The healthcare sector in the U.S has significantly reviewed and modified its technical, policy and structural capabilities to help improve quality of outcomes and patient safety. There has been so much focus on the need to ensure that the healthcare system achieves the optimal value for money though eliminating the cases of illnesses, infections and injuries that have previously occurred within the settings. Despite these measures, the cases of hospital acquired Illnesses and infections have been rife. This has been associated with poor outcomes namely, high mortality rates, high morbidity rates and more glaringly the erosion of the public confidence with the healthcare system (Marchetti & Rossiter, 2013).
Problem statement
Patients need to be assured that their arrival at the clinical setting is an initial move towards ensuring facilitating their recovery and restoration. The associated costs with HAIs have an impact on the patients, their families and the healthcare facilities in general especially with the Center for Medicare and Medicaid having reviewed their reimbursement rules on HAIs. For instance, every year, there are up to 2 million patients who acquire HAIs (Marchetti & Rossiter, 2013). Up to 90, 000 of these patients are estimated to die. The overall costs for management of these HAIs for hospitals are approximately $28 and $45 billion annually and these costs are catered for by the respective healthcare institution. These costs could have been saved to improve the quality of care in other areas and the burden on an already strained budget becomes increasingly unsustainable (Marchetti & Rossiter, 2013).
Clinical practice problem
Population of interest
Hospitalized patients are usually subjected to an environment that limits their movement and their independence. At times, this limitation could be enforced by the hospital policies to minimize the risk of falls and ensure that the nurses and the staff can monitor their progress well. At other times, the primary illnesses could limit their ambulatory capabilities thus sidelining them to the bed. For those with severe primary illnesses, and particularly those in the intensive care units, and most of who require the assistance of the nurses or the available caregivers to accomplish their basic needs such as bathing and toileting, the risk for acquiring skin breakdown or pressure ulcers is high. This is mainly due to the ling durations in the bed and as a result of their physical limitations they cannot turn leading to apparent pressure on some parts of the body. This pressure ultimately leads to skin damage which leads to wounds and further pain and suffering for the patient (Marchetti & Rossiter, 2013).
Background information
Nurses are the at the point of interaction between the patient and the healthcare system. Their involvement in the prevention and management of HAIs and in this case, skin breakdown for patients within the intensive care unit cannot be overemphasized. Apparently, the focus on the nurse does not imply that they are the cause of the current menace that is pressure ulcers/skin breakdown. Rather, their involvement in prevention of these cases is effective both on costs as well as outcomes. There are many risk factors that lead to the development of skin breakdown and related complications such as wounds for patients in the ICU. Among them include poor nutrition, poor attendance by the nurses on shift, poor hygiene, poorly structured beds and mattresses as well as physical restraints where applied. The use of Chlorhexidine bathing, Prophylactic dressings as well as silicone border foam are some of the methods that have been applied in the management of skin breakdown in intensive care units and Medical-surgical units. The efficacy of these interventions is a long held debate and there has been persistent search for evidence through research to ascertain their applicability and ultimate outcomes. However, as a result of varying findings, there has been need for further research geared towards determining the best practices and methods for management and prevention of skin breakdown within the specified settings.
Description of evidence
Databases utilized:
Pubmed, Medscape
Keywords:
Skin breakdown, pressure ulcers, hospital acquired infections, Chlorhexidine, nutrition, intensive care unit, medical-surgical unit
Literature analysis
Iizaka, Okuwa, Sugama & Sanada (2010) in their survey utilized data from 207 home care settings in which 290 patients with home-acquired pressure ulcers and a further 456 patients without pressure ulcers participated. The researchers sought to examine the impact of nutrition on the cases of pressure ulcers and skin breakdown during which they discovered that there were higher incidences of pressure ulcers in settings where malnutrition cases were high. The researchers attributed the cases of malnutrition and the associated incidences of pressure ulcers on the lack of caregiver knowledge on the importance of diet. In a different perspective, Noto et al., (2015) in their Cluster randomized-crossover study, they utilized a sample population of 9, 340 patients within the ICU. The participants were subjected to a program that involved daily bathing with chlorhexidine-bathed group while a control group from the sample was subjected to standard bathing techniques. The results indicated that there were up to 50 cases in the intervention group and 60 cases of infections in the control group thus indications that even the use of chlorhexidine did not have significant benefits. Brindle & Wegelin (2012) in their randomized controlled trial utilized a sample population of 100 participants in an ICU from a university medical center in which they subjected the intervention group (n=56) to prophylactic dressing and the control group (n=39) to standard preventive care. There were a total of nine (9) cases of pressure ulcers from which eight cases were reported in the control group.
Chaiken (2012) in a prospective study that included 270 patients within an ICU level-2 trauma setting utilized silicone-border foam dressing as an intervention for managing the cases of sacral pressure ulcers. Over the period of the study, only 1.8% cases of sacral pressure ulcers were recorded as compared to 13.5% cases in the observational or follow up period. In another study by Fujii, Sugama, Okuwa, Sanada & Mizokami (2010), the focus was on determining the incidences of pressure ulcers within a neonatal setting and ultimately determining the risk factors. Within the sample population of up to 81 infants, who had been placed in an incubator up to 13 infants acquired a total of 14 cases of pressure ulcers with majorty of them being locaed in the nose. This was associated with the skin texture and the use of endotracheal intubation. In the sample that utilized chlorhexidine frequently (n=28) during this period, there was only a single case of pressure ulcers as compared to the 13 cases in the other group.
PICOT question
For patients in the Intensive Care Unit and the Medical-Surgical Units (P), does the adoption of a daily bathing program with chlorhexidine (I) as compared to tailored dietary patterns (C) reduce the incidences of skin breakdown (O) over a period of 11 months (T)?
Conclusion
Apparently, there is no single method that has been regarded as effective in the management and prevention of pressure ulcers. It is important that healthcare facilities develop a set of methods tailored to their units that can be applied simultaneously to help close the gap on the cases of skin breakdown. As much as the use of chlorhexidine or any other dressing agent can play a key role, there are other risk factors such as nutrition that need be managed if at all the rates of pressure ulcers can be tackled. Each single intervention has proven to be partly effective therefore indicating that a gap exists even with adoption of any of them at a particular time and therefore a need for multifaceted approaches (Marchetti & Rossiter, 2013).
References
Brindle, C. T., & Wegelin, J. A. (2012). Prophylactic dressing application to reduce pressure ulcer formation in cardiac surgery patients. Journal of Wound Ostomy & Continence Nursing, 39(2), 133-142.
Chaiken, N. (2012). Reduction of sacral pressure ulcers in the intensive care unit using a silicone border foam dressing. Journal of Wound Ostomy & Continence Nursing, 39(2), 143-145.
Fujii, K., Sugama, J., Okuwa, M., Sanada, H., & Mizokami, Y. (2010). Incidence and risk factors of pressure ulcers in seven neonatal intensive care units in Japan: a multisite prospective cohort study. International wound journal, 7(5), 323-328.
Iizaka, S., Okuwa, M., Sugama, J., & Sanada, H. (2010). The impact of malnutrition and nutrition-related factors on the development and severity of pressure ulcers in older patients receiving home care. Clinical Nutrition, 29(1), 47-53.
Marchetti, A., & Rossiter, R. (2013). Economic burden of healthcare-associated infection in US acute care hospitals: societal perspective. Journal of medical economics, 16(12), 1399-1404.
Noto, M. J., Domenico, H. J., Byrne, D. W., Talbot, T., Rice, T. W., Bernard, G. R., & Wheeler, A. P. (2015). Chlorhexidine bathing and health care–associated infections: a randomized clinical trial. JAMA, 313(4), 369-378.
