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EeperanzaEvidence Based Practice on Pressure InjuryA1. Healthcare ProblemThe Prevalence of pressure injuries amongst the adult and geriatric population continues to be a problem in healthcare facilities, as well as in the home. According to Qaseem et al (2015), an estimated amount of three million people in the United States are affected (p 370).   A2. Significance of ProblemThe multitude of issues associated with the problem include, infection, additional complications, lowered quality of life, risk of death, extensive hospital stays, costs and injury to caregivers such as nurses and family.  Patients already face the daunting task of what lies ahead the road to recovery, the added stress of developing a pressure injury is a tremendous obstacle to add to, as Bergquist-Beringer et al (2013) reports hospital mortality rates and a lowered quality of life are closely associated with it; also suggesting a link between pressure injuries resulting in longer hospital stays has costs Medicare patients’ huge sums of money (p 404).An important aspect of prevention relies on the healthcare worker to turn and reposition patients, failure to do so helps facilitate pressure injury occurrence.  The healthcare worker’s consistency of this task may be hindered due to the caregiver sustaining an injury because the duty was carried out (Alves et al, 2017).A3. Current PracticeVariations of existing protocols and procedures regarding pressure injuries depends on the healthcare facility; however same core principles can be found throughout.  A basic guideline for gauging and evaluating pressure injuries called the Pressure Injury Prevention Points by the National Pressure Ulcer Advisory Panel (2016), has compiled a list of considerations such as risk assessments, skin care, nutrition, repositioning and mobilization, and education for healthcare workers to abide by.  Risk assessment advises to view bed ridden and chair-fast patients as exceptional candidates to pressure injury, imploring the assessment of fragile skin, preexisting injury, healed or not, as well as issues with blood circulation.  Inspecting the skin daily, especially from the start of admittance, keeping an eye out for tissue suppleness, tone, and color; documenting any observed abnormalities.  Nutrition is vital to skin condition, so malnutrition can be detrimental and contribute to pressure injuries; due diligence and inspection of weight is essential.  Unless contraindicated, the most popular and effectual practice comes from repositioning and mobilization, because the relief of pressure it provides.  A scheduled routine and frequency of turning a patient, with at least turning every 2-hours being the gold standard, and off-loading is critical to ensure proper distribution of weight, particularly for problem areas like the sacrum and heels.  During this time, additional skin assessments can be done and more focused during the repositioning, especially if a patient has been identified at an increased risk for development of pressure injury.  Educating family members about the risks and interventions of pressure injuries cannot be overstated, as it is an integral element for patient safety and health management (NPUAP, 2016).A4. Impact on Background Pressure injuries have a profound effect on many levels, affecting the caregiver, whose duty is to protect the patient from such injuries from happening or expanding, not to mention the medical institution’s inquiry and investigation of the pressure injury; directing attention and resources from other pressing matters.  Family members can also lose confidence in care that the facility provides, scrutinizing staff incessantly; and the declination of staff and department morale.  More importantly is the patient who is the victim of this dismal circumstance.  It is already hard to bounce back from a significant medical ordeal, but compounded with a pressure wound makes it doubly hard.  There is a decrease in quality of life attributed to pressure injuries as well as high mortality hospitalizations that can have an exponential cost for insurances and the healthcare centers.B. PICO Table P (patient/problem) Patients at risk for or have pressure injuries I (intervention/indicator) Repositioning and/or use of equipment C (comparison) Non-repositioning and/or no use of equipment O (outcome) Reduction and treatment of pressure injures B1. PICO QuestionFor patients at risk for or have pressure injuries, will repositioning and/or use of equipment versus non-repositioning and/or non-use of equipment reduce the risk and incidence of pressure injuries?C1. Keywords:Repositioning, turning, prevention, pressure injury, pressure injury prevention, risk, clinical practice, decision making, judgement, nurses, bedridden patients, bedsores, caregivers, training, hospital, panel, randomised clinical trial, RCT, cluster, technology, pressure injury, preventative turning, and nursing interventions.C2. Number and Types of ArticlesThere was a total of 5,444 items that came up on the initial search.  A number of articles unrelated to the pressure ulcer prevention and repositioning also populated.  Exploring in detail, the searched items came down to 1,244, and articles relevant to the chosen topic came up.  Four primary quantitative research pieces, one primary qualitative, and one secondary research paper caught my attention.  After narrowing the search even more by including secondary keywords, it went down to 351, and two non-research papers came from a physician specialty and wound care specialty journal on practice guidelines and panel discussion on pressure prevention.C2a. Research and Non-Research EvidenceResearch ArticlesA survey that looked at the role of patients in pressure injury prevention was most interesting to me because it delved into the extent of knowledge the patient has of the subject, and the willingness to be proactive in their own care.  Although data on patient perspective is scarce, the article looked to see what participation, if any, the patient partook to avoid and prevent pressure related injuries.  The survey employed a questionnaire given by researchers to participants, and consisting of fixed and open-ended answers.  Subjects eighteen years and older from neurology or orthopedic units, who were also admitted at least twenty-four hours prior to enrollment took part of the study.  Some questions included what their pain and comfort level is, knowledge of the subject, and what their personal views on what their role was as a patient.  Of the fifty-one individuals participating there was a high number of them knew what was a pressure sore, and they were aware and knowledgeable about pressure injury prevention.  However, most of the patients reported no education were given at admission and/or during the hospitalization (McInnes et al., 2014).A clinical trial about the effect of a wearable patient sensor called The Leaf Patient Monitoring System used to record patients turning practices; aimed to evaluate if the device can aid facilitate turning compliance time and help decrease rates of hospital acquired pressure injuries.  A study group over the age of eighteen years participated in the study, in addition nurses were given education on how to use the device appropriately.  The intervention trial showed exceptional results and a positive effect against pressure related injuries, but ultimately the device’s clinical use was deemed to unacceptable due to its resource-intensive nature (Pickham et al., 2018). Non-Research ArticlesThe article from the American College of Physicians set out to compare advantages and effectiveness of beds designed as interventions and treatment for pressure injuries, as conducted by the Agency for Healthcare Research and Quality. Comparisons of an air-fluidized bed, aimed to produce a fluid-like surface by redistributing pressure, and an alternating air bed, which periodically switches pressure, as well as a low-air-loss bed, capable of pressure adjustments, and heat and humidity regulation; were all tested for quality of evidence and overall treatment effect.  It was determined that air-fluidize beds displayed a moderate quality of evidence with patient’s conditions improved, while the other two had no effect on overall treatment, with poor or moderate quality of evidence (Qaseem, 2015)Another article by Alvez et al (2017), is a general report about pressure injury prevention and clinical outcomes.  The piece provides helpful understanding that most pressure injuries are preventable, and identifying patients such as geriatric, critical conditioned, and palliative care are most susceptible for it.  An interesting perspective is how the healthcare industry is solely fixated in clinical outcomes and attitudes towards quality care, safety, and patient satisfaction often take a backseat but are equally important.  The article also explains how turning and positioning is imperative for pressure injury prevention, but the repetitive nature of the responsibility may cause harm and injury to staff.  The article goes on, touching on topics like the high cost of quality interventions are a hefty investment but quality care should also be valued and taken into serious consideration when making decisions to not use evidence supported products in favor for cheaper ones.  The report also states that ample preventative plans, practices, and strategies should be ingrained throughout the medical establishment, from the upper echelons of boardroom members to the bedside caregivers (Alves et al., 2017).D. Evidence MatrixSee attached E. Recommended Practice ChangeFor patients at risk for or have pressure injuries, repositioning and use of equipment reduces the risk and incidence of pressure injuries according to a study done by Pickham et al (2018) that used a portable sensor on patients who were acutely ill.  Because of the advancements in technology, attaining new devices or equipment that can assist nursing staff to be more vigilant with their frequency of turning as well as repositioning of patients consistently has a direct effect in lowering the incidence of pressure injuries.  Cost of new equipment and devices may counter or offset the total cost of what hospital-acquired pressure injuries to a medical facility.  As secondary findings, education of the topic on pressure injuries and the importance of patients and family members being proactive in their role against pressure injuries have also resulted in positive outcomes and can be further assist nurses (McInnes et al., 2014). Worth mentioning is the attitudes from administration and bedside healthcare workers need to be more driven towards the prevention of pressure injuries, this can is geared towards being more patient satisfactory oriented (Alvez et al., 2017).F1. Key StakeholdersThe first stakeholder that would need to be involved would be wound ostomy nurses and department, because their specialty requires them to be current with all preventative care measures and treatment plans on pressure injury prevention pertaining to but not limited to repositioning.  These may include new technology available to assist with turning, position-assisting beds or mattresses, and/or other innovative ways that can be trialed at the facility.  Next group that should be incorporated is the staff education department.  Confirmation of the research prior to presenting this change in practice to nursing administration and staff.  In the same token, the department can verify the differences in cost to implement this test of change versus current practices that may not be effective with pressure injury prevention.  The last stakeholder involvement would be bedside nursing, once approval has been made by the other stakeholders.  Bedside nursing would be key to making the implementation happen.  An initial educational assembly to happen, then in-service training will be needed as well as any updates to the program, and maintenance through annual competencies.  Nursing staff may even assign a champion in each department or a committee that would have additional training and aid unit-based staff that may have concerns or questions, and after approval again by other stakeholders, provide educational materials to staff and/or patients if possible.F2. BarriersCost to the hospital or medical facility obtaining this change by adding an assistive device or equipment for pressure injury prevention can be a main pushback.  Not only will cost be for the new devices or equipment, but also cost for trainings, maintenance and/or upgrade of equipment.  Another barrier can be the nursing staff due to the fact they would have to learn about how to use the new devices, when and who to apply it on, and annual competencies to maintain knowledge on yet another added intervention to an already long list of other interventions for preventing pressure injuries.F3. Strategies for BarriersA data analysis would have to be provided for all stakeholders involved, as well as including nursing administration to get the buy-in to the change or additional cost.  This analysis will include cost to the facility for having hospital-acquired pressure injuries, along with cost for training of staff, the new devices or equipment, and maintenance and possible upgrades of them.  Another strategy includes having nursing staff get updates during annual competencies can help with cost, and that only if the device or equipment had an update.  Also educating the nursing staff on how beneficial the new devices or equipment can be to act as a visual reminder, especially when most facilities have gone to an electronic record.  Computer are widely used, and these devices will be uploaded to every computer in each room.  Explaining that the devices will provide a visual aid as a reminder for repositioning (Pickham et al., 2018).F4. Indicator to Measure OutcomeThe main indicator for measuring outcome would be the decrease incidence of hospital-acquired pressure injuries and increased healing of present pressure wounds. These will help identify if this change or addition to practice has made any difference to the medical centers.  Along with this reduction, there will be an increase in turning compliance, change in attitudes from caregivers, and more patient and family involvement in the care and prevention of pressure injuries.ReferencesAlves, P., Creehan, S., Gefen, A., Santamaria, N., Trevellini, C. (2017). Meeting report: pressure injury prevention: clinical outcomes explained by robust scientific evidence: a panel discussion. Wounds International, 8(3), 46-53.Bergquist-Beringer, S., Dong, L., He, J., and Dunton, N. (2013). Pressure Ulcers and Prevention  Ulcers and Prevention Among Acute Care Hospitals in the United States. The Joint Commission Journal on Quality And Patient Safety, 39404-414. doi:10.1016/S1553-7250(13)39054-0Dearholt, S., Dang, D., Sigma Theta Tau, I., and Institute for John Hopkins, N. (2012). Johns Hopkins Evidence-Based Practice Model and Guidelines, Second Edition. Indianapolis, IN: Sigma Theta Tau International.Gunningberg, L., Sedin, I., Andersson, S., and Pingel, R. (2017). Pressure mapping to prevent pressure ulcers in a hospital setting: A pragmatic randomized controlled trial. International Journal Of Nursing Studies, 7253-59. doi:10.1016/j.ijnurstu.2017.04.007Kaur, S., Singh, A., Tewari, M.K., and Kaur, T. (2018). Comparison of Two Intervention Strategies on Prevention of Bedsores among the Bedridden Patients: A Quasi Experimental Community-based Trial. Indian Journal Of Palliative Care, 24(1), 28-34. doi:10.4103/IJPC.IJPC_60_17McInnes, E., Chaboyer, W., Murray, E., Allen, T., and Jones, P. (2014). The role of patients in pressure injury prevention: a survey of acute care patients BMC Nursing, 13(1), 1-15. doi:10.1186/s12912-014-0041-yNational Pressure Ulcer Advisory Panel. (2016). Pressure Injury Prevention Points. Retrieve from, D., Berte, N., Pihulic, M., Valdez, A., Mayer, B., and Desai, M. (2018). Effect of a wearable patient sensor on care deliver for preventing pressure injuries in acutely ill adults: A pragmatic randomized clinical trial (LS-HAPI study). International Journal Of Nursing Studies, 80-12-19. doi:10.1016/j.ijnurstu.2017.12.012Qaseem, A., Humphrey, L.L., Forciea, M.A., Starkey, M., and Denberg, T.D. (2015). Treatment of pressure ulcers: a clinical practice guideline from the American College of Physicians. Annals Of Internal Medicine, 162(5), 370-379. doi:10.7326/M14-1568Whitty, J.A., McInnes, E., Bucknall T., Webster, J., Gillespie, B.M., Banks, M., and … Chaboyer, W. (2017). The cost-effectiveness of a patient centred pressure ulcer prevention care bundle: Findings from the INTACT cluster randomized trial. International Journal Of Nursing Studies, 7535-42. doi:10.1016/j.ijnurstu.2017.06.014