Use of Prophylactic Dressings to Prevent Pressure Ulcers

Running head: PROPHYLACTIC DRESSINGS Task Two: Use of Prophylactic Dressings to Prevent Pressure Ulcers 1 PROPHYLACTIC DRESSINGS 2 A1. Healthcare Problem Patients who need hospitalization, especially those who are critically ill, are already at great risk due to their disease process(es) and admitting diagnosis or diagnoses. They are admitted to the hospital to receive treatment and due to the extent of the disease or condition, end up having limited mobility or are immobile. It is these patients, as well as those already with limited mobility, who are at risk of a hospital acquired pressure ulcer (HAPU) during their length of stay. According to Huang et al., (2015) pressure ulcers (PUs) generally occur over bony prominences in the body such as the sacrum, coccyx, and heels, and are created, as the name suggests, by pressure, usually excessive or prolonged in nature, as well as other forces such as friction and shear. PUs progress in stages and there are several different types including Stages IIV, Unstageable, and Deep Tissue Injury (DTI). In Stage I the skin is red and does not blanch (i.e., turn white when pressed), Stage II is a partial thickness wound and the skin is open and red, and is oftentimes confused for moisture wounds or incontinence dermatitis, Stage III is considered full thickness, is more extensive and the fatty layer under the skin can be seen, and Stage IV is also full thickness, and is the worst of the stages, where bone, muscle, tendon, or ligament is visible. If a Stage III or IV wound is covered by dead tissue such as slough (greyishyellow in color) or eschar (a very dark, dry scabbing) it is considered Unstageable and cannot be Staged correctly until the slough/eschar is removed, usually by a surgeon. A2. Significance of Problem According to Padula (2017), HAPUs are unfortunately very common, and in the United States alone, occur in a shocking “2.5 million patients per year”, cost between “$500 to $150,000 per case” and total approximately “$11 billion annually”. Another article states that the estimated PROPHYLACTIC DRESSINGS mean cost of treatment for a PU is “$1200-$1600 per day” (Byrne et al., 2016). Besides the hospitals going uncompensated for these extremely expensive HAPUs due to policies for repayment that are set by Medicare & Medicaid, Stage III and IV wounds “cause an astounding 60,000 deaths per year” (Padula, 2017). With these statistics alone, it is easy to see why healthcare providers must do everything possible to prevent HAPUs from occurring. A3. Current Practice HAPUs are not a new issue for hospitals, and up until now, those caring for patients at risk have been preventing PUs from occurring by turning and repositioning the patient at a minimum of every two hours among other efforts. Regular repositioning, offloading pressure with pillows, specialty mattresses, and other interventions aimed at relieving or redistributing pressure are currently recommended as best practice (Huang et al., 2015). A4. Impact on Background Patients that acquire PUs not present on admission can impact the workplace in many ways. Depending on the severity of the PU, patients may require a multitude of interventions including dressing changes, use of negative pressure wound therapy, antibiotics, pain management, surgery to debride (clean) the wound, and in some cases post-discharge therapy. These interventions are very costly to the hospital, including an increased cost with providing nursing staff and healthcare providers that can care for patients with these wounds. Patients who experience a HAPU, also affect bed placement, since wounds such as these are at high risk for becoming infected with bacteria that can potentially be easily spread and increase the number of nosocomial infections. B. PICO Table (P) - Patient/problem (I) - Intervention Patients at risk for pressure ulcers Use of prophylactic dressings to prevent pressure ulcers (PU) 3 PROPHYLACTIC DRESSINGS (C) - Comparison (O) - Outcome 4 Standard care, no dressing reduced number of PU not present on admission B1. PICO Question Does the use of prophylactic dressings prevent pressure ulcers (PU) not present on admission in patients at risk as compared to standard care? C1. Keywords Pressure ulcers; prevention; silicone foam dressings; foam dressing; pressure injury; pressure injury prevention; pressure ulcer; pressure ulcer prevention; prophylactic dressing; wound dressings; preventative; C2. Number and Types of Articles To begin the article search, I started with the Western Governors University Library website home page and typed in “prophylactic dressings to prevent pressure ulcers” into the main search box. This cursory search provided me with 48,936 results. I filtered my search a bit further by checking the options for Full Text and Peer Reviewed articles and changed my publication date range to include the last five years of 2013-2018, which reduced the number of populated results down to 940. For the research articles I reviewed a total of twelve articles, five were Randomized Controlled Trials (RCTs), two quasi-experimental, two non-experimental, two systematic reviews, and one meta-analysis. Of these ten articles, I selected two RCTs, one meta-analysis, one quasi-experimental, and one non-experimental to make up the five needed for this task. From this point, I moved on to selecting non-research articles by typing “practice guideline OR literature review” in the second-tier search field, which populated a total of 841 results. A total PROPHYLACTIC DRESSINGS 5 of ten articles were reviewed for the non-research aspect, and one literature review, and one consensus panel were chosen. C2a. Research and Non-Research Evidence The first research article that I reviewed, was a quantitative, level I, RCT, that took place in Australia, and examined how effective a multiple layer, soft, silicone-based foam dressing was at preventing PUs in intensive care unit (ICU) patients if applied upon arrival to the emergency care center (ECC). The study involved 440 patients, admitted from the ECC to the ICU. The first group had preventative Mepilex® dressings, made by Mölnlycke Health Care, applied to their sacrum and heels in the ECC, maintained for their entire ICU stay in addition to standard care. The control group received only standard care, which included a specialty mattress, ongoing assessment with the Braden Scale (used for PU risk assessment), frequent repositioning, and regular skin care. The researchers for this study used a minimal inclusion and exclusion criteria, where patients only needed to be over the age of 18 and present to the ECC and require ICU admission to be included in the study, but these patients must not present with a spinal injury that would prevent them from being turned, or have any pre-existing trauma or PUs to the sacrum or heels. The researchers’ conclusion was that use of a prophylactic dressing in at risk patients is extremely beneficial (Santamaria et al., 2015). The second research article I reviewed, was also a quantitative, level I, RCT with a nonblinded approach, which also examined the effectiveness of the Mepilex® sacral dressings at a 569-bed, level II trauma center in the United States. There was a total of 366 participants in the study, and similarly to the first RCT one group received a sacral dressing, maintained throughout the patient’s length of stay, and the other group did not. All participants received standard care, which in this study followed a bundled approach, including a specialty mattress, use of the PROPHYLACTIC DRESSINGS 6 Braden Scale on admission and every shift, full skin assessment every shift, routine positioning and offloading of heels, and skin care with frequent checks for incontinence. The skin under the dressing was assessed on a daily basis by partially peeling back the dressing, as the nature of the dressing’s adhesive allows, and the dressing was changed once per three days and as needed if soiled or displaced. This particular study also assessed estimated material and labor costs related to this intervention. Data was collected using a form designed to evaluate compliance with the standard care bundle, and data was also collected on risk factors for PU development. Data was analyzed with SPSS software and using standard statistical tests. As in the first RCT I reviewed, this study also concluded that use of a prophylactic dressing is effective and valuable (Kalowes, Messina, & Li, 2016). The first non-research article I reviewed was a non-systematic literature review conducted by a tissue viability specialist in the UK. This article discusses the use of prophylactic dressings and the author cites that originally the idea was “frowned upon, raising concerns that this would result in less frequent skin inspection, skin would be damaged on removal, and that the ability of dressings to reduce pressure is non-existent,” (Cornish, 2017) but that recent interest has been shown regarding how preventative dressings redistribute pressure and prevent friction and shear (Cornish, 2017). This review of literature also states that current research implies “that only one type of dressing (soft silicone, multilayer foam) may assist in the prevention of PUs” (Cornish, 2017), and that according to the European and National Pressure Ulcer Advisory Panels a multimodal approach is needed in addition to preventative dressings to thoroughly prevent PUs (Cornish, 2017). Cornish (2017) generally concludes that prophylactic dressings are of use, but that dressing used must be the correct size and type for the patient, and that overall more research is required. PROPHYLACTIC DRESSINGS 7 The second non-research article reviewed gives recommendations for the use of dressings to prevent PUs by a consensus panel of experts, and once again Mepilex® dressings seem to be gold-standard. There is a total of eleven recommendations made for practice regarding prophylactic dressings. These recommendations include consideration for using a five-layered, soft silicone, bordered foam dressing (e.g., a Mepilex®) on the sacrum and heels to enhance current prevention efforts, considering whether or not the patient’s skin qualifies and the ease of dressing removal to prevent skin stripping, applying the dressing to skin that is dry and intact without use of barrier cream, selecting a dressing that is larger than the area of at-risk skin to adequately protect, regular inspection of skin under the dressing, dressing changes consistent with hospital policy and/or manufacturer guideline and as needed if soiled or displaced, discontinuation of dressings as risk for PU development declines, and considering placement of dressings on the sacrum and heels prior to events where the patient may become immobile or cannot be moved (e.g., in surgery) and when the head of bed must be continuously elevated (Black et al., 2015). As in the previous non-research article, it is stated by the authors that evidence supports the use of prophylactic dressings as part of a multi-factor approach to PU prevention, and that further research is needed. D. Evidence Matrix See attachment. E. Recommended Practice Change Based on the results of the research reviewed, a prophylactic dressing should be added to the current practice to further assist in preventing pressure ulcers. All five research studies found that patients who had the dressings applied had a lower incidence of developing a HAPU. In the RCT conducted by Santamaria et al., (2015), there was a reported 10% difference in incidence PROPHYLACTIC DRESSINGS 8 rate between the two groups studied. Those with the Mepilex® dressings had a 3.1% incidence rate of HAPU and those without, a 13.1% rate of occurrence, with no adverse events related to the dressings noted, proving that use of a prophylactic dressing in at risk patients is indeed effective, so much so, that the hospital being studied mandated use of this intervention after the study ended. In the second RCT of 366 patients comparing use of a sacral Mepilex® in addition to standard care (intervention group), to standard care only (control group), the results of the study found that the incidence of HAPU was much less in the intervention versus the control group, with rates of occurrence at 0.7% and 5.9% respectively, also with no adverse events noted, once again proving the efficacy and value of the use of these dressings (Kalowes, Messina, & Li, 2016). In the non-randomized, quasi-experimental trial, 200 patients meeting the inclusion criteria had a preventative Allevyn sacral dressing made by Smith & Nephew applied. This intervention was not evaluated in addition to standard skin care for this study. It was reported that “implementation of the sacral dressing reduced unit-acquired sacral pressure ulcers anywhere from 3.4 to 7.6 per 1000 patient days” and the authors concluded that “a prophylactic sacral dressing may prevent ICU-acquired sacral pressure ulcers” (Byrne et al., 2016). The metaanalysis performed by Huang et al., (2015) reviewed studies that compared several different types of dressings including hydrocolloid, foam, corpitolinol 60, and film with routine standard care, as well as studies comparing foam dressings to hydrocolloid dressings. The results showed that “using a range of hydrocolloids, foams, and films is more effective that standard care in preventing PUs in a variety of hospitalized patients,” that “foam dressings are more effective than hydrocolloid,” and that “early application of dressings…in addition to other evidenceinformed measures should be considered” for at-risk patients (Huang et al., 2015). PROPHYLACTIC DRESSINGS 9 Finally, the non-experimental, longitudinal study involved examining the usefulness and associated cost of Mepilex® dressings at 38 UHC hospitals over a period of six years. This study showed that approximately 2,586 dressings were purchased per 90 days, which gave a mean of about 1.5 dressings used per patient “over an average length of stay of 7 days,” costing between $7 to $8 for each patient (Padula, 2017). This study also reported an average reduction in stage 3, 4, or unstageable HAPUs of about 1 in 1000 cases over the six year period, and a potential cost savings of “$200,000 to $600,000 per year in expenses associated with pressure injuries” (Padula, 2017) once more proving that this intervention should be established as part of standard practice. F1. Key Stakeholders There are several key stakeholders in the prophylactic use of dressings to prevent PUs, including, but not limited to, hospitals, patients, patient families, and nurses to name a few. Although more research is needed, there is enough currently in circulation to prove the effectiveness, value, and cost reduction that can be gained by instituting the use of preventative dressings. The hospitals are benefitted by the overall cost reduction that comes from using dressings like Mepilex® to prevent PUs, thus allowing for budget allocation to other areas such as a potential increase staffing, in turn lowering nurse to patient ratios and risk for caregiver burnout. The patients benefit by not developing a HAPU which would be painful, costly, and potentially increase their length of stay and risk for infection and death. Patient families benefit in that they are not required to provide their loved one wound care for which they may or may not be able to in terms of skill, time, and cost required. Lastly, nurses benefit in that they ultimately are not contributing to the number of tasks to be performed in one shift, thereby increasing productivity and time-management. PROPHYLACTIC DRESSINGS 10 It would be essential to involve the financial department of the hospital to provide facts about the overall cost reduction possible, as well as nurse educators or product representatives to ensure that all bedside nurses receive adequate training and knowledge regarding use of these products in the healthcare setting. F2. Barriers Some barriers to initiating this practice change could be that nurses may see it as “yet another task to be done” and that nursing staff is unwilling to institute the change. This reluctance could be related to a lack of education about how PUs really affect the patient, or they may not know how beneficial this practice change could be. Another possible barrier is that patients may not understand the need for preventative dressings and may be uncertain as to how it will feel to wear these dressings at all times during their stay. F3. Strategies for Barriers One strategy for overcoming barriers to any change, which applies to all parties involved, is sufficient knowledge. Suitable knowledge on the use of prophylactic dressings to prevent PUs can be ensured through education. In-services could be conducted by either nurse educators or company representatives to demonstrate to bedside nurses how to properly apply and use the dressings, allowing opportunity for any questions that may arise to be answered. Proper application technique and use could then be refreshed upon at annual nursing competencies. Knowledge gained from the in-services and competencies could then be used by nurses to educate their patients on the value of using preventative dressings. F4. Indicator to Measure Outcome To ensure that prophylactic dressings are effective in preventing PUs from occurring, there must be a few indicators implemented concerning documentation. Documentation in the PROPHYLACTIC DRESSINGS 11 patient’s chart that they did not present on admission with a PU, that a prophylactic dressing was applied, that the site was reassessed at least once a shift, and that the dressing was changed at a minimum of every two to three days and as needed would be critical to determining the benefits, effectiveness, and associated cost of this intervention.