Nurse-led Design and Development of an Expert System for Pressure Ulcer Management

The use of Clinical Practice Guidelines (CPGs) is known to enable better care outcomes by promoting a consistent way of treating patients. This paper describes a user-centered design approach involving nurses, to develop a prototype expert system for modelling CPGs for Pressure Ulcer management. The system was developed using Visirule, a software tool that uses a graphical approach to modeling knowledge. The system was evaluated by 5 staff nurses and compared nurses’ time and accuracy to assess a wound using CPGs accessed via the Intranet of an NHS Trust and the expert system. A post task qualitative evaluation revealed that nurses found the system useable with a systematic design, that it increased access to CPGs by reducing time and effort required by other usual methods of access, that it provided opportunities for learning due to its interactive nature, and that its recommendations were more actionable that those provided by usual static CPG documents

Nurse-led design and development of an expert system for pressure ulcer management

The use of Clinical Practice Guidelines (CPGs) is known to enable better care outcomes by promoting a consistent way of treating patients. This paper describes a user-centered design approach involving nurses, to develop a prototype expert system for modelling CPGs for Pressure Ulcer management. The system was developed using Visirule, a software tool that uses a graphical approach to modeling knowledge. The system was evaluated by 5 staff nurses and compared nurses’ time and accuracy to assess a wound using CPGs accessed via the Intranet of an NHS Trust and the expert system. A post task qualitative evaluation revealed that nurses found the system useable with a systematic design, that it increased access to CPGs by reducing time and effort required by other usual methods of access, that it provided opportunities for learning due to its interactive nature, and that its recommendations were more actionable that those provided by usual static CPG documents

Comparing alternating pressure mattresses and high-specification foam mattresses to prevent pressure ulcers in high-risk patients: the PRESSURE 2 RCT

Background: Pressure ulcers (PUs) are a burden to patients, carers and health-care providers. Specialist mattresses minimise the intensity and duration of pressure on vulnerable skin sites in at-risk patients. Primary objective: Time to developing a new PU of category ≥ 2 in patients using an alternating pressure mattress (APM) compared with a high-specification foam mattress (HSFM). Design: A multicentre, Phase III, open, prospective, planned as an adaptive double-triangular group sequential, parallel-group, randomised controlled trial with an a priori sample size of 2954 participants. Randomisation used minimisation (incorporating a random element). Setting: The trial was set in 42 secondary and community inpatient facilities in the UK. Participants: Adult inpatients with evidence of acute illness and at a high risk of PU development. Interventions and follow-up: APM or HSFM – the treatment phase lasted a maximum of 60 days; the final 30 days were post-treatment follow-up. Main outcome measures: Time to event. Results: From August 2013 to November 2016, 2029 participants were randomised to receive either APM (n = 1016) or HSFM (n = 1013). Primary end point – 30-day final follow-up: of the 2029 participants in the intention-to-treat population, 160 (7.9%) developed a new PU of category ≥ 2. There was insufficient evidence of a difference between groups for time to new PU of category ≥ 2 [Fine and Gray model HR 0.76, 95% confidence interval (CI) 0.56 to 1.04; exact p-value of 0.0890 and 2% absolute difference]. Treatment phase sensitivity analysis: 132 (6.5%) participants developed a new PU of category ≥ 2 between randomisation and end of treatment phase. There was a statistically significant difference in the treatment phase time-to-event sensitivity analysis (Fine and Gray model HR 0.66, 95% CI 0.46 to 0.93; p = 0.0176 and 2.6% absolute difference). Secondary end points – 30-day final follow-up: new PUs of category ≥ 1 developed in 350 (17.2%) participants, with no evidence of a difference between mattress groups in time to PU development, (Fine and Gray model HR 0.83, 95% CI 0.67 to 1.02; p-value = 0.0733 and absolute difference 3.1%). New PUs of category ≥ 3 developed in 32 (1.6%) participants with insufficient evidence of a difference between mattress groups in time to PU development (Fine and Gray model HR 0.81, 95% CI 0.40 to 1.62; p = 0.5530 and absolute difference 0.4%). Of the 145 pre-existing PUs of category 2, 89 (61.4%) healed – there was insufficient evidence of a difference in time to healing (Fine and Gray model HR 1.12, 95% CI 0.74 to 1.68; p = 0.6122 and absolute difference 2.9%). Health economics – the within-trial and long-term analysis showed APM to be cost-effective compared with HSFM; however, the difference in costs models are small and the quality-adjusted life-year gains are very small. There were no safety concerns. Blinded photography substudy – the reliability of central blinded review compared with clinical assessment for PUs of category ≥ 2 was ‘very good’ (kappa statistic 0.82, prevalence- and bias-adjusted kappa 0.82). Quality-of-life substudy – the Pressure Ulcer Quality of Life – Prevention (PU-QoL-P) instrument meets the established criteria for reliability, construct validity and responsiveness. Limitations: A lower than anticipated event rate. Conclusions: In acutely ill inpatients who are bedfast/chairfast and/or have a category 1 PU and/or localised skin pain, APMs confer a small treatment phase benefit that is diminished over time. Overall, the APM patient compliance, very low PU incidence rate observed and small differences between mattresses indicate the need for improved indicators for targeting of APMs and individualised decision-making. Decisions should take into account skin status, patient preferences (movement ability and rehabilitation needs) and the presence of factors that may be potentially modifiable through APM allocation, including being completely immobile, having nutritional deficits, lacking capacity and/or having altered skin/category 1 PU. Future work: Explore the relationship between mental capacity, levels of independent movement, repositioning and PU development. Explore ‘what works for whom and in what circumstances’. Trial registration: Current Controlled Trials ISRCTN01151335. Funding: This project was funded by the National Institute for Health Research Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 23, No. 52. See the NIHR Journals Library website for further project information

The Effect of Standardized Photodocumentation on Coding of Pressure Injuries

Background and Purpose: Pressure injuries (PI) are prevalent and costly for hospitals. Hospitals implement different practices to accurately document PIs ranging from pen and paper to photodocumentation in electronic medical records (EMRs). In some instances, PIs that have been documented are not coded for billing and reporting. The purpose of this study is to determine if different documentation practices affect the number of coded PIs. Methods: Counts of coded PIs were collected from 2011- 2017 from two hospitals: a 500-bed acute care hospital (ACH) and a 42-bed acute rehabilitation hospital (ARH). A series of PI documentation practices were implemented over the course of the six years data were collected. The aim of the changes were to improve the accuracy of wound assessment, facilitate transparent and accurate reporting, and improve care. The four documentation practice time periods included 1) baseline, 2) PI photodocumentation with paper and all paper charting, 3) PI photodocumentation on paper and EMR for all other charting, and finally 4) all charting and documentation in the EMR. Results: In the 500-bed facility, a statistically significant difference was found in the mean number of PIs coded among the four documentation periods (F(3) = 45.460; p \u3c 0.001), with the highest number of PI’s reported during PI photodocumentation with paper and all paper charting. In the ARH there was a statistically significant difference in the average number of PIs among the four different documentation periods (Period 1-ARH Mean = 56, Period 2-ARH Mean = 31, SD = 11.3, Period 3-ARH Mean = 36.1, SD = 14.4, Period 4-ARH Mean = 58.7, SD = 11.3; F(3) = 5.994; p = 0.006). In post hoc analysis a significant difference between Period 2-ARH and Period 4-ARH (p = 0.036), as well as between Period 3-ARH and Period 4-ARH (p = 0.005) was observed. Discussion: Changes in documentation practice coincided with significant changes in the number of PIs being coded in the ACH and ARH. Improper or inaccurate documentation of PIs has the potential to result in inaccurate coding and therefore missed payment for services provided. More serious PIs that are not coded properly may cost the facility thousands of dollars in missed payments. Accurate assessment and subsequent coding of PIs ensures the facility is fairly compensated for services provided

Developing a pressure ulcer risk factor minimum data set and risk assessment framework

AIM: To agree a draft pressure ulcer risk factor Minimum Data Set to underpin the development of a new evidenced-based Risk Assessment Framework.BACKGROUND: A recent systematic review identified the need for a pressure ulcer risk factor Minimum Data Set and development and validation of an evidenced-based pressure ulcer Risk Assessment Framework. This was undertaken through the Pressure UlceR Programme Of reSEarch (RP-PG-0407-10056), funded by the National Institute for Health Research and incorporates five phases. This article reports phase two, a consensus study.DESIGN: Consensus study.METHOD: A modified nominal group technique based on the Research and Development/University of California at Los Angeles appropriateness method. This incorporated an expert group, review of the evidence and the views of a Patient and Public Involvement service user group. Data were collected December 2010-December 2011.FINDINGS: The risk factors and assessment items of the Minimum Data Set (including immobility, pressure ulcer and skin status, perfusion, diabetes, skin moisture, sensory perception and nutrition) were agreed. In addition, a draft Risk Assessment Framework incorporating all Minimum Data Set items was developed, comprising a two stage assessment process (screening and detailed full assessment) and decision pathways.CONCLUSION: The draft Risk Assessment Framework will undergo further design and pre-testing with clinical nurses to assess and improve its usability. It will then be evaluated in clinical practice to assess its validity and reliability. The Minimum Data Set could be used in future for large scale risk factor studies informing refinement of the Risk Assessment Framework

The Impact of a Clinical Mentor Program on Patient Outcomes

The increasing complexity of patient care requires an expert nurse to navigate the hospital stay, yet today\u27s workforce brings a declining supply of seasoned nurses, creating a patient need/nurse expertise gap. The clinical mentor role was developed to bridge this gap and create a safety net, using expert nurses, relieved of a patient assignment, to provide oversight for quality patient care. Results reported elsewhere showed improvements in failure to rescue and pressure ulcers six months before and after implementation. The purpose of this study was to examine the long-term impact of this new care model over the subsequent three years on these nurse-sensitive indicators, and to explore the process by which patient outcomes were affected. A mixed-method embedded descriptive design made use of quantitative secondary data analysis of outcome measure data, along with qualitative situational analysis of data from 25 clinical mentor interviews. Results showed that failure to rescue maintained the initial gain post implementation, but did not decrease (or increase) further over the study period. Medical surgical unit hospital acquired pressure ulcers (HAPU) and fall rates showed statistically significant improvement over time; Intensive care unit HAPUs did not significantly change. Qualitative mentor interviews validated their affect on these patient outcomes as well as on staff nurse growth and development, practice improvement, patient satisfaction, error prevention and the development of effective communication. To identify problems or gaps in care, mentors looked for congruency between what they noted in report or chart checks with what they found on rounds when assessing the patient. Eleven themes emerged to describe the processes used to affect patient outcomes, which, when analyzed as a whole, were categorized into three areas of focus: improving effective communication, real time teaching, and taking the time for deeper, expert assessment and evaluation of patient situations. The study added to the general knowledge of expert/non-expert practice and the effect of a unit-based catalyst or guide on patient outcomes

Pressure Ulcer Risk and Prevention: Examining the Inter-Rater Reliability of the National Database of Nursing Quality Indicators® (NDNQI)

ABSTRACT Measuring and reporting performance have become the norm. The purpose of this descriptive multi-site (N = 36 NDNQI-participating hospitals) study was to examine the reliability of the National Database of Nursing Quality Indicators® (NDNQI®) pressure ulcer (PrU) risk and prevention measures. This is the first known study to examine the inter-rater reliability of these measures. Data for Part 1 of this two-part study were extracted from 1,637 patient records by 120 raters. One rater at each hospital was considered the "expert". Agreement between the expert and non-expert raters was calculated for the risk measures. Among the patients, 530 were "at risk" for PrU, and included in calculations of agreement for the prevention measures. In Part 2, raters completed an online survey about the methods they use to collect these data. Cohen's kappa values varied widely within and across hospitals. Because most patients were assessed for PrU risk, and those at risk received prevention, the prevalence of a "Yes" response was high suggesting prevalence-adjusted kappa (PAK) may be a better estimate of inter-rater reliability than Cohen's kappa. PAK values for: Skin assessment, PAK = .977, 95% CI [.966 - .989]; Risk assessment, PAK = .978, 95% CI [.964 -.993]; Time since last risk assessment, PAK = .790, 95% CI [.729 - .852]; Risk assessment scale, PAK = .997, 95% CI [.991 - 1.0]; Risk status, PAK = .877, 95% CI [.838 - .917]; Any prevention, PAK = .856, 95% [.769 - .943]; Skin assessment documented, PAK = .956, 95% CI [.904 - 1.0]; and Pressure-redistribution surface use, PAK = .839, 95% CI [.763 - .916] indicated substantial to near perfect agreement. PAK values for: Routine repositioning, PAK = .577, 95% CI [.494 - .661]; Nutritional support, PAK = .500, 95% CI [.418 - .581]; and Moisture management, PAK = .556, 95% CI [.469 - .643] indicated moderate agreement. Results provide support for the reliability of all (5) PrU risk measures, and three of six prevention measures. Areas of disagreement between the expert and non-expert raters should direct education to improve reliability. Results of the online survey suggest raters need further training on the NDNQI guidelines for PrU data collection

Pressure UlceR Programme Of reSEarch (PURPOSE): using mixed methods (systematic reviews, prospective cohort, case study, consensus and psychometrics) to identify patient and organisational risk, develop a risk assessment tool and patient-reported outcome Quality of Life and Health Utility measures

Background: The Pressure UlceR Programme Of reSEarch (PURPOSE) consisted of two themes. Theme 1 focused on improving our understanding of individuals’ and organisational risk factors and on improving the quality of risk assessments (work packages 1–3) and theme 2 focused on developing patient-reported outcome measures (work packages 4 and 5). Methods: The programme comprised 21 individual pieces of work. Pain: (1) multicentre pain prevalence study in acute hospitals, (2) multicentre pain prevalence study in community localities incorporating (3) a comparison of case-finding methods, and (4) multicentre, prospective cohort study. Severe pressure ulcers: (5) retrospective case study, (6) patient involvement workshop with the Pressure Ulcer Research Service User Network for the UK (PURSUN UK) and (7) development of root cause analysis methodology. Risk assessment: (8) systematic review, (9) consensus study, (10) conceptual framework development and theoretical causal pathway, (11) design and pretesting of draft Risk Assessment Framework and (12) field test to assess reliability, validity, data completeness and clinical usability. Quality of life: (13) conceptual framework development (systematic review, patient interviews), (14 and 15) provisional instrument development, with items generated from patient interviews [from (1) above] two systematic reviews and experts, (16) pretesting of the provisional Pressure Ulcer Quality of Life (PU-QOL) instrument using mixed methods, (17) field test 1 including (18) optimal mode of administration substudy and item reduction with testing of scale formation, acceptability, scaling assumptions, reliability and validity, and (19) field test 2 – final psychometric evaluation to test scale targeting, item response categories, item fit, response bias, acceptability, scaling assumptions, reliability and validity. Cost–utility: (20) time trade-off task valuations of health states derived from selected PU-QOL items, and (21) validation of the items selected and psychometric properties of the new Pressure Ulcer Quality of Life Utility Index (PUQOL-UI). Key findings:Pain: prevalence studies – hospital and community patients experience both pressure area-related and pressure ulcer pain; pain cohort study – indicates that pain is independently predictive of category 2 (and above) pressure ulcer development. Severe pressure ulcers: these were more likely to develop in contexts in which clinicians failed to listen to patients/carers or recognise/respond to high risk or the presence of an existing pressure ulcer and services were not effectively co-ordinated; service users found the interactive workshop format valuable; including novel components (interviews with patients and carers) in root cause analysis improves the quality of the insights captured. Risk assessment: we developed a Pressure Ulcer Risk Assessment Framework, the PURPOSE-T, incorporating the Minimum Data Set, a screening stage, a full assessment stage, use of colour to support decision-making, and decision pathways that make a clear distinction between patients with an existing pressure ulcer(s) (or scarring from previous ulcers) who require secondary prevention and treatment and those at risk who require primary prevention (http://medhealth.leeds.ac.uk/accesspurposet). Quality of life: the final PU-QOL instrument consists of 10 scales to measure pain, exudate, odour, sleep, vitality, mobility/movement, daily activities, emotional well-being, self-consciousness and appearance, and participation (http://medhealth.leeds.ac.uk/puqol-ques). Cost–utility: seven items were selected from the PU-QOL instrument for inclusion in the PUQOL-UI (http://medhealth.leeds.ac.uk/puqol-ui); secondary study analysis indicated that item selection for the PUQOL-UI was appropriate and that the index was acceptable to patients and had adequate levels of validity. Conclusions: The PURPOSE programme has provided important insights for pressure ulcer prevention and treatment and involvement of service users in research and development, with implications for patient and public involvement, clinical practice, quality/safety/health service management and research including replication of the pain risk factor study, work exploring ‘best practice’ settings, the impact of including skin status as an indicator for escalation of preventative interventions, further psychometric evaluation of PU-QOL and PUQOL-UI the measurement of ‘disease attribution.’ Funding: The National Institute for Health Research Programme Grants for Applied Research programme

Wound Care Referral Algorithm

The purpose of this study was to develop a wound care referral algorithm for primary providers at a Long Term Acute Care Hospital, and the use of this algorithm to increase the prompt referrals of patients with complex wounds to specialty care by 10%. This study used a model of program evaluation called objective-based evaluation, in which the objectives were evaluated by the creation and use of a wound care referral algorithm in a laminated card and tracking the number of referrals to the Wound Nurse Practitioner in a tracking log. The data analysis was the evaluation of the raw number of referrals made to the Wound Care Nurse Practitioner before and after the use of the wound care referral algorithm. A referral algorithm was created and implemented, a tracking log used to measure the number of referrals made to Wound Nurse Practitioner, but the number of referrals did not increase by 10%. However, the use of an algorithm proved to be a best practice that helped define the appropriate use of resources, human and otherwise

Pressure RElieving Support SUrfaces: a Randomised Evaluation 2 (PRESSURE 2): study protocol for a randomised controlled trial

Background Pressure ulcers represent a major burden to patients, carers and the healthcare system, affecting approximately 1 in 17 hospital and 1 in 20 community patients. They impact greatly on an individual’s functional status and health-related quality of life. The mainstay of pressure ulcer prevention practice is the provision of pressure redistribution support surfaces and patient repositioning. The aim of the PRESSURE 2 study is to compare the two main mattress types utilised within the NHS: high-specification foam and alternating pressure mattresses, in the prevention of pressure ulcers. Methods/Design PRESSURE 2 is a multicentre, open-label, randomised, double triangular, group sequential, parallel group trial. A maximum of 2954 ‘high-risk’ patients with evidence of acute illness will be randomised on a 1:1 basis to receive either a high-specification foam mattress or alternating-pressure mattress in conjunction with an electric profiling bed frame. The primary objective of the trial is to compare mattresses in terms of the time to developing a new Category 2 or above pressure ulcer by 30 days post end of treatment phase. Secondary endpoints include time to developing new Category 1 and 3 or above pressure ulcers, time to healing of pre-existing Category 2 pressure ulcers, health-related quality of life, cost-effectiveness, incidence of mattress change and safety. Validation objectives are to determine the responsiveness of the Pressure Ulcer Quality of Life-Prevention instrument and the feasibility of having a blinded endpoint assessment using photography. The trial will have a maximum of three planned analyses with unequally spaced reviews at event-driven coherent cut-points. The futility boundaries are constructed as non-binding to allow a decision for stopping early to be overruled by the Data Monitoring and Ethics Committee. Discussion The double triangular, group sequential design of the PRESSURE 2 trial will provide an efficient design through the possibility of early stopping for demonstrating either superiority, inferiority of mattresses or futility of the trial. The trial optimises the potential for producing robust clinical evidence on the effectiveness of two commonly used mattresses in clinical practice earlier than in a conventional design