Evidence_Based

ce to Inform Nursing Practice and patient values. Of particular interest to the author of this document is the use of constant low pressure mattresses (CLP) or alternate pressure (AP) and the need to ascertain whether these are more beneficial than standard foam mattresses; while also identifying the advantages & disadvantages of their use. Pressure sore prevention is an important element of care of critically ill patients. According to NICE (2005) an estimated 4-10% of patients admitted to acute wards develop a pressure ulcer. Pressure ulcers are a major cause of illness, reduced quality of life and morbidity. They are also associated with a 2-4 fold increase in risk of death in older people in intensive care and also have substantial financial costs. Cullum et al (2000) defines pressure sores as areas of localised damage to the The aim of this essay is to discuss a clinical issue identified on a placement and how it ties in with research, providing evidence that informs practice; otherwise known as evidence based practice. Sackett et al (1997) defines the former as the conscientious, explicit and judicious use of current best evidence in making decisions about the care of individual patients. As stipulated by the NMC (2008) and also the Caldicotte Report, confidentiality will be maintained throughout this document, thus there will be no mention of names of hospital, ward, staff or patients. The focus patient group of this essay will be adults admitted to medical wards, particularly within the complex care and high dependency units; who due to the nature of their illnesses are immobile or bed ridden. The patients in question are deemed to be at greater risk of developing pressure or bed sores, also termed pressure or decubitus ulcers. Hence the need to utilise interventions that prevent/reduce the risk of damage to the skin, as well as allow skin that is already damaged/broken to heal speedily. In that regard evidence based practice is thus an important aspect to nursing or health care. Evidence-based practice is defined as the integration of best systematic research evidence with clinical expertise skin and underlying tissue, attributed to pressure, shear or friction. The base of the spine, hips and heels are bony prominences of the body which are more prone to developing pressure sores. There was a wide usage of a variety of pressure relieving beds/mattresses in the care of those patients classed as high risk of developing pressure sores. Taking this into consideration there was overwhelming need to undertake an extensive study/review of the evidence in order to establish the benefits they bring to the clinical setting and in the care of patients. From a student perspective it was essential to understand and assess the effectiveness of using such interventions in contrast to the more conventional standard hospital mattresses. According to the NMC (2008) it is vital that safe, ethical and professional practice is adhered to at all times; in this regard it is important to reduce patients’ discomfort and that they are allowed to recuperate in a therapeutic environment. Ensuring that the right equipment is used for those patients most at risk and that patients health is not further compromised by the development of pressure sores, prompted the desire to gain more in-depth knowledge on pressure relieving beds/mattresses, to justify their continued usage and why they are an important aspect of everyday nursing care. McInnes et al (2010) state that the identification of people at high risk and the use of intervention strategies such as pressure relieving equipment, are measures taken by health professionals to reduce the incidence of severe pressure ulcers. They add that such measures should be based on the best available clinical and cost effectiveness evidence. Are pressure relieving beds/mattresses more effective than standard foam mattresses in the prevention of pressure sores in critically ill adult patients' P- critically ill adult patients; I- pressure relieving mattresses; C- Standard foam mattresses; O- Prevention of pressure sores. Asking questions in PICO format results in an effective search that yields, he best, relevant information, and saves an inordinate amount of time, (Melnyk & Fineout-Overholt 2002). The PICO format has been used to break down the question into key words to aid the process of searching for evidence. This framework was invented by Sacket et al (1997) as a way of making questions more focused. Craig and Smyth (2003) state that the PICO formula cannot always be simply applied but argue that it is however a useful tool. Perkins et al (1997) suggests that blind acceptance of technology skilfully marketed by company representatives or the absolute rejection of change to existing practices may have severe negative impact on patient outcome, resources as well as cost. Therefore a sense or attitude of research mindedness is must prevail, hence the need in this case to closely examine the efficacy of pressure relieving devices over standard mattresses in averting bedsores in acutely ill patients. Craig & Smyth (2003) assert that the success or failure of explicitly basing nursing practice on best evidence, hinges on nurses being able to question both new and established nursing interventions in the care of patients. Nursing care interventions aimed at the prevention, assessment and treatment of pressure ulcers should therefore be based on research or evidence-based practice (Potter & Perry, 2004) The search strategy sought to find existing and new relevant research/evidence material. As the search was done in and concerned with the UK practice, it has been done in the English language and will focus on content published between the years 2000 to 2010. A comprehensive search was conducted of databases such as CINAHL, MEDLINE, Inter Nurse, NHS Evidence and The Cochrane Library, etc. The initial search was focused on CINAHL where key words from the question were used to find information applicable to the question. Keywords used included the terms pressure sores, pressure relieving devices, critically ill patients; the searches were also refined by date to make them more relevant by looking at research/evidence from last 10 years, i.e. 2000 to present. Search modes also included the use of smart text and bolean phrases. The rationale for refreshing and refining the search hits was to narrow down the results to specific keywords and therefore address the question. MEDLINE database was also searched first on its own and again in combination with CINAHL. A number of web based resources and journals were also utilised in the compilation of evidence on the subject in question. Books have also played a vital role in informing the research into available evidence; providing information on pressure sores, nursing interventions and evidence based practice. Face to face interaction with patients and clinicians during placement has also contributed to this process. Patients who expressed their views did so during the administration of their care and were not approached outside of this time. Some patients reported that there was no worsening of skin damage once they were transferred onto pressure relieving beds. Other reports were the discomfort patients on initial use of pressure relieving equipment; patients stated they “do take some getting used to” but reported that once they put their body weight on the beds, their weight was absorbed and distributed evenly, thereby reducing discomfort or onset of pressure ulcers. There were clearly some positive and negative aspects on the use of pressure relieving equipment. A handful of patients reported it took long to get equipment in place, while they continued to experience excruciating pain and discomfort. Clinician views were first hand information obtained from nurses while caring for patients during placement period of author of this document. Ward nurses and tissue viability nurses directly involved in patient care strongly believed the use of pressure relieving equipment greatly increased the quality of care patients receive, and offset emotional and physical pain caused by suffering from pressure sores. Voss (2000) states that an estimated 60 000 people die annually, from complications associated with pressure sores. Nursing care interventions aimed at the prevention, assessment and treatment of pressure ulcers should be based on research or evidence-based practice (Potter & Perry, 2004). Another writer, Bryan-Brown (2006) agrees by stating research shows that patients' outcomes are at least 28% better when clinical care is based on evidence rather than tradition or common sense. According to McInnes et al (2008) there are several studies conducted to examine the effectiveness of pressure ulcer prevention strategies. Cullum et al (2000) carried out a systematic review of randomised controlled trials (otherwise known as RCTs) to test the effectiveness of special beds & mattresses in the prevention and treatment of pressure sores; this done in comparison to the standard foam hospital mattresses. This has been done as an integrative research review. Standard foam hospital mattresses were compared to other low technology/pressure mattresses. In high risk patients the standard foam mattresses were out performed by the softform mattress and also a water filled-mattress. Cullum et al (2000) alleges that people with hip fractures were three times more prone to developing pressure sores on standard foam mattresses than they did on special foam surfaces. They do state however, in their study/review, that there is variation in what is known as a standard foam mattress. Comparisons of alternate pressure devices and others give more blended results and that there is hardly any difference; they reduced the incidence when compared standard foam mattresses but were found to have lower levels of pressure when compared to constant low pressure ones. Another review by Ohlsson (2005) contrasted standard foam and low pressure mattresses and the main outcome was a reduction in the incidence of pressure sores. The foam mattress and the gel mattress both appeared not to have any adequate effect/impact on reducing pressure sores. Other forms of special foam mattresses appeared to have the desired outcome of reducing pressure sores. Cullum et al (2000) does suggest that there is limited evidence that low air loss beds reduce the prevalence of pressure sores in intensive care units. This is a significant as during placement, the author of this essay observed patients in high dependency unit being cared for on these types of mattresses. There is however good evidence that air-fluidised and low air loss beds improve healing rates. It is clear that standard foam mattresses are probably the least effective in the prevention of pressure sores. Cullum et al (2000) also notes that it is impossible to determine which surface/type of mattress is the most effective in preventing or treating pressure sores. Bergstrom (2000) like the other authors collated information from randomised controlled trials (RCTs) through searching a host of databases and informs that methodology was relatively poor due to small sample sizes. There is acknowledgement however, that products designed to prevent or cure pressure sores are generally more effective than standard mattresses. Most of the research evidence concurs and identifies Comfortex DeCube mattress, Beaufort Bead bed, Softform mattress and a water filled mattress were better than standard foam mattresses in the care of high risk patients; Clinifloat, Therarest, Transfoam and Vaperm mattresses were better in the incidence of pressure sores for all patients, over standard foam mattresses. Most studies published did not find a statistically significant difference as they tended to agree in many areas. There is evidence to suggest methodological flaws were common as the following were lacking or absent; blind or independently verified outcomes, allocation concealment, baseline comparability, high attrition rates and intention to treat analyisis. During the search for evidence most yielded results were on research evidence; there were no published results on patient reported evidence or clinician reported evidence. Hence evidence in this field can only be first hand person reports. There were no significant concerns from patients that would necessitate the questioning of continued use of pressure relieving equipment. A couple of patients raised concerns that the alternating pressure mattresses sometimes deflated on their own, but acknowledged that this could be isolated faults not common features in all these mattresses. Clinicians found that pressure relieving equipment ensured patients weren’t unnecessarily developing pressure sores and then having to stay in hospital for extended periods. Clinician reports suggested that patients are more comfortable than on standard foam mattresses and that those deemed to be at risk of pressure sores are properly cared for. For this particular essay search question it proved very difficult to find published or unpublished articles on patient and clinician reported evidence. Author will in future refine search question and research further on how to maximise search question in order to yield more results, which would be relevant and specific to subject of research. This process could also include liaising and discussing search strategies with peers and tutors. Bergstrom N. (2000). Review: Specially Designed Products to Prevent or Heal Pressure Sores. Evidenced Based Nursing. Apr; 3(2): 54 Bryan-Brown, C.W. 2006, Evidence-Based Practice is Wonderful. American Journal of Critical Care. Craig J.V. and Smyth R.L. (2003) The Evidence-Based Practice Manual For Nurses. London. Churchill Livingstone. Cullum N, Deeks J, Sheldon T.A, Song F and Fletcher AW. (2000) Beds, Mattresses and Cushions for Pressure Sore Prevention and Treatment. (Cochrane Review). The Cochrane Library. McInnes E, Cullum N.A, Bell-Syer S.E.M, Dumville J.C and Jammali-Blassi A. (2010). Support Surfaces for Pressure Ulcer Prevention. Cochrane Database of Systematic Reviews. Issue 4. Art. No.CD001735. Melnyk BZ and Fineout-Overholt (2002) Evidence Based Practice In Nursing and Healthcare: A Guide to Best Practice. Lippincott Williams & Wilkins. NICE (2005). www.nice.org.uk Pressure Ulcer Risk Assessment and Prevention. NMC (2008) Nursing and Midwifery Council. www.nmc.org.uk Ohlsson E. (2005) Intraoperative Pressure Sore Prevention: A literature Study Comparing Pressure Relieving Mattresses. Perkins ER, Simnet I and Wright L. (1999). Creative Tensions In Evidence Based Practice. In Perkins ER, Simnet I and Wright L (Eds). Evidence Based Health Promotion. New York. Wiley. Potter, P. and Perry, A. 2004. Fundamentals of Nursing. Mosby. Sackett D, Richardson WS, Rosenberg W, Haynes RB (1997). Evidence Based Medicine: How to Practice & Teach EBM. New York. Churchill Livingstone. Voss A. (2000) Pressure Ulcer Management: The Importance of Nutrition. MedSurg Nursing.