Research Question and Nursing

Preventing Pressure Ulcers in Nursing Home Patients With growing numbers of the American population joining the elderly ranks, there has been a corresponding increase in the number of residents of long-term care facilities including approximately 16,100 nursing homes in recent years (Palumbo & Mclaughlin, 2011). As a result, there has also been increased interest among clinicians concerning optimal turning and repositioning rates for immobile nursing home patients to reduce pressure ulcers (Miller & Ward, 2010).

The need for improved care of pressure ulcers is great, and it has been estimated that the cost of each pressure ulcer incident ranges between $500 and $70,000 for a staggering total of $11 billion annually (Lilly & Estocada, 2014). Therefore, the question of interest for this study is whether turning and repositioning a patient more frequently (i.e., every 2 hours) reduces the risk of patients developing pressure ulcers compared with patient turned and repositioned less frequently (i.e., every 4 hours).

To develop an informed and timely answer to this question, this paper reviews a study by Rich, Margolis, Shardell et al. (2011) concerning optimal manual repositioning pressure ulcer prevention protocols for a population of immobilized hip fracture patients treated in tertiary health care facilities, followed by a summary of the research and important findings concerning these issues. Research question for the Rich et al.

(2011) study Citing the conventional intervention for the prevention of pressure ulcers in bed-bound patients and current clinical guidelines for the prevention of pressure ulcers which prescribe manual repositioning at least every 2 hours, the research question of interest in the Rich et al. study was based on the dearth of timely and relevant research concerning optimal frequency of manual repositioning as part of a pressure ulcer prevention program.

In order to develop new data collected by nursing staff from patient charts that can be used to identify optimal manual repositioning rates among a group of elderly (i.e., 65 years and older) hip fracture patients who were confined to bed based on a cohort study from nine Pennsylvania and Maryland hospitals for the period between 2004 and 2007.

Description of the research design of this study This was a retrospective, observational study that relied on data from patient chart reviews and follow-up assessments of the incidence of pressure ulcers among the study participants. How the sample was selected and number of participants Out of 1,055 potentially eligible participants, a total of 269 participants were ultimately determined to be eligible for inclusion in the retrospective Rich et al. study. Approximately 2.5 million patients develop pressure ulcers in the United States each year (Preventing pressure ulcers in hospitals, 2016).

Given the difficulties in studying human beings and the specificity of the guiding research question, the sample size used in the Rich et al. study was deemed adequate for the purposes of developing an informed and timely answer to its guiding research question concerning optimal manual repositioning rates for bedridden elderly patients notwithstanding its limitations (which are discussed below).

Data collection method(s) including who collected data, what tools were used, and other pertinent information The manual repositioning data and follow-up assessments for stage 2+ pressure ulcers for the Rich et al. (2011) study were collected from the nursing flow sheets by specially trained registered nurses who were experienced in medical record review or trained chart abstractors.

The respective repositioning rates for bed-bound participants were categorized as being "frequent" in those cases where repositioning was provided at least 12 times per inpatient day which equals an average frequency of at least once every 2 hours which is consistent with the recommendations provided by numerous prevention of pressure ulcer clinical guidelines (Rich et al., 2011). Identify the limitations of the study, and describe how the limitations could be overcome in subsequent studies The most significant limitation of the Rich et al. study was its observational nature.

According to the study's authors, a superior approach would be a randomized clinical study which would provide stronger evidence concerning the efficacy of current guidelines for pressure ulcer care that indicate optimal frequency is every 2 hours.

Unless future study participants were manually repositioned even more frequently than every 2 hours (a costly and potentially ineffective alternative), Rich and her associates point out that, "[G]iven that repositioning every 2 hours is the current standard of care, it would be difficult and possibly unethical to perform experimental studies where patients are randomized to less frequent intervals of repositioning" (2011, p. 16). How the findings were reported in the study Interestingly, the results of the Rich et al.

(2011) study showed that there was no discernible difference in the incidence of pressure ulcer among the participants based on the frequency of manual repositioning, suggesting that current guidelines that stipulate manual repositioning every 2 hours may be wasting scarce organizational resources that could be better applied elsewhere. These findings were reported in both tabular and graphic formats and interpreted in a narrative fashion. Summary of the article In sum, the findings that emerged from the Rich et al.

(2011) study indicated that there is no evidence to support current manual repositioning guidelines that stipulate a frequency of every 2 hours in at-risk populations. Although the participants in the Rich et al. study were hospital inpatients, it is possible to extrapolate these findings to other populations that are at high risk of developing pressure ulcers, including patients in long-term care facilities such as nursing homes. For instance, as Rich et al.

point out, "There is no known reason that the effect of frequent repositioning in this population would differ from that in other populations at risk for pressure ulcers" (2011, p. 16). Although additional research is needed in this area, these findings provide strong.