March 5, 2009

Sample Research Proposal on An Audit of the Reduction of Pressure Ulcers

Pressure ulcers continue to be a distressing medical problem. Not only do patients experience pain and discomfort but intensive wound care also incurs considerable costs to both patients and hospitals. Therefore both health care professionals and patients should consider the prevention of pressure ulcers of extreme importance. Hospital nursing teams are especially concerned with the prevention of pressure ulcers that develop during hospitalization, i.e. the nosocomial pressure ulcers.


The aim of this project is to improve pressure ulcer risk assessment and prevention through the implementation of guideline recommendations, many of which related to accurate and timely documentation of risk, adequate care planning and the provision and review of appropriate equipment. To achieve this, clinical audit will be used. The clinical areas audited provided care to patients identified anecdotally at higher risk of pressure ulcer development due to their physical condition. A quantitative form of research is applied in this project.




In keeping with the classical audit cycle this project seeks to identify current best practice in prescribing, survey the actual practice, and then institute measures to improve prescribing up to the identified standards. The audit tool will be used to collect data on length of stay, mattresses and repositioning provided to patients in each of the following hospital wards: medical, orthopedic or geriatric ward, groups considered to have a higher risk of pressure ulcer development, recovery room for the postoperative stay until first ambulation. This audit tool included demographic data as well as data on the modified Norton scale for evaluation of a patient's risk of developing a pressure ulcer. A score of 16 or less indicates increased risk for developing a pressure ulcer.


The audit tool will also include data on accompanying medical conditions, i.e. incontinence, diabetes, heart insufficiency and peripheral vascular diseases. Continence means that a patient has full control on urine and feces. Inserting a Foley catheter into the bladder can bypass the problem of urine incontinence. In case of urine incontinence, continued contact between skin and urine weakens the cell wall and may alter the skin pH, making it more susceptible to breakdown (Peich & Margalit, 2004).


Literature Review

Pressure ulcer is most commonly known as bedsore. Other names for it include pressure sore, decubitus ulcer and trophic ulcer. It is an ischemic necrosis and ulceration of tissues overlying a bony prominence which has been subjected to prolonged pressure against an external object like a bed, wheelchair, cast or splint for example (Bickley & Szilagyi, 2003). The condition results to impaired skin integrity related to unrelieved, prolonged pressure (Potter & Perry, 2004).


Such a condition is seen most frequently in patients who have diminished or absent sensation, or are debilitated, emaciated, paralyzed, or otherwise long bedridden. Any patient experiencing decreased mobility, decreased sensory perception, fecal or urinary incontinence and/or poor nutrition can therefore be at risk for pressure ulcer development. Tissues over the sacrum, ischia, greater trochanters, external malleoli, and heels are especially susceptible but other sites may be involved, depending on the patient's position. Pressure ulcers can affect not only superficial tissues, but also muscle and bone.


Both intrinsic and extrinsic factors precipitate pressure ulcers. Intrinsic factors include loss of pain and pressure sensations that ordinarily prompt the patient to shift position and relieve the pressure, and the thinness of fat and muscle padding between bony weight-bearing prominences and the skin. Disuse atrophy, malnutrition, anemia, and infection play contributory roles. The most important of the extrinsic factors is pressure. Its force and duration directly determine the extent of the ulcer. Pressure severe enough to impair local circulation can occur within hours of an immobilized patient, causing local tissue anoxia that progresses, if unrelieved, to necrosis of the skin and subcutaneous tissues.


The best treatment for pressure ulcers is prevention. Pressure on sensitive areas must be relieved. Unless a full-flotation bed such as a water bed is used, providing even distribution of the patient's weight. If the patient is using braces or plaster casts, a protective padding at bony prominences should be used under braces or plaster casts, and a window in the cast should be cut over potential pressure sites.


Skin inspection is also important. Pressure points should be checked for erythema or trauma at least once/day in an adequate light. Able patients, mobile or immobile, and their families must be taught a routine of daily visual inspection and palpation of sites for potential ulcer formation. Exquisite skin care for neurologically damaged parts is necessary to prevent maceration and secondary infection. Maintaining cleanliness and dryness helps to prevent maceration.


The prevention of pressure ulcers is a priority in caring for patients and is not limited to patients with restrictions in mobility. Impaired skin integrity may not be a problem in healthy, immobilized individuals but is a serious and potentially devastating problem in ill or debilitated patients. Prompt identification of the high-risk patients and their risk factors aids in prevention of pressure ulcers.


A well-balanced diet, high in protein, is important in the treatment of pressure ulcers. Blood transfusions may be needed for anemia. Threatened pressure sores require energetic use of all the above mentioned prophylactic measures to prevent tissue necrosis. The area should be kept exposed, free from pressure, and dry.


The major problem in treating pressure ulcer is that the ulcer is like an iceberg, a small visible surface with an extensive unknown base, and there is no good method of determining the extent of tissue damage.


More advanced ulcers require surgical treatment. Surgical debridement and closure is required for fat and muscle involvement. Affected bone tissue requires surgical removal; disarticulation of joint may be needed. Necrotic tissue can promote pathogen growth and delay healing, so it should be removed. An exception may be eschar or necrotic tissue on a heel ulcer because an open heel wound can easily become infected and lead to osteomyelitis. Several debridement methods are available; the choice depends on the amount of necrotic tissue, absence or presence of infection, patient preferences, and economic considerations (Baranoski, 2006).


Significance of the study

Protect patients from developing pressure ulcer, it is important to improve pressure ulcer risk assessment and prevention through the implementation of guideline recommendations. Therefore, an intervention program will be prepared and implemented based on the results of the project. The program will be prepared as an addition to the basic health care practice that is common for bedridden patients and other patients at risk for pressure ulcer development.


Evidence-based pressure ulcer prevention and treatment


Evidence-based practice, which is often referred to as evidence-based nursing or evidence-based medicine, is the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients. (1) It involves integrating the individual clinical expertise of the physician or nurse with the best available external clinical evidence from systematic research and individual patient preferences. (2) Research shows that patients' outcomes are at least 28% better when clinical care is based on evidence rather than tradition or common sense (Bryan-Brown, 2006). The following paragraphs would discuss health care practices and interventions on pressure ulcers which are evidence-based and are widely used in health care settings today.


A major aspect of nursing care is the maintenance of skin integrity. Consistent, planned skin care interventions are critical to ensuring high quality of care (Kozier & Erb, 2004). Nurses constantly observe their patient's skin for breaks or impaired skin integrity. Impaired skin integrity occurs from prolonged pressure, irritation of the skin, or immobility, leading to the development of pressure ulcers. Nursing care interventions aimed at the prevention, assessment and treatment of pressure ulcers should be based on research (Potter & Perry, 2004) or evidence-based practice.


There are several instruments for assessing patients who are at high risk for developing a pressure ulcer. Patients with little risk for pressure ulcer development are spared the unnecessary and sometimes costly preventive treatments and the related risk of complications.



Prevention and treatment of pressure ulcers are major nursing priorities. The incidence of pressure ulcers in a facility or agency is an important indicator of quality of care. There is evidence that a program of prevention guided by risk assessment can simultaneously reduce the institutional incidence of pressure ulcers by as much as 60% and bring down the costs of prevention at the same time (Potter & Perry, 2004).



Evidence-based practice shows that lack of documentation of patients at risk demonstrates the need for hospitals to increase prediction and prevention strategies. Use of a risk scale can provide triggers to plan care to decrease risk factors.


As a predictive measure, individuals should be assessed for risk of pressure ulcer development upon admission to acute care and rehabilitation hospitals, nursing homes, home care programs, and other health care facilities (Kozier & Erb, 2004). Pressure ulcer risk assessment should be done systematically.


Evidence-based practice also shows that extended stays of over 7 days increase the risk of pressure ulcer development (Lyder, et al, 2001). Nurses must therefore remain vigilant in the prevention of pressure ulcers in patients with longer hospital stays.


Evidence-based practice shows that the use of care practices such as daily skin assessment, use of pressure-relief surfaces and objective risk assessment measures, such as the Braden scale, identified at risk patients and reduce evidence of pressure ulcers (Lyder, et al, 2001). The Braden scale was developed based on risk factors in a nursing home population. It is highly reliable when used to identify patients at greatest risk for pressure ulcers. It is also the most commonly used assessment scale for pressure ulcer (Potter & Perry, 2004).


Evidence-based practice also shows that the use of nutritional consultation was associated with decreased incidence of pressure ulcers, suggesting a nutritional consultation may sensitize the staff that the older adult is at risk for pressure ulcer development (Lyder, et al, 2001).


Nursing interventions for reducing and treating pressure ulcers are evaluated by determining the patient's response to nursing therapies and by determining whether each goal was achieved. To evaluate outcomes and responses to patient care, the nurse measures the effectiveness of interventions. The optimal outcomes are to prevent injury to the skin and tissues, reduce injury to the skin and underlying tissues, and restore skin integrity (Potter & Perry, 2004). The care of a patient with a pressure ulcer requires a multidisciplinary team approach.


There is a strong relationship between nutritional status and pressure ulcer development, yet nutrition is an area often overlooked by clinicians in pressure ulcer care. Nutrition, including adequate hydration, plays an important role in pressure ulcer prevention and healing, and is critical in maintaining tissue integrity. Patients defined as malnourished at hospital admission are twice as likely to develop pressure ulcers as well-nourished patients. Therefore, nurses and dietitians should work together to assess the patient's nutritional and hydration status and ensure that these factors are addressed in the patient's care plan (Voss, 2000).


Pressure ulcers, regardless of their origin, represent negative outcomes for patients. These negative outcomes may include pain, additional treatments and surgery, longer hospital stays, disfigurement or scarring, increased morbidity; and increased costs. Although all negative outcomes are of concern, a hospital-acquired pressure ulcer can result in increased cost of treatment, patient dissatisfaction with care, and a potential litigious situation (Schultz, 2005).


Research Question

            Are nurses and other health care staff implementing the right risk assessment and prevention strategies for pressure ulcer?


Aims / Objectives



Ÿ           To review the research literature regarding the prevention of pressure ulcer

Ÿ           To reflect the implementation of risk assessment in pressure ulcer prevention

Ÿ           To improve pressure ulcer risk assessment and prevention to reflect the guideline recommendations




Ÿ           Develop a dissemination and implementation strategy to accompany the guideline

Ÿ           Audit care in pressure ulcer risk assessment and prevention, using criteria based on the guideline

Ÿ           Make recommendations for practice and future research based on the findings of the study.



            Clinical audits have become popular tools in the attempt to change behavior in health care to improve quality of care and is the one used for this study. For decades, health-care systems have used clinical audits as a tool for quality assessment. Audits of this type usually seek to characterize care through the systematic review of a series of patient experiences. Most often, the information is obtained by examining charts or medical records for documentation of specific clinical practices/procedures. While clinical audits are widely used to assess performance, there is conflicting evidence regarding whether or not they are effective in changing provider behavior.


Sampling Procedure


As the project had a short timeframe, a decision will be taken with the advisory panel that four to six sites would provide sufficient patient numbers to allow improvement in practice to be detected between the audits. Sites were included if they provided care to medical, orthopedic or geriatrics, groups considered to have a higher risk of pressure ulcer development. A sample was selected from these sites. As this was an audit project, ethics committee approval will not be required. However confirmation of this will be sought and obtained from all hospital sites involved in the project.


The audit criterion is that a practitioner with 'appropriate and adequate training' should undertake the initial risk assessment and document findings. For audit purposes, the grade of the nurse or health care professional will be recorded.


Dissemination and implementation strategy


The dissemination and implementation strategy was informed by evidence and reflected the advice of site link nurses and staff from the clinical areas on possible barriers to change. This ensured the strategy reflected best evidence to bring about change, and encouraged local ownership of the guideline. Dissemination comprised the identification of a nurse from each clinical area who could support clinical staff involved in the project and assist with the audits; circulating copies of the project proposal, quarterly newsletters and summaries of the guideline recommendations to all relevant staff.


Implementation and Data Collection


Implementation focused on the development of an evidence-based resource pack by the project team and provision of education sessions by the project manager. A resource pack was given to each senior member of staff in the clinical area to be audited, the site link nurses and directors of nursing, and included an implementation guide and copies of the audit tools.


The project manager shall lead education sessions at each site, with the assistance of the site link nurse, following audit 1. The sessions were to be attended by nursing staff from the clinical areas to be audited, senior nurses and/or ward managers. The sessions focused on a description of evidence-based practice and clinical guideline development; the development and recommendations of the RCN guideline; an outline of the project; site specific feedback and recommendations for practice from audit 1.


To ensure standardization of pressure ulcer grading for the audit, the European Pressure Ulcer Advisory Panel (EPUAP) tool was used by the project team (Stephens, 2003). Reduction in pressure ulcer prevalence is not a study outcome due to the time constraints and need to take account of potential contributory factors. Nevertheless, it is considered important to assess prevalence to enable audit findings to be more generalizable. Each site will be asked to identify clinical areas that met inclusion criteria and arrange dates for the project manager to undertake audit 1. Audit 2 will commence at each site five to six months later.


Development of Audit Tools

Two audit tools will be developed; one for the patient and one for the clinical area. The tools are developed using recommendations for audit criteria proposed by Baker and Fraser (1995), which included the following:

Ÿ           Criteria should be based on evidence where possible.

Ÿ           Criteria should be prioritized according to the strength of the evidence and effect on patient outcome.

Ÿ           Criteria should be measurable and appropriate to the clinical setting.


Audit criteria will then be derived from the guideline. This will be followed with a consultation with the advisory panel where and agreement will take place on what the audit would comprise.


Measurement and Analysis


On the first audit and data analysis, to be included are all patients admitted to the hospital with no skin breakdown during a six-month period, but are at risk for pressure ulcer development. The nurse will collect the data, using the audit tool. The information sources are patients' records, interviews with patients and/or patients' families, and nurses.


This is quantitative form of research wherein patient age range and mean will be computed both in the first and second audit. Pressure ulcer risk was elicited using clinical assessment and a tool to obtain a risk assessment score. Risk assessment scores for each patient were verified by the auditors (Stephens, 2003).


Data from audit 2 will then be compared with audit 1. The Statistical product and Service Solutions (SPSS) for Windows version 13 will be used. Statistical analysis of the quantitative data generated from the audit will involve the use of descriptive statistics to establish means, standard deviations, frequencies and distributions.


Data will be coded and entered onto an Excel spreadsheet, and results collated in an anonymised form using simple descriptive statistics to enable comparative analysis to be undertaken. Each site will then receive feedback comparing results from both audits by clinical area in an anonymised form.


Ethical Considerations


            In all countries, research works that involve human subjects and animals should be carried out in accordance with high ethical standards set by various ethics committee. The privacy and dignity of every individual involved in the research was protected. The participants in this study will be assured confidentiality and anonymity through identification coding and reports of aggregate data. The participants that will be involved will be notified of the aims, methods, expected outcome, benefits and potential hazards of the study conducted. Ethics committee approval is not required.




Patient safety should be the number one concern during hospital stay and also before, during and after each hospital procedure performed. A detailed knowledge of the epidemiology, based on adequate surveillance methodologies, is necessary to understand the pathophysiology and the rationale of preventive strategies that have been demonstrated to be effective in preventing and treating pressure ulcers. The principles of general preventive measures such as the implementation of standard and isolation precautions, following guidelines, and the control of antibiotic use should be reviewed. Some patients are more at risk for pressure ulcer development than others, and this should be taken into account by health care professionals.

 The necessity to audit is seen in the high prevalence of pressure ulcer development in hospital stays despite established clinical guidelines. There is a need to improve pressure ulcer risk assessment and prevention through the implementation of guideline recommendations, many of which related to accurate and timely documentation of risk, adequate care planning and the provision and review of appropriate equipment involved. The success of the health care professional who practices pressure ulcer prevention and control techniques is measured by determining whether the goals for reducing or preventing infection are achieved. A comparison of the patients' response with expected outcomes determines the success of the health care interventions.

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