A Reflection: Pressure Ulcer
Introduction
Good health may be the most valued attribute of life, and being a healthcare professional, we express our concern for others by inquiring about their health and wishing them well. Material concerns are being overshadowed when our own health is threatened, for good health is determined as an essential element for our pursuit of happiness and life-long contentment (‘Medicare: A Strategy for Quality Assurance’ 1990). With good health, we can seize a variety of opportunities in terms of our profession, family and personal lives. This aspect can be achieved with the help of healthcare professionals, being well-known experts in contributing to public protection and safety. In creating and maintaining a safe healthcare environment, quality assurance and risk management strategies with good decision making practices are useful to improve healthcare services and provide with the public, a safe and secured environment.
As a nurse in the acute orthopedics ward in hospital Authority in Hong Kong, I am too much aware that the public health is concerned with threats to the overall health of a community. With the concern of public health, risk management and quality assurance strategies take part in its preservation. As a nurse decision making is important, for once risks in public health safety have been identified and evaluated, it would be easier to develop risk management strategies. This paper is a reflective summary of my experience as nurse in handling patients with pressure ulcers. This paper illustrates relevant information based on my experience and desk researches that I initiated.
Background
Like some other professions but unlike many other goods and even services, it is difficult for the consumer (the patient) to evaluate the quality of services received. Much depends on the self-control and reliability of the individual practitioner, the supplying group, and the medical profession as a whole, in ways that the ordinary patient cannot readily check whenever he/she needs to.
These institutions must simultaneously improve the health and well being of the public, cut costs and remain competitive. To achieve these goals, many healthcare institutions have implemented total quality management (TQM). Evidence from hospital-based studies, however, suggests that the success of TQM is constrained by inadequate information systems and poor application of information technology.
Change appears to be a driving force in society today and the Hong Kong healthcare system is no exception. In addition to the need for change in today's society, the importance of creativity in bringing about needed change must also be considered. An organization will quickly lose strategic advantages that it has worked hard to gain unless it invests in innovation and creativity, and consequently, change (Redmond, et al, 1999).
With this respect, the healthcare industry in Hong Kong is an interesting case. Aside from the demand for quality healthcare, there is also a drive to reduce the cost of healthcare expenses. It was reported that the Hong Kong Special Administrative Region (HKSAR) spent HK.9 billion, equivalent to 15.4 % of total public expenditure in the year 2003-2004 on healthcare (Tsang, 2003). This escalating increase calls for the initiative to reduce costs in healthcare (Tsang, 2003). However, it is perceived that by doing so, the quality of the delivery of healthcare services across Hong Kong will be jeopardized (Tsang, 2003). This poses as a challenge for HKSAR in managing the healthcare sector. This situation, of course, is also applicable to private healthcare companies in Hong Kong that are anxious to reduce their costs without the hampering the quality of their services.
One of the major concerns among the elderly according to Donini, Savina & Canella (2003) is the deterioration of the intake of food. The researchers pointed out that the reduced intake of energy can be either social or physiological, or a combination of both factors. In the social aspect it can be due to poverty, loneliness and social isolation and the most common is depression mainly because of the loss of communication and association with the people around him or her. And on the physiological aspects the authors discussed that the loss of appetite may be due to reduced urge of food intake or more potent inhibitory signals. Medical conditions such as malabsorption and gastrointestinal infections can also contribute to the loss of appetite of elderly. Another factor is the medicines that elders intake which can cause medical conditions like those two mentioned above. The researchers suggested that health workers especially workers in the care home facilities must understand the factors that are partly responsible for the poor nutrition of the elders in order to develop and create proper preventive measures against malnutrition at the same time improving the health condition of the elders. In addition, Noll (2004) suggested that the primary health workers can use the different strategies in restoring and elder’s appetite due to the fact that reduced appetite and weight loss are mostly multifactorial and the best strategy is to recognize the fundamental reasons of weight and appetite loss among elders.
In addition, Braun, Kunik, Rabenek and Beyth (2001) discussed the risk factors that are associated with malnutrition, the normal aging, institutionalized patients and patients with Dementia. For the elders going through normal aging the common risk factors are:
a.) Physical Changes in which the senses such as smell and taste decrease that leads to decrease in appetite.
b.) Comorbidities- As a person ages multiple diseases begins to appear that may also lead to a decrease in appetite.
c.) Medications- There are a number of ways to manipulate and increase the food intake of the elderly. And among those is using flavor enhancements.
d.) Medications- this factor is related above since elders experienced comorbidity, they take a number of medications that usually diminished taste perceptions such as chemotherapeutic agents and anticonvulsants.
e.) Psychological Factors- depression is the most common psychological factor as stated by Donini et al, and most often it is untreated, depression usually decreases one’s motivation to eat whether the person is young or old.
f.) Environmental Factors- elders that are not admitted to institutions and are living alone may have a problem in accessing food due to lack of transportation or ability to buy the basic necessities such as food.
For Institutionalized elders Braun et al enumerated these risk factors:
a.) Medications- just like normal aging elders, institutionalized elders experienced a number of diseases that needs medications that usually lead to the decrease in appetite.
b.) Psychological Factors- depression in institutionalized elders are more prevalent compare to non-institutionalized because elders are separated from their loved ones and friends and most of the relatives of these elders do not pay a visit, that leads to severe depression, it is reported to be the most common cause of weight loss in nursing care facilities.
c.) Environmental Factors- the environmental factors include the health workers, food and the facilities. A number of home care facilities do not have enough caregivers to assist all the elderly patients in which may lead to a decrease in the food intake. In food most home care facilities serve less palatable foods for specialized diets to residents. In facilities, a number of home care have been reported to have facilities that are not on standard which may also contribute to depression or appetite loss.
d.) Cultural Factors- in a diverse country like the United Kingdom, elders that are admitted in these institutions have diverse ethnic and cultural backgrounds in which have their own food preference that cannot be addressed in some home care facilities in a long-term basis.
In this paper, aside from making a reflection of my personal experience regarding pressure ulcer and practices in health care, I also conducted some relevant desk researches. The summary of the information are presented in Appendix. After the evaluation, relevant issues were emerged, which include pressure ulcer increase the cost of hospitalization; pressure ulcer risk assessment is necessary for clinical assessment, various risk factors in risk assessment scale; suitable wound care method can treat the pressure ulcer effective; elderly has a higher risk to have pressure ulcer; clinical experience of nurse is important for assessing the pressure ulcer and ethical consideration is needed for a research.
Discussions and Analysis
Pressure ulcers have recently been chosen as a target, condition for quality improvement in geriatric care (Sloss et al, 2000). Pressure ulcers have been defined by the Agency for Health Care Policy and Research as any lesion caused by unrelieved pressure resulting in damage of underlying tissue (Berlowitz, 2000). From the study of Berlowitz, (2000) pressure ulcers are the most common chronic wound in the elderly. Actually, more than half of all patients with pressure ulcers are older than age 70. And this is true from my experience as a nurse whereas elderly women are affected more frequently than are elderly men. Risk factors implicated in causing pressure ulcers include immobility, incontinence, diabetes mellitus, and increasing age, decreased dietary protein intakes, impaired nutrition, and lymphopenia, decreased body weight, dry skin, and altered level of consciousness.
Chronic wound such as pressure ulcer constitute a challenge in patient rehabilitation. The development constitutes a major problem which cause excessive pain and suffering in affected patients. To determine the amount of healing in response to treatment, sequential assessments of changes in wound size and essential.
While doing desk researches for this paper (see Appendix) and comparing it from my own experiences, some ideas were emerged. Actually, all relevant information that I’ve been searching is mostly concerning about on how to reduce the number of pressure ulcers, which increase the cost of hospitalization. Other context are also somewhat related on how pressure ulcer risk assessment is necessary for clinical assessment; various risk factors in risk assessment scale, suitable wound care method can treat the pressure ulcer effectively, local heat application to open wound is effective, it is common for elderly to have pressure ulcer, knowledge of health careers is important for assessing the pressure and improve the quality of nursing care is important.
After assessing the articles I’ve read and comparing it from my personal experience in handling patients in our Hospital, I discovered that there are several methods to improve the lives of the elderly people who are having pressure sores. According to Bernabei et al (1998) findings, healing rate for the NNWT group was significantly greater than for the chronic full-thickness pressure ulcers group. This result was supported by Stoner & Wood (1991) study, which stated that primary response of human skin to locally applied external heat is an increase in capillary (p.50).
In addition, Lee (1994) demonstrated a significant reduction in the growth of Staphylococcus aureus following treatment of infected dermal flags with noncontact radiant heat dressing in an ovine model. As a result, NNWT is an effective wound dressing. In Pham H et al (2000) research, the research firstly described the method of transparency tracings and photography independently. It stated that direct tracing is a simple, inexpensive, consistent and reproducible method of wound measurement, but it may be unacceptable due to the risk of contamination and patient pain. When an instant camera is not used, the need to develop and process the film before measurements can be made and the uncertainty about the success of the photograph contribute uncertainty about the success of the photograph contribute to challenges in obtaining data. The results of this study show that combined wound measurement method is better than use them independently.
It is indeed true that nurses should understand that nature of pressure ulcers and learn practicing good decision making. As Hawes et al (1995) said, decision making in nursing is tough to be affected by levels of specialist knowledge and familiarity with the clinical setting. On the hand, the result of Jencks, (1994) article showed that different clinical experience and qualifications of health careers would categorize different grade of risk with the same patient. It stated that registered nurses have more accurate assessment that student nurse.
In Marshall et al (2000) study, the advice of an expert panel was used to provide external validity as recommended by McClellan & Staiger (2000). All were known for their work in pressure ulcers assessment field nationally, had adequate clinical experience and had international recognition. The assessment of expert panel was used to judge the ratings made by clinical nurses.
Pressure ulcers have recently been chosen as a target condition for quality improvement in geriatric care (Sloss, 2000). Geriatricians are logical clinical leaders and teachers of this subject, which involves an interdisciplinary approach to care, attention to functional status, nutrition, incontinence, and pain management and knowledge of wound management.
In our ward, we use Norton scale to assess patients when they admit. Although they had no pressure ulcer before, we should also need to reassess their skin integrity daily, as our experience justified older people would have higher risk for pressure ulcers. Actually, there are other departments that use other methods to assess patients. Some also uses the so-called Waterlow risk assessment tool and we also tried it once. From our experience, it shows that the Waterlow risk assessment tool has satisfactory predictive ability and the potential for further development. With the result, it showed increased likelihood of HAPU development is associated with being categorized as occasionally incontinent, having discolored skin or broken skin. It should be paid more attention on these risk factors in future.
Waterlow risk assessment offered the groundwork for the development of an empirically-based risk assessment scale. It also evaluated the predictive performance of the underlying empirical model.
A major source of ambiguity is the relationship between recorded skin conditions and pressure ulcer assessment. According to the grading system in use, reddened skin which does not fade when pressure is removed, however waterloos RAS predicted it is a risk factor as patent immobilized.
Anyway, I should suggest that we need to use simulations to collect data in examining the validity of pressure ulcer risk assessment scales. Simulations are of particular advantage in research studies where large samples are necessary to achieve statistical power. Our ward is belonged to medical unit; use Norton Score to assess the risk of forming pressure ulcer. However in other department, they may use other methods to assess patients. Simulation may be useful to allow numerous variables to be manipulated under conditions that are held standard.
It has been reported that health is concerned with threats to the overall health of a community, based on population health analysis, and the importance of programs concerning public health is on reducing the incidence of disease, disability, and the effects of aging (‘Public Health’ 2009). With the concern of public health, risk management and quality assurance strategies take part in its preservation. In health assessment, risk management and risk assessment is important, for once risks in health safety have been identified and evaluated, it would be easier to develop risk management strategies. In the context of elderly people with pressure ulcers, risk assessment is the process of quantifying the probability of a harmful effect to individuals or populations particularly to elderly people from certain human activities, and this includes assessing the use of specific chemicals and radiation, or the operations of specific facilities, such as power plants, factories and manufacturing plants (‘Risk Assessment’ 2009). However, to come up with risk management strategies in creating and maintaining good health, it is essential to identify the principal types of risks in healthcare. These risks include clinical operating risk, which is the risk of variations in the costs incurred by a provider in providing clinical services; event risk, or the risk associated with fluctuating demand for the healthcare in the covered population; pricing risk, or the risk inherent in setting prices given the unpredictable expenses of event risk; and the financial risk, which are the basic business risks faced by all companies, such as capital, partner insolvency, cash flow, liability, and regulatory risks (Mulligan, Shapiro and Walrod 1996).
With these risks, I must say that as a healthcare professional, I can contribute in creating and maintaining a safe healthcare environment to the benefits of elders with pressure sores by several risk management strategies.
The primary goal of a quality assurance system should be to make healthcare more effective in bettering the health status and satisfaction of a population, within the resources which society and individuals have chosen to spend for that care, having a quality in which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge. With quality assurance, the public can be assured of high quality healthcare services, to help them achieve a safe environment. With a quality assurance system, the public would be able to perform their tasks well concerning their family, profession and personal lives. Keeping in mind the goal of quality assurance, it would be easier to come up with quality assurance strategies that would help contribute to fostering a safe environment and public health.
Conclusion
From my experience, I must say that Waterlow risk assessment scale is useful in the clinical practice which includes more areas to evaluate the risk factors. We need to give continue daily skin assessment for patients whatever they have pressure ulcers or not on admission. The combined photography and transparency tracings are highly reliable and wounds treated with noncontact normothermic wound therapy healed faster than wounds in the standard wound care which we are still using in the ward. Moreover, we need to improve and updated our knowledge to provide a better quality of service. Simulation can be a method of data collection is studies where large samples are necessary.
With these findings, we would like to change our risk assessment scale, from Norton scale to Waterlow scale, and change wound management, combined instant photography tour present transparency tracing, however we would like to add three dimensional measurements to assess the ulcers which involved epidermal layers. With daily wound assessment and updated our knowledge, the chance of pressure ulcer formation would be reduced. Furthermore, with NNWT, the wound healing rate is faster than standard wound care; it will shorten the length of hospitalization and will reduce the cost.
To sum up with the findings, I would like to reduce the number of pressure ulcer, increase the quality of health care therefore patients can have better quality of health Service and the cost of hospitalization should be reduced.
References:
Berlowitz, D. R., Bezerra, H. Q., Brandeis, G. H., Kader, B., Anderson, J. J., (2000). Are we improving the quality of nursing home care: The case of pressure ulcers. Journal of the American Geriatrics Society. 48:59-62.[Medline]
Bernabei, R., Gambassi, G., Lapane, K., Landi, F., Gatsonis, C., Dunlop, R., et al (1998). Management of pain in elderly patients with cancer. SAGE Study Group. Systematic Assessment of Geriatric Drug Use via Epidemiology. Journal of the American Medical Association. 279:(23), 1877-1882.[Abstract/Free Full Text]
Braun, U.K., Kunik, M.E., Rabeneck, L. & Beyth, R.J. (2001). ‘Malnutrition in Patients With Severe Dementia: Is There a Place for PEG Tube Feeding?’ Annals of Long Term Care. Vol. 9, no. 9
Hawes, C., Morris, J. N., Phillips, C. D., Mor, V., Fries, B. E., Nonemaker, S., (1995). Reliability estimates for the minimum data set for nursing home resident assessment and care screening (MDS). The Gerontologist,. 35:172-178.[Abstract]
Jencks, S., (1994). The government's role in hospital accountability for quality of care. Joint Commission Journal on Quality Improvement,. 20:364-369.
Lee J. (1994). Staphylococcus intermedius isolated from dog-bite wounds. J Infect.Jul;29(1):105.
Marshall, M. N., Shekelle, P. G., Leatherman, S., Brook, R. H., (2000). The public release of performance data: What do we expect to gain? A review of the evidence. Journal of the American Medical Association. 283:1866-1874.[Abstract/Free Full Text]
Medicare: A Strategy for Quality Assurance (1990). The National Academies Press, viewed 14 October, 2009, <http://fermat.nap.edu/books/0309042305/html/19.html>.
McClellan, M. & Staiger, S. (2000). The changing hospital industry: Comparing not-for-profit and for-profit institutions. Chicago: The University of Chicago Press, pp. 93–112.
Mulligan, D. Shapiro, M. & Walrod, D. (1996). ‘Managing Risk in Healthcare’, The McKinsey Quarterly, no. 3.
Noll, D.R. (2004). ‘Restoring Appetite in the Elderly’ Clinical Geriatrics. vol. 12 no. 2, pp. 27-32
Pham H, Armstrong DG, Harvey C, Harkless LB, Giurini JM,Veves A. (2000). Screening techniques to identify people at high risk for diabetic foot ulceration: a prospective multicenter trial. Diabetes Care;23:606-11.
Public Health (2009). Online Encyclopaedia, 14 October, 2009, < www.encyclopedia.com/topic/public_health.aspx>.
Redmond, G., Riggleman, J., Sorrell, J.M. & Zerull, L. (1999). Creative Winds of Change: Nurses Collaborating fro Quality Outcomes. Nursing Administration Quarterly.
Risk Assessment (2009). Online Encyclopaedia, viewed 14 October, 2009, < www.encyclopedia.com/doc/1O11-riskassessment.html >.
Stoner M.L. & Wood F.M. (2000). The treatment of hypopigmented lesions with cultured epithelial autograft. J Burn Care Rehabil;21:50-4.
Sloss, E. M., Solomon, D. H., Shekelle, P. G., Young, R. T., Saliba, D., MacLean, C. H., et al (2000). Selecting target conditions for quality of care improvement in vulnerable older adults. Journal of the American Geriatrics Society. 48:363-369.[Medline]
Tsang J.H.Y. (2003). Total quality management in UK service organisations: some key findings from a survey. Managing Service Quality Volume 11, Number 2; pp. 132-141
Appendix. Summary of References Used
First Article
1. Focus
Papanikoloan et al research (2003) was focus on pressure ulcer risk assessment, to investigate the relative importance of key factors affecting the likelihood of hospital acquired pressure sore.
2. Background
The background was pressure ulcer imposes a significant burden on patients and careers and demand substantial resource from the health care system. However, there is lack of risk assessment measurement tools.
3. Terms of reference
The aim of the study were to provide the groundwork for the development of an empirically, produced risk-assessment scale for the prediction of hospital acquired pressure ulcer (HAPU) occurrence and to capture the relative importance of key influences, for example, mobility, skin condition on the likelihood of HAPUS.
4. Study design
This is an action research. The study was designed to produce a new data set, drawn from a more tightly defined population, dealing with issues of data quality as far as possible and preparing the data for in multiple regression analysis. Its overall aim was to use the Waterlow Scale to show how improvements could be made in its ability to make useful assessments of the risks of pressure ulcer development.
5. Tool of data collection
Many existing risk assessment methods were devised by nurse on the basis of clinical experience. These risk assessment tools, often termed risk assessment scales (RASs) assign numerical values to various patient traits, for example, level of continence, with a total score produced from the sum of these values. Rycroft-Malone and Mclnness (2000) considered that RASs are helpful in altering staff to the existence of risk factors and encouraging regular inspection of susceptible areas.
Investigator such as Cullum et al (1995) and Authorry et al (2000) have called for the use of multivariate methods to develop empirically-based RASs and investigation of properties, such as sensitivity and specificity to assess the predictive ability of these instruments.
6. Ethnical consideration
Approval from the local Research Ethics Committee was granted before beginning data collection. As the study did not involve direct contact with patients and all data were obtained from the records, the committee did not require consent from individual patients, written permission to access the records was obtained form all consultants admitting patients to the study wards. Patients’ confidentiality was assured and data handling storage confined to the authors.
7. Sample
A cross-sectional study was conducted in a large teaching hospital in Wales. On the advice of clinicians at the hospital, the focus of the study was on older patients admitted to medical wards. Accordingly, the project was designed to obtain a sample of 600 inpatient episodes randomly drawn from the population of older people admitted to a group of medical wards which specialize in their care. The inclusion criteria were the patient was aged 65 years or over, the length of stay was 4 days or longer and the record contained a completed Waterlow Scale.
8. Data presentation
The results are presented by tables mainly. According Bland. M. (1996), a table is intended to communicate information, so it should be easy to read and understand.
A table should have a clear title, stating clearly and unambiguously what the table represents. The rows and columns must also be labeled clearly.
In the table it showed the area under the curve (AUC) which ranges form 0.5 for no detestability to 1.0 for perfect dectability and this range showed within the table .It let readers likely to understand.
9. Main findings
The main finding is the Waterlow risk assessment tool has satisfactory predictive ability and the potential for further development. With the result, it showed increased likelihood of HAPU development is associated with being categorized as occasionally incontinent, having discolored skin or broken skin. It should be paid more attention on this risk factors in future.
10. Conclusion and recommendations
Waterlow risk assessment offered the groundwork for the development of an empirically-based risk assessment scale. It also evaluated the predictive performance of the underlying empirical model.
A major source of ambiguity is the relationalship between recorded skin conditions and pressure ulcer assessment. According to the grading system in use, reddened skin which does not fade when pressure is removed, however waterloos RAS predicted it is a risk factor as patent immobilized.
11. Readability
Reader could understand the research although there is jargon. The jargon is the study was explained. For instance, Brier score is computed as the average square error difference between an observed outcome and its prediction. This index can take any value between 0 and 1, with 0 indicating perfect agreement of the predictions on the outcomes and 1 indicating perfect disagreement.
12. Implication for practice
Norton score is commonly used in the ward; however there is no information about the skin condition, nutrition state. The waterloo risk factors, appetite, continence skin condition and mobility have an impact on the likelihood of HPAU occurrence. It is useful for us to evaluate our risk assessment method.
Second Article
1. Focus
The focus of this article is to conduct an in-depth analysis regarding the quality of nursing home care in Taiwan. The use of resident satisfaction and clinical outcomes was used as indicators.
2. Background
The background of the study was to determine the implication of the aging population to health care industries. The quality of health care services in Taiwan play significant role to the health of the aging population.
3. Terms of reference
The study provided several implications to the health care industry and to the patients. The aim of the study was to give a longitudinal evaluation of the quality of the services provided by the health care institutions.
4. Study design
A longitudinal research design was used to explore the quality of care in nursing homes over a 1-year period. Names of target nursing homes (N=13) for this study were selected at random from a list of nursing homes registered with the department of Health in Taiwan. Study subjects were selected from 13 nursing homes by tossing a coin for each nursing home to determine whether residents in even or odd number beds would be asked to participate. Elderly individuals with mental problems or to the individuals were not able to respond verbally to the interview questions were also included in this study, provided informed consent from their legal family guardians were obtained.
5. Tool of data collection
To attain the goal of the study, Shu-Hui Yeh, Li-Wei Lin and Sing Kai Lo (2003) employed 6 structured questionnaires to collect the data on nursing homes: resident demographics; nursing home demographics; patient short portable mental status; functional independence; clinical outcomes and satisfaction with nursing home care.
6. Ethnical consideration
This study was supported by grant NHI-DD01-86IX-HP602S from the National Health Research Institutes. The consent of the participants was solicited in order to come up with meaningful conclusions and recommendations. Participants with mental problems were also included in the study with consent of their legal family guardians.
7. Sample
From the target participants, 306 agreed and 4 refused to participate in the initial interview. At the completion of the 1-year-follow up period, 50 residents had died, 55 residents had turned home, and 37 residents had been hospitalized. The remaining 170 were still under nursing home care.
8. Data presentation
In this article, the data are presented in ±SD. In addition to descriptive statistics, repeated measures ANOVA was used to test the changes in various characteristics from the initial interview to 1-year follow-up. Because of the presence of the missing data, the repeated-measures ANOVA were carried out by setting up mixed models, treating subject as a random factor and time as a fixed factor. Percentage and Chi-square analysis was also presented.
9. Main findings
With respect to the findings of the article, the article divided the results into four different subsections such as, characteristics of the residents, nursing home characteristics, status of the residents after the initial interview, level of satisfaction of nursing home care and changes in clinical outcomes. From the findings, the nursing home placement significantly decreased the chance of having pressure sores, but not falls or residents’ perceived personal health conditions. Nursing home stays actually increased the use of physical restrains and the occurrence of focal impaction. In addition, there are several nursing homes failed to live up to residents’ expectations.
10. Conclusion and Recommendations
The findings of this research alert health professionals and administrators of the necessity for nursing homes to set appropriate goals targeting decreased use of physical restraints and improved quality of life for nursing home residents and in general, closer monitoring and enhancement of care quality provided by nursing homes. In addition, nursing interventions and long term regulations can then be better directed to help the elderly regain control over their lives once relocated to a nursing home. Nurses and long term care tend to have the prolonged contact with both the family and recipients of elderly care. Therefore, health care providers are in the best positions to make generalizations about health issues fro elderly patients and to point out specific inadequacies in current nursing home care practice.
11. Readability
Although there are technical difficulties in understanding the statistical analysis shown in the paper, the reader could still easily determine the meaning of this computed values. Even though the paper has technical concepts the discussion shows simplicity to reach the capacities of the reader.
12. Implication for practice
From the results and findings in this article, the quality of life of any health care patient depends on the quality of the services provided by the health care practitioners. It is then suggested that health care institutions and organizations should carefully evaluate the needs of their patient in order to have quality life.
Third Article
1. Focus
The focus of this research is to guide the nurses or the health care practitioners in using pressure relieving equipment through differing modes of education delivery.
2. Background
The Department of Health has set targets for a 5% reduction per annum in the incidence of pressure ulcers. Electric profiling beds with a visco-elastic polymer mattress are a new innovation in pressure ulcer prevention; however, mattress efficacy is reduced by tightly tucking sheets around the mattress.
3. Terms of reference
To examine the impact of written and verbal education on bedmaking practices, in an attempt to reduce the prevalence of pressure ulcers.
4. Study design
A prospective randomized pre/post-test experimental design.
5. Tool of data collection
Ward managers at a teaching hospital were approached to participate in the study. Two researchers independently examined the tightness of the sheets around the mattresses. Wards were randomized to one of two groups. Groups A and B received written education. In addition, group B received verbal education on alternate days for one week. Beds were re-examined one month later. One researcher was blinded to the educational delivery received by the wards.
6. Ethnical consideration
This study was approved by the relevant research ethics committee.
7. Sample
Fifteen ward managers were approached to obtain consent for their ward to be included in the study during August 2002. Twelve ward managers (80%) consented to the study. Two wards (13.3%) were day wards, and were thereforedeemed unsuitable for inclusion and one ward manager (6.7%) felt unable to consent, because of current staff shortages on the ward. The 12 wards included a total of 245 beds, distributed over three directorates as follows:
• Surgery: two wards (17%);
• Medicine: seven wards (58%);
• Rehabilitation: three wards (25%).
8. Data presentation
SPSS for Windows was used to analyse the data (SPSS Inc.,Chicago, IL, USA). Chi-squared statistics and P values were calculated to determine whether or not there were any significant differences between pre- and post-education bed making and between delivery methods. Analysis using chisquared statistics assumes that the data are independent, and that a different combination of nurses made the beds on the two separate assessment days.
9. Main findings
Twelve wards agreed to participate in the study and 245 beds were examined. Before education, 113 beds (46%) had sheets tucked correctly around the mattresses. Following education, this increased to 215 beds (87.8%) (P < 0.001). There was no significant difference in the number of correctly made beds between the two different education groups: 100 (87.72%) beds correctly made in group A vs. 115 (87.79%) beds in group B .
10. Conclusion and recommendations
Clear, concise written instruction improved practice but verbal education was not additionally beneficial.
11. Readability
The presentation of this article considered the general reader. Although there are some technical information discussed in this paper, the quality and clarity of discussion was still well-presented.
12. Implication for practice
Nurses are receptive to clear, concise written evidence regarding pressure ulcer prevention and incorporate this into clinical practice.
Fourth Article
1. Focus
The focus of the article of LINDGREN M., UNOSSON M., KRANTZ A.N. & EK A.C. (2002) is to evaluate the reliability and validity of a risk assessment scale for the prediction of pressure sore development.
2. Background
From the article, the ability to assess the risk of a patient developing pressure sores is a major issue in pressure sore prevention. Risk assessment scales should be valid, reliable and easy to use in clinical practice.
3. Terms of reference
To develop further a risk assessment scale, for predicting pressure sore development and, in addition, to present the validity and reliability of this scale.
4. Study design
This prospective study was performed at one university hospital and one county hospital in Sweden from 1996 to 1998. Data for the interrater reliability were collected at the same two hospitals in 1999.
5. Tool of data collection
The risk assessment pressure sore (RAPS) scale, includes 12 variables, five from the re-modified Norton scale, three from the Braden scale and three from other research results. Five hundred and thirty patients without pressure sores on admission were included in the study and assessed over a maximum period of 12 weeks. Internal consistency was examined by item analysis and equivalence by interrater reliability. To estimate equivalence, 10 pairs of nurses assessed a total of 116 patients. The underlying dimensions of the scale were examined by factor analysis. The predictive validity was examined by determination of sensitivity, specificity and predictive value.
6. Ethnical consideration
The Research Ethical Committee of the Faculty of Health Sciences, Linköping University, approved the study.
7. Sample
Patients included in the study were newly admitted to acute, medical, surgical, infection, orthopaedic, rehabilitation, or geriatric wards. The inclusion criteria were: 17 years of age or older, an expected hospital stay of at least 5 days and, for patients undergoing surgical treatment, an expected time on the operating table of at least 1 hour. The exclusion criteria were pressure sore on admission. The patients were included in the study on three fixed days per week. These days could differ between the wards depending on the rules of admission on each ward. A total of 588 patients were asked to participate and 530 (90Æ1%) were included after their informed consent had been obtained. In some of the assessments values are missing, which explains why the analysis was based on a figure less than 530.
8. Data presentation
The data were presented and analysed using the Statistical Package for the Social Sciences (SPSS) (SPSS Inc., Chicago, IL, USA) version 10Æ1.
9. Main findings
Two variables were excluded as a result of low item–item and item–total correlations. The average percentage of agreement and the intraclass correlation between raters were 70% and 0Æ83, respectively. The factor analysis gave three factors, with a total variance explained of 65Æ1%. Sensitivity, specificity and predictive value were high among patients at medical and infection wards.
10. Conclusion and recommendations
The RAPS scale is a reliable scale for predicting pressure sore development. The validity is especially good for patients undergoing treatment in medical wards and wards for infectious diseases.
11. Readability
The presentation of this article considered the general reader. Although there are some technical information discussed in this paper, the quality and clarity of discussion was still well-presented. The graphs and figures in this manuscript were also presented in a readable and concise manner.
12. Implication for practice
From the finding of the study, it indicates that the RAPS scale may be useful in clinical practice for these groups of patients. For patients undergoing surgical treatment, further analysis should be performed.
Fifth Article
1. Focus
The paper of LEGOOD R. & McINNES E. (2005) focused on the guideline of development and economic modelling in accordance to pressure ulcers.
2. Background
Previous UK guidelines on the use of pressure-relieving devices to prevent pressure ulcers have not considered whether any recommendations made are cost effective. The routine inclusion of cost effectiveness evidence in guidelines is a recent policy development, and there has been little research into its potential role in the guideline process.
3. Terms of reference
This paper presents the development process for clinical guidelines on the use of pressure-relieving devices (beds, mattresses and overlays), with emphasis on incorporating economic evidence.
4. Study design
LEGOOD R. & McINNES E. (2005) systematically reviewed the literature to assess both the clinical and cost effectiveness of pressure-relieving devices for prevention of pressure ulcers. Where there was sufficient evidence on the comparative clinical effectiveness between alternative devices, economic modelling was undertaken to assess comparative cost effectiveness. A guideline development group (comprising both clinicians and patient representatives) reviewed all the available evidence to formulate clinical practice guidelines and recommendations for further research.
5. Tool of data collection
As part of data collection, the use of economic literature was assessed in order to have a meaningful analysis. The aim of reviewing the economic literature was to identify economic evaluations and UK costing studies. By definition, economic evaluations compare at least two interventions and combine evidence on both costs and effects. Economic evaluations differ in the outcome measures used. Where outcomes are all measured in monetary terms, these are known as cost-benefit studies. More commonly, economic evaluations use a clinical outcome measure, such as pressure ulcers prevented (cost-effectiveness analysis), or a generic measure, such as QALYs (cost-utility analysis).
6. Ethnical consideration
Individual papers were checked for methodological rigour (using quality checklists appropriate for each study design which were formulated in conjunction with the Centre for Statistics in Medicine and which reflect commonly-agreed principles of quality assessment for each of the major quantitative study designs), applicability to the UK and clinical significance. Assessment of study quality concentrated on internal and external validity. Information from each study meeting the quality criteria was summarized and entered into evidence tables.
7. Sample
This study explored the difference in costs and effects of providing either a standard hospital mattress or a high specification foam mattress for 100 patient episodes.
8. Data presentation
Basically, four scenarios were presented, reflecting patients’ absolute level of risk of developing pressure ulcers when nursed on a standard mattress. The results of the clinical evidence review gave an estimate of the relative risk of developing pressure ulcers with high-specification foam mattresses compared with standard foam mattresses. This relative risk estimate was used to calculate the total number of patients developing pressure ulcers (of 100 patient episodes) if they were cared for on a high-specification foam mattress, for patients in each risk scenario.
9. Main findings
Studies showed that caring for people vulnerable to developing pressure ulcers on high-specification foam mattresses compared with standard hospital mattresses significantly reduced their risk of developing a pressure ulcer. Cost effectiveness modelling indicated that, because of savings accruing through treating fewer pressure ulcers, high-specification foam mattresses are likely to cost less overall and are more effective. The resulting clinical practice guideline was uncompromising on the use of high-specification foam mattresses as the minimum provision in patients vulnerable to pressure ulcers. Significant weaknesses were identified in both the quality and availability of evidence for most of the other pressure relieving devices considered.
10. Conclusion and recommendations
Cost effectiveness assessment was an integral part of the guideline development process. It clarified the shortcomings of some of the clinical effectiveness evidence and helped in formulating pragmatic clinical practice recommendations.
11. Readability
From the presentation of the article, there are several jargons that might affect the general reader. However, the researchers and writers of this manuscript provide a clear explanation of the technical terms. The graphs and figures were also presented in a readable and concise manner.
12. Implication for practice
From the findings, there are shortcomings in some of the research on high-tech pressure-relieving devices thus further research on this area should be given enough consideration by the industry.
Sixth Article
1. Focus
The main focus of this study was to identify factors associated with pressure ulcers among palliative home care clients. Identifying associations specific to each setting is important for ulcer prevention and has implications for clients overall well-being and quality of life.
2. Background
Studies have identified factors associated with pressure ulcers in many health care settings including acute care, complex continuing care, long-term care, and home care.
3. Terms of reference
The study aimed to evaluate and identify factors associated with pressure ulcers among palliative home care clients.
4. Study design
The study included all palliative home care clients diagnosed with terminal cancer from one palliative home care agency in Ontario. Information on health was gathered using the interRAI instrument for palliative care.
5. Tool of data collection
Information on health was gathered using the interRAI instrument for palliative care. The interRAI PC is an instrument designed to provide a comprehensive assessment of palliative care clients. It includes a number of domains such as psychological, physical, social, and spiritual well-being.
6. Ethnical consideration
The researcher seeks the approval of the family of clients diagnosed with terminal cancer receiving palliative home care from one of Ontario’s Community Care Access Centres (CCACs).
7. Sample
The study sample included all home care clients diagnosed with terminal cancer receiving palliative home care from one of Ontario’s Community Care Access Centres (CCACs). In Ontario, a Province of Canada, home care delivery is coordinated by the CCACs to coordinate in home services and ensure timely access when needed. Health information from 561 home care clients were gathered using the interRAI instrument for palliative home care.
8. Data presentation
All data analyses were performed using SPSS version 11.0 (SPSS, Inc., Chicago, IL). A series of independent and t tests between means were used to determine association with pressure ulcer development. Associations were tested with a number of variables representing health conditions commonly found in palliative home care. Further analyses used binary logistic regression to determine factors associated with pressure ulcers.
9. Main findings
The study found male gender, the inability to lie flat because of shortness of breath, catheter, or ostomy care, and a reduced ability to perform activities of daily living to be associated with pressure ulcers.
10. Conclusion and recommendations
Symptoms that contribute to pressure ulcer development may be a consequence of terminal disease and/or the dying process. Even though fewer ulcers develop by adopting proper care procedures like repositioning and better catheter/ostomy care, informal caregivers may lack the resources and skills necessary to cope with the increased demands of care. Also, when levels of comfort are compromised by treatment and prevention techniques, the goal of care may shift away from treatment and prevention. Turning, repositioning, and pressure ulcer care become more painful toward end of life and the goal may shift to increase comfort level. However, when this transition occurs must be determined by the client. The principles of palliative care point out that it is the patient’s right to make informed decisions and to determine their goals of care.
11. Readability
From the article, there are several jargons which is difficult to understand. However, the researchers and writers of this article provide a clear explanation of these technical terms. The graphs and figures were also presented in a readable and concise manner.
12. Implication for practice
In some instances, treatment and prevention of pressure ulcers is the primary goal of care. However, pressure ulcers are also suggestive of deterioration and considered as a part of the disease trajectory. Sometimes the primary goal of care of treatment and prevention is displaced by a greater need for comfort.
Credit:ivythesis.typepad.com
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