Translating Pressure Ulcer Prevention Into Intensive Care Nursing Practice: Overlaying a Care Bundle Approach With a Model for Research Implementation

Implementation contexts and strategies for alternative peripherally inserted central catheter material and design selection: A qualitative exploration using CFIR/ERIC approach

AIM

To explore the implementation contexts and strategies that influence the uptake and selection of alternative peripherally inserted central catheter (PICC) materials and design.

DESIGN

Qualitative evaluation of end user perspectives within a randomized control trial of different PICC materials and design.

METHODS

Semi-structured interviews with key stakeholders were undertaken via an adapted, rapid-analytic approach using the Consolidated Framework for Implementation Research. Outcomes were mapped against the Expert Recommendations for Implementing Change (ERIC) tool for strategies to guide innovation in PICC practice.

RESULTS

Participants (n = 23) represented a combination of users and inserters/purchasers, from adult and paediatric settings. Dominant themes included intervention characteristics (intervention source), inner setting (structural characteristics) and individuals involved (self-efficacy). Strategies emerging to support a change from ERIC mapping (n = 16) included promotion of intervention adaptability, inclusion of staff and consumer perspectives and sufficient funding. Implementation contexts such as inner setting and individuals involved equally impacted PICC success and implementation effectiveness and enabled a greater understanding of barriers and facilitators to intervention implementation in this trial.

CONCLUSION

Trial evidence is important, but healthcare decision-making requires consideration of local contexts especially resourcing. Implementation contexts for Australian healthcare settings include a practical, strategic toolkit for the implementation of alternative PICC materials and designs.

REPORTING METHOD

This study adhered to COREQ guidelines.

PATIENT OR PUBLIC CONTRIBUTION

No patient or public contribution.

Safety and usability of proning pillows in intensive care: A scoping review

OBJECTIVES

Proning is an established technique for the care of intubated patients with severe respiratory failure. Positioning devices used to support the head and body of patients placed in the prone position are often associated with the formation of pressure injuries. Despite robust literature on the prevention and monitoring of pressure injuries, little is described about the role of proning pillows on pressure injuries. The objective of this review is to understand the extent of evidence pertaining to the safety and usability of different types of proning pillows in the intensive care setting.

REVIEW METHOD

A scoping review of the literature was completed using predefined search terms in three databases and identified 296 articles. An additional 26 were included from reference lists. Twenty studies are included in the analysis; most were published in the past 3 years, with >50% in surgical settings.

DATA SOURCES

Three databases were searched: PubMed, Scopus, and EMBASE.

REVIEW METHODS

The review followed the PRISMA Extension for Scoping Reviews, and data were reviewed using Covidence.

RESULTS

The most prevalent proning pillow is a standard, noncontoured foam head positioner. It is responsible for the majority of facial pressure injuries in all settings of care. Memory foam pillows and helmet-based systems offer improved surface pressure distribution, although their usability in the intensive care setting remains poorly studied. Inflatable air-cell-based devices present an alternative, but the lack of supporting research and the costs may explain their poor uptake. Several articles proposed the use of pressure sensor systems to evaluate devices. We propose a set of ergonomic parametres to consider when choosing or designing a positioning device for proned patients.

CONCLUSION

The evidence pertaining to the safety and usability of proning pillows in the intensive care setting is scarce, which provides opportunities for future research to improve the efficacy in the prevention of pressure injuries and the user experience.

Reduction in the Incidence Density of Pressure Injuries in Intensive Care Units after Advance Preventive Protocols

(1) Background: Patients who are critically ill or undergo major surgery are admitted to intensive care units (ICUs). Prolonged immobilization is the most likely cause of pressure injuries (PrIs) in the ICU. Previous studies of Western populations found that effective protocols could reduce the incidence of PrIs, and the efficacy of systemic targeted intervention protocols in preventing PrIs in the Chinese population needs to be surveyed. (2) Methods: We reviewed cases of PrIs in the ICUs of Taipei Veterans General Hospital from 2014 to 2019. The ICU nurses at the hospital began to implement targeted interventions in January 2017. The incidence density of PrIs was calculated by dividing the number of PrIs by person days of hospitalizations in the pre-bundle (2014-2016) and post-bundle (2017-2019) stages. Poisson regression was performed to compare the trend of incidence densities. (3) Results: The incidence density of PrIs was 9.37/1000 person days during the pre-bundle stage and 1.85/1000 person days during the post-bundle stage (p < 0.001). The relative risk (RR) was 0.197 (95% confidence interval: 0.149-0.26). The incidence densities of iatrogenic PrIs and non-iatrogenic PrIs decreased as the RRs decreased. (4) Conclusions: Targeted interventions could significantly reduce the incidence of PrIs. Healthcare providers must follow the bundle care protocol for PrI prevention to improve the quality of healthcare and promote patient health.

Pressure injury prevention practice in Australian intensive care units: A national cross-sectional survey

INTRODUCTION

Pressure injury (PI) is an ongoing problem for patients in intensive care units (ICUs). The aim of this study was to explore the nature and extent of PI prevention practices in Australian adult ICUs.

MATERIALS AND METHODS

An Australian multicentre, cross-sectional study was conducted via telephone interview using a structured survey instrument comprising six categories: workplace demographics, patient assessment, PI prevention strategies, medical devices, skin hygiene, and other health service strategies. Publicly funded adult ICUs, accredited with the College of Intensive Care Medicine, were surveyed. Data were analysed using descriptive statistics and chi-square tests for independence to explore associations according to geographical location.

RESULTS

Of the 75 eligible ICUs, 70 responded (93% response rate). PI was considered problematic in two-thirds (68%) of all ICUs. Common PI prevention strategies included risk assessment and visual skin assessment conducted within at least 6 h of admission (70% and 73%, respectively), a structured repositioning regimen (90%), use of barrier products to protect the skin (94%), sacrum or heel prophylactic multilayered silicone foam dressings (88%), regular PI chart audits (96%), and PI quality improvement projects (90%). PI prevention rounding and safety huddles were used in 37% of ICUs, and 31% undertook PI research. Although most ICUs were supported by a facility-wide skin integrity service, it was more common in metropolitan ICUs than in rural and regional ICUs (p < 0.001). Conversely, there was greater involvement of occupational therapists in PI prevention in rural or regional ICUs than in metropolitan ICUs (p = 0.026).

DISCUSSION AND CONCLUSION

This is the first study to provide a comprehensive description of PI prevention practices in Australian ICUs. Findings demonstrate that PI prevention practices, although nuanced in some areas to geographical location, are used in multiple and varied ways across ICUs.

Repositioning Practice of Bedridden Patients: An Evolutionary Concept Analysis

Introduction

Repositioning practice is an essential pressure ulcer prevention intervention that has emerged in the history of nursing. Numerous terms are employed to indicate its meaning, such as turning, positioning, or posturing. However, there is no available analysis that distinguishes these terms or analyzes repositioning practice attributes.

Objective

To analyze repositioning practice as a concept of bedridden patients in hospitals by combining methods from Foucault's archeology of knowledge and Rodger's concept analysis.

Concept Description

Repositioning practice passes through three eras: classical, modern, and research. The repositioning practice is “turn a bedridden patient in a harmonized way and ends with anchor and documentation.” The analysis concludes seven attributes for the repositioning practice: pre-turn, assessment, turn, harmonization, anchor, documentation, and time. The analysis assumes bedridden patients, and assigned nurses on duty are the antecedents. Moreover, the main consequence is pressure ulcer prevention, while patient safety and quality of care are the secondary consequences.

Discussion

Repositioning practice understanding has grown with time. Each era has added to or removed from nursing's understanding for repositioning practice until it appears as it now. The current analysis expects further development in repositioning practice understanding and applications.

Conclusion

Repositioning practice is an important nursing intervention and has shown a dynamic movement over history. It is expected that this dynamic will continue in the future.

Implementation and evaluation of multilayered pressure injury prevention strategies in an Australian intensive care unit setting

BACKGROUND

Pressure injuries are a ubiquitous, yet largely preventable, hospital acquired complication commonly seen in critically ill patients in the intensive care unit.

OBJECTIVES

The objectives of this study were to implement targeted evidence-based pressure injury prevention strategies and evaluate their effect through measurement of patient pressure injury observations.

METHODS

A prospective multiphased design was used in the intensive care unit of an Australian tertiary referral hospital using three study periods (period 1, weeks 1-18; period 2, weeks 19-28; and period 3, weeks 29-52). The interventions included staff-focused interventions and patient-focused interventions, with the latter defined in a work unit guideline. Weekly visual observations of critically ill patients' skin integrity were conducted by trained research nurses over 52 weeks from November 2015 to November 2016. The primary outcome measure was a pressure injury of any stage, identified at the weekly observation, and the effect of the intervention was evaluated through logistic regression. Reporting rigour has been demonstrated using the Standards for Quality Improvement Reporting Excellence checklist.

RESULTS

Over the whole study, 15.4% (95% confidence interval [CI] = 12.6, 18.2%, 97/631) of patients developed a pressure injury, with the majority of these injuries (73.2%, 95% CI = 64.4%, 82.0%, 71/97) caused by medical devices. After adjustment for covariates known to influence hospital-acquired pressure injury development, pressure injury rates for period 3 compared with period 1 were reduced (odds ratio = 0.41, 95% CI = 0.20-0.97, p = 0.0126).

CONCLUSIONS

We found the use of defined pressure injury prevention strategies targeted at both staff and patients reduced pressure injury prevalence.

Factors affecting repositioning policy compliance: an integrative review

Objective

To explore the factors affecting nurses’ compliance with repositioning policy.

Methods

An integrative review was conducted following the Whittemore and Knafl methodology to identify the problem related to repositioning policy compliance. We searched the following databases: Coherence Wounds Group Specialized Register (Jan 1997 to Jun 2019), Ovid MEDLINE (Jan 1997 to Jun 2019), EBSCO CINAHL (Jan 1997 to Jun 2019), and Clinical Key database (Jan 2014 to Oct 2018).

Results

The review revealed three factors that influence repositioning compliance: nurse-related factors, patient-related factors, and Environment-related factors.

Conclusions

These factors directly impact one another and, in turn, influence the compliance of nurses to the repositioning policy. However, there is no evidence currently available that explains the collective impact of these factors and how they interact to affect repositioning policy compliance. Nevertheless, all these factors are important and should be considered to enhance and further improve the quality of nursing care and adherence to the repositioning policy.

The Effectiveness of the SKINCARE Bundle in Preventing Medical-Device Related Pressure Injuries in Critical Care Units: A Clinical Trial

OBJECTIVE

To examine the impact of a medical device-related pressure injury (MDRPI) prevention bundle/mnemonic on the incidence of acquired MDRPIs in critically ill patients.

METHODS

This study used a prospective, single-arm, open-label clinical design and was carried out from January to April 2020 in CCUs in a Saudi Arabian tertiary hospital. All participants received the SKINCARE bundle intervention, which is based on the best available evidence for MDRPI prevention in CCUs. The primary outcome was the development of MDRPI.

RESULTS

The MDRPI cumulative incidence was significantly lower after the implementation of the SKINCARE bundle (0.89%, 90% lower than historic incidence).

CONCLUSIONS

The SKINCARE bundle demonstrates significant improvement of skin care through decreased cumulative incidence of acquired MDRPI.

Medical Device-Related Pressure Injuries

Medical device-related pressure injuries result from use of medical devices, equipment, furniture, and everyday objects in direct contact with skin and because of increased external mechanical load leading to soft tissue damage. The resultant pressure injury generally mirrors the pattern or shape of the device. The nurse and clinician must be hypervigilant of increased risk of pressure injuries with the use of these devices. This article provides evidence-based information regarding the most common devices that cause pressure injuries in adults and describes current best evidence-based prevention strategies. Evidence-based prevention strategies are key to minimizing the harm devices can cause.

Moisture associated skin damage (MASD) in intensive care patients: A Norwegian point-prevalence study

BACKGROUND

Critically ill patients are at risk of developing moisture associated skin damage and pressure ulcers. These conditions may co-exist and be difficult to distinguish, but a simultaneous investigation may provide a true prevalence.

OBJECTIVES

To investigate the prevalence of moisture associated skin damage and associated factors among Norwegian intensive care patients.

METHODS

A multi-centre one-day point-prevalence study.

RESULTS

Totally, 112 patients participated in the study. Overall, 15 patients (13%, 15/112) had some type of moisture associated skin damage of which six cases (5%, 6/112) were related to faeces and/or urine (incontinence associated dermatitis). Skin breakdown occurred primarily in the pelvic area. Overall, 87% (97/112) had an indwelling urinary catheter. Stools were reported in 42% (47/112) of the patients on the study day, mostly liquid or semi-liquid. Overall, 11% (12/112) had a faecal management system. Only a few care plans for moisture associated skin damage prevention and care existed.

CONCLUSION

Patients in this study were vulnerable to skin breakdown in the pelvic area. Nevertheless, a low prevalence of skin breakdown existed. This may relate to intensive care nurses' qualifications, the 1:1 nurse-patient staffing, the high prevalence of urinary catheters and few patients having stools.

Preventing pressure ulcers in nursing homes using a care bundle: A feasibility study

Pressure ulcers can be painful and negatively affect health-related quality of life and healthcare costs. Many people living in nursing homes are at risk of developing a pressure ulcer. Nursing home staff, tissue viability nurses and researchers have co-designed the first theory and evidence-informed care bundle specifically for nursing homes, which consists of three prevention practices (skin inspection, support surfaces, repositioning) and a range of behaviour change techniques to promote these practices. We conducted a mixed methods feasibility study of the use of this care bundle in one nursing home in the North of England using an uncontrolled, before-and-after study design. We collected quantitative data on pressure ulcer prevention behaviours of the nursing home staff and pressure ulcer incidence rates for 5 weeks prior to implementing the bundle. Data collection continued for a further 9 weeks during the bundle implementation phase. We explored adherence to the bundle and participants' experiences of using it. The Conceptual Framework for Implementation Fidelity and the Theoretical Domains Framework informed the semi-structured interviews. Quantitative and qualitative data were analysed using descriptive statistics and deductive framework analysis respectively. We collected data for 462 resident bed days prior to implementing the bundle; five new pressure ulcers were recorded and repositioning was the only documented pressure ulcer prevention behaviour. We collected data for 1,181 resident bed days during the intervention phase; no new pressure ulcers developed and the documented prevention behaviours included repositioning, skin inspection and checking support surfaces. Participants reported that the bundle enhanced the care they delivered and offered suggestions for future improvements. Our findings have highlighted a number of feasibility issues surrounding recruitment and retention, collecting data and implementation fidelity. A pressure ulcer prevention bundle specifically designed for nursing homes was acceptable. The feasibility work has highlighted the potential for the intervention and the areas that require development and refinement.

Healthy Skin Wins: A Glowing Pressure Ulcer Prevention Program That Can Guide Evidence-Based Practice

BACKGROUND

In 2013, an observational survey was conducted among 242 in-patients in a community hospital with a pressure ulcer (PU) prevalence of 34.3%. An evidence-based pressure ulcer prevention program (PUPP) was then implemented including a staff awareness campaign entitled "Healthy Skin Wins" with an online tutorial about PU prevention.

AIMS

To determine the effectiveness of the PUPP in reducing the prevalence of PUs, to determine the effectiveness of the online tutorial in increasing hospital staff's knowledge level about PU prevention, and to explore frontline staff's perspectives of the PUPP.

METHODS

This was a mixed methods study. A repeat observational survey discerned if the PUPP reduced PU prevalence. A pre-test post-test design was used to determine whether hospital staff's knowledge of PU prevention was enhanced by the online tutorial. Qualitative interviews were conducted with nurses, allied health professionals, and health care aides to explore staff's perspectives of the PUPP.

RESULTS

A comparison of initial and repeat observational surveys (n = 239) identified a statistically significant reduction in the prevalence of PU to 7.53% (p < .001). The online tutorial enhanced staff knowledge level with a statistically significantly higher mean post-test score (n = 80). Thirty-five frontline staff shared their perspectives of the PUPP with "it's definitely a combination of everything" and "there's a disconnect between what's needed and what's available" as the main themes.

CONCLUSIONS

Incorporating evidence-based PU prevention into clinical practice greatly reduced the prevalence of PUs among hospital in-patients. Due to the small sample size for the pre-test post-test component, the effectiveness of the online tutorial in improving the knowledge level of PU prevention among hospital staff requires further research.

LINKING EVIDENCE TO ACTION

Evidence-based PU prevention strategies are facilitated by using a multidisciplinary approach. Educational tools about PU prevention must target all members of the healthcare team including healthcare aides, patients and families.