Research

NK1EO The organization supports the advancement of nursing research.

 

Provide one completed IRB-approved nursing research study. Use format presented. Results of data analysis (quantitative) or findings (qualitative); must have occurred within the four years before documentation submission.

 

RESEARCH TITLE

“The effects of an educational intervention based on visual cues and a ‘buddy system’ on the incidence and prevalence of pressure ulcers”.

 

INTRODUCTION

 

Study Rationale
In July of 2011, members of the 3 South Unit Practice Council (UPC) noticed that their rates of unit-acquired pressure ulcers (UAPU) had fluctuated widely between January and June of the same year. In addition, there was an unusual trend in the data; while the quarterly point prevalence that was reported to the National Database of Nursing Quality Indicators (NDNQI) reflected a “0” prevalence of UAPU, unit-level logs and incidence reports that were collected on a monthly basis reflected a higher rate.  Several members of the UPC decided to form a subcommittee that would focus its efforts on achieving improvement in the daily UAPU rates towards better concurrence with NDNQI data.

 

Led by Clinical Nurse Rosa Filomeno, RN, the subcommittee began by brainstorming on the possible reasons for the current UAPU rates. The team conducted a fishbone analysis in September of 2011 which revealed three factors that may have contributed to the higher rates:  1. Repositioning methodologies lacked standardization; 2. Nurses and clinical partners were unable to identify which patients were at risk; and 3. Staff lacked assistance in repositioning patients.

 

At the advice of Magnet Project Director Julie David, ARNP, the group met with the hospital’s Research Specialist Maria Ojeda, ARNP in October 2011. At that meeting, it was determined that the best way to address the problem was via an intervention research study.  Between October 2011 and January 2012, the team designed the study and completed the Institutional Review Board (IRB) application.

 

Research question and hypothesis

1. Will an educational intervention introducing a new system for pressure ulcer prevention reduce self-reported barriers and encourage better compliance with patient repositioning?
1. A significant difference in the pre- & post-intervention pattern of responses on a survey measuring staff perceived barriers and compliance with patient repositioning was used to evaluate research question #1. (Chi-square goodness of fit).

2. Will a new system for the recognition and management of patients at risk for pressure ulcers, utilizing visual cues and a “buddy system” for the scheduled repositioning of patients reduce the incidence of pressure ulcers on MS3 & 3S when compared to baseline?
1. The mean number of UAPU per quarter pre-intervention (January 2011 – February 2012) was compared to the mean number of UAPU post-intervention (April 2012 - December 2012) in order to evaluate research question #2. (Descriptive statistics).

3. Will the incidence of UAPU on MS3 & 3S using weekly unit-based logs differ significantly from the point prevalence of UAPU reported to NDNQI on post-intervention?
1. Three months post-intervention, the NDNQI reported point-prevalence for July - December of 2012 was compared to the mean incidence of UPAU per unit logs for congruence to evaluate #3. (Descriptive statistics).

 

Literature Review
Pressure ulcers are a type of complication that is highly prevalent among hospitalized patients. During the 2-year period of 2006-2007, the estimated incidence of pressure ulcers among hospitalized patients in the United States was 4.5% (Lyder, Wang, Metersky, Curry, Kliman, Verzier & Hunt, 2012).  Risk for pressure ulcer development is highest among hospitalized patients who are elderly, who have impaired mobility, diabetes, suffered a stroke, or are on vasopressors (Tschannen, Bates, Talsma & Ying, 2012; Cox, 2011). Pressure ulcers increase the odds of death among hospitalized patients and the costs associated with the treatment of hospital-acquired pressure ulcers is estimated at ~$3.3 billion (Van Den Bos, Rustagi, Gray, Halford, Ziemkiewicz & Shreve, 2011).

 

Within the hospital setting, prevention of UAPU is a multidisciplinary effort in which nurses play a significant role.  A recent metanalysis of 39 studies published 1990-2009 found evidence for the positive effect on pressure ulcer rates of quality improvement efforts utilizing nursing interventions (Soban, Hempel, Munjas, Miles & Rubenstein, 2011). The systematic repositioning of bed-bound patients every 2-4 hours is a nursing intervention that is recommended and supported by research as an effective UAPU prevention strategy (Stechmiller et al., 2008; Reddy, Gill & Rochon, 2006).  Unfortunately, a study of missed nursing care opportunities found that 82% of nurses surveyed reported failure to reposition patients every 2-hours during their shift; nurses attributed the largest proportion of missed care to unexpected increases in patient volume or acuity in their units (93%) and to the emergence of urgent situations in the care of individual patients (84%) (Kalisch, Landstrom & Williams, 2009).

 

Adopting a systems approach to complex problem solving within organizations helps to encourage a focus on faulty processes and encourages participation of team members at all levels in the improvement of safety and quality (Petula, 2005). Eliminating ambiguity regarding the role expectations and responsibilities related to patient care as well as clarification of specific methods involved in delivering such care helps increase compliance with evidence-based guidelines (Gurses, Siedl, Vaidya, Bochiccio, Harris, & Hebden et al., 2008). The simplification and standardization of interventions along with staff education are key strategies of successful quality improvement efforts for pressure ulcer prevention (Sullivan & Schoelles, 2013).  The use of visual cues to deliver reminders for future performance of tasks such as handwashing compliance has been found effective (Williams & Woodman, 2012; Nevo, Fitzpatrick, Thomas, Gluck, Lenchus, & Arheart et al., 2010). The researchers involved in this study sought to determine whether the combination of traditional staff education, standardized schedules for repositioning patients, and the innovative use of visual cues as effective reminders to repositioning tasks, could help improve performance on pressure ulcer prevention at Homestead Hospital.  

 

PARTICIPANTS

 

Name/Credentials	Years RN / Years Specialty Experience	Title	Department	Role in the Team
Rosa Filomeno MSN, RN, CMSRN	20 years RN /10 years specialty	Clinical Nurse	3 South	Principal Investigator
Gloria Gamboa, RN	7 years RN	Clinical Nurse	3 South	Co-Investigator
Adriana Garay, RN	9 years RN	Clinical Nurse	3 South	Co-Investigator
Shelly Ann Commock, BSN, RN, CMSRN	8 years RN	Clinical Nurse	3 South	Co-Investigator
Maria Ojeda, DNP/Phd(c), MPH, ARNP, NP-C	16 years experience as RN; 20+ years in research	Nurse Scientist	Nursing and Health Sciences Research	Key Personnel; consultant on study design & IRB application process; data analysis and interpretation.
Erica Cuthbert	11 years	Clinical Partner	3 South	Key Personnel

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

METHODS

 

Study Design
A non-randomized, quasi-experimental pre- and post-intervention design was chosen for the study. That way, the researchers could assure that all patients would receive the same standard of care while allowing them to evaluate the effectiveness of their interventions. 

 

Study Timeline
On January 18th, 2012, the Homestead Hospital Evidence-Based Practice and Research Council (EBPRC) approved the study and on February 17th, 2012, the Baptist Health South Florida (BHSF) IRB approved it as an expedited review study. Upon IRB approval, the research team began to implement the study protocol. They completed the research on December 2012.

Research Sample
The researchers collected study data via: 1. A paper and pencil survey delivered following a departmental staff-meeting from  a convenience sample of N=83 nurses and clinical partners; 2. Inpatient data regarding incidence of UAPU on Med/Surg3 (MS3) and 3South (3S) from routinely collected unit-based weekly logs and point prevalence of UAPU from NDNQI reporting data. 

 

Data Collection Methods
The team collected survey data immediately pre-intervention and 3-months post-intervention. All participation was voluntary and confidential.

Interventions.  There were two types of interventions initiated during the study:

1. An educational piece in the form of a video and an opportunity for follow-up questions from staff.  The educational piece lasted approximately 10 minutes and was delivered to all who consented to be part of the study immediately following a staff meeting.
2. The “Cue Turn Triad” (CTT) was implemented which consisted of the “U Turn” magnet (Exhibit NK1EOa)  to identify patients at risk, the “Cue Turn” instrument (Exhibit NK1EOb) reminding staff of scheduled patient repositioning times, and the formal “Buddy System” which partnered staff members for the purpose of assisting one another in the turning of patients.

 

Exhibit NK1EOa: U Turn Magnet

 

Exhibit NK1EOb: Cue Turn Poster – AM and PM

 

 

Instrumentation.  The research team searched the literature for a validated instrument that could identify the specific staff perceptions regarding repositioning of patients.  Since no such instrument was available, a qualitative survey based upon open-ended questions was formulated by the research team to determine the Patient Care Supervisors’ (PCSs), Direct Care Registered Nurses’ (DCRN), and Clinical Partners’ (CP's) subjective  attitudes, practices, and opinions on barriers to repositioning patients. 
The instrumentation for the CTT consisted of:

 

1. The “It’s Your Cue to Turn” video was developed to instruct the staff on the principles of the CTT.
2. The research team developed two visual reminders or tools to provide visual cues for the timely repositioning of patients: the "U turn" door magnet and the "Cue Turn" (Day & Night versions) instrument to be used in the patient's room.
3. The "Buddy System" was defined by the team as a formal system for "partnering of staff to reposition bedridden patient during a 12-hour shift".

 

RESULTS

 

Results of Data Analysis
The researchers completed the survey data analysis in October of 2012. They compared UAPU and NDNQI data for the 2 quarters immediately following the implementation of the “Cue Turn” triad in December of 2012.  A total of 83 nurses participated in the study, n=48 pre-intervention and n=35 post-intervention.

 

Research question #1.  The pre- and post-implementation surveys were examined for patterns of responses which were used to form categories. Chi-square goodness of fit tests determined there was a significant change in the pattern of responses for all 9-items within the Cue Turn Triad Assessment Tool (CTTAT) between pre-intervention and post-intervention assessments (Exhibit NK1EOc).

 

Exhibit NK1EOc: Chi-square goodness of fit tests results for CTTAT pre- & post-implementation results.

*Note:  All 9-items of the CTTAT demonstrated patterns of responses indicating improvement on post-implementation surveys over baseline.

There were significantly fewer RN on post-intervention who indicated having difficulty with: 1. Repositioning patients; 2. Repositioning a specific type of patient; 3. A lack of help in repositioning their patients; 4. A  lack of time in repositioning their patients; and 5. A lack of a set schedule for repositioning patients. 
There were significantly more RNs on post-intervention that indicated: 1. Using special equipment; and 2. Using the assistance of personnel in repositioning patients.
Criteria used by RNs to determine whether a patient would require assistance with repositioning also changed; on pre-intervention most RNs used patients’ activity levels to determine need for assistance, while on post-intervention a combination criteria were used including activity level, report received at shift change, the Cue Turn visual cues, patient age and Braden scale scores.

 

Research question #2.  The mean number of UAPU for the entire pre-intervention period was ~1 per quarter (.997), in the 6-month period immediately post-intervention (July 2012 – December 2012), the mean number of UAPU per quarter was 0 (Exhibit NK1EOd).  The researchers continued to monitor quarterly data on UAPU post-intervention through December 2013 and found the mean number of UAPU per quarter was = .11 (Exhibit NK1EOd). This signifies a >88% drop in mean UAPU occurrences since the implementation of “Cue Turn” triad.

 

Research question #3.  Post-intervention, the mean number of UAPU per quarter was 0 (July 2012 – December 2012); congruent with the reported NDNQI point prevalence for the units as well as the NDNQI benchmark of 0 pressure ulcers (Exhibit NK1EOd).

 

Exhibit NK1EOd: Comparison of mean incidence of UAPU on MS3 and 3S pre-and post Intervention with NDNQI benchmark.

 

 

*Note:  The study was IRB approved in February of 2012, the CTT intervention was implemented in April of 2012, and the study was closed in December of 2012.

DISCUSSION

 

Summary of Key Findings
The CTT was effective at decreasing barriers to repositioning patients and increasing compliance with patient repositioning among nurses on MS3 and 3S. Nurses reported less difficulty repositioning their patients, more help repositioning patients, more time available to complete the task of repositioning patients, and a more organized approach to the timing of patient repositioning. Nurses also reported more use of assistive equipment in repositioning patients and more use of assistive personnel in repositioning.

 

Analysis of the Findings
It is likely that reports of “less difficulty” in repositioning were associated with perceptions of increased availability of assistance for task completion and the increased use of assistive equipment.  Likewise, improvements in perceived adequacy of time for task completion may have been influenced by the standardized scheduling of repositioning implemented by the CTT.  Standardized scheduling of repositioning would allow nursing staff to prioritize and plan their day more efficiently as well as encourage teamwork among staff members when the need for assistance is anticipated.  Nevertheless, the relationship between the perceived availability of assistance and the perceived adequacy of time for task completion was not explored and should be the focus of future studies.

 

After the implementation of the CTT, rates of UAPU on MS3 and 3S improved significantly. The study demonstrates the potential impact of tools based on visual cues at affecting positive outcomes within the clinical practice setting.  The finding is congruent with that of a study conducted in 2010 that examined the impact of visual cues at improving hand hygiene compliance (HHC) among a group of physicians (n=75) and nurses (n=75) within a medical-surgical unit (Nevo, Fitzpatrick, Thomas, Gluck, Lenchus, & Arheart et al., 2010). Participants were observed for HHC during a patient examination before and after the introduction of one of five different visual cues encouraging the completion of HHC tasks. All visual cues used in the study trended towards greater HHC among participants on post-examination.  A visual cue consisting of a sign posted on the door to the patient’s room significantly increased HHC among participants. This study did not directly observe nurses utilization of the CTT, however despite the fact that self-reported data is vulnerable to response bias, rates of UAPU within the study units on post-intervention lend support to the validity of the self-reported data. Despite the potential value of visual cues in the improvement of clinical and quality outcomes, physical space limitations and organizational policies may hinder their widespread use.  Future studies should focus on the types of reminders that should be displayed within patients’ rooms and look at the effectiveness of electronic reminders as alternatives.
 
A comparison found no difference between the mean number of UAPU recorded in weekly unit logs and the NDNQI point prevalence reporting for the study time period.  Point prevalence is snapshot of the number of individuals with a given condition during a specific period of time.  The findings indicate that NDNQI reported data was an accurate reflection of the incidence of UAPU on the units during the time of the study.

 

The CTT research project has been presented at several conferences via podium and poster presentations during 2012 and 2013. (NK1EO 01 Cue Turn Poster)

 

Conference	Date	Podium or Poster
8th Annual Research Conference Baptist Health South Florida, Inc.  – Miami, FL	April 12, 2013	Podium
Symposium on Advanced Wound Care – Spring – Denver, CO	May 1-5, 2013	Poster
Homestead Hospital’s Evidence-based Practice Fair 2013 – Homestead, FL	August 20, 2013	Poster

 

Implications of the Findings
Although the study period was officially closed in December of 2012, the researchers found the use of the CTT maintained UAPU rates on MS3 and 3S well below baseline through December 2013.  The CTT continues to provide staff with an innovative set of practice tools that has encouraged greater teamwork within MS3 and 3S while facilitating the provision of the very best in pressure ulcer prevention care to their patients. 

 

References

 

Cox, J. (2011).  Predictors of pressure ulcers in adult critical care patients.  American Journal of Critical Care, 20(5):364-75. doi: 10.4037/ajcc2011934.
Gurses, A., Seidl, K., Vaidya, V., Bochicchio, G., Harris, A., Hebden, J., & Xiao, Y.(2008). Systems ambiguity and guideline compliance: a qualitative study of how intensive care units follow evidence-based guidelines to reduce healthcare associated infections.  Quality & Safety in Health Care, 17, 351–359. doi:10.1136/qshc.2006.021709
Lyder, C., Wang, Y., Metersky, M., Curry, M., Kliman, R., Verzier, N., & Hunt, D. (2012).  Hospital-acquired pressure ulcers: results from the national Medicare Patient Safety Monitoring System study.  Journal of the American Geriatrics Society, 60(9):1603-8. doi: 10.1111/j.1532-5415.2012.04106.x.
Nevo, I., Fitzpatrick, M., Thomas, R., Gluck, P., Lenchus, J., Arheart, K., Birnbach,
D. (2010). The efficacy of visual cues to improve hand hygiene compliance. Simulation in Healthcare, 5(6):325-331. doi: 10.1097/SIH.0b013e3181f69482.
Petula, S. (2005). Can applying systems theory improve quality in healthcare systems? Journal for Healthcare Quality, 27(6), W6-2–W6-6.
Reddy, M., Gill, S., & Rochon, P.  (2006). Preventing pressure ulcers: a systematic review.  JAMA, 296(8), 974-984.
Soban, L., Hempel, S., Munjas, B., Miles, J., & Rubenstein, L. (2011). Preventing pressure ulcers in hospitals: a systematic review of nurse-focused quality improvement interventions.  Joint Commission Journal of Quality and Patient Safety, 37(6), 245-252.
Stechmiller, J., Cowan, L., Whitney, J., Phillips, L., Aslam, R., Barbul, A. …& Stotts, N. (2008). Guidelines for the prevention of pressure ulcers.  Wound Repair and Regeneration, 16, 151-168.
Sullivan, N., & Schoelles, K. (2013).  Preventing in-facility pressure ulcers as a patient safety strategy:  a systematic review.  Annals of Internal Medicine, 158(5), 410-416.
Tschannen, D., Bates, O., Talsma, A., & Ying, G. (2012). Patient-specific and surgical characteristics in the development of pressure ulcers. American Journal Of Critical Care, 21(2), 116-125. doi:10.4037/ajcc2012716
Van Den Bos, J., Rustagi, K., Gray, T., Halford, M., Ziemkiewicz, E., & Shreve, J. (2011).  The $17.1 billion problem:  The annual costs of measurable medical errors.  Health Affairs, 30(4), 596-603.

Summary Attachments/Hyperlinks/Evidences

 

Exhibit NK1EOa: U Turn Magnet
Exhibit NK1EOb: Cue Turn Poster – AM and PM
Exhibit NK1EOc: Chi-square goodness of fit tests results for CTTAT pre- & post-implementation results.
Exhibit NK1EOd: Comparison of mean incidence of UAPU on MS3 and 3S pre-and post Intervention with NDNQI benchmark.
NK1EO 01 Cue Turn Poster

 

 

 

 

 

 

 

 

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