The need for cost-effective care is increasing as total healthcare expenditures grow. Healthcare providers are challenged with evaluating scientific evidence to inform a practice change aimed at improving patient outcomes. Being a costly yet mostly preventable complication, hospital-acquired pressure ulcers (hapus) cause much suffering to patients in acute care settings. The paper will discuss this particular practice problem at both the national and local level, as well as appraise available evidence to address it.
The prevention of HAPUs should include a thorough articulation of the practice problem, its significance, prevalence, and economic ramifications. The purpose of the paper is to discuss these components to give a broad view of the current issues associated with this medical condition. Then, it is important to identify appropriate sources of research evidence that can be used to support a practice change.
Practice Problem Identification
Pressure ulcers are considered to be a major long-lasting issue that involves patient suffering and is associated with poor quality of care. The aging of the population only contributes to the growing incidence of this condition (Clark et al., 2014). Even though there are pressure ulcer prevention guidelines elaborated by international healthcare agencies, the recommended care plans usually lack appropriate evidence (Pickham et al., 2018). The practice problem of pressure ulcers needs to be studied in the light of current credible scientific evidence that will be discussed below.
Sources of Research Evidence Identification
To investigate the chosen practice problem and collect findings that will help answer the evidence-based question, six research studies published within the last five years have been selected. There are three pairs of articles that are categorized based on the type of evidence. The first pair includes quantitative studies that evaluate the use of the evidence-based pressure ulcer prevention program and wearable patient sensors (Pickham et al., 2018; Kwong, Lee, & Yeung, 2016). The second pair includes qualitative descriptive studies that investigate facilitators and barriers to the implementation of the pressure ulcer prevention care bundle (Roberts et al., 2016; Roberts et al., 2017). The third pair includes systematic reviews of randomized control trials that discuss the utilization of prophylactic dressings and alternative types of surfaces instead of standard hospital mattresses (Clark et al., 2014; Shi, Dumville, & Cullum, 2018). All these studies have been appraised according to evidence type, level of evidence and quality, limitations, and meaningful results that could be integrated into the healthcare practice. Then, six research articles were critically evaluated, and conclusions have been made regarding the feasibility of their utilization to inform a practice change.
Implications of the Practice Problem at the National and Local Level
Pressure injuries are insidious complications that may occur in different healthcare settings across the country. At the national level, implications of this condition include its growing incidence rate, which currently stands at 30% per thousand discharges (Pickham et al., 2018, p. 13). As a result, direct and indirect healthcare costs associated with the condition are considerable. At the local level, the implications of pressure ulcers are viewed in the context of a healthcare setting. For example, in non-profit nursing homes where residents cannot afford to pay high fees, the incidence of the discussed medical complication is a major clinical risk (Kwong et al., 2016). Local nursing homes and hospitals thus need to adjust their standard plans of care and implement pressure ulcer prevention care bundles.
Pressure ulcers place a significant burden on people as they feel permanent pain because of skin lesions and are subject to an increased risk of getting a serious infection. Apart from physical problems, these injuries cause psychological and social discomfort. Currently, hospital-acquired pressure injuries prevention is the critical patient safety indicator and a great challenge faced by hospitals in the United States (Clark et al., 2014). Therefore, the development of evidence-based pressure ulcer prevention protocols and care bundles is a top priority for many healthcare organizations.
HAPUs are among the major health problems around the world. Approximately 6.5% of patients die worldwide as a direct result of this condition (Roberts et al., 2016, p. 65). In the US, more than 60,000 patients die annually due to complications of pressure injuries (Shi et al., 2018, p. 2). The high prevalence of pressure ulcers is associated with the activity, friction/shear, and changed position. Elaboration of new assessment techniques by healthcare organizations could decrease high prevalence rates of HAPUs.
Pressure ulcers represent a serious economic concern both to healthcare providers and the government. A great proportion of direct healthcare costs is associated with prolonged hospitalization due to HAPUs (Roberts et al., 2017). Apart from treatment-related costs, pressure injuries also result in litigation and government penalties. Considering the discontinuation of reimbursement for HAPUs, the financial implications of this condition for patients are going to be daunting. This, in turn, emphasizes the need for early-stage prevention of pressure injuries.
Synthesis of Evidence to Address the Practice Problem
Two qualitative studies investigated nurses’ and patients’ perceptions of a HAPUs prevention care bundle. It has been found that improved communication, awareness, and participation in a pressure ulcer prevention program are facilitators to the implementation of the care bundle (Roberts et al., 2016). Another study discovered that patients consider enhanced communication with the nursing staff to be the main facilitator to the implementation of the care bundle (Roberts et al., 2017). One quantitative study found that the effectiveness of a pressure ulcer prevention program should be preceded by appropriate training of the nursing staff (Kwong et al., 2016). Another quantitative study discussed a great protective effect that wearable patient sensors demonstrate against the development of HAPUs (Pickham et al., 2018). One systematic review claimed that the incidence of HAPUs could be reduced by the utilization of prophylactic dressings by patients (Clark et al., 2014). Finally, the sixth study investigated the beneficial effects of non-powered reactive water surfaces that help reduce the risk of the development of HAPUs (Shi et al., 2018). Apart from this one, other types of surfaces were also considered.
It can be stated that all the six studies assume that implementation of care bundles or HAPUs prevention protocols could reduce the incidence of the condition. It has been found that the main barriers to their successful implementation are the lack of training of the nursing staff and its high workload (Roberts et al., 2016; Roberts et al., 2017; Kwong et al., 2016). As to the main facilitators, they include communication between patients and the nursing staff and appropriate training of nurses. The findings of the studies do not contradict each other as they investigate different aspects of the practice problem. If one study recommends optimal turning practices, other research suggests using specialized surfaces and prophylactic patient dressings (Pickham et al., 2018; Clark et al., 2014; Shi et al., 2018). However, objectively speaking, two qualitative studies have medium generalizability of findings, two quantitative studies do not have sufficient clinical data, and two systematic reviews lack external validity.
Appraisal of the Evidence to Address the Practice Problem
Both qualitative studies have level 5 of evidence as they are based on non-research data. They have good quality, consistent results, and clear objectives and may be further used to provide support for the practice problem. Both quantitative studies have level 1 of evidence as they are randomized control trials. They have high quality, consistent and generalizable results, and can be used to address the practice problem. Both systematic reviews have level 5 of evidence and high quality because of definitive conclusions and formal quality improvement methods used. The findings of these two studies may also be used to prevent HAPUs.
At the local level, the practice problem of HAPUs makes local hospitals and nursing homes experience the urgent need to prevent the incidence of the condition by implementing pressure ulcer prevention protocols. At the national level, the practice problem is associated with the soaring of healthcare expenditures and high prevalence rates of this condition. All the six research articles that have been chosen for review have high or good quality and may be used to inform a practice change. Findings obtained from these studies are mostly generalizable and consistent, and they can be applied to multiple healthcare settings. Synthesis of the evidence suggests that there are several different ways in which HAPUs may be prevented. These ways include the implementation of a pressure ulcer prevention care bundle, optimization of patient-turning practices with wearable sensors, the substitution of standard mattresses with powered active surfaces, and utilization of prophylactic dressings.
- Clark, M., Black, J., Alves, P., Brindle, C., Call, E., Dealey, C., & Santamaria, N. (2014). Systematic review of the use of prophylactic dressings in the prevention of pressure ulcers. International Wound Journal, 11(5), 460-471.
- Kwong, E. W., Lee, P. H., & Yeung, K. (2016). Study protocol of a cluster randomized controlled trial evaluating the efficacy of a comprehensive pressure ulcer prevention programme for private for-profit nursing homes. BMC Geriatrics, 16(1), 20-27.
- Pickham, D., Berte, N., Pihulic, M., Valdez, A., Mayer, B., & Desai, M. (2018). Effect of a wearable patient sensor on care delivery for preventing pressure injuries in acutely ill adults: A pragmatic randomized clinical trial (LS-HAPI study). International Journal of Nursing Studies, 80, 12-19.
- Roberts, S., Mcinnes, E., Wallis, M., Bucknall, T., Banks, M., & Chaboyer, W. (2016). Nurses’ perceptions of a pressure ulcer prevention care bundle: A qualitative descriptive study. BMC Nursing, 15(1), 64-74.
- Roberts, S., Wallis, M., Mcinnes, E., Bucknall, T., Banks, M., Ball, L., & Chaboyer, W. (2017). Patients’ perceptions of a pressure ulcer prevention care bundle in hospital: A qualitative descriptive study to guide evidence-based practice. Worldviews on Evidence-Based Nursing, 14(5), 385-393.
- Shi, C., Dumville, J. C., & Cullum, N. (2018). Support surfaces for pressure ulcer prevention: A network meta-analysis. PLOS One, 13(2), 1-29.