Healthcare professionals are responsible for not only facilitating recovery of a patient from health issues, but also preventing injuries to the patient during and after care. Despite the immense efforts by stakeholders in health to ensure safety of the patients under care, zero cases have not yet been achieved, as sentinel events are still a major challenge to patients and the healthcare industry. Park-Lee and Caffrey (2009) estimates that 9.2% of all people admitted in hospital acquire one or more nosocomial infections. The Joint Commission (2015) defines a sentinel event as an unexpected situation that leads to the physical and/or psychological injury, or death of a patient. One common sentinel event that poses a challenge to the wellbeing of patients in hospital is pressure ulcers, which is a nosocomial infection.
Hospital acquire infections are one of the major causes for disability and death for inpatients. Pressure ulcers, a hospital acquired infection, affect 2-34 % of patients in long-term care and 0.4-38% of patients in acute care, and have the ability to cause irreparable damages to the skin and bones of the infected (Lyder et al., 2012). In addition, pressure ulcers contribute to increased medical expenses for hospitals and patients. This paper will provide a literature review on what is being done about the issue of pressure ulcers, which will give information on the prevalence of the issue in the United States. In addition, possible causal factors and probable root causes will be identified using the root cause analysis process.
Literature Review on Pressure Ulcers
Zaratkiewicz et al. (2010) defines a pressure ulcer as wound which is caused by excessive pressure on one part of the skin. Pressure ulcers commonly appear where there is a bone under the skin over which the excess pressure is exerted, for example the hips, shoulders, and back. The first national goal to reduce the incidences of pressure ulcers was released in 1989, with a 50% reduction target (Cuddigan, Berlowitz & Ayello, 2001). Since then, medical professionals and stakeholders in healthcare have continually unveiled efforts and address the issue.
The prevalence of pressure ulcers in a healthcare facility is used as a metric for the measurement of quality of care provided in that facility. Pressure ulcers are classified from stage I-IV, based on the depth and severity of the ulcer, with stage IV being the most severe stage. Each stage is characterized by its own symptoms, but redness of the skin, abrasions of the skin, and loss of the thickness of the skin are the most common across all stages (Lyder et al., 2012). A report by Park-Lee and Caffrey (2009) shows that pressure ulcers are more common among patients of 64 years and below, as well as among patients who have lived in nursing homes for less than one year.
In addition, assessment tools have been developed for assessing the risk of development of a pressure ulcer, as recommendations given in the case of risk. Lyder et al. (2012) mentions the Braden, Norton, and Waterlow scales as the most common scales used to assess the risk of pressure ulcers. The Braden scale is commonly used in the United States, and it is composed of six elements; “sensory perception, moisture, activity, mobility, nutrition, and friction and shearing” (Gill, 2015). The importance of using a risk assessment tool like the Braden scale is not only limited to the prevention of development of pressure ulcers, but as Zaratkiewicz et al. (2010) observed, adopting prevention measures is in fact financially viable, compared to treatment of the pressure ulcers.
Apart from the development of guidelines to prevent and manage pressure ulcers when they occur, the Centers for Medicaid and Medicare have implemented a regulation that denies remuneration for the treatment of acquired pressure ulcers. The directive is intended to put into effect the use of pressure ulcers prevention guidelines in hospitals (Chou et al. 2013). Members of the healthcare industry place more importance on the prevention, rather than the treatment of pressure ulcers. Some of the prevention strategies usually adopted for people at risk of acquiring the nosocomial infection include use of appropriate beddings and sitting materials, avoiding excessive pressure on one part of the body by frequently changing positions of an immobile patient, and the use of appropriate dressings for areas vulnerable to pressure ulcers (Lyder et al., 2012).
Health literacy is also a widely adopted method of preventing pressure ulcers among at-risk patients. This involves enlightening patients on the effects of pressure ulcers, as well as ways to prevent development of the ulcers. Park-Lee and Caffrey (2009) found that patients who were aware of causes of pressure ulcers and how to prevent them are more likely to adopt preventive measures than those who are not informed about the ulcers. It is the responsibility of the healthcare professionals to empower patients with information that enables them to adopt healthier living. For patients at risk of pressure ulcers, it is prudent that if a patient is in a position to avoid pressure ulcers, he/she should be encouraged and supported to do so.
The rising cases of pressure ulcers acquired by patients while they are in care continues to be a concern to the health care industry due to increased morbidity rate, rising costs of treatment, and the limitations in reimbursement for this health concern. A report by Park-Lee and Caffrey (2009) indicated that there were 257,412 cases of pressure ulcers. This was a significant increase, as Gill (2015) reported 159,000 cases in 2004. This increase is an indication that the cases continue to soar, despite the extensive efforts adopted to curb the issue. In fact, Lyder et al. (2012) observed that these figures could be an underestimation of the real situation on the ground, as physicians are less likely to indicate presence of pressure ulcers upon discharge from hospital.
Statistics also indicate that stage II pressure ulcers are most common, and affect people of or under the age of 64 years. Also, patients who have lived in nursing homes for more than one year are less likely to develop pressure ulcers compare to those who have less than one year stays in similar facilities. Male patients are at a higher risk of developing pressure ulcers compared to their female counterparts. Weight loss, incontinence, immobility, and drug/medication use are some of the factors that have been identified by researchers as facilitators for the development of pressure ulcers.
Gill (2015) observed that patients registering a recent weight loss while under care had pressure ulcers compared to those who didn’t have weight loss. Also, patients with recent cases of incontinence were reported to be more predisposed to pressure ulcers, compared to those without incontinence. Patients using more than 8 medications were also reported to have more pressure ulcers than those consuming fewer medications, as did the patients who had mobility restrictions such as those in the ICU or wheelchairs.
Studies show that efforts to reduce pressure ulcers are bearing results in private clinics and care facilities. However, this is not true for the general healthcare industry because the cases are still prevalent. The challenge can be attributed to some of the measures and directives that have been adopted for preventing pressure ulcers (Park-Lee & Caffrey, 2009). Lack of remuneration for hospital acquired pressure sores continues to put pressure on provision of care services due to the diminishing resources.
Consequently, units where high rates of the ulcers are reported are being eliminated due to the strained resources. Accordingly, there is a growing demand for such units, and an overworked workforce, which results to reducing quality of care services, and most likely, increase in prevalence of pressure ulcers. Therefore, health care industry and policy makers must adopt more sustainable measures, if 50% reduction in the prevalence of pressure ulcers is to be attained.
Possible Causal Factors using Root Cause Analysis Process
Root Cause Analysis, RCA, process is a method use for solving problems through the identification of the root causes of the problems (Giardina et al., 2014). A root cause is a factor that not only contributes to the development of the problem, but one whose removal prevents the recurrence of the problem. On the other hand, a causal factor is an element that affects the outcome of an event, but doesn’t have impact on the root cause of that problem. The difference between a causal factor and a root cause is that the exclusion of a causal factor improves the outcome, but doesn’t guarantee preventing recurrence of the problem.
The exclusion of a root cause not only improves the outcome, but also prevents the recurrence of the problem (Giardina et al., 2014). In addition to identification of root causes and causal factors, the RCA process is also used to correct the root causes in an effort to avert/eliminate the problem. Through this reactive method, probable causes can also be identified before they occur. Therefore, the RCA process is typically used to identify causes, reveal the problems, and identify solutions to the problems.
Hospital acquired pressure ulcers are localized injuries of the skin and its underlying tissues, which results from excessive pressure being exerted on one part of the body, usually one that has a bony prominence (Giardina et al., 2014). A literature review of studies that have been carried out regarding pressure ulcers indicate that patients with restricted movement are at a high risk of acquiring pressure ulcers, making immobility one of the causal factors of pressure ulcers. Also, studies indicate that weight loss is another factor common among those suffering from pressure ulcers. Patients suffering from any type of illness are prone to weight loss, and this consequently predisposes such patients to pressure ulcers due to the loss of agility and atrophy of the muscles (Chou et al., 2013). Weight loss is another causal factor.
Another causal factor for pressure ulcers is the moisture or dryness of the skin. Gill (2015) observed that patients whose skins were exposed to more moisture or excessive dryness are more predisposed to the pressure ulcers than those that are not exposed to these conditions. Excess moisture or dryness of the skin is more prone to injury from friction between the skin and the beddings of clothes. Incontinence is another factor that is common among people suffering from pressure ulcers (Gill, 2015). This is because fecal matter contains bacteria that facilitate development of skin injuries. Therefore, if a patient who suffers from incontinence is not frequently cleaned, such bacteria, in combination with excessive pressure, starts to eat on the skin, causing pressure ulcers.
Chou et al. (2013) observed that people consuming more than eight types of medications are more prone to developing pressure ulcers than those consuming less. Consumption of a variety of medications alters the normal functioning of the body, including the maintenance of the normal skin elasticity and agility. Consequently, the disruption of the functioning predisposes the patients to pressure ulcers. Poor nutrition is another causal factor, as evidenced by numerous research findings. Maintenance of skin elasticity requires a balanced diet and hydration. People who have limited mobility, and lack balanced diet, are more predisposed to pressure ulcers than those who consume balanced diet and stay hydrated.
Other health conditions, for example, kidney failure, heart diseases, diabetes, and COPD predispose a patient to pressure ulcers. While the patient may not be restricted by immobility, even little pressure over a bony area for patients suffering from these medical conditions can cause a pressure ulcer. This is because these diseases are associated with distracted blood flow, which is a contributory factor to the development of pressure ulcer. If a body part lacks supply of enough blood, that part suffers from localized ischemia, facilitating development of pressure ulcers.
Other causal factors commonly mentioned from various researches include lack of adherence to the prevention guidelines, such as those outlined by NICE, and undermining the power of assessment tools such as the Braden assessment tool before the admission of a patient. Assessing the skin before a patient is admitted informs the care giver on the type of skin care that the patient requires in order to prevent development of pressure ulcers.
Lack of assessment implies lack of proper and relevant care to individual patients. Also, Adherence to the prevention guidelines for patients at-risk of developing pressure ulcers averts the possibility of their occurrence. It is imperative to note that removal of the causal factors does not guarantee that a patient will not suffer from pressure ulcers, which is why it is important to identify the root cause of the ulcers. Identification of the root cause is critical in improving the outcomes and addressing the health issue.
Probable Root Cause using the Root Cause Analysis Process
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