GATES – LEBANESE GERMAN

UNIVERSITY

PROJECT IN HEALTHCARE AND QUALITY MANAGEMENT

Management of Pressure Ulcers in Intensive Care Unit

Prepared by:

Fadia Chabchoul

Fattoum Awad

Alya Solh

Submit in partial fulfillement of the requirements of the Healthcare and

Quality Management Diploma Program

1/8/2015

Advisor: Dr. Marale Atechian

ii

ACKNOWLEDGMENT

Graduation reminds me of everyone who has touched my life. The gift of their

Presence and acknowledgment is truly appreciated

We would like to thank

Dar Al Amal University Hospital

Dr. Marale Atechian

GATES and LGU

My family and friends

For treasured memories and loving support throughout my education and graduation.

Fadia Chabchoul

Fattoum Awad

Alya Solh

iii

ABSTRACT

Pressure ulcers (PU) are a potential complication for intensive care patients and their prevention

is a major issue in nursing care. Therefore, this study aims to assess pressure ulcer prevalence in

ICU in Dar AL Amal University hospital including the path physiology, risk factors, risk

assessment, prevention, treatment and outcomes and to develop the performance level of staff.

Knowing that the rate of PU in ICU in 2014 increased to (7.9%) from all complete bed rests

patients compared with 2013 (5.59%).

This topic will determine the factors related to increase occurrence of PU in ICU and to manage

it, because of its importance issue in nursing care. 42 Registered nurses are sampled. Data

collected from a questionnaire and competency test. Our study shows that the Nurses had limited

knowledge about critical parameters of pressure ulcers especially the new employees in addition

the increase in the admission of critical and complicated cases, these 2 factors increase the rate of

Occurrence of PU in 2014.

It is an important to focus on pressure ulcer as a serious issue because it affects negatively on the

patient health and the hospital and to apply certain and immediate interventions as continuous

training and education of the employees' in order to manage bed sore and prevent its

development.

iv

TABLE OF CONTENTS

ACKNOWLEDGMENT ...................................................................................... II

ABSTRACT ....................................................................................................... III

LIST OF FIGURES ............................................................................................. V

LIST OF GRAPHS .............................................................................................. V

LIST OF TABLES ............................................................................................. VI

LIST OF ABBREVIATIONS ........................................................................... VII

INTRODUCTION ................................................................................................1

PROBLEM STATEMENT ...................................................................................2

OBJECTIVES .......................................................................................................3

LITERATURE REVIEW .....................................................................................4

HYPOTHESIS ......................................................................................................8

PROJECT DESIGN AND METHODOLOGY ....................................................9

DATA ANALYSIS AND RESULTS ................................................................ 11

CONCLUSION .................................................................................................. 14

RECOMMENDATIONS AND FUTURE WORK ........................................... 15

REFERENCES ................................................................................................... 16

APPENDICES ................................................................................................... 17

v

LIST OF FIGURES

Figure 1: Stages of pressure ulcer ................................................................................................... 4

Figure 2 Nursing interventions to prevent PU ................................................................................ 5

Figure 3: Fishbone analyse major causes of pressure ulcer occurrence in ICU ........................... 10

LIST OF GRAPHS

Graph 1: Distribution of patients gender 10

Graph 2: Distribution of pressure ulcer related to age 10

Graph 3: Percentage of PU related to admitted diagnosis 10

Graph 4: Risk factors related to PU 10

Graph 5: Percentage related to PU degree 11

Graph 8: Availability of equipment’s 12

Graph 9: Causes that prevent nurse from PU 12

Graph 10: Staff nurse education about bed sore 12

vi

LIST OF TABLES

Table 1: line list for pressure ulcer in ICU department.

vii

LIST OF ABBREVIATIONS

PU : Pressure Ulcer

ICU: Intensive Care Units

HN: Head Nurse

CBR: Complete Bed Rest

RN: Register Nurse

e.g.: Example

K.cal: Kilo calories

SBAHC: Sultan Bin Abdulaziz Humanitarian City

KPI: Key of Performance Indicator

INTRODUCTION

Pressure ulcer (PU) or bedsore is significant health care problem especially for geriatric

population (1). Over one million of hospitalized patients are subjected to the affliction of bed

sores every year. Data from United States indicates that about 11% of all hospital admissions

mostly in intensive care departments have PU (2). In Saudi, the rate of PU in ICU was 27% in

2012, the SBAHC (Sultan Bin Abdulaziz Humanitarian City) launched its wound care service to

prevent and manage PU; it uses guidelines from National Pressure Ulcer Advisory Panel

(NPUAP) and puts its efforts to eradicate pressure ulcer by approving a team for identifying,

preventing and managing PU (3).

PU is areas of tissue necrosis that tends to develop when soft tissue is compressed between a

bony prominence and an external surface for a prolonged period of time. Pressure ulcers are

associated with adverse patient outcome; contribute to patient pain, depression, loss of function

and independence, increase incidence of infection and sepsis, additional surgical interventions,

significant economic costs and prolonged hospital stays. Therefore, the most effective treatment

for pressure ulcers is to prevent their development.

The development of pressure ulcers remains a problem and a major issue in nursing care. The

development of PU is very complex phenomenon. Contributing factors are related to both

patients' conditions and extrinsic factors.

Pressure ulcer remains the chief complications of prolonged hospitalization, specifically in

situations of poor nutrition; it increases moisture on skin (e.g. incontinence) and prolonged

pressure. Pressure ulcer increases the cost of hospitalization, morbidity, mortality and plays a

significant role in the spread of infection, leading to dictum of preventive therapy being not only

beneficial to the patient but also to the health care system.

In clinical area, the presence or absence of PU has been generally regarded as performance

measure of quality nursing care and over all patient health; an average 60.000 people die yearly

world wide due to pressure ulcers related causes (5). Pressure ulcers have plagued critically ill

and debilitated patients since the dawn of recorded medicine.

Studies have shown a clear association between development of pressure ulcers and increased

mortality (6). Since we focused in our hospital to achieve nine goals of patient safety, the

evaluation of this topic was followed from 2005 as a Key of Performance Indicator (KPI). We

noticed that not only the underlying physiologic causes as CBR may predispose to develop PU

but also the knowledge deficit of health care personnel. Eventually, it is a must to deal with these

causes as a serious issue in hospital and improvement actions should be taken to manage PU.

2

PROBLEM STATEMENT

Patients in Intensive Care Units (ICU)) are at high risk of developing pressure ulcers. PU is

considered to be chronically contaminated wounds and this may lead to sepsis occurrence.

In 2014, PU incidence declaration in ICU at Dar at Al Amal University Hospital was increased

compared with 2013. So there was an alarm to take a certain corrective and preventive measures

toward this issue in order to identify factors related to this rasing, to put certain interventions to

manage it and to assess the personal knowledge level.

3

OBJECTIVES

The objective of this thesis:

1. To analyse the data and to identify the underlying causes and unrelieved factors behind

the development of PU and to make management for it.

2. To identify the adequacy of personnel, materials and supplies.

3. To assess the performance level of the employees in ICU and to increase their levels.

4. To improve the quality of care by resolving gaps in order to attempt Zero target and to

increase staff consciousness regarding harm caused by PU.

5. To support clinical practice by providing consistent research-based information related

PU, initiating better practice, better patient outcome

4

LITERATURE REVIEW

Definition of pressure ulcers PU is localized areas of tissue necrosis that tend to develop when soft Tissue is compressed

between a bony prominence and an external surface for a prolonged period of time.

PU occurs when the pressure on the skin reduces the blood flow to the area. PU most commonly

occurs over body areas or prominences in the body such as shoulders, hips, or heels. PU can be

difficult to treat in extreme cases. (7)

Staging of pressure ulcers Stage I

A redden area on the skin that when pressed does not turn white.

Stage II

It is a partial thickness loss of dermis presenting as a shallow open ulcer with a red wound.

Stage III

There is damage to the tissue below the skin. Subcutaneous fat may be visible but bone, tendon

or muscle is not exposed.

Stage IV

PU becomes so deep that there is damage to the muscle and bone, and sometimes to the tendons

and joints.

Stage V

There is full thickness tissue loss with exposed bone, tendon or muscle.

Figure 1: Stages of pressure ulcer

5

Deep tissue injury

Purple localized area of discoloured intact skin or blood-filled blister due to damage of

underlying soft tissue from pressure. (8)

Figure 2 : common sites for PU prevalence

Risk Factors of PU - Immobility is one of the most important host factors that contribute to pressure ulcer

development. Immobility may be permanent or transient.

- Urinary incontinence is frequently cited as a predisposing factor for pressure ulcers.

- Mal nutrition: The role of nutritional status in the development of pressure ulcers is

uncertain.

- Neurological diseases such as dementia, delirium, spinal cord injury, and neuropathy are

important contributors to pressure ulcer development. This may in large part be related to

immobility, plasticity, and contractures that are common in these conditions. Sensory loss

is also common, suggesting that patients may not perceive pain or discomfort arising

from prolonged pressure.

- Other factors identified in some studies are: older age, white race, and male gender.

Specific diagnoses that have been associated with ulcer development include the presence

of dry skin, recent lower extremity fractures, diabetes, and cardiovascular disease. (9)

Valuation of Pressure Ulcers (9) The patient must be evaluated through the scales for identify the patients who have risk to

develop pressure ulcer in intensive care units. The Braden and Norton scales are the most used.

Pathogenesis Development of a pressure ulcer is a complex process that requires the application of external

forces to the skin. However, external forces alone are not sufficient to cause an ulcer; their

interaction with host-specific factors culminates in tissue damage.

6

Prevention - Skin moisturising and hygiene to all complete bed rest patients.

- Regular turning schedule of 2 hours is recommended.

- Patient should be placed at a 30 degree angle to avoid direct pressure over the greater

trochanter.

- Pillows or foam wedges may need to be placed between the ankles and knees.

- Implement measures to reduce the risk of developing pressure ulcers.

- using heel protection devices

- Use air mattress for CBR patients.

- Use skin protection cream for patients with frequent faecal incontinence.

- Offer individuals with nutritional and PU risks a minimum 30-35kcal/day per kg body

weight per day.

- After urinating or having bowel movements, clean the area and dry it well.

Nursing intervention to prevent PU Nurses play an important role in preventing PU in CBR patients by doing the following steps by

using "PROMPT".

P: Pressure Points

Nurses should regularly check areas of the body that may be under pressure.

R: Report it.

Report promptly to your health professionals any painful areas.

O: Oral intake

It is important to eat a balanced diet and drink plenty of fluids.

M: Moisture

Keep the skin clean and dry.

P: Position

Poor position can contribute to development of pressure ulcers. Avoid pressing down on heels to

move up the bed.

T: Take pressure off

Change position every 2 hours.

7

Complications:

- Pressure ulcers may be associated with both medical (cellulites, bone and joint infections

and sepsis) and psychosocial complications. The medical complications can be life

threatening and are more common with stage 3 and 4 ulcers.

- Psychosocial consequences are not often considered. However, patients with pressure

ulcers may suffer pain and feel stigmatized by the development of chronic skin ulcer.

This could result in depression, social isolation, and decrements in overall health-related

quality of life.

- The worst complication of PU is the infection, bacteria multiply, the healing is disrupted

and damage tissues. The symptoms typical are inflammation, pain, hot and blush.

Treatment:

Most stage 1 and stage 2 sores will heal within weeks with conservative measures. But stage 3

and 4 may require surgery.

- Wound should be evaluated for stage, size, necrotic tissue, exudates, and presence of

granulation.

- Pressure reduction

- positioning

- Adequate pain relief

- Infection management. (Local antibiotic)

- Dressings - Debridement and surgery

8

HYPOTHESIS

We hypothesized that PU rate was increased in intensive care units in 2014 because of:

- Most patients admitted to ICU have more risk factors to develop pressure ulcers, as

complete bed rest patients, urinary incontinence and age. These factors may be the major

causes to develop PU.

- PU may be caused by mal practice of ICU employees or lack of performance of RN’s

especially in skin assessment.

- PU may be increased in intensive care units due to limit available of preventive tools as

ICU bed standards.

- PU increases the morbidity and mortality rate and affect negatively on the quality of the

hospital.

9

PROJECT DESIGN AND METHODOLOGY

Methodology:

Part A:

- A retrospective descriptive, data collection was approved by hospital administration to make - -

statistical analysis about percentage of PU occurrence in intensive care departments in Dar al

Amal hospital in 2014. (Data included in Appendix A).

- Characteristic of Data Collection: data were abstracted from the hospital’s existing

computerized documentation systems of sheet of PU indicator, included the following study

variables: pressure ulcer, Norton scale, age, length of ICU stay, risk factors. Demographic data

and patient characteristics included sex and admitting diagnosis, PU stages, and sites of PU.

- Criteria of inclusion: patients who had risks for developing PU (complete bed rests patients,

diseases that affect blood flow, CVA cases, respiratory cases and patients of long period

hospitalizations).

- Criteria of exclusion: Patients who had PU at time of admissions to ICU, diabetic patients.

The prevalence of PU indicator in ICU was calculated according to the following formula:

Prevalence = 100 * total PU in ICU / (Number of CBR patients)

Description of the sample:

Number of CBR patients= 515 by reviewing the medical files, Norton scale and statistical

data of ICU department

o In-ICU PU = 41 had bed sore

Tools:

– Computerized data: PU Indicator of 2013 -2014

– Cause and Effect analysis (fishbone) to analyze major causes of PU occurrence.

01

Figure 3: Fishbone analyse major causes of pressure ulcer occurrence in ICU

Part B:

- A prospective study, through analysis of knowledge assessment questionnaire, conducted

among 42 ICU Nurses (included in Appendix B).

Criteria of inclusion: All ICU nurses.

Criteria for exclusion: All nurses in nursing floors except ICU.

Data Analysis

Excel, version 2003 for windows, was used for data analysis. Descriptive statistics included

frequency distribution for study variables and demographic data.

00

DATA ANALYSIS AND RESULTS

Part A: Results of data collected as indicator by ICU department

From PU indicator data of 2014 collected by ICU department we have conclude the following

points:

o PU prevalence= 7.96%. We suggest this increasing by 1.4% in 2014 may be due to,

knowing that this rate was 5.59% in 2013 while in 2014 it becomes 7.96%:

- increase admission of critical cases

- most of who developed PU had more than 2 risk factors on admission

- increase ICU bed number in 2014 more admission of critical patients

- New RN’s not well trained in PU care especially in skin assessment

o Graph 1: Females were more affected by bed sores due to their complicated cases at

admission.

o Graph 2: 19% of PU patients were less than 50 years due to Polytrauma & post

operative cases.

o Graph 3: Major diagnosis of aged patients was related to neurological & respiratory

problems.

Distribution of PU

related to Age4%

15%

81%

<25 years

25-50 years

>50 years

Graph 1 Graph2 Graph 3

02

o Graph 4: The highest prevalence of PU: grade 1(48.7%), grade 2 (39%), grade 3(12%)

and grade 4 (2.3%).

o Graph 5: Most of ICU patients who developed PU in 2014 had the following risk

factors:

- Age > 60 years (92%),

- CBR (87%),

- Mmalnutrition (78%)

- Dehydration (60%)

- Most patients had more than 1 risk factor to develop PU.

Graph 4 Graph 5

o Graph 6: The most common site that developed PU in ICU was sacrum (56%) and then

heels (24.4%).

o Graph 7: 65.8% from patients who developed PU had long period of hospitalization

(more than 20 days), and 29.2% had period between 10-20 days, and 5% had less than 10

days of hospitalization. We conclude that PU was increased as hospitalization period

increased.

Graph 6 Graph 7

03

Part B: Statistical analyses of questionnaire that analysis the knowledge of nurses

According to employees’ opinions:

o Graph 8: 98% of nurses agreed the availability of equipment used for pressure ulcer in

ICU department (mattress, dressing types, creams, ointments). In fact, hospital insure all

nursing care unit all preventive measures to prevent PU occurrence since the

establishment of hospital.

o Graph 9: shows causes that prevent nurse from PU care, in which the lack of experience

(55%) was the highest percentage, then the negligence (28%) and insufficient time

(15%). From these data effort should be done to increase knowledge of the employees,

and to manage negligence by motivating the employees.

o 55% of nurses answered that PU occurrence due to lack of experience. Otherwise 30% of

nurses are interested in evidence base practice to increase their knowledge.

Graph 8 Graph 9

Education of patient family upon discharge

Graph10: reflects the poor involvement of nurses in giving

proper instructions to home. 55% from nurses educate

patients and family about PU upon discharge while 45%

from nurses don’t involve them. Education of patient

family is one of the most important steps for treatment at

home and how to deal with bed sore. It’s important to

involve patients and family in treatment plan. Graph 10

04

CONCLUSION

It is known that pressure ulcer prevalence is higher in intensive care patients than in other health

care settings and this supports the hypothesis that pressure ulcer is higher in intensive care

patients. The most common sites in intensive care patients are the sacrum and the heel.

It is crucial to select appropriate and applicable preventive measures (nursing care and materials

or devices); furthermore, the factors that are significantly related to pressure ulcer, such as old

age and bowel incontinence should be considered for the prevention of further pressure ulcer

development.

Also the mal practice of new employees due to lack of knowledge about management of PU will

affect negatively on patients status it lead to increase rate of morbidity and mortality and this

effect on the quality hospital. Not only PU cost the patient, cause pain, loss of self esteem and

altered body image but also PU cost the hospitals by increase length of stay, increase use of

resources and increased use of nursing time.

The incidence of PU is likely to increase if hospitals and employees put their effort to manage it.

The best method of addressing PU in the intensive care setting is thorough institution of

preventive measures that target patients at greatest risk. The preventive measures should remain

the primary goal, early recognition and treatment of PU is imperative. Raising awareness of

preventive and treatment strategies among nurses and other health care professionals is

recommended. Also the managers have an opportunity to motivate employees by providing a

climate that encourages growth and productivity.

05

RECOMMENDATIONS AND FUTURE WORK

We recommend the following solutions in order to decrease PU rate, increase employee’s

knowledge and maintain high standards of care:

Specify “PU – team” to round twice a week on :

the most vulnerable patients

bedside education provided on skin assessment

staging definitions and prevention techniques to avoid PU

Improve communication between staff and PU team (pre-shift huddles)

All ICU employees should take precautions and do risk assessment to prevent bedsore

development

Taking preventive measures and corrective actions to reduce PU

Enhancing continuous education and training schedules for employees for better

performance

Efficacy of intervention for preventing the development of pressure ulcers, and

facilitating wound healing

Validity of tools used to assess patients at risk and pressure ulcer healing (oscillating

support surface for positioning)

Initiating of a multidisciplinary committee to set a plan of action to decrease PU

incidence.

Continuous follow up progress technologies as a technique called platelets rich fibrin

(PRF) that is generated from plasma of the patients that applied to PU site to promote

healing.

For future work we will focus on management of PU care upon and after discharge. We will

make study about availability of preventive equipments at home and we will involve family in

playing role in management of PU at home. In fact, family can be a good partner and support

patients and to improve quality of life of patient.

06

References

1. Cowart V.Pressure ulcers preventable, say many clinicians.JAMA 1987, 589-93.

2. Perdue RW, Wilson JL. Decubitus ulcers. J Am Board Fam Pract 1989; 2:43-8

3. Joane Aspiras Jovero,BSEd, BSN,RN, Hussam Al-Nusair , MSc Critical care ANP,RN.

4. Data collected from ICU departments including KPIs and statistics. (Dar Al Amal University

Hospital).

5. Pressure ulcers in the intensive care units: the forgotten enemy Evans JM, Andrews KL,

Chutka DS, et al: Pressure Ulcers prevention and management. Mayo Clin Pro 1995:70: 789-

799.

6. Berlowitz DR, Wilking SV. The short-term outcome of pressure sores. J Am Geriatr Soc

1990; 38:748-52.

7. C.Richard. Gibbs. MD, Differential Diagnosis of dermatology, chapter 7, 2005, p: 104.

8. Scienkiewiz size, E. Whitney & T. Wads won, Nutrition, concept & contra version, chapter 6

and 10. 2005, pp: 186-192

9. P. Angelton &H.Chalmers, Nursing Model and Nursing Practice, chapter 4 second editions,

2003, p: 120.

10. Data collected from ICU department as KPI,indicators,protocols,competency test, medical

files, register. Statistics 2013-2014

07

Appendices

Appendix A: Line list for pressure ulcer in ICU: Table (1)

Dep

.

To

tal P

ati

en

t

To

tal b

ed

so

re

Risk Factors Degree Site ICU

hospitalization

Bed Sore

Progression

CB

R

Deh

yd

rati

on

Maln

utr

itio

n

Ag

e >

60y

1st

2n

d

3rd

4th

Elb

ow

s

Bu

tto

cks

Sac

ral

Heels

Oth

ers

<10d

ays

10-2

0d

ays

>20d

ays

Heale

d

Un

heale

d

Wo

rsen

ICU 515 41 36 25 32 38 20 16 5 1 2 4 23 10 2 2 12 27 12 18 11

08

Appendix B: Knowledge assessment questionnaire

GATES – LEBANESE GERMAN

UNIVERSITY

Addressed to: ICU nurses

Aim: to assess the knowledge; attitudes and practices of pressure ulcer care of nurses at Dar Al

Amal University Hospital.

Prepared by: Fadia Chabchoul, Fattoum Awad and Alya Solh

This study is made just for scientific aim, its confidentiality is respected and the link to specific

individuals will not be disclosed to any other research personnel.

Thanks for help

09

eneral dataG

1. Age:

20-29

30-39

40 and above

2. Sex:

Male

Female

3. Status:

Single

Married

4. Educational level:

Master degree

BS

LT

TS

5. What is your job description?

HN

RN

N

6. What are the experience years in this hospital?

Less than 1 year

From 1-5 years

From 5-10 years

More than 10 years

7. What is your duty shift? Daily

Night

Both

Specific Data:

1. In your opinion do you have enough data and experience about management of pressure

ulcers? Yes

No

2. in your opinion, what are the main factors related to Pressure ulcer occurrence in your

department? You can Chose 3 answers as maximum. Factors related to patient: complicated cases

Mal nutrition

Bad positioning

Unavailability of specific equipments for bedsore care and prevention as mattress….

21

Negligence of employees

Lack of knowledge of employee toward PU

Number of employees is not sufficient for ICU department

3. In your opinion, do you agree that the equipments used in ICU are sufficient for preventing

PU? Yes

No

4. In your opinion, do you offer good care to all patients suffer from bed sores? Yes

No

5. In your opinion, what are the causes that prevent nurse from caring of bed sore? Negligence

Lack of experience

No sufficient time for caring PU

6. Have you share with training about PU (Management and Care)? Yes

No

7. Have you make researches (up to date) on PU? Yes

No

8. Do you agree that the low number of employees is from factors that related to PU occurrence? Yes

No

9. What is number of nurses in every shift in your department? What is number of beds?

Nurses' number……………beds number…………….

10. Is there a specific policy to put actions that prevent PU occurrence? Yes

No

11. Is there a follow up plan by your head nurse toward prevention and management of PU? Yes

No

12. Does the employees punish if bed sore occurrence is due to negligence? Yes

No

13. If PU occurs, are there specific forms to evaluate bedsores? Yes

No

If yes, list the available forms:

---------------------------------------------------------------------------------------

20

14. Was competency test (pressure ulcer) done for you? Yes

No

15. Do you collect data and make statistics about PU occurrence in your department? Yes

No

16. Do you consider that PU cases occur in 2014 in your department is a result of? Community acquired

Hospital acquired

Unit acquired

17. Do you support the patients by suitable education about caring and preventing PU upon

discharge from hospital? Yes

No

18. Is there a specific team for PU in your hospital? Yes

No

19. Mention suggestions you have to manage PU in your department?

............................................................................................................................................................

............................................................................................................................................................

............................................................................................................................................................

....................................................................................

22

Appendix C: Pressure Ulcer- Risk Assessment

In order to determine which patients might be at increased risk of developing pressure, several

scales are used and the most frequently one is the Norton Scale. This scale was created in

England in 1962.

Physical

condition

Mental

condition

Activity

Mobility

Incontinence

4 4 Good

3 Fair

2 Poor

0 Very Bad

4 Alert

3 Apathetic

2 Confused

0 Stuporous

4 Ambulant

3 Walks with help

2 Chairbound

0 Bedfast

4 Full

3 Slightly

impaired

2 Very limited

0 Immobile

4 None

3 Occasional

2 Usually urinary

0 Urinary

&Faecal

Low Risk Greater than 18

Medium Risk Between 18 and 14

High Risk Between 14 and 10

Very High Risk Less than 10