A Clinical Nurse Specialist-Led Interprofessional Quality Improvement Project to Reduce Hospital-Acquired Pressure Ulcers.

PURPOSE: The purpose of this clinical nurse specialist-led interprofessional quality improvement project was to reduce hospital-acquired pressure ulcers (HAPUs) using evidence-based practice. BACKGROUND: Hospital-acquired pressure ulcers (PUs) have been linked to morbidity, poor quality of life, and increasing costs. Pressure ulcer prevention and management remain a challenge for interprofessional teams in acute care settings. RATIONALE: Hospital-acquired PU rate is a critical nursing quality indicator for healthcare organizations and ties directly with Mount Sinai Hospital's (MSH's) mission and vision, which mandates providing the highest quality care to patients and families. DESCRIPTION: This quality improvement project, guided by the Donabedian model, was based on the Registered Nurses' Association of Ontario Best Practice Guideline Risk Assessment & Prevention of Pressure Ulcers. A working group was established to promote evidence-based practice for PU prevention. Initiatives such as documentation standardization, development of staff education and patient and family educational resources, initiation of a hospital-wide inventory for support surfaces, and procurement of equipment were implemented to improve PU prevention and management across the organization. OUTCOME: An 80% decrease in HAPUs has been achieved since the implementation of best practices by the Best Practice Guideline Pressure Ulcer working group. CONCLUSION: The implementation of PU prevention strategies led to a reduction in HAPU rates. The working group will continue to work on building interprofessional awareness and collaboration in order to prevent HAPUs and promote an organizational culture that supports staff development, teamwork and communication. IMPLICATIONS: This quality improvement project is a successful example of an interprofessional clinical nurse specialist-led initiative that impacts patient/family and organization outcomes through the identification and implementation of evidence-based nursing practice.

Is Twice-Daily Skin Moisturizing More Effective Than Routine Care in the Prevention of Skin Tears in the Elderly Population?

BACKGROUND: Skin-moisturizing routines are part of a bundle of interventions designed to prevent skin tears. OBJECTIVE: This Evidence-Based Report Card reviews the effect of twice-daily moisturization of the skin on skin tear occurrence versus occurrence rates using routine skin care. SEARCH STRATEGY: The literature was systematically reviewed for studies that evaluated the use of standardized skin moisturizers on the rate of skin tears in the older adults (>60 years of age). A professional librarian performed the literature search, which yielded 446 articles. Following title and abstract reviews, we identified and retrieved 3 studies that met inclusion criteria. FINDINGS: Evidence concerning the effectiveness of routine twice-daily skin moisturizing reducing the rate of skin tears is mixed. Routine twice-daily skin moisturizing did not significantly result in a lower incidence of skin tears in long-term care residents compared to usual care in one study. However, the occurrence of skin tears per 1000 occupied beds was 50% lower when a moisturizer applied twice daily was compared to usual care. CONCLUSION: Routine skin moisturizing is recommended as one component of a prevention program for skin tears among aged adults residing in long-term care facilities.

Should WOC nurses measure health-related quality of life in patients undergoing intestinal ostomy surgery?

BACKGROUND: Ostomy surgery requires significant reconstruction of the gastrointestinal tract, resulting in uncontrolled passage of fecal effluent from a stoma in the abdominal wall. Concerns about creation of an ostomy often supersede all other concerns. Ostomy-related concerns include impaired body image; fear of incontinence; fear of odor; limitations affecting social, travel-related, and leisure activities; and impaired sexual function. Because the creation of an ostomy affects multiple domains within the construct of health-related quality of life (HRQOL), it is not surprising that quality of life is a frequent outcome measure in ostomy-related research. OBJECTIVES: We reviewed existing research in order to identify the influence of intestinal ostomy surgery on HRQOL. We sought to identify clinical evidence documenting the influence of nursing interventions on HRQOL in patients with an intestinal ostomy. In addition, we systematically reviewed the literature to evaluate the validity and reliability of condition-specific instruments for measuring HRQOL in this patient population. SEARCH STRATEGY: We completed an integrative review using the key terms "quality of life" and "ostomy" in order to identify sufficient evidence to determine the influence of intestinal ostomy surgery on HRQOL. A systematic review using the key terms "ostomy" and "nursing" was completed to identify the effect of specific nursing interventions on HRQOL in patients with intestinal ostomies. Only randomized clinical trials were included in this review. A systematic review using the key terms "quality of life" and "ostomy" was used to review and identify condition-specific HRQOL instruments and evidence of their validity and reliability. MEDLINE and CINAHL databases were used to address all 3 aims of this Evidence-Based Report Card. Searches were limited to studies published between 1980 and January 2009. Hand searches of the ancestry of studies and review articles were completed to identify additional studies. RESULTS: An integrative literature review revealed sufficient research to conclude that intestinal stoma surgery impairs HRQOL. Multiple factors, including the underlying reason for an ostomy, presence and severity of ostomy complications, presence and severity of comorbid conditions, sexual function, age, and ability to pay for ostomy supplies influence the magnitude of this effect. HRQOL tends to be most severely impaired during the immediate postoperative period. It usually improves most dramatically by the third postoperative month, and it continues to improve more gradually over the first postoperative year. A systematic review revealed 2 randomized clinical trials demonstrating that at least 2 nursing interventions improve HRQOL in persons with intestinal ostomies. A separate systematic review identified 4 instruments for measuring HRQOL in the research setting. IMPLICATIONS FOR PRACTICE: There is sufficient research-based evidence to conclude that intestinal ostomy surgery exerts a clinically relevant impact on HRQOL, and that nursing interventions can ameliorate this effect. While a small number of instruments exist, including several that have proved valid and reliable in the research setting, no instrument has yet been adapted for routine in the clinical setting.