Role of Staff Education in Pressure Ulcer Incidence in Long-Term Care Residents
Pressure ulcers (PUs), also known as bed sores, decubitus ulcers, or pressure sores, are formed where skin and tissue are squeezed between bone and an outside surface for long periods of time, often due to immobility ("Pressure Ulcer," 2002). The development of PUs is a common problem in long-term care of the elderly. A recent report by a national pressure ulcer organization estimates the prevalence of PUs in acute care at about 15%, with about a 7% incidence after admission (National Pressure Ulcer Advisory Panel, 2001).
Because PUs are so common, cause distress to the patient and their family, and can form the basis for litigation, it is important for the long-term medical care community to find ways to reduce their prevalence and incidence. Two commonly suggested solutions to the PU problem include identifying patients at risk using risk assessment methods and initiating preventive measures (Ayello & Braden, 2002). In order for long-term care staff to identify patients at risk they must be educated in assessment of the risk for developing PUs. One risk assessment method used in this area is the Braden Scale, developed in 1987 by Drs. Barbara Braden and Nancy Bergstrom. The scale attempts to identify risk factors that increase the chance that patients will develop PUs in the future and assigns a numeric value to the risk for any particular patient (Bergstrom, Braden, Laguzza, & Holman, 1987).
Rationale for the Study
This study will attempt to evaluate the effect of training staff in a long-term care facility in the use of the Braden Scale on ulcer incidence. It will do this by examining three factors before and after training in the use of the Braden Scale: (1) the overall incidence of ulcers, (2) the average ulcer development time, and (3) the average ulcer healing time.
Definition of Terms
Braden Scale -- a risk assessment method for the development of pressure ulcers that examines various factors and assigns a numeric value of the potential risk.
Retrospective Data -- data concerning events occurring before a subject is enrolled in a study.
Prospective Data -- data concerning events occurring after a subject is enrolled in a study.
Quasi-Experimental -- a method of quantitative research design that examines causality; it does not include random selection of subjects or control groups.
REVIEW OF THE LITERATURE
Chronological presentation of the theoretical and research basis for the study
The Braden Scale is a risk assessment method for the development of pressure ulcers that was formulated in 1987 (Bergstrom et al.). Since that time, a large number of studies have been done to try to determine if the scale is reliable (consistent) and valid (accurate) in predicting those patients that will develop pressure ulcers. Work by Braden herself indicates that the scale does have clinical utility, predictive utility, and extends to various healthcare settings (Braden & Bergstrom, 1989; Bergstrom, Braden, Kemp, Champagne, & Ruby, 1998; and Bergstrom, Braden, Kemp, Champagne, & Ruby, 1996). This has been supported by research done by other groups, including studies examining patients of African-American, Hispanic, and Asian decent (Lyder, Yu, Emerling, Mangat, Stevenson, Empleo-Frazier & McKay, 1999 and Pang & Wong, 1998). However, a very recent paper calls into question the predictive value of the Braden Scale in hospitalized patients (Schoonhoven, Haalboom, Bousema, Algre, Grobbee, Grypdonck, & Buskens, 2002). Overall, though, it appears proper to evaluate an education plan including the Braden Scale and recommended preventative measures based on this analysis to determine if it could affect the incidence of ulcer occurrence, the time before ulcer development, and/or the time of ulcer healing.
The literature review of this study shows that there is significant controversy about the predictive validity of the Braden Scale in particular settings and with particular patient populations. But there is still a need for studies that examine the relationship between education about risk assessment such as the Braden Scale and a reduced number of ulcers. Also, where ulcers do occur, studies are needed to determine whether education in this area can result in an increased time from admission to ulcer development and a decreased time for the ulcer to heal. The present study attempts to find a correlation between staff education and use of the Braden Scale with changes in ulcer incidence, time for ulcer development, and time for ulcer healing for the long-term resident.
This study will utilize both retrospective and prospective data in a quasi-experimental design. Before staff education, overall ulcer incidence will be followed until a total of thirty residents develop ulcers. Staff education on the Braden Scale risk assessment and appropriate preventive measures will occur. Then ulcer incidence data will be collected until thirty more residents develop ulcers post-education. This data will be used to determine three things. First, has there been a change in the percent incidence of ulcers before and after staff education? Second, has there been a change in the average time period between admission and ulcer incidence before and after staff education? Third, is there a difference in the healing time for the ulcers before and after staff education?
All subjects will be ulcer free at the time of admission into the long-term care facility and be among the first thirty residents to develop at least a stage I ulcer before or after the education of the staff.
Staff will be requested to alert the researchers when a patient develops an ulcer. After enrollment of the patient into the study, including informed consent, a medical record review will be used to determine the date of admission and the date of ulcer development. Follow-up reviews of the enrolled patients' records will occur until the date of ulcer healing. This will be done for thirty patients before staff education and thirty patients after staff education.
The staff education program will consist of specific policies for risk assessment based on the Braden scale, pressure ulcer prevention and treatment, and education on pressure ulcer care and monitoring. After all the data is collected appropriate statistical analyses will be performed to ensure significance of the results.
Patient confidentiality and anonymity will be maintained by assignment of patient numbers to each of the sixty participants.
Presence of ulcers will depend on evaluation of at least a stage I lesion by the long-term care staff using the standard staging method of Shea, as revised by the Pressure Ulcer Clinical Practice Guidelines. (Agency for Health Care Policy and Research, 1992).
Presence of ulcer healing will be found when the wounds reaches a recorded objective parameter of zero in ulcer size, depth, amount of necrotic tissue, amount of exudate, and presence of granulation.
Validity and Reliability
Because the Braden Scale will be used for educational purposes only, and not evaluated in this study, previous measurements of the scale's validity or reliability are of only secondary of concern here. The greatest risk of validity and reliability for this study is whether any measured changes in ulcer incidence, time before development, and time of healing are truly due to the staff education or some other variable.
Analysis of the Data
The time to ulcer development will be determined by the number of days from date of admission to date of first staff documentation of at least a stage I ulcer. The total number of days will be added together for all thirty patients pre-education and divided by thirty to find an average time. The same analysis will be done for the first thirty patients developing an ulcer post-education. The time for healing will be determined by the number of days from date of first staff documentation to documentation of complete ulcer healing. The total number of days will be added together for all thirty ulcer patients pre-education and divided by thirty to find an average healing time. The same analysis will be done for the first thirty patients developing an ulcer post-education. For each of the data sets that involve a time to event measurement, complete analysis will require a log rank and a p value calculation in order to determine statistical significance. An example of a study that does this is Xakellis, Frantz, Lewis & Harvey (2001).
Ayello, E. & Braden, B. (2002). How and why to do pressure ulcer risk assessment. Advances in Skin & Wound Care, 15: 125-131.
Bergstrom, N., Braden, B., Kemp, M., Champagne, M., & Ruby, E. (1996). Multi-site study and incidence of pressure ulcers and the relationship between risk level, demographic characteristics, diagnoses, and prescription of preventive interventions. Journal of the American Geriatric Society, 44: 22-30.
Bergstrom, N., Braden, B., Kemp, M., Champagne, M., & Ruby, E. (1998). Predicting pressure ulcer risk: a multisite study of the predictive validity of the Braden Scale. Nursing Research, 47: 261-269.
Bergstrom, N., Braden, B., Laguzza A., & Holman, V. (1987). The Braden scale for predicting pressure sore risk. Nursing Research, 36: 205-210.
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