Promoting Qaulity Health Care - Essay Example

Promoting Quality Health Care Pressure ulcer is defined as a ‘localized injury’ to the uppermost layer of the skin as well as its underlying tissue, in consequence to pressure, with or without the combination of friction and/or shear. Pressure ulcers are commonly observed above a bony prominence in the patient’s body and often pose the risk of remaining unidentified when the injury is caused to the underlying tissue, but have minimum or no sign on the skin surface. Risks of pressure ulcer can be measured at four stages where, Stage I implies preliminary signs of pressure ulcer, often challenging to be detected in dark-skinned patients, Stage II implies bruising on the skin tissue and more apparent signs of pressure ulcer, Stage III implies tissue loss with full thickness while Stage IV signifies the most severe category of pressure ulcer (National Pressure Ulcer Advisory Panel, 2007). According to the study findings of Hyun & et. al. (2011), patients basically witness high risks of pressure ulcer during their stay in the Intensive Care Units (ICU). As pressure ulcers can cause non-negligible impacts on increasing the chances of mortality and patients’ morbidity, imposing massive economic burdens on healthcare services, it is necessary to be diagnosed at an early stage so that effective preventive measures can be applied. It is in this context that the Braden Scale is used to assess the risk of pressure ulcers among patients, mostly those in continuous bed-rest, as observed in the case of ICU patients (Hyun & et. al., 2011). In this essay, the effectiveness of Braden Scale will be examined. Accordingly, an elaboration will be drawn emphasizing the risk assessment procedure followed through the use of Braden Scale when diagnosing the risk of pressure ulcer and its shortcomings as a risk-assessment tool, followed by critical evaluations focused on its usefulness in the current medical practices. In order to accomplish this particular objective, three specific pieces of literature will be studied with prime significance, which include “Predictive Validity of the Braden Scale for Patients in Intensive Care Units” by Hyun & et. al. (2013), “An interrater reliability study of the Braden scale in two nursing homes” by Kottner & Dassen (2008) and “Using the Braden Q Scale to Predict Pressure Ulcer Risk in Pediatric Patients” by Noonan & et. al. (2011). However, due significance has also been provided to other external sources, relevant to define the risk and elaborate on the usefulness of Braden Scale as a risk assessment tool. Braden Scale is commonly used in majority of the health care units of the US for measuring the menace of pressure ulcer at its defined levels of severity, i.e. level I, II, III and IV (GOV.UK, n. d.). The categories based on which the risk of pressure development can be determined through Braden Scale include monitoring the nutritional balances of the patient, their physiological ability to move independently, as well as their tenure of bed rest in or outside ICU settings (Noonan & et. al., 2011). Apart from these monitoring categories, there are other factors as well which contribute to the risk of pressure ulcers, among which, few are yet to be elucidated. It is majorly due to this reason that Braden Scale and its accuracy has a major significance in ensuring patients’ safety to pressure ulcer risks. Braden Scale basically rates a patient within the range of 6 and 23. As per this scale, a lower score projects an increase in the chance of pressure ulcers for ICU patients (Hyun & et. al., 2013). Following the success of Braden Scale in medical practices for treating pressure ulcer, a new kind of pediatric pressure ulcer risk calculation tool, which was termed as Braden Q Scale, also came into existence in 1996. This risk assessment tool was developed by ‘Quigley’ and ‘Curley’ and it got its validation on 2003 for medical practices. This scale helped in identifying two major factors, i.e. pressure and tissue tolerance, which mostly contributed to the formation of pressure ulcer problem among patients (Noonan & et. al., 2011). It is worth mentioning in this context that the factors such as ‘mobility of the patient’, ‘sensory perception’ and ‘activity’ help in determining the time duration and intensity of pressure ulcer. According to Noonan & et. al. (2011), the factors contributing for the patient’s tissue tolerance, further giving rise to the risk of pressure ulcer, can be categorized as either intrinsic or extrinsic. Where on one hand, the patient’s nutritional strengths, age, stress coping abilities, smoking habits and body temperature are considered to be intrinsic factors, on the other hand, patient’s skin moisture, friction exposure and shear force exposure are categorized as the extrinsic factors increasing the risk of pressure ulcer among the patients (Noonan & et. al., 2011). Noonan & et. al. (2011) further noted that with due consideration to these risk factors, the Braden Scale technique, depends on extracted data for the sub-scaling purpose, which forms a significant facet of the risk assessment process. It often happens that medical professionals lack current data, necessary for conducting the risk assessment process through the use of Braden Scale. In such cased, if no current data is available, the process can even operate on the previous available data for assessing the patients, offering the medical professionals with adequate flexibility to suffice the patient’s right to safety (Noonan & et. al., 2011). As stated by Noonan & et. al. (2011), the effectiveness of this pressure ulcer measuring tool depends on how accurately its sub evaluation steps get executed, implying that the practitioners have to face challenges in maintaining accuracy following the multidimensional approach of these risk assessment tools. For instance, the initial step in using the risk assessment process using Braden Scale is mobility determination, which evaluates the patients capability towards making changes or controlling his/her body movements. The scoring is mainly done based on four criteria. The first criterion is of ‘No limitation in mobility’, where the patient can easily shift positions without anyone’s assistance. The second criterion refers to ‘Slight limitation of mobility’ in which, the patient only faces difficulty in cases of extreme mobility (NICE, 2014). The third criterion is ‘Very limited mobility’, where the patient, although being able to move and shift body positions independently, faces difficulties in doing so and hence, restrains from moving their body to avoid pains. Ultimately, the final criterion is of ‘Complete immobility’ in which the patient is unable to shift positions without assistance, i.e. a situation of complete or partial paralysis. The case of complete immobility is rated with a score of (1) whereas a score of (4) is given in case if the patient faces no difficulty in mobilizing his/her body positions. Repositioning support provided by medical support staff is disregarded during the evaluation process to eradicate biases in the medical practice (Noonan & et. al., 2011). The second phase in the process is of sensory perception, which evaluates patients capability in retorting towards pressure uneasiness. Similar to the previous method, this evaluation process is also implemented on the basis of three categories. The first category is of ‘No impairment’ in which, the patient is able to show responsive signs to verbal commands and have no discomfort towards pain. The second category is of ‘Slightly limited impartment’ in which the patient responds to verbal commands, however projecting slight signs of discomfort because of pain. The third category emphasized in this process is of ‘Very limited impartment’ where the patient only responds to throbbing provocation, Subsequently, the final category in this phase of Braden Scale implementation of ‘Complete Impartment’ in which the patient shows no sign of response and mostly remain in an unconscious state. The score of (1) is given in case of completely limited impartment and a score of (4) is given to no impartment stage depicting the severity of the pressure ulcer (Noonan & et. al., 2011). Following this stage, in the third evaluation step, concentration is provided on the nutritional health of the patient in which an observation is made on patient’s nutrition consumption for continuous five days before any score or rank is offered, considering the fact that nutrition can also act as a major determinant of such risks faced by the ICU patients. This evaluation method disregards the patient’s location into consideration. Basically the food intake pattern is taken into consideration for determining the patients body nutritional reserve. A rank of (1) is offered in case of very poor results and (4) is given in case of excellent outcomes (Noonan & et. al., 2011). Subsequently, in the fourth step, the evaluation of ‘Tissue Perfusion and Oxygenation’ status of the patient is conducted. The extremely compromised state is given a score of (1) and the excellent state is given a score of (4). The entire evaluation is done based on studies related to blood and oxygen saturation, which provides a deep analysis about the tissue tolerance of the patient (Noonan & et. al., 2011). From a critical point of view, it can be argued that the complex structure and inclusion of multiple variances in the risk assessment process of the Braden Scale, as explained in Noonan & et. al. (2011) can raise obstacles in its effective implementation. As stated in Department of Health (2010) and by Currie (2007), complexities in medical risk assessment tools are a major challenge for nurses and healthcare professionals, which not only impose negative impacts on the patients’ safety needs but also hinder the effectiveness of the overall medical treatment practices. Shojania & et. al. (2001) thus argued that failure of Braden scale in accurately diagnosing pressure ulcer might result in jeopardizing the patients’ safety to a non-negligible extent. For instance, it might increase risks of inappropriate evaluation of the patient’s ratings regarding nutritional levels, stay duration in the ICU and other factors or ratings required to examine the patient accurately. Hence, improper use of this scaling can result in hindering patients’ safety (Shojania & et. al., 2001). Braden Scale depends largely on the efficiencies and the experiences of the medical professionals or ICU care givers to identify, measure and interpret the ratings accurately. Certainly, inaccurate interpretation of the scaling will result in misdiagnosis or maltreatment of the patients exhibiting medical disregard to the patient’s safety demands. Unfortunately, this is one of the limitations of Braden Scale when measuring pressure ulcer risks among ICU patients. As argued in Hyun & et. al. (2013), although its methodical application seems to be highly effective on the theoretical context, practical implementation of the scaling reflects limitations in terms of its effectiveness. As per the results obtained in Hyun & et. al. (2013), the Braden Scale proved ineffective in differentiating between ICU patients having high degree of risk to pressure ulcer and those having minimum or no risk to such diseases. Comparison with other scales such as the Douglas scale and the Cubbin and Jackson scale also revealed that the Braden scale offers poor classification between patients having high possibilities of developing pressure ulcer. Hence, considering this particular aspect with the issues related with patient safety, it can be asserted that ineffectiveness of Braden Scale might result in serious effects to the patient’s short term recovery. When concerning the problem within the ICU patients, the fallacy may also result in life threatening risks for the patients, deciphering high degree of nursing inefficacies. However, it is worth mentioning in this context that the reasons of the failure of Braden Scale were not comprehensibly explored in Hyun & et. al. (2013), which certainly demands for an extensive amount of study to be conducted, aimed at the identification of the success drivers and obstructions to the effectiveness of Braden Scale. Nevertheless, the study findings stated in Kottner & Dassen (2007), revealed certain crucial facts that might be asserted as potential determinants to the effectiveness of Braden Scale. As concluded by Kottner & Dassen (2007), although Braden Scale proved effective in generating differentiated results in patients facing high risks of pressure ulcer, certain “clinically relevant differences” were observed amid nurses involved in the implementation of the scaling method. It is worth mentioning in this context that the patients considered as the same size in this study, were not featuring ICU record. This implies that in common settings of using the Braden Scale, “clinically relevant differences” may cause significant influence on the effectiveness of the tool (Kottner & Dassen, 2007). Hence, inferences can be drawn stating that application of this tool, disregarding the influential differences amid the nurses or practitioners may result in ineffective outcomes when treating patients in ICU. Relating the above inferred understandings to the effectiveness of the risk assessment tool, better insights can be drawn with reference to my professional experiences. During my experience in the medical field, I came around with such an incident when a patient got admitted in the nursing home for a bypass surgery. He was kept in the ICU for a couple of days post surgery, during which the Braden Q Scale of pressure ulcer measuring tool was implemented on him. The obtained score turned out to be less than 16, thus projecting him to be under the risk level. As mentioned in Hyun & et. al. (2013), when measuring ICU patients’ risks to pressure ulcer, the scale must be at a cutoff-score of 16. Below this scale, the patients are supposed to be facing the risks of pressure ulcer and vice-versa. Accordingly, the patient’s supervisory health personal evaluated him on multiple factors, which included ‘mobility’, ‘sensory perception’, ‘friction and shear’, ‘tissue perfusion and oxygenation’ and ‘nutrition’ levels to assess the risk factors associated with his possible sufferings of pressure ulcer. The patient was also made to undergo the ‘International Classification of Diseases’ coding program where he got ICD-9 code of 707.05, which according to the supervising medical staff, was considered as a case of pressure ulcer. Soon after, the medical staff got involved in collecting out the patient’s demographics data such as age, sex, and ethnicity along with his period length of stay in ICU. Although the patient never developed a pressure ulcer problem, it can be inferred that the level of risk projected through the application of Braden Scale might have been erroneous. Considering this particular fact, application of other scaling methods could have also been used to obtain confirmed results on the pressure ulcer risks being faced by the patient in ICU. It might also have been the precautionary measures adopted by the nurses in the ICU setting that prevented the possible risks of pressure ulcer faced by the patient, indicating that the chances of developing error free results with the use of Braden Scale is equal to the obtainment of faulty results. The results obtained through the Braden Scale is also observed to be highly influenced by the past records and experiences of the nursing practitioners, which may also be signified as a possible hindrance to the effectiveness of the tool. As mentioned in Aras & Crowther (n.d.), nursing fallacies generating bias results may result in maltreatment of the patients and are mostly attributable as the consequence of poor governance practices in healthcare settings. A similar notion has also been presented in Chambers & et. al. (2004). Reynard & et. al. (2009) further argued that irresponsible behavior of nurses when practicing risk assessment tools may deliver unreliable test results and lead to clinical error, further putting stress on the safety concerns of the patient. Based on these understandings, it is suggestible that a rationale and practical evidence based benchmark system is applied to ensure that the Braden Scale results are interpreted in an unbiased manner (Department of Health, 2010). Undoubtedly, a more rigorous analysis is required in the field to identify the actual benefits, loopholes and risks of inaccurate results associated with the use of Braden Scale. The most apparent reasons for the ineffectiveness of the Braden Scale can be identified in terms of its high dependency on the proficiencies of the nurses involved in applying the risk assessment tool. As the Braden Scale mainly emphasizes scaling methods, it is highly essential that nurses are provided with adequate training and practical guidance to generate accurate results concerning the risks of pressure ulcer faced by patients (Milligan & Robinson, 2003). As noted in a report published by National Patient Safety Agency (2004), training the nursing staff should be considered as one of the preliminary steps towards effective care facilities and patient safety from issues such as pressure ulcer. Vincent (2010) and National Patient Safety Agency (2006) also asserted that delivering training to nurses can ensure effective utilization of risk assessment tools, delivering the highest possible accuracy in interpreting the scaling results and satisfying the safety needs of the patient. However, a major concern identified in this context, when concerning the effectiveness of the tool among ICU patients, is that the tool develops almost accurate results for patients given care in general medical settings, while it fails to differentiate between patients having risks for pressure ulcer in ICU settings. Conclusively, emphasizing the usefulness of the Braden Scale as a risk assessment tool to measure the possibilities of ICU patients facing chances of developing pressure ulcer remains debatable and subjected to further examination. Nevertheless, the effectiveness in using the tool has been evidently observed as dependent on the efficiencies and experiences of the nurses or professionals using the Braden Scale. For instance, while Hyun & et. al. (2013) argued against the effectiveness of Braden Scale in measuring risks of pressure ulcer among ICU patients based on empirical results, Noonan & et. al. (2011) and Kottner & Dassen (2008) advocated in favor of using the tool as an effective risk assessment scale. The point of difference in the reliability and relevancy of these studies were that Hyun & et. al. (2013) was based on studying ICU patients while the other studies had been emphasizing on the assessment of pediatric patients (as in Kottner & Dassen (2008)) and general wards of nursing homes (as in Noonan & et. al. (2011)). Hence, based on these findings, it can be more justifiably inferred that effective use of the risk assessment tool, i.e. the Braden Scale, depends largely on the proficiency of the nurses and the other professionals involved with its application, owing to its complex criteria and scaling methods. The findings obtained through this study also depicts that usefulness of this scaling method is marginal and not at all self-sufficient owing to which further research on the issue is demanded along with comparative analysis of the principles followed in other scales so as to determine its efficacy. References Aras, G. & Crowther, D., No Date. A Handbook of Corporate Governance and Social Responsibility. Grower Publishing. Chambers, R. & et. al., 2004. 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