D Assessment Of Methodological Quality Of Individual Studies
Predefined criteria will be used to assess the quality of individual controlled trials, systematic reviews, and observational studies by using clearly defined templates and criteria as appropriate. Randomized trials and cohort studies will be evaluated with appropriate criteria and methods developed by the U.S. Preventive Services Task Force.16 These criteria and methods will be used in conjunction with the approach recommended in the chapter, Assessing the Risk of Bias of Individual Studies When Comparing Medical Interventions17 in the Methods Guide for Effectiveness and Comparative Effectiveness Reviews developed by the Agency for Healthcare Research and Quality.
Individual studies will be rated as good, fair, or poor. Studies rated good will be considered to have the least risk of bias, and their results will be considered valid. Good-quality studies include clear descriptions of the population, setting, interventions, and comparison groups a valid method for allocation of patients to treatment low dropout rates and clear reporting of dropouts appropriate means for preventing bias and appropriate measurement of outcomes.
Each study evaluated will be dual reviewed for quality by two team members. Any disagreements will be resolved by consensus.
American College Of Physicians Releases New Guidelines Forpreventing And Treating Bedsores
Evidence showed that nutritional supplementation with protein or amino acids reduced wound size
Read Prevention Guideline | Read Prevention Summary for Patients | Read Treatment Guideline | Read Treatment Summary for Patients | Read Editorial
Philadelphia, March 3, 2015 â The American College of Physicians today published two evidence-based clinical practice guidelines in Annals of Internal Medicine for the prevention and treatment of bedsores, also called pressure ulcers. Bedsores commonly occur in people with limited mobility, such as those in hospitals or long-term care settings.
Up to $11 billion is spent annually in the United States to treat bedsores and a growing industry has developed to market various products for pressure ulcer prevention, said Dr. David Fleming, president, ACP. ACPâs evidence-based recommendations can help physicians provide quality care to patients while avoiding wasteful practices.
Creation And Implementation Of A Pressure Ulcer Prevention Program
A steering committee, comprised of academics, nurses, allied health professionals, educators and administrators was established to oversee the development and implementation of the PUPP, which was entitled âHealthy Skin Wins.â The Iowa Model of Evidence-Based Practice to Promote Quality Care in conjunction with Rogersâ Diffusion of Innovations Model served as guiding frameworks for the PUPP .
This committee facilitated the adoption of best practices in PU prevention with the objective of decreasing PUs on all in-patient units. Several subcommittees reviewed current evidence to determine best practices in prevention and management of PUs . âInnovations in the hospital setting can be defined as changing standard practices based on current knowledge and research dataâ . These subcommittees were comprised of multidisciplinary members from various hospital departments including nursing, dietetics, occupational therapy, physical therapy, materials management, and wound care.
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Turn Everyone And Move Study
The Turn Everyone And Move study13 was a 12-month paired facility 2-arm randomized intervention trial that tested the effectiveness of musical cues reminding LTC nursing and ancillary staff to help residents to move or reposition all residents, regardless of identified risk level, every 2 hours in 10 US LTC facilities. Staff and visiting family members received education on both PrU prevention and the intervention. Musical selections based on facility preferences were played over the facility public address system every 2 hours for the 12-hour daytime period. Intervention facility residents were 45% less likely than comparison facility residents to develop a new PrU. The researchers concluded that a broad approach involving customized musical cues that prompt multidisciplinary staff teams to encourage or enable all residents to move holds promise for reducing facility-acquired PrUs in LTC settings.13,26
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Pressure And Shear Injury
It is possible to determine the potential source of pressure and shear injury based on the patients posture, activities, mobility, lifestyle and current support surfaces such as sleeping and sitting surfaces. When pressure is exerted near a bony prominence, the risk of pressure injuries increases by 35 times. Shear injuries may happen when trying to change the positions of the patient.
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Pressure Injury Prevention & Management
Implementing an evidence-based best practice system for pressure injury prevention and management can reduce the potential for pressure injury development and promote healing of existing pressure injuries.
Each person should be assessed for pressure injury risk factors on admission and receive an in-depth assessment of any existing pressure injuries. The assessment process drives the development of person-centered goals and interventions to prevent or heal pressure injuries.
The care plan should reflect the persons preferences, values and needs and identify the interventions necessary to meet his/her goals for treatment. The care plan should also include guidelines for reassessment to evaluate the effectiveness of the care provided and to prompt changes in treatment as needed. The use of any particular intervention should be based on the strength of the evidence provided by existing clinical trials or literature reviews.
Evaluation and monitoring outcomes are vital components of any program for managing pressure injury risk and treating existing pressure injuries. An effective system includes reassessment of the persons risk for developing a pressure injury. The frequency of reassessment will depend on a variety of factors, with more frequent assessments for people with existing pressure injuries, those who are at high risk for developing pressure injuries, or those who have experienced a significant change of condition.
Acp Clinical Practice Guidelines
The 2015 American College of Physicians clinical practice guidelines for risk assessment, prevention, and treatment of pressure ulcers included the following recommendations and statements :
Edsberg LE, Black JM, Goldberg M, McNichol L, Moore L, Sieggreen M. Revised National Pressure Ulcer Advisory Panel Pressure Injury Staging System: Revised Pressure Injury Staging System. J Wound Ostomy Continence Nurs. 2016 Nov/Dec. 43 :585-597. . .
NPIAP pressure injury stages. National Pressure Injury Advisory Panel. Available at . Accessed: April 29, 2022.
Woolsey RM, McGarry JD. The cause, prevention, and treatment of pressure sores. Neurol Clin. 1991 Aug. 9:797-808. .
Abrussezze RS. Early assessment and prevention of pressure ulcers. Lee BY, ed. Chronic Ulcers of the Skin. New York: McGraw-Hill 1985. 1-9.
Schweinberger MH, Roukis TS. Effectiveness of instituting a specific bed protocol in reducing complications associated with bed rest. J Foot Ankle Surg. 2010 Jul-Aug. 49:340-7. .
Zhao G, Hiltabidel E, Liu Y, Chen L, Liao Y. A cross-sectional descriptive study of pressure ulcer prevalence in a teaching hospital in China. Ostomy Wound Manage. 2010 Feb 1. 56:38-42. .
Pham B, Stern A, Chen W, Sander B, John-Baptiste A, Thein HH, et al. Preventing pressure ulcers in long-term care: a cost-effectiveness analysis. Arch Intern Med. 2011 Nov 14. 171:1839-47. .
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Infrastructure To Support Change
Sarasota Memorial Healthcare System, a magnet recognized not-for-profit organization, is committed to delivering safe, high-quality care that results in desired outcomes and is consistent with current professional knowledge . The organizational culture is reflected in the mission statement as well as the organizations participation with several agencies including The Joint Commission, the Agency for Healthcare Research and Quality Patient Safety Indicators, the American Nurses Credentialing Center Magnet Program , and many other health care accrediting agencies. Interdisciplinary collaboration is encouraged as evidenced by interdiscipli-nary meetings that focus on identifying the need for change and implementing evidence-based practice . Change that results in improved patient outcomes is encouraged by the executive team, risk management, nurse educators, several practice councils, and unit managers. Initiation of and participation in change is recognized by nurse of clinical excellence awards. At SMH, proposed changes are commonly presented to unit practice councils throughout the organization. Council members vote on the proposed change, and if the majority of the UPC members and council chair agree upon the proposal, the specified change in practice is implemented systematically.
Purchase hardcopyAbout this Guideline
This guideline provides best practice recommendations in three main areas:
B Searching For The Evidence: Literature Search Strategies For Identification Of Relevant Studies To Answer The Key Questions
We will search Ovid MEDLINE®, CINAHL®, EBM Reviews, including the Cochrane Central Register of Controlled Trials and the Cochrane Database of Systematic Reviews, and Health Technology Assessments.
Additional literature will be identified by reviewing the reference lists of articles and from recommendations from the TEP and peer reviewers.
Device manufacturers will have the opportunity to submit data for this review by using the portal for submitting scientific information packets on the Effective Health Care Program Web site .
Pre-established criteria will be used to determine eligibility for inclusion and exclusion of abstracts. To ensure accuracy, all excluded abstracts will be dual reviewed. All citations deemed appropriate for inclusion by at least one of the reviewers will be retrieved.
Each full-text article will be independently reviewed for eligibility by two team members. Any disagreements will be resolved by consensus.
|Limit: all adult humans|
Note: The comprehensive search strategies are available in the Appendix.
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A Toolkit For Improving Quality Of Care
Each year, more than 2.5 million people in the United States develop pressure ulcers. These skin lesions bring pain, associated risk for serious infection, and increased health care utilization. The aim of this toolkit is to assist hospital staff in implementing effective pressure ulcer prevention practices through an interdisciplinary approach to care.
Prepared by: Dan Berlowitz, M.D., M.P.H. Bedford VA Hospital and Boston University School of Public Health Carol VanDeusen Lukas, Ed.D. VA Boston Healthcare System and Boston University School of Public Health Victoria Parker, Ed.M. D.B.A. Andrea Niederhauser, M.P.H. Jason Silver, M.P.H. and Caroline Logan, M.P.H. Boston University School of Public Health Elizabeth Ayello, Ph.D., RN, APRN, BC, CWOCN, FAPWCA, FAAN, Excelsior College School of Nursing, Albany, New York and Karen Zulkowski, D.N.S., RN, CWS, Montana State University-Bozeman.
Skin And Wound Care Practices Today
You will hear clinicians who would never dream of practicing medicine and nursing exactly the same way they did 30 years ago falling back on what they perceive as acceptable care for patients at risk for or presenting with a pressure ulcer. I STILL hear people promoting liquid antacids, povidone iodine, sugar, off the grocery shelf honeythe list seems endless. Yet they will swear their patient healed. My assertion is that some patients healed despite the awful things someone put on their wound. We need to apply evidenced-based practice in skin and wound care the same careful way we apply those principles to other aspects of health care.
About The AuthorPaula Erwin-Toth has over 30 years of experience in wound, ostomy and continence care. She is a well-known author, lecturer and patient advocate who is dedicated to improving the care of people with wounds, ostomies and incontinence in the US and abroad.
The views and opinions expressed in this blog are solely those of the author, and do not represent the views of WoundSource, Kestrel Health Information, Inc., its affiliates, or subsidiary companies.
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Wound Care In Nursing: Diagnosis For Pressure Ulcers And Prevention
Pressure ulcers are an unfortunate and potentially serious complication faced by patients often already experiencing conditions of poor health or limited mobility. Pressure ulcers can cause significant pain and discomfort, impact a patients quality of life, and worsen the financial burden of care through additional treatment.
Further complicating the situation is the added frustration that pressure injuries are preventable. Appropriate screening for patients who would be considered at risk for developing a pressure ulcer and early intervention can significantly reduce the prevalence of pressure ulcers.
Establishing a nursing diagnosis for pressure ulcers requires nursing professionals to be familiar with what puts a patient at risk for developing a pressure ulcer, how to properly assess for and stage pressure injuries, and what interventions are appropriate.
Review Of Key Questions
For all EPC reviews, KQs were reviewed and refined as needed by the EPC with input from Key Informants and the TEP to assure that the questions are specific and explicit about what information is being reviewed. In addition, for Comparative Effectiveness reviews, the KQs were posted for public comment and finalized by the EPC after review of the comments.
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F Grading The Evidence For Each Key Question
The strength of evidence for each KQ will be assessed by one researcher for each applicable outcome by using the approach described by Owens, et al.18 To ensure consistency and validity of the evaluation, the grades for each review will be reviewed by the entire team of investigators for:
We will also estimate publication bias by examining whether studies with smaller sample sizes tended to have positive or negative assessments of pressure ulcer treatment.
The strength of evidence will be assigned an overall grade of high, moderate, low, or insufficient according to a four-level scale:
- HighHigh confidence that the evidence reflects the true effect. Further research is very unlikely to change our confidence in the estimate of effect.
- ModerateModerate confidence that the evidence reflects the true effect. Further research may change our confidence in the estimate of effect and may change the estimate.
- LowLow confidence that the evidence reflects the true effect. Further research is likely to change the confidence in the estimate of effect and is likely to change the estimate.
- InsufficientEvidence either is unavailable or does not permit estimation of effect.
About The American College Of Physicians
The American College of Physicians is the largest medical specialty organization and the second-largest physician group in the United States. ACP members include 141,000 internal medicine physicians , related subspecialists, and medical students. Internal medicine physicians are specialists who apply scientific knowledge and clinical expertise to the diagnosis, treatment, and compassionate care of adults across the spectrum from health to complex illness. Follow ACP on and .
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Starting With A Clinical Problem
The initiative began in 1993 when an increase in the incidence of pressure ulcers was perceived in our setting. There had been more referrals to the enterostomal therapist and to plastic surgery, and sporadic reporting by clinical staff of their suspicions that skin breakdown was increasing in their areas. At that time no unit based mechanism for capturing reliable data on pressure ulcers was in place nor was it possible to retrieve data from the hospital information system.
Even though it is a quality issue, the pressure ulcer initiative was set in a larger context of professional practice by linking it to the existing nursing quality improvement, research, and education infrastructures. The nurse specialists for quality improvement and research and evaluation took the lead on the project with support from several clinical nurse educators and managers. Critical to the success of the project was the support of the chief nursing officer who was vice president of patient services.
The task force recommended that the following issues be addressed in planning for effective care and prudent use of resources:
Baseline assessment of the extent of the problem
Evaluation of the accuracy of a risk assessment method
Practice changes including development of an educational strategy to upgrade nursing skills in pressure area assessment using grading or staging of sores
A method for ongoing monitoring.
Pu Prevention Implementation Project
Each hospitals team completed an inventory of PU prevention program components and provided copies of accompanying documentation, along with prevalence and incidence data. Site visits to the four participating hospitals were arranged to provide opportunities for more in-depth analysis and support. Following the initial site visit, the project team at each hospital developed action plans for the top three barriers to PU program implementation. A series of conference calls was held between the site visits.
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Pressure Ulcers: A Brief Overview
Pressure ulcers are also sometimes referred to by other names. These names may include pressure injury, decubitus ulcers, and bed sores. Whichever you may be used to hearing, they all amount to the same physiologic process.
Our skin is a living organ made of many layers that need to be fed a steady supply of oxygen and nutrients to remain healthy. Our skins cells receive this oxygen and nutrients by blood flowing through tiny vessels and capillaries. When that blood flow is interrupted, the skin is deprived of what it needs and is at risk of breaking down if not corrected.
In the situation of a pressure ulcer, there is increased pressure on those tiny vessels and capillaries feeding the skin. The vessels get pressed between something hard like a bone and something outside of our body, slowing or stopping the blood flow. This is why there is a high incidence of pressure ulcers around bony prominences.
If the pressure interrupting the supply of blood to the cells of our skin is allowed to remain in place for too long, as occurs with decreased mobility, the skin starts to change. Early pressure ulcers may start with redness on the skin. As the injury progresses, the redness may darken and the skin may start to break down where an open wound is noticed. Without relieving the pressure, the wound will continue to worsen affecting deeper layers of the skin.
Translating Evidence Into Practice For Pressure Ulcer Prevention
Joint Commission Resources and Hill-Rom created the Nurse Safety Scholar-in-Residence program in 2009 to foster the professional development of expert nurse clinicians to become translators of evidence into practice . The first nurse safety scholar-in-residence activity focused on PU prevention. Four hospitals with established PU programs participated in the PU prevention implementation project. The project was designed to achieve
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