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Evidence-Based Policy and Practice

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Nicole O'Neil

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Introduction

Pressure ulcers, also known as pressure damage, pressure injuries, pressure sores,

bedsores or decubitus ulcers, are defined as areas of localized damage to the skin and underlying tissues and are believed to be caused by a combination of pressure, shear and friction (McGinnis, 2014, para. 2). A pressure ulcer on the skin can ultimately decrease blood flow to the area and without enough blood to perfuse the tissues, necrosis can develop and an ulcer can form (McGinnis, 2014, para. 3). Their location typically is over bony prominences and are common among the ill, those with neurological difficulties, diabetics, and people who are immobile for periods of time. Other individuals at high risk include those with vascular disease, malnutrition, and previous history of pressure damage (McGinnis, 2014, para. 6).

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Once a pressure ulcer has occurred, treatment is concerned with reducing the amount of exposure to pressure and ultimately the management of the wound. Reducing the extent and duration of applied pressure can be achieved by either changing a person’s position, or also by using equipment designed to aid in the reduction of pressure (McGinnis, 2014, para. 5). The pressure-reducing equipment can be used for the whole body, such as a mattresses, or can be used for specific areas of the body prone to pressure such as with foot protectors and booties (McGinnis, 2014, para. 3). It is worth mentioning, that many present interventions are designed for prevention; however, if an ulcer has occurred, it is necessary to reduce the risks of further tissue breakdown by these recommended interventions.

There are two main approaches to preventing pressure ulcers using pressure-relieving devices including the use of a conforming support surface to distribute the body weight over a large area, as well as the use of an alternating support surface where inflatable cells alternately inflate and deflate (McGinnis, 2014, para. 11). According to the National Center for

Biotechnology Information, pressure-relieving devices cover all types of beds, mattresses, and overlays and other devices aimed at pressure redistribution. These pressure-relieving devices largely differ from each other and can be classified in various ways and vary in the materials they are made from and in their pressure-relieving mechanisms of action. For example, constant low pressure (CLP) devices mold around the patient to distribute their weight over a larger area, while alternating pressure (AP) devices mechanically vary the pressure beneath patients so that the duration of pressure is reduced (McGinnis, 2014, para. 16).

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include nursing interventions for prevention, such as the incorporation of pressure relieving devices. The policy of this pressure ulcer prevention protocol includes the implementation of the Braden scale upon admission, 2 weeks later, and after that period, upon weekly assessments. This allows nursing staff to properly identify those at risk for pressure sore development, but fails to actually prevent worsening of pressure ulcers or the development of pressure ulcers. The prevention protocol also includes weekly skin assessments to be completed by the licensed nurses to aid in the identification of alterations in skin, but again, this intervention fails to prevent the development of pressure related injuries. The facility is in need of a prevention policy that assists in the prevention of pressure ulcers to improve patient outcomes, prevent any further injuries from occurring, as well as provide more cost-saving measures. This facility presently has a patient census of 157 residents with active pressure ulcer treatments on 34 residents, ranging from stage II to stage IV.

Review of the Literature

A quantitative research study was performed by researchers in 2013 to determine the effects of pressure-relieving interventions for treating pressure ulcers on the heel. Pressure-relieving devices such as beds, mattresses, heel troughs, splints and pillows are used as part of the treatment to reduce or relieve the pressure on the ulcer. Heel ulcers were studied specifically since their structure differs largely from other body sites, which are prone to pressure ulcers. This specific area is also more prone to commonly reported diseases, such as poor circulation, which do not affect other pressure ulcer sites (McGinnis, 2014, para. 5).

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include mattresses and specific heel devices. The study involved participants with existing heel pressure ulcers of any grade and across any care setting. The type of interventions used in this RCT included pressure relieving devices such as mattresses; foam overlays; foam mattress replacements; alternating air-filled overlays; alternating air-filled mattress replacements; air overlays; and air-fluidized beds (McGinnis, 2014, para. 4). Trials reviewing the following outcomes were considered such as the number of heel ulcers healed within a defined time period and the time required to heal the pressure ulcer on the heal. Secondary outcomes measured in this study include costs of pressure-relieving devices, total costs of interventions, patient comfort, ease of use, health-related quality of life, as well as any adverse events that occurred (McGinnis, 2014, para. 3). To reduce bias and improve the accuracy of the results, comparisons were made by researchers by using search methods of other studied RCTs through proven reliable sources such as Cochrane Wounds Group Specialized Register, The Cochrane Central Register of Controlled Trials, Ovid MEDLINE, as well as electronic databases in EBSCO CINAHL (McGinnis, 2014, para. 7). Researchers also assessed the risk of bias by including two review authors that independently reviewed each study using the Cochrane Collaboration Tool for assessing risk of bias. The study randomized 141 people of which 113 of those individuals had heel pressure ulcers to one of two different alternating mattress replacements. The duration of the study was originally planned to be 12 months, but later was extended to 18 months as the patients were followed up until the ulcer either healed, or they were discharged from the facility (McGinnis, 2014, para. 8). All participants were recruited from a dementia facility in a United Kingdom’s community hospital with an average age 84 years. The underlying medical

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included outcomes for sacral and heel pressure ulcers predominantly as these are the main reported pressure-related injuries.

The researchers concluded that based on this evidence, there should be a current guideline in place for practice that recommends the use of pressure-relieving devices for all participants with pressure ulcers. Although not all of the RCTs met the inclusion criteria presented, and some areas of evidence indicated further research is needed, it is still highly recommended to incorporate this intervention into practice to aid in the healing and prevention of ulcers. The above evidence supports the recommended policy of pressure ulcer prevention and the incorporation of pressure-relieving devices to those patients at risk in the facility mentioned above. Based on this evidence, this intervention can largely aid in the treatment of existing pressure ulcers, as well as in the prevention of pressure ulcers to those individuals at greatest risk.

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The results showed a more effective pressure relief at the heel with the Foot WAFFLE Air Cushion on day one in both positions, and day three in the elevated position. One important consideration to make is the cost of the products. The cost an organization can save if pressure ulcers are prevented are significant as an estimated $5,000 to $40,000 can be saved on average to treat a pressure ulcer (Aquila, A., & Ferretti, D. 2013, para. 9). As mentioned, the findings showed more effective pressure relief and more positive patient responses to the Foot WAFFLE Air Cushion, which could ultimately lead to better prevention of pressure ulcers on the heel in the future. Although this study primarily covers the effectiveness of these different pressure-relieving devices, it also illustrates how effective these devices can be in the prevention and treatment of pressure ulcers by using a pressure reducing product in conjunction with proper patient positioning. These findings coincide with the facility’s need of a revised pressure ulcer prevention policy as this evidence-based practice model suggests.

Another quantitative study that was conducted by researchers further illustrates how pressure reducing support devices can be utilized for the prevention of pressure ulcer

development in the acute setting. The main questions that were focused on were related to the extent that pressure-relieving cushions, beds, mattress overlays, and mattress replacements, reduce the incidence of pressure ulcers compared with standard support surfaces, as well as how effective the different pressure-relieving surfaces are in the prevention of pressure ulcer

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was a third author whose primary focus was on possible uncertainty within the study (U.S. National Library of Medicine National Institutes of Health, 2009, p. 6). RCTs were eligible for data assessment if they reported an objective, clinical outcome that was measurable by factors such as incidence and severity of new pressure ulcer development. Trial data was measured and evaluated by one researcher and checked by a second. Also, where appropriate, similar studies were pooled in a meta-analysis for further review to allow for a thorough assessment of evidence (U.S. National Library of Medicine National Institutes of Health, 2009, p. 6).

Results of this research study conclude that specialized foam mattresses can reduce pressure ulcer incidence in comparison with standard hospital mattresses. The study results also further indicate that alternating pressure mattresses are likely to reduce pressure ulcer incidence in those individuals at greatest risk of skin breakdown. For this study, 11 trials met the inclusion criteria, which brought the total number of RCTs included in this systematic review to 52 (U.S. National Library of Medicine National Institutes of Health, 2009, p. 7). It was also concluded that foam alternatives to the standard hospital foam mattress can reduce the incidence of pressure ulcers in those people at risk. The researcher’s conclusions also illustrated in their findings that higher-tech constant low pressure and alternating pressure devices were found to be unclear, but alternating pressure mattresses may be more cost effective than alternating pressure overlays (U.S. National Library of Medicine National Institutes of Health, 2009, p. 7). Ultimately, their findings coincide with the previous research studies indicating that the best practice for the prevention of pressure ulcer development in those individuals at risk, is the implementation of pressure-relieving devices to be used in clinical practice.

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As mentioned, the current policy for pressure ulcer prevention includes the incorporation of the Braden scale, as well as weekly skin assessments by all licensed nurses. However, the policy doesn’t address the issue of prevention, as these current interventions are mainly geared at the identification of those individuals at risk. The present policy fails to effectively prevent, and or, treat all pressure ulcers from developing, or potentially worsening. Based on the above research evidence supporting the numerous benefits of pressure-relieving devices, it is highly recommended that this facility begin to utilize this evidence-based practice model to enhance patient outcomes and deliver higher quality care. As a clinical nurse leader (CNL) working within the community, it is part of their job description to take full accountability of all patient outcomes and to continuously incorporate the most recent evidence-based practice into their clinical microsystem to deliver the best care possible. In order to begin the process of this change in policy, the CNL must include other key team members to ensure the most success. The Associate Director of Nursing (ADON) must be notified first of this evidence-based practice, as well as admissions to implement these devices into patient care. The charge nurses, admission nurses, central supply coordinators, physical therapist, treatment nurses, as well as case

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help with this barrier by thoroughly documenting when a pressure-relieving device is in need. This will help case managers obtain the needed approvals for purchase and clearance.

The CNL, as an outcomes manager, must aid in the coordination of this policy change by bringing forth the most up-to-date evidence, incorporating all team members, and managing and leading the team until the new policy has been implemented. The CNL must take several

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References

Aquila, A., & Ferretti, D. (2013). The Effectiveness of Two Heel Pressure Reduction Devices for Heel Pressure Ulcer Prevention. Retrieved from

http://www.ehob.com/education/clinical.html?content_id=53

Eunice Park-Lee, Christine Caffrey. (2009). Pressure Ulcers among Nursing Home Residents: United States, 2004. Retrieved from http://www.cdc.gov/nchs/data/databriefs/db14.pdf McGinnis, S. E. (2014). Pressure-relieving devices for treating heel pressure ulcers. Retrieved

from http://www.update-software.com/BCP/WileyPDF/EN/CD005485.pdf

References

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