Guidelines for Critiquing Research Designs in Quantitative Studies

Original Article

Inpatient Pressure Ulcer Prevalence in an Acute Care Hospital Using Evidence-Based Practice M. Elizabeth Beal, MSN, RN, CWON • Kimberly Smith, MSN, RN, CWON


Pressure ulcer prevention,

prevalence rate, hospital-acquired,

evidence-based practice,

acute care

ABSTRACT Background: A national goal was set in 2004 for decreasing hospital-acquired pressure ulcers (HAPUs). A mean to achieve that goal was initiated in 2005 with long-term care facilities. Acute care facilities, with encouragement from the Centers for Medicare and Medicaid Services, took action.

Aims: Pressure ulcer prevention efforts at MaineGeneral Medical Center (MGMC), a 192-bed acute care hospital in Augusta, Maine, sought to reduce HAPU prevalence from a mean of 7.8% in 2005.

Methods: A retrospective study over a 10-year period, from 2005 through 2014, tracked HAPUs and evidence-based practice (EBP) initiatives to decrease the annual mean prevalence rate.

Results: The annual mean HAPU prevalence rate of 7.8% in 2005 decreased to 1.4% in 2011, then maintaining this level through 2014 at MGMC. Evidence-based practices for pressure ulcer prevention were implemented using data collection tools from the National Database of Nursing Quality Indicators; guidelines from the National Pressure Ulcer Advisory Panel; and procedural guidance tools from the 5 Million Lives Campaign and the Agency for Healthcare Research and Quality.

Conclusions: Accurate data collection methods and evidence-based guidelines are vital to im- proving care; yet planning with annual review, fostering an EBP culture, by-in of stakeholders, and education, are the means to long-term consistent implementation of pressure ulcer prevention measures.

Linking Evidence to Action: Keys to decreasing and maintaining the rate were based on effec- tive scientific evidence for prevention of pressure ulcers: assessment tools, education, planning guidance, documentation, and evidence-based practice guidelines.

BACKGROUND The National Council on Disability Government Performance and Results Act (National Council on Disability, 2005) set a national goal to reduce long-term care facility pressure ulcer prevalence rates. The Centers for Medicare and Medicaid Ser- vices (CMS, 2004) was directed by this act to create a means to achieve that goal (Lyder & van Rijswijk, 2005). In response, the Institute for Healthcare Improvement (IHI; 2006) began the Protecting 5 Million Lives From Harm campaign, build- ing on its 100,000 Lives campaign started in 2004, to help hospitals engage in preventing pressure ulcers. In 2006, the Agency for Healthcare Research and Quality (2014) developed the Pressure Ulcer Prevention Toolkit citing the National Pres- sure Ulcer Advisory Panel (NPUAP, 2014) as a resource for pressure ulcer best practice.

Pressure ulcer prevention efforts at MaineGeneral Medi- cal Center (MGMC), a 192-bed acute care hospital in Augusta, Maine, has been successful in reducing hospital-acquired pres-

sure ulcers (HAPU) prevalence in patients from an annual mean of 7.8% in 2005, to 1.4% in 2014 (see Figure S1, avail- able with the online version of this article), using measurement tools from the National Database of Nursing Quality Indicators (NDNQI; Press Ganey Associates, 2015). HAPUs are any stage of pressure ulcer assessed on a patient after 24 hours of being in the hospital that was not documented upon admission. This ar- ticle will discuss the successful process used by MGMC to reach and maintain the decrease in annual mean hospital-acquired pressure ulcer prevalence rate through evidence-based prac- tices (EBP).

AIMS AND METHODS This is a retrospective study addressing the impact of various implementations to decrease hospital-acquired pressure ulcers (see Figure S2, available with the online version of this article). Over the 10 years included in this discussion the same certified wound, ostomy nurse (CWON) directed the implementations.

112 Worldviews on Evidence-Based Nursing, 2016; 13:2, 112–117. C© 2016 Sigma Theta Tau International

Original Article Four medical-surgical RNs were members of the process for this period of time. Other “skin champions,” Wound Treatment Associates (WTAs), and wound committee members changed as staff terminated their employment, or transferred to other departments. Records were kept from 2005 on plans of action, data collected from chart reviews and studies, and the educa- tional plans, as well as copies of trainings. The prevalence rate is determined through the NDNQI prevalence study, conducted quarterly, by determining the number of HAPUs documented in the hospital on the day of the study. The number of HA- PUs is then divided by the number of patients assessed in the hospital that day. The mean prevalence rate of the combined quarterly studies is the annual mean prevalence rate.

DISCUSSION In order for CMS to make progress toward a decrease in HAPUs, regional and state multidisciplinary health task forces were initiated. The Maine Department of Health and Human Services established a pressure ulcer task force in 2005 (Maine Healthcare Association, n.d.), that included MGMC and CWONs. A literature review from this task force cited two national studies emphasizing the need for action. One was published in the Journal of Wound, Ostomy & Continence Nursing (Whittington, Patrick, & Roberts, 2000), and the other in Advances in Skin & Wound Care (Whittington & Briones, 2004). This sparked the development of a wound committee at MGMC guided by the CWONs and consisting of nurse representatives from medical surgical units, critical care (CCU), operating room (OR), rehabilitation, and float pool. The NDNQI study of HAPUs was started in November 2005, re- sulting in a prevalence of 7.8%. After learning the national rate was 7% (Cuddigan, Berlowitz, & Ayello, 2001), one of the first actions was to recommend nurse training in pressure ulcer prevention (PUP).

Responding in 2006 the CWONs developed a voluntary self- study program with testing on pressure ulcer staging and pre- vention based on the National Pressure Ulcer Advisory Panel (NPUAP) guidelines (Press Ganey Associates, 2015). Those who completed this program were skin-care champions on their units and conducted the NDNQI survey each quarter. Data was collected on each patient on each unit with a bedside skin assessment completed by the “skin-champions,” followed by a chart review with specific categories such as various pres- sure ulcer risk factors, and whether pressure ulcer plans of care were in place. Inter-rater reliability was increased by the CWON assessing patients who were deemed by the skin-care champion to have a hospital-acquired pressure ulcer.

A 2006 year-end goal of 5% for HAPU prevalence was set. MaineGeneral’s objectives were created based on data collected from the NDNQI study and chart reviews. To increase the Braden score (Braden & Bergstrom, 1998) skin breakdown risk assessment completion upon admission from 85% to 100%, and to increase compliance with implementation of the pressure ulcer prevention NPUAP guidelines from 15% to 100% and increase documentation of interventions from 15%

to 100%. To reach these objectives, in-services were provided on compliance issues and best practice based on NPUAP guidelines (2014); performance of monthly chart audits in between the study dates; and the CWONs made regular visits to each unit and assessed the electronic medical record (EMR) for ease and accuracy of wound documentation. Despite these actions, the annual mean rate of HAPU prevalence at the end of 2006 was 8%.

In 2007, a qualitative survey on one unit of 11 registered nurses (RN) and 5 nursing unit assistants (NUA) was con- ducted to determine attitudes and understanding of pressure ulcer prevention (PUP). This showed the greatest perceived ob- stacles to prevention interventions were lack of time and poor communication. Lack of knowledge and inadequate equipment were also cited. After education via in-services and staff meet- ings on best practice, skin-care champions encouragement at the bedside, and monitoring through chart reviews and the prevalence study, the annual mean prevalence rate decreased minimally in 2007 to 6.9%. At that time it was predicted that when nurses were given the knowledge, they would automat- ically turn it into practice. This prediction was not realized in the study rate. According to a national retrospective study in the northeast region of the United States, the annual mean prevalence rate for 2007 was 4.6% (Lyder et al., 2012).

In 2008, the 5 Million Lives Getting Started Kit: Prevent Pressure Ulcers How to Guide (IHI, 2006) was used to support and incorporate EBP. In particular, small tests of change were conducted, using the plan-do-study-act cycle with one medical surgical unit as a test case. For instance, the unit RNs posted a paper clock on the wall in the patient’s room, to remind staff of the need to turn the patient every 2 hours. It was learned that at first the clock helped, but then it was ignored, blending in with the other items of importance. Next, a yellow card was used. The cared was attached to the outside of the door jam signifying the patient was at high-risk for pressure ulcers to prompt more frequent assessment. This was successful, as staff said it was easy to see and a reminder to go into the room to turn the patient more frequently.

At the same time, other hospital EBP initiatives began. For example, the OR established a policy for PUP using gel pads and memory foam, developed a four-person transfer process to minimize skin shearing, and initiated skin assessments before and after a patient was in the prone position. Case studies on positioning and the Braden scale were presented at staff meet- ings on the medical surgical units. An algorithm was devel- oped by the CWONs for pressure redistribution surfaces, such as when to use a chair air cushion or a low-air-loss mattress. Distribution started of a monthly PUP newsletter highlight- ing skin tips of the month. By the end of 2008, the Agency for Healthcare Research and Quality tool kit (2014), and guidelines from the NPUAP (2014), effectively impacted the planning and implementation process in regards to five areas: patient as- sessment including the Braden score, management of excess skin moisture, optimization of patient nutrition, skin hydra- tion, and pressure minimization. In December of 2008, the

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Decreasing Pressure Ulcers Using EBP

annual mean prevalence rate was a mean of 6.8%. There was a notable amount of effort with minimal positive outcome in the data.

Starting in 2009, encouraging change began, with a detailed plan for an integrated PUP program written by the CWONs with goals, objectives, content, teaching and learning strategies, method of delivery, resources, and time frame guidelines provided. This plan, with input from nursing-quality and clinical education, the wound committee, and nurse unit managers, proposed a two-phase process of education and im- plementation. In the first phase, in-services and annual compe- tency reviews were mandatory, accentuating RN and NUA re- sponsibilities following the 5 Million Lives content (IHI, 2007). Four areas were stressed: the creation of a patient and family brochure, intranet access to pressure ulcer resources, new nurse orientation presentation, and clinical documentation. A key to this phase was accountability for tasks being clearly stated and distributed between wound nurses, managers, clinical education, informatics, and nursing administration.

Action on the second phase of implementation began in July 2009, and was promoted system-wide via the Clinical Practice Model’s (Elsevier, 2015) central partnership council, providing a method for dissemination of information on pressure ulcer EBP. Nursing units were charged with developing a commu- nication process to ensure that all staff, including the primary care provider, was aware of at-risk patients. Methods included skin assessment during daily interdisciplinary unit rounds, and the placement of a prevention plan in the chart. Each unit was required to use the same PUP audit tool developed by the CWONs in order to standardize the monitoring of compliance. The data obtained from the audit tool was reported to nursing quality administration monthly. By the end of 2009, there was a drop in the annual mean prevalence rate to 4.1%.

In 2010, additional EBP actions were added. These ac- tions included the use of air mattresses on all beds in medical surgical units with low-air-loss mattresses in the CCU, addi- tional low-air-loss enveloping rental mattresses available within 12 hours of order, the wound committee reorganization as a task force of the central partnership council (Elsevier, 2015), inclusion of a patient and family PUP brochure included in ad- mission packets, nutrition consults initiated for those patients with a Braden score of 16 or less, and collaboration with in- formatics to maximize the use of current EMR pressure ulcer assessment and intervention documentation.

MGMC has continued to participate in state initiatives through the Maine Pressure Ulcer Collaborative, which de- veloped out of the Maine Task Force in the fall of 2010 (Maine Quality Counts, 2011). Six key change concepts were identi- fied by the collaborative, which were overlapping actions al- ready established at MGMC. These included a reliable process for conducting skin assessments on all patients, accountability for a PUP plan being in place for high-risk patients, a system for monitoring clinical implementations, providing education to patients and families about the importance of PUP, con- tinuing education on PUP to staff, and support of a culture of collaboration among partners. This encouraged more staff

involvement and a heightened awareness of PUP. By the end of 2010, the annual mean prevalence rate was 0.5%.

In 2011, the CWONs collected data from MGMC for each of the collaborations six key change concepts and shared at monthly meetings. These meetings provided a deeper assess- ment of practice. Assessments occurred in the required time- frame and documented. An update on the EMR provided the opportunity to establish a pressure ulcer treatment plan by a prompt to the RN when the Braden score was 16 or less. Doc- umentation compliance went from 75% in April 2011 before the prompt, to 100% in August 2011. Continual assessment and data were gathered through the quarterly NDNQI stud- ies, monthly chart audits, and root cause analysis (The Joint Commission, 2013) on HAPUs stage III or IV. Education for patients and family was provided through the brochure given in the admission packet. Continued education for staff included mandatory annual training, skills fair, posters, staff meetings and new employee orientation. Supporting collaboration came through a revision of the communication process on skin as- sessment between acute and long-term care facilitates. A skin assessment form was developed by the Maine Collaborative was in use by June of 2011.

The upgrading of the EMR provided an opportunity to build the pressure ulcer parameter and the PUP plan of care. Evidence-based guidelines were built into the system so that access to the guidelines with visual and written descriptions for pressure ulcer stages and prevention was available by click- ing the mouse. The plan-of-care check boxes were related to pressure redistribution, turning, nutrition, and use of barrier creams or other protective devices. The pressure ulcer parame- ter allowed for staging, detailed description of the ulcer, actions to encourage wound healing, and free written comments. This made chart reviews clearer and the progress of patients easier to track. At the conclusion of 2011, the annual mean prevalence rate was 1.4% which was slightly higher than 2010, but within an acceptable range below the national average.

Maintaining Gains Maintaining rates of between 1.2% and 1.4% for 2012–2014 was facilitated by work done the previous years as well as new implementations. In 2012, a qualitative survey of 44 medical surgical nurses concluded that 73% felt RNs should initiate a pressure ulcer plan of care, but only 50% felt confident to do so. A survey of 20 NUAs suggested 65% felt confident providing PUP. As a result of these findings, the PUP plan goals, objec- tives, content, learning and teaching methods, resources, time, and evaluation were revised. An in-service on PUP became mandatory for NUAs. The annual RN competency for 2012 was changed to the NDNQI Press Ganey, (2015) pressure ulcer training modules requiring a print-out of the completion cer- tificate. A Wound Resource Manual with detailed information on staging, prevention, and products was created and placed on each unit as a reference. On the clinical education hospital intranet page, a wound care folder was created with PUP re- sources, internet websites for wound education, and updates

114 Worldviews on Evidence-Based Nursing, 2016; 13:2, 112–117. C© 2016 Sigma Theta Tau International

Original Article on wound care. Each unit had several informative posters with quizzes.

In 2013, nursing orientation was changed to include prob- lem solving with use of case studies, which reinforced the PowerPoint and product demonstration. Many of the mecha- nisms for PUP were in place. Resources were readily available on each unit and the intranet, including ceiling-lifts available upon request, education on staging and PUP, EMR set up for ease and accuracy of documentation, and consults for nutri- tion and CWON generated by the unit RN. The CWONs also increased education at the bedside with RNs and NUAs.

In 2014, a pressure ulcer algorithm was made available by clicking an icon at the top of the charting page regardless of which screen was being used. Despite a multitude of resources, the implementation of practice at the bedside has been difficult to assess. The chart reviews demonstrate documentation; but if all required actions are occurring why does the rate of HAPUs remain low yet unchanged? Skin-care champions supported RNs and NUAs for assessment and interventions of bedside practice. Those who became skin-care champions were on the wound task force and conducted prevalence studies. Recruiting new champions proved a challenge until 2013, when nursing administration agreed to purchase the license for facilitating the Wound Treatment Associate (WTA) Program created by the Wound, Ostomy, and Continence Nurses Society (2012). The WTA has been placed as a step on the clinical advancement pro- gram, fostering interest. This is a 3-month online EBP course focusing on the wound healing process and PUP. Facilitation by the CWONs with four in-class sessions and demonstration of competency with a final test were conducted. One course was facilitated in 2013, and a second in 2014, with 40 RNs completing the course. WTAs are readily available resources for unit nurses in wound assessment and care, chart reviews and prevalence study.


� NDNQI study: assessing the prevalence of hospital-acquired pressure ulcers.

� NPUAP practice guidelines: implementation of skin assessment, pressure redistribution, mois- ture control, and nutrition.

� AHQR tool kit: development of a written pressure ulcer prevention and educational plan.

� EMR evidence-based practice parameters: for RN and nursing assistant to improve accuracy of doc- umentation.

� Education: by CWONs for RNs based on NPUAP evidence-based practice guidelines.

� Medical/Surgical RNs: skin champions and wound treatment associates.

Moving Forward For 2015, in an effort to further decrease HAPUs, MGMC is engaging more staff to consistently follow EBPs. The pressure ulcer plan is being updated. Supported by nursing quality ad- ministration, the VHA Inc. (2013), rapid opportunity improve- ment assessment is being trialed. Taking one nursing unit at a time, by reviewing what happens during a shift, assessing obstacles to evidence-based practice, seeking staff-generated ideas for improvement, and looking at resources, then priori- tize and take action. The goal is to develop a process that works well for that unit, using input from the bedside nurses. The CWONs along with the clinical education department are cre- ating an NUA educational program for skin-care champions, which will become a step on the clinical ladder. WTAs are be- ing encouraged to take initiative in assessing patients on their unit at risk for skin breakdown and reporting any concerns to the CWON. Quarterly WTA meetings will update changes in PUP initiatives and share case studies. The CWONs have developed a revised RN pressure ulcer competency rubric for those who are not WTAs but want to participate in the preva- lence study. Fostering a culture of respect for EBP, providing rewards through the clinical ladder, encouraging staff to take ownership of nursing practice, and providing excellent patient care is the ultimate goal.

IMPLICATIONS FOR PRACTICE Over the course of 10 years, pressure ulcer prevention has been an active concern for MGMC. A significant decrease in HAPUs is noted, yet the ultimate desire is for 0%. The EBP studies and guidelines are readily available and have been reinforced through education, the central partnership council, CWONs, WTAs, skin-care champions, unit managers, and nursing ad- ministration. Other important keys to decreasing the rate oc- curred in 2009 and 2010. Having a clearly written pressure ulcer plan backed by EBP guidelines, following the plan with two phases of education and implementation, disseminating the information and gaining support through the central part- nership council model, use of consistent forms of evaluation, and reinforcement of priorities through the Maine Collabora- tive made the difference. Maintaining a reduced prevalence rate came through regular reassessment of PUP initiatives, an- nual revision of the overall plan, creation of the WTAs, and updating implementations, in particular documentation in the EMR.

IMPLICATIONS FOR RESEARCH Further sharing of retrospective studies including the pro- cesses, gains, and struggles of decreasing hospital-acquired pressure ulcers as well as other patient-care concerns can as- sist organizations and the nursing profession in determining how to consistently support staff in the implementation of evidence-based practices. The research is available for how to reduce pressure ulcers. Nursing to needs to identify more of what works to make those evidence-based practices happen consistently. Involved is the nursing process of assessment,

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Decreasing Pressure Ulcers Using EBP

planning, implementation and evaluation; accountability; com- munication; education; support and involvement at all levels of the organization; and providing the right resources at the right time. Conducting EBP is both a science and an art, working with the stakeholders to bring about the best possible health benefits.

CONCLUSIONS Through 10 years of intentional assessment, education, and evidence-based implementations, MaineGeneral has made great strides in reducing the annual mean prevalence rate of hospital-acquired pressure ulcers. There is still much work to do. MGMC has implemented a number of interventions to continue on the improvement trajectory, such as focusing on education and buy-in of new hires and reminders for longer term staff, encouraging the culture and actions that sustain an attitude of 0% HAPUs, maintaining those interventions that have proven to be effective in this hospital, while disposing of ineffective action, and reviewing the overall program annu- ally. WVN

Author information

M. Elizabeth Beal, Wound Care Coordinator, Wound Heal- ing Clinic, MaineGeneral Medical Center, Augusta, ME; Kimberly Smith, Unit Manager, Wound Healing Clinic, Mai- neGeneral Medical Center, Augusta, ME

Address correspondence to M. Elizabeth Beal, Wound Healing Clinic, MaineGeneral Medical Cen- ter, 35 Medical Center Parkway, Augusta, Maine 04330;

Accepted 18 July 2015 Copyright C© 2016, Sigma Theta Tau International

References Agency for Healthcare Research & Quality. (2014). Pre-

venting pressure ulcers in hospitals: A tool kit for improv- ing quality care. Retrieved from professionals/systems/long-term-care/resources/pressure-ulcers/ pressureulcertoolkit/index.html

Braden, B., & Bergstrom, N. (1988). The Braden scale for pre- dicting pressure sore risk. Prevention Plus. Retrieved from

Centers for Medicare and Medicaid Services. (2004). CMS Manual System Pub. 100–07 State Operations Provider Certification: Revisions to appendix P (Survey protocols for long-term care facilities) and appendix PP (Guidance to sur- veyors for long-term care facilities). Retrieved from https:// als/downloads/R5SOM.pdf

Centers for Medicare and Medicaid Services. (2006). Fact sheets: Eliminating serious, preventable and costly medical errors—never events. Retrieved from MediaReleaseDatabase/Fact-Sheets/2006-Fact-Sheets- Items/2006-05-18.html

Cuddgan, J., Berlowitz, DR., Ayello, EA., Eds. (2001). Pres- sure ulcers in America: Prevalence, incidence and implica-

tions for the future. Advances in Skin & Wound Care, 14, 208- 215.

Elsevier. (2015). Bringing evidence to the point of care. Retrieved from tdence-based-practice/

Institute for Healthcare Improvement. (2007). 5 Mil- lion Lives Getting started kit: Prevent pressure ul- cers, how to guide. Retrieved from resources/Pages/Tools/HowtoGuidePreventPressureUlcers.aspx

Lyder, C., & van Rijswijk, L. (2005). Pressure ulcer preven- tion and care: Preventing and managing pressure ulcers in long-term care: An overview of the revised federal reg- ulation. Ostomy Wound Management, 2-6. Retrieved from<![if !supportAnnotations]>

Lyder, C., Wang, Y., Metersky, M., Curry, M., Kliman, R., Verzier, N., & Hunt, D. (2012). Hospital acquired pressure ulcers: Re- sults from the national Medicare patient safety monitoring sys- tem study. Journal of American Geriatric Society, 60, 1603-1608. doi:10.1111/j.1532-5415.2012.04106.x

Maine Healthcare Association. (n.d.). Pressure ulcer reduc- tion. Retrieved from QualityPressureUlcers.htm

Maine Quality Counts. (2011). Maine Pressure Ulcer Prevention Collaborative. Retrieved from http://qid.mainequalitycounts. org/project/maine-pressure-ulcerprevention-collaborative

National Council on Disability. (2005). National Council on Disabil- ity Government Performance and Results Act annual report to the President and Congress, fiscal year 2004. Retrieved from https://

National Pressure Ulcer Advisory Panel. (2014). Prevention and treatment of pressure ulcers: Clinical practice guidelines. Western Australia: Cambridge Media.

Press Ganey Associates. (2015). National Database of Nursing Quality Indicators: Pressure ulcer survey guide. Retrieved from Training/Module3/Default.aspx

The Joint Commission. (2013). Framework for conducting a root cause analysis and action plan. Retrieved from http://www. cause_analysis_and_action_plan/

VHA Inc. (2013). Rapid opportunity identification assessments. Re- trieved from Documents/Brochure_ROIServiceLine_Performance Services.pdf

Whittington, K., & Briones, R. (2004). National prevalence and incidence study: 6-year sequential acute care data. Advances in Skin & Wound Care, 17(9), 490-494.

Whittington, K., Patrick, M., & Roberts, J. (2000). A national study of pressure ulcer prevalence and incidence in acute care hos- pitals. Journal of Wound, Ostomy & Continence Nursing, 27(4), 209-215.

Wound, Ostomy, and Continence Nurses Society. (2012). Wound treatment associate program. Retrieved from

doi 10.1111/wvn.12145 WVN 2016;13:112–117

116 Worldviews on Evidence-Based Nursing, 2016; 13:2, 112–117. C© 2016 Sigma Theta Tau International

Original Article SUPPORTING INFORMATION Additional supporting information may be found in the online version of this article at the publisher’s web site:

Figure S1: Decrease in the yearly mean rate of HAPU’s at MGMC from 7.8% in 2005 to 1.4% in 2014. MGMC data with use of the NDNQI (Press Ganey, 2015) pressure ulcer prevalence study tools. Figure S2: Chronological flow chart of interventions. Supplementary Material: Abbreviations.

Worldviews on Evidence-Based Nursing, 2016; 13:2, 112–117. 117 C© 2016 Sigma Theta Tau International

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