following discussion outlines the conclusions and recommendations for the EBP proposal to implement a pressure ulcer prevention program.

Conclusions`

Hospital acquired pressure ulcers are a serious and potentially preventable patient safety concern associated with negative patient outcomes and high healthcare costs. The development of a stageable pressure ulcer can interfere with a patient’s functional recovery, cause pain and infection, increase hospital stays, and cause premature mortality. In addition to negative patient outcomes, hospital acquired pressure ulcers pose a significant financial burden on healthcare facilities from additional treatment/staffing expenses and decreased Medicare reimbursement.

A review of research and evidence suggests that an effective pressure ulcer prevention program should consist of a care bundle of nursing interventions. The care bundle interventions can be categorized by: risk assessment, nutrition, repositioning/mobilization, skin care, support services/medical devices, and education. Additionally, sufficient research supports that the implementation of a pressure ulcer prevention program does reduce the occurrence of hospital acquired pressure ulcers.