Risk Assessment in Pressure Ulcer Prevention

Abstract

Pressure ulcer is one of the common causes of death. Its impact on the lives of an individual is great. First, it leads to pain and time consumption. It also increases the financial burden to the patient. On the other hand, pressure ulcer strains the national budget by increasing the amount of money spent on its control and management. Research has however shown that risk identification can reduce the impact both on individuals and on health care system as a whole. Nurses need to be given appropriate knowledge on risk assessment so that they acquire pertinent skills to control the issue.

On the other hand, they should be taught on the importance of their role. This calls for an educational campaign that aims at changing the mentality and placing nurses at the fore front of the fight against this condition. The move is meant to change the mental set up of the nurses. After that, there will be continuous teaching sessions twice every year. The sessions shall be crowned by an examination that will culminate into certification. The certification will be the identification factor on whether a nurse is competent or not. To have a channel for questions, a consultant shall be visiting each institution once every week. He shall be the mediator in communication between the management and the nurses.

Introduction

Pressure ulcers may be defined as wounds resulting from unalleviated pressure on body tissue. According to the National Pressure Ulcer Advisory Panel (NPUAP), pressure ulcers are parts of a specific area, mostly bony places, where cells or tissues are dead owing to inadequate blood supply (Gunningberg, Lindholm, Carlsson and Sjödén, 2001, p. 263).

In a study undertaken in Canada in 2004, it was established that the range of prevalence of pressure ulcers varied from 13.1% to 53% within Ontario. Among health care providers that participated in the study, it was identified that nonacute health care settings demonstrated the highest rate of prevalence. In Australia alone, it was established that treating a stage four pressure ulcer would cost an approximated AUS $61,000.

On the hand, the United Kingdom has been spending approximately 1.4 to 2.1 billion British pounds every year to treat and contain pressure ulcer. This accounts for 4% of the total budget of the health care sector. Given this prevalence in Canada and the economic implication that this condition can have, it is necessary to ascertain whether risk assessment can assist in reducing the prevalence rate and at the same time overall economic burden to health care institutions (Robinson, 2005).

Research Problem

In any health care set up, risk assessment is the most effective approach to treatment and containment of an issue. In pressure ulcer treatment, risk assessment plays an important role in ensuring relative lower rates or stages of severity of the problem. Furthermore, this reduces the economic burden of the condition to an individual and the state.

Given the implication and prevalence of pressure ulcer, it becomes necessary to understand whether risk assessment practice should be incorporated in nursing practice. The main problem of this study was therefore to establish whether risk assessment, if incorporated within nursing practice can positively impact on the individuals with the condition by reducing the severity of the condition and reducing the economic burden both to the individual and the hospital.

Research Objectives

The main objective of this study will be to identify whether incorporating risk assessment in nursing practice can reduce the prevalence and economic burden of pressure ulcers on individuals and health care institutions. The study will seek to establish whether risk assessment can reduce the overall preventive measures used on a patient and whether the fact that it is developed early within the continuum could positively contribute to reducing severity of the cases and preventing other cases from developing. Generally, it would seek to establish that incorporating risk assessment into nursing practice can reduce the prevalence and economic implication of pressure ulcer on individuals and the health care institutions.

Hypothesis

The proposed solution of this study is that identifying risk factors can greatly improve the future of pressure ulcer management and treatment. To begin with, nurses will have the technical know-how which is relevant for the identification of the likelihood of development of this condition. By identifying the likelihood, appropriate measures will be taken early. This will save individuals from spending too much time and pain, and the health care institutions from spending too much time and money on the issue. Therefore, the study proposes that risk identification be incorporated in nursing as a career.

Literature Review

Severens, Hobraken, Duivenvoorden and Frederiks (2002) argue that development of pressure ulcer during hospitalization can be alleviated through development of appropriate guidelines necessary for the reduction. This is what this paper advocates for. The development of appropriate guidelines might include the development of methods and ways of determining risk factors. By gaining the ability to identify risk factors, the study argues that establishment of pertinent guidelines might alleviate pain and reduce quality of life by individuals who have developed the complication. This can also help health care institutions to save enough time for other purposes and also save substantial amount of dollars that could be wasted in treating the condition.

Furthermore, health care institutions will incur more costs in relation to pressure ulcer if preventive measures are not developed. For instance, Center for Medicare and Medicaid stopped financially supporting facility-acquired complications. Each institution has to foot for the bill of such cases. It is therefore necessary that nurses are imparted with knowledge on identifying risk factors so that they can check the problem before it becomes severe.

Clarke, Bradley and Whytock (2005) argue that the number of deaths resulting from pressure ulcers and its complexities is estimated to be about 60,000 per year. Complications resulting from pressure ulcers such as wound bacteremia make the risk of death even higher. They affect the wellbeing of patients, elongate their stay in hospital, slow their recuperation process and put them at risk of dying from the arising complications. They also pose financial burdens to healthcare providers and families (Braden & Maklebust, 2005).

Frantz, Gardner, Harvey and Spetch (1991) point out that the occurrence of pressure ulcers is widespread and ever increasing. According their study, the yearly cost of treating pressure ulcers acquired while in hospital in 1999 ranged from $2.2 billion and $3.6 billion. The expenses range from the costs of treating the ulcer to include the hospital and room bills for the ulcers on top of the usual amount to be paid for the real condition that led to hospitalization (Bluestein & Javaheri, 2008).

According to the National Health Service in the United Kingdom as quoted by Braden and Maklebust (2005), the direct cost of treating pressure ulcers and their related illnesses for 2000 alone was between £1.4 billion and £2.1 billion. In Netherlands, it consumes one percent of the budget allocated for healthcare (Severens, Hobraken, Duivenvoorden and Frederiks, 2002). In the US, the cost per year runs to $11 billion. The costs of reconstructing operations per patient go at around $25000, human suffering not withstanding (Gunningberg, Lindholm, Carlsson and Sjödén, 2001). These costs do not even include the indirect costs to families and law suits.

According to Frantz, Gardner, Harvey and Spetch (1991), in the US alone, over 2.5 million in acute care institutions are undergoing treatment for pressure ulcers every year. Incidents of pressure ulcers range from 0.4% -38% in intensive care setting; 2.2% -23.9 % in long term clinical settings and 0-17% in home based care facilities. About 60000 patients in the US perish yearly from complexities arising from pressure ulcers acquired while in hospital.

Gunningberg, Lindholm, Carlsson and Sjödén (2001) point out that all bedridden patients are at risk. However, the aged patients are more vulnerable owing to the weakened state of their body organs. ICU patients are most likely to suffer from pressure ulcers in relation with general care patients. The risk is heightened by various intrinsic and external factors. Similarly, a study on the extent of pressure ulcers among people suffering from spinal cord (SCI) injuries alongside other malignant problems shows that patients with high degree SCI injuries have a higher risk of suffering from pressure ulcers as opposed to patients with relatively low injuries.

Some studies also advance that individuals with darker skin colors are more likely to suffer severe pressure ulcers compared to those with lighter skin (Graves, Birrell and Whitby 2005) since it is quite hard to discover inflammation in dark skin early to prevent pressure ulcers.

Bluestein and Javaheri (2008) argue that pressure ulcers are known as severe consequences of hospitalization and are among the five popular sources of harm for patients. Studies indicate that implementing good practices in healthcare institutions can reduce the occurrence of pressure ulcers thus preventing pressure ulcers is the most essential part of intensive care provision. It involves a culmination of factors i.e. improving the quality and ways of nursing such as training of caretakers, improving skincare and leadership.

On their part, Clarke, Bradley and Whytock (2005) highlight the importance of assessment of risks. They argue that assessing patients on admission to determine their risk factors and constantly monitoring them ensures that they do not develop pressure ulcers during their stay in hospital. Early signs are noted and dealt with precisely. Evaluating risk factors helps determine the severity and the prevailing length of the pressure and the ability of the skin to put up with it. Patients conditions change daily hence requiring constant reevaluation of risk factors. This is common in terminally ill patients whose skins are also likely to be damaged and evaluation of their risk factors goes a long way in preventing pressure ulcers from developing. Making this a daily practice is recommended.

Robinson (2005) points out that monitoring of the skin of patients with high likelihoods of developing pressure ulcers would assist in determining whether the skin can wear away easily in these patients. Inadequate nutrition puts the patient at risk of since it not only slows down the healing process but also leads to skin deterioration. Maximizing nutrition, water and fluids among high risk patients reduces the chance of them developing the ulcers. Hydration ensures a healthy skin.

He further argues that relieving pressure on body parts susceptible to pressure ulcers also would assist in reducing chances of pressure ulcers. Repositioning patients after every two and ensuring that the resting surfaces are comfortable and pressure alleviating prevents pressure from being exerted on particular body parts. This enables free circulation of blood to all body parts. Pressures relieving mattresses, chairs or wheel chairs are also used to suit different conditions. These include air chambered and air fluidized mattresses which not only have the ability to reduce pressure as they can distribute weight equally and for a longer time but they can also move.

On their part, Severens, Hobraken, Duivenvoorden and Frederiks (2002) argue that providing nutritional additions and administering of fluids, orally, nasally or intravenously boosts patients’ nutritional intake. It is therefore the role of nurses to ensure that proper nutrition is given to patients to prevent them from developing this complication.

On his part, Kritsonis (2005) argues that monitoring bowel and urinary movement of immobile patients is another role that nurses can play to ensure that the risks of developing pressure ulcers are reduced. Moist skin is more susceptible to decay. Application of moisture reducing materials and procedures such as mackintosh, catheters, stuffing, and loose undergarments prevent moisture from adhering to the skin.

Patients who cannot control their bladders or bowels are washed, wiped clean, dries carefully and cream is spread to provide a protective barrier for the skin. This argument was consistent to Lippitt, Watson and Westley (1958) who also identified the role of moist skin in development of pressure ulcer. Lippitt et al further identify the role of good care of cuts, scratches, wounds and other infections in the reduction of pressure ulcers. It involves sterilizing, cleaning, removal of dead tissues and constant dressing of cuts and infections of any kind in reducing the chances of developing ulcers.

Theoretical Framework

Lewin’s three step change theory states that three steps are necessary to implement change within an organization. First step involves unfreezing the existing status quo. The status quo usually makes employees stick to what they have been made to believe. In this case, nurses will be made to understand that the practices they undertake could be inappropriate. They will be made to understand that it is not just the role of doctors to cure a patient but also they have an important role to play. The plan will unfreeze the notion that it is the role of a doctor to prescribe medication that would cure the patient (Kritsonis, 2005).

The second step in Lewin’s change theory is movement. This involves moving the employees from their day to day beliefs and practices to another desirable level. In this case, the seminars will play this role they will act as avenues or agents upon which the education will be imparted upon the nurses. The movement will involve transiting from point A which holds the belief that doctors have to cure patients to point B which is founded on the belief that nurses have a great role in prevention of pressure ulcer.

The final step involves freezing. After transiting from point A to point B, chances are high that employees would regress to point A. it is therefore necessary that the proper measures are developed to discourage retrogression. The process of ensuring that the employees stay at point B is referred to as freezing. In this case, after the nurses are taught of their responsibilities in prevention and management of pressure ulcer and they understand that they need to identify risk factors, they will remain at the level through the continuous half year evaluations. This will ensure that they do not regress (Kritsonis, 2005).

Plan for the implementation

It is evident from the research above that assessing risks could be the best way upon which prevalence and severity of pressure ulcers can be reduced. It is therefore necessary that a very detailed plan is outlined to ensure that nurses are given relevant skills in risk assessment. The following is an outline of the plan and how it shall be implemented.

Aspects of the plan

It has been identified that most of the instances of pressure ulcer have been as a result of nursing practices. This is what is referred to as facility acquired illnesses. With a proper knowledge, there are high chances the prevalence will reduce. The plan will involve a strong education based approach. It will involve training of nurses to ensure that they have pertinent knowledge on how this condition is developed and how it can be curbed.

In this plan, there will be educative seminars for nurses. The main theme of each seminar will be study of risk factors that must be put in consideration in every aspect of their daily lives. The seminars will be one week long staying the whole day. Several speakers who have enough experience in nursing will take the responsibility of teaching. The main target audience will be newly employed nurses. However, those who have worked for some time will also be incorporated in the seminars. The topics that will be given priority will be:

  • Determination of early signs of pressure ulcer among patients
  • Determining patients with high likelihood of developing pressure ulcers
  • Factors to consider when carrying out a daily surveys
  • Monitoring of patient positions
  • Bowel and urinary movements and there role in pressure ulcer development
  • Role of nutrition in pressure ulcer prevention
  • Important skills in treatment of open wounds and sores

Necessary resources

To ensure that all these are well implemented, certain resources must be available. The foremost resource needed will be financed. This will facilitate rooms for seminars, snacks during the seminar, stationary necessary for the education, payment of seminar coordinators and presenters, and finally, the money will be necessary for the purchase of presentation equipment like projectors and writing materials.

The other resources needed will be educators. It will require experienced and knowledgeable people to take the responsibility of teaching. This would require use of consultants who will be given the role of identifying the most appropriate people to act as educators and presenters during the seminars.

The outcomes will be monitored through undertaking of an exam. Although the exam will not be compulsory, there will be awarding of certificates to point out that the possessor of the certificate has adequate knowledge in the field of pressure ulcer risk assessment. The certificate will only be awarded to those that will pass exemplarily the exam that will involve practical and theory. Finally, this exam will be carried out after every six months. The nurses will be required to renew their certification by undertaking the exam after every six years.

Although the financial implication required to ensure proper implementation of this plan is enormous, it cannot be measured to the dollars spent each year on pressure ulcer treatment and management. In addition, to financial salvation, the plan will also save on time that is wasted on treating pressure ulcer. This will be directed on other productive activities. Finally, patients will be saved from the economic burdens of treating pressure ulcer and also the physical and psychological pains associated with it.

The solution will be evaluated in two ways

  • The rate of prevalence
  • Reduced deaths
  • Overall cost and expenditure on pressure ulcers in health care sector
  • Patient satisfaction through researches

To measure the outcome, a study will be carried out to ascertain whether the overall expenditure on pressure ulcer will have gone down or up. The study shall also ascertain whether there is increasing or reducing number of deaths in relation to pressure ulcer. Reduction in the number of deaths and reduction in the overall expenditure will indicate that the outcome was achieved. However, an increase or Constance in any of the two will be an indicator of failure in whole venture.

This approach is very important because it is sensitive to change in that if nurses understand there roles in pressure ulcer prevention, they will curb the problems in their earlier stages thus saving on the expenses that would be incurred in treating advanced stages. By identifying early symptoms, pain will be relieved and there will be fewer deaths. This means that the number of deaths and expenditure is directly related to prevalence and severity of the cases. Therefore, using the number of deaths and overall expenditure to determine outcome is appropriate.

Data Collection

Data to determine outcome will be collected through evaluation of statistical data from institutions. It will depend on the institutions’ data on the number of deaths and cases that result from pressure ulcer. It will also depend on statistical data from the national and health care budget of the money that was spent on pressure ulcer prevention and management.

These sources are important because they are reliable in showing whether more deaths resulted from pressure ulcer. In addition, the data will also show whether the prevalence has reduced or increased. Finally, the data will offer a clear picture on whether the government spent more money on pressure ulcer or less. Furthermore, this method of data collection will require comparatively fewer resources. Money required for data analysis can not be compared to the total sum that is required in interviews or questionnaires.

Decision Making

The main problem in this issue is mentality. Most nurses have a mentality that their role in pressure ulcer prevention is limited. The best approach therefore, is changing this attitude. This can be done through teaching them on the importance of their role. They have to be made to understand the role of risk assessment in management of pressure ulcer. Therefore, using education seminars might work. In addition, the nurses are likely to forget about their role. This is why the certification will have to be renewed after every six months. This will guarantee continuity.

Incase of failure, the root shall be identified and the reason shall be incorporated in the syllabus. This is true given that the education and exam shall be a continuous process. Problems identified in a previous section shall be corrected in the subsequent one.

The one week seminars will be used as the media for feedback. One hour each day shall be designated for question and answer sessions where nurses will have the chance to express their feelings on the issue. During the other times, a feedback suggestion box will be available for any question. Furthermore, a consultant will be available once every week in each health care institution. Every question will be answered by him. It will also be role of this consultant to make reports that will be handed over to the management and other groups outside of the project.

Reference List

Bluestein, D. and Javaheri, A. (2008). Pressure ulcers: prevention, evaluation, and management. Amer Fam Physician, 78(10), 1186-1194.

Braden, B., & Maklebust, J. (2005). Preventing pressure ulcers with the Braden scale. American Journal of Nursing, 105 (6), 70–72.

Clarke, H.F., Bradley, C. and Whytock, S. (2005). Pressure ulcers: implementation of evidence-based nursing practice Advanced Nursing. 49(6), 578–590.

Frantz, R.A., Gardner, S., Harvey, P. and Spetch, J. (1991). The cost of treating Pressure Ulcers in a Long term care facility. Decubitus, 4, 37-42.

Graves, N., Birrell, F. and Whitby, M. (2005). Modeling the economic losses from Pressure ulcers among hospitalized patients in Australia. Wound Repair Regen,13 (5), 462–467.

Gunningberg, L., Lindholm, C., Carlsson, M. and Sjödén, P. (2001). Risk, prevention And treatment of pressure ulcers: nursing staff knowledge and documentation. Scand Journ Caring Science, 15(3), 257–263.

Kritsonis, A. (2005). Comparison of change theories. International Journal of Scholarly Academic Intellectual Diversity, 8(1), 1-7.

Lippitt, R., Watson, J. and Westley, B. (1958). The Dynamics of Planned Change. New York: Harcourt, Brace and World.

Robinson, M. (2005). Australian Council on Health Care Standards. Prim Intention.13(3), 104.

Severens, J. L., Hobraken, J.M., Duivenvoorden, S. and Frederiks, C.M. (2002). The Cost of illness of pressure ulcers in the Netherlands. Adv Skin Wound Care, 15(2), 72–77.

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