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 Table of Contents  
ORIGINAL ARTICLE
Year : 2017  |  Volume : 1  |  Issue : 3  |  Page : 75-79

A pre-post study evaluating the effectiveness of a new initiative, the “PRESSURE Bundle,” Compared with standard care in reducing the incidence and prevalence of sacral pressure ulcers in Critically Ill Patients in an intensive care unit in Riyadh, Saudi Arabia


1 Department of Intensive Care, Imam Abd Alrahman Alfaisal Hospital, Ministry of Health, Riyadh, Saudi Arabia
2 Department of Intensive Care, King Saud Medical City, Ministry of Health, Riyadh, Saudi Arabia

Date of Web Publication16-Feb-2018

Correspondence Address:
Anas Ahmad Amr
Department of Intensive Care, Imam Abd Alrahman Alfaisal Hospital, Ministry of Health, Riyadh, P. O. Box 11594, Jeddah 21463
Saudi Arabia
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/sccj.sccj_29_17

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  Abstract 


Objective: Pressure ulcers present a major health challenge worldwide, and critically ill patients are considered to be at the greatest risk for pressure ulcer development. A study was undertaken to evaluate the effectiveness of pressure ulcer prevention measures (“PRESSURE bundle”) compared with standard care in reducing the incidence and prevalence of sacral pressure ulcers in critically ill patients in an Intensive Care Unit (ICU) in Riyadh, Saudi Arabia. Methods: Patients were assigned to the standard care group (n = 330) or the “PRESSURE bundle” group (n = 360). The follow-up period for both treatment groups was 2 months. A pre-post study design was used where data were collected in two samples. Patients were aged 16 years or over and included all new patients admitted to the ICU who did not have but were considered at risk of developing, sacral pressure ulcers (Braden scale score <18). Results: In the PRESSURE care bundle group, there was a significant reduction (P < 0.001) in the incidence of newly developed sacral pressure ulcers in the 2 months treatment period (n = 1, 0.3%) compared with the standard care group (n = 16, 4.6%). There was also a significant reduction (P < 0.001) in the prevalence of sacral pressure ulcers in the PRESSURE care bundle group (4.75%) compared with the standard care group (22.7%) when prevalence figures were compared at the end of the treatment periods. Conclusion: The application of a group of pressure ulcer prevention measures (“PRESSURE bundle”) coincided with a reduction in incidence and prevalence of sacral pressure ulcers in critically ill patients who are at risk for developing pressure ulcers.

Keywords: Intensive Care Unit pressure ulcers, pressure ulcer incidence, pressure ulcer prevalence, pressure ulcer prevention, sacral pressure ulcers


How to cite this article:
Amr AA, Yousef AM, Amirah MF, Alkurdi MH. A pre-post study evaluating the effectiveness of a new initiative, the “PRESSURE Bundle,” Compared with standard care in reducing the incidence and prevalence of sacral pressure ulcers in Critically Ill Patients in an intensive care unit in Riyadh, Saudi Arabia. Saudi Crit Care J 2017;1:75-9

How to cite this URL:
Amr AA, Yousef AM, Amirah MF, Alkurdi MH. A pre-post study evaluating the effectiveness of a new initiative, the “PRESSURE Bundle,” Compared with standard care in reducing the incidence and prevalence of sacral pressure ulcers in Critically Ill Patients in an intensive care unit in Riyadh, Saudi Arabia. Saudi Crit Care J [serial online] 2017 [cited 2018 Aug 19];1:75-9. Available from: http://www.sccj-sa.org/text.asp?2017/1/3/75/225731




  Introduction Top


A pressure ulcer is a localized injury to the skin and/or underlying tissue, usually over a bony prominence, as a result of pressure, or pressure in combination with shear.[1] Pressure ulcers are more likely to occur in people who are seriously ill, have a neurological condition, impaired mobility, impaired nutrition, poor posture, or deformity. The use of equipment such as seating or beds which are not specifically designed to provide pressure relief can also cause pressure ulcers.[2]

Critically ill patients in the Intensive Care Unit (ICU) are considered to be at the greatest risk for pressure ulcer development as they are likely to be immobile; present with higher severity of illness; require mechanical ventilation, associated sedation, and pharmacological drugs; which could all potentially reduce peripheral circulation. Therefore, the identification of patients at the risk of pressure ulcer development in the ICU is essential.[3] Reported prevalence rates of pressure ulcers in the ICU population vary substantially, ranging from 4% to 42%, while reported incidence rates range from 0.25% to 44.4%, with wide variations reported between countries.[4]

Guideline recommendations for preventing pressure ulcers include methods for identification and risk assessment and preventive measures including skin assessment, nutrition, repositioning, and choosing appropriate support surfaces.[1],[2] It has long been recognized that pressure ulcers are a major cause of morbidity, mortality, and health-care burden globally and that many pressure ulcers are avoidable.[5]

The largest adult ICU in Saudi Arabia is located in Riyadh, at the King Saud Medical City, and contains 90 active medical and surgical beds. At the end of January 2013, the prevalence of sacral pressure ulcers in the ICU was 31.7%, and the incidence of new sacral pressure ulcers for that month was 6.8%. An audit on current practices, in preparation for Joint Commission International accreditation, revealed a number of problems with the current pressure ulcer prevention strategy.

An ICU wound care team, comprising an intensivist, quality manager, clinical dietitian, nursing educator, and nursing supervisor, was set up to review these audit results and undertake a root cause analysis. Their analysis revealed that only 65% of a patients' initial assessment was completed, only 62% of turns were done in line with the 2 hourly positioning protocols, and only 60% of patients at risk of pressure ulcers had special nutrition plans in place. In addition, there were no daily follow-up assessments, no use of skin protective barriers for patients at risk of developing pressure ulcers, there was no wound care team in place, and no evidence of guidelines or locally approved policies of pressure ulcer prevention being followed. There was also no defined monitoring and reporting system for pressure ulcers and no structured awareness programs to highlight factors that could lead to pressure ulcer development, such as skin and risk assessment education or special measures to decrease skin friction and shear.

Consequently, a plan was constructed to address these shortcomings in consistency and quality of care in pressure ulcer prevention. The ICU wound care team was involved in the process of data collection, education, follow-up, and implementation of this plan. This study details an initiative to reduce the incidence and prevalence of pressure ulcers.


  Methods Top


Each problem was addressed according to the evidence after going through a systematic literature review. The National Pressure Ulcer Advisory Panel-European Pressure Ulcer Advisory Panel (NPUAP-EPUAP) pressure ulcer prevention guidelines (2009)[1] and regional performance improvement projects formed the basis of the pressure ulcer prevention plan that was called the “PRESSURE bundle” [Box 1]. The “PRESSURE bundle” measures were approved by the wound care team in the ICU and hospital quality management department.



The “PRESSURE bundle” measures involved systematic review and change of existing practices. Following the literature review, a risk assessment tool was implemented to improve documentation. The BRADEN scale was chosen, which has been identified as the most appropriate tool for pressure ulcer risk assessment in ICUs.[6] Documentation of Braden scale score, skin assessment, and incidence of sacral pressure ulcers was carried out at admission and 8 hourly with all new sacral pressure ulcers being recorded. The ICU wound care team was involved in the process of data collection, education, follow-up, and implementation. Education sessions were given to staff on a daily basis, addressing areas such as physical examination and skin assessment. All patients were assessed for their dietary needs and high-protein diets on approved dietician protocol were requested for those patients at risk of developing pressure ulcers.

With respect to the management of shear strain, a multilayered, self-adhesive, soft silicone-faced polyurethane foam island dressing (Mepilex Border: Molnlycke Health Care, Sweden) was applied to the sacral area to prevent shear strain in the tissue due to friction, absorb moisture, and manage microclimate. The dressing was changed weekly or when needed (in accordance with the manufacturers' recommendation). Air mattresses and pillows were introduced to reduce pressure from support surfaces with the head of the bed elevated at <30°, unless contraindicated by the patients' medical condition. A turning position schedule was undertaken 2 hourly. If the patient developed a pressure ulcer, the “PRESSURE bundle” measures were still continued to prevent the development of further pressure ulcers.

Changes in communication included a structured awareness and training program conducted through bedside sessions, group discussion, monthly departmental meetings, assessment of pressure ulcers, and monthly announcements of rates of pressure ulcer incidence and prevalence.

A study was implemented to evaluate the effectiveness of the “PRESSURE bundle” measures in the prevention of sacral pressure ulcers in critically ill patients who were admitted to the ICU and were evaluated as being at risk of developing pressure ulcers. A pre-post study design was used where data were collected in two samples. The standard care group followed existing practice in the prevention of pressure ulcers. Subsequently, the “PRESSURE bundle” measures were implemented, and once compliance was established, the measures were evaluated. The primary end-points were the difference in the incidence of new sacral pressure ulcers and the prevalence of sacral pressure ulcers in the “PRESSURE bundle” group compared with the standard care group after a follow-up period of 2 months. Incidence density was used to indicate the percentage of patients developing a sacral pressure ulcer per 1000 hospital inpatients, as this method is the best quality measure of pressure ulcer prevention programs.[7] The severity of illness was measured using the Apache IV (Cerner Corporation, USA) electronic scoring system to determine whether there was any significant difference in severity of illness between the two groups. Following approval by the ICU chairman, hospital research group, quality management department, and in line with the requirements set out in the Declaration of Helsinki: inpatient recruitment took place.

Inclusion criteria were all new patients admitted to the ICU who were considered at risk of developing a pressure ulcer (Braden scale score <18), had no partial thickness sacral pressure ulcers (defined as below category II, as detailed in the NPUAP-EPUAP guidelines, 2009),[1] were 16 years of age or over and had an ICU stay of more than 24 h. The exclusion criteria were spinal injury cases or head trauma cases, as defined by the treating physician and documented in the patients' records; and patients who had been admitted to the ICU postoperatively for less than 48 h. All patients were treated as per study protocol.

Data for patients who received standard care (n = 330, 69% male and 31% female, mean age = 52 years of age, mean APACHE IV score = 93.4, mean Braden scale score = 13.69 at commencement of the study) were collected over 2 months (01/04/2013-30/05/2013) before the implementation of the “PRESSURE bundle.”

Three months were taken to implement the “PRESSURE bundle” and ensure that full compliance was met (every measure implemented where medically possible, June 1, 2013–August 30, 2013). Throughout the implementation and “PRESSURE bundle” study periods, a follow-up form assessed staff compliance with the “PRESSURE bundle,” and whether each aspect of the bundle was “met,” or “not met.” The ICU quality management nurse monitored compliance of the “PRESSURE bundle” strategies daily.

After nursing, staff had reached full compliance with the “PRESSURE bundle” 2 months (September 1, 2013–October 30, 2013) of data collection was taken from the treatment group (n = 360, 63% male and 37% female, mean age = 55, mean APACHE IV score = 97.8, mean Braden scale score = 12.63 at commencement of the study), indicating that the two groups were similar at baseline.

For comparison of incidence of new pressure ulcers during treatment and prevalence of sacral pressure ulcers at the end of treatment between treatment groups, Fisher's exact test was used. SPSS software was employed for statistical analysis throughout the study.


  Results Top


The mean acute patient stays in the study across both treatment groups was 7 days. The mean medical ICU stay was 6–8 days, and the mean surgical ICU stay was 10–12 days. The mean BRADEN scale score throughout the study remained between 12 and 14 for both treatment groups.

The “PRESSURE bundle” measures were well adopted by nurses with compliance maintained consistently above 90% during the treatment period [Figure 1].
Figure 1: Staff compliance with the “PRESSURE bundle”

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In the “PRESSURE bundle” group, there was a significant reduction in the incidence of new pressure ulcers in the 2 months treatment period (n = 1, 0.3%) compared with the standard care group (n = 16, 4.6%; P < 0.001).

There was also a significant reduction in the prevalence of sacral pressure ulcers in the “PRESSURE bundle” group (4.75%) compared with the standard care group (22.7%) when the prevalence figures were compared at the end of the treatment period (P< 0.001) [Table 1].
Table 1: Prevalence and incidence rates for sacral pressure ulcers at the end of study period

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Due to the success of the “PRESSURE bundle” strategies, they were continued after the end of the study where their effect was still evident in the incidence of newly developed sacral pressure ulcers in the ICU for December (0.35%), and in the prevalence rate at the end of that month (7.9%). The impact the “PRESSURE bundle” strategies had on the incidence and prevalence of sacral pressure ulcers is illustrated when the figures for the year are viewed before and after the strategies were put in place [Figure 2].
Figure 2: The Impact of the “PRESSURE bundle” on Incidence and prevalence of sacral pressure ulcers in the Intensive Care Unit in 2013 (arrow indicates time of implementation of “PRESSURE bundle”

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  Discussion Top


This study provides data supporting the effectiveness of the “PRESSURE bundle” strategies for the prevention of sacral pressure ulcers in patients at risk of developing pressure ulcers in an ICU. Consequently, the study can be used to raise awareness, to reduce pressure ulcer occurrence and to improve clinical practice.[5]

Effective implementation of evidence-based practice requires systematic change of existing care units.[8] The quality improvements from the “PRESSURE bundle” pressure ulcer prevention strategies brought about systematic change on the ICU, which was both evidence-based and effectively implemented. Once implemented, full compliance was met before the effectiveness of the “PRESSURE bundle” strategies was measured, as spreading a tool before good compliance is achieved in the testing phase can lead to implementation of something that is not yet fit for purpose and therefore, likely to fail.[9]

One of the measures introduced by the “PRESSURE bundle” was the use of foam dressings in the prevention of pressure ulcers, which are recommended by NPUAP-EPUAP on body areas and pressure ulcers at risk for shear injury.[1] Mepilex Border is recommended for use on sacral areas in the ICU to reduce pressure, shear, and keep skin clean and dry to control microclimate.[9] This recommendation is supported by results from a randomized controlled trial which showed that there were significantly fewer critically ill patients with pressure ulcers who wore Mepilex Border dressings compared with a control group who did not.[10] The dressings were also more cost-effective compared with the associated costs of treating pressure ulcers in the control group.[11]

A limitation of the study design was that while the “PRESSURE bundle” measures considered the holistic care of the patient in the prevention of all pressure ulcers the prevalence and incidence figures collected only compared sacral pressure ulcers and so further research is needed to confirm that the results can be extrapolated to pressure ulcers on other areas of the body. In addition, new pressure ulcers may also have been hidden by the Mepilex Border dressing as it was only designed to be replaced weekly, which was the average length of patient stay in the study and patients were not followed up after leaving the ICU. Therefore, these results should not be viewed in isolation and further studies assessing the “PRESSURE bundle” measures in other ICU departments are required to test the effectiveness of these measures in the prevention of pressure ulcers.


  Conclusion Top


The application of a group of pressure ulcer prevention measures (“PRESSURE bundle”) coincided with a reduction in the incidence and prevalence of sacral pressure ulcers in critically ill patients who are at risk for developing pressure ulcers. Further research in other ICU populations will help to further establish the effectiveness of the “PRESSURE bundle” measures in the prevention and treatment of pressure ulcers in critically ill patients.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
European Pressure Ulcer Advisory Panel and National Pressure Ulcer Advisory Panel Prevention of Pressure Ulcers: Quick Reference Guide. Washington DC: NPUAP; 2009.  Back to cited text no. 1
    
2.
National Institute for Health and Care Excellence. Pressure Ulcers: Prevention and Management of Pressure Ulcers. NICE Clinical Guideline 179. Issued April, 2014.  Back to cited text no. 2
    
3.
Tayyib N, Coyer F, Lewis P. Pressure ulcers in the adult Intensive Care Unit: A literature review of patient risk factors and risk assessment scales. J Nurs Educ Pract 2013;3:11, 28-42.  Back to cited text no. 3
    
4.
National Pressure Ulcer Advisory Panel, European Pressure Ulcer Advisory Pane and Pan Pacific Pressure Injury Alliance. Prevention and Treatment of Pressure Ulcers: Clinical Practice Guideline. In: Haesler E, editor. Prevention and Treatment of Pressure Ulcers: Clinical Practice Guideline. Perth, Australia: Cambridge Media; 2014.  Back to cited text no. 4
    
5.
International Guidelines. Pressure Ulcer Prevention: Prevalence and Incidence in Context. A Consensus Document. London: MEP Ltd.; 2009.  Back to cited text no. 5
    
6.
Garcia-Fernandez FP, Pancorbo-Hidalgo PL, Soldevilla-Agreda JJ, Rodriguez Torres M. Risk assessment scales for pressure ulcers in intensive care units: A systematic review with meta-analysis. EWMA J 2013;13:2, 7-13.  Back to cited text no. 6
    
7.
National Pressure Ulcer Advisory Panel. Pressure Ulcer Incidence Density as a Quality Measure; 11 March, 2014. Available from: http://www.npuap.org/pressure-ulcer-incidence-density-as-a-quality-measure/. [Last accessed on 2017 May 15].  Back to cited text no. 7
    
8.
Padula WV, Mishra MK, Makic MB, Valuck RJ. A framework of quality improvement interventions to implement evidence-based practices for pressure ulcer prevention. Adv Skin Wound Care 2014;27:280-4.  Back to cited text no. 8
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9.
Whitlock J, Rowlands S, Ellis G, Evans A. Using the SKIN bundle to prevent pressure ulcers. Nurs Times 2011;107:35, 20-3.  Back to cited text no. 9
    
10.
Santamaria N, Gerdtz M, Sage S, McCann J, Freeman A, Vassiliou T, et al. Arandomised controlled trial of the effectiveness of soft silicone multi-layered foam dressings in the prevention of sacral and heel pressure ulcers in trauma and critically ill patients: The border trial. Int Wound J 2015;12:302-8.  Back to cited text no. 10
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11.
Santamaria N, Liu W, Gerdtz M, Sage S, McCann J, Freeman A, et al. The cost-benefit of using soft silicone multilayered foam dressings to prevent sacral and heel pressure ulcers in trauma and critically ill patients: A within-trial analysis of the border trial. Int Wound J 2015;12:344-50.  Back to cited text no. 11
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