Date of Award
College of Nursing
ED (emergency department) personnel are admitting to inpatient services increasing numbers of elderly clients who are at risk for skin breakdown. The ED environment is designed for short term care in response to emergent situations. Pressure related injuries originating in the ED lead to both physical suffering and financial burdens. Pressure relief strategies have been actively employed on an inpatient basis without translation to the ED environment. Evidence for best practice in PUP (pressure ulcer prevention) in the ED is not widely embraced. Prevention of PUs is primarily within the scope of nursing practice and amenable to improvements in the standard of care. Therefore, the purpose of this project is to translate current evidence for PUP from the literature to sustainable best practice in emergency nursing.
Synthesis of existing literature revealed the most effective strategies for PUP focused on enhanced support surfaces, patient positioning, moisturizing dry skin, restricting head of bed (HOB) elevation, and timely removal of backboards. These measures reflect current evidence and were proposed as innovative strategies in the ED. A logic model was utilized to guide planning and evaluation of the program. The theory of planned behavior, the consolidated framework for implementation research, and polarity thinking were employed to ensure theory driven practice.
Following an organizational assessment and IRB approval, the project was implemented at a 254 bed community hospital in the Midwestern United States with a 20 bed ED. A significant challenge to implementation was the culture of ED nursing which was focused upon stabilization and disposition versus prevention. The timeline for the project involved data collection, intervention, and evaluation over a four month period.
A chart review was conducted to establish current practice of skin assessments and ED interventions directed at maintaining skin integrity. Nursing and support staff participated in an educational intervention addressing the relationship between routine care and the unintended consequence of skin breakdown. Evidence for best practice in prevention was reviewed and realistic measures for PUP presented for adoption. Learning was evaluated in pre-test/post-test format. Nurse's intention to implement best practice measures and perceived barriers/facilitators were identified. The post intervention evaluation period lasted two months and documented utilization of skin moisturizer from ED supply. The terminal outcome was repeat chart audit of vulnerable elderly patients which assessed for increased documentation of skin assessments and identified PU strategies.
Follow up chart audit revealed a 56.6% improvement in the frequency of nursing documentation of integumentary assessments. Documentation of prevention measure improved less dramatically. Inventory analysis, however, demonstrated actual use of recommended products. Nursing knowledge regarding pressure ulcer identification, staging, and prevention increased in 93% of participants. All four evidence-based strategies were embraced with greater than 70% of participants reporting intent to implement. The most frequently identified barriers to implementing prevention measures were time and staffing. The most common facilitators were availability of supplies and visual reminders. Recommendations include revision of the electronic health record to facilitate documentation of strategies by staff and inclusion of the protective dressing in the bedside treatment carts.
Zoeteman, Jennifer L., "Protecting the Skin of Older Adults Through Surveillance and Pressure Ulcer Prevention Beginning in Emergency Services" (2014). Doctoral Dissertations. 19.