Running head: EVIDENCE-BASED PRACTICE PRESSURE ULCERS

Evidence-Based Practice Pressure Ulcers Chelsea Dean University of South Florida

EVIDENCE-BASED PRACTICE PRESSURE ULCERS Decubitus or pressure ulcers are a serious problem within todays healthcare system often interrelated with patient morbidity, mortality, and health care costs. It is estimated that over three million Americans are affected by pressure ulcers (Smith et al., 2013). The National Pressure Ulcer Advisory Panel (NPUAP) reports that pressure ulcer incidence ranges between 0.4 to 38 percent in hospitals, between 2.2 to 23.9 percent in skilled nursing facilities, and between 0 to 17 percent for home health agencies. Pressure ulcer incidence is especially high with the elderly, and it is reported that at least 15 percent of elderly patients will develop pressure ulcers within the first week of hospitalization. Patient mortality has a strong association with pressure ulcers. Studies have noted mortality rates as high as 60 percent within one year of hospital discharge for elderly patients (Lyder & Ayello, 2008). As well as health-related issues associated with pressure ulcers, there is also the issue of pressure ulcers and their connection to health care costs. In October 2008, the Centers for Medicare and Medicaid Services stopped providing reimbursement for various hospital-acquired conditions, including stage III and stage IV pressure ulcers (Armour-Burton, Fields, Outlaw, & Deleon, 2013). It is noted that the average cost for pressure ulcer treatment is approximately 37,800 dollars the cost of treating pressure ulcers is two and a half times greater than the cost of preventing them (Lyder & Ayello, 2008). Pressure ulcers develop when tissues are compressed by an external force. Examples of external forces, especially seen in hospitals, include mattresses, wheelchair pads, or bed rails. The compression of tissues causes microcirculatory occlusion, due to pressure rising above capillary filling pressure, resulting in ischemia. Ischemia often leads to inflammation and tissue anoxia, eventually leading to cell death, necrosis, and ulceration. Pressure ulcers can begin developing after as little as two hours of uninterrupted tissue compression (Revis, 2012).

EVIDENCE-BASED PRACTICE PRESSURE ULCERS Pressure ulcer severity is assessed using a staging system ranging from a stage I ulcer to a stage IV ulcer (Smith et al., 2013). Stage I ulcers represent intact skin with signs of impending ulceration. Stage I ulcers are generally erythemic and blanchable. Stage II ulcers represent a partial-thickness loss of skin. Stage II ulcers generally involve the epidermis and possibly dermis, and present as an abrasion, blister, or superficial ulceration. Stage III ulcers represent a full-thickness loss of skin with extension into subcutaneous tissue. Stage III ulcers generally present as a crater. Stage IV ulcers represent full-thickness loss of skin and subcutaneous tissue and extension into the underlying fascia. Sinus tracts and severe undermining are common characteristics of stage IV ulcers (Revis, 2012). There are various pressure ulcer treatment strategies that have been proven effective for use in a hospital setting. An article by Smith et al. (2013) identified 174 studies that addressed the comparative effectiveness and harms of multiple examples of pressure ulcer treatment. The article found moderate-strength evidence that air-fluidized beds, protein-containing nutritional supplements, radiant heat dressings, and electrical stimulation improved healing of pressure ulcers. The article also found that alternating-pressure surfaces, platelet derived growth factor, hydrocolloid dressings, and light therapy may also improve healing, although evidence was more limited in regards to those therapies (Smith et al., 2013). While the implementation of appropriate and effective prevention strategies is necessary, nurse education is also critical in the prevention and treatment of pressure ulcers in clinical practice. Florence Nightingale believed that, If he has a bedsore, its generally not the fault of the disease, but of the nursing (Lyder & Ayello, 2008). An article by Armour-Burton, Fields, Outlaw, and Deleon (2013) researched the impact of a hospital implemented, nurse-driven project, The Healthy Skin Project, created to treat and prevent hospital-acquired pressure ulcers.

EVIDENCE-BASED PRACTICE PRESSURE ULCERS The study consisted of three specific components, a unit-based wound liaison nurse, staff education, and involvement of nursing assistants in the prevention of pressure ulcers. Additionally, the project included a skin care plan which summarized the specific treatment techniques nurses should utilize dependent on a patients pressure ulcer staging. For example, the orders for treatment of a stage I pressure ulcer include positioning the patient off of the affected area, elevating the patients heels off of the bed, and turning the patient every two hours (Armour-Burton et al., 2013). A recent article regarding Tampa General Hospital (Tampa General) is an example in which clinical settings do not always utilize appropriate pressure ulcer prevention and treatment strategies. According to the Tampa Bay Times, Tampa General is currently facing litigation regarding two previous patients, Perry Harvey Jr. and Tiffany Albury, and their development of pressure ulcers during their hospital stay. While hospitalized, the two patients both developed pressure ulcers on the sacrum. Specifically regarding the case of Ms. Albury, it was documented that due to the patients size, a lift team was required to turn the patient in bed. During Ms. Alburys stay in the intensive care unit of the hospital, the unit was understaffed, and Ms. Albury was not turned on a routine schedule, per Tampa Generals hospital policy. Ms. Albury and Mr. Harvey died a short time after discharge from Tampa General (Danielson, 2013). Although Tampa General failed at routinely turning patients as dictated by hospital policy, there was also a lack of additional hospital prevention strategies discussed throughout the periodicals article. While turning patients frequently, if actually implemented by a facility, is an effective pressure ulcer treatment and prevention strategy, there are various other strategies that should have been utilized by Tampa General as well.

EVIDENCE-BASED PRACTICE PRESSURE ULCERS References Armour-Burton, T., Fields, W., Outlaw, L., & Deleon, E. (2013). The healthy skin project: Changing nursing practice to prevent and treat hospital-acquired pressure ulcers. Critical Care Nurse, 33(3), 32-40. doi:10.4037/ccn2013290 Danielson, R. (2013, November 17). Tampa general hospital's care of Perry Harvey Jr. brings more litigation. The Tampa Bay Times. Retrieved from http://www.tampabay.com/news/health/medicine/tampa-general-hospitals-care-of-perryharvey-jr-brings-more-litigation/2152940 Lyder, C. H., & Ayello, E. A. (2008). Pressure ulcers: A patient safety issue. In R. G. Hughes (Ed.), Patient safety and quality: An evidence-based handbook for nurses (chapter 12). Retrieved from http://www.ncbi.nlm.nih.gov/books/NBK2650/ Revis, D. R. (2012). Decubitus ulcers. Retrieved from http://emedicine.medscape.com/article/190115-overview#a0112 Smith, M., Totten, A., Hickam, D. H., Rongwei, F., Wasson, N., Rahman, B., & Saha, S. (2013). Pressure ulcer treatment strategies. Annals Of Internal Medicine, 159(1), 39-50.