Pressure injury risk assessment and prescription of preventative interventions using a structured tool versus clinical judgement: An interrater agreement study.

AIM: To assess agreement of pressure injury risk level and differences in preventative intervention prescription between nurses using a structured risk assessment tool compared with clinical judgement. DESIGN: Interrater agreement study. METHODS: Data were collected from November 2019 to December 2022. Paired nurse-assessors were allocated randomly to independently assess pressure injury risk using a structured tool (incorporating the Waterlow Score), or clinical judgement; then prescribe preventative interventions. Assessments were conducted on 150 acute patient participants in a general tertiary hospital. Agreement of risk level was analysed using absolute agreement proportions, weighted kappa and prevalence-adjusted and bias-adjusted kappa. RESULTS: Ninety-four nurse assessors participated. Absolute agreement of not-at-risk versus at-risk-any-level was substantial, but absolute agreement of risk-level was only fair. Clinical judgement assessors tended to underestimate risk. Where risk level was agreed, prescribed intervention frequencies were similar, although structured tool assessors prescribed more interventions mandated by standard care, while clinical judgement assessors prescribed more additional/optional interventions. Structured tool assessors prescribed more interventions targeted at lower-risk patients, whereas assessors using clinical judgement prescribed more interventions targeted at higher-risk patients. CONCLUSION: There were clear differences in pressure injury risk-level assessment between nurses using the two methods, with important differences in intervention prescription frequencies found. Further research is required into the use of both structured tools and clinical judgement to assess pressure injury risk, with emphasis on the impact of risk assessments on subsequent preventative intervention implementation. IMPACT: The results of this study are important for clinical practice as they demonstrate the influence of using a structured pressure injury risk assessment tool compared to clinical judgement. Whilst further research is required into the use of both structured tools and clinical judgement to assess pressure injury risk and prescribe interventions, our findings do not support a change in practice that would exclude the use of a structured pressure injury risk assessment tool. REPORTING METHOD: This study adhered to the GRRAS reporting guideline. PATIENT/PUBLIC CONTRIBUTION: No patient or public involvement in this study. IMPLICATIONS FOR THE PROFESSION AND/OR PATIENT CARE: Educators and researchers can use the findings to guide teaching about pressure injury risk assessment and preventative intervention and to direct future studies. For clinical nurses and patients, a change in clinical practice that would exclude the use of a structured risk assessment tool is not recommended and further work is needed to validate the role of clinical judgement to assess risk and its impact on preventative intervention.

Assessment of pressure injury risk in intensive care using the COMHON index: An interrater reliability study.

OBJECTIVES: To assess the interrater reliability of the COMHON (level of COnciousness, Mobility, Haemodynamics, Oxygenation, Nutrition) Index pressure injury risk assessment tool. DESIGN: Interrater reliability was tested. Twenty-five intensive care patients were each assessed by five different nurse-raters from a pool of intensive care nurses who were available on the days of assessment. In total, 25 nurses participated. SETTING: Two general and one cardiovascular surgery intensive care units in Istanbul, Turkey. MAIN OUTCOME MEASURES: Interrater reliability was analysed using intraclass correlations, and standard errors of measurement (SEM) were calculated for sum scores, risk level and item scores. Minimally detectable change (MDC) was also calculated for sum score. Consistency between paired raters was analysed using Pearson's Product Moment Correlation (r) for sum score and Spearman's rho (rs) for ordinal variables. RESULTS: All assessments were completed in ≤5 min. Interrater reliability was very high [ICC (1,1) = 0.998 (95 % CI 0.996 - 0.999)] with a SEM of 0.14 and MDC of 0.39. Consistency between paired raters was strong for sum and item scores and risk levels (coefficients >0.6). All scale items showed correlations of >.3 with the sum score. CONCLUSION: The results demonstrate near-perfect interrater reliability. Further research into the psychometric properties of the COMHON Index and its impact on preventative intervention use is warranted. IMPLICATIONS FOR CLINICAL PRACTICE: Pressure injury risk assessment within intensive care should be setting-specific due to the unique risk factors inherent to the patient population, which are not considered by general pressure injury risk assessment tools. An intensive care-specific pressure injury risk assessment tool was tested and demonstrated high reliability between intensive care nurses. Further research is needed to understand how its use in practice affects preventative intervention implementation and, in turn, how it impacts pressure injury outcomes.

The impact of a structured assessment and decision tool (I-DECIDED®) on improving care of peripheral intravenous catheters: A multicenter, interrupted time-series study.

BACKGROUND: Peripheral intravenous catheters are the most widely used invasive device in hospitals but have serious risks. OBJECTIVE: To determine if a structured assessment and decision tool (I-DECIDED®) improves daily peripheral intravenous catheter assessment and care decisions. DESIGN: Prospective, interrupted time-series study. SETTINGS: Seven adult inpatient wards in three Australian hospitals. PARTICIPANTS: 825 adults with 867 peripheral intravenous catheters. METHODS: Between August 2017 and December 2018, peripheral intravenous catheter assessments and chart audits were undertaken with informed patient consent. Following a 4-month pre-intervention period (with 2-weekly measures), the I-DECIDED® tool was implemented over 3 months (no data collection) using multiple strategies (stakeholder meetings, vascular access device form, education sessions, ward champions, lanyard cards, and posters), followed by a 4-month post-intervention period (with 2-weekly measures). Primary outcomes were device utilization (number of peripheral intravenous catheters per total number of patients screened); idle/unused catheters; insertion site complications, substandard dressing quality; and primary bloodstream infections. RESULTS: Of 2055 patients screened, 1175 (57.2%) had a peripheral intravenous catheter, and 825 patients (867 catheters) consented and were included in the final analysis. Device utilization increased from 42.0% of catheters at baseline to 49.6% post-intervention (absolute risk difference [ARD] 7.5%, 95% confidence interval [CI] 4.8, 10.3; relative risk [RR] 1.18, 95% CI 1.11, 1.25; p < 0.001). The proportion of idle catheters reduced from 12.7% to 8.3% (ARD -4.4%, 95% CI -8.5, -0.3; RR 0.66, 95% CI 0.44, 0.97; p = 0.035). Peripheral intravenous catheter complications reduced from 16.1% to 10.9% (ARD -5.2%, 95% CI -9.7, -0.6; RR 0.68, 95% CI 0.48, 0.96; p = 0.026). Substandard dressings reduced from 24.6% to 19.5% (ARD -5.2%, 95% CI -10.7, 0.4; RR 0.79, 95% CI 0.61, 1.02; p = 0.067). Only one primary bloodstream infection occurred (post-intervention). CONCLUSIONS: Implementation of a comprehensive device assessment and decision tool (I-DECIDED®) reduced idle catheters and catheter complications, despite higher device utilization. Dressing quality improved but was not statistically significant. Further implementation of the tool could improve hospital safety for patients with an intravenous catheter. ANZCTR TRIAL REGISTRATION: ACTRN12617000067370. Date of registration 13 January 2017. Date of first data collection 3rd August 2017. TWEETABLE ABSTRACT: #IDECIDEDassessment reduces prevalence of idle peripheral catheters and device complications.

Comparison of pressure injury risk assessment outcomes using a structured assessment tool versus clinical judgement: A systematic review.

BACKGROUND: Whilst performing a pressure injury risk assessment is not in itself preventive, risk status identification is critical to inform the judicious implementation of prevention strategies. Risk assessment is mostly undertaken using a structured tool informed by clinical judgement, though there is a perception that use of clinical judgement alone may be sufficient. OBJECTIVES: Within acute hospital settings, to identify differences in outcomes (risk status, preventive interventions) following nursing assessment of pressure injury risk when using a structured assessment tool compared to clinical judgement. DESIGN: Systematic review. DATA SOURCES: EBSCO CINAHL Complete, EBSCO MEDLINE Complete, Scopus, Web of Science, Ovid EMBASE. METHODS: Primary research relevant to the objectives was eligible for inclusion. Databases were searched in February 2021 (limits: date 2010-2020, English language, adults). Two reviewers undertook the review process, with a third as arbitrator. Appraisal was undertaken using Joanna Briggs Institute critical appraisal tools. Included studies are synthesised narratively. Reporting is in accordance with the PRISMA Statement. RESULTS: Five moderate to high-quality studies were included. Synthesis was limited by heterogeneity. Several risk assessment tools and methods of clinical judgement were used. Three studies reported pressure injury risk status using both assessment approaches, but in only one did nurses undertake both. Risk status, as identified by each method, varied and was sometimes contradictory. Three studies reported some elements of preventive intervention prescription and/or implementation following risk assessment, but comparison between approaches was limited. CONCLUSIONS: Some research suggests that risk status varies across different methods of pressure injury risk assessment, but it is unclear what impact this has on preventive intervention use. Risk status was not well linked to preventive interventions. Research is warranted to examine the influence that each approach to risk assessment alone and combined has on identified risk and preventive intervention prescription and implementation. REGISTRATION: A protocol was prospectively registered with PROSPERO (CRD42021224747).

Translation and piloting of the Chinese Mandarin version of an intensive care-specific pressure injury risk assessment tool (the COMHON Index).

Objective: To translate an intensive care-specific pressure injury risk assessment tool (the COMHON Index) from English into Chinese Mandarin. Methods: A four-step approach to instrument translation was utilised: 1) English-Mandarin forward-translation by three independent bilinguists; 2) Mandarin-English back-translation by two other independent bilinguists; 3) comparison of forward and back-translations, identification of discrepancies, with required amendments returned to step one; and 4) piloting of the translated instrument. The pilot study was undertaken in a Chinese surgical intensive care unit with a convenience sample of 20 nurses. A five-point ordinal scale (1 = very difficult; 5 = very easy) was used to assess ease-of-use and understanding. Translations were retained where medians ≥ 4 indicated use and understanding was easy to very easy. Results: Five iterations of steps 1 to 3, and two sets of amendments to the original English instrument, were required to achieve translation consensus prior to pilot testing. Subscale scoring, sum scoring, and risk categorisation were documented in most pilot assessments (≥ 80%), but three sum scores were incorrectly tallied. The overall tool and all subscales were easy to use and understand (medians ≥ 4), and most assessments (16/20, 80%) took ≤ 5 min to complete. Thus, translations were retained, with minor amendments made to instrument instructions for scoring and risk categorisation. Conclusions: An easy-to-use Chinese Mandarin intensive care-specific pressure injury risk assessment tool has been introduced through cross-cultural translation. However, it requires further testing of interrater reliability and agreement. A rigorous translation and reporting exemplar is presented that provides guidance for future translations.

The Fifth International Survey of Critical Care Nursing Organizations: Implications for Policy.

PURPOSE: To examine the activities, concerns, and expectations of critical care nurses and professional critical care nursing organizations worldwide. DESIGN: A descriptive survey methodology was used. This study is the fifth worldwide quadrennial review of its type to monitor variations in critical care nursing needs and provide robust evidence to inform policy related to critical care nursing practice. METHODS: The fifth World Federation of Critical Care Nurses international survey of critical care nursing organizations was emailed to potential participants from countries with critical care nursing organizations or known critical care nurse leaders. Data were collected online. Responses were entered into SPSS version 23 software (IBM Corp., Armonk, NY, USA) and analyzed by geographical region and national wealth group. FINDINGS: Eighty-two national representative respondents participated in the survey, of whom two thirds (n = 56, 68%) had an established critical care nursing organization in their country. The five most important issues identified were working conditions, teamwork, staffing levels, the need for formal practice guidelines and competencies, and wages. The top five critical care nursing organization services that were considered to be of most importance were professional representation, as well as provision of workshops and education forums, national conferences, practice standards and guidelines, and local conferences. The most important contributions expected from the World Federation of Critical Care Nurses were standards for clinical practice and professional practice, international conferences, professional representation, and study and education grants. CONCLUSIONS: The results highlight priority areas for critical care nursing and reinforce the need to address factors that can inform critical care nursing policy and practice. Results of this survey should be incorporated into strategic action plans at the national and international levels. CLINICAL RELEVANCE: Nursing leaders, policymakers, and other interested stakeholders should consider these findings when planning critical care workforce requirements. Interested parties should work collaboratively to inform recommendations for further policy and action.

The relationship between pressure ulcer risk assessment and preventative interventions: a systematic review.

OBJECTIVE: Hospital-acquired pressure ulcers (PU) continue to occur despite an ongoing focus on prevention. The aim of this review was to identify and evaluate primary research which links pressure ulcer risk assessment with prescription and implementation of preventative interventions for hospitalised adults. METHOD: A systematic review of the databases EBSCO CINAHL Complete, EBSCO MEDLINE Complete, Scopus and Web of Science was undertaken, using search terms related to pressure ulcers, hospital-acquired, risk, planning, implementation, prevention and outcome. Primary research reports that linked PU risk assessment with prescription and implementation of preventative interventions in some way were included. RESULTS: From 589 potentially eligible publications, 20 primary research reports were included. Of these, seven linked PU risk assessment to preventative intervention implementation and 13 linked it to preventative intervention prescription and implementation in some way. No studies linked PU risk assessment to preventative intervention prescription alone. CONCLUSION: While the included studies linked these components in some way, there was little focus on the relationship between the three. PU preventative intervention prescription is not well defined, with inconsistencies noted in intervention prescription across studies. Many studies reported inadequate provision of prevention measures for patients at risk of PU. Further research is required to explore the relationship between PU risk assessment and preventative intervention prescription alone, and with implementation.

Effectiveness of programs to promote cardiovascular health of Indigenous Australians: a systematic review.

BACKGROUND: Indigenous Australians carry a greater burden of cardiovascular disease than other Australians. A variety of programs has been implemented with the broad aim of improving Indigenous cardiovascular health, however, relatively few have been evaluated rigorously. In terms of effectiveness, understanding how to best manage cardiovascular disease among this population is an important priority. The review aimed to examine the evidence relating to the effectiveness of cardiovascular programs for Indigenous Australians. METHODS: PubMed, CINAHL, PsycINFO, Scopus and Web of Science databases were systematically searched for relevant studies, limited to those published in English between 2008 and 2017. All studies that used experimental designs and reported interventions or programs explicitly aimed at improving Indigenous cardiovascular health were considered for inclusion. Methodological quality of included studies was appraised using design-specific Joanna Briggs Institute critical appraisal checklists. Data were extracted using the Joanna Briggs Institute data extraction form and synthesised narratively. RESULTS: Eight studies met the inclusion criteria and were assessed to be of varying methodological quality. Common features of effectiveness of programs were integration of programs within existing services, provision of culturally appropriate delivery models with a central role for Indigenous health workers, and provision of support processes for communities such as transportation. It was noted however, that the programs modelled the interventions based on mainstream views and lacked strategies that integrated traditional knowledge and delivery of health care. CONCLUSIONS: Very few cardiovascular healthcare programs designed specifically for Indigenous Australians, which had undergone rigorous study, were identified. Whilst the majority of included articles were assessed to be of satisfactory methodological quality, the nature of interventions was diverse, and they were implemented in a variety of healthcare settings. The limited evidence available demonstrated that interventions targeted at Indigenous cardiovascular health and related risk factors can be effective. The results indicate that there are opportunities to improve cardiovascular health of Indigenous people at all stages of the disease continuum. There is a need for further research into evidence-based interventions that are sensitive to Indigenous culture and needs. TRIAL REGISTRATION: Registered with PROSPERO International: CRD2016046688.

Prescription of pressure injury preventative interventions following risk assessment: An exploratory, descriptive study.

This exploratory, descriptive study aimed to identify and describe the pressure injury preventative interventions prescribed by nurses following the assessment of a patient's pressure injury risk and to compare the prescribed interventions relative to the assessed risk level. A total of 200 inpatients in a tertiary Australian hospital were included. Patients' charts were audited within 24 hours of admission. Data collected included patient characteristics, pressure injury risk assessment score and level, and preventative interventions prescribed. Most patients were assessed as not being at risk, with the largest group of at-risk patients assessed as being at high risk. Some not-at-risk patients were prescribed interventions intended for those at risk, while prescription rates of preventative interventions recommended for those at any level of risk were variable (6%-64%). Significant associations were found between assessed pressure injury risk and preventative intervention prescription. Preventative intervention prescription was inadequate, potentially exposing some patients to pressure injury. However, the association between intervention prescription and risk level suggests that nurses are prescribing interventions relative to risk. A more structured approach to intervention prescription according to risk level, such as a care bundle, may help to improve nurses' preventative intervention prescription and ensure that all at-risk patients receive appropriate preventative interventions.

Implementation and evaluation of a 'Navigator' role to improve emergency department throughput.

BACKGROUND: Emergency department overcrowding impacts patients, staff, and quality of care, and there is government pressure to optimize throughput and reduce waiting times. One solution for improving patient flow is the emerging 'navigator' role: a nurse that supports staff in care delivery; facilitating efficient and timely patient movement through the emergency department. METHODS: A 20-week project was implemented to evaluate an emergency department nurse navigator role. A controlled trial was used. The navigator worked on a week-on-week-off basis, eight hours per day, seven days per week. Time-based and cost-associated outcomes were compared. RESULTS: Data from nearly 20,000 presentations during the trial period were analysed. All outcomes were improved during the ten weeks the Navigator was working. A slight improvement in National Emergency Access Target compliance was shown, with an average of 4.5min per presentation saved. The labour cost associated with the time saved was estimated to be $170,000. CONCLUSIONS: The results from this study indicate that for a relatively small investment, complementary nursing roles such as the navigator can impact emergency department patient flow. However, further studies are required to determine optimisation of the role. RELEVANCE TO PRACTICE: This study provides rigorous evidence of the effects of a nurse navigator role on emergency department throughput. Whilst positive outcomes were demonstrated, suggesting a whole-of-system benefit, the magnitude of effect on a per-presentation basis was relatively small. Further studies are required to demonstrate the clinical relevance of such roles.

Pressure injury risk assessment in intensive care: comparison of inter-rater reliability of the COMHON (Conscious level, Mobility, Haemodynamics, Oxygenation, Nutrition) Index with three scales.

AIM: To test the psychometric properties of the COMHON (Conscious level, Mobility, Haemodynamics, Oxygenation, Nutrition) Index. BACKGROUND: Pressure injury risk assessment is a crucial aspect in determining the relative risk of patients and the need for preventative intervention. In the intensive care setting there are few risk assessment scales that have been developed specifically for critically ill patients. DESIGN: Instrument development. METHODS: A convenience sample of 26 intensive care patients was used. Data were collected in December 2012. Five intensive care nurses scored each patient with all four scales. Intraclass correlation coefficients and standard errors of measurement were used to assess inter-rater reliability and agreement of the sum, risk category and item scores. Convergent validity of the COMHON Index was investigated by examining correlations between the sum scores and similar constructs of the scales. RESULTS: Inter-rater reliability of the COMHON Index was higher than the other scales and strong correlations were found between it and the Braden and Norton scales but not the Waterlow score. Two items common to all scales (mobility; neurological status) demonstrated significant correlations between the COMHON, Braden and Norton scales but not the Waterlow score. One item (nutrition) was significantly correlated between the COMHON and Braden scales. CONCLUSION: Inter-rater reliability and agreement of the COMHON Index were the highest of the four scales, with the Norton and Braden performing similarly and the Waterlow score the least well. The strong and significant associations between the Braden, COMHON and Norton scales suggest they are measuring similar constructs.

Sleep assessment of hospitalised patients: a literature review.

BACKGROUND: Sleep is a dynamic and essential part of human life and health. In healthcare settings, nurses are strategically placed to promote sleep and sleep health. In this regard, nursing actions should be based upon effective methods of assessment of patient sleep. Standardised sleep assessment does not currently occur in the care of acute hospitalised patients. Use of an appropriate measurement tool would help evaluate inpatient sleep. An effective, efficient sleep assessment tool is needed to aid clinicians. Such assessment would enable specific nursing intervention to be tailored to individual patients. OBJECTIVE: The objective of this paper was to examine the literature on sleep measurement to identify subjective sleep assessment tools that may be suitable for routine use with hospitalised patients, and to evaluate their reliability and validity. METHOD: A review of existing literature was undertaken to identify and evaluate subjective sleep measurement tools. RESULTS: The initial literature searches identified 402 articles, of which ten met the criteria for review. These reported on three subjective sleep measurement scales: the Richards-Campbell Sleep Questionnaire; the St Mary's Hospital Sleep Questionnaire; and the Verran Snyder-Halpern Sleep Scale. The Richards-Campbell Sleep Questionnaire is brief and easy to use. In specific samples, its items correlate with domains reflecting sleep quality and has shown excellent internal consistency. Equivocal results and scoring challenges were found with the St Mary's Hospital Sleep Questionnaire. The Verran Snyder-Halpern Sleep Scale captured sleep disturbance and total sleep time, but time-to-complete is more burdensome than the Richards-Campbell Sleep Questionnaire. CONCLUSIONS: The current use of sleep assessment instruments in the acute hospital setting is restricted mainly to research activities. Of the three tools identified that could be used clinically to measure inpatient sleep, and although it was developed for use in the intensive care setting, the Richards-Campbell Sleep Questionnaire held greatest potential due to its ease and rapidity of use. However, it has yet to be validated for use with general hospital inpatients, and further research is required in this area.

Education for outreach: development of an interprofessional MSc in critical care.

This article describes the development of a new multi-professional Master's degree programme, which is aimed at supporting the education of practitioners in meeting the needs of Level 1 critically ill patients. The main drivers that influenced its development were Comprehensive Critical Care (Department of Health, 2000a) and the National Health Service Modernisation Agency for Critical Care. The programme was aimed primarily at junior doctors, senior ward nurses, senior physiotherapists and members of Outreach teams. The programme was designed to maximize work-based learning and is framed around two clinically focused units. The programme is informed by principles of quality improvement and aims to prepare practitioners to meet the needs of Level 1 patients 'at the point of need'.

Advancing the clinical perspective: a practice development project to develop the nurse practitioner role in an acute hospital trust.

AIMS: The aims of this project were to investigate awareness and foster understanding of the concept of the nurse practitioner and to facilitate and support the development of nurse practitioner roles within an acute hospital trust. BACKGROUND: A limited understanding of and minimal support for the development of the nurse practitioner (NP) role were identified within an acute hospital trust in the south of England. This was the impetus for pursuing the project outlined in this paper. THEORETICAL PERSPECTIVE: The project used practice development theory synonymously with action research methodology comprising of four action research cycles. METHOD: Data were collected in a variety of ways within the four overlapping cycles using formal and informal methods, which were analysed concurrently during the project. Techniques included questionnaires, semi-structured interviews, meetings, discussions and the project leader's field notes' diary. OUTCOMES: A better understanding of the concept and support for NP posts were enhanced across the trust. A Nurse Practitioner Development Group (NPDG) was established, which helped to facilitate the development of NP posts. An example of such a post was established within a NP-led gynaecology pre-operative assessment clinic, which was a pilot project and constituted Action Research cycle 3. CONCLUSION: It is concluded that the development of NP roles, with the support of a NPDG, within an agreed strategy offers a robust process for NP development within an acute hospital setting. RELEVANCE TO CLINICAL PRACTICE: This project demonstrated how practice development and action research might be used together as a systematic process for developing and supporting professional roles that aim to improve the quality of patient care and the effectiveness of health care services.