Pressure injury prolongs hospitalization and increases treatment costs as well as morbidity and mortality.1–3 Pressure injury continues to be a worldwide problem, despite highly trained staff and advances in medical technology and healthcare.4 It is particularly common in ICUs because of various factors including restricted physical activity, inadequate tissue perfusion arising from hemodynamic changes, skin damage because of moisture/incontinence, and deterioration in nutrition status. The rate of pressure injury in ICUs varies from 15% to 49%.5–7
Pressure injury prevention and treatment require an interdisciplinary team with a holistic care approach.8 However, nurses in particular play a key role in preventing pressure injury, making numerous daily decisions in clinical practice that directly affect the outcomes of care. It has been shown that care can be provided more effectively and efficiently with algorithms developed according to evidence-based clinical practice guidelines used to prevent pressure injury.9 Algorithms provide step-by-step guidance for clinical decision-making and, especially for less experienced nurses, seem to play an important role in increasing self-confidence and helping to prevent care errors; however, the use of algorithms is not widespread.9
Various studies10–13 demonstrate that when using a prevention algorithm the rate of pressure injury decreases considerably. Despite this, there are only a few prior studies about the use of pressure injury prevention algorithms, and most algorithms in the literature appear to involve limited evidence-based practice.10–13 In similar studies in the literature, no algorithm covers all current topics in the prevention of pressure injury. In this sense, the pressure injury algorithm developed for this study, founded on current staging systems, holistic risk factors, and evidence-based clinical practice guidelines with comprehensive scientific content, was hypothesized to be comparatively more effective in preventing pressure injury.
This study evaluated the effect of nursing education and a new, comprehensive pressure injury prevention algorithm on pressure injury prevention (primarily stage 1) in the ICU.
Study Design, Setting, and Participants
This intervention study was conducted in the anesthesiology and reanimation ICU (ARICU) of a university hospital in Ankara, Turkey. The university hospital has a stoma and injury care unit. A dedicated stoma and injury care nurse also provides care for patients with pressure injury in the ARICU.
The study included two sample groups (nurses and patients). All 15 of the nurses who worked at the ARICU between November 1, 2016, and April 30, 2017, agreed to participate in the study. All patients older than 18 years in the ARICU during the pre- and postalgorithm periods (prealgorithm, N = 63; postalgorithm, N = 57) who gave verbal permission were included in the study (Table 1).
There were no interventions in the prealgorithm period; routine care (twice-daily skin care and positioning) was provided by nurses working in the ARICU and stoma and injury care nurses. During this period, pressure injuries were examined by the researcher. In the postalgorithm period, pressure injuries were monitored by ARICU nurses under the guideline of the pressure injury prevention algorithm. Patients were followed up for a maximum period of 6 months, and newly developed stage 1 pressure injuries were assessed when evaluating the pressure injury incidence. When stages 2, 3, and 4 pressure injuries were identified, care was provided by a stoma and injury care nurse.
Data Collection Technique and Tools
The data in the study were collected using the following forms:
Patient and Nurse Information Tools. These demographic questionnaires were prepared by the researchers, using extant literature.1,10,14–17 It was administered to patients in both the pre- and postalgorithm periods and to nurses in the postalgorithm period.
Braden Scale for Predicting Pressure Sore Risk. In Turkey, the first reliability and validity study of the Braden Scale for Predicting Pressure Sore Risk developed by Braden and colleagues18 was conducted by Pinar and Oğuz19 (Cronbach’s α = .95) in 1997. In 1998, its reliability and validity were further examined by Oğuz and Olgun20 (Cronbach’s α = .85). The reliability and validity of the scale were found to be high in both studies.19,20 The Braden Scale was administered to patients daily in both the pre- and postalgorithm periods.
Tool for Pressure Injury Information. This tool was created by the researchers to assess nurses’ pre- and posttraining knowledge.1,12,14,16,17 This form consists of 20 questions that assess nursing proficiency in evaluation of pressure injury risk, skin assessment and preventive skin care, activity management, nutrition management, and moisture/incontinence management. The final form was scrutinized by seven specialists (two wound, ostomy, and continence nurses and five surgical nurses) who had experience or training in pressure injury. Nurses who correctly answered 80% or more of the questions were determined to have sufficient knowledge.
Pressure Injury Prevention Follow-up Tool. This tool included titles of areas where pressure injuries have been seen, skin evaluation and care, pressure injury risk assessment, activity management, nutrition management, wetness/incontinence management, and support surface management.1,10,12–14,16,17,21,22 The final form was reviewed by the same specialists who reviewed the Tool for Pressure Injury Information. In this pre- and postalgorithm period, pressure injury stages, locations, and incidence were determined by and recorded with this form.
Evaluation Tool for the Pressure Injury Prevention Algorithm. This tool, developed by the researchers, included questions that enabled the nurses to evaluate the pressure injury prevention algorithm and respond in the form of “I agree/I do not agree with these statements.”22 Nurses evaluated the algorithm in terms of the extent, adequacy, and necessity of preventing pressure injury; whether or not it helped in clinical decision-making; and time and convenience.
Literature Review and Algorithm Development
Intervention studies and guidelines published since 2010 and indexed in MEDLINE, the Cumulative Index to Nursing and Allied Health Literature, The Cochrane Library, and Google Scholar between December 2015 and March 2016 were scanned. The search terms “pressure injury AND prevention,” “pressure injury AND guides,” “pressure injury AND algorithms,” “pressure injury AND clinical map,” “pressure ulcer AND prevention,” “pressure ulcer AND guides,” “pressure ulcer AND algorithms,” and “pressure ulcer AND clinical map” were used to search the literature. Consequently, 4 guidelines and 291 publications were found, and the corresponding abstracts were examined. Repeat publications, those for which full-text access was not available to the researchers, and any that were irrelevant to the subject were excluded from the scope of the review. Ultimately, researchers examined 74 publications. Based on the 74 studies and 4 guidelines,1,23–25 an evidence-based pressure injury prevention algorithm and pressure injury prevention training booklet were created. The final algorithm and booklet were reviewed by the seven experts and researchers mentioned in previous sections.
Ethics approval for this study was granted by the Ethics Commission of Gazi University and the administration of the university hospital. Verbal and/or written approvals were obtained by describing the research process to conscious patients or the patients’ relatives and the ARICU nurses.
Data were entered in SPSS version 21 (IBM, Armonk, New York). The descriptive statistics (number, percentage, mean ± SD, median [min–max]), Shapiro-Wilk, Friedman, Wilcoxon, Mann-Whitney U, χ2, and Bonferroni corrected z ratios tests were used. Pressure injury incidence was calculated by dividing the number of stage 1 pressure injury patients in the ARICU by the number of patient-days and was expressed on a 1,000-patient-day basis. Incidence rates in the pre- and postalgorithm periods were compared with a specific z test. Statistical significance was P < .05.
The study was carried out in four phases.
First Phase. In the prealgorithm period (April 1 to September 30, 2016), the pressure injury stage, location, and incidence data from 80 patients in the ARICU study were obtained by the researchers. In the prealgorithm period, there were no interventions for the patients; routine care (twice daily skin care and positioning) was provided by ARICU and stoma and injury care nurses. During this phase, the pressure injury prevention algorithm, training booklet, and data collection tools were created, reviewed, and prepared for dissemination.
Second Phase. Fifteen nurses working in the ARICU were trained by the researcher in one day on how to prevent pressure injury and the pressure injury prevention algorithm. The training was conducted with three nurses each day for 5 days. In addition to the demographics of the nurses before the training, the Nurse Information Tool and the Tool for Pressure Injury Information were administered during this phase.
At the end of the training, the pressure injury prevention training booklet was supplied. Preliminary application of the pressure injury prevention algorithm was performed on 22 patients for 15 days after the end of the training. During this period, researchers ensured nursing compliance and correct use of the algorithm (including position changes, deep rubbing, and no massage). Necessary adjustments were made to the algorithm based on this preliminary application data. Data from the patients involved in the preliminary application were not included in the study, although they did provide informed consent. Three months after the training, the Tool for Pressure Injury Information was reapplied.
Third Phase. Nurses filled out the Patient Information Tool for each patient who consented to the study during the postalgorithm period (November 1, 2016, to April 30, 2017), and the patient was assessed daily using the Braden Scale. The pressure injury prevention algorithm was placed in a location visible from the patient’s bed and was used every day to evaluate the patient and to record information about the patient on the Pressure Injury Prevention Follow-up Tool.
During this period, the researcher visited the ARICU twice a week on different days and hours and evaluated the patients according to the pressure injury stage, location, and incidence. Researchers were available to answer any questions from the nurses during this time. Three months after the training, the Tool for Pressure Injury Information was applied again to evaluate the long-term effectiveness of the nursing education. At the end of 6 months, nurses were given the Evaluation Tool for the Pressure Injury Prevention Algorithm, and their opinions about the use of the algorithm were recorded.
Fourth Phase. In the fourth phase, the incidence of pressure injury during the prealgorithm period (April 1 to September 30, 2016) was compared with the postalgorithm period (November 1, 2016, to April 30, 2017), and the effectiveness of the algorithm was evaluated (Figure 1).
Characteristics of the Nurses
The mean age of the 15 nurses in the study was 26.47 ± 3.44 years; three were male (20.0%), eight had bachelor’s degrees (53.4%), and seven were diploma nurses. The total clinical working experience was 4 years (min-max, 1–10), and the ARICU working experience was 3 years (min-max, 0.5–9.0).
Knowledge of Pressure Injury Prevention
The average scores on the nurses’ knowledge test were 9 (min-max, 4–13), 17 (min-max, 14–20), and 16 (min-max, 12–20) out of 20, before, after, and at 3 months posttraining, respectively. The total scores changed significantly over this time period (χ2 = 28.429, P < .001). The pretraining knowledge scores were found to be significantly lower than the posttraining and 3-month scores (P < .05). When the nurses’ knowledge scores were examined, 80.0% (n = 12) of the nurses after the training and 60.0% (n = 9) at 3 months after training were found to have sufficient knowledge, whereas none did before the training.
The nurses thought the algorithm was sufficient, necessary, and helpful in deciding what methods to implement to prevent pressure injury. However, some nurses (26.7%) reported that the pressure injury prevention algorithm was complex and time consuming.
During the pre- and postalgorithm periods, 80 and 74 patients, respectively, were given care in the ARICU (Table 1). The characteristics of the patients were similar during both periods, although the mean body mass index (t = 2.490, P = .018) and number of patients with hypertension (χ2 = 5.567, P = .018) differed. Body mass index was higher, the incidence of hypertension lower, and length of stay longer in the postalgorithm period.
Pressure injury was observed in 93.7% (n = 59) of the patients during the prealgorithm period and in 49.1% (n = 28) of the patients during the postalgorithm period, a significant decrease (χ2 = 27.568, P < .001; Table 1). In the prealgorithm period, 57.2% (n = 108) of 189 pressure injuries were stage 1, 22.8% (n = 43) were stage 2, stages 3 and 4 ulcers represented 7.9% (n = 15) each, 4.2% (n = 8) were deep-tissue injuries, and none were unstageable. In the postalgorithm period, 35.6% (n = 37) of the 104 pressure injuries were stage 1, 39.4% (n = 41) were stage 2, 13.5% (n = 14) were stage 3, none were stage 4 or deep-tissue injuries, and 11.5% (n = 12) were unstageable (Table 2). The majority of pressure injuries developed in the sacrum area, during both the pre- (46.7%) and postalgorithm (30.8%) periods.
During the prealgorithm period, the incidence of stage 1 pressure injuries was, on average, 46.1 per 1,000 patient-days. This rate decreased during the postalgorithm period, to an average of 9.21 per 1,000 patient-days (Figure 2). A comparison of these rates revealed a significant decrease (z = 9.590, P < .001).
Prevention of pressure injury is an indication of care quality. For this reason, pressure injury prevention is a major outcome of nursing care.16 Pressure injury rates can be reduced with algorithms established on evidence-based clinical practice guidelines.26,27
Knowledge of Pressure Injury Prevention
Although some studies on nurse knowledge of pressure injury prevention have indicated that current knowledge is adequate,28–31 other studies disagree.15–17,32 In this study, no nurse had sufficient knowledge before the training, but 80.0% (n = 12) of the nurses after the training and 60.0% (n = 9) of the nurses at 3 months after the training were considered sufficiently knowledgeable about pressure injury prevention. When repeat scores were evaluated 3 months after the training, scores decreased. This situation suggests that educational interventions can be forgotten, and therefore it should be repeated at regular intervals. Based on this training, the nurses had feedback on the content of the algorithm, such as current staging systems, holistic risk factors, and evidence-based clinical practice guidelines. In this case, it can be deduced that the nursing education was effective in reducing the incidence of pressure injury.
Nurse Feedback about the Algorithm
Algorithms are not exhaustive, but they are ideal for identifying appropriate management strategies and assisting in clinical decision-making.9 In this study, all of the nurses stated that the pressure injury prevention algorithm was sufficient, necessary, and useful in decision-making, although some nurses stated that it was complicated and time consuming (26.7%); that said, 73.3% of the nurses implemented the algorithm without difficulty. A study by Rijswijk and Beitz22 concluded that algorithms are of interest and should be easy to follow, although detail is needed in certain action steps. Accordingly, researchers worked to make the algorithm simple and not time consuming.
Pressure Injury Stage and Location
In this study, pressure injuries during the prealgorithm period were primarily stage 1 (57.2%), followed by stage 2 (22.8%). This order was reversed during the postalgorithm period, with stage 2 (39.4%) pressure injuries predominating and then stage 1 (35.6%; Table 2). Stages 1 and 2 pressure injuries are frequently seen in intensive care patients, although there is no consensus about which is more prevalent. Suriadi et al33 noted that stage 2 pressure injuries were more prevalent than stage 1. In contrast, in a study conducted by Uzun and Tan34 in an ICU, stage 1 pressure injuries were observed at a greater rate (72.3%) than stage 2 (14.9%).
The main purpose of this study was to reduce stage 1 pressure injury using an algorithm for care. Tayyib et al14 found that stage 1 pressure injury was significantly reduced with the application of a pressure injury prevention care bundle. Researchers suspect that stages 3 and 4 pressure injuries also decreased, and this resulted in the relative increase seen in stage 2 pressure injuries. The training given to the nurses may also have resulted in more accurate staging of pressure injuries.
In this study, pressure injuries primarily developed in the sacrum region, during both the pre- (46.7%) and postalgorithm (30.8%) periods. Studies by Mallah et al35 and Inan and Oztunç36 also found that pressure injuries were most frequent in the sacrum area (50% and 43.9%, respectively). To reduce the risk of aspiration and pneumonia, providers often lift bed heads above 30°, concentrating pressure in the sacral region and resulting in pressure injury.
Pressure Injury Incidence
The incidence of stage 1 pressure injury in the prealgorithm period was 46.1 per 1,000 patient-days. In the postalgorithm period, this rate decreased to 9.21 per 1,000 patient-days, a significant difference (z = 9.590, P < .001). Therefore, the pressure injury prevention algorithm was more effective in preventing pressure injury than the routine care used in the prealgorithm period.
Tayyib et al14 performed a study in ICUs and observed that their pressure injury incidence dropped from 32.86% to 7.14% after the implementation of a pressure injury prevention care bundle. Several other studies have found similar decreases.10,12,37 Although significant decreases in pressure injuries are possible, the incidence rates do not approach zero, for a variety of reasons; inactivity, nutrition deficiency, and extended stays in intensive care favor the secondary presence of the disease.14
This study was carried out as an intervention study to evaluate the effect of education and a pressure injury prevention algorithm on stage 1 pressure injury incidence. Only new pressure injuries were recorded. Control groups are recommended in future studies. Further, support surfaces used to prevent pressure injury were not available in the ARICU, which could have affected results. All patients were managed on air mattresses. It is also possible that these findings may not be generalizable because the study was conducted in a single ICU.
Application of the training and pressure injury prevention algorithm under the direction of the evidence-based guidelines reduced the pressure injury rates. It is recommended that ICUs implement a pressure injury prevention algorithm and this particular algorithm be reassessed in a wider population.
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