Theoretical Foundation

Literature Synthesis

Practice Change Recommendation

i) Patients in the intensive care unit (ICU) have an increased risk for pressure injuries (PIs) due to a multitude of risk factors, including poor nutrition, hemodynamic instability, immobility, and many others (Webb-Anderson et al., 2018).

ii) The Trauma Neuro Intensive Care Unit (NICU) where this doctoral learner is employed is significantly impacted by a high number of hospital-acquired pressure injuries (HAPIs) and currently uses a standard approach to preventing them. Although risk assessment and standard interventions are utilized, there are no formal processes in place for this critically ill patient population when they are required to remain in the supine position for long periods of time. These patients often require multiple interventions such as magnetic resonance imaging (MRI) and multiple operative procedures, placing them at greater risk for sacral skin breakdown.

iii) Theoretical Foundations:

(1) Ida Jean Orlando Pelletier’s deliberative nursing process discipline theory will be the foundation of the DPI project. The framework of her theory contains three elements: patient behavior (risk assessment), nurse reaction, and what the nurse does to mitigate the problem (interventions) (1961).

(2) Kotter’s (1995) 8-step change model best aligns with the DPI project for decreasing the incidence of pressure injuries (PIs) among critically injured patients in a trauma neuro-intensive care unit (TNICU). The facilitator will create a sense of urgency by sharing the rates and staging of the previous month’s PIs. By identifying the potential reimbursement and quality threats to the key stakeholders and engaging in honest discussions, the organization will want to implement the new practice (Kotter, 1995). The second step involves the formation of a coalition. This will be the task of engaging the unit-based skin champions and asking for a commitment to the change in practice. Step three is to create a vision for change by incorporating the solution to the identified problem. The skin champions and DPI facilitator will then communicate the vision to the frontline colleagues to create buy-in. Identification and removal of obstacles in step 5 will ensure success. In this step, early adopters will be encouraged and recognized, and those that are resistant will be re-educated on the importance of the change. Short-term wins will be celebrated, such as decreased incidence of PIs. Step 7 includes building on the change and continuous improvement. In step 8, anchoring the changes into the unit culture will ensure standard work continues (Kotter, 1995).

iv) Annotated Bibliography:

Annotated Bibliography

Hahnel, E., Genedy, M.E., Tomova-Simitchieva, T., Hau, A., Stroux, A., Lechner, A., Richter, C., Akdeniz, M., Blume-Peytavi, U., Lober, N., & Kottner, J. (2020). The effectiveness of two silicone dressings for sacral and heel pressure ulcer prevention compared with no dressings in high-risk intensive care unit patients: a randomized controlled parallel-group trial. The British Journal of Dermatology, 183, 256-264. https://pubmed.ncbi.nlm.nih.gov/31628863/. This randomized control trial sought to determine if the use of silicone preventative dressings applied to the sacrum and heels among patients in intensive care units (ICU) from a tertiary hospital had reduced the incidence of pressure injuries. A total of 475 patients were included in the study and divided into two groups. The results of the study revealed that patients with interventions had a cumulative pressure injury incidence of 2.8%, whereas the control group was 10.5%. The results of this trial concluded that silicone dressings are effective in preventing hospital-acquired pressure injuries in the ICU.

Padula, W. (2017). Effectiveness and value of prophylactic 5-layer foam sacral dressings to prevent hospital-acquired pressure injuries in acute care hospitals. Journal of Wound, Ostomy and Continence Nursing, 44(5), 413- 419. https://doi.org/10.1097/won.0000000000000358.

This observational cohort study examined the effectiveness of a five-layer prophylactic foam dressing in preventing pressure injuries among patients in acute care settings. Over a 5-year period, using the prophylactic 5-layer foam dressing decreased the rate of pressure injuries when combined with a prevention protocol. It was also identified that the cost of the dressing is well within a reasonable expense of $7 per dressing.

Riemenschneider, K.J., (2018). Prevention of pressure injuries in the operating room. Journal of Wound Ostomy Continence Nursing, 45(2), 141-145.

This study utilized a sample of 81 patients who underwent vascular surgery in an operating room at a level 1 trauma acute care setting in the Northeastern United States. The use of a five-layer silicone foam dressing was utilized in the intervention group, which consisted of forty-four patients. Results revealed that 50% of patients in the pre-intervention group developed pressure injuries between the third and seventh postoperative days, whereas only one person (2%) developed a pressure injury in the intervention group. These findings add to the evidence that silicone foam dressings decrease the incidence of pressure injuries when used in conjunction with standard interventions.

Stankiewicz, M., Gordon, J., Dulhunty, J. M., Brown, W., Pollock, H., & Barker-Gregory, N. (2019). A cluster-controlled clinical trial of two prophylactic silicone sacral dressings to prevent sacral pressure injuries in critically ill patients. Wound Practice & Research, 27(1), 21–26. https://doi-org.lopes.idm.oclc.org/10.33235/wpr.27.1.21- 26. This cluster-controlled randomized clinical trial compared the effectiveness of two prophylactic silicone sacral dressings among critically ill patients. This study did not show a statistical difference in the effectiveness of two different dressings, but it recorded a significant cost difference. With the use of the dressings on all patients, only 5/302 patients developed pressure injuries among both groups, revealing that the dressings are effective regardless of brand.

Strauss, R., Preston, A., Zalman, D.C., & Rao, A.D. (2019). Silicone foam dressing for prevention of sacral deep tissue injuries among cardiac surgery patients. Advances in Skin & Wound Care, 32(3), 139-142. This uncontrolled quality improvement design evaluated the effectiveness of silicone foam dressings that were placed preoperatively. Pre- and post-interventions were assessed. Patients with the dressing were placed for up to five days in intensive care and step-down units after cardiac surgery. Pre-intervention patients revealed a sacral deep tissue pressure injury (DTPI) incidence rate of 2.33%. Zero patients in the intervention group developed sacral DTPI, concluding that using silicon foam dressings for prophylactic prevention of sacral DTPIs is effective in this high-risk patient population.

v) Practice Change Recommendation: Evidence suggests using a five-layer prophylactic foam dressing decreases the incidence of pressure injuries. The practice change recommendation will be the placement of a five-layer silicone-bordered foam on critically ill patients that are at increased risk for pressure injuries. The use of variously shaped foams will be used and placed on bony prominences such as the sacrum and heels.

vi) Patients in the TNICU are critically injured and require multiple diagnostic tests and operating room procedures that require them to be placed in the supine position on a hard surface for long periods of time. Because of this, they are at increased risk of developing pressure injuries. Research has shown that the use of a five-layer prophylactic foam dressing has been linked to a decrease in the incidence of pressure injuries in the operating room as well as in the ICU. The practice change recommendation is to place a five-layer silicone foam dressing on the bony prominences of patients in the TNICU to decrease the incidence of pressure injuries.

It is unknown if implementing a five-layer prophylactic silicone foam dressing placed on bony prominences would decrease the incidence of pressure injuries among patients in the trauma neuro ICU.

(P) Among adult patients in a suburban Pennsylvania Level I Trauma Neuro Intensive Care Unit (TNICU), (I) how does the translation of Padula’s research on the use of a five-layer prophylactic foam dressing (C) compared to current practice ( O) impact the rate of pressure injuries ( T) over a period of eight weeks?

Evidence-Based Question:

To what degree will the implementation of a five-layer prophylactic foam dressing impact pressure injury rates among adult patients in a trauma neuro ICU in Pennsylvania?

Setting

Location

Inclusion and Exclusion Criteria

i) Sample and Sample Size: Adult patients in the TNICU who are at risk for skin breakdown. The estimated sample size will be 25-30 patients that meet the inclusion criteria over an eight-week period and will be compared to the pre-intervention period based on the sample size calculator. Potential bias will be related to the overall four-week census pre- and post-intervention and the acuity of the patient population.

ii) Setting: Inpatient, trauma neuro intensive care unit.

iii) Location: Suburban Pennsylvania

iv) Inclusion Criteria

· Patients > 18 years old

· Admitted to the Trauma Neuro Intensive Care Unit

· Braden scale score < 18

· Bony prominences that do not have pre-existing, present on admission pressure injuries

v) Exclusion Criteria

· Patients < 18 years old

· Not admitted to the trauma neuro intensive care unit

· Braden scale score > 18

· Bony prominences with pre-existing, present on admission pressure injuries.

i) Independent Variable: Five-layer Foam Dressing

ii) Dependent Variable: pressure injury rates.

i) Quality Improvement projects are developed to improve practice or performance based on a determined goal. The implementation of a new product or process to improve patient care defines a quality improvement project (Hirshon, 2021). This DPI project is designed to improve the outcomes of patients by utilizing a five-layer prophylactic foam dressing to prevent skin breakdown among critically injured trauma patients.

ii) Research is regulated and is designed to investigate and test new processes or interventions that can translate into new knowledge. Research utilizes a systematic approach and requires review through an institutional review board (IRB) prior to beginning the research. This ensures all federal ethical standards are met (Hirshon, 2021).

iii) In summary, quality improvement projects are intended to improve practice or patient outcomes. This DPI project utilizes primary research as a preface for implementing an intervention that is backed by primary research already conducted. It is meant to improve patient outcomes based on a five-layer prophylactic foam dressing intervention.

This quality improvement project aims to determine if implementing a five-layer prophylactic foam dressing would impact the development of pressure injuries among critically ill adult patients. The project will be piloted over an eight-week period in a suburban, Level 1, Pennsylvania trauma neuro intensive care unit.

i) An Excel spreadsheet will be used to gather patient demographic information from the electronic health record. Items include age, gender, mechanism of injury, Braden risk assessment, test/procedure, and length of time of the procedure.

ii) The organization’s quality report, Tableau, will be accessed to obtain measurable patient outcomes. This system tracks rates of pressure injuries by unit. It tracks rates monthly. This system does not contain confidential patient identifiers; therefore, consent is not needed.

iii) There is no instrument for this project. The data source is the electronic health record and the Tableau system

iv) Describe the step-by-step process you will use to collect the data, explain where the data will come from, and how you will protect the data and participants.

1. Obtain comparative and implementation pressure injury rates from the Tableau system.

2. Obtain demographic data through a report located in the electronic health record.

3. To determine usage, obtain a usage report of the five-layer prophylactic foam dressings for the comparative and implementation period.

4. All participant data will be protected, and identifiable information will not be included in the data that is gathered.

v) Potential ethical issues pertaining to this DPI project include a convenience sample of participants. All patients who meet the inclusion criteria will receive the same intervention with the intent of improved outcomes for all patients. All data will be stored appropriately on an encrypted password-protected computer at the project site, only accessible by the project manager and the mentor.

vi) Adherence to the principles of the Belmont Report falls under the realm of beneficence or doing good. The clinical question and theoretical framework are developed to improve patient outcomes with the intent to decrease hospital-acquired pressure injuries in critically injured trauma patients.

Data analysis will encompass the comparison of patients pre-and post-intervention. Participants’ descriptive information will not impact the DPI project. A chi-squared test will be used for the data analysis portion of the DPI project. This method will help answer the question if the five-layer prophylactic foam dressing influences the incidence of pressure injuries when used on the same patient population of trauma patients. Intellectus statistics will utilize the regression interface to select the dependent and independent variables. Potential pressure injury bias will be mitigated using the expert clinician WOCN dedicated to the TNICU.

Hirshon, J.M. (2021). Quality improvement versus research: What is ethically and regulatorily right? Annals of Emergency Medicine, 1-3. https://doi.org/10.1016/j.annemergmed.2021.03.038

Jean, I. (1961). The dynamic nurse-patient relationship: Function, process, and principles. G. P. Putnam’s Sons

Kotter, J. (1995). Leading change. Harvard Business Review Press.

Padula, W. (2017). Effectiveness and value of prophylactic 5-layer foam sacral dressings to prevent hospital-acquired pressure injuries in acute care hospitals. Journal of Wound, Ostomy and Continence Nursing, 44(5), 413- 419. https://doi.org/10.1097/won.0000000000000358

Riemenschneider, K.J., (2018). Prevention of pressure injuries in the operating room. Journal of Wound Ostomy Continence Nursing, 45(2), 141-145. https://doi.org/10.1097/won.0000000000000410

Stankiewicz, M., Gordon, J., Dulhunty, J. M., Brown, W., Pollock, H., & Barker-Gregory, N. (2019). A cluster-controlled clinical trial of two prophylactic silicone sacral dressings to prevent sacral pressure injuries in critically ill patients. Wound Practice & Research, 27(1), 21–26. https://doi-org.lopes.idm.oclc.org/10.33235/wpr.27.1.21- 26

Strauss, R., Preston, A., Zalman, D.C., & Rao, A.D. (2019). Silicone foam dressing for prevention of sacral deep tissue injuries among cardiac surgery patients. Advances in Skin & Wound Care, 32(3), 139-142. https://doi.org/10.1097/01.asw.0000553111.55505.84

Webb-Anderson, K., Daley, P., Isenor, C., McMullen, S., Kelly, E., & Bishop, L. (2018). Intensive care unit (ICU) pressure injury prevention: When ‘under pressure’, use evidence to inform action!  The Canadian Journal of Critical Care Nursing, 29(2), 60-61