DNP-820 Literature Synthesis for Proposed Intervention GCU
Literature Synthesis for the Proposed Intervention
Providing safe and quality patient care should be a universal objective for health care professionals. As a result, health care professionals should engage in quality improvement practices that help to achieve better outcomes, such as high care quality and optimal safety in health care settings (Oldland et al., 2020). Direct practice improvement (DPI) projects offer nurses an opportunity to improve patient care outcomes by translating scientific evidence into clinical practice. Scientific evidence for nursing research should be high-level, current, and relevant to the clinical problem (Saeed et al., 2018). Its objective should be guiding nurses in practice change to improve excellence in outcomes. The purpose of this paper is to synthesize the literature for the proposed intervention.
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Clinical Issue and Problem Statement
Clinical Issue
Patients visit critical care settings with a myriad of severe illnesses and conditions. While receiving care for their conditions, patients in critical care settings are at a high risk of developing pressure ulcers. Susceptibility ranges from 12% to 32.7% and varies with illnesses, treatment methodologies, and the length of hospital stay (Cox et al., 2022). Old and debilitated patients are at high risk, and patient-centered interventions are vital in all health care settings. Other risk factors include immobility and incontinence (Gray & Giuliano, 2018). Understanding the risk and the implications of pressure ulcers on patients’ health are instrumental in developing evidence-based solutions.
Problem Statement
Health care settings have a professional and ethical mandate to provide quality, safe, and cost-effective care. Pressure ulcers are detrimental to patient care since it impairs a patient’s overall functioning and quality of life. Health research demonstrates that pressure ulcers are a significant cause of extended hospitalization, high health care costs due to the need for bed rest, and increased care burden on patients and families (Rutherford et al., 2018; Lavallée et al., 2019). Pain, functional impairment, and distress can intensify mental pressure, causing depression. Pressure ulcers also increase patient mortality, and the risk of death is high among elderly patients (Song et al., 2019). The practicum site relied on standard pressure ulcer prevention care. Due to its effectiveness, a preventive care bundle for pressure ulcers was proposed to reduce the incidence of pressure ulcers.
Search Methods
Health care research on the effectiveness of preventive care bundles for pressure ulcers extensively explores different concepts. In selecting the appropriate articles to support the project, the search was limited to high-level evidence and primary research articles. Such articles include randomized controlled trials and quasi-experimental studies. Articles were sourced from the leading nursing databases, including CINAHL Plus with Full Text, PubMed, the Cochrane Library, Nursing Reference Center, and MEDLINE. All the selected articles were published in the last five years to meet the CRAAP Test, which requires nursing research to be current, relevant, authoritative, accurate, and purposeful (New Jersey Institute of Technology, 2022). Other considerations included being peer-reviewed, available in full text, and written in English. Any article that met these criteria and explored the effectiveness of a preventive care bundle for pressure ulcers or a component of the bundle was included.
Synthesis of Literature
Repositioning is among the critical components of a pressure ulcer preventive care bundle. Accordingly, Darvall et al. (2018) explored the effects of changing from 5-hourly turns to 3-hourly turns on reducing pressure injury incidence in critically ill patients. In this pre-post intervention evaluation study, subjects were patients admitted to the intensive care unit. The nursing staff conducted the patient turns and relevant data derived from the reporting database. Darvall et al. (2018) found that a change in turn frequencies reduced pressure injury incidence by 50%. The article supports the proposed intervention by underlining the importance of repositioning and increasing the frequency to optimize health outcomes.
In a different study, Pickham et al. (2018) explored the effects of optimizing turning compliance with wearable sensors. The research hypothesized that optimizing turns would give a better protective effect against pressure ulcers. In this randomized controlled trial, the study’s participants included 1312 patients in two intensive care units (ICUs) in a large medical center in California. In the intervention group (n = 659), patient turns were optimized through wearable sensors and data was relayed to a secure SQL database. The control group received care guided by traditional turn reminders. The primary finding was that patients in the intervention group had fewer pressure injuries than the control group. The study supports the DPI intervention by affirming the importance of optimized patient turns (repositioning) as a protective cover against pressure injuries.
Protective dressings are another crucial component of a preventive care bundle for pressure ulcers. To explore its effectiveness in pressure ulcer prevention, Hahnel et al. (2020) conducted a randomized controlled trial hypothesizing that appropriate dressing on the risk areas will significantly reduce pressure ulcers. The study’s subjects included 475 patients in a tertiary care facility in Berlin. The intervention group (n =212) received protective dressing on the sacrum and heels beside the standard care the control group received. The primary finding was a lower incidence of pressure ulcers in the intervention group (2.8%) than in the control group (10.5%). The study supports the DPI intervention by affirming the positive effects of preventive dressing as a care bundle component for pressure ulcers.
Yap et al. (2021) conducted a study to assess the impact of repositioning on reducing the occurrence of pressure ulcers. The study, a pragmatic cluster randomized controlled trial with three arms, involved 992 residents across 9 nursing homes. Each arm investigated the effects of different repositioning intervals (2-hour, 3-hour, or 4-hour) on nurses’ compliance and the incidence of pressure ulcers. The findings revealed that the incidence of pressure ulcers during the intervention (repositioning) was 0.0%, contrasting with a baseline incidence of 5.245. Notably, a 4-hour repositioning interval demonstrated superior results, providing 95% protection, compared to 90% and 85% for the 3-hour and 2-hour intervals, respectively. The study supported the DPI intervention by highlighting the positive outcomes of repositioning and emphasizing the impact of varying turn intervals.
Santamaria et al. (2018) conducted a randomized controlled trial investigating the effectiveness of multi-layer silicone foam dressing in preventing pressure ulcers among elderly adults. The study included 288 patients in residential aged care facilities in Australia, with the intervention group (n = 138) receiving protective dressings on vulnerable areas, while the control group (n = 150) received standard care. The primary outcome indicated a lower incidence of pressure injuries in the intervention group compared to the control group (p = 0.004). This study supported the DPI intervention by illustrating the efficacy of protective dressing as a crucial preventive care component for pressure ulcers.
Fallahi et al. (2022) explored the impacts of aloe vera gel, olive oil, and their combinations in preventing pressure ulcers in a randomized controlled trial involving 240 ICU patients in Iran. The study demonstrated a higher incidence of pressure ulcers in the control group compared to the treatment groups (p = 0.001). This research supported the DPI intervention by showcasing the positive effects of skin care as an essential preventive care component for pressure ulcers.
Parizi et al. (2022) conducted a randomized controlled trial to evaluate the effectiveness of rosemary extracts in enhancing healing in ICU patients with pressure ulcers. The intervention group received rosemary extracts on susceptible areas, while the control group received standard care. The primary outcome indicated a significant reduction in pressure ulcers in the intervention group, reinforcing the importance of skin care in reducing the incidence of pressure ulcers and supporting the DPI intervention.
Zhang et al. (2021) assessed the effectiveness of a pressure injury care bundle in reducing the incidence of pressure injuries in ICUs through a quasi-experimental pre-and-post intervention study in Chinese hospitals. Implementation of the pressure injury care bundle led to a reduction in the incidence of pressure injuries from 13.86% to 10.41%, supporting the positive effects of a comprehensive care bundle in critically ill patients and aligning with the DPI intervention.
Oe et al. (2020) conducted a randomized controlled trial on the effectiveness of silicone foam dressing in preventing pressure ulcers in high-risk patients. The study randomized 600 patients into intervention and control groups, demonstrating a lower incidence of pressure ulcers in the intervention group (p = 0.001). This study reinforced the DPI intervention by showcasing the positive effects of preventive dressing as a crucial component in a pressure injury preventive care bundle.
Forni et al. (2022) evaluated the effectiveness of foam dressing in preventing pressure ulcers in a multi-center randomized controlled trial involving 709 ICU patients. The intervention group, in addition to standard preventive care, had a multi-layer polyurethane dressing applied, resulting in a lower incidence of pressure ulcers compared to the control group. This study supported the DPI intervention by demonstrating the effectiveness of protective dressing as a component of a pressure injury preventive care bundle.
Tayyib et al. (2021) conducted a prospective, open-label clinical design to evaluate the SKINCARE bundle’s effectiveness in reducing the incidence of device-related pressure injuries in critical care units. Implementation of the SKINCARE bundle led to a significant reduction in pressure injury incidence, confirming the effectiveness of a care bundle in preventing pressure ulcers and aligning with the DPI intervention.
Renganathan et al. (2019) focused on improving turn compliance in patients with a high susceptibility to pressure ulcers. In a prospective, multiphase, multicenter trial, the intervention group received alerts through a monitoring system to optimize turn compliance. The primary finding was a higher incidence of pressure ulcers in the control group, supporting the DPI project by emphasizing the protective benefits of patient turns and the potential for improvement through enhanced turn compliance.
Hassan et al. (2020) conducted a quasi-experimental study on the effectiveness of body repositioning in reducing pressure ulcer incidence in immobilized patients. The implementation of 2-hourly repositioning led to a reduced incidence of pressure ulcers, reinforcing the positive effects of repositioning in reducing the occurrence of pressure ulcers and supporting the DPI intervention.
Hekmatpou et al. (2018) conducted a randomized, triple-blind clinical trial on the effectiveness of an evidence-based skin care routine in preventing pressure ulcers. The study included patients admitted to an orthopedic ward, demonstrating a lower incidence of pressure ulcers in the intervention group compared to the control group. This study supported the DPI intervention by confirming the protective benefits of a skin care routine as a critical component of a pressure injury preventive care bundle.
Sharp et al. (2019) conducted a cross-sectional survey, hypothesizing that repositioning alone may not achieve desired outcomes in pressure ulcer prevention. The study reviewed medical records of elderly patients in aged care facilities in Australia, revealing that repositioning prevented pressure ulcer development in 76% of patients. The article supported the DPI intervention by suggesting the importance of a multi-component care bundle that includes repositioning for effective pressure ulcer prevention.
Comparison of Articles:
The articles share common themes in confirming that a preventive care bundle can effectively reduce the incidence of pressure ulcers. Repositioning, protective dressing, and skin care emerge as key components, with their effectiveness demonstrated across various studies. However, differences exist in terms of participants, study locations, samples, and methods. Common themes include the efficacy of repositioning (Sharp et al., 2019; Hassan et al., 2020; Yap et al., 2021; Darvall et al., 2018), protective dressing (Hahnel et al., 2020; Santamaria et al., 2018; Forni et al., 2022, and Oe et al. 2020), and skin care routine (Parizi et al., 2022; Fallahi et al., 2022), with some studies exploring the effectiveness of a multi-component care bundle.
Methods vary, with most articles being randomized controlled trials and others experimental studies of high-level evidence. Conclusions from studies exploring the effectiveness of repositioning highlight its efficacy for pressure ulcer prevention, emphasizing the optimization of turn compliance for better outcomes. Other conclusions include the effectiveness of protective dressings and the importance of an evidence-based skin care routine in caring for critically ill patients (Parizi et al., 2022; Fallahi et al., 2022). Limitations include small sample sizes affecting generalizability (Fallahi et al., 2022; Tayyib et al., 2021; Hassan et al., 2020), lack of subject blinding (Santamaria et al., 2018), and selection bias (Pickham et al., 2018). Overall, no major controversies were observed, as the studies consistently found positive effects of the care bundle or its components on pressure injury prevention.
Recommendations for Future Research:
A significant research gap lies in understanding the comparative effectiveness of repositioning, protective dressing, and skin care in preventing pressure ulcers. While existing studies confirm the efficacy of each component and their combination, there is a lack of analysis regarding the optimal method in terms of outcomes. This gap raises uncertainty about the priority area when implementing the DPI intervention. Another research gap involves assessing whether findings from studies conducted in ICUs can be extrapolated to other settings, considering the severity of pressure ulcers. In line with Fallahi et al. (2022), future research should involve more extensive studies with subjects in different units. Additionally, future research should compare the outcomes of each component and provide a comprehensive rating.
Conclusion:
Pressure ulcers pose a significant risk to patients in critical care settings, necessitating evidence-based interventions to reduce their incidence among elderly and debilitated individuals. The synthesized literature consistently demonstrates the effectiveness of a pressure injury preventive bundle in decreasing the occurrence of pressure ulcers in healthcare settings. Expectations for similar positive results can be anticipated with the implementation of the DPI intervention.
References
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Fallahi, M., Soroush, A., Sadeghi, N., Mansouri, F., Mobaderi, T., & Mahdavikian, S. (2022). Comparative evaluation of the effect of aloe vera gel, olive oil, and compound aloe vera gel-olive oil on prevention of pressure ulcer: A randomized controlled trial. Advanced Biomedical Research, 11(6). doi: 10.4103/abr.abr_121_21
Forni, C., Gazineo, D., Allegrini, E., Bolgeo, T., Brugnolli, A., Canzan, F., … & Zanelli, S. (2022). Effectiveness of a multi-layer silicone-adhesive polyurethane foam dressing as prevention for sacral pressure ulcers in at-risk in-patients: Randomized controlled trial. International Journal of Nursing Studies, 127, 104172. https://doi.org/10.1016/j.ijnurstu.2022.104172
Gray, M., & Giuliano, K. K. (2018). Incontinence-associated dermatitis, characteristics and relationship to pressure injury: A multisite epidemiologic analysis. Journal of Wound, Ostomy, and Continence Nursing: Official Publication of the Wound, Ostomy and Continence Nurses Society, 45(1), 63–67. https://doi.org/10.1097/WON.0000000000000390
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