Impact of the Problem on the Patient

Prolonged pressure, usually over a bony prominence, from body weight or a medical device results in localized damage to the skin and, in some cases, the underlying soft tissue (Fulbrook et al., 2019). The damage, called pressure injuries, may occur from prolonged wearing of a medical device or prolonged patient position in case of immobility, causing significant physical pain and possible infection (Fulbrook et al., 2019; Labeau et al., 2021). Pressure injuries worsen the affected patients’ healthcare outcomes and increase their hospitalization duration ad risk of readmission, among other adverse reactions. Developing pressure injuries may cause disability, compromising the patient’s quality of life (Fulbrook et al., 2019; Labeau et al., 2021). Additionally, the economic burden of pressure injuries on the patients is not limited to treatment and management costs but also work productivity or possible loss of income (Al-Otaibi et al., 2019).  

Impact of the Problem on the Organization

Hospital-acquired pressure injuries may result in patient and family dissatisfaction, increased hospital costs and resources for management and treatment, and even possible litigation (Al-Otaibi et al., 2019). When patients develop pressure injuries, they have an additional condition to manage, are in more pain, and have an increased risk of infection, inconveniences them and their family members, whose satisfaction with the facility is affected. Additionally, the increased length of stay and utilization of hospital resources after discharge, including readmissions, increases hospital spending (Fulbrook et al., 2019). In the United States (US), the additional per-patient costs of treating hospital-acquired pressure injuries are estimated to be $10,708 at the individual level and up to $26.8 billion at the national level (Labeau et al., 2021).

Pressure injuries among hospitalized and long-term care patients are considered indicators of the quality of care provided at the facility; hence high incidences result in lower ratings and financial penalties (Labeau et al., 2021). Possible hospital readmissions resulting from pressure injuries also affect the service quality rating because hospital readmissions are considered quality indicators. Low patient satisfaction scores, such as those with hospital-acquired pressure injuries, negatively affect the hospital quality rating (Labeau et al., 2021). Low scores regarding patient satisfaction and service quality negatively impact the hospital providers’ income, given the role of these thresholds in the value-based care reimbursement model (Teisberg et al., 2020).

Identify the PICO components.

Pressure injuries are preventable if the patients at risk are identified and interventions implemented to prevent development. The focus intervention is the prophylactic use of dressing to prevent the development of pressure injuries in hospitalized patients.

P – Patients at risk of developing pressure injuries

I – Use of prophylactic dressing

C – Lack of prophylactic dressing

O – Reduced incidences of pressure injuries.

Evidence-Based Practice Question

In patients at risk of developing pressure injuries (P), does the use of prophylactic dressing (I) compared to lack of prophylactic dressing (C) reduce the incidences of pressure injuries (O) within 12 weeks?  

Research Article (Effectiveness of Prophylactic Sacral Protective Dressings to Prevent Pressure Injury)

Background Introduction

Pressure injuries negatively affect patient and hospital outcomes, requiring systematic preventative measures (Fulbrook et al., 2019). Friction and shear compromise the skin and underlying tissue integrity, causing pressure injuries. Therefore, preventive measures should focus on reducing or avoiding pressure, shear, and friction forces between the skin and external surfaces. The use of protective dressing on the sacrum or heels as a prophylactic measure has recently gained recognition as a strategy for preventing pressure injuries. The dressing may include layered foam materials to create a smooth and flexible cushioning layer between the skin and surface to counter the pressure injury causing friction and shear. However, the authors noted that the effectiveness of prophylactic dressing could be clearer, given the lack of national and international standards for evaluating their use. Different studies have reported varying evidence regarding the strategy’s effectiveness in preventing pressure injuries (Fulbrook et al., 2019). The authors conducted a systematic review and meta-analysis to investigate the evidence in randomized controlled trials regarding the prophylactic use of sacral protective dressings to prevent pressure injuries.

Methodology

The study was a systematic review and meta-analysis based on Cochrane guidelines. The authors conducted an electronic search to identify peer-reviewed articles on using protective sacral dressing to prevent pressure injuries published between 2008 and 2019. Studies met the inclusion criteria if they were RCTs, the population studied was patients within a hospital or community, the intervention was reported to use sacral dressings, and the incidences of sacral pressure injuries were measured as the outcome. Three authors conducted the review, two of whom extracted data and assessed for bias, while the third served as the arbitrator.  

Level of Evidence

Level I.

The article was a systematic review, describing a comprehensive search strategy and the appraisal method for the included studies. The studies included only RCTs, which ranked highly on the evidence level. The article met the criteria for level 1 evidence based on the John Hopkins research evidence appraisal (Dang et al., 2022).

Data Analysis (What tests were used to analyze the data?)

Data analysis was conducted using the Review Manager software (RevMan Version 5.3; The Cochrane Collaboration, 2014), using a random effects model (MantelHaenzel). Risk ratios and 95% confidence intervals were used to describe the effect sizes. The primary outcome measured was sacral pressure injury incidence, where all but two studies used intention-to-treat analysis in their RCT design. For the two studies that used per-protocol analyses, only the data from prophylactic sacral dressing intervention groups were used in the analysis.

Ethical Considerations

The study was a systematic review and meta-analysis, so there were subjects. Therefore, were no specific ethical considerations. The authors, however, indicated that ethical considerations for using sham dressing limited adequate blinding in the studies included due to the visible nature of the sacral dressings.

Quality Rating

A: high quality

The authors identified the variables of interest, the key search terms, the databases searched, and the inclusion/exclusion criteria. Additionally, the design, methods, sample, results, outcomes, and limitations/strengths of each study were included in the systematic review. The authors concluded the results based on the meta-analysis findings and the research question. The article also discussed the limitations of conducting the systematic review and how they were addressed. The contents included in the article meet the criteria for a high-quality level of evidence (Dang et al., 2022).

Analysis of the Results / Conclusions

The results indicated that the interventions were effectively supported by a risk ratio of 0.3 and a 95% confidence and prediction interval. The findings indicate that patients who used prophylactic dressing had positive health outcomes compared to those who did not.

How does the article support the EBP question?

The article’s findings prove that using prophylactic sacral protective dressings reduces the incidence of pressure injuries. The authors recommended further research to determine the efficiency of the different dressings used.

Non-Research Article (Reducing hospital-acquired pressure injuries)

Background Introduction

The quality improvement project was conducted in a 144-bed government hospital in Saudi Arabia that had higher than the national average of pressure injuries. The hospital had a pressure injury prevalence of 7.5%, higher than the healthcare system and international benchmarks of 3% and 4%, respectively. The risk factors for developing pressure injuries include immobility, mental condition, and hospitalization. Preventative strategies rely on risk identification and mitigation; hence, the authors aimed to use the two strategies to reduce the prevalence of pressure injuries in the government-run hospital. The authors aimed to reduce the prevalence of pressure injuries from 7.5% to below 4% within a year by implementing an evidence-based risk assessment tool and a bundled pressure injury prevention intervention.

Type of Evidence

The study was a quality improvement project based on the Institute for Healthcare Improvement Model. The authors used the plan do study act (PDSA) cycle to implement an evidence-based guideline. The daily risk assessment guideline using a standardized tool was integrated into the daily bedside practice. A bundled intervention consisting of patient repositioning every three hours, using specialized mattresses, and prophylactic dressing of bony prominences were implemented after nurse training. The interventions were redesigned, further training was conducted during implementation as needs arose, and the prophylactic dressings were changed from hydrocolloid to foam.

Level of Evidence

Level V. The article was a quality improvement project report, rated as a level V level of evidence in the John Hopkins non-research evidence appraisal tool (Dang et al., 2022).

Quality Rating

A: High quality.

The aim of the project was clearly stated, a formal quality improvement method – PDSA- was used, the method was fully described, and the outcome measures and results were fully described. Therefore, the article meets the Johns Hopkins nonresearch evidence appraisal criteria for high quality evidence (Dang et al., 2022).

Author’s Recommendations

The authors achieved the projected goal of reducing pressure injury prevalence to below 4%. Recommendations included scaling up the quality improvement project across the government hospitals in the region. Additionally, the authors recommended using the PDSA cycles to assess, monitor, and facilitate changes within the intervention according to the needs of different settings.

Recommended Practice Change

The recommended practice change is to incorporate the use of standardized risk assessment and prophylactic dressing on patients at risk into standard bedside practice. The use of prophylactic dressing has been established as effective for preventing incidences of pressure injuries in hospitalized and community patients (Fulbrook et al., 2019). The additional use of a standardized risk assessment tool improves the efficiency of the prophylactic use of protective dressings (Al-Otaibi et al., 2019). The recommended practice change is the combination of the two interventions, a risk assessment tool and the use of the protective dressing, incorporated into standard care practice for immobile patients.

Key Stakeholders

The key stakeholders in implementing the practice change include nurses, nurse managers, and hospital administrators. The nurse managers would facilitate training by encouraging nurses to participate and reviewing the training materials introducing the intervention. The hospital administrators will provide training resources, such as room, and projector, among others, and permit the implementation with subsequent changes and training sessions to address emergent challenges. The nurses would be responsible for attending the education sessions and implementing the practice change.

Barrier to Implementation

Some of the possible barriers to implementation would be low adoption rates and challenges related to sustainability. Low adoption rates could result from nurses’ unwillingness to accept change or lack of awareness of the interventions’ importance. Sustainability challenges could include the need to identify the specific types of dressing matched with individual risks and new employees needing to be made aware of the practice.

 Strategy to Overcome the Implementation Barrier

Adoption rates can be addressed by engaging the stakeholders to find reasons and implement strategies to promote adoption. Education sessions could be conducted to address specific challenges. Evaluating and training nurses to determine the best approach can address sustainability challenges. Engaging stakeholders at the management level is also an effective strategy for promoting sustainability through hospital policies.

 Indicator to Measure the Outcome

The incidences of pressure injuries during the intervention compared to before the intervention could be used as an outcome measure. Comparing the incidences of pressure injuries with and without the intervention would provide an opportunity to evaluate the suggested intervention’s effectiveness.

References 

Al-Otaibi, Y. K., Al-Nowaiser, N., & Rahman, A. (2019). Reducing hospital-acquired pressure injuries. BMJ Open Quality, 8(1), 1-5. http://dx.doi.org/10.1136/bmjoq-2018-000464

Dang, D., Dearholt, S., Bissett, K., Ascenzi, J., & Whalen, M. (2022). Johns Hopkins evidence-based practice for nurses and healthcare professionals: Model and guidelines. 4th ed. Sigma Theta Tau International

Fulbrook, P., Mbuzi, V., & Miles, S. (2019). Effectiveness of prophylactic sacral protective dressings to prevent pressure injury: a systematic review and meta-analysis. International Journal of Nursing Studies, 100, 2-36. https://doi.org/10.1016/j.ijnurstu.2019.103400

Labeau, S. O., Afonso, E., Benbenishty, J., Blackwood, B., Boulanger, C., Brett, S. J., Calvino-Gunther, S., Chaboyer, W., Coyer, F., Deschepper, M., François, G., Honore, P. M., Jankovic, R., Khanna, A. K., Llaurado-Serra, M., Lin, F., Rose, L., Rubulotta, F., Saager, L., Williams, G., … European Society of Intensive Care Medicine (ESICM) Trials Group Collaborators (2021). Prevalence, associated factors, and outcomes of pressure injuries in adult intensive care unit patients: The DecubICUs study. Intensive Care Medicine, 47(2), 160–169. https://doi.org/10.1007/s00134-020-06234-9

Teisberg, E., Wallace, S., & O’Hara, S. (2020). Defining and Implementing Value-Based Health Care: A Strategic Framework. Journal of the Association of American Medical Colleges, 95(5), 682–685. https://doi.org/10.1097/ACM.0000000000003122