Who Is Turning the Patients? A Survey Study

Pressure injury risk assessment and prescription of preventative interventions using a structured tool versus clinical judgement: An interrater agreement study

AIM

To assess agreement of pressure injury risk level and differences in preventative intervention prescription between nurses using a structured risk assessment tool compared with clinical judgement.

DESIGN

Interrater agreement study.

METHODS

Data were collected from November 2019 to December 2022. Paired nurse-assessors were allocated randomly to independently assess pressure injury risk using a structured tool (incorporating the Waterlow Score), or clinical judgement; then prescribe preventative interventions. Assessments were conducted on 150 acute patient participants in a general tertiary hospital. Agreement of risk level was analysed using absolute agreement proportions, weighted kappa and prevalence-adjusted and bias-adjusted kappa.

RESULTS

Ninety-four nurse assessors participated. Absolute agreement of not-at-risk versus at-risk-any-level was substantial, but absolute agreement of risk-level was only fair. Clinical judgement assessors tended to underestimate risk. Where risk level was agreed, prescribed intervention frequencies were similar, although structured tool assessors prescribed more interventions mandated by standard care, while clinical judgement assessors prescribed more additional/optional interventions. Structured tool assessors prescribed more interventions targeted at lower-risk patients, whereas assessors using clinical judgement prescribed more interventions targeted at higher-risk patients.

CONCLUSION

There were clear differences in pressure injury risk-level assessment between nurses using the two methods, with important differences in intervention prescription frequencies found. Further research is required into the use of both structured tools and clinical judgement to assess pressure injury risk, with emphasis on the impact of risk assessments on subsequent preventative intervention implementation.

IMPACT

The results of this study are important for clinical practice as they demonstrate the influence of using a structured pressure injury risk assessment tool compared to clinical judgement. Whilst further research is required into the use of both structured tools and clinical judgement to assess pressure injury risk and prescribe interventions, our findings do not support a change in practice that would exclude the use of a structured pressure injury risk assessment tool.

REPORTING METHOD

This study adhered to the GRRAS reporting guideline.

PATIENT/PUBLIC CONTRIBUTION

No patient or public involvement in this study.

IMPLICATIONS FOR THE PROFESSION AND/OR PATIENT CARE

Educators and researchers can use the findings to guide teaching about pressure injury risk assessment and preventative intervention and to direct future studies. For clinical nurses and patients, a change in clinical practice that would exclude the use of a structured risk assessment tool is not recommended and further work is needed to validate the role of clinical judgement to assess risk and its impact on preventative intervention.

Comparison of pressure injury risk assessment outcomes using a structured assessment tool versus clinical judgement: A systematic review

BACKGROUND

Whilst performing a pressure injury risk assessment is not in itself preventive, risk status identification is critical to inform the judicious implementation of prevention strategies. Risk assessment is mostly undertaken using a structured tool informed by clinical judgement, though there is a perception that use of clinical judgement alone may be sufficient.

OBJECTIVES

Within acute hospital settings, to identify differences in outcomes (risk status, preventive interventions) following nursing assessment of pressure injury risk when using a structured assessment tool compared to clinical judgement.

DESIGN

Systematic review.

DATA SOURCES

EBSCO CINAHL Complete, EBSCO MEDLINE Complete, Scopus, Web of Science, Ovid EMBASE.

METHODS

Primary research relevant to the objectives was eligible for inclusion. Databases were searched in February 2021 (limits: date 2010-2020, English language, adults). Two reviewers undertook the review process, with a third as arbitrator. Appraisal was undertaken using Joanna Briggs Institute critical appraisal tools. Included studies are synthesised narratively. Reporting is in accordance with the PRISMA Statement.

RESULTS

Five moderate to high-quality studies were included. Synthesis was limited by heterogeneity. Several risk assessment tools and methods of clinical judgement were used. Three studies reported pressure injury risk status using both assessment approaches, but in only one did nurses undertake both. Risk status, as identified by each method, varied and was sometimes contradictory. Three studies reported some elements of preventive intervention prescription and/or implementation following risk assessment, but comparison between approaches was limited.

CONCLUSIONS

Some research suggests that risk status varies across different methods of pressure injury risk assessment, but it is unclear what impact this has on preventive intervention use. Risk status was not well linked to preventive interventions. Research is warranted to examine the influence that each approach to risk assessment alone and combined has on identified risk and preventive intervention prescription and implementation.

REGISTRATION

A protocol was prospectively registered with PROSPERO (CRD42021224747).

Effect of interface pressure and skin surface temperature on pressure injury incidence: a turning schedule pilot study

OBJECTIVE

This study aimed to evaluate the interface pressure and skin surface temperature in relation to the incidence of pressure injury (PI) using three different turning schedules.

METHOD

This was a pilot study with a three-armed randomised clinical trial design. Participants at risk of PI and treated in the high dependency care unit in a regional hospital in Makassar, Indonesia participated in this study. Patients were repositioned at three different turning schedules (two-, three- and four-hourly intervals). Interface pressure measurement and skin surface temperature were measured between 14:00 and 18:00 every three days. The incidence of PI was assessed during the two-week observation period.

RESULTS

A total of 44 participants took part in the study. A one-way ANOVA test revealed no difference in interface pressure among the three different turning schedule groups within two weeks of observations: day zero, p=0.56; day four, p=0.95; day seven, p=0.56; day 10, p=0.63; and day 14, p=0.92. Although the average periumbilical temperature and skin surface temperature were not significant (p>0.05), comparison between these observation sites was significant on all observation days (p<0.05). Regarding the incidence of PI, the proportional hazard test for the development of PI in the three groups was considered not different (hazard ratio: 1.46, 95% confidence interval: 0.43-4.87, p=0.54).

CONCLUSION

No difference in interface pressure and incidence of PI on the three turning schedules was observed; however, there was a potential increase in skin surface temperature in comparison with periumbilical temperature for all three turning schedules.

Pilot study: Assessing the effect of continual position monitoring technology on compliance with patient turning protocols

Aim

The study aim was to evaluate if continual patient position monitoring, taking into account self‐turns and clinician‐assisted turns, would increase the percentage of time a patient's position changed at least every 2 hr.

Background

While patient turning has clinical benefits, current models to help staff remember to turn patients, such as “turn clocks” and timers, have not resulted in high compliance with turning protocols. In addition, reminders are based on arbitrary 2‐hr windows (such as turning on “even” hours) rather than on individual patient activity, including self‐turns.

Design

This is a first inpatient, non‐randomized, pre‐/postintervention study.

Methods

Data collection occurred from May 2013–February 2014 on a 39‐bed medical unit in a community hospital. Baseline patient turning data were recorded by a sensor; however, the patient data were not displayed at the nurses’ station to establish compliance with the hospital's turning protocol. Postintervention, patient position information was wirelessly displayed on nurses’ station computer monitors in real time. A Student t test was used to compare baseline to postintervention “mean time in compliance.”

Results

Data from 138 patients (N = 7,854 hr of monitoring) were collected. The baseline phase yielded 4,322 hr of position monitoring data and the postintervention phase yielded 3,532 hr of data. Statistically significant improvement was demonstrated in the percentage of time a patient's position changed at least every 2 hr from baseline to postintervention.

Reducing Pressure Injury Incidence Using a Turn Team Assignment: Analysis of a Quality Improvement Project

PURPOSE

The purpose of this study was to analyze outcomes of a quality improvement project that evaluated a turning intervention for prevention of facility-acquired pressure injuries.

DESIGN

A descriptive correlational study design examined the effectiveness of using a "turn team assignment" on pressure injury incidence and staff perceptions.

SUBJECTS AND SETTING

The study sample comprised RNs and patient care associates assigned to provide care for patients admitted on the first or any subsequent day of hospitalization to a surgical intensive care unit at a Midwest inner-city teaching hospital.

METHODS

Direct observation by expert clinicians occurred in 2-hour increments over a 14-day period using an 11-item, unit-designed process improvement tool. We collected information regarding cueing, concurrent turning, independent turning in lieu of the cue, staff support, and possible barriers to turning and repositioning. Staff perceptions were collected using an online tool via survey. The survey utilized a 14-item questionnaire, and a 5-point Likert Scale to identify staff perceptions and beliefs about the turn team intervention. Pressure injury occurrences were measured using data from our monthly prevalence study.

RESULTS

Pressure injury occurrences declined from 24.9% to 16.8% over the data collection period. There was a strong positive correlation between verbal cueing and turning (r = 0.815; P < .05). Staff perceptions supported preintervention education (64.3%) and cueing (93%; 78%) as effective interventions in completing patient turning.

CONCLUSIONS

Findings suggest that turn team assignments using verbal cueing are an effective intervention that decreases pressure injury occurrence. This intervention required no increase in staffing personnel, making this type of intervention reasonable and effective in improving frequency of repositioning and decreasing pressure injury prevalence rates.

Nursing staff induced repositionings and immobile patients' spontaneous movements in nursing care

The aim of this study was to investigate nursing staff induced repositionings and the patients' spontaneous movements during the day and night among older immobile patients in nursing care. Furthermore, the aim was to identify factors associated with the nursing staff induced repositionings and the patients' spontaneous movement frequency. An observational cross-sectional design was used. Spontaneous movements among patients (n = 52) were registered continuously using the MovinSense monitoring system. The nursing staff documented each time they repositioned the patient. Patients spontaneous movements were compared with nursing staff induced repositionings. There were large variations in the patients' spontaneous repositioning frequency during both days and nights, which shows that, although immobilised, some patients frequently reposition themselves. Analgesics were positively related to the movement frequency and psycholeptics were negatively related. The nursing staff more often repositioned the patients who were assessed as high risk than those assessed as low risk, but the patients' spontaneous movement frequency was not correlated to the risk score. This may be important when planning repositioning schedules. A monitoring system may be useful in decision making with regard to planning repositioning and positions used in the prevention of pressure ulcers among elderly immobile patients.

The Effects of Different Lying Positions on Interface Pressure, Skin Temperature, and Tissue Blood Flow in Nursing Home Residents

Background:

Although repositioning is considered an important intervention to prevent pressure ulcers, tissue response during loading in different lying positions has not been adequately explored.

Aim:

To compare the effects of different lying positions on interface pressure, skin temperature, and tissue blood flow in nursing home residents.

Method:

From May 2011 to August 2012, interface pressure, skin temperature, and blood flow at three tissue depths were measured for 1 hr over the sacrum in 30° supine tilt and 0° supine positions and over the trochanter major in 30° lateral and 90° lateral positions in 25 residents aged 65 years or older. Measurement of interface pressure was accomplished using a pneumatic pressure transmitter connected to a digital manometer, skin temperature using a temperature sensor, and blood flow using photoplethysmography and laser Doppler flowmetry.

Results:

Interface pressure was significantly higher in the 0° supine and 90° lateral positions than in 30° supine tilt and 30° lateral positions. The mean skin temperature increased from baseline in all positions. Blood flow was significantly higher in the 30° supine tilt position compared to the other positions. A hyperemic response in the post pressure period was seen at almost all tissue depths and positions.

Conclusion:

The 30° supine tilt position generated less interface pressure and allowed greater tissue perfusion, suggesting that this position is the most beneficial.