Please provide a brief overview of your EBP project , discuss your findings and ways you hope to implement them into your nursing Practice. Pos
Please provide a brief overview of your EBP project , discuss your findings and ways you hope to implement them into your nursing Practice. Postings should provide a brief comprehensive overview, be spellchecked, and be succinct in grammar.
2
Comparison of Silicone Foam Dressings Versus Pressure Reduction Techniques
Student Name
Minnesota State University, Mankato
NURS 320-W 02 Critical Inquiry and Evidenced-Based Practice for RNs
Dr. Ellen Vorbeck
Date: mm/dd/year
Abstract
The purpose of this paper was to determine if silicone foam dressings are more beneficial for preventing pressure injuries than pressure reduction techniques alone. Special focus was placed on patients who have the additional risk factor of incontinence. Discussion was focused on assessment tools and differentiating between incontinence-associated dermatitis and pressure injury. Eleven studies were reviewed for this paper. Evidence suggested that applying silicone foam dressings may be beneficial for preventing pressure injuries in addition to pressure reduction techniques. However, the evidence was not strong related to difficulty creating double blind studies and small sample sizes. More evidence will be needed in the form of randomized controlled studies or piloting programs prior to implementing practice change in a hospital system.
Keywords: pressure injury, prevention, incontinence, silicone foam dressing
Comparison of Silicone Foam Dressings Versus Pressure Reduction Techniques
Pressure injuries can have significant negative consequences for patients including infection, reduced quality of life, disability and even death (Campbell, et al., 2020). Pressure injuries are also very costly for patients and healthcare systems, estimated to average between $37,000-$70,000 per patient (Walker, et al. 2015). In patients who were both immobile and incontinent, Gray & Guiliano found the “prevalence of facility-acquired pressure injury in the sacral area remained statistically significant” compared to patients who were continent (2018, p. 65). Placing a silicone foam dressing over the sacrum is a common preventative practice in patients with stage 1 pressure injuries, but does research support this intervention when incontinence is involved? It is important to utilize evidence-based research to determine if this is the best practice to prevent skin breakdown in this population, as they have increased vulnerability to pressure injuries.
Background
The first step toward preventing pressure injuries is thorough assessment. The Agency for Healthcare Research and Quality (AHRQ) recommends inspecting skin for the following: temperature, color, moisture, turgor and integrity. They advise utilization of assessment tools such as the Braden Scale to standardize skin assessments and determine patient risk for skin breakdown (Berlowitz, et al., 2014). There are two main types of skin breakdown in the pelvic area, pressure injuries and incontinence-associated dermatitis. Pressure injury is defined by Campbell et al., as “localized damage to the skin and/or underlying tissue, usually over a bony prominence” (2020, p. 30). When a patient is determined to be at risk for developing pressure injury through a Braden score or other scale, pressure reduction techniques are utilized to prevent breakdown. Pressure reduction techniques vary by hospital but typically include turning and repositioning, placing pillows to cushion bony prominences, and utilizing pressure-reducing mattresses. In contrast, incontinence-associated dermatitis (IAD) is defined by Gray & Guiliano as “erythema and edema of the surface of the skin, sometimes accompanied by serous exudate, erosion or secondary cutaneous infection” specifically found in patients who are incontinent of bowel and/or bladder (2018, p. 63). Though these two conditions are separate, incontinence is found to worsen the risk of developing pressure injuries. In their multivariate analysis on immobility, incontinence and pressure injury, Gray & Guiliano found that the presence of IAD significantly increased the likelihood of developing a pressure injury (2018.) Some of the prevention strategies overlap between these conditions, such as preventing moisture and pressure reduction techniques.
Research Problem Statement
With this known link between IAD and pressure injury, it is important for clinicians to determine the best interventions to prevent skin breakdown in populations where both are present. This paper is comparing the use of silicone foam dressings in this population, versus pressure reduction techniques alone.
Research Purpose
The purpose of this paper is to determine whether silicone foam dressings prevent skin breakdown more effectively than pressure reduction techniques alone, in hospitalized patients who have stage 1 pressure injuries and incontinence.
Research Question
In individuals with both incontinence and stage 1 pressure injuries, how does a silicone foam dressing compared to pressure reduction techniques affect skin integrity within a hospital stay?
Research Utilization Model
The Johns Hopkins Nursing Evidenced-Based Practice Model (JHNEBP) is an appropriate research model to use for this research focus as it was developed to make incorporating evidence more manageable for nurses during clinical practice. This makes it well suited to research and implementation within a hospital system. Melnyk and Fineout-Overholt (2019) describe the three main steps: Practice Question, Evidence, and Translation. First, the question is developed and refined, a leader is determined, and an interdisciplinary team is formed. Then, evidence is screened, rated, and summarized. This phase ends with specific recommendations determined by the strength of the research. Recommendations can be one of four options such as changing the practice immediately because the evidence is strong, considering a pilot or research study, or if there is little evidence, continuing research or ending the project. Finally, the results of the study are integrated into practice (Melnyk & Fineout-Overholt, 2019, pp. 413-414).
While utilizing this model, the interdisciplinary team should be composed of bedside nurses, managers, WOC nurses and hospitalists. The research obtained will guide the interdisciplinary team in answering the research question and determining the best way to disseminate this research into clinical practice in the hospital setting. Figure 1 visually depicts the JHNEBP model utilized in this research project.
Figure 1
The Johns Hopkins Nursing Evidence-Based Practice Model
Search Criteria and Results
The research for this study was completed utilizing CINAHL, PubMed, Medline, and Cochrane, including 313 articles from 2015 to present. Table one notes the keywords used in these searches.
Table 1
Data Research Table
|
Keyword |
CINAHL |
PubMed |
Medline |
PsychInfo |
Cochrane |
|
Pressure injury AND prevention AND incontinence Full Text 2015-2020 |
15 |
35 |
0 |
||
|
Pressure injury AND prevention AND silicone foam dressing Full Text 2015-2020 |
16 |
16 |
|||
|
Pressure injury AND silicone foam dressing Full Text 2015-2020 |
19 |
17 |
28 |
2 |
|
|
Incontinence AND silicone foam dressing Full Text 2015-2020 |
5 |
1 |
|||
|
Pressure injury AND prevention AND case study Full Text 2015-2020 |
159 |
11 research articles were included in this research project: two systematic reviews, two randomized-controlled trials, one non-randomized controlled trial, one case study, one case study analysis, one follow-up analysis, one non-experimental analysis, and two clinical guides. Figure 2 illustrates the strength of evidence of this research visually with the Strength-of-evidence rating pyramid which was found in Melnyk & Fineout-Overholt (2019, p. 116, Figure 4.2).
Figure 2
Strength-of evidence rating pyramid.
Findings
In the case study about nurse practices and preventing pressure injuries, Teo et al. found that “timely escalation of care, effective communication, support from the wound nurses, and bridging the knowledge-practice gap” were the most effective mechanisms (2019, p. 153). For more information regarding this case study, see Appendix Table 2. This research aims to help bridge the knowledge-practice gap specifically for the hospitalized patient with IAD and pressure injury. In the cross-case analysis by Ghiasas et al., occupational therapy researchers examined how patient involvement contributes to pressure injury development and healing. They found that of 25 participants, 19 participants who adopted positive lifestyle changes also experienced improvement of pressure injuries (2020). See Appendix Table 4 for more detailed information.
Several studies were found comparing the use of silicone foam dressings with pressure reduction techniques alone. Walker, et al. performed a pilot study regarding the prophylactic use of silicone foam dressings to prevent sacral pressure injuries in a general medical surgical setting. In the study, silicone foam dressings were applied to the sacrum of patients indicated as high risk on the Waterlow Scale, in addition to pressure reduction techniques (Walker, et al. 2015). In the follow-up report, they found that of 67 patients that completed the trial, only one patient within the intervention group developed pressure injury, compared to two in the control group (Walker & Aitken, 2015). This study offered promising results, however greater sample size is needed.
Two studies were identified utilizing silicone foam dressings in intensive care hospital settings. Santamaria et al., found that of the 440 trauma patients studied, only 5 patients in the intervention group developed pressure injury compared with 20 in the control group (2015). In this study, dressings were applied to sacrum and heels of patients admitted to the ED who transferred to ICU. Dressings were applied prophylactically in addition to pressure reduction techniques. For more information regarding this study see Appendix Table 1. Park specifically studied silicone foam dressings for prevention of pressure injury and incontinence-associated dermatitis (IAD) in intensive care. This study examined 102 patients with Braden scores of 16 or less and utilized the Incontinence Associated Dermatitis and its Severity Instrument (IADS) for evaluation. They found that as the IADS score increased, so did the incidence of pressure injuries. They also found that in the intervention group, both the incidence of pressure injury (6% vs.46%) and IADS were decreased (Park, 2014). This study was limited in that it was not blind, and the sacral dressings were applied for only 9 days. Even so, the results were positive toward using silicone foam dressings for decreasing incidence of both pressure injuries and IAD. See Appendix Table 2.
In the systematic review regarding effectiveness of pressure injury prevention strategies, Tayyib and Coyer found that the three studies included involving silicone foam dressings indicated a statistically significant decrease of pressure injuries in ICU. However, because of small sample sizes, lack of randomization and overall differences in structure of studies, “no conclusions could be reached regarding effectiveness” (Tayyib & Coyer, 2016, p. 442). The Cochrane Systematic Review that was utilized in this paper had similar concerns with data reliability related to quality of evidence and reliability (Moore, et al., n.d.). This review included 18 trials, six of which compared silicone dressings versus pressure reduction techniques. They did find that of the 1247 participants across six studies, 16 participants within the intervention group compared with 65 in the control group, developed pressure injury. With these findings, Moore et al. concluded that “silicone dressings may reduce the incidence of pressure ulcers. However the low level of evidence certainty means that additional research is required to confirm these result.” (n.d., p. 28). See Appendix Table 3 for more information regarding this review.
Discussion
These studies indicate that silicone foam dressings may prevent further skin breakdown in hospitalized patients with stage 1 pressure injury and incontinence. They also may help to decrease incontinence associated dermatitis. However, more and better data is necessary to support this intervention. It is difficult to have a true blind study related to the nature of the question (dressing vs. no dressing). But factors like sample size and standardized evaluation practices, could be improved for future studies. Patient experience case studies would be helpful for determining if patient experience is improved by these interventions. Cost-benefit analysis may also be helpful for hospital systems interested in implementing this intervention. The recommendation at this point as indicated by the JHNEBP model would be to consider a pilot or research study prior to implementing a larger scale change.
Recommendations for Nursing Practice
The research is generally supporting utilizing silicone foam dressings, however the evidence is not very strong. With this population it is very difficult to create double blind scenarios, but thought should be given to make them as blind as possible for credibility. Because of the lack of strong evidence nursing recommendations would be for further studies. Additionally, a piloting period would be recommended prior to implementing this intervention in a hospital system. Cost, efficacy, and risk versus benefit should be part of this analysis of the pilot prior to large scale intervention or practice change. Webster & Moore advised that “future trials should be large enough to show meaningful differences; include patient-related outcomes, such as product acceptability, adverse events and quality of life, and economic evaluations to assist healthcare managers to make rational decisions” (p. 29, 2018). Hospital systems may choose to determine specific requirements of when silicone foam dressings should be added to maximize effectiveness and cost vs. benefit.
The Agency for Healthcare Research and Quality (AHRQ) website offers a toolkit and a training program for hospitals. This would be an excellent place to start when implementing this policy change. It offers a plethora of information in addition to resources to roll out a new program (Berlowitz et al., n.d.). In addition, further training on assessing pressure injuries, risk for skin breakdown, and the differences between pressure and dermatitis would be helpful training points.
Conclusion
This research project sought to answer whether a silicone foam dressing was more effective than pressure reduction techniques alone in preventing pressure injury in hospitalized patients with incontinence. Evidence from all steps of the Strength-of-evidence rating pyramid was reviewed (Melnyk & Fineout-Overholt, 2019, p. 116, Figure 4.2). Further research is needed in the form of a piloting period or additional randomized controlled trials. Prior to implementation, the research team should focus on determining the most effective scenarios to utilize silicone foam dressings, cost versus benefit for hospitals, and patient experience related to this intervention.
Berlowitz, D., VanDeuzen Lukas, C., Parker, V., Niederhauser, A., Silver, J., Logan, C., Ayello, E., Zulkowski, K. (2014). Preventing Pressure Ulcers in Hospitals. Agency for Healthcare Research and Quality. https://www.ahrq.gov/patient-safety/settings/hospital/resource/pressureulcer/tool/index.html.
Campbell, J., Barakat-Johnson, M., Hogan, M., Maddison, K., McLean, J., Rando, T., Samolyk, M., Sage, S., Weger, K., & Dunk, A. M. (2020). A clinical guide to pelvic skin assessment. Wounds International, 11(1), 30–39.
Ghaisas, S., Pyatak, E. A., Blanche, E., Blanchard, J., & Clark, F. (2015). Lifestyle Changes and Pressure Ulcer Prevention in Adults With Spinal Cord Injury in the Pressure Ulcer Prevention Study Lifestyle Intervention. The American Journal of Occupational Therapy, 69(1), 1-10. http://dx.doi.org.ezproxy.mnsu.edu/10.5014/ajot.2015.012021
Gray M, Giuliano KK. (2018). Incontinence-Associated Dermatitis, Characteristics and Relationship to Pressure Injury: A Multisite Epidemiologic Analysis. J Wound Ostomy Continence Nurs, 45(1), 63-67. doi:10.1097/WON.0000000000000390
Melnyk, B. & Fineout-Overholt, E. (2019). Evidence-based Practice in Nursing & Healthcare (4th ed). Philadelphia: Lippincott, Williams & Wilkins.
Park K. H. (2014). The effect of a silicone border foam dressing for prevention of pressure ulcers and incontinence-associated dermatitis in intensive care unit patients. Journal of wound, ostomy, and continence nursing : official publication of The Wound, Ostomy and Continence Nurses Society, 41(5), 424–429. https://doi-org.ezproxy.mnsu.edu/10.1097/WON.0000000000000046
Santamaria, N., Gerdtz, M., Sage, S., McCann, J., Freeman, A., Vassiliou, T., De Vincentis, S., Ng, A. W., Manias, E., Liu, W., & Knott, J. (2015). A randomised controlled trial of the effectiveness of soft silicone multi-layered foam dressings in the prevention of sacral and heel pressure ulcers in trauma and critically ill patients: the border trial. International Wound Journal, 12(3), 302–308. https://doi-org.ezproxy.mnsu.edu/10.1111/iwj.12101
Tayyib, N., & Coyer, F. (2016). Effectiveness of Pressure Ulcer Prevention Strategies for Adult Patients in Intensive Care Units: A Systematic Review. Worldviews on evidence-based nursing, 13(6), 432–444. https://doi-org.ezproxy.mnsu.edu/10.1111/wvn.12177
Teo, C., Claire, C. A., Lopez, V., & Shorey, S. (2019). Pressure injury prevention and management practices among nurses: A realist case study. International wound journal, 16(1), 153–163. https://doi-org.ezproxy.mnsu.edu/10.1111/iwj.13006
Walker, R., Aitken, L.M., Huxley, L. & Juttner, M. (2015) Prophylactic dressing to minimize sacral pressure injuries in high‐risk hospitalized patients: a pilot study. Journal of Advanced Nursing 71( 3), 688– 696. doi: 10.1111/jan.12543
Walker, R., & Aitken, L. (2015). Pressure injury prevention pilot study: a follow-up. Queensland Nurse, 34(3), 33.
Webster, J., & Moore, Z. E. (n.d.). Dressings and topical agents for preventing pressure ulcers. Cochrane Database of Systematic Reviews, 12.
Appendix
Literature Review Table 1
|
Article, Source, year |
Gray M, Giuliano KK. (2018). Incontinence-Associated Dermatitis, Characteristics and Relationship to Pressure Injury: A Multisite Epidemiologic Analysis. J Wound Ostomy Continence Nurs, 45(1), 63-67. doi:10.1097/WON.0000000000000390 |
Santamaria, N., Gerdtz, M., Sage, S., McCann, J., Freeman, A., Vassiliou, T., De Vincentis, S., Ng, A. W., Manias, E., Liu, W., & Knott, J. (2015). A randomised controlled trial of the effectiveness of soft silicone multi-layered foam dressings in the prevention of sacral and heel pressure ulcers in trauma and critically ill patients: the border trial. International Wound Journal, 12(3), 302–308. https://doi-org.ezproxy.mnsu.edu/10.1111/iwj.12101 |
|
Purpose |
To measure the prevalence of incontinence-associated dermatitis (IAD) among incontinent persons in acute care setting, characteristics of IAD in this group, and associations among IAD, urinary, fecal, and dual incontinence, immobility, and pressure injury in the sacral area. |
To investigate the effectiveness of multi-layered soft silicone foam dressings in preventing intensive care unit pressure ulcers when applied in the emergency department. |
|
Sample |
N=5342 (n=2492/5342, 46%) incontinent or urine, stool or both (n=1140/5342, 21.3%) prevalence of IAD (n=1140/2492, 45.7%) prevalence of IAD within incontinent population (n=596/1140, 52.3%) IAD considered mild within incontinent population (n=318/1140, 27.9%) IAD considered moderate within incontinent population (n=105/1140, 9.2%) IAD considered severe within incontinent population (n=169/1140, 14.8%) patients with IAD who also had a fungal rash (n=427/2492, 17.1%) prevalence of pressure injury in sacral area among individuals with incontinence (n=95/2492, 3.8%) prevalence of full-thickness pressure injury among individuals with incontinence |
N=440 (n=219) Mepilex Border Sacrum and Mepilex Heel dressings applied in ED and maintained throughout ICU stay. (n=221) Control group receiving usual care. |
|
Design and level of evidence (Melnyk 4.2) |
Epidemiologic analysis utilizing multivariate analysis. This type of study seeks to describe the distribution of diseases in the population and analyze the causes of these diseases – analyzing multiple variables at one time. Categorized as non-experimental study. Variables are not being changed, data is gathered at particular time. In the second level of the Strength-of-evidence rating pyramid seen in Melnyk & Fineout-Overholt (2019, p.116, Figure 4.2). |
Randomized controlled trial – this type of study seeks to reduce bias while testing the effectiveness of a certain treatment by having two groups – control group and experimental group. Categorized as experimental research study, it is an RCT. This is found in the third level of the Strength-of-evidence rating pyramid from Melnyk & Fineout-Overholt (2019, p. 116, Figure 4.2). |
|
Variables, measurement |
Clinical variables include incontinence of urine, stool, or both urine and stool, immobility, concurrent fungal infection. |
Clinical variables include reason for admission, comorbidity, physiological variables, Australasian Triage scale score, and time commenced on mechanical ventilation. |
|
Results, findings |
Prevalence of facility-acquired pressure injury in sacral area among individuals with incontinence was 17.1%. Patients with IAD were more likely to experience a facility-acquired pressure injury of the sacral area compared to those without IAD (32.3% vs. 1.5%). Patients who were immobile were almost 3.5 times more likely to develop facility-acquired sacral pressure injury than those who were mobile (12.1% vs. 3.2%). Prevalence of IAD and facility-aquired pressure injury in the sacral area remained statistically significant even after adjusting for immobility (P<0.0001). |
The intervention group had significantly less patients who developed a pressure ulcer in ICU (5 vs. 20, P=0.001). |
|
Implications |
Both mobility and incontinence – specifically incontinence associated dermatitis – are significant risk factors for developing sacral pressure injuries in acute care. IAD was found to be an independent risk factor apart from immobility. |
A benefit was found for applying mepilex dressings to sacrum and heels of ICU patients, in combination with pressure reduction and skin care. As a result, this hospital has now mandated the use of these dressings for all patients who are high risk for pressure injury. |
|
Limitations of Research |
Not all data was filled out on each electronic survey as each field was not mandatory. Participants did not receive standardized training in assessment of IAD and pressure injury. Assessments of IAD were not made using a validated instrument. Interventions and products used for prevention of skin breakdown was not standardized. |
Study was conducted at a single site for a limited time. It was impossible to blind data collectors to the nature of the treatment intervention. Only studied patients who admitted to ICU from ED, cannot be generalized to other patient populations. While patients with incontinence were not excluded from the study, there was no comment toward how much of the population was incontinent and if that affected the results in any way. |
|
Comments |
The purpose of this study was to establish the link between IAD and pressure injury. Further study is needed to indicate which interventions best prevent pressure injuries specific to the population of patients who are incontinent in acute care. |
This is promising evidence for using a particular silicone foam dressing to prevent pressure injury in a specific population. More research would need to be done to determine whether these results can be duplicated in the medical/surgical population, with a greater sample size, and for my research specifically examining the implications of concurrent incontinence. |
Literature Review Table 2
|
Article, Source, year |
Park K. H. (2014). The effect of a silicone border foam dressing for prevention of pressure ulcers and incontinence-associated dermatitis in intensive care unit patients. Journal of wound, ostomy, and continence nursing : official publication of The Wound, Ostomy and Continence Nurses Society, 41(5), 424–429. https://doi-org.ezproxy.mnsu.edu/10.1097/WON.0000000000000046 |
Teo, C., Claire, C. A., Lopez, V., & Shorey, S. (2019). Pressure injury prevention and management practices among nurses: A realist case study. International wound journal, 16(1), 153–163. https://doi-org.ezproxy.mnsu.edu/10.1111/iwj.13006 |
|
Purpose |
To determine if the development of pressure injuries and incontinence-associated dermatitis are lessened when silicone border foam dressings are applied to patients in ICU. |
To portray what nurses current pressure injury prevention practices are in a hospital in Singapore. |
|
Sample |
N=102 n=52, experimental group n=50, control group |
N=24 |
|
Design and level of evidence (Melnyk 4.2) |
Quasi-Experimental Study. This type of study is a nonrandomized control study, which falls under the category of experimental research studies. This is in the third level of the Strength-of-evidence pyramid in Melnyk & Fineout-Overholt (2019, p. 116, Figure 4.2). |
Case Study. This type of study uses a small case size and interviews participants to obtain data. It falls on the bottom of the Strength-of-evidence rating pyramid mentioned by Melnyk & Fineout-Overholt (2019, p. 116, Figure 4.2). |
|
Variables, measurement |
Clinical variables include gender, age, reason for ICU admission, urinary continence, stool form, BMI and braden score. |
Clinical variables include gender, ethnicity, years of nursing experience, and type of nursing employment (those not responsible for pressure injury prevention were excluded). |
|
Results, findings |
Patients in experimental group (with silicone foam dressing applied) had lower occurrence of pressure injury than control group (6% vs. 46%, P <0.001) Patient’s in experimental group (with silicone foam dressing applied) had lower occurrence of incontinence-associated dermatitis than control group (0.54 +/- 0.73 vs 0.98 +/- 1.25, P <0.033). Correlation between pressure injury and incontinence-associated dermatitis (r = 0.264, P = 0.005). With every 1-point increase in IADS score, risk of developing pressure injury increased by a ratio of 1.9. |
There were 5 conjectured context-mechanism-outcomes (CCMOs) that arose throughout the study: escalation of care, maximizing opportunities for communication, adopting novel forms of communication, support from wound nurses, and bridging theory-practice gaps (Teo et al., 2019). |
|
Implications |
In this study they found that the silicone foam dressing did decrease the occurrence of pressure injury development in ICU setting. They found that the dressing improved both the incidence of pressure injuries and incontinence-associated dermatitis. It also found a link between incontinence-associated dermatitis and pressure injuries. |
The study found that nurses need hands-on training of information that is directly applicable to their work. Education should be individualized to the nurses role (this study included nursing assistants, nurses, and specialists). Resources should be appropriately allocated to maximize pressure injury prevention.</p Collepals.com Plagiarism Free Papers Are you looking for custom essay writing service or even dissertation writing services? Just request for our write my paper service, and we'll match you with the best essay writer in your subject! With an exceptional team of professional academic experts in a wide range of subjects, we can guarantee you an unrivaled quality of custom-written papers. Get ZERO PLAGIARISM, HUMAN WRITTEN ESSAYS Why Hire Collepals.com writers to do your paper? Quality- We are experienced and have access to ample research materials. We write plagiarism Free Content Confidential- We never share or sell your personal information to third parties. Support-Chat with us today! We are always waiting to answer all your questions.  All Rights Reserved Terms and Conditions |