Effectiveness of unequal time intervals in patient repositioning for pressure ulcer prevention

Nursing Utilization Review

Preparation

Scientific research states findings that positional rotation prevents pressure ulcers when performed within specific guidelines. The following findings from research in this area and specific to implementation of this positional rotation of patients has also found to be implemented most effectively when the attitudes, behaviors and perceived barriers toward pressure ulcer prevention among nurses are addressed. Pressure ulcers are caused by a shortage of oxygen to the tissue in cases of pressure and shearing forces with a prevalence of 2-3% to 28% in long-term care facilities demonstrating that attention is necessary to prevention of pressure ulcers. Research has shown that repositioning on a regular basis as a preventionary measure for pressure ulcers is effective. Vanderwee, Grypdonck, De Bacquer and Defloor (2006) state the fact that: "Repositioning is commonly recognized and recommended as an important and effective preventative measures." (Panel for the Prediction and Prevention of Pressure Ulcers in Adults, 1992, EPUAP, 1998, Rycroft-Malong & McInness, 2000; and Romanelli, et al. 2006)

The study of Vanderwee, Grypdonck, De Bacquer and Defloor in the work entitled: "Effectiveness of Turning with Unequal Time Intervals on the Incidence of Pressure Ulcer Lesions" explores the 'effectiveness of turning with unequal time intervals on the incidence of pressure ulcer lesions' which is an investigations into whether "repositioning patients lying on a pressure-reducing mattress alternately for 2 chorus in a lateral position and 4 hours in a supine position reduces the incidence of pressure ulcers in comparison with repositioning every 4 hours." (2006) Findings of this study provides evidence that:

repositioning alternately 2 hours in a lateral position and 4 hours in a supine position on a pressure reducing mattress does not lead to fewer pressure ulcers in comparison with repositioning every 4 hours. Intervention is stated to involve repositioning with unequal time intervals in the following sequence: semi-Fowler 30 degrees, right-side lateral position 30 degrees; semi-Fowler 30 degree, right-side lateral position 30 degrees, semi-Fowler 30 degrees, left-side lateral position 30 degrees. The patients lay for a four-hour period in a semi-Fowler 30-degree position and then 2 hours in a later position 30 degree. The semi-Fowler position "consisted of a 30 degree elevation of the head end and the foot end of the bed. In a lateral position, the patient was rotated 30 degrees with their back supported with an ordinary pillow. It was checked to see whether the sacrum was pressure-free. In the control group, patients were repositioned according to the same turning scheme as used in the experimental group, but with equal time intervals of four hours in later 30 degree as in semi-Fowler 30-degree position. In both groups, the heels of the patients were elevated from the mattress by placing a cushion, shaped like a wedge consisting of visco-elastic polyethylene-urethane foam, between the lower legs resulting in the heels being pressure-free. The sitting protocol was identical in both groups and standardized. In gaining compliance among nurses for following this procedure previous research has noted that "the more pressure ulcer prevention is valued the greater the likelihood of preventative practices being carried out." (Vanderwee, Grypdonck, De Bacquer and Defloor, 2006)

The work of Moore and Price entitled: "Nurses' Attitudes, Behaviors and Perceived Barriers toward Pressure Ulcer Prevention" (2004) states that the work of Ajzen and Madden (1986) held that there are two independent influences that determine an individual's intention to perform a specific behavior which are:

Personal: the attitude towards the behavior; and Social: pressure on a social level to perform the behavior.

Also considered as a variable is 'perceived control influenced by factors including:

knowledge; skill; time; opportunity; autonomy; and resources. (Moore and Price, 2004)

Loss of control over behavior is influenced by:

1) Internal; and 2) External factors.

Internal factors include: (1) skill; and (2) knowledge. Inclusion criteria in the study of Moore and Price included: "...all staff nurses working full time on the permanent staff of the hospitals in either medical, surgical, burns or plastics, orthopedic or care of older people wards. Excluded from the study were "staff nurses working in any area of the hospital where direct inpatient assessment, pressure ulcer prevention care planning and delivery are not a routine part of the nurses' daily working life." (Moore and Price, 2004) the following labeled Figure 1 illustrates the nurse's attitudes toward pressure ulcer prevention.

Staff Nurses Attitudes Towards Pressure Ulcer Prevention

Source: Price and Moore (2006)

Barriers to carrying out pressure ulcer prevention include those as follows:

Lack of staff

Lack of Time

Patient- Specific Problems

Lack of Aids

Lack of Equipment

Unstable Patient

Uncategorized (Price and Moore, 2006)

Stated as barriers to carrying out pressure ulcer risk assessment were those as follows:

Patient uncooperative or too ill

Lack of time

Short-staffed

Lack of training, resources, equipment and guidelines

Problems with assessment tool

Others aspects of care more important of continuity

Forget

Lack of Knowledge

Unable to assess (Price and Moore, 2006)

Phase II: Validation

Potential Predictor

Potential predictors are stated to be based on prior multivariate studies which include: (1) age; (2) BMI, (3) spontaneous movements during the day; (4) spontaneous movements during the night; and (5) maximum duration of sitting out of bed." (None of these factors found to be statistically significant predictor of ulcer development) the study states that in patients with NBE, "other predictors should be considered, and neurological abnormality, anemia, diagnosis, diabetes, fever and blood pressure could be investigated." (Vanderwee, Grypdonck, De Bacquer and Defloor, 2007) (2) in patients for whom turning protocols were found to be ineffective in the prevention of pressure ulcers: "...more intensive preventive measures are needed" including low-air-loss mattresses and air-fluidized systems, which are effective even in the case of critical case patients.

Low degree -x-High degree

The following chart lists the patient characteristics of participants in the study conducted by Vanderwee, Grypdonck, De Bacquer and Defloor (2006).

Baseline and Mobility Characteristics of Patients

Source: Vanderwee, Grypdonck, De Bacquer and Defloor (2006)

Level of Similarity: __x____ acceptable

____ unacceptable

Phase III: Comparative Evaluation

Fit of Setting

Study Sample: The study sample was comprised of participants that were recruits from 84 wards of 16 elder care nursing homes in Belgian. The median age of patients was 84 years with a median length of stay being stated as 42 months. Participants were eligible if: (1) they had no pressure ulcer lesion at the beginning of the study; (2) if they could be repositioned; and (3) if they were expected to stay more than three days in the nursing home. Patients were stated to be included in the study "if they developed non-blanchable erthema (NBE) at pressure areas which was observed at the study's beginning and reassessed on a daily basis. The study was limited to five weeks to assure that adherence to the protocol and the quality of data would decrease if the very strict protocol were to be followed for periods longer than five weeks. Patients were randomly assigned to either the experimental or control group with randomization completed at ward level using SPSS12 randomization lists. Calculation of the sample size was on the basis of "an incidence of pressure ulcer lesions (grade 2 or higher) in nursing homes of 17% (x-0.05; power=80%)

Resources

Resources needed for implementation of this preventative care plan for pressure ulcers will include manpower or labor as stated above as well as the wedges, pressure mattresses and other aids stated previously in this report.

Substantiating Evidence

The material reviewed in this report and specifically the work of Moore and Price (2006) and the work of Vanderwee, Grypdonck, De Bacquer and Defloor (2006) is in the nature of research- based reports

Phase IV: Decision-Making

Given all the factors listed previously, it is the belief of this researcher that the research findings are:

____ Not applicable at this time

____ Applicable, but only at the cognitive to conceptual level

__X__Applicable at the instrumental or symbolic level

The findings in the research reviewed support change within the organization that educates and informs nursing staff of the best treatment practices for older individuals in prevention of pressure ulcers and further that implements a positional supine rotation of every four hours in a model of behavior. Resources needed include manpower and positional aids mentioned previously in this report. Evaluation of the effectiveness of the change would be accomplished through data collection related to the frequency of pressure ulcer occurrence in patients and nurse compliance in the four hours supine positional rotation of patients. Questionnaires will also be administered to nursing staff in order to gain insight as to their attitudes, behaviors and perceived barriers to pressure ulcer prevention.

Phase V: Transplantation and Application

This study concludes that positional rotations of every four hours has been shown to be the most effective prevention of pressure ulcer formation in older patients in elderly care homes and further that that attitudes, behaviors and perceptions of barriers in the view of staff nurses predicts the effectiveness of the implementation of such a prevention program for pressure ulcer care. (Moore and Price, 2006)

Exact Nature of Practice Implications

____ Change the practice

____X__ Support he Practice

____ Modify the Practice

Phase VI.

Expected outcomes in this study include better informed nursing staff, better timed and regulated rotational positioning of patients and ultimately less pressure ulcer occurrence among patients. Feasibility has been determined in the use of this specific procedures of rotational positioning based upon the research study conducted in the work of Vanderwee, Grypdonck, De Bacquer and Defloor (2006) and the work of Moore and Price (2006)