course materials

1. CMU Prevention of Pressure Ulcers in Palliative Patients
CMU Prevention of Pressure Ulcers in Palliative PatientsCMU Prevention of Pressure Ulcers
in Palliative PatientsPrevention of Pressure Ulcers for End of Life Patients in Hospitals:
Adoption of an Evidence-Based Pressure Ulcers Risk Assessment Protocol for Standing
Orders 1.0 Background The philosophical literature on good death ed the early framework
of achieving a natural death free from medical intervention at home surrounded by friends
and family (Campbell, 2020). This traditional way of conceptualising good death,
particularly outside the hospital setting, places palliative care in opposition to mainstream
healthcare services (Robinson et al.,2016). However, Palliative care, to help provide relief
from symptoms and offer to patients and their family members at the end of their lives, is
expected to be offered in all care settings (4th edition of the National Consensus Project’s
Clinical Practice Guidelines for Quality Palliative Care). Similarly, palliative care policy in
England emphasizes that high-quality care should be available wherever the person may be:
at a hospital, in home, in a care home, in a hospice, or elsewhere (Leadership Alliance for the
Care of Dying People, 2014 and NHS, 2008). CMU Prevention of Pressure Ulcers in Palliative
PatientsORDER NOW FOR CUSTOMIZED, PLAGIARISM-FREE PAPERSThis focuses on
solving the problem associated with the hospital as a place of palliative care and end-of-life.
Also, in 2012, the NHS identified pressure ulcer prevention as a quality improvement target,
which was in furtherance of the Department of Health set a target of an annual reduction of
at least 5-10% in the incidence of pressure ulcers in 1994 (Department of Health (DH),
2012. However, as there was no requirement for trusts to provide data relating to this
target, there is no evidence to suggest this has been addressed. Likewise, there is no
requirement for data to be collected about the needs or outcomes of services used by
patients of acute hospitals, resulting in a significant lack of such literature in the United
Kingdom (Kerrison and Pollock, 2001). Therefore, despite the attention given to the area of
pressure ulcer prevention, what remains uncertain is what constrains hospitals from
implementing national guidelines on pressure ulcer prevention ((National Institute for
Clinical Excellence (NICE), 2001; 2003; DH, 2001; 2003)) and the evidence-based
recommendations of the International Pressure Ulcer Prevention and Treatment Guidelines
(National Pressure Ulcer Advisory Panel (NPUAP) et al, 2019) in terms of improving the
outcomes for patients. This study aims at addressing some of these gaps. Particularly, the
researcher would be working closely with the staff in one of the placement hospitals to
identify the barriers to change and then to work with the healthcare professionals and
management to implement best practices in pressure ulcer prevention. In addition,

2. considering the increasing population of patients requiring palliative care in acute hospital
(Cruz-Oliver, 2017; Etkind, S.N., Bone, A.E., Gomes, B. et al. 2017; Healthtalk.org., 2014)
amid established evidence that: i) end-of-life patients are susceptible to pressure ulcer
(Ferris, Price & Harding, 2019; Carville, 2018), ii) Some 80 to 95% of pressure ulcers are
preventable (Institute for Healthcare Improvement, 2021; Ebi, Hirko & Mijena, 2019; NHS,
2015), and iii) hospital settings are inadequate in providing palliative care (the Mid
Staffordshire NHS Foundation Trust, 2013; Gardiner et al., 2011), this area requires
systematic application of evidence-based practice research. The existing end-of-life and
palliative care in hospitals in England fit a proposed practice change given its inadequacy in
terms of coverage, variation in practices, and sustainability (Ó Coimín et al., 2019). For
instance, dying in hospital in the UK is characterised by a deficit of vital end-of-life care
because of the lack of specialist available out of hours and at weekends. Those who die
overnight or at the weekend may be denied the right care because only some (11%, 2016
End of Life Care Audit – Dying in Hospital) of hospital trusts in England provide face-to-face
specialist palliative services round the clock 1 Monday to Sunday, as the majority of trusts
offer a specialist telephone helpline. Though most healthcare professionals giving end-of-
life care do it to a very good standard when things start to go wrong out-ofhours in the
middle of the night and at weekends, then the nurses that need access to specialists in
palliative care are without it, patients with complex problems like pressure ulcers may not
get the care they need. Which is a problem. Consequently, practice research toward
improving the prevention of pressure ulcers among end-of-life patients in an acute hospital
is needed to ensure improved patient outcomes, including symptom control and quality of
life, and family outcomes, such as decreased anxiety. The purpose of this study is, therefore,
to describe the process of a nurse-led practice improvement project to implement an
evidence-based standing order set for risk management of pressure ulcers in a hospital-
based palliative care setting using patients’ experience data as an evaluative component.
CMU Prevention of Pressure Ulcers in Palliative PatientsConsidering the progressive end-
stage deterioration of the skin usually experienced by patients receiving palliative care,
ongoing regular assessment of pressure ulcer risk is required (NPUAP et al, 2019). The
Marie Curie Centre Hunters Hill Risk Assessment Tool (Chaplin, 2000), is identified in
literature as a recommended tool that can be used in conjunction with clinical judgment to
conduct a broad pressure ulcer risk assessment in patients under the end of life and
palliative care (NPUAP et al, 2019). In this light, the underlying elements of the PICO model:
Patient / Problem, Intervention, Comparison and Outcome being considered will be as
follows: Table 1: PICO Process Population/Patient/Problem Intervention Comparison
Outcome In end-of-life patients and Prevention of Comparison between Make a difference in
among family members of pressure ulcers in old and new standing meeting the care
patients individuals receiving orders need of patients and palliative care significantly
reduce in-hospital using pressure ulcer evidence-based risk incidence in hospital
assessment management 2.0 Methods: The steps of the Iowa Model for Evidence-Based
Practice Change will be utilised for this practice implementation project. Survey data will be
conducted as a proxy for assessing the intervention effectiveness. The Iowa Model of
Evidence-Based Practice The Iowa Model of Evidence-Based Practice for organizational

3. scientific evidence as described by Spellman (2016) provides the framework for
identification of a relevant topic for clinical inquiry, team formation appraisal and synthesis
of the relevant best evidence, application of changes, evaluation and dissemination. It
involves identifying practical issue of concern and formulation of research questions;
determining how much of a problem the priority issue is for the organization; determine if
the evidence is sufficient – otherwise, search; but if the evidence is sufficient and the
changes are appropriate, conduct 2 a pilot study to change the practice; evaluate pilot
results, disseminate results and implement change (Camargo et al.,2017).CMU Prevention of
Pressure Ulcers in Palliative PatientsReference Campbell, S.M. (2020) Well-Being and the
Good Death. Ethic Theory Moral Prac 23, 607–623. https://doi.org/10.1007/s10677-020-
10101-3 Robinson, J., Gott, M., Gardiner, C. & Ingleton, C. (2016) The ‘problematisation’ of
palliative care in hospital: an exploratory review of international palliative care policy in
five countries. BMC Palliative Care 15:64. doi 10.1186/s12904-016-0137-0 Department of
Health (2012) Using the Commissioning for Quality and Innovation (CQUIN) Payment
Framework: Guidance on New National Goals for 2012–13 London: Department of Health,
London. NHS (2008), High Quality Care for All. NHS Next Stage Review Final Report No. CM
7432, Presented to Parliament by the Secretary of State for Health by Command of Her
Majesty. Leadership Alliance for the Care of Dying People (2014). One chance to get it right,
Reference 01509. Kerrison S, Pollock A (2001) Caring for older people in the private sector
in England. BMJ 323(7312): 566 National Institute for Clinical Excellence (2001) Pressure
ulcer risk assessment and prevention. NICE, London National Institute for Clinical
Excellence (2003) Pressure Ulcer Prevention. Clinical Guideline 7. NICE, London
Department of Health (2001) The Essence of Care – patient-focused benchmarking for
health care practitioners. DH, London Department of Health (2003) Essence of Care Patient-
focused benchmarks for clinical governance. NHS Modernisation Agency. Department of
Health, London National Pressure Ulcer Advisory Panel and European Pressure Ulcer
Advisory Panel (2019) Prevention and treatment of Pressure Ulcers/injuries: Clinical
Practice Guideline. The International Guideline, 3rd Edition (2019), NPUAP, Washington DC
Cruz-Oliver, D. M. (2017). Palliative Care: An Update. Missouri medicine, 114(2), 110–115.
Healthtalk.org. (2014) Living with Dying: Where people want to die. University of Oxford;
UK. [Accessed: 2/2/21]. Available from: http://www.healthtalk.org/peoples-
experiences/dying-bereavement/livingdying/where-people-want-die. Etkind, S.N., Bone,
A.E., Gomes, B. et al. (2017) How many people will need palliative care in 2040? Past trends,
future projections and implications for services. BMC Med 15, 102.
https://doi.org/10.1186/s12916-017-0860-2 Ferris A, Price A, Harding K. (2019) Pressure
ulcers in patients receiving palliative care: A systematic review. Palliative Medicine
33(7):770-782. doi:10.1177/0269216319846023 3 Carville K. (2018)CMU Prevention of
Pressure Ulcers in Palliative PatientsPressure Injury Prevention and Management in
Palliative Care. In: MacLeod R., Van den Block L. (eds) Textbook of Palliative Care. Springer,
Cham. https://doi.org/10.1007/978-3-31931738-0_116-1 Institute for Healthcare
Improvement (2021). Pressure Ulcers. [Accessed: 2/2/21]. Available from:
http://www.ihi.org/Topics/PressureUlcers/Pages/default.aspx NHS (2015) Stop the
Pressure. [Accessed: 2/2/21]. Available from: www.nhs.stopthepressure.co.uk Ebi, W.E.,

4. Hirko, G.F. & Mijena, D.A. (2019) Nurses’ knowledge to pressure ulcer prevention in public
hospitals in Wollega: a cross-sectional study design. BMC Nurs 18, 20.
https://doi.org/10.1186/s12912019-0346-y Gardiner, C., Cobb, M., Gott, M. & Ingleton, C.
(2011) Barriers to providing palliative care for older people in acute hospitals, Age and
Ageing, Volume 40, Issue 2, March, pp.233–238, https://doi.org/10.1093/ageing/afq172
The Mid Staffordshire NHS Foundation Trust (2013). Public inquiry. [Accessed: 2/2/21].
Available from
http://webarchive.nationalarchives.gov.uk/20150407084231/http://www.midstaffspublic
inquiry.com/r eport. Ó Coimín, D., Prizeman, G., Korn, B. et al. (2019). Dying in acute
hospitals: voices of bereaved relatives. BMC Palliative Care 18, 91.
https://doi.org/10.1186/s12904-019-0464-z Spellman, C.F. (2016) A Practice
Improvement Project to Improve Knowledge and Perceptions of Palliative Care among
Patients with Heart Failure and Cancer in the Acute Setting Using Video Enhanced
Education. DNP Projects submitted to College of Nursing, University of Kentucky Camargo,
F.C., Iwamoto, H.H., Galvão, C.M., et al (2017). Models for the Implementation of
EvidenceBased Practice in Hospital Based Nursing: A Narrative Review.CMU Prevention of
Pressure Ulcers in Palliative PatientsTexto Contexto Enferm 26(4):e2070017.
doi.org/10.1590/0104-07072017002070017 Chaplin J. (2000) Pressure sore risk
assessment in palliative care. Journal of Tissue Viability, 10(1):27-31 4 Part 1: Literature
review Introduction and background • Put the innovation in context of local and National
policy • Give a rationale for the focus of your project and say why it is important • State the
aims and outcomes of the proposed innovation Literature review • State the purpose of the
literature review and identify the different types of literature included in the review •
Describe how you searched, selected and appraised the literature • Discuss and summarise
your findings. Give a picture of the overall body of knowledge in this field – point out its
strengths and weaknesses and highlight any gaps • Make a critical analysis of the evidence
informing the need for your innovation. Critically analyse the evidence that informs your
innovation. • You should demonstrate your ability to systematically search for research,
select and appraise research, analyse several studies and form conclusions linked to your
innovation plan. Part 2: The implementation plan Introduction and background Introduce
your choice of change model and briefly explain why you have made that choice. Change
management plan Move on to look at ing theories for preparing for change – such as SWOT
analysis, stakeholder analysis (these are suggestions not requirements) You need to
describe the step by step process of your plan. There should also be a discussion with
evaluative commentary. You should highlight any strengths and acknowledge any
limitations of your plan. Evaluating the success of the innovation You need to return to the
aims and outcomes of the innovation plan and discuss how you will know if they have been
achieved. Your discussion should be informed by theory related to evaluation methods as
well as give practical examples of measure or data collection tools that could be used.
Chapter 2. Literature Review 2.1. Introduction This paper planning to explores a proposed
Innovation and expliontes on a strategy. wpich may optimally contribute to resolving the
problem of falls in the inpatient settings: The use of a yellow wristband to identify the
inpatients at high risk of folls. CMU Prevention of Pressure Ulcers in Palliative PatientsThe

5. purpose of this literature review is to critically analyse and synthesise the relevant
literature on this topic and the consequent review will underpin the construct of project
proposal The Problem.Intervention-Comparison-Outcome (PICO) framework, as
recommended by Gerrish and Lacey (2010) forms the basis of the current literature review
Gerrish and Lacoy (2010) explain that the PICO framework) works well for questions about
healthcare Interventions”. PICO is particularly useful in formulating questions about the
offectiveness of a particular intervention (Moule & Goodman, 2013). It is also useful for
collating quantitative questions, answered with numerical data (Houset. 2012). This project
has utilized both these tools in the review, The problem (P) explored in this review is falls in
the inpatient settings. The intervention (1) and comparison (C) refer to the foll’s prevention
strategios generally, and colour coded wristbands for high-risk patients specifically – versus
no fail’s prevention THARAMA in in the center les into the LIELM D Rare Man ** A. EA
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handige le Sublime effectiveness of a particular intervention (Moule & Goodman, 2013). It is
also useful for collating quantitative questions, answered with numerical data (Houset,
2012). This project has utilized both these tools in the review. The problem (P) explored in
this review is falls in the inpatient settings. The intervention (1) and comparison (C) refer to
the tall’s prevention strategies – generally, and colour- coded wristbands for high-risk
patients specifically – versus no fall’s prevention strategies. The outcome (o) is the
number/rate of falls, and also indicates the consequences of falls (for example, injury to the
patient or extended hospitalization) CMU Prevention of Pressure Ulcers in Palliative
Patients