The use of skin care bundle among hospitalized adult sick people can reduce the risk of skin breakdown compared to standard care of practice
Pressure ulcers are a common problem in acute care hospitals, specifically among obese patients in intensive care units. Pressure ulcers or sores are common, serious but preventable health issues in the healthcare system. Pressure ulcers are associated with low quality of life, increased expenditure, increase hospital stay, and poor health outcomes (Bhattacharya & Mishra 2015). Hospital-acquired pressure ulcers (HAPU) are preventable if repositioning and turning techniques. However, the evidence on the effectiveness on these techniques is unclear, wherein most healthcare authorities require more comprehensive and effective strategies. In a recent review, a team of researchers stated that certain risk factors of HAPU should be identified and can be used against to prevent and control it among the target population (Baumgarten, et al. 2012). However, the use of care-bundle for skin care have been associated with reduced rate of HAPU (Agrawal & Chauhan 2012). Nurses should focus on providing evidence-based care to patients, wherein HAPU over standard care for skin is highly recommended (Balas, et al. 2012).
Change model overview
The Johns Hopkins Nursing Evidence-Based Practice (JHNEBP) model helps in improving the clinical decision-making skills of nurses by focusing on research and problem solving strategies. Nurses should use the JHNEBP to facilitate change, improve patient outcomes, focus on evidence -based practices, and facilitate translation in medicine. Nurses would enhance their knowledge and skills which would in-turn increase standard of care and patient satisfaction (Parkosewich, 2013). The JHNEBP comprises of practice, research, and education. Nurses must adopt and learn through various intrinsic and extrinsic factors while applying EBP to their practice (Aarons, Farahnak, Ehrhart, & Sklar 2014).
Practice Question
Inter-professional Team
The inter-professional team would comprise of the physician, clinical nurse educator, unit manager, physiotherapist, registered dietician, nurse, pharmacist, and unit manager. The physician and nurse would be in direct contact with the patient for medical needs. The clinical nurse educator would help and assist the nurse on the various pharmacological and non-pharmacological approaches for faster recovery. The registered dietician would provide an ideal meal plan for the patient based on symptoms and extent of pressure ulcers/wounds. The physiotherapist would assist the patient on regular and light exercises for mobility. The unit manger would be involved in managing the entire unit and staff involved in the care of the patient, inventory, and administrative requirements (Baker, Boyce, Gairy, & Mighty 2011).
EBP question
Pressure ulcers have increased exponentially in the US, specifically among obese patients in the ICU. The prevention of pressure ulcer wounds is preventable, but management techniques such as repositioning and turning the patient are considered sacred cows or conventional practices that have limited efficiency. Since these conventional strategies have been ineffective in controlling or preventing pressure ulcers, the use of bundle skin care has been proposed. Nurses can adopt such new practices to help and prevent pressure ulcers among obese patients in the ICU. However, the bundle care should be applied in combination with patient mobilization techniques (Downie, Perrin, & Kiernan 2011). Turning and mobilization plan in combination with the proposed bundled skin care plan is expected to reduce the rate of pressure ulcers, prevent skin breakdown, improve patient satisfaction, reduce hospitalization stay, healthcare expenditure, and overall quality of life (Tayyib, Coyer, & Lewis 2016).
Scope of the EBP
The rate of pressure ulcers, sores, and wounds have increased exponentially in the past 3 decades. Based on a recent report, nearly 11% of patients in US nursing homes have pressure ulcers while most them were identified to have stage 2 pressure ulcers. Patients above 64 years of age are more likely at risk of developing pressure ulcers/wounds (CDC 2011). Pressure ulcers are more common among patients who stay for less than a year compared to those to stay for more than a year owing to multivariable factors (CDC 2011). 1 out every 5 patients with pressure ulcer are either obese or overweight. Special wound care services were provided to more than 35% of nursing home residents for stage 2 pressure ulcers/sores. Lastly, pressure ulcers affect more than 2.5 million people in the US (CDC 2011).
Responsibility of team members
The nurse would act as a facilitator between the patient and the physician, both involved in the medical management of the patient. The dietician would develop meal plans, provide feedback on food upgrades, and assess the patient’s outcome based on dietary interventions. The physiotherapist would play a key role in the care and management of the patient with respect to turning, positioning, and mobilization. The unit manager and pharmacist would help in addressing inventory, medicines, and other supplies required for the staff to carry out normal functioning of the unit. Lastly, the clinical nurse educator would assist, educate, and train the patient on various aspects self-care practices (Samuriwo R 2011).
Evidence
Review and appraisal of evidence
In the past 5 years, there have been many qualitative and quantitative studies that highlight the overall efficiency of bundle care for skin to prevent and control skin breakdown and pressure ulcers for patients in the ICU. There is clear and strong evidence on how bundle care plans along or in combination with turning/repositioning or mobilization of patients can be effective in reducing the risk of pressure ulcers/sores among patients in the ICU. A guideline was published by the NHS to emphasize bundled care for patients at high risk of developing pressure ulcers or sores. The NHS recommends the following in the bundled care: (a) Surface cleansing/disinfection (b) Regular skin inspection (c) Repositioning of the patient (d) Proper nutrition/hydration and (e) Incontinence and moisture. Most of the research publications identified have a Level I evidence (Considered to be the highest in terms of research and evidence appraisal). Most of the research publications identified have a large sample size, comprise of systematic reviews, and includes comparison with standard skin care practices. However, it is important to relate and discuss the results of these studies.
Evidence summary
In a recent quantitative analysis of HAPU and the use of bundled care, a team of researchers reported and confirmed that bundled care plan should be implemented as a quality improvement strategy with an aim to reduce HAPU by 50% (Visscher, et al. 2013). In a recent qualitative descriptive study, a team of researchers stated that nurses found the use of bundled care to be feasible and acceptable. However, there are perceived barriers that may prevent the use of bundled care such as patient engagement (Roberts, et al. 2016). In a cross-sectional study across 14 community care sites in Norway, a team of researchers reported that nurses recommended the use of bundled care over standard care to prevent and control HAPU (Johansen, Bakken, & Moore 2015). In a recent systematic review, researchers claimed that inculcating evidence-based practice among nurses, specifically the use of bundle care helped in preventing skin breakdown or HAPU among patients (Flodgren, Rojas-Reyes, Cole, & Foxcroft et al. 2012). In a recent study, a team of researchers reported that the use of the skin integrity care bundle (InSPiRE) was associated with lower incidence of pressure injuries among patients (Coyer, et al. 2015).
Recommendations for change based on current evidence
Based on current evidence and basis on the PICO, wherein the usefulness of bundled care in terms of control and prevention of pressure injuries, sores/ulcers, the pilot program should be based on implementing such practices. Based on a review of published literature and insights gained from Mary Elizabeth Paciella, an experienced registered nurse who has provided valuable intuitions on the concept of bundled care and prevention, the following recommendations can be made: (a) Comprehensive skin assessment of the patient is highly recommended, specifically those who are obese, immobile, and admitted for long-term care (b) Nurses should carry out a universal or standardized pressure ulcer risk assessment to provide optimal care to high risk patients (c) Use of repositioning/turning and mobilization practices to prevent pressure injuries or sores and (d) Educate and train nurses to implement evidence-based practice methods, in correlation to prevent pressure injuries (Paciella, EM. 2009).
Translation
Action plan
The Entire project is estimated to take 6 months to complete. The first step of the program would include education and training of nurses and healthcare staff on the importance of bundled care and control of HAPU. The training sessions should last for 3 weeks followed by a crash course and briefing session on the 4th week. A pilot project would be implemented from the next month, wherein nurses would be supervised on their care activities with focus on bundled care. The pilot session would continue for 30 days. The incidence rate of HAPU would be assessed prior to the implementation of bundled care. This would help in assessing the overall outcomes and efficiency of bundled care. Patient feedback would also be qualitatively assessed based on their inputs for bundled care (Agrawal & Chauhan 2012).
Evaluation of outcomes and reporting outcomes
Reduced incidence of HAPU, reduced hospital stay among patients, improved quality of life, and patient satisfaction are key outcomes for the pilot project. The incidence rate of HAPU would be assessed pre- and post-implementation of bundled care to assess the desired outcomes. A quality of life assessment tool would be used to assess the health outcomes of patients while feedback forms would be used to assess patient satisfaction. A statistical report would be developed and presented to key stakeholders in the form of a presentation. The report would also be stored in the hospital website and can be accessed by the stakeholders as and when required (Aarons, Farahnak, Ehrhart, & Sklar 2014).
Identification of next steps
The concept of bundled care can be applied for a larger target population. However, a comparative analysis would be made for larger population. A randomized control study, wherein bundled care is the intervention while standard care practices would be followed in the control group. The incidence rate of HAPU would be assessed and compared. A reduced rate of HAPU in the interventional group (bundled care) is the expected outcome.
Findings
The findings would be documented and presented to the key stakeholders. A monthly meeting would be organized among team members to reflect upon the pilot study to assess the impact of bundled care and HAPU. The results of the study would be sent for publication to a reputed internal journal. Post-publication, the entire details of the pilot study would be disclosed on the organization’s website and the weekly health magazine.
Conclusion
Based on current evidence, it can be concluded that bundled care in combination with mobilization is an effective strategy to prevent and control HAPU among patients in the ICU. Nurses should have an inclination towards evidence-based practice.
References
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