Pressure Ulcers Risk Management - Research Proposal Example

 Introduction:   Pressure Ulcers are also called bedsores or decubitus ulcer. It is caused by breaking down of skin of an area due to staying in one position for too long and not shifting weight. Due to constant pressure on a particular area the blood supply to that area is reduced and the tissues die. It normally begins as redness of the skin and then forma a blister and later an open sore. Finally it becomes a crater. Areas where the bones are close to the skin are most likely places to develop these ulcers. Patients on wheel chair or bedridden, either temporarily or permanently, are at risk of developing pressure ulcers. Apart from being static in a position there are some other reasons responsible for this like fragility of skin, chronic problems like diabetes, lack of nourishment, mental disability, incontinence or old age. Pressure ulcer management has definitely changed dramatically over the last 3 decades or so. Earlier, pressure ulcers did not receive much attention and they were treated with betadine, maalox, heat lamps and there were no low air loss beds. After the works of Braden and Bergstrom, pressure ulcers began to receive the attention deserved. Still lot of work is yet to be done to get the word out. That is why this project needs to be taken up. In year 2000-2002, there were 474,692 new cases of pressure ulcer( Patient safety in American Hospitals, Health Grades 2004) it is about 0.17% incidence rate. Out of this 13.13% of pressure ulcer cases resulted in death. 34,320 deaths due to pressure ulcer were attributable to patient safety. It also has a cost factor to it. In the year 200-2002 in US, $2,574.02 million were spent to treat pressure ulcers. At the same time $2.57 were spent to prevent pressure ulcer. (WD) Regulatory issues Regulatory agencies such as CMS, JCAHO & the State Departments of Health consider pressure ulcers to be preventable and so nosocomial pressure ulcers are the fault of the facility or agency in which they occur. Nursing Homes receive citations, fines and even criminal charges for these types of wounds. Patients sue facilities and nurses and win. This is such a hot topic that all the agencies that deal with this problem are busy updating information, preventative measures and heightened awareness. If a streamlined process can be developed that addresses education and a nursing focused approach, perhaps we will see a drop in pressure ulcers. The National Pressure Ulcer Advisor Panel (NPUAP) has recently (Feb 2007) released some updates. The staging system was updated to both clarify the four stages AND name deep tissue injury into the staging system. They have also added the definition of pressure redistribution to replace the old pressure reduction and pressure relief definitions. This was mainly due to new findings associated with shearing injuries. CMS is changing reimbursement on nosocomial pressure ulcers. Basically, CMS will reimburse to acute care facilities for pressure ulcers if the patient was admitted with the pressure ulcer, but if it is a nosocomial pressure ulcer then CMS will not pay. JCAHO has added pressure ulcers to the 2008 National Patient Safety Goal list for long term care:- “Goal 14 Prevent health care-associated pressure ulcers (decubitus ulcers). 14A Assess and periodically reassess each resident’s risk for developing a pressure ulcer (decubitus ulcer) and take action to address any identified risks.” Braden scale Braden Scale is a clinically validated tool used in the medical profession to get a reliable score of the risk level for developing pressure ulcers in a patient. With its help even those nurses who do not have uniform level of experience and capacity of judgment, can have consistency in identifying the risk level of the patient. This also helps them to monitor their patient care in a busy schedule. It also helps them to pay appropriate attention to the six specific risk factors. These factors are sensory perception, moisture, levels of activity, mobility, nutrition, friction and shear. All these factors are evaluated at 3-4 levels and a weighted value is achieved. By adding up all the factor scores we get a total score that indicates the risk level. The lower the score, it indicates higher risk level. 15-18 is risk level, 13-14 is moderate risk, 10-12 is high risk. 9-or less is very high risk. It is said that Braden scale needs to be used with clinical judgment for correct interpretation. If a patient has undergone surgery he may show very low scores but if he is young and is expected to recover fast, he may not need intervention for preventing pressure ulcer. At the same time a very old patient may have other factors that are not covered by the Braden scale like low blood pressure, high body temperature and poor nutrition level. The guideline of AHCPR clinical practice recommends to do initial pressure ulcer risk assessment at the time of admission and then at periodic intervals. The reassessment intervals depend upon the condition of the patient and also on the changes in his condition for good or for bad. According to the research done by Bergstrom and Braden, 80% of the ulcers develop within 2 weeks of admission and 96% within 3 weeks of admission. Reassessment must be done every 48 hours. In long term care it can be done on a weekly basis and gradually reduced to monthly and then to quarterly and so on.   Once the nurse completes the assessment process using the Braden Scale, the next step is to develop a plan of care that addresses any area in which the patient scores low. For example, if a patient is incontinent of urine and the bed linen has to be changed at least once a shift, then a score of 2 is given in the area for moisture and the nurse would provide interventions such as a moisture barrier cream to protect the skin. If the patient has a problem with sensory perception, such as in diabetic neuropathy and has limited ability to feel pain over most of the body, then a score of 1 is given. The nursing intervention needs to include some preventative measure to address this. If the issue is peripheral vascular disease, then heels need to be floated off the bed to completely eliminate risk for heel ulcers. Each parameter includes a descriptor so that the nurse should be able to score each patient. Problem Identification Not many people are quite aware about the Braden Scale or how it is used as proven time and time again in medical records. The problems common in medical practice are : Braden Scale not completed, Braden Scale completed but not correct, Braden Scale completed but no plan of care, Braden Scale completed on admission but if patient's condition changes, there is no update. All of these cases result in pressure ulcer. This can lead to devastating consequences for patients and for the health care providers also. In the context of new regulatory issues it has become even more important to control it. That is why a massive education process to nurses could be helpful. The practice guideline has made specific recommendations for identifying and intervening to prevent pressure ulcers in adult patients. It believes that the ulcers can be prevented in most of the cases. In some cases where it can not be prevented, intensive therapy must be administered to reduce the risk factors. It has four goals – identifying the at-risk patients, improving tissue tolerance as a preventive measure, protection against external mechanical forces and reducing the incidence of pressure ulcers through educational programs. Definition of the problem: Pressure ulcers have great financial impact on the health care systems. In 1999, 1.6 million pressure ulcer cases had taken place in US hospitals. It had an yearly cost of $2.2 to 3.6 billion. A stage III or stage IV case can add $ 14,000 to $ 23,000 as care cost. In fact it is more than that as it needs extended care.( Beckrich & Aronovitch, 1999). The adverse effect of these ulcers are emotional also as the patient undergoes the mental agony, anger and frustration. At the same time, the family members also suffer who are not trained or educated for preventing pressure ulcers but they have to perform the role of the care giver. Occurrence of pressure ulcer makes them depressed and damages their self esteem.   Question to define the Project-outlook Is it possible to decrease the occurrence of pressure ulcers by re-educating nurses on the Braden score and teaching the nurses to use the score daily as part of their assessment because in the clinical areas Braden Scales are not completed appropriately, which leads to devastating consequences for the patient. The study would need to be designed around a specific patient population where the risk is high anyway, such as in the long term care arena. The next step would be to design education activities that address all nurses working in the facility and add the education activity to the new nurse orientation. There should be specific training programs for new nurses as well as existing ones. This is the most important step as we have discussed before. The lack of complete knowledge about Braden scale results in not following it properly. Once this knowledge is imparted, it can be put into practice more effectively. In practice, the Braden Scale should be added to the treatment record right along side daily weights, calorie counts, etc. so that it is required to be completed on a daily basis. It only takes a few minutes once the nurses know what they are doing. This will be ensured by the Braden scale education programs. Then a follow up of medical record reviews should be set up to re-evaluate the appropriateness of the scoring, preventative measures added where needed and then re-calculate the prevalence and incidence in that long term care facility as compared to the national average. This will form the continuing education base. The data of prevalence and incidence can be compared with the earlier ones. This will give a concrete measure of improvement. In the context of rising costs and regulatory issues, this study is very important and must be taken up urgently.   Appendix :- Patient safety Guidelines :- available on  www.ahrq.gov/clinic/cpgonline.htm (Agency for Health Research and Quality) Reference: Prevention Plus, Braden Scale, http://www.bradenscale.com/bradenscale.htm Braden Scale, http://www.o-wm.com/article/350 www.wocn.org (Wound, Ostomy, Continence Nurses Society) www.npuap.org (National Pressure Ulcer Advisory Panel)  Beckrich K, Aronovitch SA. Hospital-acquired pressure ulcers: a comparison of costs in medical vs surgical patients. Nurs Econ 1999;17:263-71. http://www.jointcommission.org/PatientSafety/NationalPatientSafetyGoals/08_ltc_npsgs.htm WD, http://www.wrongdiagnosis.com/ Elizabeth A Ayello, Barbara Braden. (2002). How and why to do pressure ulcer risk assessment. Advances in Skin & Wound Care, 15(3), 125. Retrieved October 5, 2007, from Health & Medical Complete database. (Document ID: 128808381).   Elizabeth A Ayello, Barbara Braden. (2001, November). Why is pressure ulcer risk assessment so important? Nursing, 31(11), 74-80. Retrieved October 5, 2007, from Career and Technical Education database. (Document ID: 88794644).   Barbara Braden, Nancy Bergstrom, Joanne Bagel, Marion Phipps. (2000). A conceptual schema for the study of the etiology of pressure sores / Commentary. Rehabilitation Nursing, 25(3), 105. Retrieved October 5, 2007, from Health & Medical Complete database. (Document ID: 69855667).   Joanne Lynn, MD, Jeff West, RN, MPH, Susan Hausmann, MS, David Gifford, MD, MPH, Rachel Nelson, MHA, Paul McGann, SM, MD, Nancy Bergstrom, RN, PhD, Judith A. Ryan, RN, PhD. (2007). Collaborative Clinical Quality Improvement for Pressure Ulcers in Nursing Homes. Journal of the American Geriatrics Society, 55(10), 1663-1669. Retrieved October 5, 2007, from Research Library database. (Document ID: 1348421151).   The National Pressure Ulcer Long-Term Care Study: Outcomes of Pressure Ulcer Treatments in Long-Term Care Nancy Bergstrom, PhD, RN, Susan D. Horn, PhD, Randall J. Smout, MS, Stacy A. Bender, MS, RD, et al. Journal of the American Geriatrics Society. New York: Oct 2005. Vol. 53, Iss. 10; p. 1721   Description of the National Pressure Ulcer Long-Term Care Study Susan D Horn, Stacy A Bender, Nancy Bergstrom, Abby S Cook, et al. Journal of the American Geriatrics Society. New York: Nov 2002. Vol. 50, Iss. 11; p. 1816   Multi-site study of incidence of pressure ulcers and the relationship between risk level, demographic characteristics, diagnoses, and prescription of preventive interventions   Bergstrom, Nancy, Braden, Barbara, Kemp, Mildred, Champagne, Mary, Ruby, Elizabeth. Journal of the American Geriatrics Society. New York: Jan 1996. Vol. 44, Iss. 1; p. 22 Read More