Hospital Turn Teams and Bedsore Prevention: A Nursing Review

Introduction to Pressure Ulcers

A pressure ulcer (PU), commonly known as a bedsore, can be defined as an injury to the underlying tissue of the skin that occurs due to pressure or friction. In most cases, the injured tissue becomes sore due to pressure exerted over a prominent bone. PUs have also been defined as areas of necrosis resulting from tissue compression between a bony prominence and an external surface over a prolonged period of time (Gray & Krapfl, 2008). It is therefore apparent from these definitions that prolonged exposure to pressure is the primary cause of bedsores.

To prevent or minimize bedsores, it is imperative that medical practitioners put intervention measures in place that will reduce exposure to pressure. The human sensory system is naturally equipped with prompts that enable individuals to reposition themselves automatically from time to time in order to avoid tissue damage. However, immobile patients — and even otherwise healthy individuals confined to bed — are prone to PUs. These circumstances require the intervention of medical practitioners, who can employ a number of preventative measures such as pressure redistribution, alleviation of contributing factors (including moisture and poor nutrition), patient education, reduction of friction, and risk assessment. Frequent patient repositioning, however, has been widely accepted as the most effective method of preventing PUs (Gray & Krapfl, 2008).

To determine how effective repositioning is for patients, this paper seeks to answer the question: does the implementation of a hospital-wide turn team have a positive impact on the reduction of bedsores? A review of five research papers was undertaken to address this question and to determine how frequently repositioning should be performed.

Problem Statement

Patients who are immobile and/or unable to feel pain are largely affected by PUs, whether in hospitals or at home. PUs are also more prevalent in areas with prominent bone structures, such as the pelvis, sacrum, and heels. Consequently, patients who are chair-bound or confined to a side-lying position are most vulnerable to bedsores. There are significant costs and emotional burdens associated with PUs. For instance, the Australian government spends an estimated $350 million annually on PU treatment (Sharp, Burr, Broadbent, Cummins, Casey, & Merriman, 2000). In the United States, the cost of treating PU patients is estimated at $2.2–$3.6 billion annually (Kaitani, Tokunaga, Matsui, & Sananda, 2010). These figures illustrate the enormous scale of the problem.

Moreover, nurses and other medical personnel are expected to deliver quality care and may face legal ramifications if a patient develops a bedsore while hospitalized (Sharp et al., 2000). It therefore becomes mandatory for practitioners to adhere to strict routines and implement proven measures to prevent PU occurrences.

Literature Review

A review of five research papers on the causes and prevention of bedsores, organized using the PICOT framework (Patient problem, Intervention, Comparison, Outcomes), revealed the following.

Patients suffering from PUs are typically bedridden and may be unable to reposition themselves or may lack the sensation of pain. As a result, the supply of oxygen to tissues near areas of bony prominence is impaired by compression. The affected area becomes incapable of healing, ultimately developing into an ulcer. PUs tend to disproportionately affect elderly patients compared to other patient groups (Gray & Krapfl, 2008; Vanderwee et al., 2007; Sharp et al., 2000; Kaitani et al., 2010).

PUs are generally chronic wounds described as debilitating. Studies indicate that the condition affects more than 10% of hospitalized patients and approximately 5% of non-hospitalized patients. The numerous risks associated with PUs include functional disability and, in many cases, elevated mortality rates. Patients' psychological and social well-being are also negatively affected (Gorecki et al., 2009).

Repositioning was identified as the most appropriate intervention to reduce the magnitude of PUs. Despite the costly nature of PU management, the problem is preventable when the right measures and strategies are in place. Government agencies and healthcare organizations have published guidelines for PU control measures, which healthcare organizations are expected to use to help prevent future occurrences. The primary focus is quality improvement (QI) for those already affected and those at risk (Soban, Hempel, & Munjas, 2011).

The projected outcome over a study period of six months is a reduction of PU occurrences by half of current case counts. Although PUs remain a persistent challenge — particularly in developing countries — trained personnel with a thorough understanding of the condition offer hope for improvement. The main barrier to achieving the best outcomes is a shortage of preventive facilities and measures, which are essential to managing this serious problem (Ikechukwu et al., 2012).

Frequent repositioning has proven effective in most cases and remains the leading recommendation for controlling PUs. When repositioning is compared to other preventive measures, repositioning every four hours on a pressure-redistributing surface is found to be more efficient than the commonly prescribed two-hour regime (Krapfl & Gray, 2008).

A list of keywords was identified and searched through electronic databases (PubMed and EBSCO). The keywords used were pressure ulcer(s), reposition, and turning. This search returned 74 research papers, which were further analyzed and narrowed down to five papers that were reviewed independently.

References

Gorecki, C., Brown, J. M., & Andrea, N. E. (2009). Impact of pressure ulcers on quality of life in older patients: A systematic review. Journal of American Geriatrics Society. DOI: 10.1111/j.1532-5415.

Gray, M., & Krapfl, L. A. (2005). Does regular repositioning prevent pressure ulcers? Journal of Wound, Ostomy and Continence Nursing, 35(6), 571–577.

Ikechukwu, E. C., Idowu, O. A., & Anekwe, D. E. (2012). Prevalence and factors associated with healing outcomes of hospital-acquired pressure ulcers among patients with spinal cord injury. Journal of Public Health and Epidemiology, 4(2), 44–47.

Kaitani, T., Tokunaga, K., Matsui, N., & Sananda, H. (2010). Risk factors related to the development of pressure ulcers in the critical care setting. Journal of Clinical Nursing, 19, 414–421.

Krapfl, L. A., & Gray, M. (2008). Does regular repositioning prevent pressure ulcers? Journal of Wound, Ostomy and Continence Nursing, 35(6), 571–577.

Moore, Z., & Cowman, S. (2010). Systematic review of repositioning for the treatment of pressure ulcers. EWMA Journal, 10(1).

Sharp, C., Burr, G., Broadbent, M., Cummins, M., Casey, H., & Merriman, A. (2000). Pressure ulcer prevention and care: A survey of current practice. Journal of Quality in Clinical Practice, 20, 150–157.

Soban, L. M., Hempel, S., & Munjas, B. A. (2011). Preventing pressure ulcers in hospitals: A systematic review of nurse-focused quality improvement interventions. The Joint Commission Journal on Quality and Patient Safety, 37(6).

Vanderwee, K., Grypdonck, M. H. F., De Bacquer, D., & Defloor, T. (2007). Effectiveness of turning with unequal time intervals on the incidence of pressure ulcer lesions. Journal of Advanced Nursing, 57(1), 59–68.