Event-based Therapeutic Repositioning an Evidence-Based Practice Change

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The Ohio State University

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The problem: Patients in the ICU, particularly obese patients, are at high risk for developing pressure ulcers. Turning and repositioning are the primary approaches to their prevention. However, strong evidence has established that these strategies are not provided on the accepted every-two-hour policy in wide use. Significance: Hospital-acquired pressure ulcers (HAPUs) are a never event in CMS quality care standards. HAPUs cost the US between 2.2 and 3.5 billion dollars annually. Hospitals receive financial penalties for HAPUs and absorb the cost of their treatment and extended length of stay, about $43,000 per patient. The human cost in constant pain is incalculable. The PICOT Question: In the adult intensive care patient how does the implementation of an event-based therapeutic repositioning bundle as compared to usual care (by the clock) affect the incidence of hospital acquired pressure ulcers (HAPU) and the reliability of repositioning? The Intervention Tested: Because evidence fails to support both the efficacy and effectiveness of current policy, an evidence-based review led to the development of a HAPU Prevention Bundle for ICU Patient, dubbed Event-Based Turning (EBT) by the staff. Included actions were: event-based turning using therapeutic repositioning strategies, low-air-loss bed surface, and use of a special repositioning sheet for obese patients. Methods: The project was implemented in a 12-bed community ICU. All ICU patients admitted with intact skin during the study period were included. A pretest period with 20 patients established baseline nurse compliance with the existing policy and patient HAPU outcomes. Following staff nurse education and a coaching period, a second sample of 8 patients were followed and nurse compliance was measured again. Outcomes of interest were: HAPU development, compliance with both turning schedule and therapeutic positioning. EVENT-BASED THERAPEUTIC REPOSITIONING 3 Results: The two samples were non-equivalent. Sample 1 was younger and experienced a lower severity of illness than patients in Sample 2. There were no HAPUs in either group; compliance with turning schedule was 34.7 percent in normal care group and 84.3 percent in the bundled group; perfect scores on therapeutic positioning occurred 41% of the normal care group and 63% in the bundled group. Nurses favorably reviewed the bundle, but a majority felt that they were not responsible for the prevention of HAPUs. Conclusion: The EBT bundle improved both the compliance with timing and the quality of repositioning. The EBT bundle appears safe to test in similar settings and with higher acuity patients. Nurses’ attitudes towards HAPU prevention are problematic and require further study.



Evidence-Based Practice, Prevention of Hospital Acquired Wounds: Critical Care