Pressure ulcers represent a relatively common and potentially serious health issue for elderly patients, and the incidence of pressure ulcers figures predominantly as an outcome measure in the assessment of quality of care for patients. A low incidence rate of pressure ulcers is highly desirable and is considered to be a major indication of high quality of care by patients, caregivers, and regulatory authorities. Historically, state and federal agencies have used pressure ulcer incidence rates as an important indicator of quality of care. The pilot Nursing Home Public Reporting Quality Initiative, which was established by the Centers for Medicare and Medicaid Services, included pressure ulcer prevalence as one of 11 quality indicators (Childs, 2002).
The incidence and prevalence of pressure ulcers vary by institutional setting. This variance may be attributed in part to the lack of a single, universal standard in assessment, leading to a wide variation in assessment methods (Allcock, Wharrad, & Nicolson, 1994). Grading pressure ulcer severity also can vary widely among studies (Collier, 1999; Reid & Morison, 1994).
While studies correlating risk to institutional setting are varied, the correlation between patient age and the incidence of pressure ulcers is well established (Barczak, Barnett, Childs, & Bosley, 1997; Bergstrom, Braden, Kemp, Champagne, & Ruby, 1996; Bridel, Banks, & Mitton, 1996; Clark & Watts, 1994; Kemp, Keithley, Smith, & Morreale, 1990; O'Dea, 1995; OotGiromini, 1993; Papantonio, Wallop, & Kolodner, 1994; Perneger, Heliot, Rae, Borst, & Gaspoz, 1998). Estimated percentages of patients suffering from pressure ulcers range from 2.4% to 23% for nursing homes and skilledcare facilities (Langemo et al., 1989; Petersen & Bittmann, 1971; Young, 1989) and from 2.7% to 29.5% for hospitals (Clarke & Kadhom, 1988; Gerson, 1975).
The risk for development of pressure ulcers focuses broadly on patient characteristics, with bedridden and wheelchair-bound elderly patients at particular risk. Research shows an effective program for the successful prevention of pressure ulcers should:
* Identify at-risk individuals and the specific factors placing them at risk.
* Maintain and improve tissue tolerance to pressure to prevent injury.
* Protect against the adverse effects of external mechanical forces (i.e., pressure, friction, shear).
* Reduce the incidence of pressure ulcers through educational programs (Bergstrom et al., 1992).
Nosocomial pressure ulcers can develop rapidly in patients who are bedridden. Versluysen (1985, 1986) noted there is insufficient preventive care for pressure ulcers within the first few days after admission. Initial assessment of patients is an integral part of developing a useful care plan. Systematic approaches to constructing a patient-specific care plan based on scales such as the Braden Scale or Norton Score have become common practice.
Initial assessment of new patients should address levels of mobility and immobility, physical activity, and incontinence. Immobility, pressure, moisture, shearing forces, and friction are considered to be four major factors leading to the development of pressure ulcers. Other risk factors that have been identified include decreased activity levels, incontinence, poor nutritional status, and dementia (Bergstrom et al., 1992; Macklebust & Sieggreen, 1996; Nixon & McGough, 2001; j Rueler & Cooney, 1981).
Simultaneously, there is evidence that caregivers, including, nursing staff, may be unaware of best practices and may not be using recent advances in pressure ulcer prevention, assessment, and treatment (Bcitz, Fey, & O'Brien, 1998). Advisory panels such as the National Pressure Ulcer1 Advisory Panel (1992) and the European Pressure Ulcer Advisory Panel (2002) call for a more systematic focus on prevention through education. Awareness and education programs have been shown to reduce the incidence and severity of pressure ulcers (Berquist & Frantz, 1999; Leary, 1990; Moody et al., 1988).
Thus, nursing staff training programs have become a crucial component in the prevention of pressure ulcers. Additionally, the literature points toward broad, team-based programs. Bergstrom et al. (1992) noted:
More continuity of care is reported when team approaches are used and each person on the team has specific, identified responsibilities, (p. 5)
This article describes a program designed to raise awareness of best practices in pressure ulcer prevention and to provide early detection and treatment by nursing staff, with the ultimate goal to reduce incidence rates.
The purpose of this study was to investigate the effects of a roving team of nurses engaged in a set of practices (referred to as the turn-team program) designed to reduce the incidence of pressure ulcers in a 280-bed, non-profit, geriatric hospital.
AVERAGE NUMBER OF TURNS PERFORMED PER DAY BY UNIT
The turn-team program was instituted by senior nursing management during an initial 8-week trial period. The immediate goals were to raise educational awareness among staff and to reduce the incidence of pressure ulcers. Preliminary analysis of the program at the end of the trial period convinced hospital administrators to continue the program, and data were collected for an additional 4 months. Thus, all practices within the program continued uninterrupted for a total of 6 months.
Collected data covered both expected positive and negative effects of the program. Expected positive effects included selected patient and staff variables associated with a reduction in the incidence rate and severity of decubiti, while potential negative effects focused on the incidence of nosocomial infections among patients.
Part of the hospital's mission involves serving individuals with diminished financial resources. The staff believed existing problems with pressure ulcers were partially caused by the fact that many patients did not have significant caregiver support in their home settings. This void heightened the need for a thorough initial assessment process and also revealed concerns that Stage I deterioration was likely to be more advanced at admission. Nursing staff believed the progression of pressure ulcers would be reduced if patients were admitted earlier. The formation of the turn team was the direct result of the nursing staff's attempt to improve quality of care at admission and to achieve reductions in rates of pressure ulcer progression.
Each turn team consisted of two nursing assistants. Members of the turn team underwent an 8-hour training program that stressed a more holistic approach and the importance of systematic, preventive care. After a discussion of the goals and purposes of the program, all participants discussed the importance of consistency in treatment and recordkeeping for the study, and the use of current best practices in preventive care. Participating staff discussed major risk factors contributing to the development of pressure ulcers.
Specific aspects of staff training included early recognition of the signs of skin breakdown and its documentation, infection control techniques, and minimizing the effects associated with loss of bowel or bladder control. A review of the proper techniques for turning, moving, and ambulating patients was included. This training covered the needs and comfort of patients in the process of being turned, the minimization of friction and shearing in the ambulation process, and the prevention of musculoskeletal injury to the caregiver.
Three groups of patients were chosen for the turn-team program:
* Patients under physician or nursing orders to be "up in chair."
* Patients under physician or nursing orders to be ambulated every 2 hours.
* Patients requiring postoperative ambulation.
The turn team treated patients across selected floors and sections of the hospital. The average number of turns per day varied by unit (Table).
Duties assigned to the turn team included:
* Keeping patients' skin clean and well-moisturized, yet dry.
* Cleansing soiled patients.
* Ambulating patients at frequent and regular time intervals.
* Documenting and reporting potential signs of skin breakdown to patients' nurses.
Senior nursing staff monitored the study closely, and biweekly meetings were held among the turnteam staff, medical-surgical clinical directors, clinicians, and the administrative director of nursing to monitor the program and make any necessary adjustments.
Potential positive effects. It was posited the turn team would provide a range of potential positive effects. Primary among these positive effects was the reduced incidence and progression of pressure ulcers leading to reduced patient referrals to the staff enterostomal nurse. Additionally, the program was designed to potentially decrease recuperative periods for patients (i.e., reduced length of stay), as well as the incidence of other problems associated with immobility (e.g., deep vein thrombosis, emboli, pneumonia).
Two other aspects of the program also were expected to be beneficial to the institution and nursing staff. First, senior staff believed the program might help boost and maintain morale among the nursing staff. Although the rate of staff turnover was not specifically an issue, general problems with staff turnover in geriatric settings have been well documented (Decker, Dollard, & Kraditor, 2001). It was believed that if staff morale improved, it might help to achieve a reduced staff turnover rate while making the facility more attractive to potential staff and patients. Analyses of positive effects on morale and staff turnover were, however, beyond the scope of this study.
Nursing directors also were concerned with an increased incidence of musculoskeletal injuries among staff that were associated with ambulating patients. Deutschman (2001) notes that in hospitals and nursing homes, the rates of injury and illness among employees have been rising while rates for private industry have been flat or have fallen during the past two decades. In the 3 years prior to the study, the number of workdays lost per year from musculoskeletal injuries had risen from 30 days to 131 days. These injuries are inherent to the tasks of manual lifting, transferring, and repositioning of patients performed by caregivers in nursing homes and "are associated with an increased risk of pain and injury to caregivers, particularly to the back" (Occupational Safety and Health Administration, 2002).
The administrative director of nursing felt that having the turn team specialize in moving immobile patients would not only provide more focused and consistent practices in the treatment of pressure ulcers, but also would help reduce musculoskeletal injuries among staff. Therefore, data also were collected on musculoskeletal injuries.
Potential negative effects. To assess whether the turn-team program would have any negative effects on the incidence of nosocomial infection across the facility, incidence rates for nosocomial methicillin-resistant Staphylococcus aureus (MRSA), Clostridium difficile, and postoperative pneumonias were documented during the study period
RESULTS AND DISCUSSION
Data for the 12-month period prior to the study (pre-turn team) were compared with data from the 6month study period (post-turn team) and were analyzed statistically for the hypothesized positive and negative effects. Although data were collected on all of the variables described, sufficient sample characteristics were available only for:
* Patient referrals to the enterostomal nurse.
* Average length of stay.
* Musculoskeletal injuries among staff.
* Incidence of nosocomial infections.
For these variables, the MannWhitney nonparametric U test was conducted. This statistic makes no underlying assumptions concerning the distribution of observations before and after the institution of the turn-team program.
Patient Referrals to the Enterostomal Nurse
One purpose of the turn team was to reduce the incidence of Stage II and higher pressure ulcers. Referrals of Stage II pressure ulcers to the staff enterostomal nurse in the pre-turn team period averaged 5.8 per month compared with 3.5 per month (p = .152) in the post-turn team period.
Average Length of Stay
Another posited benefit of the turn-team program was a reduction in patients' average length of stay. It was speculated that reducing the incidence and severity of pressure ulcers, holding other things constant, would likely achieve this result.
The average length of stay was 9.38 days for the pre-turn team period compared with 8.43 days for the post-turn team period (p = .003). While this decrease is statistically significant, interpretation of this result is difficult. A host of variables that were not controlled for or measured could have affected the average length of stay in this study. Thus, given the broad number of factors that could affect average length of stay, an interpretation that turn-team practices caused the reduction is unwarranted. Although difficult to control for, further research in turn-team practices should attempt to measure other factors such as random variations and seasonality over time that might reduce average length of stay during the study period.
Musculoskeletal Injuries Among Staff
A third variable of interest was the incidence of musculoskeletal compensable injuries among nursing staff. It was posited the turn team, having been specifically trained in turning, ambulating, and moving patients, would exhibit reductions in musculoskeletal injuries. Because the turn team would have primary responsibility for this activity, in lieu of regular nursing staff, it was possible that injuries among non-turn-team nursing staff also would decline.
The average number of musculoskeletal compensable injuries per month among the entire nursing staff was 1.07 in the pre-turn team period versus .75 in the post-turn team period (p = .253). It is important to note there were no musculoskeletal injuries among turn-team staff during the study. Although this reduction was not statistically significant and cannot be attributed to the turn team alone, the fact that no injuries were recorded among turn-team staff is positive. Further analysis in this area is needed.
Incidence of Nosocomial Infections
Both nosocomial infection rates and the incidence of C. difficile decreased dramatically between the two sample periods. The average number of cases per month was 4.2 for the pre-turn team period compared with 1.5 cases for the post-turn team period (p = .023).
Nosocomial pneumonia also exhibited a declining pattern. The average number of cases per month was .93 for the pre-turn team period compared with .75 cases for the post-turn team period (p = .439).
However, while the rates of both of these nosocomial infections fell, it is incorrect to attribute a causal relationship to the turn-team program. What is important for the purposes of this study is that concerns the turn team might increase the incidence of nosocomial C. difficile and pneumonia were not substantiated by the study results.
The statistical analyses provide support for the posited positive effects of the turn team. All three measured positive effects moved in the correct direction, and two of the three were statistically significant. Furthermore, statistical analysis of the program data indicates the concern that the program might increase nosocomial infection rates across the facility were unwarranted.
This study also indicates the turnteam program was associated with a reduction in musculoskeletal injuries among turn-team nursing staff. Reductions in staff injuries lead to reductions in days lost to injury, and over the longer term, to increased staff continuity and reductions in the costs of staff insurance and workers' compensation claims.
Pressure ulcers can develop in patients who are bedridden or wheelchair bound. Reductions in the incidence of pressure ulcers can serve to signal a higher quality of care to all involved parties. The factors leading to pressure ulcer development and degeneration are well established in the literature, as are best practices for reduction of incidence rates and progression.
The turn-team program outlined in this article can be instituted in any setting in which pressure ulcers are a concern. Neither new technology nor specialized training is required, and because the data collected are normally monitored by hospital staff, additional recordkeeping efforts associated with the program are minimal. Training that accompanies the program is relatively simple and can be provided at low cost. The team approach reinforces best practices and allows caregivers to sustain their efforts. The turn-team program brings focus to the issue of pressure ulcers and provides an educationalbased, unified framework to address this difficult problem. Finally, the cooperative, holistic approach embodied in the turn-team program has the potential to positively impact all stakeholders including the facilities and their nursing staffs, state and federal regulators, and ultimately the patients themselves.
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AVERAGE NUMBER OF TURNS PERFORMED PER DAY BY UNIT