Implementing evidence-based practice to reduce hospital-acquired pressure ulcers

Planning and Implementing Change

Pressure ulcers are one of the most serious concerns facing hospitals and nursing homes today. This is particularly the case with older people and those with serious disabilities that keep them bed-bound for an extended period of time. Remaining in one position for too long can cause painful and severe pressure ulcers, which often require hospitalization and invasive intervention. Indeed, according to Perry et al. (2012), nearly 60,000 hospital patients in the United States die as a result of complications resulting from pressure ulcers they acquire in hospitals.

In addition to mortality, the financial costs can also be severe, with a single full thickness pressure ulcer requiring as much as $70,000 to manage. Indeed, the total cost of treatment for pressure ulcers in the country is estimated at $11 billion per year.

Obviously, the effects of these costs are severe, including many stakeholders, including those suffering from pressure ulcers, their families, caregivers, and health care managers.

Exacerbating the matter is the fact that the prevalence of pressure ulcers has a tendency to increase in health care facilities. Depending upon the clinical setting, ulcers range fro 0.4% to 38% in acute care facilities, from 2.2% to 23,9% in long-term care, and from 0% to 17% in home care (Perry et al., 2012). It is therefore important to implement an evidence-based practice plan to address this problem in the long-term.

The implementation should include the advice and support of all stakeholders and an evaluation of the effectiveness resulting from implementation. Hence, the first step towards implementation would be analyzing the impact of proposed changes on stakeholders and end users. This will be determined by means of interviews, facility investigations, and recommendations for optimal practice.

Implementing EBP Projects: Stakeholders (Managers)

The most important stakeholders are of course those most directly affected by pressure ulcers, who are bedbound patients. However, the first investigations and interviews will need to be with hospital and nursing home managers to determine various factors, such as permission to conduct interviews with patients and also to determine the willingness of managers to implement change practices.

Preliminary interviews will therefore include approaching such managers with research information regarding pressure ulcers, their severity, and the potential disadvantages they hold for the facility in question. Black et al. (2011), for example, suggest that the prevalence of pressure ulcers tends to be in indicator of quality of care. A facility where the percentage of these wounds is lower, for example, would necessarily have a reputation for better quality care, which in turn would be to the ultimate advantage of the establishment in question. Those with a higher percentage among their patient population, on the other hand, would suffer in terms of general public perception. Such perceptions can, in turn lead to preferential funding for institutions with better reputations.

Hence, when approaching managers as stakeholders, the possibility of more funding will be used as a point of interest and incentive to implement change as well as to gain access to the facility to interview caregivers and patients.

Of course the assumption must also be that hospital and nursing home managers are concerned not only with funding, but also with providing optimal care to their patients and residents. This point will be made in combination with the incentive of funding to provide impetus behind the drive for change and implementation. Once access is granted for further investigation, primary caregivers will be the second point of investigation.

Stakeholders: Patients

The third set of interviews will be conducted with patients and their families. Patients who are bedbound for extended periods of time will be approached to determine their experiences and perceptions of care in the facilities where they reside. This is an important step, but one that may involve many barriers to accurate information. Nurses and managers may, for example, be apprehensive regarding any negative perceptions that might emerge from patients. Patients, in turn, may fear to be entirely truthful for the same reason. To alleviate any such fears, it may be advisable to conduct some interviews with patients, managers, and nurses while emphasizing the fact that the main purpose of the interview is to ensure the implementation of top quality care without any penalties for existing shortcomings.

For this reason, patients must be encouraged to be truthful in as diplomatic manner as possible so that accurate information can be obtained while offering useful ways of implementing evidence-based practice programs. This must be emphasized in all interviews and remain a focus point until the implementation phase.

Interviews conducted with patients and their families will therefore focus on determining how patients have experienced their care and what can be done to improve such care, with particular focus on pressure ulcers. Patients and their families will also be questioned regarding the possibility of being educated on repositioning themselves. Indeed, family members can also be enlisted for this task if patients are unable to move themselves and in the case of nursing shortages.

By implementing methods that involve not only nurses and physicians, but also family members and patients themselves, a team of care giving can be created to improve the overall experience of patients along with the reputation of the establishment where they reside and the quality of care they receive.

Evaluation of Implementation Methods: After the Interviews

After the interviews were conducted, a general document will be created containing the results of each interview phase. A copy will be made available to managers, nurses, and patients for their evaluation and comments. Stakeholders will then be approached again to obtain feedback regarding the interview results and to generate a plan of action for implementing the management of pressure ulcers among patients.

Again, the emphasis will be on non-punitive and positive change that will benefit not only patients, but also mangers, caregivers, and the reputation of the establishment in the long-term. Emphasis will also be on the possibility of increased funding that is associated with a better reputation of care in each establishment.

Once the support of staff members and managers is obtained, the implementation phase can begin, along with continuous evaluation efforts. The next step would be to start implementation.

Implementing EBP Projects

As mentioned, the most desired outcome of the EBP projects to improve the repositioning schedule of patients will be the minimization of bed ulcers and a general perception of higher quality care for such patients. After meeting with all the stakeholders to discuss the interview results, evidence will be offered that supports the benefits of two-hourly repositioning to minimize pressure ulcers (Hagisawa and Ferguson-Pell, 2008).

Stakeholders will then be questioned regarding ideas for implementation. It is projected that the most viable implementation method will be a combination of education for patients and family members, with some assistance by primary caregivers. Where family members and patients are able to take considerable responsibility for their own repositioning schedule, nurses can act as supervisors, especially during initial implementation.

Challenges may include methods to remind patients and their caregivers to reposition at specific times of the day, since it is possible to simply forget when two hours have lapsed. A reminder system will therefore need to be implemented in the form of an alarm or other reminder methods. Family members can also be of help in this regard.

It is projected that the implementation of two-hourly repositioning for bedbound patients will decrease morbidity and mortality issues that relate to pressure ulcers. Preventing these wounds will result not only in better quality patient care and safety, but also in significant savings for medical care systems.

The benefits will therefore extend both to patients, care giving establishment managers, and to the public in general, since there is already significant pressure on tax payers for the care of hospital and nursing home residents. The reputation of nurses and care giving establishment will also improve, thus providing a generally better system of care for those who enter these establishments.

Evaluating EBP Projects

The final stage of the investigation, after implementation, will be the evaluation of the project for its effectiveness and its retention among managers, nurses, and patients. The first evaluation strategy will be final interviews with the major stakeholders. These interviews will determine the general attitude of managers, nurses, and patients towards the project, its implementation, and its actual effects as compared with its initially desired and projected effects. This will be followed with a statistical investigation of pressure ulcer prevalence.

Nurses and patients will be questioned regarding these, while hospital records will also be investigated regarding the prevalence of pressure ulcers as compared with the period before implementing the project.

New practice guidelines will include team-based practices. Nurses will be regarded as part of a care giving team that includes managers, physicians, patients, and families. This is projected to remove the burden of care somewhat from nurses while also improving patient safety. As such, the guidelines will include an education drive for patients and their families, who will then be educated to reposition themselves as far as possible. Nurses will act as supervisors, especially during the initial phases. Continual monitoring will form part of the new practice to ensure that the benefits of regular repositioning are maximized.

New standards of care will therefore involve a focus on team work and education. Nurses must regard themselves as part of a larger implementation team. In addition to their fellow nurses, they can also use the expertise of managers and the care of family members as part of their drive to provide patients with optimal care.

Today, nurses should no longer regard themselves as solely responsible for the care of patients. They should also regard themselves as educators and researchers who function as part of a larger system that exists to provide patients with optimal care. Implementing the above program to help patients minimize the mortality and morbidity associated with pressure ulcers will provide patients themselves with a better experience while residing in hospitals and nursing homes. It will also relieve nurses from the day-to-day pressure of their work, while managers will benefit from a better reputation for offering quality care for their residents.