Pressure Ulcers in ICU Patients

Pressure Ulcers in ICU Patients

Introduction

Pressure ulcers are skin and tissue injuries that occur when pressure is exerted on the skin for a long period. They often develop on the parts of skin covering bony areas of the body, such as heels and hips (Alderden 2017). Nurses play a big role in helping prevent pressure ulcers in patients, and this has been an issue of concern in nursing for a long time. Pressure ulcers develop in patients as they cannot turn or reposition themselves, resulting in mechanical loading. The most common practice by nurses in reducing mechanical load and prevent pressure ulcers is the frequent turning of repositioning the patients. Current practice protocol requires nurses to turn patients 30˚ at two-hour intervals. The current practice of turning patients 30˚ every two hours is, however, not preventing pressure ulcer injury in critically ill ICU patients.

Head nurses have a significant role to play in addressing this problem as the nurse leaders are accountable for cases of pressure in patients at intensive care units.  As head nurse, it is important to take a systematic approach and apply my knowledge and skills in leadership and management in developing appropriate strategies to address the problem. Ensuring collaboration between bedside nurses and other supervisors is essential in ensuring that proper methods of preventing pressure injuries in the patients are used. The Quality and Safety Education for Nurses (QSEN) competencies provide guidelines for nurses and nurse leaders to use in improving patient safety and quality of health care (“QSEN Competencies,” 2020). The competencies that nurses can use to address this problem as provided by the QSEN guidelines include Quality Improvement (QI), Evidence-Based Practice (EPB) safety competencies, teamwork and collaboration, and informatics.

Assessment/ Analysis

Evidence-based research was used to identify solutions for addressing this problem. Sound research form documented articles in nursing practice and medical research was used in coming up with the intervention methods and procedures. The current procedure for reducing hospital-acquired pressure ulcers (HAPU) in critical care patients is repositioning the patients at a 30˚ lateral recumbent position. The head of the bead is usually elevated at a less than 30˚ position (Krapfl 2017). This position helps minimize the pressure on the bony areas, especially the hips and sacrum. However, clinical findings and evidence provide that regular positioning of patients in a 30˚ position is not always possible for ICU patients for various reasons. This is because the complexity and instability of ICU patients limit the nurse’s ability to reposition the patient leading to pressure ulcers. This leads to a challenging situation for nurses as they have to find other ways to reduce the risk of HAPU on ICU patients.

The underlying cause of the problem is that the turning of ICU patients is limited due to the complexity of mobility issues in ICU patients. For instance, turning ICU patients may result in fatal changes to hemodynamic status (Krapfl 2017). ICU patients are also prone to moisture, which increases their risk of acquiring pressure ulcers. This affects patient care in that it increases the risks of ICU patients acquiring HAPU. Nurses need to adopt other strategies other than turning of patients to address this problem. Another cause is the lack of continuous monitoring tools to monitor patients’ positions and alert nurses in most hospitals.

The best method for addressing this issue is the use of interventional technology. This involves the use of wearable sensors attached to patients so as to monitor their movements and position (Renganathan 2019). The sensors are attached to the chest of the patients and determine the rotation of the patient with respect to the bed. These devices alert the nurses and supervisors about the patient’s movements at regular periods. Through the use of this technology, nurses can get visual cues. The data can also be accessed by head nurses and doctors through the use of a cloud-based web application (Renganathan 2019). The devices alert nurses and supervisors by providing visual cues. Yellow colour shows that there is no danger of pressure ulcers, while red color shows that the patient requires turning immediately.

These sensors should be accompanied with the use of continuous bedside pressure mapping (CBPM) and micro shifts and airbed adjustments. The CBPM technologies enable the nurses to access areas of high pressure in patients. Airbed and micro-shifts are then used for pressure redistribution in the patients (Coleman, 2017). This change reduces nurse workload while ensuring that patients do not acquire pressure ulcers. They also avoid the risk of damage to the patient by making very small adjustments to the patient’s position “micro shifting.” That cannot be made manually without causing complications on the patient No patient has been recorded to have obtained pressure ulcers with the use of this method or any other damages as a result of turning.

Planning/ Literature Review

A lot of research has been conducted on the use of software technology in preventing pressure ulcers in ICU  patients and there are quite a lot of articles on the same. One article crucial for this paper is “Approaches that use software to support the prevention of pressure ulcer: A systematic review” by Marchione. The article addresses the use of software based approaches in the prevention of patient ulcers (Marchione 2015). This article details a technology that involves the use of pressure sensors that are used to estimate the body position of patients by identifying the body parts that are under pressure. The system works by monitoring the body positions that are under pressure. It then uses an algorithm to detect the risk of developing pressure ulcers on the area under pressure and determines how frequently the patient needs to be turned to prevent pressure ulcers. The algorithm also determines the next position that the patient should be rotated to minimize the danger of pressure ulcers.

Marchione also identifies software that uses an algorithm to schedule the patient’s position. The scheduling of patients’ positions is based on two metrics: the effort and stress for changing of the position by the patient. The stress to change position is the effects of excess pressure in an area of the body while effort is the time taken to change the position of a patient as well as the number of nurses required. The algorithm is based on monitoring the body part of patients under pressure so as to provide the guides for change of the patient. Another article used for this paper is… article “Reducing pressure ulcers with prolonged acute mechanism ventilation: A quasi experiment study” this article provides different management styles that could be used for developing intervention. It is important for me as it helps me identify the strategies. I would use in implementing the intervention.

Leichman also identifies in her article the use of new technologies to monitor patient position and prevent pressure ulcers in patients. The article addresses the use of an Israel developed Monitor Alert Protect (MAP). MAP is the first monitoring device in the world that is able to monitor locations where patients are developing high pressure in real-time (Leichman 2020). MAP is even better than other software as it uses a sensing mat instead of attaching devices on the patient. The mat is placed on the top of the bed and is wired to a monitor. The monitor provides color-coded visual feedback that aids in the positioning of patients by identifying pressure points that should be rotated. According to the article, MAP has helped reduce the rate of patients acquiring pressure ulcers from 5% each year to 0.3% per year.

De Meyer conducted a study to compare the cost effectiveness of using the usual care routine with the effectiveness of using a turning and repositioning system and an algorithm for tailored repositioning (De Meyer et al., 2017). In their report, the researchers recommend the use of pressure redistributing support surfaces and systematic patient repositioning to prevent pressure ulcers in patients.  The researchers recognized the importance of the use of advanced technology in preventing pressure ulcers for patients in Intensive care units. These advanced techniques will help in, redistribution of pressure and management tissue load of microclimate of the patient. The technologies will also be used for systematic repositioning of the patients with the use of algorithm to determine the individual’s position (De Meyer et al., 2017). Patients who were at risk of developing pressure ulcers were used in the study.  This report is relevant and important to my study as it

Intervention

The best intervention for prevention pressure ulcers in patients would be would be to introduce new technological systems. These systems will monitor the positions and movements of the patients and alert the nurses of the need to love patients. The technologies also alert supervisors; hence they can monitor nurse compliance and adherence to protocol. Research has show that increased use of technology has decreased the cases of hospital acquired pressure ulcers (Kayser 2019). In making the intervention, teamwork, and collaboration between nurses and their leaders is crucial to ensure that the positive results from intervention. Before making the intervention, nurses’ opinions should be gathered to understand their perceived usefulness of the new technological systems. Interviewing the nurses also helps nurse leaders understand the intention to use, the ease of use, and compatibility of the systems with the nurses’ clinical practices and competencies.

As the nurse leader in charge of making the change, I would use Lewin’s planned change process to implement the new technology. This is a three-step change model towards problem-solving. The first stage of the model is the freezing stage. This involves the creation of motivation and readiness for change and will include communication with the nurses on the need for change so that they understand the need for change (Archer 2019). It is normal that a lot of people will resist the change. The goal here will be to create awareness on how the current status quo hinders the quality of patients’ health outcomes. Communication will be key in this stage as the employees will need to be well informed of the logic behind the change in order to change their attitude. Motivation and a positive of employees is crucial in determining the success of the change. Team work and collaboration will be also be crucial and will be attained through communication.

The second stage in his model is the moving stage in which the first notable changes will occur. Nurses’ involvement is crucial as they will be required to provide feedback to determine whether the change has positive or negative effects. This stage is, therefore, a test stage for the change method. The technology will only be used on a few patients and the results will be compared with the rest of the patients. Nurses’ and patient’s response to the change will be monitored. Once the change proves to be positive, the actual change can be planned and initiated. The final stage, known as the unfreezing stage, will then follow and involves the integration of the change into the system. This would only follow if the use Micro Shifts and Airbed Adjustments with the use of CBPM proves to be effective in the second stage (test stage).It involve a complete change and shift and installation of the new technology for all critically ill patients in ICU wards. My role as s nurse leader here will be to ensure that the positive attitude towards the change is not lost so that it remains positive. This will be done by acknowledging and rewarding individuals.

I find it that the best management style to use in addressing this issue would be the systems management theory. This theory of management identifies that systems cannot work as parts functioning in isolation. It states that in order to understand a system as a whole, one need to first understand how its different parts operate (Huber 2017). Through this theory, managers have learned that changing a part of the system leads to changing the whole system. This management system would be the best to apply in solving the issue as health care operates as a series of interdependent parts. The inputs to the health care system include people, technology, and money, while outputs include clinical outcomes and better quality of lives. Nursing services and management form part of the throughputs. Customer and nurse satisfaction forms part of the feedback.

The contingency leadership theory is best suited to address the issue of adherence to the protocol by nurses. In using the contingency leadership theory, nurse leaders need to consider the situation at all the elements before making a decision. This leadership is especially perfect for this situation as it goes well with the systems management theory (Huber 2107). In using the contingency theory of leadership, nurse leaders will need to look at the key players affected by the problem at hand and provide a solution that will provide for all the affected aspects. In this case, patients, as well as nurses, are affected by the issue in that it increases their risk of acquiring pressure ulcers. Nurses are also affected in the sense that it increases being required to check patients and turn them increases their workload. Using the contingency leadership theory helps nurse leaders come up with an intervention that suits both the nurses and the patients.

Evaluation

Outcome evaluation will be used in evaluating whether of the use of wearable sensors attached to patients so as to monitor their movements and position helps in reducing pressure ulcers in ICU patients. In the articles I used for research, an outcome-based evaluation was used in the assessment of the different interventions used. Outcome evaluation focuses on the outcomes of implementing the technology. This method determines the results achieved by implementing the solution were desirable or not. The evaluation is based on the outcome objectives that had been set when implementing the intervention strategy. The degree to which the desired objectives have been achieved is measured. The first step in the evaluation process will be to plan for evaluation. This will be done by determining the levels of evaluation. Four levels of evaluation will be used. The first level is the reaction level, which will measure the degree to which the nurses reacted positively to the new implementation.

The second level is the learning level. This will access the degree to which nurses acquired the necessary skills and knowledge to be able to use the new technology. The third level is the application level, which will measure the degree to which nurses and supervisors applied the new technology. The third level of evaluation is the results or organizational impact level, which will access the degree to which application of the intervention produces the desired outcomes. The fifth level is the Return of investment. The degree to which the benefits of the intervention outweigh the costs will be measured (Thurman 2015). In planning for the evaluation, key measures, and indicators to be used in evaluation will be identified, data analysis techniques will be chosen, and an evaluation team will be established.

Data collection is crucial in the evaluation process and will start at choosing the appropriate methods for data collection. The methods for data collection will depend on the level which is being evaluated. The data collection methods to be used in the evaluation will include pre-tests and post-tests, questionnaires, tests, observation checklists, and satisfaction surveys. After data collection methods have been prepared, the data will be collected at different times. The evaluation will look to find out the short-term as well as the long term effectiveness of the intervention (Thurman 2015). Data will, therefore, be collected during the implementation, immediately after the implementation, and in the long term. Nurses and patients will be the main sources for data collection as the evaluating will be looking to identify the effects of the intervention on adherence of nurses to turn protocols as well as the outcomes of patients.

After data has been collected, the next step will be to analyze it so as to acquire results. The data collected at the five levels of evaluation identified during planning will then be analyzed. Data will be in the form of descriptive statistics, comments from nurses, supervisors, and doctors, and performance reviews. Data from the fourth and fifth level will be analyzed by making the monetary calculations for costs. After data analysis, the last step in evaluating the intervention will be to review the results of the evaluation. This will help in determining which desired outcomes were achieved and those that were not. This will help in identifying the areas for improvement. Reviewing the outcomes will also help in suggesting actions that can be used to better achieve the desired outcomes.

Conclusions

Current practice protocol requires nurses to turn patients 30˚ every two hours. However, the current practice of turning patients 30˚ every two hours in not preventing pressure ulcer injury in critically ill ICU patients. To address this issue, the use of interventional technology that involves the use of wearable sensors attached to patients so as to monitor their movements and position is crucial. Nurse leaders play a big role in implementing this change and the method they use will be important in determining the success of implementing the new technologies. leaders should ensure they use different management and leadership styles during intervention as provided in this article.

References

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