DNP 815 Week 2 Assignment Selection

Utilizing preventive care bundle to reduce the incidence of pressure ulcers among elderly and debilitated patients.

Theoretical Foundation

Literature Synthesis

Practice Change Recommendation

List the primary points for six sections.

i)       Background of the practice problem/gap at the project site

All patients require quality care irrespective of their conditions, age, knowledge, and other factors. As primary care providers, nurses should explore opportunities for quality improvement in practice sites to ensure patient needs are adequately addressed. Pressure ulcers significantly threaten patient safety and care quality and increase morbidity and hospitalization (Darvall et al., 2018). As a result, nurses should identify and implement appropriate evidence-based interventions to improve quality. The practicum site primarily relies on routine pressure ulcer prevention. Although it is somewhat effective, outcomes can be further improved through other creative practices.

ii)     Significance of the practice problem/gap at the project site

As mentioned above, pressure injuries are a significant risk to patient safety. Increasing morbidity, cost, and hospitalization hampers organizational functions, patient-provider relationships, and patients’ trust in care providers. As change leaders, nurses should guide organizations in implementing quality improvement projects to improve health outcomes. A preventive care bundle will be instrumental in reducing pressure ulcer incidence hence achieving better care outcomes. Implementing it implies reducing the gap between the current and the desired health outcomes.

iii)   Theoretical Foundations (choose one nursing theory and one evidence-based change model to be the foundation for the project):

Nursing theories are organized knowledge bodies that define what nursing involves and why nurses should do it. They provide a way to deliver care and respond to situations. Imogene King’s Goal Attainment theory suits this project. Hence it will be used to guide implementation. Its conceptual framework will be used as the change model. The theory’s fundamental principle is that nursing care is transactional; health is attained through the nurse-patient relationship (Butts & Rich, 2021). In this case, the nurse and patient goals and functions should be in line with each other. As a result, the nurse and patient should have a mutual understanding of needs, objectives, and the expected outcomes of the preventive bundle and related interventions.

iv)   Create an annotated bibliography using the “Preparing Annotated Bibliographies (APA 7th)” located in the Student Success Center.

Darvall, J. N., Mesfin, L., & Gorelik, A. (2018). Increasing frequency of critically ill patient turns is associated with a reduction in pressure injuries.

Critical Care and Resuscitation, 20(3), 217-222. https://europepmc.org/article/med/30153784.

Darvall et al. (2018) evaluated the effects of changing from a 5-hourly to 3-hourly turns on pressure injury incidence among critically ill patients. The study was founded on the tenet that prolonged immobility is a significant risk factor for pressure injuries; thus, increasing mobility would reduce the risk. The authors conducted pre-post intervention evaluation study for six months in an intensive care unit. They compared outcomes between patients under 5-hourly and 3-hourly turns. The primary finding was that a change in turn frequency from 5 hours to 3 hours halved the incidence of pressure injuries among critically ill patients. Similar outcomes are expected in the proposed project after implementing the preventive bundle.

Hahnel, E., El Genedy, M., Tomova‐Simitchieva, T., Hauß, A., Stroux, A., Lechner, A., … & Kottner, J. (2020). The effectiveness of two silicone dressings for sacral and heel pressure ulcer prevention compared with no dressings in high‐risk intensive care unit patients: A randomized controlled parallel‐group trial. British Journal of Dermatology, 183(2), 256-264. https://doi.org/10.1111/bjd.18621

Preventive dressing is a key component of preventive bundle for pressure ulcers. In this study, Hahnel et al. (2020) determined the effectiveness of preventive dressings on high-risk patients in intensive care units in reducing the incidence of pressure ulcers. In the intervention group, 212 patients had preventive dressing applied to the sacrum and heels while the control group received only standard prevention. The primary finding was that the incidence was lower in the intervention group (2.8%) compared to 10.5% in the control group. The authors underscored the importance of applying appropriate dressings in preventing pressure ulcers.

Lavallée, J. F., Gray, T. A., Dumville, J., & Cullum, N. (2019). Preventing pressure ulcers in nursing homes using a care bundle: A feasibility study. Health & Social Care in the Community, 27(4), e417-e427. https://doi.org/10.1111/hsc.12742

In this study, Lavallée et al. (2019) explored the effectiveness of a care bundle in preventing pressure ulcers in nursing homes. The study was founded on the principle that many people living in nursing homes are at risk of developing pressure ulcers. In response, Lavallée et al. (2019) conducted a mixed methods feasibility study of the effectiveness of a care bundle through a before-and-after care design. The incidence rate was evaluated five weeks before implementing the bundle and continued for nine weeks during the bundle implementation phase. The primary finding was that ulcer prevention techniques such as repositioning, skin inspection, and checking support services enhanced the quality of care delivered. Accordingly, the study affirmed the potential for the intervention, and similar outcomes are expected in the current project.

Pickham, D., Berte, N., Pihulic, M., Valdez, A., Mayer, B., & Desai, M. (2018). Effect of a wearable patient sensor on care delivery for preventing pressure injuries in acutely ill adults: A pragmatic randomized clinical trial (LS-HAPI study). International Journal of Nursing Studies, 80, 12-19. https://doi.org/10.1016/j.ijnurstu.2017.12.012.

Routine repositioning of at-risk patients is highly recommended for preventing hospital acquired pressure injuries.  In response, Pickham et al. (2018) evaluated the effectiveness of a wearable patient sensor in improving care delivery and patient outcomes in acutely ill patients. The role of the sensor was to increase the total time with turning compliance. The study was conducted in two ICUs in California and included two groups. The first group received turning care based on traditional turn reminders and practices (n = 653) while the other group received real-time, optimized turning practices through a wearable patient sensor (n = 659). The primary finding was that optimizing turning through a wearable patient sensor had a significant protective effect against the development of pressure injuries. The study underscores the effectiveness of a preventive bundle that contains different practices in reducing the incidence of pressure ulcers.

Yap, T. L., Horn, S. D., Sharkey, P. D., Zheng, T., Bergstrom, N., Colon-Emeric, C., … & Kennerly, S. M. (2021). Effect of varying repositioning frequency on prevention of pressure injuries in nursing home residents: TEAM‐UP cluster‐randomized clinical trial results. Research Square, 1-21. https://doi.org/10.21203/rs.3.rs-717425/v1

Pressure injuries cause a lot of pain and infections besides lengthening hospital stays and increasing health care costs. Repositioning is highly recommended as a preventive measure that can reduce the incidence of pressure injuries in health care settings. In this study, Yap et al. (2021) investigated the clinical effectiveness of repositioning intervals among patients in selected nursing homes. The primary finding was that repositioning intervals of four hours were more effective (95%) in reducing pressure injuries compared to 3-hour repositioning frequency (90%) and 2-hour repositioning (80%).  The study demonstrates the effectiveness of repositioning but implementers must understand the appropriate frequency depending on the criticality of patient needs.

v)      Practice Change Recommendation: Validation of the Chosen Evidence-Based Intervention

Patient care standards should be improved progressively. Practice change through quality improvement projects can effectively improve outcomes. As a result, the preventive bundle will produce more desirable outcomes than routine pressure ulcer prevention strategies. It presents an excellent opportunity for reducing pressure ulcers and overall care cost.

vi)   Summary of the findings written in this section.

The annotated research underscores the benefits of a preventive care bundle in reducing the incidence of pressure ulcers. Recommended practices include a change in turn frequency to increase mobility, optimizing turning practices using a wearable sensor, repositioning, skin inspection, and checking support services. The preventive bundle should combine different practices, and the studies confirm its effectiveness in reducing pressure injuries.

3)      Problem Statement:

Describe the variables/groups to project in one sentence.

The preventive bundle is expected to reduce the incidence of pressure ulcers in the facility but the magnitude of the impact can only be established after implementing the project and analyzing the outcomes.

4)      PICOT Question Converts to Evidence-Based Question:

In elderly and debilitated patients, will the implementation of a pressure preventive bundle reduce the incidence of pressure injury within 60 days?

Evidence-Based Question:

Provide the templated statement.

To what extent will the implementation of a pressure preventive bundle reduce the incidence of pressure injury among elderly and debilitated patients in the long-term care facility?

Setting

Location

Inclusion and Exclusion Criteria

5)      Sample, Setting, Location

Identify sample, needed sample size, and location (project phenomena with small numbers and variables/groups with large numbers).

i)       Sample and Sample Size: the sample will contain elderly and debilitated patients with pressure injuries or at risk of pressure injuries. A sample size of 50 participants is reasonable to implement the current project.

ii)     Setting: The setting for the study is a long-term care facility

iii)   Location:  suburban Maryland City

iv)   Inclusion Criteria

Participants should be patients of sound mind, willing to participate in the study, and not part of another related or unrelated study.

v)      Exclusion Criteria

Participants unwilling to participate, of unsound mind, or likely to leave the country within the study period will be excluded. Those unable to read and write will be excluded too.

6)      Define Variables:

i)       Independent Variable (Intervention): application of preventive bundle (preventive interventions)

ii)     Dependent Variable (Measurable patient outcome): incidence of pressure injuries.

7)      Project Design:

This project applies a quality improvement approach.  You must be able to explain and cite the difference between research and quality improvement (one paragraph each).

i)       Quality Improvement: Quality improvement initiatives focus on improving care. Health care practitioners implement quality improvement projects to standardize processes to improve patient outcomes and reduce variation (CMS.gov, 2021). The initiatives use knowledge from evidence-based research.

ii)     Research: Research involves the quest for new knowledge. Researchers usually study and test phenomena to prove or disprove hypothesis.  The knowledge developed through research is used in quality improvement projects.

iii)   Summarize:  the current project is a quality improvement initiative since its objective is to reduce outcome variations. Patient care outcomes will improve after reducing the incidence of pressure injuries through a preventive care bundle.

8)      Purpose Statement:

Provide the templated statement.

The purpose of this quality improvement project is to determine if the implementation of a Care Bundle Intervention would impact pressure ulcer prevention among elderly and debilitated patients in a long-term-care facility. The project will be piloted over an eight-week period in a suburban Maryland city in a long term care facility.

9)      Data Collection Approach:

i)       Essential patients’ demographics such as age, gender, education level will be collected. Their knowledge of the intervention will also be evaluated.

ii)     The incidence of pressure ulcers will be measured, and the baseline data will be sourced from electronic health records (EHRs).

iii)   Data pre- and post-intervention will be collected while primarily focusing on the incidence.

iv)   Describe the step-by-step process you will use to collect the data, explain where the data will come from, and how you will protect the data and participants.

1. Record patients’ essential demographics.

2. Obtain the baseline data from the EHRs.

3. Measure the incidence of pressure ulcers before and after the intervention and compare outcomes. A reduction of incidence by over 50% will be considered statistically significant.

4. Ensure the data is inaccessible to unauthorized personnel

v)      Various potential ethical issues include protection of human subjects, voluntary participation, and privacy. All data will remain confidential and no participant should be coerced for any reason.

vi)   The project must adhere to ethical principles of beneficence, non-maleficence, and autonomy. It is designed to benefit the patients by improving outcomes and presents no harm. Participants will also be allowed to make independent decisions to avoid biased results.

10)  Data Analysis Approach:

Data will be analyzed through comparative data analysis. The difference between the incidence before and after the project will be used to compute the percentage difference.

Statistically significant outcome: a reduction by 0.5

Clinically significant outcome- value <0.5

Butts, J. B., & Rich, K. L. (2021). Philosophies and theories for advanced nursing practice. Jones & Bartlett Learning.

Darvall, J. N., Mesfin, L., & Gorelik, A. (2018). Increasing frequency of critically ill patient turns is associated with a reduction in pressure injuries.

Critical Care and Resuscitation, 20(3), 217-222. https://europepmc.org/article/med/30153784.

Hahnel, E., El Genedy, M., Tomova‐Simitchieva, T., Hauß, A., Stroux, A., Lechner, A., … & Kottner, J. (2020). The effectiveness of two silicone dressings for sacral and heel pressure ulcer prevention compared with no dressings in high‐risk intensive care unit patients: A randomized controlled parallel‐group trial. British Journal of Dermatology, 183(2), 256-264. https://doi.org/10.1111/bjd.18621

Lavallée, J. F., Gray, T. A., Dumville, J., & Cullum, N. (2019). Preventing pressure ulcers in nursing homes using a care bundle: A feasibility study. Health & Social Care in the Community, 27(4), e417-e427. https://doi.org/10.1111/hsc.12742

Pickham, D., Berte, N., Pihulic, M., Valdez, A., Mayer, B., & Desai, M. (2018). Effect of a wearable patient sensor on care delivery for preventing pressure injuries in acutely ill adults: A pragmatic randomized clinical trial (LS-HAPI study). International Journal of Nursing Studies, 80, 12-19. https://doi.org/10.1016/j.ijnurstu.2017.12.012.

Yap, T. L., Horn, S. D., Sharkey, P. D., Zheng, T., Bergstrom, N., Colon-Emeric, C., … & Kennerly, S. M. (2021). Effect of varying repositioning frequency on prevention of pressure injuries in nursing home residents: TEAM‐UP cluster‐randomized clinical trial results. Research Square, 1-21. https://doi.org/10.21203/rs.3.rs-717425/v1