Impact of implementing clinical practice guidelines to prevent pressure ulcers - Literature review Example

? Pressure Ulcer: Impact of Implementing Clinical Practice Guidelines Number] Pressure Ulcer: Impact of Implementing Clinical Practice Guidelines Introduction Over the years, researches and similar works have recognised the ill effects of extended immobility. In fact, Clavet, et al. (2008) found that immobility leads to skeletal degeneration, while Smorawinski, et al. (2001) found that immobility causes oxygenation problem. In addition, Paddon-Jones, et al. (2004) revealed that patients who stay bedridden for a long period of time experience loss of muscle mass, the severity of which depends on the length of immobility. Still, among the most adverse effects of immobility is the development of pressure or decubitus ulcers. Pressure ulcers are usually caused by the shearing effects of friction against the skin surface constantly in contact with the bed or mattress. They are a major concern for healthcare professionals because of their impact on the patient, the costs and challenges they present to the healthcare delivery system, and because of their prevalence and severity. Indeed, in the United States alone, around one million individuals develop pressure ulcers. Bedsores are also most commonly found in elderly individuals, both in hospitals and nursing homes or similar institutions. According to Park-Lee and Caffrey (2009), 11 percent of nursing home residents (or 159,000 patients) developed pressure ulcers in 2004. Patients who are around 64 years of age are more prone to developing pressure ulcers, the most common of which is Stage 2 bedsores. Moreover, in terms of severity, the same authors noted that pressure ulcers have been observed as the direct cause of death in around eight percent of paraplegic patients. Finally for the United States, Cuddigan, Berlowitz and Ayello (2001) revealed that around 60% of quadriplegics, 25% of nursing home residents, and 10% if all hospital patients all develop bedsores. In the United Kingdom (UK), Clark, et al. (2004) found that one in five admitted hospital patients has, or is developing, a pressure ulcer. This statistic translates to around 20,000 inpatients in the UK at any given time. As for residential settings, although not much documentation is available, patients are constantly referred to the healthcare system for solutions or interventions. Moreover, around 400,000 patients develop a new bedsore every year in the United Kingdom. This high prevalence of pressure ulcers has also been observed in hospitals and other settings in Ireland. In the study by Gallagher, et al. (2008), the authors found that in three university teaching hospitals, around 18.5% of patients have developed pressure ulcers. Of these, 77% are hospital-acquired, and 49% are grade one. Also, in another study by Moore and Cowman (2011), it was revealed that in the Republic of Ireland, the prevalence rate of pressure ulcers is nine percent. Although relatively low, this percentage is made complicated by the fact that the greatest percentage of the documented cases are grade two sores (33%), mainly located on the heel (25%) and on the sacrum (58%). Also, around 53% of the study’s respondents were completely immobile or had very limited mobility. Other than the risk posed by its prevalence, pressure ulcers also present challenges to the individual and the community. For the patient and his/her family, much pain and discomfort is caused by the presence of pressure ulcers. Indeed, according to the Institute of Medicine (2001), pressure ulcers hamper the patient’s recovery, as well as cause unnecessary strain on the caregiver. For the community, pressure ulcers also present challenges in terms of costs. In terms of costs, pressure ulcers drain a lot of financial resources for the healthcare sector. In the US, for example, around $1 billion was used in 2004 for the treatment of pressure ulcers. Similarly, in the UK, the NHS spends around ?1.8-2.6 billion on hospitalisations and treatments involving pressure ulcers or bedsores (Hampton, 2008). Given these problems related to pressure ulcers, several guidelines have been implemented around the globe to prevent and treat bedsores. However, as much as these guidelines exist, they cannot really be labelled as effective unless their impacts are assessed. Thus, the degree by which these guidelines affect the prevalence and treatment of pressure ulcer is a significant avenue for inquiry. Determining which interventions or standards really work can greatly help in improving the patients’ quality of life, as well as in decreasing the costs and health challenges related to pressure ulcers. In relation, this paper will then explore different implementing clinical guidelines for pressure ulcer prevention and treatment, as well as the impacts of these guidelines. This paper will first present the search strategy employed in finding the literatures reviewed. Then, the aetiology of pressure ulcers will be discussed, followed by the common themes arising from the studies analysed. Afterwards, a presentation of the background of the studies will be given, to be followed by the actual discussion of the findings. In addition, this paper will also present some of the methodological issues of the studies reviewed. Finally, a summary of the data presented in this paper will be provided. Search Strategy Relevant literatures to be reviewed for this paper were chosen with the aid of certain search terms. These search terms include: pressure ulcer, bedsore, decubitus ulcer, pressure ulcer prevalence, implementing guidelines, effect/impact of pressure ulcer guidelines, and numerous others. In the discussion of the aetiology of pressure ulcers, other search terms were also used such as aetiology or pathophysiology of pressure ulcers. Initially, the Yahoo! and Google search engines were used to look for possible articles to be reviewed, but Google was then later used as the complementary search engine for the various journal databases. Certain limitations were also used in the search for the articles. These limitations include the following: (a) the articles should be published in English, (b) they should be scholarly articles published in peer-reviewed journals or similar documents, (c) the study participants involved adults, (d) they must be current, so they should have been published between 2001 and 2012, and numerous other criteria. More importantly, the following databases were used for the search of the studies to be reviewed: Medline, CINAHL Plus, Pubmed, Ovid, Proquest, and others. Although thousands of articles came out the search, twelve articles were chosen for the review, since they met the limitations, and they most discussed the subject of this review. Table 1 below presents a summary of the outcomes of the searches in the different databases. Table 1. Outcomes of Database Search (Number of Article/Sources) Keyword Medline CINAHL Pubmed Ovid Proquest Pressure ulcer 484 1788 12298 3612 1559 Bedsore/decubitus ulcer 51 24 11352 326 202 pressure ulcer prevalence 19 50 1915 231 103 Pressure ulcer implementing guidelines 15 29 27 1632 96 Implementing guidelines Ireland 1 2 0 2 0 effect/ impact of pressure ulcer guidelines 28 9 37 168 2305 Aetiology of Pressure Ulcers A pressure ulcer begins from the first word of its label, “pressure”. According to the World Health Organisation (2008), a pressure ulcer is a lesion on any skin surface that develops as a result of constant pressure; it may include necrotic, broken, and blistered skin, as well as reactivity hyperaemia. Usually observed in bony prominences, pressure ulcers most commonly begin with some deep tissue damage that gradually rises to involve the more superficial layers of the skin (Hampton, 2008). Pressure ulcers develop through several processes, the most common of which involves the combined effects of shearing pressure and occlusion of blood vessels supplying the ulcerated area. Blood vessel occlusion occurs as a result of the direct outside pressure of the patient’s weight, while shearing of the skin surfaces is caused by the friction and pressure between the patient’s skin and the mattress, which can cause endothelial injury to the area’s microcirculation and arterioles (Sheerin and Gillick, 2004). Depending on certain factors, the extent of damage to the ulcerated area can become severe, and may involve or expose even the bones. The processes described earlier all combine to create the pressure ulcer, but the amount of pressure applied on the surface, as well as the length of time the pressure is applied can make the progression of the pressure ulcer faster. In fact, Park-Lee and Caffrey (2009) mentioned that the extent of bedsore damage is directly proportional to the time duration the body part was placed under pressure. This sustained or prolonged application of pressure then reduces local blood flow, which is made more complicated by injuries to the endothelium, as well as high levels of carbon dioxide in the area. Ironically, though, suddenly relieving the pressure increases the blood flow to the area by 30%, causing a bright red flush in the skin, and this reperfusion then causes the release of free radicals, resulting to more tissue damage in the affected area (Sheerin and Gillick, 2004). The severity or stage of a pressure ulcer is based on the characteristics of the erythema, as well as the degree of tissue damage involved. In Stage 1, there is a persistent redness in the skin, although no break in the skin is observed yet. In Stage 2, partial thickness of the skin is lost and the wound may appear as some shallow crater, blister, or abrasion. In Stage 3, the subcutaneous tissues are exposed, and the full thickness of the skin is gone, with an observable deep crater. Finally, in Stage 4, the patient has lost the full thickness of both the skin and subcutaneous tissues, which exposes the bone or the muscle (Park-Lee and Caffrey, 2009). Themes In looking at the different literatures chosen for this paper, certain themes have been observed. After thematic analysis, four main themes have been extracted from the twelve studies chosen for the review. First, the studies agree that there is a need for a more heightened implementation of the guidelines for pressure ulcer prevention and care. This theme is otherwise more commonly recognised by the scientific world as the “theory-practice gap”, wherein as much as clinical implementing guidelines exist to direct healthcare professionals, they are not necessarily followed or implemented. Also, another significant theme is the need for a standardisation of the different implementing guidelines for pressure ulcer care. Indeed, as much as there are guidelines to help the healthcare provider, some are contradictory, while others were based on evidences that were already obsolete. Some guidelines are also ambiguous in terms of the procedures that should be followed, the positions the patient should be placed in, or even the frequency and intervals of repositioning and log-rolling. In relation to this, another theme that surfaced from the literatures is the need for more evidence-based practice, especially in terms of pressure ulcer prevention, as well as several other interventions for pressure ulcer reduction. This theme was observed in relation to the earlier theme that there is a need for a more intensified implementation of the guidelines for pressure ulcer prevention and care. Still, perhaps the most significant theme derived from the researches is that the nurses’ knowledge, beliefs, and perceptions regarding pressure ulcer and pressure ulcer care affects the degree by which clinical guidelines are implemented or followed. Background Different guidelines exist for the care and prevention of pressure ulcers. One such example is the guideline provided by the Occupational Safety and Health Administration of the United States Department of Labor. This guideline provides some standards of practice for nursing homes for the prevention of musculoskeletal disorders, especially pressure ulcers (Occupational Safety and Health Administration (OSHA), 2009). Still, for European countries, the European Pressure Ulcer Advisory Panel (EPUAP) screens, reviews, and releases guidelines for practice. In an article published in the Journal of Wound Care, the EPUAP summarised international guidelines for pressure ulcer care and prevention. A common theme in all these guidelines is that organisations around the globe is the use of repositioning and log-rolling, as well as appropriate wound care once the ulcer has developed. Different organisations are also aiming for better access to care, as well as more funding for pressure ulcer prevention programs. More importantly, the various organisations around the globe also revealed that guidelines should also involve education, and they also recognised the importance of developing a unified international guideline for pressure ulcer care and prevention (European Pressure Ulcer Advisory Panel (EPUAP), 2008). All of these standards or guidelines were mentioned or analysed in the articles chosen for review. Of the twelve articles chosen, two articles compared current international guidelines for pressure ulcer care (Wimpenny and Zelm, 2007; Milne and Houle, 2002). By looking comparing these guidelines, the authors were able to reveal the impacts of the different guidelines in relation to one another. Also, five of the chosen articles explored the degree of implementation of the different guidelines for practice, or the translation of theory into practice: Richens, Rycroft-Malone and Morrell (2004) studied the process of getting guidelines into practice; Xakellis, Frantz, Lewis and Harvey (2001) also explored the difficulty of translating guidelines into practice; Moore (2010) discussed the theory-practice gap in ulcer prevention; Gethin, McIntosh and Cundell (2011) analysed the dissemination of guidelines on wound management in Ireland; and finally, O’Brien and Cowman (2011) studied the documentation of pressure care in Ireland. Moreover, two articles explored the nurses’ knowledge, perceptions, and beliefs on pressure ulcer, as well as pressure ulcer prevention and care (Barrett, Cassidy and Graham, 2009; Moore and Price, 2004). The other two articles explored different guidelines that were most effective in preventing and caring for pressure ulcer. Reddy, Gill and Rochon (2006) analysed the most effective interventions for preventing pressure ulcers, while Thomas (2001) explored which interventions work in preventing and treating pressure ulcers. Finally, the last article, authored by Saliba, et al. (2003), looked into the adherence to guidelines on pressure ulcer prevention in nursing homes. Discussion Theory-Practice Gap: Need for more Heightened Guideline Implementation One of the most prominent issues realised from the different sources analysed is that there is a gap between the practice of nurses and the guidelines for pressure ulcer prevention and care. Indeed, in the study by Saliba, et al. (2003), they found that in the study population of 834 healthcare providers, it was only in around 41% of instances involving pressure ulcer that guidelines were followed. The authors concluded that the nursing homes’ overall adherence to guidelines involving pressure ulcer prevention and treatment is relatively low and needs improvement. Moore (2010) agreed with Saliba, et al. (2003), wherein she discussed that numerous guidelines are available for the prevention of pressure ulcers but their prevalence remains high, especially for the cases which could have been prevented. According to the same author, education plays a significant role in the care for decubitus ulcers, and it must therefore be included in the guidelines. Still, Moore (2010) added that education is not really the sole factor to be considered, but rather, the effectivity of a clinical guideline can be most influenced by the health care workers’ commitment to quality and improvement. She even highlighted that this commitment can be the reason why despite good knowledge on decubitus ulcers, these are not always incorporated into the nurse’s practice. Richens, et al. (2004) agreed with the previous authors and looked into the possible factors affecting successful incorporation of guidelines into practice. According to these authors, putting evidence into practice is a messy and complex affair that involves multifaceted approaches. Xakellis, et al. (2001) supported the claims of Richens, et al. (2004), wherein these authors found that translating pressure ulcer guidelines into practice is a lot more difficult than it seems. Their study looked into a total of 203 patients over a period of three, non-consecutive years (1994, 1995, and 1997), and they found that implementation of pressure ulcer guidelines yielded mixed results, and little to no cost benefits have been truly observed during the three years of observation. Still, another reason that a gap exists between practice and theory could be in the fact that implementing guidelines are not disseminated properly. Indeed, in a study conducted by Gethin, McIntosh and Cundell (2011) among 130 members of the Wound management Association of Ireland (WMAI), they found that only around 50% of the participants who responded (70 out of 130) had “heard” of, or studied, the wound management guidelines for pressure ulcers. Also, only a few percent of the respondents (17%) had given presentations regarding the guidelines. Thus, this low number of individuals disseminating the guidelines can reflect a low impact for the guidelines, since they cannot really exert any effect unless they are disseminated. In addition, another possible reason for the gap between the guidelines (theory) and its implementation (practice) is the lack of documentation of the care for pressure ulcers provided by nurses. In the study by O’Brien and Cowman (2011), this documentation of the care plan for pressure ulcers was explored among large teaching hospitals in Ireland. The authors found that around 47% of the patients being cared for were at high risk of developing pressure ulcers, but only 45% of the charts had some evidence of documentation of the care plan. The authors concluded that the documentation of the care for pressure ulcers is in need of a lot of improvements. Need for Standardisation of Implementing Guidelines for Pressure Ulcer Care Another theme that was extracted from the literatures reviewed is the need for standardised and universal implementing guidelines for pressure ulcer care and prevention. Today, almost all health organizations have released their own standards or guidelines for the care of pressure ulcers. Although these guidelines are based on studies and similar evidences, they do not necessarily guarantee that one guideline is more accurate than the other. Indeed, in the study by O’Brien and Cowman (2011), they found that one of the reasons that the documentation of care was not effective was the fact that the guidelines for pressure ulcer care documentation were not standardized. In fact, in their study, Wimpenny and van Zelm (2007) agreed that not all guidelines are the same or equal. By looking at four national pressure ulcer guidelines in different countries, these authors found that some noteworthy shortcomings were present in all the guidelines, requiring a greater response in order to address these shortcomings and to guarantee quality care. In relation, Milne and Houle (2002) agreed with these previous authors that there are too varied and numerous guidelines for pressure ulcer prevention and care. Thus, they attempted to summarize the most common and recent developments in the care for wounds, including pressure ulcers. Similarly, the study by Reddy, et al. 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