Evidence Based Project


Evidence Based Project: Pressure Ulcers in Home Care Setting
Brittany Sovran
Rochester College

The management of pressure ulcers can present a challenge to health care providers. Pressure ulcers have a significant impact on one’s quality of life, can be an indicator of poor standards of care, and increase health care costs. Prevalence of pressure ulcer development in home care settings ranges from 8.7-20%, while the incidence is estimated to be between 17-29%. Home care nurses spend 50-75% of their visits on wound care management. Practicing prevention can improve patient outcomes and reduce costs. The objective of this paper is to answer the clinical question: is educating home healthcare nurses on the Pressure Ulcer Prediction, Prevention, and Treatment Pathway an effective tool in identifying potential ulcers, reducing the amount of ulcers, and facilitating proper treatment for existing ulcers? Results will be measured with the Pieper Zulkowski Pressure Ulcer Knowledge test that will measure home care nurse’s knowledge pre-intervention and compare it with post-intervention results.
Keywords: Pressure ulcers, pressure ulcer prevention strategies, treatment, home care setting, interventions, toolkit.

Evidence Based Project: Pressure Ulcers in Home Care Setting
A pressure ulcer is defined as 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 (Ellis, 2017). There is a gap in practice regarding pressure ulcer prediction, prevention, and treatment in the home care setting. Home care patients which refers to any patient residing in their home whether it be long-term care facilities, hospice, or their personal homes are at risk. The burden of pressure ulcers in the home care setting is enormous and can hold detrimental effects to the patient, caregiver, and overall health care system. There is a 60-90% chance that those over the age of 65 will develop pressure ulcers, and it costs anywhere from $500-$40,000 to heal each ulcer (Berrguist, 2011). For the patient pain and discomfort from pressure ulcers can prolong illness, decreased mobility, cause social isolation, and even contribute to disability and death (Sullivan & Schoelles, 2013). For home health care nurses, it is estimated that they spend about 50-75% of their time during visits performing wound care (Berrguist, 2011). Practicing prevention of pressure ulcers can reduce costs, and improve patient outcomes. Education regarding pressure ulcers for home health care nurses is crucial in order to properly identify, prevent, and treat. This paper will explore an educational intervention that educates home care nurses on how to predict pressure ulcers, reduce the amount of ulcers, and treat existing ulcers.
Literature Review
Databases used to conduct the literature search are AHRQ, CINAHL, and Pubmed. Full article texts published between the years 2008-2018 were searched using the keywords: Pressure ulcers, pressure ulcer prevention strategies, treatment, home care setting, interventions, and toolkit. Twelve articles were reviewed and five pertinent articles were chosen. Reddy & Rochon (2008), created a Pressure Ulcer Prediction, Prevention, and Treatment Pathway that assists staff in determining the appropriate care for an individual resident. This primary source aids in critical thinking skills to ensure all areas of concern are met. The tool is in form of a flow chart for easy and accessible use. It addresses potential risk factors and solutions to prevent the risk factors from becoming an problem.
Berrguist (2011) identified that guidelines for pressure ulcers were well-established in acute care settings, yet lacked in the home care setting. The purpose of this primary source was to decipher the differences between hospital and home care guidelines and ways to incorporate interventions into a home care setting. This study collaborated with nine home wound care nurses and through a teleconferenced 75 minute focus group discussed obstacles in home care that are not present in the hospital setting. Some of these obstacles include lack of medical staff for second opinions on wound management, lack of educational caregiver resources, and lack of involvement with community resources to attain supplies (Berrguist, 2011). This study signifies pressure ulcer prevention and treatment is more complex in home care setting than in hospitals and proper education is needed in order to collaborate and achieve success.
Kwong, Pang, Aboo, & Law (2009), assessed pressure ulcer incidence and factors among older age nursing home residents. Their primary study included 346 nursing residents spread across four nursing homes. Each week for four weeks they assessed their skin condition, and they also assessed the nurse’s and nursing assistants knowledge regarding malnutrition, friction and shear force, and problems of pressure ulcers using a simple questionnaire. Results found that a pressure ulcer incidence was 25.6% at the end of the four weeks (Kwong et al., 2009). It showed that those residents living in the nursing homes where the nurses got 1 or more questions wrong on the questionnaire had a higher chance of developing pressure ulcers. The significance of this study proves that education is needed to minimize possible problems of malnutrition, and friction and shear in order to reduce pressure ulcers (Kwong et al., 2009).
Paquay, Wouters, Defloor, Butunix, Debaillie, ; Geys (2008), aims were to analyze adherence of guidelines by nurses to preventing pressure ulcers in the home care setting. The primary source used the Guideline for the Prevention of Pressure Ulcers as a standard to evaluate compliance. They found that out of 2279 random clients, 774 were at risk for developing pressure ulcers (Paquay et al., 2008). Out of those 774, only 33 received preventative measures from their nursing care. Thus, the study demonstrates that education is necessary to increase nurses adherence to guidelines for pressure ulcer prevention.
Ellis (2011), investigates the challenges of pressure ulcer prevention in the home care setting. He recognizes that proper assessment of the skin and of individual risk factors is mandatory. He also realizes that an individualized plan of care and consistent evaluations are needed for success. This primary source signifies that pressure ulcer prevention and treatment is achievable through proper education.
The Pieper-Zulkowski pressure ulcer knowledge test is a 47 item test that is used to assess nurses knowledge on pressure ulcer prevention and treatment. When administered to a random sample of 108 nurses, results displayed nurses with wound care certification scored remarkably higher than those who did not (Pieper ; Zulkowski, 2014). The full test includes information on staging, wound characteristics, risk factors, and treatments. The tool is an effective indication on whether more education is necessary in order to facilitate success.
Pressure ulcers are now considered an indicator of quality of care. For nurses it is their duty to ensure safety and protection of their patients. In home care this is especially important, as nurses are entering patient’s safe havens and they are entrusting them to provide for them. As the population ages, pressure ulcers continue to be a concern. Prevalence of pressure ulcer development in home care settings in the United States ranges from 8.7-20%, while the incidence is estimated to be between 17-29% (Berrguist, 2011). In addition, the health care system spends about $11 billion per year in preventing and treating pressure ulcers (Berrguist, 2011). Home care nurses also spend 50-75% of their visits on wound care management. Preventing and treating pressure ulcers in the home care setting can pose a challenge due to lack of proper education and compromised resources (Ellis, 2017). Lack of education can stem from nurse’s uncertainty in regards to the treatment plan, lack of communication between the patient and the provider, and nurses inability to properly educate patients and their caregivers. 53% of nurses also felt that they lacked on educating their patients because they had a lack of resources and time to do so (Ellis, 2017). These problems can be addressed by proper education and implement of tools that allows for limited time and easy access. Proper assessment parameters of the patient and individual risk factors will increase the ability to predict possible pressure ulcers. Delivering a plan of care tailored specifically for each patient allows the nurse to facilitate proper treatment and prevention (Ellis, 2017). With proper education, evidence-based interventions can be implemented to improve practice. When nurses practice evidence-based quality of care every time, health care costs will be reduced and positive patient outcomes will increase.
Recommendation and Dissemination
Registered nurses in the homecare environment will be educated on the Pressure Ulcer Prediction, Prevention, and Treatment pathway. This pathway will assist nurses in identifying potential ulcers through risk factor assessment, reducing the amount of ulcers through prevention methods, and facilitating proper treatment for existing ulcers. The independent variable that will be measured is nurse’s knowledge regarding these three factors-prediction, prevention, and treatment prior to the intervention. This pathway is a convenient, quick, and helpful way to ensure all three aspects of pressure ulcer care are met in the home care environment.
Using the Pieper-Zulkowski questionnaire nurse’s knowledge will also be measured after the intervention has been implemented. Prediction of pressure ulcers will be taught by using a specific flow chart that determines proper assessment methods based on whether the patient has a pressure ulcer or not. It goes further into detail by providing subgroups that the nurse should address and questions they should ask. Using the flowchart is a simple and suitable way to ensure assessment guidelines for predicting potential ulcers are achieved. The educational intervention highlights the acronym “TNT” or turning, nutrition, and toileting as the main aspects for prevention. Nurses will be held accountable for turning by using the safe turns EZ clock, learn about proper dietary guidelines, and the importance of a proper toileting routine. In regards to treatment, nurses will be educated to identify the specific type of pressure ulcers and the proper treatment. This questionnaire is 47 questions that assess nurses knowledge of assessment, risk factors, prevention methods, and treatment resources. This questionnaire is used to identify gaps in nurse’s knowledge and areas for improvement. By using this questionnaire and implementing the evidence-based pathway the goal is for nurses to increase knowledge post-intervention and reduce the overall amount of ulcers in the home care setting. For continuing education take home resources will be provided for those whom attended the presentation such as pamphlets, and flow charts. Yearly education with home health care agencies through interactive online modules with quizzes to test knowledge will also be implemented. Through team collaboration and the continuing education the intervention will be successful.
In order to reduce costs that stimulate from pressure ulcers and improve patient outcomes education is necessary. Emphasis is placed on predicting pressure ulcers based on individual risk factors, preventing them using proper prevention methods, and treating them using correct resources. Using the Pressure Ulcer Prediction, Prevention, and Treatment Pathway nurse’s will learn how to implement these interventions. The Pieper-Zulkowski knowledge test will test nurse’s knowledge in a pre-intervention setting then compare it to their knowledge post-intervention. The use of this pathway will increase nurses knowledge and successfully reduce amount of pressure ulcers in the home care setting.

Berrguist, D. (2011). Adapting Pressure Ulcer Prevention for Use in Home Health Care. Retrieved from https://www.nursingcenter.com/journalarticle?Article_ID=1141419&Journal_ID=448075&Issue_ID=1141289
Ellis, M. (2017). Pressure ulcer prevention in care home settings. Nursing Older People, 29(3), 29-37. doi:10.7748/nop.2017.e906
Kwong, E. W., Pang, S. M., Aboo, G. H., & Law, S. S. (2009, October 12). Pressure ulcer development in older residents in nursing homes: Influencing factors. Retrieved from https://onlinelibrary.wiley.com/doi/abs/10.1111/j.1365-2648.2009.05117.x
Paquay, L., Wouters, R., Defloor, T., Buntinx, F., Debaillie, R., & Geys, L. (2008, February 11). Adherence to pressure ulcer prevention guidelines in home care: A survey of current practice. Retrieved from https://onlinelibrary.wiley.com/doi/abs/10.1111/j.1365-2702.2007.02109.x
Pieper, B., & Zulkowski, K. (2014). The Pieper-Zulkowski Pressure Ulcer Knowledge Test. Advances in Skin & Wound Care, 27(9), 413-420. doi:10.1097/01.asw.0000453210.21330.00