CULTIVATING QUALITY
By Elizabeth Roe, PhD, RN, and Deborah Lou Williams, MA, BSN, RN, CWOCN
Using Evidence-Based Practice to Prevent Hospital-Acquired Pressure Ulcers and Promote Wound Healing A hospital and a nursing education program collaborate to improve skin care.
P
ressure ulcers are an age-old problem and continue to pose a significant challenge to modern health care providers and systems. Consider that approximately 2.5 million patients are treated for pressure ulcers in U.S. health care facilities annually, and almost 60,000 patients die each year from complications of hospital-acquired pressure ulcers.1 A 2011 publication of the Institute for Healthcare Improvement, How-to Guide: Prevent Pressure Ulcers, cites research showing that pressure ulcer prevalence and incidence in acute care settings are approximately 15% and 7%, respectively.2 Surprisingly, accurate, up-to-date estimates of the costs associated with pressure ulcers are not easy to find; costs frequently cited for a decade or more are $70,000 to treat a full-thickness pressure ulcer and $11 billion for the total U.S. expenditure on pressure ulcer treatment.1, 3 In addition to the financial cost and associated morbidity and mortality, there are the multiple human burdens on patients and caretakers, including pain and poorer quality of life—all caused by a condition that is, in many cases, relatively easy and inexpensive to prevent.4 While preventing pressure ulcers has long been a fundamental nursing goal and a high priority for health care institutions, in 2008 the Centers for Medicare and Medicaid Services added a strong financial incentive for hospitals to promote best practices in the prevention and management of skin breakdown when it announced that newly acquired stage 3 and 4 pressure ulcers were among the “reasonably preventable” conditions for whose treatment it would no longer provide reimbursement.5 Likewise the National Quality Forum considers stage 3 and 4 pressure ulcers acquired after admission to a health care facility “serious reportable events,” explicitly linking pressure ulcer development to failure in patient safety and quality of care.6 The European and National Pressure Ulcer Advisory Panels define a pressure ulcer as a “localized [email protected]
injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear.”7 Pressure ulcer prevalence is one of the health quality measures tracked by the National Database of Nursing Quality Indicators, which collects nursing unit–level data on “nurse-sensitive” health care safety and quality measures—that is, measures that are significantly affected by nursing care—in approximately 2,000 hospitals nationwide, making it possible for hospitals to compare their performance with national benchmarks.8, 9 According to the Institute for Healthcare Improvement, “there’s strong evidence to support dramatic reductions in pressure ulcers if hospitals implement proven best practices.”10 However, we know from our own experience that barriers that prevent the full implementation of such programs exist and may present problems for both institutions and providers. And because of the aging of the population, in the future we are likely to see a greater incidence of pressure ulcers among older adults. What follows is a description of a collaborative initiative undertaken by a hospital and a nursing education program to increase the use of evidencebased nursing practice to reduce the incidence of hospital-acquired pressure ulcers and promote wound healing.
OUR INITIATIVE
For the past 16 years, the nursing education program at Saginaw Valley State University (SVSU), a teaching university in rural Michigan with bachelor of science in nursing (BSN), master of science in nursing, and doctor of nursing practice programs, has collaborated with a variety of community health care agencies, primarily nearby hospitals, to promote the use of evidence-based practice (EBP) in clinical settings. McLaren Bay Region Medical Center, an acute care hospital near the university, is one such agency. More AJN ▼ August 2014
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Table 1. Ten Barriers to Utilizing Research in Practice Cited by Staff Nurses at McLaren Bay Region Medical Center Rank
Barrier
1
The amount of information is overwhelming.
2
The relevant literature is not compiled in one place.
3
There is insufficient time on the job to implement new ideas.
4
The nurse does not have time to read research.
5
The nurse does not feel she/he has enough authority to change patient care procedures.
6
The nurse is unaware of the research.
7
Physicians will not cooperate with the implementation.
8
Statistical analyses are not understandable.
9
Other staff are not supportive of the implementation.
10
The nurse feels results are not generalizable to her/his setting.
recently, the hospital and the nursing program have focused their collaboration on implementing best practices to promote pressure ulcer prevention and wound healing. One of us (ER), an SVSU nursing faculty member, has acted as a mentor in a variety of efforts promoting EBP at the hospital and elsewhere11; the second author (DLW), an enterostomal therapist, is responsible for the prevention of pressure ulcers at the hospital. In 2010, we took the first step in the initiative described
on a Likert-like scale from 1 (indicating “to no extent”) to 4 (indicating “to a great extent”) to rate their agreement with each statement. The BARRIERS Scale was selected because of its applicability to clinical nursing and ease of completion. Of the 101 respondents, 43% had a BSN; 43%, an associate’s degree in nursing; 3%, a diploma; and 7%, a bachelor’s degree in another field; four respondents did not answer the question about education. Most of the respondents worked on a medical unit (24%), surgical unit (16%), or critical care unit (20%). Respondents most frequently identified the immense amount of available research information as the greatest barrier to implementing EBP. The items with the highest means were those associated with difficulty in accessing research and in finding time to read and understand it (see Table 1). Based on the survey results, the effort to facilitate the integration of EBP into pressure ulcer prevention and treatment now included education in EBP and active solicitation of questions on skin-related issues. Education on EBP. To increase staff nurses’ knowledge, we developed a basic education module on EBP; the SVSU faculty mentor (ER), assisted by the staff development department at the hospital, approved the module for one contact hour of continuing nursing education and made the module available to staff nurses. The focus of this module was on evaluating research for applicability and quality—that is, did a given research article or group of articles provide enough evidence to warrant a change in practice? More than 150 nurses from nine units participated, and many more have since completed the educational module on the hospital’s intranet. Feedback on the educational module has been very positive.
Important nursing student outcomes include learning the EBP process and understanding the importance of having reliable, up-to-date evidence to support clinical practice. here and conducted a survey of hospital nurses to better understand the barriers they experienced in their efforts to use current research to inform their practice. After discussion with hospital administration and approval by university and hospital institutional review boards, we distributed a survey using the BARRIERS Scale12 to 253 RNs at the hospital; 101 returned the survey (a 40% response rate). The scale consists of 29 items that describe possible barriers to the utilization of research findings in practice; participants respond 62
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Interprofessional skin team. McLaren Bay Region Medical Center first developed an interprofessional skin team eight years ago; the team includes representatives of the departments of nursing, nutrition, physical therapy, and occupational therapy. Four years ago, the SVSU faculty mentor joined the interprofessional skin team to help increase EBP and involve nursing students in skin team activities. She attended the team’s quarterly meetings, provided expertise in EBP, and assisted the skin team in activities including ajnonline.com
Table 2. Completed Evidence-Based Practice Reviews Related to Prevention of Pressure Ulcers and Promotion of Wound Healing Evidence-Based Question
Outcome
For inpatients on medical and critical care units, is the Braden Scale the most reliable and valid method of assessing for risk of pressure ulcers compared with other risk assessment scales?
Confirmed use of the Braden Scale for pressure ulcer risk assessment. Staff education regarding the Braden Scale is included in yearly competencies with an emphasis on the sensory and shear subscales.
What is the optimal Braden Scale score to use to determine that a patient is at risk for pressure ulcers?
Evidence supported a cutoff score of 16. As current policy supported this, no change was made.
For inpatients on medical and critical care units, what is best practice for the frequency of Braden Scale assessment?
Every shift for critical care and every 24 hours for other units.
For patients with sternotomy wounds, does the use of baby shampoo result in fewer infections compared with other cleansing solutions?
No change in policy (use of baby shampoo not supported). Staff education completed.
For patients undergoing surgery, what is the best risk assessment scale for pressure ulcers?
Continued use of the Braden Scale.
For patients undergoing surgery, what is best practice for pressure ulcer prevention?
Staff education regarding additional risk factors for pressure ulcers in the operating room.
For patients in acute care, what is best practice for the treatment of skin tears?
Policy for the treatment of skin tears was developed. Staff educated on policy.
For patients in acute care, what are the evidencebased criteria for the use of wound cultures?
Policy for wound cultures was revised. Staff educated on policy revision.
For patients with wounds, does the use of maggot therapy promote wound healing compared with other methods of wound debridement?
Education provided to staff about the use of maggot therapy.
For adult hospitalized patients, is low albumin a predictor of pressure sore incidence?
Recommendations made to interprofessional group regarding the use of albumin to predict pressure ulcer risk.
For patients with wounds, is photography a valid and reliable way to assess wounds?
Recommendations about the use of photography made to the administration.
What is best practice for pressure ulcer prevention in critical care?
Current pressure ulcer prevention policy was supported. Education of staff reinforced.
For patients in acute care, does the use of reusable bath basins increase risk of infection?
Trial of alternative versus traditional bath basins completed. Staff educated on the use of bath basins.
literature reviews, data collection and analysis, and policy development. Braden Scale reliability. One project the hospital’s interprofessional skin team completed examined the reliability of the Braden Scale. An international systematic review published in 2006 had concluded that, compared with other risk assessment scales, the Braden Scale offers the best balance between sensitivity and specificity and the best risk estimate.13 However, several staff nurses and members of the skin team [email protected]
voiced concern about the reliability of the Braden Scale as used in the hospital, which requires nurses to document the Braden Scale once a day for medical– surgical patients and every 12 hours for critical care patients. How could providers know whether two nurses who assessed the same patient would give that patient the same Braden Scale rating? To answer the question, the faculty mentor designed an interrater reliability study and two nursing supervisors and two SVSU nursing students assisted with data collection. AJN ▼ August 2014
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For 80 patients on medical and surgical units, Braden Scale scores were calculated independently by the staff nurse who cared for each patient and a skin team member. We then used Cohen’s κ—a measure similar to Pearson’s r, a correlation coefficient— to make a statistical comparison of the two sets of scores. Cohen’s κ scores range from -1 to 1, with 1 indicating perfect agreement, 0 indicating no agreement other than what would be expected by chance, and -1 indicating perfect or systematic disagreement. While there has been some difference in professional opinion regarding the interpretation of κ values, particularly in regard to the precise value that should be considered indicative of a minimally acceptable level
The Process of Answering Clinical Questions
Two examples of how evidence-based reviews led to policy changes. For patients in acute care, what is best practice for the treatment of skin tears? Nurses on several hospital units were concerned about both an increasing number of skin tears in patients, primarily in older adults, and a lack of consistency in treatment. A policy review found that no specific policy addressed the treatment of skin tears. Nurses reported a variety of treatments that included the use of different types of cleansing agents, ointments, and dressings. The skin team conducted an evidence-based review and made recommendations on the prevention and treatment of skin tears. This resulted in the development of a policy for skin tears that was approved by the hospital’s practice council. The faculty mentor then educated staff nurses on this policy. Since the implementation of the new policy, a quality assurance review found that nurses were documenting and treating skin tears consistently. For patients in acute care, what are the evidence-based criteria for the use of wound cultures? Nurses on medical and surgical units were concerned about the number of wound cultures being performed on patients for suspected infection and that patients were put on antibiotics before results were received, possibly increasing their lengths of stay. A review of hospital policies revealed no clear criteria on when a wound culture should be performed; the policy addressed only how the culture should be performed. Often the decision to perform a wound culture was based on provider and nurse preference rather than on objective signs and symptoms. The skin team completed an evidence-based practice review and made recommendations on when and how wound cultures should be performed. Hospital administration revised the wound culture policy based on these recommendations, and the faculty mentor educated the staff on the signs and symptoms of wound infection and when and how a wound culture should be performed. 64
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of agreement between raters, it’s generally accepted that κ values from 0.60 to 0.79 indicate “moderate agreement,” values from 0.80 to 0.90 indicate “strong agreement,” and values of 0.91 or greater indicate “almost perfect” agreement.14 For the 80 patients surveyed, all κ values were above the 0.60 threshold, and most indicated strong agreement between raters. The interrater reliability score for the whole Braden Scale (N = 80) was κ = 0.887. The κ values for the six subscales were 0.623 for sensory perception, 0.910 for moisture, 0.851 for activity, 0.852 for mobility, 0.825 for nutrition, and 0.686 for friction and shear. Because the κ values for the sensory perception and friction and shear subscales were acceptable but somewhat lower than the other subscales, we added an education module on the assessment criteria for all the subscales, with a special focus on sensory perception and friction and shear. Nurses must demonstrate knowledge of these criteria in annual competency evaluations. In addition, the education module links the use of the Braden Scale to EBP and the importance of using a welldocumented tool in clinical assessments. Collaborations involving nursing students. As noted above, the initiative described here is one in a longstanding series of collaborations between the nursing education program at SVSU and nearby hospitals and health care agencies, all with a focus on promoting the use of EBP in clinical settings. As part of their coursework, nursing students use an EBP approach to answer clinical questions posed by nurses in participating agencies and then develop recommendations based on their review of the research. Important student outcomes include learning the EBP process and understanding the importance of having reliable, up-to-date evidence to support clinical practice. These collaborative efforts have been very well received by students, staff nurses, and hospital administrators. Over the past five years, the SVSU faculty mentor has worked with nursing students and staff nurses at a variety of agencies to conduct EBP reviews. In each review, nursing students assisted by the faculty mentor provided the agency with a notebook containing the review process, recommendations concerning practice changes, a chart of the research articles used to develop the recommendations, and copies of all the articles. The results of the EBP reviews have been disseminated to agency staff and, as shown in Table 2 (which pertains to SVSU’s collaboration with McLaren Bay Region Medical Center), the recommendations have resulted in changes in practice, policies, and procedures as well as in new education initiatives. (See The Process of Answering Clinical Questions for examples of the process used.) Informal comments from nurses at all ajnonline.com
levels support the notion that these collaborations have sparked greater interest in and knowledge of EBP, better teamwork and collaboration, and an increase in the use of up-to-date patient care practices. At McLaren Bay Region Medical Center, staff nurses have submitted many questions for EBP review to the research council, the committee that oversees research and EBP.
Since the EBP initiative, the prevalence of hospital-acquired pressure ulcers has decreased from 11.6% six years ago to less than 2%. Because of the EBP projects, practice changes have occurred with revision and development of new policies for pressure ulcer prevention and wound healing. In addition, students have been involved in other skin team activities, including staff education and data collection for quarterly pressure ulcer prevalence studies and other skin-related studies. The involvement in this effort has also resulted in other benefits, including increased interprofessional teamwork and increased knowledge of EBP. Since the inception of the interprofessional skin team and the multifaceted EBP initiative, the prevalence of hospital-acquired pressure ulcers at the hospital has decreased from more than 11.6% of patients six years ago (before the implementation of this evidence-based initiative) to less than 2% in the last several years. In the third quarter of 2013, the most recent quarter for which data are available, the prevalence rate was 1.8%. The steep decline in prevalence rate may be due in part to the increased focus— because of the changes in Medicare reimbursement noted above—on the identification of pressure ulcers at hospital admission. This result compares favorably with the findings of the 2011 International Pressure Ulcer Prevalence Survey of 104,266 patients in 932 facilities, which included an acute care facility–acquired prevalence of 4.5%.15 The involvement of students in this initiative has helped them to obtain both scholarly and practical skills in EBP as it relates to pressure ulcers and wound healing, along with collaborative experience and knowledge of patient safety and quality improvement. ▼ [email protected]
Keywords: evidence-based practice, hospitalacquired pressure ulcer, nursing education, pressure ulcer, skin care, wound healing
Elizabeth Roe is professor of nursing at the Crystal M. Lange College of Health and Human Services, Saginaw Valley State University, in University Center, MI, and Deborah Lou Williams is an enterostomal therapist at the McLaren Bay Region Medical Center in Bay City, MI. Contact author: Elizabeth Roe, [email protected]. The authors have disclosed no potential conflicts of interest, financial or otherwise.
REFERENCES 1. Reddy M, et al. Preventing pressure ulcers: a systematic review. JAMA 2006;296(8):974-84. 2. Institute for Healthcare Improvement. How-to guide: prevent pressure ulcers. Cambridge, MA; 2011 Dec. http:// www.ihi.org/resources/Pages/Tools/HowtoGuidePrevent PressureUlcers.aspx. 3. Russo CA, et al. Hospitalizations related to pressure ulcers among adults 18 years and older, 2006. Rockville, MD: Agency for Healthcare Research and Quality, Healthcare Cost and Utilization Project; 2008 Dec. HCUP statistical brief #64; http://www.hcup-us.ahrq.gov/reports/statbriefs/sb64.jsp. 4. Hopkins A, et al. Patient stories of living with a pressure ulcer. J Adv Nurs 2006;56(4):345-53. 5. Centers for Medicare and Medicaid Services. Hospitalaquired conditions (present on admission indicator) 2009/2014. https://www.cms.gov/Medicare/MedicareFee-for-Service-Payment/HospitalAcqCond/index. html?redirect=/hospitalacqcond. 6. National Quality Forum (NQF). Serious reportable events. n.d. http://www.qualityforum.org/Topics/SREs/Serious_ Reportable_Events.aspx. 7. European Pressure Ulcer Advisory Panel and National Pressure Ulcer Advisory Panel. Prevention and treatment of pressure ulcers: quick reference guide. Washington, DC: National Pressure Ulcer Advisory Panel; 2009. http://www. npuap.org/wp-content/uploads/2012/02/Final_Quick_ Prevention_for_web_2010.pdf. 8. American Nurses Association. About NDNQI (National Database of Nursing Quality Indicators). n.d. http://www. nursingquality.org/About-NDNQI/Quality-Data-Solutions #intro. 9. Bergquist-Beringer S, et al. The reliability of the National Database of Nursing Quality Indicators pressure ulcer indicator: a triangulation approach. J Nurs Care Qual 2011; 26(4):292-301. 10. Institute for Healthcare Improvement. Relieve the pressure and reduce harm. 2011. http://www.ihi.org/knowledge/ Pages/ImprovementStories/RelievethePressureandReduceHarm.aspx. 11. Roe EA, Whyte-Marshall M. Mentoring for evidence-based practice: a collaborative approach. J Nurses Staff Dev 2012; 28(4):177-81. 12. Funk SG, et al. BARRIERS: the barriers to research utilization scale. Appl Nurs Res 1991;4(1):39-45. 13. Pancorbo-Hidalgo PL, et al. Risk assessment scales for pressure ulcer prevention: a systematic review. J Adv Nurs 2006; 54(1):94-110. 14. McHugh ML. Interrater reliability: the kappa statistic. Biochem Med (Zagreb) 2012;22(3):276-82. 15. VanGilder C, et al. Overall results from the 2011 International Pressure Ulcer Prevalence Survey. Charlotte, NC: Wound Ostomy and Continence Nursing Conference; 2012.
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By Elizabeth Roe, PhD, RN, and Deborah Lou Williams, MA, BSN, RN, CWOCN
Using Evidence-Based Practice to Prevent Hospital-Acquired Pressure Ulcers and Promote Wound Healing A hospital and a nursing education program collaborate to improve skin care.
P
ressure ulcers are an age-old problem and continue to pose a significant challenge to modern health care providers and systems. Consider that approximately 2.5 million patients are treated for pressure ulcers in U.S. health care facilities annually, and almost 60,000 patients die each year from complications of hospital-acquired pressure ulcers.1 A 2011 publication of the Institute for Healthcare Improvement, How-to Guide: Prevent Pressure Ulcers, cites research showing that pressure ulcer prevalence and incidence in acute care settings are approximately 15% and 7%, respectively.2 Surprisingly, accurate, up-to-date estimates of the costs associated with pressure ulcers are not easy to find; costs frequently cited for a decade or more are $70,000 to treat a full-thickness pressure ulcer and $11 billion for the total U.S. expenditure on pressure ulcer treatment.1, 3 In addition to the financial cost and associated morbidity and mortality, there are the multiple human burdens on patients and caretakers, including pain and poorer quality of life—all caused by a condition that is, in many cases, relatively easy and inexpensive to prevent.4 While preventing pressure ulcers has long been a fundamental nursing goal and a high priority for health care institutions, in 2008 the Centers for Medicare and Medicaid Services added a strong financial incentive for hospitals to promote best practices in the prevention and management of skin breakdown when it announced that newly acquired stage 3 and 4 pressure ulcers were among the “reasonably preventable” conditions for whose treatment it would no longer provide reimbursement.5 Likewise the National Quality Forum considers stage 3 and 4 pressure ulcers acquired after admission to a health care facility “serious reportable events,” explicitly linking pressure ulcer development to failure in patient safety and quality of care.6 The European and National Pressure Ulcer Advisory Panels define a pressure ulcer as a “localized [email protected]
injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear.”7 Pressure ulcer prevalence is one of the health quality measures tracked by the National Database of Nursing Quality Indicators, which collects nursing unit–level data on “nurse-sensitive” health care safety and quality measures—that is, measures that are significantly affected by nursing care—in approximately 2,000 hospitals nationwide, making it possible for hospitals to compare their performance with national benchmarks.8, 9 According to the Institute for Healthcare Improvement, “there’s strong evidence to support dramatic reductions in pressure ulcers if hospitals implement proven best practices.”10 However, we know from our own experience that barriers that prevent the full implementation of such programs exist and may present problems for both institutions and providers. And because of the aging of the population, in the future we are likely to see a greater incidence of pressure ulcers among older adults. What follows is a description of a collaborative initiative undertaken by a hospital and a nursing education program to increase the use of evidencebased nursing practice to reduce the incidence of hospital-acquired pressure ulcers and promote wound healing.
OUR INITIATIVE
For the past 16 years, the nursing education program at Saginaw Valley State University (SVSU), a teaching university in rural Michigan with bachelor of science in nursing (BSN), master of science in nursing, and doctor of nursing practice programs, has collaborated with a variety of community health care agencies, primarily nearby hospitals, to promote the use of evidence-based practice (EBP) in clinical settings. McLaren Bay Region Medical Center, an acute care hospital near the university, is one such agency. More AJN ▼ August 2014
▼
Vol. 114, No. 8
61
CULTIVATING QUALITY
Table 1. Ten Barriers to Utilizing Research in Practice Cited by Staff Nurses at McLaren Bay Region Medical Center Rank
Barrier
1
The amount of information is overwhelming.
2
The relevant literature is not compiled in one place.
3
There is insufficient time on the job to implement new ideas.
4
The nurse does not have time to read research.
5
The nurse does not feel she/he has enough authority to change patient care procedures.
6
The nurse is unaware of the research.
7
Physicians will not cooperate with the implementation.
8
Statistical analyses are not understandable.
9
Other staff are not supportive of the implementation.
10
The nurse feels results are not generalizable to her/his setting.
recently, the hospital and the nursing program have focused their collaboration on implementing best practices to promote pressure ulcer prevention and wound healing. One of us (ER), an SVSU nursing faculty member, has acted as a mentor in a variety of efforts promoting EBP at the hospital and elsewhere11; the second author (DLW), an enterostomal therapist, is responsible for the prevention of pressure ulcers at the hospital. In 2010, we took the first step in the initiative described
on a Likert-like scale from 1 (indicating “to no extent”) to 4 (indicating “to a great extent”) to rate their agreement with each statement. The BARRIERS Scale was selected because of its applicability to clinical nursing and ease of completion. Of the 101 respondents, 43% had a BSN; 43%, an associate’s degree in nursing; 3%, a diploma; and 7%, a bachelor’s degree in another field; four respondents did not answer the question about education. Most of the respondents worked on a medical unit (24%), surgical unit (16%), or critical care unit (20%). Respondents most frequently identified the immense amount of available research information as the greatest barrier to implementing EBP. The items with the highest means were those associated with difficulty in accessing research and in finding time to read and understand it (see Table 1). Based on the survey results, the effort to facilitate the integration of EBP into pressure ulcer prevention and treatment now included education in EBP and active solicitation of questions on skin-related issues. Education on EBP. To increase staff nurses’ knowledge, we developed a basic education module on EBP; the SVSU faculty mentor (ER), assisted by the staff development department at the hospital, approved the module for one contact hour of continuing nursing education and made the module available to staff nurses. The focus of this module was on evaluating research for applicability and quality—that is, did a given research article or group of articles provide enough evidence to warrant a change in practice? More than 150 nurses from nine units participated, and many more have since completed the educational module on the hospital’s intranet. Feedback on the educational module has been very positive.
Important nursing student outcomes include learning the EBP process and understanding the importance of having reliable, up-to-date evidence to support clinical practice. here and conducted a survey of hospital nurses to better understand the barriers they experienced in their efforts to use current research to inform their practice. After discussion with hospital administration and approval by university and hospital institutional review boards, we distributed a survey using the BARRIERS Scale12 to 253 RNs at the hospital; 101 returned the survey (a 40% response rate). The scale consists of 29 items that describe possible barriers to the utilization of research findings in practice; participants respond 62
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Interprofessional skin team. McLaren Bay Region Medical Center first developed an interprofessional skin team eight years ago; the team includes representatives of the departments of nursing, nutrition, physical therapy, and occupational therapy. Four years ago, the SVSU faculty mentor joined the interprofessional skin team to help increase EBP and involve nursing students in skin team activities. She attended the team’s quarterly meetings, provided expertise in EBP, and assisted the skin team in activities including ajnonline.com
Table 2. Completed Evidence-Based Practice Reviews Related to Prevention of Pressure Ulcers and Promotion of Wound Healing Evidence-Based Question
Outcome
For inpatients on medical and critical care units, is the Braden Scale the most reliable and valid method of assessing for risk of pressure ulcers compared with other risk assessment scales?
Confirmed use of the Braden Scale for pressure ulcer risk assessment. Staff education regarding the Braden Scale is included in yearly competencies with an emphasis on the sensory and shear subscales.
What is the optimal Braden Scale score to use to determine that a patient is at risk for pressure ulcers?
Evidence supported a cutoff score of 16. As current policy supported this, no change was made.
For inpatients on medical and critical care units, what is best practice for the frequency of Braden Scale assessment?
Every shift for critical care and every 24 hours for other units.
For patients with sternotomy wounds, does the use of baby shampoo result in fewer infections compared with other cleansing solutions?
No change in policy (use of baby shampoo not supported). Staff education completed.
For patients undergoing surgery, what is the best risk assessment scale for pressure ulcers?
Continued use of the Braden Scale.
For patients undergoing surgery, what is best practice for pressure ulcer prevention?
Staff education regarding additional risk factors for pressure ulcers in the operating room.
For patients in acute care, what is best practice for the treatment of skin tears?
Policy for the treatment of skin tears was developed. Staff educated on policy.
For patients in acute care, what are the evidencebased criteria for the use of wound cultures?
Policy for wound cultures was revised. Staff educated on policy revision.
For patients with wounds, does the use of maggot therapy promote wound healing compared with other methods of wound debridement?
Education provided to staff about the use of maggot therapy.
For adult hospitalized patients, is low albumin a predictor of pressure sore incidence?
Recommendations made to interprofessional group regarding the use of albumin to predict pressure ulcer risk.
For patients with wounds, is photography a valid and reliable way to assess wounds?
Recommendations about the use of photography made to the administration.
What is best practice for pressure ulcer prevention in critical care?
Current pressure ulcer prevention policy was supported. Education of staff reinforced.
For patients in acute care, does the use of reusable bath basins increase risk of infection?
Trial of alternative versus traditional bath basins completed. Staff educated on the use of bath basins.
literature reviews, data collection and analysis, and policy development. Braden Scale reliability. One project the hospital’s interprofessional skin team completed examined the reliability of the Braden Scale. An international systematic review published in 2006 had concluded that, compared with other risk assessment scales, the Braden Scale offers the best balance between sensitivity and specificity and the best risk estimate.13 However, several staff nurses and members of the skin team [email protected]
voiced concern about the reliability of the Braden Scale as used in the hospital, which requires nurses to document the Braden Scale once a day for medical– surgical patients and every 12 hours for critical care patients. How could providers know whether two nurses who assessed the same patient would give that patient the same Braden Scale rating? To answer the question, the faculty mentor designed an interrater reliability study and two nursing supervisors and two SVSU nursing students assisted with data collection. AJN ▼ August 2014
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CULTIVATING QUALITY
For 80 patients on medical and surgical units, Braden Scale scores were calculated independently by the staff nurse who cared for each patient and a skin team member. We then used Cohen’s κ—a measure similar to Pearson’s r, a correlation coefficient— to make a statistical comparison of the two sets of scores. Cohen’s κ scores range from -1 to 1, with 1 indicating perfect agreement, 0 indicating no agreement other than what would be expected by chance, and -1 indicating perfect or systematic disagreement. While there has been some difference in professional opinion regarding the interpretation of κ values, particularly in regard to the precise value that should be considered indicative of a minimally acceptable level
The Process of Answering Clinical Questions
Two examples of how evidence-based reviews led to policy changes. For patients in acute care, what is best practice for the treatment of skin tears? Nurses on several hospital units were concerned about both an increasing number of skin tears in patients, primarily in older adults, and a lack of consistency in treatment. A policy review found that no specific policy addressed the treatment of skin tears. Nurses reported a variety of treatments that included the use of different types of cleansing agents, ointments, and dressings. The skin team conducted an evidence-based review and made recommendations on the prevention and treatment of skin tears. This resulted in the development of a policy for skin tears that was approved by the hospital’s practice council. The faculty mentor then educated staff nurses on this policy. Since the implementation of the new policy, a quality assurance review found that nurses were documenting and treating skin tears consistently. For patients in acute care, what are the evidence-based criteria for the use of wound cultures? Nurses on medical and surgical units were concerned about the number of wound cultures being performed on patients for suspected infection and that patients were put on antibiotics before results were received, possibly increasing their lengths of stay. A review of hospital policies revealed no clear criteria on when a wound culture should be performed; the policy addressed only how the culture should be performed. Often the decision to perform a wound culture was based on provider and nurse preference rather than on objective signs and symptoms. The skin team completed an evidence-based practice review and made recommendations on when and how wound cultures should be performed. Hospital administration revised the wound culture policy based on these recommendations, and the faculty mentor educated the staff on the signs and symptoms of wound infection and when and how a wound culture should be performed. 64
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of agreement between raters, it’s generally accepted that κ values from 0.60 to 0.79 indicate “moderate agreement,” values from 0.80 to 0.90 indicate “strong agreement,” and values of 0.91 or greater indicate “almost perfect” agreement.14 For the 80 patients surveyed, all κ values were above the 0.60 threshold, and most indicated strong agreement between raters. The interrater reliability score for the whole Braden Scale (N = 80) was κ = 0.887. The κ values for the six subscales were 0.623 for sensory perception, 0.910 for moisture, 0.851 for activity, 0.852 for mobility, 0.825 for nutrition, and 0.686 for friction and shear. Because the κ values for the sensory perception and friction and shear subscales were acceptable but somewhat lower than the other subscales, we added an education module on the assessment criteria for all the subscales, with a special focus on sensory perception and friction and shear. Nurses must demonstrate knowledge of these criteria in annual competency evaluations. In addition, the education module links the use of the Braden Scale to EBP and the importance of using a welldocumented tool in clinical assessments. Collaborations involving nursing students. As noted above, the initiative described here is one in a longstanding series of collaborations between the nursing education program at SVSU and nearby hospitals and health care agencies, all with a focus on promoting the use of EBP in clinical settings. As part of their coursework, nursing students use an EBP approach to answer clinical questions posed by nurses in participating agencies and then develop recommendations based on their review of the research. Important student outcomes include learning the EBP process and understanding the importance of having reliable, up-to-date evidence to support clinical practice. These collaborative efforts have been very well received by students, staff nurses, and hospital administrators. Over the past five years, the SVSU faculty mentor has worked with nursing students and staff nurses at a variety of agencies to conduct EBP reviews. In each review, nursing students assisted by the faculty mentor provided the agency with a notebook containing the review process, recommendations concerning practice changes, a chart of the research articles used to develop the recommendations, and copies of all the articles. The results of the EBP reviews have been disseminated to agency staff and, as shown in Table 2 (which pertains to SVSU’s collaboration with McLaren Bay Region Medical Center), the recommendations have resulted in changes in practice, policies, and procedures as well as in new education initiatives. (See The Process of Answering Clinical Questions for examples of the process used.) Informal comments from nurses at all ajnonline.com
levels support the notion that these collaborations have sparked greater interest in and knowledge of EBP, better teamwork and collaboration, and an increase in the use of up-to-date patient care practices. At McLaren Bay Region Medical Center, staff nurses have submitted many questions for EBP review to the research council, the committee that oversees research and EBP.
Since the EBP initiative, the prevalence of hospital-acquired pressure ulcers has decreased from 11.6% six years ago to less than 2%. Because of the EBP projects, practice changes have occurred with revision and development of new policies for pressure ulcer prevention and wound healing. In addition, students have been involved in other skin team activities, including staff education and data collection for quarterly pressure ulcer prevalence studies and other skin-related studies. The involvement in this effort has also resulted in other benefits, including increased interprofessional teamwork and increased knowledge of EBP. Since the inception of the interprofessional skin team and the multifaceted EBP initiative, the prevalence of hospital-acquired pressure ulcers at the hospital has decreased from more than 11.6% of patients six years ago (before the implementation of this evidence-based initiative) to less than 2% in the last several years. In the third quarter of 2013, the most recent quarter for which data are available, the prevalence rate was 1.8%. The steep decline in prevalence rate may be due in part to the increased focus— because of the changes in Medicare reimbursement noted above—on the identification of pressure ulcers at hospital admission. This result compares favorably with the findings of the 2011 International Pressure Ulcer Prevalence Survey of 104,266 patients in 932 facilities, which included an acute care facility–acquired prevalence of 4.5%.15 The involvement of students in this initiative has helped them to obtain both scholarly and practical skills in EBP as it relates to pressure ulcers and wound healing, along with collaborative experience and knowledge of patient safety and quality improvement. ▼ [email protected]
Keywords: evidence-based practice, hospitalacquired pressure ulcer, nursing education, pressure ulcer, skin care, wound healing
Elizabeth Roe is professor of nursing at the Crystal M. Lange College of Health and Human Services, Saginaw Valley State University, in University Center, MI, and Deborah Lou Williams is an enterostomal therapist at the McLaren Bay Region Medical Center in Bay City, MI. Contact author: Elizabeth Roe, [email protected]. The authors have disclosed no potential conflicts of interest, financial or otherwise.
REFERENCES 1. Reddy M, et al. Preventing pressure ulcers: a systematic review. JAMA 2006;296(8):974-84. 2. Institute for Healthcare Improvement. How-to guide: prevent pressure ulcers. Cambridge, MA; 2011 Dec. http:// www.ihi.org/resources/Pages/Tools/HowtoGuidePrevent PressureUlcers.aspx. 3. Russo CA, et al. Hospitalizations related to pressure ulcers among adults 18 years and older, 2006. Rockville, MD: Agency for Healthcare Research and Quality, Healthcare Cost and Utilization Project; 2008 Dec. HCUP statistical brief #64; http://www.hcup-us.ahrq.gov/reports/statbriefs/sb64.jsp. 4. Hopkins A, et al. Patient stories of living with a pressure ulcer. J Adv Nurs 2006;56(4):345-53. 5. Centers for Medicare and Medicaid Services. Hospitalaquired conditions (present on admission indicator) 2009/2014. https://www.cms.gov/Medicare/MedicareFee-for-Service-Payment/HospitalAcqCond/index. html?redirect=/hospitalacqcond. 6. National Quality Forum (NQF). Serious reportable events. n.d. http://www.qualityforum.org/Topics/SREs/Serious_ Reportable_Events.aspx. 7. European Pressure Ulcer Advisory Panel and National Pressure Ulcer Advisory Panel. Prevention and treatment of pressure ulcers: quick reference guide. Washington, DC: National Pressure Ulcer Advisory Panel; 2009. http://www. npuap.org/wp-content/uploads/2012/02/Final_Quick_ Prevention_for_web_2010.pdf. 8. American Nurses Association. About NDNQI (National Database of Nursing Quality Indicators). n.d. http://www. nursingquality.org/About-NDNQI/Quality-Data-Solutions #intro. 9. Bergquist-Beringer S, et al. The reliability of the National Database of Nursing Quality Indicators pressure ulcer indicator: a triangulation approach. J Nurs Care Qual 2011; 26(4):292-301. 10. Institute for Healthcare Improvement. Relieve the pressure and reduce harm. 2011. http://www.ihi.org/knowledge/ Pages/ImprovementStories/RelievethePressureandReduceHarm.aspx. 11. Roe EA, Whyte-Marshall M. Mentoring for evidence-based practice: a collaborative approach. J Nurses Staff Dev 2012; 28(4):177-81. 12. Funk SG, et al. BARRIERS: the barriers to research utilization scale. Appl Nurs Res 1991;4(1):39-45. 13. Pancorbo-Hidalgo PL, et al. Risk assessment scales for pressure ulcer prevention: a systematic review. J Adv Nurs 2006; 54(1):94-110. 14. McHugh ML. Interrater reliability: the kappa statistic. Biochem Med (Zagreb) 2012;22(3):276-82. 15. VanGilder C, et al. Overall results from the 2011 International Pressure Ulcer Prevalence Survey. Charlotte, NC: Wound Ostomy and Continence Nursing Conference; 2012.
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