evidenced based pratice

Prevention of Pressure Ulcers

Evidence-Based Practice for Intervention

Project Question: Can quarter hour turning and positioning minimize pressure ulcers within the elderly population who are bed bound residing in hospitals or nursing homes?

The elderly often deal with various potential problems throughout their life, from pain and chronic disease, to harsh medication and treatment. Often elderly patients are forced to live in nursing homes and stay in hospitals to avoid accidental death and help them with eating and cleaning themselves. While living in hospitals and elderly homes, sometimes the elderly are bed bound. One common dilemma these bed bound elderly patients suffer from are pressure ulcers. Research indicates turning someone every two to four hours will lessen rate of pressure ulcer occurrences. The latest articles demonstrate not only the efficacy of turning but also provide supplemental supportive actions like mattress substitution and longest time interval for turning that will still result in a lessening of pressure ulcer occurrence.

PrUs or Pressure ulcers are a recurrent and difficult problem experienced in hospitals and nursing homes. NH residents and elderly patients often complain about pain and discomfort from the ulcers that occur while staying in bed. The prevalence of PrUs in elderly populations at high risk of developing PrUs at the commencement of studies like the ones examined here, typically range from 15% to nearly 25% PrU incidence on standard mattresses or foam overlays. While support surfaces along with shifting was acknowledged as more costly features of minimization of pressure ulcers, bed turning has come into attention for lessening of pressure ulcers due to the positive outcomes of the various studies concluded displaying the solution that turning decreases the pressure not only on the skin but also at the border amidst bony protrusions and protuberant surfaces that thoroughly hinder or diminish blood flow to flesh. This pressure is believed to be the cause of PrUs.

PrUs in association with other kinds of injuries that elderly patients and nursing home residents acquire in a hospital or nursing home setting must be considered in order to reduce such injuries as a decrease in these types of injuries results in higher quality care and overall higher patient/resident satisfaction. "The prevention of hospital acquired pressure injuries (PIs) is an indicator of care quality, according to the Australian Commission on Safety and Quality in Health Care" (Miles, Nowicki & Fulbrook, 2014, p. 32). Repositioning and redistribution of the body, to lessen the length of contact to the pressure sensitive areas, prevents PrUs. Other than quarterly turning, evidence proposes Hhgh-density foam mattresses distribute pressure more regularly than the standard and frequently used spring form mattresses. Evidence also demonstrates that repositioning, in theory and practice, is accomplished less continually than the recommended every 2 hours. Additional research suggest every 2-4 hours would be more appropriate intervals. Because research lacks in relation to quarter turning of elderly patients to minimize PrUs, there is no conclusive interval recommended other than every two to four hours.

In a study, by Bergstorm et al., the authors highlight the 2-hour time interim along with inclusion of substitution of mattresses with the recommended high-density foam mattresses. "There was no difference in PrU incidence over 3 weeks of observation between those turned at 2-, 3-, or 4-hour intervals in this population of residents using high-density foam mattresses at moderate and high risk of developing PrUs when they were repositioned consistently and skin was monitored" (Bergstrom et al., 2013, p.1706). The study's results demonstrate no difference in terms of mattresses used, as long as the patients were transposed within the recommended two to four hour range. The substitution of standard mattresses for the high-density foam mattresses might have assisted in alleviating the possible manifestation of PrUs to some degree, but because the study focused on turning, it was not fully acknowledged.

Substitution of mattress seems like an idea worth following through with due to the common sense of the idea. Spring mattresses have long been shown to not provide enough support for pressure points within the body. That is why many people have chosen to substitute their own standard spring form mattresses for the slight more expensive foam ones. Even the higher end stores have now included foam mattresses because of the good reviews these mattresses have created. Customers stated they get better sleep and are not in as much pain when they sleep on a foam mattress vs. A standard one. A

Although the focus of this paper is quarterly turning to avoid pressure ulcers, for elderly homes and hospitals that can afford the slightly more expensive option of foam mattresses, it will definitely leave staff less reliant on turning patients in order to prevent ulcers. These kinds of mattress therefore, are meant to supplement quarter turning but are not the main preventative measure against quarter turning. Quarter turning is and has been, as evidence suggests, the best way to reduce and lessen the occurrence of pressure ulcers.

In a study by Still et al., the authors show how repeated turning improved pressure ulcers and diminished occurrence. "At baseline, when frequent turning was encouraged but not required, a total of 42 pressure ulcers were identified in 278 patients. After implementation of the turn team, a total of 12 pressure ulcers were identified in 229 patients" (Still et al., 2013, p. 373.) Nevertheless, the study did not demonstrate nor highlight the importance of turning within the hour or the suggested every two hours. Frequency of turning therefore, does not have to be as often as every hour, in fact it can be reduced to every four hours for reduction of pressure ulcers.

Still et al. (2013) assessed the efficacy of turning patients every two hours and showed frequency can be modified. The results not only were positive, with forty two ulcers recognized and more pressure ulcers shown in high risk patients, reduced overall to twelve ulcers. The conclusion also highlighted the continual positive effects of turning patients that have pressure ulcers. "A team dedicated to turning SICU patients every 2 hours dramatically decreased the incidence of pressure ulcers. The majority of stage I and stage II ulcers appear to be preventable with an aggressive intervention aimed at pressure ulcer prevention" (Still et al., 2012, p. 373). A study done by "Repositioning every 3 hours, using 30° tilt, has been shown to be more effective in less costly in terms of nurse time compared with standard care" (Moore, Cowman, & Posnett, 2013, p. 2354). Also shows the benefits of turning. They achieved the same positive results every three hours. If they can achieve it every two to three hours, they can achieve positive results every fours hours.

Every four hours means patients can be turned at minimum 6 times a day. Once before going to sleeping, once while sleep, once while waking, and the rest throughout the day. Not only is this less work for staff, but it also means less time and resources spent on alleviating pressure ulcers as the extra time and energy can be used for other tasks throughout the hospital or nursing home. In order to promote quarterly turning, it would be imperative for hospitals and nursing homes to implement a kind of turning protocol that every staff member must adhere to in order to reduce all over the facility, pressure ulcer incidences. It is the most cost effective solution, especially if results can be achieved in as little as every four hours.

Often elderly patients experience pressure ulcers because staff feel or are too busy to turn them every hour or two hours. Imagine turning someone 12 times a day. If that can be cut in half, as studies suggest, then staff will be more willing to perform the appropriate tasks. Frequently elderly who experience pressure ulcers are due in part to staff repositioning them every day. In fact some are left there for days to simply wallow in their own pain and filth. This is not the case for all facilities, but some cases have been reported where elderly patients had a myriad of pressure ulcers and muscle weakness from simply being left on the bed, alone.

As previously stated, mattresses are a great alternative to quarter turning. Although a more expensive option, it does have it benefits. Studies show quality of mattress diminished pressure ulcers along with repositioning. Irrespective of the flaws, the strengths based on evidence suggests transposition and turning helps to reduce pressure ulcers. It decreases pressure ulcers and gives staff a chance to provide improved or better quality of care reduction of pressure ulcers also minimizes risk of additional injury. Nursing homes, hospitals and the staff within these facilities must learn implement effective strategies in order to train their personnel to turn and reposition patients so as to reduce and avoid higher risk development of pressure ulcers.

In an article by Ayello (2011), the author explains the use of the Braden Scale for prediction of Pressure Sore Risk. "Assessing risk in six areas (sensory perception, skin moisture, activity, mobility, nutrition and friction/shear), the Braden Scale assigns an item score ranging from one (highly impaired) to three/four (no impairment)." The Braden Scale is a useful tool for the documentation and assessment of pressure sores. Staff need something to determine whether or not the rate of turning is effective against reduction of pressure ulcers. When deciding on implementation of any strategy, observation and evaluation are two important aspects of any ongoing intervention strategy. The Braden Scale then become a tool within the evidence-based practice that allows for proper implementation and reassessment of quarterly turning.

Turning patients can be hard to manage, especially for busy and often tired personnel. Sing tools like the Braden Scale allows for further examination of what is being done and how effective these actions are against reduction of pressure ulcers. Not only that, but staff will be able to determine if the frequency at which they turn patients is enough to less pressure ulcer occurrence. They can even change it to less turns if the patients respond well to the modification or increase turns if the patients begin to develop pressure ulcers.

It's important to prevent pressure ulcers not only to improve quality care of patients, but to also reduce medical insurance costs and hospital costs for the facilities and the patients. Estimates suggest that PU management can be expensive, with numbers going upwards to the $11 billion mark annually. Some of the expenses relate to life-threatening infections and lengthier patient stays. Another facet to assess before executing a plan of action is the type of individuals more at risk for development of pressure ulcers. In chapter 12 of Patient Safety and Quality: An Evidence-Based Handbook for Nurses, the author talks over risk factors for the development of PU. "Some physiological (intrinsic) and no physiological (extrinsic) risk factors that may place adults at risk for pressure ulcer development include diabetes mellitus, peripheral vascular disease, cerebral vascular accident, sepsis, and hypotension" (Hughes, 2008, p. 1). With information of who which populations are more at risk and how to evaluate need, the next four articles will estimate the efficiency of turning patients who experience PU.

In a study by Defloor, Bacquer, & Grypdonck (2005), the authors perform turns within the longer time frame of every four hours and experience positive results. The results suggest again, turning not only has positive outcomes for patients experiencing PU, but it can be done only ever four hours. "Turning every 4 h on a VE mattress resulted in a significant reduction in the number of pressure ulcer lesions and makes turning a feasible preventive method in terms of effort and cost" (Defloor, Bacquer, & Grypdonck, 2005, p. 37). Another study also highlights the effectiveness of turning patients with PU involving a sound implementation strategy.

In an article by Gill & Rochon, the authors utilized 59 patients suffering from pressure ulcers. Between other factors, they found turning as a reasonably effective and inexpensive implementation strategy for reduction of pressure ulcers. Their results proved turning, amongst other actions like observation and evaluation, provided improved reduction of pressure ulcers. Given existing evidence, utilizing support surfaces, transposition of the patient, enhancing nutritional status, and conditioning sacral skin all fall within a range of appropriate strategies to prevent pressure ulcers (Gill & Rochon, 2006, p. 974). Furthermore, turning also delivered relief from immovability and discomfort.