Pressure Ulcer Protocol in the Emergency Department

PICOT Question

In patients that are identified as high risk for developing a pressure ulcer (P), does the implementation of a pressure ulcer protocol initiated in the emergency department (I) as compared to patients who receive usual care (C), reduce the incidence of hospital-acquired pressure ulcers (O) on day 3 of hospitalization (T)?

The PICOT research question suggests that a comparison group will be in place not being subjected to the implementation of emergency department pressure ulcer protocol. It will serve as a control group since the patients will be receiving standard care. The comparison allows us to directly compare the results of the intervention in a health care institution under similar conditions but following significantly varying protocols.

The decision to introduce time is appropriate within the context of the research question. It is necessary to determine a period that would be established to determine the effectiveness of the protocol. Therefore, time is necessary for observation of the incidence of hospital-acquired pressure ulcers (PU).

	Study #1	Study #2	Study #3	Study #4	Study #5	Synthesis
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(p) Population	Patients admitted to the Emergency Department at Bordeaux, France.	Professional nurses working in 6 hospitals in Australia	Nursing staff working with trauma patients in the emergency department of Kashani and Bahona hospitals in Iran.	Critically ill and injured patients admitted to the emergency department and transferred to the ICU at the Royal Melbourne Hospital.	The study focused on evaluating hospital programs as a whole rather than individuals	All of the population included in the studies are either patients or staff who directly deal with PU.

(i) Intervention	The hospital staff was provided with training to diagnose and prevent pressure ulcers according to international guidelines	Multi-model intervention program including careful patient assessment using guidelines, use of nursing champions, and prevention strategies such as repositioning, skincare, and nutritional support.	Questionnaire to evaluate nurses level of knowledge about PU	Use of silicone multi-layered foam dressings applied to patients as prevention of sacral and heel pressure ulcers	The AHRQ patient, safety indicators toolkit, was used to determine the return on investment of PU prevention programs.	Interventions are aimed at prevention through either treatment or staff diagnosis.

(c) Comparison	National statistics (French) on the prevalence of pressure ulcers	No control group. The study traced prevalence before and after the intervention	No comparison	Control group received standard care		Most of the studies have a control group receiving standard care

(o) Outcome	7.8% of patients had pressure ulcers at admission and 12.3% at discharge. Length of stay longer than 4 hours and a higher mean age had a significant effect on prevalence	Prevalence of hospital-acquired pressure ulcers was reduced from national average of 6.63% to 2,47%, and the prediction rate stood at 92.3% on the Braden scale	The average percentage of correct answers is 64.6%. However, nurses have poor knowledge about pressure ulcer onset, answering only 57% of questions correctly in that category.	The intervention resulted in 10% absolute risk reduction based on the difference	A baseline return on investment ration of 1.61 which amounts to $127.51 per patient.	Interventions seek to reduce incidences of PU at emergency departments

(t) time	15 days	16 months	3 months	20 months	n/a	Studies track the flow of patients over time

Evidence Synthesis

Citation	Design	Sample size:	Major Variables:	Study findings:	Level of Evidence	Evidence
			Independent	Strengths and weaknesses
			Dependent
Dugaret, E., Videau, M., Faure, I., Gabinski, C., Bourdel-Marchasson, I., & Salles, N. (2014). Prevalence and incidence rates of pressure ulcers in an emergency department. International Wound Journal, 11(4), 386-391. doi: 10.1111/j.1742-481X.2012.01103.x	Observational cohort study. Demographical data was collected via questionnaire.	The sample size was adequate with 602 participating patients	Independent variables were identified by the study are risk factors for developing pressure ulcers, including the degree of physical activity, type of support surface, comorbidity score, CRP levels, and the reason for admission. The dependent variable is the incidence of pressure ulcers in patients at discharge	Strengths: The study considers a variety of risk factors for pressure ulcers beyond staff training. Limitations: findings cannot be generalized since emergency wards differ regarding staff training and pressure ulcer protocol	Level IV	The incidence of pressure ulcers remains high, increasing to 15.7% in patients aged 75 and older. Development factors include poly-pathology and elevated level of inflammation. The rising rates can be explained by the necessity to triage patients in a manner which will address acute problems as PU. Furthermore, longer length of stay can be a contributing factor since PU can develop in under 2 hours time.
Mallah, Z., Nassar, N., & Badr, L. K. (2015). The effectiveness of a pressure ulcer intervention program on the prevalence of hospital-acquired pressure ulcers: Controlled before and after study. Applied Nursing Research, 28(2), 106-113. doi: 10.1016/j.apnr.2014.07.001	Evaluation prospective research design controlled before and after study	A sample size of 468 patients. The study notes that similar long-term care studies only required 150 patients to determine results. Therefore it has an adequate sample size	Independent: the introduction of a multi-modal intervention program which focused on PU prevention Dependent: the rate of incidence of hospital-acquired pressure ulcers in the patient group	Strengths: study notes that it has a powered sample size, the participation of experienced nursing staff and adherence to NDNQI guidelines. Limitations: Descriptive design rather than experimental. Risk factors for PUs such as staffing ratios and impaired mobility in patients were not used for assessment	Level III	Research shows that using a multi-modal intervention based on the available resources and workforce is effective in reducing the incidence of PU. Furthermore, nursing leaders and adequate staff training allowed for a better implementation of various interventions.
Rafiei, H., Abdar, M. E., Iranmanesh, S., Lalegani, H., Safdari, A., & Dehkordi, A. H. (2014). Knowledge about pressure ulcer prevention, classification, and management: A survey of registered nurses working with trauma patients in the emergency department. International Journal of Orthopaedic and Trauma Nursing, 18(3), 135-142. doi: 10.1016/j.ijotn.2014.03.004	Cross-sectional exploratory study	159 participants. It is an acceptable sample size and a large percentage of the 185 nurses that were eligible for the study.	IV: An examination assessing nurses knowledge about the characteristics and prevention of pressure ulcers DV: A calculated statistical score which determines nurse competency on the issue.	Strengths: Created a classified test which allows to determine staff competence on the rising issue of pressure ulcers. Limitations: Convenience sample with the possibility of selection bias. Self-reporting could reduce result validity	Level V	Trauma patients are at high-risk for the prevalence of pressure ulcers. Since nursing staff is directly involved in the prevention and management of the condition, it is critical that their level knowledge should be adequate to respond appropriately and create a necessary environment to reduce incidence rates.
Santamaria, N., Gerdtz, M., Sage, S., McCann, J., Freeman, A., Vassilious, T., & Knott, J. (2015). A randomised controlled trial of the effectiveness of soft silicone multi-layered foam dressings in the prevention of sacral and heel pressure ulcers in trauma and critically ill patients: the border trial. International Wound Journal, 12(3), 302-309. doi: 10.1111/iwj.12101	Prospective open-label randomized controlled trial	440 trauma and critically ill patients. The adequate sample for the experiment	IV: The intervention group had specially designed Mepilex dressings applied to sacrum and heels throughout the hospital stay. DV: Number of patients developing a pressure ulcer. Including rate per group and anatomical site.	Strengths: Introduced mechanical medical prevention instead of focusing on staff awareness training which is more prone to human error. Weaknesses: The study was limited to a single site. Data collectors were not blind due to the nature of treatment intervention. The study only applies to critically ill patients, not the general population.	Level II	The significant sample size was comparable in this intervention treatment. A 10% lower incidence rate suggests that multi-layered silicone dressings can have a significant effect on the reduction of sacral and heel pressure ulceration.
Spetz, J., Brown, D., Aydin, C., & Donaldson, N. (2013). The value of reducing hospital-acquired pressure ulcer prevalence: An illustrative analysis. Journal of Nursing Administration, 43(4), 235-241. doi: 10.1097/NNA.0b013e3182895a3c	Illustrative meta-analysis	The CALNOC database was used to extract data for 78 hospitals and 258,456 patients. The sample size is adequate to evaluate prevention programs as a whole.	IV: Measurement of improvement in HAPU rates through intervention and prevention programs DV: Costs saved per patient based on predicted costs of treatment in comparison to implementing a prevention program.	Strengths: offers a crucial numerical statistic on the cost savings per patient that the prevention programs offer instead of a generalized description of benefits. Limitations: Based on the assumption that prevention programs work to reduce HAPU rates, which is a costly and long-term commitment. Data used is from prevalence studies which are very sensitive to researcher standards.	Level I	Programs aimed at surveillance and prevention of hospital-acquired pressure ulcers can bear significant cost-saving effects for a hospital considering that Therefore, such interventions should be utilized by nurse executives to ensure high-quality outcomes inpatient care.

References

Dugaret, E., Videau, M., Faure, I., Gabinski, C., Bourdel-Marchasson, I., & Salles, N. (2014). Prevalence and incidence rates of pressure ulcers in an emergency department. International Wound Journal, 11(4), 386-391. Web.

Mallah, Z., Nassar, N., & Badr, L. K. (2015). The effectiveness of a pressure ulcer intervention program on the prevalence of hospital acquired pressure ulcers: Controlled before and after study. Applied Nursing Research, 28(2), 106-113. Web.

Rafiei, H., Abdar, M. E., Iranmanesh, S., Lalegani, H., Safdari, A., & Dehkordi, A. H. (2014). Knowledge about pressure ulcer prevention, classification and management: A survey of registered nurses working with trauma patients in the emergency department. International Journal of Orthopaedic and Trauma Nursing, 18(3), 135-142. Web.

Santamaria, N., Gerdtz, M., Sage, S., McCann, J., Freeman, A., Vassilious, T., & Knott, J. (2015). A randomised controlled trial of the effectiveness of soft silicone multi-layered foam dressings in the prevention of sacral and heel pressure ulcers in trauma and critically ill patients: the border trial. International Wound Journal, 12(3), 302-309. Web.

Spetz, J., Brown, D., Aydin, C., & Donaldson, N. (2013). The value of reducing hospital-acquired pressure ulcer prevalence: An illustrative analysis. Journal of Nursing Administration, 43(4), 235-241. Web.

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