Adekemi Taiwo, Jason Garner, Leonard Fortney, and Trang Nguyen University of Oklahoma College of Nursing EBP Symposium

1. Adekemi Taiwo, Jason Garner, Leonard Fortney, and Trang Nguyen University of Oklahoma College of Nursing EBP Symposium Spring 2010

2. PICO Question For adult patients in medical-surgical units, are pressure relieving mattresses more effective than standard hospital mattresses in decreasing the incidence of hospital acquired pressure ulcers?

3. Identification of the problem KEY TERMS A pressure ulcer is defined as ... Hospital acquired pressure ulcers are ulcers associated with hospitalization but unrelated to the primary condition of the patient A pressure ulcer is a localized area (usually over a bony prominence) of tissue necrosis caused by unrelieved pressure that occludes blood flow to the tissuesA pressure ulcer is a localized area (usually over a bony prominence) of tissue necrosis caused by unrelieved pressure that occludes blood flow to the tissues

4. Identification of the problem KEY TERMS continued A pressure relieving mattress reduces or relieves the pressure that the patient�s body weight exerts on the skin and subcutaneous tissues The mattresses are either filled with air, water, gel, foam or mechanically vary the pressure beneath the patient Viscoelastic foam and alternating pressure air mattresses were the only specific pressure relieving mattress identified in all of the studies reviewed. Viscoelastic foam and alternating pressure air mattresses were the only specific pressure relieving mattress identified in all of the studies reviewed.

5. Identification of Problem: STATISTICS ~ 60,000 patients die each year from complications due to hospital acquired pressure ulcers The total cost for treatment of pressure ulcers in the U.S is estimated at 11 billion dollars per year

6. Identification of Problem Pressure ulcer incidence rates vary considerably by clinical setting 0.4% to 38% in acute care The estimated cost of managing a single full thickness pressure ulcer is as high as $70,000 Medicare will not pay for hospital acquired pressure ulcers Setting, such as critical care and long term care; however we decided to focus our research on medical surgical units. Setting, such as critical care and long term care; however we decided to focus our research on medical surgical units.

7. Review of the Literature Guideline implementation results in a decrease of pressure ulcer incidence in critically ill patients De Laat, E. H., Pickkers, P., Schoonhoven, L., Verbeek, A. L., Feuth, T., van Achterberg, T. (2007)

8. Guideline implementation results in a decrease of pressure ulcer incidence in critically ill patients Sample: 399 adult patients Settings: Intensive care unit Findings: A significant and sustained decrease in the development of pressure ulcers. Timely transfer to a specific mattress was the main indicator for a decrease in pressure ulcer development Sample: 399 adult ICU patients with a length of stay 48 hours or more, with no pressure ulcers on admission, and who had their first skin assessments within the first 48 hours of ICU admission. Sample: 399 adult ICU patients with a length of stay 48 hours or more, with no pressure ulcers on admission, and who had their first skin assessments within the first 48 hours of ICU admission.

9. Review of the literature Implementation of a new policy results in a decrease of pressure ulcer frequency De Laat, E. H., Schoonhoven, L., Pickkers, P., Verbeek, A. L., Van Achterberg, T. (2006)

10. Implementation of a new policy results in a decrease of pressure ulcer frequency Sample: 657 patients Settings: All inpatient units All inAll in

11. Implementation of a new policy results in a decrease of pressure ulcer frequency Findings: Inadequate prevention decreased from 19% to 4% after 4 months and to 6% after 11 months Inadequate treatment decreased from 60% to 31% A significant decrease in hospital-acquired pressure ulcer frequency from 18% to 13% after 4 months and 11% after 11 months The pressure ulcer frequency in hospital can successfully be reduced. General measures such as the introduction of adequate mattresses and guidelines for prevention and treatment are promising tools in this respect. The pressure ulcer frequency in hospital can successfully be reduced. General measures such as the introduction of adequate mattresses and guidelines for prevention and treatment are promising tools in this respect.

12. Review of the literature Quality improvement program to reduce the prevalence of pressure ulcers in an intensive care unit Elliot, R. McKinley, S., Fox. (2008)

13. Quality improvement program to reduce the prevalence of pressure ulcers in an intensive care unit Sample: 563 skin assessment surveys Settings: intensive care unit This particular study used audits to collect the data; therefore the information is just a snapshot in time an does not take into account the patients that are admitted and then moved to a different unit or were released. Setting: intensive care instead of a medical surgical unit. This particular study used audits to collect the data; therefore the information is just a snapshot in time an does not take into account the patients that are admitted and then moved to a different unit or were released. Setting: intensive care instead of a medical surgical unit.

14. Quality improvement program to reduce the prevalence of pressure ulcers in an intensive care unit Findings: The frequency of pressure ulcers of all stages showed an overall downward trend The pressure ulcer prevalence decreased from 50% to 8% The anatomical site of the pressure ulcers did not change during the study period

15. Review of the Literature Prospective study: Reducing pressure ulcers in intensive care units at a Turkish medical center. Uzun, O., Aylaz, R., Karadag, E. (2009)

16. Prospective study: Reducing pressure ulcers in intensive care units at a Turkish medical center Sample size: 186 adult patients Settings: Intensive care unit

17. Prospective study: Reducing pressure ulcers in intensive care units at a Turkish medical center Findings: Preventive and educational interventions resulted in persistent pressure ulcer reduction from 37% to 17%

18. Review of the Literature Effectiveness of an alternating pressure air mattress for the prevention of pressure ulcers. � Vanderwee, K., Grypdonck, M.H.F., Defloor, T. (2005).

19. Effectiveness of an alternating pressure air mattress for the prevention of pressure ulcers Sample: 447 adult patients The control and experimental groups were divided into two sub-groups for assessment purposes Setting: 19 internal, surgical, and geriatric wards The control and experimental groups were divided into two sub-groups for assessment purposes. The control and experimental groups were divided into two sub-groups for assessment purposes.

20. Effectiveness of an alternating pressure air mattress for the prevention of pressure ulcers Findings: No statistically significant difference between mattresses Pressure relieving mattresses can�t replace the standard of practice such as frequent turning Using an alternating pressure air mattress Less heel pressure Patients on a non-blanchable erythema scale develop fewer pressure ulcers Patients on the Braden scale developed more sacral pressure ulcers The control and experimental groups were divided into two sub-groups for assessment purposes. The control and experimental groups were divided into two sub-groups for assessment purposes.

21. Review of Literature Critique:Pros Delaat (2007): A significant and sustained decrease in pressure ulcers, and timely transfer to pressure relieving mattress was key Delaat (2006): A decrease in hospital-acquired pressures ulcer frequency from 18% to 13% (4 months), then 11% after 11 months Elliot (2008): Prevalence of pressure ulcers decreased from 50% to 8% Delaat (2007): A significant and sustained decrease in stage II-IV pressure ulcers; timely transfer to pressure relieving mattress was key. Delaat (2006): A decrease in hospital-acquired pressures ulcer frequency from 18% down to 13% (4 months), then 11% after 11 months. Elliot (2008): The prevalence of pressure ulcers decreased from 50% to 8% with an increase in pressure relieving devices. Delaat (2007): A significant and sustained decrease in stage II-IV pressure ulcers; timely transfer to pressure relieving mattress was key. Delaat (2006): A decrease in hospital-acquired pressures ulcer frequency from 18% down to 13% (4 months), then 11% after 11 months. Elliot (2008): The prevalence of pressure ulcers decreased from 50% to 8% with an increase in pressure relieving devices.

22. Review of Literature Critique:Pros Uzun (2009): A significantly lower rate of pressure ulcers was observed in the intervention group than in the comparison group Vanderwee (2005): Fewer patients developed heel pressure ulcers on an alternating pressure air mattress(APAM) Those identified at risk for pressure ulcers based on the presence of non-blanchable erythema tended to develop fewer pressure ulcers on APAMs Uzun (2009): A significantly lower rate of stage II pressure ulcers was observed in the intervention group (17%) than in the comparison group (37%). Vanderwee (2005): Fewer patients developed heel pressure ulcers on an alternating pressure air mattress (APAM). Those identified as at risk for pressure ulcers based on the presence of non-blanchable erythema tended to develop fewer pressure ulcers on APAMs. Uzun (2009): A significantly lower rate of stage II pressure ulcers was observed in the intervention group (17%) than in the comparison group (37%). Vanderwee (2005): Fewer patients developed heel pressure ulcers on an alternating pressure air mattress (APAM). Those identified as at risk for pressure ulcers based on the presence of non-blanchable erythema tended to develop fewer pressure ulcers on APAMs.

23. Review of Literature Critique:Cons Delaat (2006): Incidence is a better measure for effectiveness of prevention; patients could have been counted twice; a new guideline for only turning patients once every 3 hours; and only 1 in 10 patients were treated appropriately using the guideline Review of Literature Critique: Cons Delaat (2006): Incidence is a better measure for effectiveness of prevention than prevalence or frequency; patients could have been counted twice in successive measurements; there was a new guideline for only turning patients once every 3 hours; and only 1 in 10 patients were treated appropriately using the guideline.Review of Literature Critique: Cons Delaat (2006): Incidence is a better measure for effectiveness of prevention than prevalence or frequency; patients could have been counted twice in successive measurements; there was a new guideline for only turning patients once every 3 hours; and only 1 in 10 patients were treated appropriately using the guideline.

24. Review of Literature Critique:Cons Elliot (2008): Possible inaccuracy of skin assessment by some nurses; possible confusion among clinicians in distinguishing between stage I pressure ulcers and reactive hyperemia; audits only a snapshot in time; and limited study size Uzun (2009): Significant variability in reported pressure ulcer incidences observed; and a short 3-month follow-up Elliot (2008): There was possible inaccuracy of skin assessment by some nurses; possible confusion among clinicians in distinguishing between stage I pressure ulcers and reactive hyperemia; audits were only a snapshot in time and didn�t take into account patients moving to other units or being discharged; and the study size was limited, not allowing for anomalies such as patients with co-morbidities in the research group. Uzun (2009): Significant variability in reported pressure ulcer incidences observed, which may be attributable to differences in the inclusion or exclusion of state I pressure ulcers, the study design, and sample characteristics; and the short 3-month follow-up did not allow for measurement of adherence to the program or long term durability of the results.Elliot (2008): There was possible inaccuracy of skin assessment by some nurses; possible confusion among clinicians in distinguishing between stage I pressure ulcers and reactive hyperemia; audits were only a snapshot in time and didn�t take into account patients moving to other units or being discharged; and the study size was limited, not allowing for anomalies such as patients with co-morbidities in the research group. Uzun (2009): Significant variability in reported pressure ulcer incidences observed, which may be attributable to differences in the inclusion or exclusion of state I pressure ulcers, the study design, and sample characteristics; and the short 3-month follow-up did not allow for measurement of adherence to the program or long term durability of the results.

25. Review of Literature Critique:Cons Vanderwee (2005): Patients identified as being in need of prevention based on the Braden Scale developed more sacral pressure ulcers on an APAM Small patient sample Heel elevation was in question Vanderwee (2005): Patients identified as being in need of prevention based on the Braden Scale developed more sacral pressure ulcers on an APAM; if the data is split between the Braden and non-blanchable erythema groups, the patient sample becomes too small; it was unknown if heel elevation was done correctly; Vanderwee (2005): Patients identified as being in need of prevention based on the Braden Scale developed more sacral pressure ulcers on an APAM; if the data is split between the Braden and non-blanchable erythema groups, the patient sample becomes too small; it was unknown if heel elevation was done correctly;

26. Review of Literature Critique:Summary Pressure ulcer development was decreased in all the studies More research is necessary to determine the effects of pressure-relieving mattresses An adjunct therapy to the nursing standard of care in pressure ulcer prevention Review of Literature Critique: Summary Pressure ulcer development was decreased in all the studies, though the article by Vanderwee showed an increase in one group of patients. Because of weaknesses in some of the studies, it seems that more research is necessary to determine the effects of pressure-relieving mattresses on pressure ulcer development, though there seems to be much promise in the use of these mattresses as an adjunct therapy to the nursing standard of care in pressure ulcer prevention.Review of Literature Critique: Summary Pressure ulcer development was decreased in all the studies, though the article by Vanderwee showed an increase in one group of patients. Because of weaknesses in some of the studies, it seems that more research is necessary to determine the effects of pressure-relieving mattresses on pressure ulcer development, though there seems to be much promise in the use of these mattresses as an adjunct therapy to the nursing standard of care in pressure ulcer prevention.

27. Locally Pressure Ulcer Prevention Program includes: positioning patients Q2 hours, assessing skin and risk every shift use soft surface mattresses clean skin after elimination. Pressure relieving mattresses are not included in the standard skin care Information from a Local Hospital Both inpatients and outpatients are treated, with wound care as a Center of Excellence. Their most recent incidence of pressure ulcers on the med-surg units was 0. They perform quarterly prevalence and incidence studies and own a fleet of low-air loss mattress replacements called Synergy Air Elite. When someone is identified as at risk based on the Braden Scale of 18 or less, they implement their Pressure Ulcer Prevention Program and place a photo of a puppy outside the door to alert staff that our patient is at risk. Our wound care staff then complete a head to toe assessment, and implement our standing orders. This includes activities that we call PAUSE (proper credit goes to OSU for this acronym). Position patients at least every two hours. Assess their Braden risk and skin every shift. If Undernourished, consult the dietitian. Replace the mattress with a special Support surface. And clean skin quickly and gently after any Elimination. Information from a Local Hospital Both inpatients and outpatients are treated, with wound care as a Center of Excellence. Their most recent incidence of pressure ulcers on the med-surg units was 0. They perform quarterly prevalence and incidence studies and own a fleet of low-air loss mattress replacements called Synergy Air Elite. When someone is identified as at risk based on the Braden Scale of 18 or less, they implement their Pressure Ulcer Prevention Program and place a photo of a puppy outside the door to alert staff that our patient is at risk. Our wound care staff then complete a head to toe assessment, and implement our standing orders. This includes activities that we call PAUSE (proper credit goes to OSU for this acronym). Position patients at least every two hours. Assess their Braden risk and skin every shift. If Undernourished, consult the dietitian. Replace the mattress with a special Support surface. And clean skin quickly and gently after any Elimination.

28. Recommended Interventions Assess all patients for pressure ulcer risk on admission Reassess all patients daily for risk Inspect skin daily and manage moisture Give patients their optimal hydration and nutrition After the review of current literature and standard practice, we recommend the following intervention Assess all patients for pressure ulcer risk on admission (Vanderwee, 2005) -to know which patients may need preventative measures Reassess all patients daily for risk (Vanderwee, 2005) -In case they may need preventative measures Inspect skin daily and manage moisture -Because moisture can lead to skin maceration (Elliot, 2008) Give patients optimal hydration and nutrition -Because poor nutritional status put patients at a higher risk for pressure ulcers (Elliot, 2008) After the review of current literature and standard practice, we recommend the following intervention Assess all patients for pressure ulcer risk on admission (Vanderwee, 2005) -to know which patients may need preventative measures Reassess all patients daily for risk (Vanderwee, 2005) -In case they may need preventative measures Inspect skin daily and manage moisture -Because moisture can lead to skin maceration (Elliot, 2008) Give patients optimal hydration and nutrition -Because poor nutritional status put patients at a higher risk for pressure ulcers (Elliot, 2008)

29. Recommended Interventions Minimize pressure by turning every 2 hours and using specialized mattresses Minimize shear by using draw sheets to assist in moving patients up in their beds Frequent training on pressure ulcer prevention protocol Implement universal ulcer assessment and prevention protocol Recommended Interventions Minimize pressure through turning every and using specialized mattresses -Because alternating pressure air mattresses and repositioning reduce the duration of pressure and shearing forces. (Vanderwee, 2005) Minimize shear by using draw sheets to assist in moving patients up in their beds -National clearinghouse. Frequent training on pressure ulcer prevention protocol -To be able to assess and give proper care (Delaat, 2006) Recommended Interventions Minimize pressure through turning every and using specialized mattresses -Because alternating pressure air mattresses and repositioning reduce the duration of pressure and shearing forces. (Vanderwee, 2005) Minimize shear by using draw sheets to assist in moving patients up in their beds -National clearinghouse. Frequent training on pressure ulcer prevention protocol -To be able to assess and give proper care (Delaat, 2006)

30. Suggestions for Further Study Conduct studies in the United States Include larger client populations Conduct more studies focused on specific therapeutic surfaces in medical surgical units Which therapeutic mattress is the most effective in preventing hospital acquired pressure ulcers? Which skin assessment tools are utilized in the U.S? Suggestions for Further Study Conduct more studies in the United States Include larger client populations by including all units who utilize the pressure relieving mattresses, not limited to the specialty unit as used in the foreign studies. Conduct more studies focused on specific therapeutic surfaces. We didn�t find any study that compare the different kinds of pressure relieving mattresses. Which therapeutic mattress is the most effective in preventing hospital acquired pressure ulcers? Which skin assessment tools are utilized in the U.S? Suggestions for Further Study Conduct more studies in the United States Include larger client populations by including all units who utilize the pressure relieving mattresses, not limited to the specialty unit as used in the foreign studies. Conduct more studies focused on specific therapeutic surfaces. We didn�t find any study that compare the different kinds of pressure relieving mattresses. Which therapeutic mattress is the most effective in preventing hospital acquired pressure ulcers? Which skin assessment tools are utilized in the U.S?

31. References De Laat, E. H., Pickkers, P., Schoonhoven, L., Verbeek, A. L., Feuth, T., van Achterberg, T. (2007). Guideline implementation results in a decrease of pressure ulcer incidence in critically ill patients. Critical Care Medicine, 35(3), 815-820. De Laat, E. H., Schoonhoven, L., Pickkers, P., Verbeek, A. L., Van Achterberg, T. (2006). Implementation of a new policy results in a decrease of pressure ulcer frequency. International Journal for Quality in Health Care, 18(2), 107-112. Duncan, K. (2007). 5 Million Lives Campaign. Preventing pressure ulcers: the goal is zero. Joint Commission Journal on Quality and Patient Safety, 33(10), 605-610. Elliot, R. McKinley, S., Fox. (2008). Quality improvement program to reduce the prevalence of pressure ulcers in an intensive care unit. American Journal of Critical Care, 17(4), 328-334; quiz 335; discussion 336-337. Gunningberg, L., & Stotts, N. A. (2008). Tracking quality over time: What do pressure ulcer data show? International Journal for Quality in Health Care, 20(4), 246-253. Uzun, O., Aylaz, R., Karadag, E. (2009). Prospective study: Reducing pressure ulcers in intensive care units at a Turkish medical center. Journal of Wound, Ostomy, & Continence Nursing, 36(4), 404-411. Vanderwee, K., Grypdonck, M.H.F., Defloor, T. (2005). Effectiveness of an alternating pressure air mattress for the prevention of pressure ulcers. Age and Ageing, 34, 261-267.