Abstract
Pressure ulcers are a significant health concern for patients and care providers. With high prevalence and risk of complications, pressure ulcers can harm patient health and result in additional healthcare expenditures. The present evidence-based practice review sought to synthesize evidence on the causes and effects of pressure ulcers, as well as on the efficiency of various interventions. The results highlight the importance of the problem and the need for more evidence comparing the effectiveness of various prevention and treatment methods. The recommended intervention is a multi-component program involving risk assessments, staff education, and the use of special surfaces and dressings.
Introduction
The importance of nursing in the contemporary healthcare environment cannot be underestimated. Nurses help to improve the quality of care in facilities, ensure adequate communication between patients and other care providers, and contribute to positive patient outcomes. These health care providers are the key contributors to the alleviation of the issue of pressure ulcers. This condition is a critical nursing problem, as they affect patient health and cause additional healthcare expenses (AHRQ, n.d.). The issue is highly preventable and may decrease the health care costs in the U.S. and the world.
The prevalence of pressure ulcers in U.S. hospitals is rather high and mortality associated with these cases poses serious concerns for the health care sector. As such, the annual costs of treating this condition are between 9 and 11 billion dollars total and between 20,000 and 150,000 per patient (AHRQ, n.d.). In addition, pressure ulcers prolong patient rehabilitation term and contribute to the development of chronic wounds (Worsley, Smith, Schoonhoven, & Bader, 2016).
The organizations delivering care to patients face the consequences of pressure ulcers, including increased care expenditures which impedes the ability of a clinic to provide care to other patients. The goal of the present evidence-based practice review is to investigate the available research on hospital-acquired pressure ulcers (HAPUs), particularly with regards to their causes, impact on the healthcare sector, and possible interventions.
Background
The problem of pressure ulcers has received significant attention in research over the past few years due to its impact on healthcare. Pressure ulcers are a type of skin injury that occurs due to an area of skin being placed under constant pressure for long periods of time (Bhattacharya & Mishra, 2015). The topic of pressure ulcers is significant to nurses because millions of patients suffer from this health issue each year. According to Padula (2017), the national incidence of pressure ulcers is 2.5%, with 2.5 million patients developing pressure ulcers each year and 60,000 people dying as a result of complications. Among the major causes of HAPUs is the lack of mobility, perfusion issues, and adverse skin condition (Coleman et al., 2013).
Yet, the researchers note that all factors are highly individual and often there is rather a combination of factors that causes HAPU, which complicates the choice of proper intervention. There is a variety of possible interventions yet there seems to be no universal solution for all cases of pressure ulcers. Therefore, the researchers suggest that the issue needs to be tackled in accordance with the setting, the most prevalent cause and available funding as not all solutions may be cost-effective (Coleman et al., 2013).
As such, one of the prominent and cost-effective strategies, among others, was repositioning (Moore & Cowman, 2015; Swafford et al., 2016). Age was found to be significantly related to the risk of pressure ulcer and the length of recovery, which makes older patients one of the most vulnerable populations (Kaşıkçı, Aksoy, & Ay, 2018). Given the above-mentioned studies and their findings, the following PICO question was formulated: In older adults will reposition as compared to other interventions help better address the incidence of pressure ulcers? The key variables that will be considered as part of this research are pressure ulcer incidence, causes and complications of pressure ulcers, the economic costs associated with this health issue, and intervention options.
Methods
In order to find high-quality evidence for the review, the team searched most academic databases with a wide selection of health publications. These included PMC, PubMed, Elsevier, and Google Scholar, as well as the university library. The main keywords used in the search were “pressure ulcers” and “hospital-acquired pressure ulcers”, paired with keywords such as “prevention”, “costs”, “prevalence”, “interventions”, and “consequences” to narrow down the search results. The inclusion criteria for sources included relevance to the topic and recency as the review focused on articles published in the past five years to avoid including outdated information.
Systematic reviews and clinical guidelines were given the closest attention, as they usually offer the highest quality of evidence (“Nursing resources,” 2018). However, sources offering a lower level of evidence were also used to provide a thorough overview of the topic. Each source was evaluated by the team to ensure that the author had the required academic qualifications and that the article was based on provable sources or an original research study.
Literature Review
Causes and Risk Factors
The causes of and risk factors for pressure ulcers are well documented in research. Bhattacharya and Mishra (2015) describe the etiology of pressure ulcers, stating that they develop due to significant pressure being applied to a skin area for a short period of time, as well as due to lower pressure being applied to the skin for long periods of time. The researchers also state that the main risk factor for pressure ulcers are physical or mental conditions that cause immobility (Bhattacharya & Mishra, 2015). Nevertheless, there are also other risk factors that increase the probability of a patient developing pressure ulcers.
For example, Dumville, Webster, Evans, and Land (2015) state that incontinence and impaired nutritional status can increase an individual’s risk for pressure ulcers. Pressure ulcers are also believed to be connected to diseases that affect blood circulation and tissues, such as anemia, diabetes, hypertension, and hypotension (Marin, Nixon, & Gorecki, 2013). However, the strength of the influence of these conditions on pressure ulcers is unclear due to the lack of studies in the area.
Age is commonly perceived to be a significant predictor of pressure ulcer development. For example, Raju, Su, Patrician, Loan, and McCarthy (2015) state that patients over 65-70 years of age are at a higher risk for pressure ulcers. Other researchers state that the influence of age on pressure ulcer development is not direct because age affects the probability of having other risk factors, including immobility and risk-inducing disease (Marin et al., 2013).
It appears not possible to determine if older age can promote the development of pressure ulcers in the absence of other risk factors. Still, older adults are considered one of the most vulnerable group of patients which establishes the need to target them specifically (Kaşıkçı et al., 2018). Longer recovery, the possibility of chronic wounds, and other issues severely impact people over 65, which is why their health needs need to be met.
Organizational variables were also studied in some research articles because pressure ulcers are thought to be connected to the quality of care. For example, delayed admission to a specialist was a significant factor associated with pressure ulcers (Marin et al., 2013). Regular pressure ulcer assessments, high nurse-to-patient ratio, and ward patient safety culture contributed to a reduced risk of pressure ulcer development, thus improving patient outcomes (Bredesen, Bjøro, Gunningberg, & Hofoss, 2015; Raju et al., 2015). These organizational factors support the importance of adequate, high-quality care for the prevention and management of pressure ulcers.
Effects
The effects of pressure ulcers on patients and organizations are also evident. For patients, pressure ulcers pose a risk to life and health due to the increased risk of infection and prolonged hospital stay. Raju et al. (2015) stated that pressure ulcers increased the probability of dying in a hospital by 200% percent, causing a 69% increase in 30-day mortality. This threat is also supported by Padula (2017), who stated that pressure ulcers led to approximately 60,000 deaths each year.
Prolonged hospital stay is also typical among patients with pressure ulcers due to the need to provide care and ensure that the wounds heal before discharging a patient. On average, the hospital stay of those with pressure ulcers was 6.4 days longer than those who did not have the condition (Raju et al., 2015). Pressure ulcers can also increase the risk of infections, even when proper wound care is used (Dumville et al., 2015).
In older adults, these adverse events aggravate as they often lack mobility, and autonomy in fulfilling their basic needs (Rasero et al., 2015). On the whole, the evidence shows that pressure ulcers complicate the care process and impair patient outcomes, thus threatening their life and health.
Similarly, organizations face severe consequences associated with pressure ulcers. The average cost of treating a stage III or IV pressure ulcer in one patient is above $40,000 (Raju et al., 2015). For patients with stage III or IV pressure ulcers, the costs can rise to $70,000-$150,000 (Padula, 2017). It is also important to note that the cost of treating hospital-acquired pressure ulcers is not reimbursed under Medicaid and Medicare programs.
This leaves organizations to take on these expenses (Raju et al., 2015; Swafford, Culpepper, & Dunn, 2016). Death or injury as a result of hospital-acquired pressure ulcers also creates a risk of lawsuits against the hospital. Padula (2017) states that in these cases, the settlement requires healthcare organizations to pay at least $250,000 in each case. Increased patient care and legal expenditures by organizations might affect their day-to-day functioning by creating the need for budget cuts. By reducing costs in other areas of patient care, such as prescription medicine or nurse staffing, hospitals and other care facilities can lower the quality of care provided to other patients, which leads to more adverse events.
An increase in patient care expenses due to pressure ulcers also contributes to the overall healthcare burden in the United States, as the treatment of pressure ulcers at early stages is still reimbursed by government programs. Pressure ulcers were found to be the second most common hospital billing claim and their cost to the U.S. Health System has increased from $3.8 billion in 2008 to about $10 billion in 2016 (Padula, 2017; Swafford et al., 2016).
The costs are expected to rise further due to the changes in medication and equipment prices, as well as labor costs. The effect of pressure ulcers on the economy is thus profound, and the high incidence of this condition can result in overbearing healthcare costs.
Interventions
There are many existing and new interventions that can help in the prevention or management of pressure ulcers, thus reducing these undesirable effects. Repositioning is considered to be an essential part of prevention and treatment, as it decreases pressure on the skin (Moore & Cowman, 2015; Swafford et al., 2016). However, the evidence on the effectiveness of this method is inconclusive, and most studies found it effective to use repositioning as part of comprehensive ulcer prevention and management protocol (Moore & Cowman, 2015; Swafford et al., 2016). Another possible treatment is negative pressure wound therapy. Although it is believed to improve healing rates and time, there is not enough research comparing it to other approaches (Dumville et al., 2015).
The two interventions that are supported by research are special support surfaces (e.g., mattresses) and dressings. These can help to prevent the development of pressure ulcers as well as improve healing rates. Chou et al. (2013) state that special mattresses and static support surfaces can help to alleviate the weight from a pressured area, thus reducing the probability of a patient developing a pressure ulcer. Similarly, dressings proved to be effective by several randomized controlled trials, suggesting a high level of evidence with regards to this method (Clark et al., 2014).
Interventions such as risk assessment and staff education were also considered in some of the studies. However, there is no conclusive data on whether risk assessment contributes to pressure ulcer prevention (Chou et al., 2013). Staff education on pressure ulcer prevention and management showed positive results when used as part of a comprehensive quality improvement initiative (Swafford et al., 2016). Hence, the research suggests that there are certain types of interventions that can be used to reduce the incidence of pressure ulcers, but it is more beneficial to use comprehensive programs that include a variety of interventions.
Results
As part of the review, the team found ten publications discussing various topics related to pressure ulcers and their prevention. Five of the studies were systematic reviews of randomized controlled trials, providing the highest level of evidence (Chou et al., 2013; Clark et al., 2014; Dumville et al., 2015; Marin et al., 2013; Moore & Cowman, 2015). The systematic reviews considered risk factors on pressure ulcers and current interventions, showing that dressings and special surfaces are the most useful methods for the prevention and healing of pressure ulcers.
Three of the publications included results from well-designed quantitative studies, providing a range of evidence at levels II to IV (Bredesen et al., 2015; Raju et al., 2015; Swafford et al., 2016). There was also one publication prepared for and presented as part of the National Pressure Ulcer Advisory Panel, which suggests that it offers a high level of descriptive evidence (Padula, 2017). Lastly, one study was a qualitative study that was chosen due to the wide range of resources used and a thorough overview of most topics associated with pressure ulcers (Bhattacharya & Mishra, 2015).
These five sources provided information on the effects of pressure ulcers on patients and organizations, while also commenting on some interventions and risk factors. All in all, the research produced a range of evidence for analysis, and the quality of publications used suggests an overall high quality of information. This allows using the literature review to inform recommendations for evidence-based practice.
The main strength of the review is that it provided a useful overview of the topic of pressure ulcers, highlighting the key concerns and the current understanding of effective interventions. The overall level of evidence gathered as part of the review was high, which also adds to the usefulness of the project to practice. One particular limitation of the review was its size and scope, which did not allow for including more details about different causes, risk factors, effects, and interventions.
Consecutively, the primary weakness of the review is the fact that it provides general, factual information on the topic. This information could still be used by organizations and researchers to guide pressure ulcer prevention but requires looking to other sources for details about particular interventions. The review also identified a specific gap in current research on pressure ulcer prevention. Namely, there is a small number of randomized controlled studies investigating the possible interventions. This leads to a limited body of knowledge with regards to the comparative effectiveness of prevention and treatment methods.
Discussion
The evidence-based review of the literature resulted in three key findings. First of all, pressure ulcers have some important risk factors that affect the probability of certain patients developing them (Coleman et al., 2013; Kaşıkçı et al., 2018). The main risk factors highlighted in research include older age, the presence of conditions affecting tissues and blood circulation, and organizational factors such as low nurse-to-patient ratio and the lack of patient ward safety culture (Bredesen et al., 2015; Marin et al., 2013; Raju et al., 2015).
This appears to be true when comparing to practice, as low nurse staffing reduces the quality of care and the attention devoted to each patient, whereas individual factors lead to pathological changes in tissues. To apply the results to practice, the patients with these risk factors and those treated in high-risk environments need to be targeted with pressure ulcer prevention methods.
Secondly, the evidence suggested that pressure ulcers have significant consequences for individuals and organizations. There is evidence that the condition is linked with infections, death, and increased length of hospital stay (Dumville et al., 2015; Raju et al., 2015). Other sources also indicate the high costs of pressure ulcers to organizations and the healthcare sector (Padula, 2017; Swafford et al., 2016). These results are also valid for the team’s practice settings, as we have witnessed the consequences of pressure ulcers for patient outcomes and organizational costs. The findings also support the need for well-informed strategies for pressure ulcer prevention and management.
Lastly, the review of evidence found that the two most promising interventions are dressings and special surfaces that relieve pressure on the skin (Chou et al., 2013; Clark et al., 2014). Additionally, staff education and risk assessment may be useful when included in comprehensive prevention programs (Swafford et al., 2016). When compared to practice, these results appear plausible; however, in our practice, special surfaces and dressings are used mostly for treating pressure ulcers rather than in prevention efforts. Applying these methods as part of prevention programs could yield positive results.
Proposed Change
The proposed change is to apply comprehensive prevention strategies to patients who are at risk of developing pressure ulcers. A multi-component effort would include risk appraisal of patients, the use of dressings and special surfaces, and staff education (Chou et al., 2013; Clark et al., 2014; Swafford et al., 2016). However, as Coleman et al. (2013) note hospitals are often low on supplies, human workforce, or funds to implement a variety of evidence-based measures. A systematic review of randomized controlled studies for repositioning used in preventing HAPUs demonstrated that this recommended practice has certain inconsistencies in implementation. As such, there seems to be no conclusive evidence of whether the 30-degree rotation is more effective than 90 degrees one (Bradford, 2016).
However, as compared to no intervention and other interventions such as all prevention protocol or awareness-raising, it showed outstanding results, significantly decreasing the incidence of pressure ulcers (Padula, 2017). In addition, repositioning is more cost-effective as compared to other measures such as the introduction of a specialized wound team, visual surveillance, pressure-controlling beds, staging, and other strategies. Thus, given the successful implementation of repositioning it will be chosen as the preferred intervention. The project will aim to reduce the incidence of hospital-acquired pressure ulcers and measure healing rates of all pressure ulcers, including those developed before admission in older adults through the means of repositioning.
Plan to Measure Outcomes
The EBP practice model that will be used for the project is the ACE Star Model of Knowledge Transformation, which includes the steps and actions required to collect and translate evidence into practice. The critical indicators for outcomes are the length of stay, pressure ulcer incidence, and the stage of hospital-acquired pressure ulcers. These indicators can be collected from patient medical records, and the results from pre-intervention and post-intervention groups will be compared using descriptive statistics, correlation and regression models, and the t-test.
The validity and reliability of these instruments are over 90%, as they are based on quantitative data that is analyzed automatically in special programs, such as the SPSS. The sample will include inpatients staying in a long-term rehabilitation center, and the sample size should be over 100 participants.
The suggested method of data collection is feasible because it does not require additional tools, such as questionnaires. The minimal period required for data collection is three months pre-intervention, and three months after implementation. The resources will include instructions and manuals on repositioning and special surfaces if these are already not available in the facility. The project will involve nurses and leaders of the organization, although minimal involvement of physicians is also anticipated. The costs of the project will largely depend on the resources that are already available in the facility.
The minimum cost of the project (i.e., if no additional equipment is required) will be between $3,000 and $5,000. Given that the costs of treating pressure ulcers with other measures are a lot higher, the project is cost-effective and feasible.
Conclusion
The present evidence-based practice review investigated the current knowledge on the causes, risk factors, consequences, and interventions for pressure ulcers. The results showed that pressure ulcers are influenced by various risk factors and have significant implications for patients and care providers. The results from research and practice experience support these findings and highlight the need to develop evidence-based interventions for reducing the incidence of pressure ulcers.
It is recommended that organizations apply a comprehensive strategy including risk appraisal, special surfaces, dressings, and staff education to achieve positive change. Yet, in the absence of resources, they should resort to implementing repositioning as key prevention practice. The review also indicated that there is a lack of comparative data on the effectiveness of different prevention and treatment methods, and future research should seek to fill these gaps.
References
Agency for Healthcare Research and Qality (AHRQ). (n.d.). Preventing pressure ulcers in hospitals. Web.
Bhattacharya, S., & Mishra, R. K. (2015). Pressure ulcers: Current understanding and newer modalities of treatment. Indian Journal of Plastic Surgery: Official Publication of the Association of Plastic Surgeons of India, 48(1), 4-16.
Bradford, N. K. (2016). Repositioning for pressure ulcer prevention in adults: A Cochrane review. International Journal of Nursing Practice, 22, 108-109.
Bredesen, I. M., Bjøro, K., Gunningberg, L., & Hofoss, D. (2015). Patient and organisational variables associated with pressure ulcer prevalence in hospital settings: A multilevel analysis. BMJ Open, 5(8), e007584.
Chou, R., Dana, T., Bougatsos, C., Blazina, I., Starmer, A., Reitel, K., & Buckley, D. (2013). Pressure ulcer risk assessment and prevention: Comparative effectiveness. AHRQ Comparative Effectiveness Review, 87(1), 1-358.
Clark, M., Black, J., Alves, P., Brindle, C. T., Call, E., Dealey, C., & Santamaria, N. (2014). Systematic review of the use of prophylactic dressings in the prevention of pressure ulcers. International Wound Journal, 11(5), 460-471.
Coleman, S., Gorecki, C., Nelson, E. A., Closs, S. J., Defloor, T., Halfens, R., … Nixon, J. (2013). Patient risk factors for pressure ulcer development: Systematic review. International Journal of Nursing Studies, 50(7), 974-1003.
Dumville, J. C., Webster, J., Evans, D., & Land, L. (2015). Negative pressure wound therapy for treating pressure ulcers. Cochrane Database of Systematic Reviews, 2015(5), 1-42.
Kaşıkçı, M., Aksoy, M., & Ay, E. (2018). Investigation of the prevalence of pressure ulcers and patient-related risk factors in hospitals in the province of Erzurum: A cross-sectional study. Journal of Tissue Viability, 27(3), 135-140.
Marin, J., Nixon, J., & Gorecki, C. (2013). A systematic review of risk factors for the development and recurrence of pressure ulcers in people with spinal cord injuries. Spinal Cord, 51(7), 522-527.
Moore, Z. E., & Cowman, S. (2015). Repositioning for treating pressure ulcers. Cochrane Database of Systematic Reviews, 2015(1), 1-19.
Nursing resources: Levels of evidence (I-VII). (2018). Web.
Padula, W. (2017). Let’s start at the top: Getting administrative buy-in. Web.
Raju, D., Su, X., Patrician, P. A., Loan, L. A., & McCarthy, M. S. (2015). Exploring factors associated with pressure ulcers: A data mining approach. International Journal of Nursing Studies, 52(1), 102-111.
Rasero, L., Simonetti, M., Falciani, F., Fabbri, C., Collini, F., & Dal Molin, A. (2015). Pressure ulcers in older adults: A prevalence study. Advances in Skin & Wound Care, 28(10), 461-464.
Swafford, K., Culpepper, R., & Dunn, C. (2016). Use of a comprehensive program to reduce the incidence of hospital-acquired pressure ulcers in an intensive care unit. American Journal of Critical Care, 25(2), 152-155.
Worsley, P. R., Smith, G., Schoonhoven, L., & Bader, D. L. (2016). Characteristics of patients who are admitted with or acquire Pressure Ulcers in a District General Hospital; A 3 year retrospective analysis. Nursing Open, 3(3), 152–158.