Part 1 Interest RatesMacroeconomic factors that influence inter.docx

Part 1: Interest Rates
Macroeconomic factors that influence interest rates in general
The variables influencing microfinance interest rates for MFIs
can be characterized into two general gatherings: 1) interior –
the components MFIs can impact: for example work costs,
specialized help, creations; or 2) outer – political risks, full
scale factors, authoritative risk, and four fundamental parts
reflected in the microfinance interest rates: working costs, cost
of assets, advance misfortune costs, and benefit. Working
expenses speak to around 60 % of the all out MFI costs and
generally rely upon the credit size, age, area and customer's
appraising, and so on.
Macroeconomic factors is your industry most sensitive
Like most businesses, the carrier business is affected by the
monetary cycle's pinnacles and troughs. The present
development in created economies—like the U.S. that is driven
by the extricating money related strategy—has brought about an
ascent in business certainty, mechanical creation, and universal
exchange.
Impacts on the interest rates experienced within your chosen
industry
In any industry, the economy assumes a urgent job that
incorporates the general development of the division, and
common flight, with the ever-developing interest, is no special
case. To give a major picture, Airbus GMF 2016 evaluations the
20-year interest for new traveler and cargo airplane to be a little
more than 33,000 airplane comprising a market estimation of
over USD $5.2 trillion underlining and setting up the effect of
market development.
Part 2: Stock Valuation, Risk and Returns
Stock Valuation. As indicated by the Bureau of Economic
Analysis (or BEA), the genuine total national output (or GDP)
expanded 4% every year in 2Q14 in the wake of diminishing

2.1% in 1Q14. With financial and modern development, work
rates have expanded. This has prompted higher genuine extra
cash.
From Video
My company doesn't have stocks right now, so I'll use Costco
Wholesale as an example to explain the stock valuation. Future
Costco Wholesale Corp stock predictions formula:
P0 = Div1 / (r – g)
P0 = Stock Price;
Div1= Estimated dividends for the next period;
r = Required Rate of Return;
g = Growth Rate
In this formula, we need to know the value of estimated
dividends for the next period; required rate and return as well as
growth rate. Let’s get each number individually.
g: Growth Rate = Retention Ratio x ROE
0.52 x 0.24 = 0.1248
r: Required Rate of Return.
R = D / P0 + g
0.65 / 296.09 + 0.1248 = 0.1269
Div1: Estimated dividends for the next period is 65c. Therefore,
the future Costco Wholesale Corp stock predictions are:
P0 = Div1 / (r – g)
0.65 / 0.0021 = $309.52
The present stock worth and the assessed stock worth utilizing
the Dividend Discount Model is higher on account of the
contenders are attempting to get into the membership segment
showcase. Likewise, Amazon and Sam's club have improved
their online store distribution centers. So all in all, financing an
organization's activity utilizing stock is superior to financing
with securities, since one can anticipate the future patterns and
examples base on the information and math just as the market.
References
Roy, R. (2018). Socio-economic and demographic factors that
contribute to the growth of the civil aviation industry. Procedia

Manufacturing, 19, 2–9.
Cederholm, T. (2014, September 4). Why economic factors
support airline industry growth. Retrieved
from https://articles2.marketrealist.com/2014/09/why-economic-
factors-support-airline-industry-growth/.
List of Publicly Traded Aviation Companies. (2018, July 2).
Retrieved from http://investsnips.com/list-of-publicly-traded-
aviation-companies/.
Heakal, R. (2019, November 18). What Are the Forces Behind
Interest Rates and What Causes Them to rise? Retrieved
from https://www.investopedia.com/insights/forces-behind-
interest-rates/.
PUT YOUR HEADER HERE IN ALL CAPS
v
Reducing the cases of readmissions among patients
by
xxxxxxxxx xxxxxx
Evidence-based Practice Project
Submitted to the Faculty of NUR 49800 Capstone Course in
Nursing
College of Nursing

of Purdue University Northwest,
Hammond, Indiana
in partial fulfillment of course requirements for the degree of
Bachelor of Science
Month, 20xx
© copyright
xxxxxxxxx xxxxxx
20xx
all rights reserved
acknowledgments
Begin optional acknowledgments here.
table of contents
SectionPage
acknowledgments
iii
table of contents
iv
abstract
v
Sections
1. Introduction
xx

2. Review of Literature and Synthesis of the Evidence
xx
3. Plan for Implementation
xx
4. Plan for Evaluation
xx
5. Conclusions, Recommendations and Implications
xx
references
xx
appendices (If Applicable)
Appendix A – Put Title Here
xx
List of tables
TablePage
Table 1 Put Name of Table Here
xx
xx
xx
ABSTRACT
Begin writing abstract here. APA abstracts begin on margin and
do not indent. Please use headings in instructions

SECTION 1
Reducing the cases of readmissions among
patients.
One of the issues that are affecting the healthcare sector
is readmission. When a patient is readmitted, it means that there
is a high possibility that the healthcare practitioners failed to
intervene effectively. A person might be readmitted because he
or she did not fully recover from the previous illness. Also, a
person may be readmitted because healthcare practitioners
might have missed the cause of the illness. Therefore, it means
that they might have administered care that is not in line with
the issue of the patient.
Purpose
The purpose of the research topic is to ensure that the
problem at hand is addressed. The title of the research is trying
to look for ways in which the number of readmission cases can
be significantly reduced. In this case, it becomes evident that
the topic of research or the research is looking for an
intervention to a specific issue. The issue at hand is associated
with readmissions, and the intervention is to reduce the number
of readmission cases. The research also plays an essential role
in informing people or the audience about the issue of
readmission (Zuckerman, Sheingold, Orav, Ruhter, & Epstein,
2016). The healthcare sector has been suffering because of the
increasing numbers of readmissions. When the numbers of
readmissions continue to increase, it means that patients start to
lose faith and trust in the healthcare sector fraternity. When
research focuses on an issue, it does so because it wants people
to know more about the issue and to identify the best ways to
deal with the issue.
Relevance/significance

In the United States, there have been cases of
readmissions, and most of them are associated with
incompetent healthcare practitioners. The significance of the
research is seen in the goals that it helps to meet. The research
is relevant to the course in different ways. First, the research
has focused on an issue that is associated with the healthcare
sector. Therefore it means that the research findings will be
addressing the right audience. Second, the research has taken a
position that is essential in the field of healthcare. Healthcare
practitioners and professionals have a higher calling than only
offering care to patients (Figueroa, Joynt, Zhou, Orav, & Jha,
2017). They are also expected to look for solutions to the
problems that might be affecting patients. The significance of
the research can be tired of the direction and perspective it has
taken. The research is aimed at bringing a solution on the table,
and that means that it will be of benefit to the readers and
targeted audience (Zuckerman et al. 2016). Also, the research
has touched on an issue that is affecting patients not only in the
country but also in different parts of the world. The mentioning
of the problem creates awareness among healthcare practitioners
in different parts of the world.
Potential outcomes
The EBP project looks forward to providing a solution to the
problem at hand. The issue at hand is readmission, and the
project is looking for ways to reduce the number of people who
are readmitted. The outcomes of the project will be to outline
the strategies and methods that healthcare practitioners should
utilize to reduce the causes of readmissions in hospitals.
Clinical question
How effective is providing early discharge plan with
proper discharge education and follow up after discharge among

hospitalized patients of all ages compare to patients who don’t
get right information and no discharge follow up on decreasing
rate of readmission in hospitals?
Section 2
Review of Literature and Synthesis of Evidence
Begin writing here.
PICO Question:
Keywords:
Databases Searched:
Table 1
Summary of Reviewed Evidence
Author(s) and Date of Publication ONLY
Sample/Setting/
Design
Data Collection Tools
Findings/Results
Appraisal of Evidence: Worth to Practice include Strengths,
Weaknesses and Conclusions
Level of Evidence (LOE)

Section 3
Plan for Implementation
Begin writing here.
Table 2
Estimated Timetable Blueprint for Implementation
Task
Estimated Date
of Start
Estimated Date of Completion
Person Responsible

section 4
Plan for Evaluation
Begin writing here.
Table 3
EBP Evaluation Plan
Outcome(s)
Measures/Measurement
Time of Collection/Person Responsible
section 5
Conclusions, Recommendations and Implications
Begin writing here.
References
Figueroa, J. F., Joynt, K. E., Zhou, X., Orav, E. J., & Jha, A. K.

(2017). Safety-net hospitals face more barriers yet use fewer
strategies to reduce readmissions. Medical care, 55(3), 229.
Zuckerman, R. B., Sheingold, S. H., Orav, E. J., Ruhter, J., &
Epstein, A. M. (2016). Readmissions, observation, and the
hospital readmissions reduction program. New England Journal
of Medicine, 374(16), 1543-1551.
APPENDICES
Begin here.
PAGE
IMPLEMENTATION OF A PREVENTION PROGRAM
v
IMPLEMENTATION OF A PREVENTION PROGRAM TO
REDUCE hospital acquired pressure ulcers
by
(name)
Nursing

College of Nursing
Hammond, Indiana
Bachelor of Science
September, 2017
© copyright
kristine de castro
2017
all rights reserved
table of contents
Section Page
table of contents
iii
abstract
iv
Sections
1. Introduction
1
2. Review of Literature and Synthesis of the Evidence
4
3. Plan for Implementation
18
4. Plan for Evaluation
27
5. Conclusions, Recommendations and Implications

34
references
36
List of tables
Table
Page
Table 1 Summary of Reviewed Evidence
9
Table 2 Estimated Timetable Blueprint for Implementation
25
Table 3 EBP Evaluation Plan
30
ABSTRACT
Purpose: The purpose of this evidence based project is to
determine if implementing a pressure ulcer prevention program,
utilizing a multi-component pressure ulcer care bundle, will
result in reducing the occurrence of hospital acquired pressure
ulcers.
PICO question: “In hospitalized adult patients, what is the
effectiveness of a pressure ulcer prevention program (or care
bundle) compared to not having a pressure ulcer prevention
program on reducing the occurrence of hospital acquired
pressure ulcers?”
Significance of the problem: Hospital acquired pressure ulcers
(HAPUs) are a serious and potentially preventable patient safety
concern associated with negative patient outcomes including:
pain, infection, increase hospital stays, and premature mortality.
In addition to negative patient outcomes, hospital acquired
pressure ulcers pose significant financial implications for
healthcare facilities.
Synthesis of the evidence: A review of research and evidence
suggests that an effective pressure ulcer prevention program
should consist of a care bundle of nursing interventions related

to: risk assessment, nutrition, repositioning/mobilization, skin
care, support services/medical devices, and education. In
addition, research studies have demonstrated a reduction in the
occurrence of hospital acquired pressure ulcers as the result of
an evidence based pressure ulcer prevention program.
Recommended implementation for practice change: Sufficient
research supports that the implementation of a pressure ulcer
prevention program will reduce the occurrence of hospital
acquired pressure ulcers. Therefore, this knowledge should lead
to the development and implementation of an evidence based
pressure ulcer prevention program.
Conclusions/recommendations for practice: The
recommendation is to pursue an evidence based pressure ulcer
prevention program. Once developed, the prevention program
should be piloted on a hospital unit with either high risk or high
incidence of HAPUs. The pilot program outcomes will
determine the feasibility of implementing the prevention
program throughout the hospital.
Key words: hospital acquired pressure ulcer, pressure ulcer
prevention program, pressure ulcer care bundle, pressure ulcer
incidence
section 1
Implementation of a Prevention Program to Reduce Hospital
Acquired Pressure Ulcers
Pressure ulcers, also known as pressure injuries or decubitus
ulcers, can be defined as localized injury to skin and underlying
tissue, usually over a bony prominence, due to unrelieved
pressure, friction, or shearing forces. A hospital acquired
pressure ulcer (HAPU) is any ulcer noted 24 hours or more after
hospital admission (The Joint Commission, 2016). HAPUs are a

serious and potentially preventable patient safety concern
associated with negative patient outcomes and high healthcare
costs. Pressures ulcers are a significant patient health issue and
an organizational challenge addressed on a daily basis.
Purpose
The purpose of this evidence based project is to determine if
implementing a pressure ulcer prevention program, utilizing a
multi-component pressure ulcer care bundle, will result in
reducing the occurrence of hospital acquired pressure ulcers.
Relevance
In United States acute care facilities, more than 2.5 million
patients develop pressure ulcers annually, and approximately
60,000 patients die from pressure ulcer complications per year
(Harmon, Grobbel, & Palleschi, 2016). High risk populations
for the development of pressure injuries are individuals with
reduced mobility and physical activity such as older adult,
critically ill, and surgical patients. Pressure ulcers are assessed
and classified from stage I (mild reddening) to stage IV (tissue
loss) to determine the severity of the wound. The development
of a stageable pressure ulcer can interfere with a patient’s
functional recovery, cause pain and infection (e.g. cellulitis,
osteomyelitis, and endocarditis), contribute to increased
hospital stays, and result in premature mortality (The Joint
Commission, 2016). Therefore, a pressure ulcer acquired
during a hospital admission is typically considered an indicator
of the quality of care delivered within the healthcare facility.
In addition to negative patient outcomes, hospital acquired
pressure ulcers pose a significant financial burden on healthcare
facilities resulting from additional treatment and staffing
expenses. Since 2008, the Centers for Medicare and Medicaid
Services announced that the additional costs incurred for
HAPUs will no longer be reimbursed for those patients insured
by either Medicare or Medicaid (Bauer, Rock, Nazzal, Jones, &
Weikai, 2016). A hospital admission involving a pressure ulcer
may incur additional annual charges of up to $700,000. It is

estimated that the medical management of pressure ulcers costs
the US health system $9.1 billion to $11.6 billion per year
(Bauer et al., 2016).
Patient complications and financial implications related to
hospital acquired pressure ulcers has resulted in an increased
focus for Hospital A on prevention strategies to address this
issue.
Potential Outcomes
Hospital A would like to evaluate the effectiveness of
implementing a pressure ulcer prevention program (or care
bundle). The potential outcome of such efforts is a reduction in
the occurrence of HAPUs and ultimately, improvement in the
quality and safety of patient care.
Clinical Question (PICO)
“In hospitalized adult patients, what is the effectiveness of a
pressure ulcer prevention program (or care bundle) compared to
not having a pressure ulcer prevention program on reducing the
occurrence of hospital acquired pressure ulcers?”
Section 2
To address the clinical question (PICO), a review of literature
was performed using the keywords: “hospital acquired pressure
ulcer”, “pressure ulcer prevention program”, “pressure ulcer
care bundle”, and “pressure ulcer incidence”. Five electronic
databases (Joanna Briggs Institute, AHRQ National Guideline
Clearinghouse, CINAHL, Cochrane Library-Cochrane Database
of Systematic Reviews, and Google Scholar) were searched
using database limits (when possible) of “English language”,
"human subjects”, full text, and date range (year 2000 to
present). The search revealed thirteen articles, studies, or
clinical guidelines that provided relevant information regarding
the significance of this issue and/or evidence to analyze the
clinical question. The review of literature evaluated either: (1)
the components/interventions of an effective pressure ulcer
prevention program (or care bundle), or (2) the reduction in

hospital acquired pressure ulcers due to implementing a multi-
component pressure ulcer prevention program. In support of
this project, nine articles were used to address the clinical PICO
question: “In hospitalized adult patients, what is the
pressure ulcers?”
Literature Common Themes
The analysis of the articles revealed the common topics of: a
care bundle definition, effective components of a care bundle
prevention program, and the impact on the occurrence of
hospital acquired pressure ulcers.
Definition of care bundle. The literature discusses that an
effective pressure ulcer prevention program consists of multiple
nursing interventions or a care bundle. A care bundle is an
evidence based practice protocol that groups several evidence-
based practices together to address a specific procedure,
symptom or treatment (Downie, Perrin, & Kiernan, 2013).
Furthermore, the bundle should be constructed as a unit of care
implemented for every patient, on every occasion. A care
bundle that is consistently used as a cluster of treatments will
have a greater effect on positive patient outcomes.
Components of care bundle prevention program. Evidence
consistently demonstrates that there are various components to
an effective care bundle designed to prevent pressure ulcer
development. According to The Agency for Healthcare
Research and Quality (2014), evidence based recommendations
for the prevention of HAPUs would include nursing
interventions for nutrition, repositioning/early mobilization,
support services, and medical devices. The Joanna Briggs
Institute (2008) outlines evidence based best practices for the
prevention of pressure ulcers within the following categories of
care: risk assessment, nutrition, repositioning, and support
services. Additionally, the National Pressure Ulcer Advisory
Panel (2016) has recently released a checklist entitled Pressure

Ulcer Prevention Points which outlines key areas to address for
prevention: risk assessment, nutrition,
repositioning/mobilization, skin care, and education.
Reduction in hospital acquired pressure ulcers. Various studies
provided consistent evidence on the effect of a multiple
component pressure ulcer prevention program in the reduction
of hospital acquired pressure ulcers. A systematic review of 39
hospitals worldwide that implemented such programs revealed
that in 31 of the hospitals the overall PU incidence decreased
with the introduction of the interventions (Soban, Hempel,
Munjas, Miles, & Rubenstein, 2011). Another systematic
review (involving 18 acute care settings and 8 long-term care
settings) by Sullivan and Schoelles (2013), also resulted in a
statistically signification reduction of pressure ulcer rates in 11
of the 26 reviewed hospital studies with a median pressure ulcer
reduction rate of 67% to 100%. In addition, findings from a
single study involving the implementation of a pressure ulcer
prevention care bundle within 19 units of a Magnet hospital
revealed a reduction in HAPUs. Specifically, prevalence of
HAPUs was reduced from 6.63% (six months prior to the study)
to 2.47% (six months after the study) (Mallah, Nassar, & Badr,
2015). Finally, in a study involving an intensive care unit
within an Australian tertiary hospital, the incidence of pressures
ulcers was less in the intervention group (18.1%) using a
pressure ulcer prevention protocol as compared to the control
group (30.4%) receiving standard skin care practices (Coyer et
al., 2015).
An inconsistent finding did occur in a multi-hospital
randomized control trial utilizing a patient centered pressure
ulcer prevention program. A reduction in the number of
HAPUs did occur between patients receiving the care bundle as
compared to those who received standard care. However, once
disease process factors and hospital grouping factors were
analyzed at the patient level, no statistically significant effect
of the prevention interventions on pressure ulcer incidence
occurred. The authors believed this was potentially due to the

small number of clusters used in the study (Chaboyer et al.,
2016).
Existing Knowledge Gaps
When analyzing the various studies, some gaps in knowledge
(or necessary research) were discussed. For example, future
research should report strategies to continue the momentum of
the prevention programs once started given the persistent
significance in morbidity and mortality of pressure ulcers
(Sullivan and Schoelles, 2013). Additionally, research should
be performed on how nursing staffing levels influence a
pressure ulcer prevention program and incidence of HAPUs
(Soban et al., 2011). Lastly, more experimental rather than
descriptive studies should be performed to strengthen the level
of findings in these topic areas.
Findings
Given the review of literature, evidence suggests that an
effective pressure ulcer prevention program should consist of a
care bundle of nursing interventions. The care bundle
interventions can be categorized by: risk assessment, nutrition,
repositioning/mobilization, skin care, support services/medical
devices, and education. Additionally, sufficient research
supports that the implementation of a pressure ulcer prevention
program does reduce the occurrence of hospital acquired
pressure ulcers.
PICO Question: “In hospitalized adult patients, what is the
pressure ulcers?”
Key words: hospital acquired pressure ulcer, pressure ulcer
prevention program, pressure ulcer care bundle, pressure ulcer
incidence
Databases Searched: CINAHL, Cochrane Library, Joanna Briggs
Institute, AHRQ National Guideline Clearinghouse, Google
Scholar
Table 1

Design/ Setting/ Sample
Findings/Results
Appraisal of Evidence: Worth to Practice (include Strengths,
Weaknesses and Conclusions)
Agency for Healthcare Research and Quality (2014)
Design:
Clinical practice guideline
Setting:
Various worldwide studies
Sample:
N=356 papers (newly included papers from 2008-2013 since the
guideline builds on a previously published body of evidence)
Numerous databases were searched for pressure ulcer studies.
Studies included in the analysis are: randomized control trials
(RCTs), controlled clinical trials, quasi-experimental, cohort,
cross-sectional, surveys prevalence/ incidence, case-control,
and case
series.
The guideline outlines evidence based recommendations for the

prevention (and treatment) of pressure ulcers within the
following categories: nutrition, repositioning/early
mobilization, support services, and medical devices.
Strengths:
Clinical practice guideline is the highest level of evidence.
Expert consensus is used to formulate the recommendation.
Strength of the evidence and the strength of the
recommendations is provided.
Weaknesses:
HAPU incidence data (associated with interventions) is not
provided. However, the guideline does indicate that a reduction
in HAPU was a major outcome considered when evaluating the
effectiveness of the intervention.
Conclusions:
The clinical guideline outlines recommended evidence based
interventions that should be considered for inclusion in a
pressure ulcer prevention program.
LOE:
Level I
(clinical practice guideline)
Chaboyer, W., Bucknall, T., Webster, J., McInnes, E., Gillespie,
B., Banks, M., & . . . Wallis, M. (2016)
Design:
Cluster randomized controlled trial (RCT)
Setting:

Eight tertiary hospitals (with greater than 200 beds each) in
three Australian states
Sample:
N=8 tertiary referral hospitals
(4 clusters allocated to intervention group and 4 clusters
allocated to control group)
800 patients within each cluster consented to participate in the
study.
Data was collected using tablet computers by two research
assistant groups (RNs and other clinicians) at each hospital site.
Collected patient data included:
1. Baseline demographic and clinical data (including diagnosis
and risk factors for pressure ulcers).
2. Daily patient skin status and pressure ulcer strategies
including repositioning, nutrition, pressure relieving devices,
and skin care products.
The intervention group received the pressure ulcer prevention
care bundle (based on patient participation and clinical practice
guidelines) and the control group received standard care.
1. 6.1% of patients in the intervention group developed a HAPU
and 10.5% in the control group developed a HAPU.
2. However, once disease process factors and hospital grouping
factors were analyzed at the patient level, no statistically
significant effect of the prevention interventions on pressure
ulcer incidence occurred.
3.There was a 52% reduction in the risk of a HAPU associated

with the intervention group compared with standard care control
group.
Strengths:
Multi-site RCT of patient centered pressure ulcer prevention
care bundle targeting patient and staff behaviors.
Hospitals were randomized using a central randomization
independent service to avoid selection bias.
Weaknesses:
Low statistical relevance due to the small number of clusters
used in the study.
Conclusions:
No statistically significant effect of the pressure ulcer (patient
centered) care bundle on pressure ulcer incidence once
prognostic factors and clustering had been accounted for at the
patient level. Therefore, uncertainty regarding if the
intervention reduced HAPUs relative to usual care.
LOE:
Level II
(cluster randomized controlled trial
Coyer, F., Gardner, A., Doubrovsky, A., Cole, R., Ryan, F.,
Allen, C., & McNamara, G. (2015)
Design:
Controlled before and after study
Setting:

36 bed adult ICU in an Australian tertiary referral hospital
Sample:
N=207 ICU patients (102 control group patients receiving
standard skin care practices and 105 intervention group
receiving Inspire protocol)
Research nurses were employed and trained for data collection.
A data collection form was used to collect patient data
including: demographic variables, skin assessment data, tools
for staging ulcers, and process care interventions for pressure
injury prevention using the Inspire protocol.
The Inspire protocol has interventions for: skin assessment, skin
hygiene, repositioning, mobility, and nutrition)
1. Cumulative incidence of pressure injuries was significantly
lower in the intervention group (18.1%) compared to the control
group (30.4%) for skin injuries (x2=4.3; p-.04).
2. Significantly fewer pressure injuries developed over time in
the intervention group.
Strengths:
The study has a control and intervention group.
Weaknesses:
Randomization did not occur when placing patients in the
control or intervention group since the study was done in
phases.
Conclusions:
Patients receiving the pressure ulcer prevention Inspire protocol
had a lower incidence of pressure injuries.

LOE:
Level III
(controlled before and after study)
Mallah, Z., Nassar, N., & Badr, K. (2015)
Design:
Prospective
cohort study
Setting:
Data collected from 19 units (including medical, surgical,
oncology, and ICUs) at a 300 bed Magnet hospital in Lebanon
Sample:
N=486 inpatients
Data was collected on participating units by 20 RN project
champions, 2 wound specialists, & 2 RN quality improvement
managers.
Collected patient data included:
1. Braden score on admission
2.Use of pressure ulcer preventative strategies (yes/no)
(repositioning, skin care, nutritional support, pressure
redistribution mattress) per the INTACT care bundle)

3. Patient demographics (age, gender, diagnosis, and length of
stay)
1. Of the sample patients at risk for pressure ulcers, 81% had a
documented prevention strategy, 76% had repositioning done,
78% had skin care, 87% had nutritional support, and 73% were
placed on pressure redistribution mattresses.
2. Prevalence of HAPU was reduced from 6.63% (6 months
prior to study) to 2.47% (6 months after the study).
3. Sensitivity of the Braden scale in predicting a HAPU was
92.3% (% of patient at risk for pressure ulcers and developed
one) and specificity was 60.04% (% of patients not at risk for
pressure ulcer and did not develop one).
4. Multiple logistical regression demonstrated skin care and
Braden scores are two factors that significantly predict the
development of a HAPU.
Strengths:
The study had a powered sample size with 486 patients (N=150
in similar studies).
Interventions were documented by well-trained RN champions.
The study followed the NDNQI (National Database of Nursing
Quality Indicators) guidelines for preventative pressure ulcer
interventions.
Weaknesses:
The design of the study was a descriptive design rather than
experimental design (subjects were not randomized and no
control group).
Study relied on nursing notes that preventative interventions
were performed.

Conclusions:
The study applied a multi-modal program to prevent pressure
ulcers. The interventions included a bundle of care performed
by the nursing staff during routine care practice. The prevalence
of HAPUs was reduced.
LOE:
Level IV
(prospective
cohort study)
National Pressure Ulcer Advisory Panel (NPUAP) (2016)
Design
Expert opinion
Setting
Not applicable
Sample
Not applicable
Information is not published as to the research and data
collection process for the development of the guideline.
The Pressure Injury Prevention Points document created by the
NPUAP recommends pressure ulcer prevention nursing
interventions within the following areas: risk assessment, skin
care, nutrition, repositioning/mobilization, and education.
Strengths:
The guideline is developed by the NPUAP which is a non-for
profit professional organization composed of experts from
different health care disciplines whom share a commitment to
the prevention and management of pressure injuries.
The Joint Commission uses this guideline as the basis for their

publication (Quick Safety) for strategies to prevent pressure
ulcers.
Weaknesses:
Information is not provided as to the research studies used as
the basis for the guideline.
Conclusions:
The NPUAP is a reputable organization, and the guideline
provides valuable information for the components of a pressure
ulcer prevention program.
LOE:
Level VII
(Guideline based on opinion of expert committee-NPUAP)
Soban, L., Hempel, S., Munjas, B., Miles, J., & Rubenstein, L.
(2011)
Design:
Systematic review
Setting:
Hospital settings throughout the world
Sample:
N=39 studies representing 9 different countries
Six electronic databases were searched for publications from
1990-2009 to find studies using the following criteria: hospital
setting, experimental design (e.g. RCTs, cohort, pre-post),
testing of a quality improvement intervention to change
pressure ulcer prevention care, and at least one outcome

measure.
Selected studies were appraised of quality based on 8 criteria
published by Center for Reviews and Dissemination.
1. 31 studies reported a patient outcome measure that reflected
PU incidence. The pooled risk difference across studies was -
.07 (95% confidence interval; p<.0001) indicating overall PU
incidence decreases after the interventions
2.Majority of the studies used multiple intervention strategies in
combination with educational and quality improvement
strategies.
3. Most commonly reported pressure ulcer interventions were:
implementation of protocol-based care, staff education, risk
assessment, performance monitoring (collection of outcome
data), assembly of new team for intervention, use of new
equipment/process for beds/support surfaces, and new
intervention based on published guidelines.
Strengths:
The quality of each study was assessed using 8 criteria
published by the Center for Reviews and Dissemination.
Weaknesses:
Nearly all the studies included in the review were of lower level
of evidence since they were a simple before and after study
design without a control group/randomization.
Conclusions:
The findings suggest that multi-component prevention programs
aimed at pressure ulcer reduction may improve patient outcomes
by reducing the overall incidence of HAPU.
LOE:

Level IV
(systematic review of primarily non-experimental studies)
Sullivan, N., & Schoelles, K. (2013)
Design:
Systematic review
Setting:
Acute care settings within the United States (18 studies) and
long-term care settings (8 studies)
Sample:
N=26 studies
Studies analyzed in the systematic review included: time series
quasi-experimental (majority of the studies), RCTs, and
controlled before/after.
1. In the 18 hospital studies, multiple patient care interventions
were used to reduce patient risk for pressure ulcers. Initial and
repeated risk assessments were preformed (e.g. Braden Scale)
followed by tailored interventions based on risk
category/factors. Interventions included: support surfaces,
repositioning/mobility, skin management (e.g. care products,
incontinence interventions), friction reduction (via mechanical
means), and nutrition (assessment, interventions, and
hydration).
2. 24 of the 26 studies report some improvement in pressure
ulcer rates.

3. Statistically significant reductions in pressure ulcers rates
were reported in 11 of the 26 studies with the median reduction
of 82% (range: 67% to 100%).
Strengths:
Studies analyzed were assessed for quality using a the 19-item
SQUIRE (Standards for Quality Improvement Reporting
Excellence) guideline.
Weaknesses:
The systematic review is primarily of quasi-experimental
studies (level III) rather than RCTs (level I).
Conclusions:
Evidence suggests that implementing multicomponent initiatives
for pressure ulcer prevention in acute care settings can improve
quality of patient care and reduce pressure ulcer rates.
LOE:
Level III
(systematic review of primarily quasi-experimental studies)
Tayyib, N., & Coyer, F. (2016)
Design:
Systematic Review
Setting:
Intensive Care Units (ICUs) throughout the world
Sample:

N=24 studies
Six electronic databases were searched for publications from
2000-2015 to identify studies involving the effectiveness of
single interventions designed to reduce the incidence and
prevalence of HAPUs in intensive care units
Study interventions were appraised of quality using the Joanna
Briggs Institute Meta-Analysis of Statistics Assessment and
Review Instrument.
1. Interventions reviewed across studies for pressure ulcer
prevention interventions included: risk assessment, preventative
skin care, emerging therapies (polarized light and dressings),
nutrition, repositioning/early mobility, support surfaces,
medical device impact, and education.
2. Research findings identified that the use of a silicon foam
dressing intervention reduced the occurrence of HAPUs.
3. In individual studies addressing the use of one intervention
(related to nutrition, skin-care regime, position/repositioning,
support surfaces, or education), no statistically significant
results lead to the prevention of HAPUs in the ICUs.
4. Further RCTs studies are needed with a standardized criterion
for reporting on each pressure ulcer prevention intervention.
Strengths:
Study interventions were appraised of quality using the Joanna
Briggs Institute Meta-Analysis of Statistics Assessment and
Review Instrument.
Weaknesses:
There is uncertainty in the interpretation of many studies due to
small underpowered sample sizes with wide confidence
intervals.

Conclusions:
Research findings identified that the use of a silicon foam
dressing intervention reduced the occurrence of HAPUs. Other
single intervention studies did not demonstrate an impact on
HAPU incidence. This systematic review supports the concept
that HAPU prevention is more effective using multiple
interventions within a care bundle.
LOE:
Level IV
(systematic review of RCTs, quasi-experimental, and
comparative studies)
The Joanna Briggs Institute. (2008)
Design:
Clinical practice guideline
Setting:
Hospitals settings throughout the world
Sample:
N=4 systematic reviews (published between 2003-2006)
The 4 systematic reviews included in the bet practice sheet
reviewed the effectiveness of risk assessment scales,
repositioning, support surfaces, and nutritional supplements for
pressure ulcer prevention.
The guideline outlines evidence based best practices for the

prevention of pressure ulcers within the following categories:
risk assessment, repositioning, support services, and nutrition.
Strengths:
Clinical practice guideline is the highest level of evidence.
Recommendations are graded based on effectiveness.
Weaknesses:
HAPU incidence data (associated with each intervention) is not
provided.
Conclusions:
The guideline is recommended evidence based interventions that
should be considered for inclusion in a pressure ulcer
prevention program.
LOE:
Level I
(clinical practice guideline)
Section 3
Hospital A has recently seen an increase in the occurrence of
hospital acquired pressure ulcers. Furthermore, the Centers for
Medicare and Medicaid Services (CMMS) will no longer
reimburse additional medical expenses for Medicare or
Medicaid patients that develop a pressure ulcer during their
hospital stay. As a result, there is an intensified interest within
the facility to implement an evidence-based approach to

improve this quality indicator, eliminate the costs associated
with HAPUs, and ultimately improved the quality and safety of
patient care.
To implement evidence based practice (EBP), it is useful for the
project team to follow a framework or proven model. Once
such model is the PARIHS (Promoting Action on Research
Implementation in Health Services) framework which is based
on three categories (evidence, context, and facilitation) that are
key to a successful EBP implementation (Rycroft-Malone,
2004). The first component, evidence, involves the project’s
utilization of gathered research as well as clinical and patient
experience. Given the preceding review of literature, evidence
does appear to support the decrease in HAPUs through the
implementation of a multi-component (or care bundle)
prevention program. Additionally, clinical and patient
experience will be considered in the following “Stakeholders”
discussion. The second component in the PARIHS framework,
context, is related to the environment or facility where the new
practice will be implemented. Context dictates that the
facility’s culture and leadership needs to be considered in the
implementation plan; therefore, these aspects of the
implementation will be addressed in the following discussion of
“Organizational Fit” and “Barriers to Implementation”. Lastly,
the facilitation component of the PARIHS model relates to
assisting individuals in understanding the change required to
implement EBP. This element will be addressed in the
“Facilitation Strategies for EBP Implementation” and
“Resources Needed” discussion.
Stakeholders
Hospital A’s target population for the project is all patients
admitted to the medical center. The stakeholders for this
project are those individuals who are affected by or influence
the implementation of the pressure ulcer prevention program.
In particular, the active stakeholders (those who have a critical
role in making the project happen) will include: hospitalized

patients, staff nurses/nurse assistants, physicians, unit nursing
managers/directors, and clinical nurse educators. The passive
stakeholders (not actively involved in project but promote its
success) will include: nursing administration (including the
Chief Nursing Officer), quality improvement management, and
risk management.
A multidisciplinary PUP (pressure ulcer prevention) support
team will be established which will consist of core individuals
consistently working on the project to ensure its success. This
team will be comprised of: a team lead, a EBP mentor (a nurse
educator with an EBP certification), a group of volunteer PUP
nurse champions, a wound care nurse, a physician
representative, a registered dietician, a quality improvement
representative, a risk management representative, a finance
representative, a supplies management representative, and an
information technology representative. The non-clinical
members of the support team will be called upon as necessary to
address aspects of the project associated with their respective
departments.
To launch the project successfully, there are various hospital
personnel that will need to be persuaded for support. This
would include: nursing administration, physician
administration, the wound care department, the finance
department (e.g. financial analyst or financial controller), the
quality improvement department, and risk management. Once
there is initial approval to explore this EBP project at the
nursing unit management level, then the next step would be to
seek approval from the other indicated areas as soon as
possible. The recommended strategy for informing these areas
would be for one or more members of the PUP support team
(e.g. PUP team lead and EBP mentor) to meet one-on-one with
these respective areas to explain the recent increase in HAPUs,
to describe the EBP project/potential outcomes, and to seek
support. Once the necessary project approvals are gained, a
PUP unit pilot is complete, and approval is received for hospital

wide implementation, then all clinical hospital personnel will
need to be informed of the project thru an email communication,
unit meetings, and project support signage (e.g. professional
posters and pamphlets).
Organizational Fit
The pressure ulcer prevention program is a hospital wide
initiative; therefore, the project itself should correlate with
Hospital A’s mission, vision, and values. The hospital’s
mission statement is “to advocate the health of our communities
by providing outstanding healthcare services”. One of the
project outcomes of the EBP proposal is improvement in the
quality of patient care. This outcome correlates directly with
providing outstanding healthcare services within the
community. The hospital’s vision statement is “to be a locally
responsive, regionally relevant health system”. The creation of
a pressure ulcer prevention program is in response to an
increase in HAPUs. By addressing the issue via this project, the
hospital is demonstrating local responsiveness by providing
quality community healthcare services. Lastly, the values
statement of the hospital follows the mnemonic: D.R.I.V.E.
(determination, respect, integrity, vision, excellence, and
nurturing). All of these values will be addressed thru this EBP
project since the hospital will be demonstrating that it is: (1)
determined to improve patient outcomes; (2) committed to
respecting the patients need for quality care related to pressure
ulcers, (3) persistent in their integrity by taking action to
address the HAPU issue, (4) exhibiting vision to implement the
latest evidence based pressure ulcer prevention care, (5)
displaying excellence by continually focusing on patient-
centered care, and (6) cultivating a nurturing environment
through the utilization of evidence based prevention
interventions that result in positive patient outcomes .
Hospital A has recently implemented a prevention program
to prevent hospital acquired infections (HAIs). The project
was evidence based and did result in a reduction in occurrence

of HAIs. The PUP project will review this project’s overall
outcomes, findings, and “lessons learned” to gain insight when
planning the PUP implementation.
Barriers to EBP Implementation
One of the potential barriers to implementing the EBP
project is the potential concern of clinical providers
(specifically staff nurses and nurse assistants) that the pressure
ulcer care bundle could result in an increase in their daily
workloads. The care bundle will result in additional nursing
interventions as compared with current standard practice. For
the project to be successful, the unit nursing managers will need
to be supportive of the project and be willing to work with the
PUP support team to determine strategies to address this
concern.
A second possible barrier is that some clinicians may be
resistant to change, since they have been in the nursing industry
for many years, and prefer routine care rather than new
protocols based on evidence. PUP training will need to address
this barrier as it will demonstrate the need for change to
improve the quality and safety of patient care. Furthermore,
nurse competency return demonstrations should also be part of
the training program to ensure that all nurses understand the
new care bundle and are comfortable in implementing the
change into practice.
Facilitation Strategies for EBP Implementation
The PUP support team’s goal through facilitation is to enable
the implementation of the program so that it is successful. One
strategy in doing this is to have the support team’s “EBP
mentor” role filled by a nursing clinical educator that has a
certification in evidence based practice. This will allow a key
team member to possess the knowledge and skills to aid an EBP
project implementation.
Another facilitation strategy for the implementation is to
solicit nurse champions on the PUP support team that already

have experience with evidence based project implementations.
For example, the evidenced based HAI prevention program was
successfully implement at Hospital A. Therefore, if possible,
the PUP support team should solicit nurses involved with that
project’s support team to become a member of the PUP support
team.
Another facilitation strategy is for the information
technology representative (on the PUP support team) to work
with PUP nurse champions to automate the pressure ulcer care
bundle checklist and PUP care plan documentation into the
electronic medical record (EMR). Upfront planning for this
task will be essential so that the electronic documentation
required for the new care bundle interventions is well
developed, streamlined, and efficient for the nurses and nurse
assistants.
Lastly, an additional and very important strategy for this
project is to pilot the PUP program within a hospital unit that is
either at high risk for pressure ulcer development or has a high
incidence of HAPUs. The pilot program will allow the PUP
support team: to test the new care bundle and implementation
strategy; to gain project feedback; to review project outcomes;
and to determine the feasibility of implementing the program
hospital wide.
Resources Needed
Numerous resources will be required for the success of the
pressure ulcer prevention program. Financial funding will be a
critical resource required for this EBP project and will be
needed for items such as: (1) education and training expenses
(e.g. facility and printing expenses), (2) information technology
modifications (e.g. addition of care bundle interventions/care
plans into the EMR), and (3) new patient supplies (e.g. new
foam dressings, mattress changes, mobility devices). Another
required resource is the additional personnel time required for
the project including: (1) non-clinical time for staff meetings to

introduce/explain the project, (2) non-clinical time for
training/education of staff members, (3) non-clinical time for
PUP support team member project tasks, and (4) leadership time
to monitor and support the team.
Approval for these resources will be required on a smaller
scale initially (from nursing management and finance
department) for the PUP unit pilot. Once the unit pilot is
complete, the pilot outcome data and research evidence can be
used to outline a cost/benefit analysis for senior hospital
administration. This analysis will demonstrate if the overall
patient care benefit and cost savings will make the PUP project
feasible to implement hospital wide.
Table 2
Task
Estimated Date
of Start
Person/s Responsible
Gain approval from nursing management and Finance
department for PUP project concept and pilot unit funding
9/25/17 (2 weeks)
10/6/17
· EBP Mentor
· Student
· Nursing Management
· Finance Department
Note: It is assumed in the remaining tasks that the “student”

will be a part of the PUP support team as a volunteer nurse
champion.
· Identify PUP support team roles and responsibilities
· Solicit PUP support team members
10/9/17 (2 weeks)
10/20/17
· PUP team lead
· EBP Mentor
Solicit approval for PUP project via one-on-one meetings with
key departments needed for project support
10/23/17 (3 weeks)
11/10/17
· PUP Team Lead
· EBP Mentor
· Determine PUP pilot unit
· Solicit PUP nurse champions from the pilot unit
11/13/17 (1 week)
11/17/17
· PUP Team Lead
· EBP Mentor
Determine the evidence based nursing interventions that will be
a part of the new PUP care bundle:
· Analyze current pressure ulcer prevention interventions
· Review evidence based pressure ulcer nursing interventions
from literature/research review
· Finalize new PUP care bundle
· Solicit approval from Nursing Management

11/20/17 (8 weeks)
01/12/18
· PUP Team Lead
· EBP Mentor
· PUP Support Team
· Nursing Management (for approval)
· Determine EMR modifications required for the PUP care
bundle
· Design/Test EMR modifications
1/15/18
(6 weeks-concurrent task)
2/23/18
· PUP support team
· Determine new/changes in patient supplies required for the
PUP program
· Procure new supplies
1/15/18
2/23/18
· PUP support team
· Determine education and train materials for the pilot unit

· Design/create education and training material
2/26/18 (3 weeks)
3/16/18
· PUP support team
Meet with pilot unit to explain: HAPU issue, PUP project pilot,
and project outcome measures
3/19/18 (1 week)
3/23/18
· PUP Team Lead
· EBP Mentor
Provide training to the PUP pilot active stakeholders on the new
PUP care bundle and pilot rollout
3/26/18 (1 week)
3/30/18
· PUP Team Lead
· EBP Mentor
· PUP Support Team
Launch/implement 6-month PUP program in the pilot unit
4/2/18 (24 weeks)
9/28/18
· Pilot Unit
· PUP Team Lead

· EBP Mentor
· PUP Support Team
Measure/document pilot program outcomes
4/2/18
9/28/18
· PUP Team Lead
· PUP Support Team
Prepare and present to senior hospital management pilot
program outcomes, research evidence, and cost/benefit analysis
to determine feasibility of hospital wide PUP program
implementation
10/01/18 (2 weeks)
10/12/18
· PUP Team Lead
· EBP Mentor
section 4
Plan for Evaluation
Research evidence does supports that an evidence based
pressure ulcer prevention program will result in a decrease in
the occurrence of hospital acquired pressure ulcers. The

following discussion will provide information as to the baseline
data and outcome indicators (Table 3) that will be used to
evaluate the success of the proposed pressure ulcer prevention
program.
Baseline Data
Base line data is important to collect for the PUP unit pilot as
it demonstrates Hospital A’s performance data prior to
implementing the pressure ulcer practice change. According to
the Agency for Healthcare Research and Quality (2015),
pressure ulcer rates are the most direct measure of how well a
pressure ulcer prevention program is succeeding in averting
pressure ulcers. Given this, the baseline data that will be
collect for the pilot unit will include: (1) pressure ulcer
incidence rate (the number or percentage of patients developing
new pressure ulcers after admission), and (2) pressure ulcer
prevalence rate (the number or percentage of people having a
pressure ulcer on admission or after admission). Incidence rates
provide the most direct evidence of the quality of a prevention
program; however, prevalence rates can provide a useful
snapshot of the pressure ulcer burden within a hospital and
therefore should be collected as well (Agency for Healthcare
Research and Quality, 2015).
At Hospital A, the pressure ulcer incidence and prevalence
rates are currently being tracked manually by the staff nurses
and nursing unit manager. When a staff nurse notes the
development of a pressure ulcer for their patient, the
information is noted within the assessment notes in the EMR
(electronic medical record) and then the information is
manually logged into the unit’s pressure ulcer incidence and
prevalence log. The nursing unit manager then uses this manual
log to notify (via an email) the risk management and quality
management departments. The risk management department
then uses the log data and enters the information into their risk
management system so that a monthly report can be generated to
track pressure ulcer incidence and prevalence data hospital
wide.

For the PUP unit pilot baseline data, pressure ulcer
incidence and prevalence data will be collected for six months
prior to beginning the pilot. The staff nurses and nursing unit
manager will continue their current processes of logging
incidence/prevalence information. Additionally, PUP support
team members (EBP team lead, Nursing Unit Manager, and Risk
Management representative) will work together to gather and
review the pilot unit’s baseline incidence and prevalence
monthly reports from the risk management system.
Interpretation of Data
During the 6-month pilot implementation, monthly pressure
ulcer incidence and prevalence rates will continue to be
gathered and monitored by the PUP support team (see Table 3:
EBP Evaluation Pan for a detailed explanation of the data
collection process). After completion of the pilot, the baseline
pre-implementation rates can be compared to the pilot post-
implementation rates to determine if the pressure ulcer
prevention program is effective in reducing hospital acquired
pressure ulcers. Specifically, the project outcome indicators are
as follows:
· Within 6 months of the pilot program implementation, the
pressure ulcer (PU) incidence rate will decrease by 15% for the
pilot unit. (The pressure ulcer incidence rate will provide the
most direct evidence of the quality of a prevention program
since it measures pressure ulcers after admission.)
· Within 6 months of the pilot program implementation, the
pressure ulcer (PU) prevalence rate will decrease by 18% for
the pilot unit. (This rate will measure pressure ulcers on
admission and after admission. It is a useful measure since it
will indicate if the PUP program is assisting in
reducing/resolving the “on admission” pressure ulcers as well.)
· At the end of the 6-month pilot program, the return on
investment for the unit pilot will be a minimum 20%. (This
indicator is important for the PUP support team to demonstrate
to senior hospital administration that the additional hospital
expenses incurred from the PUP program will result in positive

financial outcomes for the hospital.)
Table 3
EBP Evaluation Plan
Outcome(s)
Measurement
Data Collection Process/ Time of Collection/
Person Responsible
1. Pressure ulcer incidence rate
Within 6 months of the pilot program implementation, the
pressure ulcer (PU) incidence rate will decrease by 15% for the
pilot unit.
2. Pressure ulcer prevalence rate
Within 6 months of the pilot program implementation, the
pressure ulcer (PU) prevalence rate will decrease by 18% for
the pilot unit.
Measurement Definition:
Pressure ulcer incidence rate is the number or percent of
patients (on the pilot unit) developing a new pressure ulcer
since admission onto the unit.
For the pilot, the calculation is as follows:
PU incidence rate=
(No. of patients that developed a new pressure ulcer) / (No. of
patients admitted on the unit for the same month) x 100
Pressure ulcer prevalence rate is the number or percent of
patients having a pressure ulcer on admissionplus those
acquired after admission.

PU prevalence rate = (No. of patients with any pressure ulcer
for the month) / (No. of patients on the unit for the month) x
100
Baseline Incidence and Prevalence Measurement:
A 6-month audit of pressure ulcer incidence and prevalence data
will be reviewed for the pilot unit prior to beginning the pilot.
This information is currently being manually sent to the risk
management department who then generates a monthly PU
incidence report.
Outcome Incidence and Prevalence Data Measurement:
During the pressure ulcer prevention program pilot, a 6-month
audit of monthly pressure ulcer incidence and prevalence data
will be compiled based on the monthly PU incidence and
prevalence report (see Data Collection Process).
The 6 months of baseline pre-implementation data will be
compared to the 6 months of post implementation data through
the creation of two bar charts (one for incidence data and one
for prevalence data). The bar charts will then allow analysis to
be performed to determine if the PU incidence and prevalence
rates have decreased as a result of the new pressure ulcer
prevention program. This information will be presented to
senior hospital management and will be used to determine if the
PUP program should be implemented hospital wide.
Data Collection Process:
The process to determine pressure ulcer data during the unit
pilot is as follows:
1. Nurses will perform a new pressure ulcer patient assessment
(as one component of the new PU prevention program) on
admission to the unit and as part of their regular patient
assessment each shift.
2. Nurses will enter the pressure ulcer assessment data into the
modified EMR that will now contain pressure ulcer assessment

data fields including indicator fields for: (1) “pressure ulcer
exists on admission”, and (2) “new pressure ulcer after
admission”.
3. These new indicator fields will send a patient pressure ulcer
alert notification to the nursing unit manager. In addition, the
indicator fields will also be linked (or interfaced) to the risk
management system so that the total number of pressure ulcers
will be maintained within a database.
4. A PU incidence/prevalence report will be generated monthly
from the risk management system outlining the pressure ulcer
data for the month.
Time of Collection:
· Patient pressure ulcer assessment data will be collected and
entered into the EMR daily
· During the 6-month pilot (April 2018-October 2018), monthly
reports will be generated from the risk management system
indicating the pressure ulcer information
Person/s Responsible:
PUP support team members will be responsible for collecting
and monitoring the PU incidence/prevalence data including:
· Nursing staff: will enter PU assessment data into the EMR
· Nursing management/EBP team lead: will monitor the PU
alert notifications and work with the PUP support team/pilot
unit to ensure the nursing staff understands and is following the
new pressure ulcer prevention interventions
· Risk Management/Quality Improvement department
representatives: will produce and monitor the monthly pressure
ulcer incidence/prevalence reports
3. Return on Investment (ROI) for the PUP program
At the end of the 6-month pilot program, the return on

investment for the unit pilot will be a minimum 20%.
The return on investment is used to assess the financial return
on implemented improvement projects.
ROI = (Pilot savings – pilot cost) / (pilot cost) x 100
1. Savings due to PUP program:
· Decrease in Hospital A’s costs associated with HAPUs (e.g.
supplies, medication, personnel)
· Decrease in revenue loss from Medicare not reimbursing for
HAPUs
2. Expenses of PUP program:
· New supplies costs
· Education/training costs
· Personnel labor costs
Baseline Data Measurement:
Baseline data is not calculated for a ROI outcome indicator.
Outcome Data Measurement:
After completion of the pilot, the ROI can be calculated by the
finance department by running expense and savings reports from
their system that tracks this data. This information will be used
to calculate the ROI.
The ROI information outcome will be presented to senior
hospital management and will be used to determine if the PUP
program should be implemented hospital wide.
Data Collection Process:
During the 6-month pilot, the PUP support team members will

provide the EBP team lead with expenses associated with pilot
program. The EBP lead will enter the information into the
finance department’s expense tracking system. In addition, the
savings information will also be derived from data that is
current being tracked in the same system.
Time of Collection:
Data will be collected/provided during the 6-month pilot
program (April 2018-October 2018).
Person/s Responsible:
PUP support team members will collect the data:
· Finance representative: will calculate the ROI outcome based
on savings/expense data provided by team members.
· EBP team lead: will enter expense information into tracking
system
· Supplies Management representative: will provide new
supplies cost
· Nurse Educator: will provide costs associated with
education/training
· Human Resources department: will provide personnel time
associated with the pilot program
section 5
Conclusions, Recommendations, and Implications
The following discussion outlines the conclusions and
recommendations for the EBP proposal to implement a pressure
ulcer prevention program.
Conclusions`
Hospital acquired pressure ulcers are a serious and potentially
preventable patient safety concern associated with negative
patient outcomes and high healthcare costs. The development
of a stageable pressure ulcer can interfere with a patient’s
functional recovery, cause pain and infection, increase hospital
stays, and cause premature mortality. In addition to negative

patient outcomes, hospital acquired pressure ulcers pose a
significant financial burden on healthcare facilities from
additional treatment/staffing expenses and decreased Medicare
reimbursement.
A review of research and evidence suggests that an effective
pressure ulcer prevention program should consist of a care
bundle of nursing interventions. The care bundle interventions
can be categorized by: risk assessment, nutrition,
repositioning/mobilization, skin care, support services/medical
devices, and education. Additionally, sufficient research
supports that the implementation of a pressure ulcer prevention
program does reduce the occurrence of hospital acquired
pressure ulcers.
Recommendations/Implications
Patient complications and financial implications has resulted in
an increased focus for Hospital A on prevention strategies for
hospital acquired pressure ulcers. This proposal suggests the
creation of a pressure ulcer prevention program, consisting of a
care bundle of preventative nursing interventions, to decrease
the occurrence of HAPUs at Hospital A. For this to occur, a
multidisciplinary PUP (pressure ulcer prevention) support team
will be established to consistently work on the project to ensure
its success. Following the development and approval of the new
preventative care bundle, the PUP support team will work
together with one hospital unit to implement a pilot program.
Outcome measures of the pilot program will determine the
feasibility of implementing the program hospital wide. The
pilot project outcome goals will include: (1) a decreased
pressure ulcer incidence rate, (2) a decreased pressure ulcer
prevalence rate, and (3) an acceptable return on investment for
the pilot program. Ultimately, however, these results will
improve the quality and safety of patient care at Hospital A.
Hospital acquired pressures ulcers are a significant patient
health issue and an organizational challenge. By moving
forward with this proposal for the development of an evidence

based pressure ulcer prevention program, Hospital A is directly
following its mission statement “to advocate for the health of
our communities by providing outstanding healthcare services”.
References
Agency for Healthcare Research and Quality. (2014).
Interventions for prevention and treatment of pressure ulcers.
In: Prevention and treatment of pressure ulcers: Clinical
practice guideline. Retrieved from
https://www.guideline.gov/summaries/summary/48865/intervent
ions-for-prevention-and-treatment-of-pressure-ulcers-in-
prevention-and-treatment-of-pressure-ulcers-clinical-practice-
guideline?q=pressure+ulcers
Agency for Healthcare Research and Quality. (2015).
Preventing pressure ulcers in hospitals: A toolkit for improving
quality care. Retrieved from
https://www.ahrq.gov/professionals/systems/hospital/pressureul
certoolkit/index.html
Bauer, K., Rock, K., Nazzal, M., Jones, O., & Weikai, Q.
(2016). Pressure ulcers in the United States' inpatient
population from 2008 to 2012: Results of a retrospective
nationwide study. Ostomy Wound Management, 62(11), 30-38.
Retrieved from http://www.o-wm.com/article/pressure-ulcers-
united-states-inpatient-population-2008-2012-results-
retrospective
Chaboyer, W., Bucknall, T., Webster, J., McInnes, E., Gillespie,
B., Banks, M., & . . . Wallis, M. (2016). The effect of a patient
centered care bundle intervention on pressure ulcer incidence
(INTACT): A cluster randomized trial. International Journal of
Nursing Studies 64, 6463-71.
doi:10.1016/j.ijnurstu.2016.09.015
Coyer, F., Gardner, A., Doubrovsky, A., Cole, R., Ryan, F.,
Allen, C., & McNamara, G. (2015). Reducing pressure injuries
in critically ill patients using a patient skin integrity care
bundle (inspire). American Journal Of Critical Care, 24(3), 199-
210. doi:10.4037/ajcc2015930
Downie, F., Perrin, A., & Kiernan, M. (2013). Implementing a

pressure ulcer prevention bundle into practice. British Journal
Of Nursing, 22(15), S4-S10 Retrieved from
https://www.ncbi.nlm.nih.gov/pubmed/24180018
Harmon, L., Grobbel, C., & Palleschi, M. (2016). Reducing
pressure injury incidence using a turn team assignment. Journal
of Wound, Ostomy & Continence Nursing, 43(5), 477-482.
doi:10.1097/WON.0000000000000258
Mallah, Z., Nassar, N., & Badr, K. (2015). The effectiveness of
a pressure ulcer intervention program on the prevalence of
hospital acquired pressure ulcers: Controlled before and after
Study. Applied Nursing Research, 28(2), 106-113.
doi:10.1016/j.apnr.2014.07.001
National Pressure Ulcer Advisory Panel. (2016). Pressure injury
prevention points. Retrieved from
http://www.npuap.org/resources/educational-and-clinical-
resources/pressure-injury-prevention-points/
Rycroft-Malone, J. (2004). The PARIHS framework: A
framework for guiding the implementation of evidence-based
practice. Journal Of Nursing Care Quality, 19(4), 297-304.
Retrieved from
http://www.effectiveservices.org/downloads/The_PARIHS_Fram
ework-
A_framework_for_guiding_the_implementation_of_evidence_ba
sed_practice.pdf
Soban, L., Hempel, S., Munjas, B., Miles, J., & Rubenstein, L.
(2011). Preventing pressure ulcers in hospitals: A systematic
review of nurse-focused quality improvements interventions.
Joint Commission Journal on Quality & Patient Safety, 37.
Retrieved from
http://www.calidadasistencial.es/images/gestion/biblioteca/317.
pdf
Sullivan, N., & Schoelles, K. (2013). Preventing in-facility
pressure ulcers as a patient safety strategy: A systematic
review. Annals Of Internal Medicine, 158(5), 410-416.
doi:10.7326/0003-4819-158-5-201303051-00008
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. doi:10.1111/wvn.12177
The Joanna Briggs Institute. (2008). Best practice: Pressure
ulcer-prevention of pressure related damage. Retrieved from
http://ovidsp.tx.ovid.com.pnw.idm.oclc.org/sp-
3.26.1a/ovidweb.cgi?&S=GHKOFPMPAADDAGKINCGKJFGC
POLMAA00&Link+Set=S.sh.22%7c1%7csl_190
The Joint Commission. (2106). Preventing pressure injuries.
Retrieved from
https://www.jointcommission.org/assets/1/23/Quick_Safety_Issu
e_25_July_20161.PDF
PAGE
Put Title Here
by
PUt Name Here
Nursing
College of Nursing
Hammond, Indiana
Bachelor of Science
Month, 20xx

© copyright
your name here
20xx
all rights reserved
acknowledgments
Begin optional acknowledgments here.
table of contents
SectionPage
acknowledgments iii
table of contents iv
abstract v
Sections
1. Introduction xx
2. Review of Literature and Synthesis of the Evidence xx
3. Plan for Implementation xx
4. Plan for Evaluation xx
5. Conclusions, Recommendations and Implications xx
referencesxx
appendices (If Applicable)
Appendix A – Put Title Here xx
List of tables
TablePage
Table 1 Put Name of Table Here xx
ABSTRACT
Begin writing abstract here. APA abstracts begin on margin and
do not indent. Please use headings in instructions

PUT YOUR HEADER HERE IN ALL CAPS ii
section 1
Place Title of Project Here
Begin writing here and add pages as needed.
Section 2
Begin writing here.
PUT YOUR HEADER HERE IN ALL CAPS 10
PICO Question:
Keywords:
Databases Searched:
Table 1
Sample/Setting/
Design
Findings/Results
Appraisal of Evidence: Worth to Practice include Strengths,
Weaknesses and Conclusions

Section 3
Begin writing here.

Table 2
Task
Estimated Date
of Start
Person Responsible

section 4
Plan for Evaluation
Begin writing here.

Table 3
EBP Evaluation Plan
Outcome(s)
Measures/Measurement
Time of Collection/Person Responsible

section 5
Conclusions, Recommendations and Implications
Begin writing here.
References
Begin first citation here.
APPENDICES
Begin here.
Dynamic is a powerful strategy and workers must have the
experience to pick up intuitional sense to actualize the best
choice in the firm to build up a successful instinct during the
time spent dynamic encourages the firm to upgrade its overall
revenues and development rates in the market. Dynamic

procedures must be demonstrated and should be talked about
with the higher specialists, so they are executed on time to
proceed with the business forms (Resnik, 2019). The association
has a custom and culture and the official and pioneers must
utilize their insight to actualize the most the compelling choice
in the firm, every procedure has some reactions and the
intuition isn't without disadvantages.
Intuition can advance or rather supplement the sound, just as the
boundedly levelheaded creation of choices. For instance, a chief
who has some involvement in a similar sort of issue or even a
circumstance can have the option to act in a speedy manner with
what may appear to be data that is constrained because of their
experience (Kaufmann, 2017). It is likewise critical to take note
of that the different people who had an encounter of
extraordinary emotions had the capacity to accomplish a better
in regard to dynamic all the more so when they comprehended
the sentiments when deciding.
Taking everything into account, it is likewise critical to have a
thought of the issues related with meddling dynamic so they can
be stayed away from. Such viewpoints incorporate defective
data, partiality, not thinking about different other options, an
enthusiastic inclination that is present moment, plication that is
improper just as absence of being open, among different
elements.
References:
Kaufmann, L., Wagner, C. M., & Carter, C. R. (2017).
Individual modes and patterns of rational and intuitive decision-
making by purchasing managers. Journal of Purchasing and
Supply Management, 23(2), 82-93.
Resnik, D. B. (2019). The Role of Intuition in Risk/Benefit
Decision-Making with Research Human Subjects. In Developing
Informed Intuition for Decision-Making (pp. 149-160). Taylor
& Francis.

Part I:
The interest rate is the profit that is received over time in
relation to an amount loaned (Gitman & Zutter, 2012). It is the
compensation that a supplier of funds expects and a demander
of funds must pay. A variety of factors can influence the
equilibrium interest rate. One of them is inflation, a rising trend
in the prices of most goods and services. For example, a lender
may be lender may be hesitant to lend money for any period of
time if the purchasing power of that money will be less when
it’s reimbursed, therefore the lender will demand a higher rate
which is called inflationary premium. Thus, inflation pushes
interest rates higher; deflation causes rates to decline. A second
factor influencing interest rates is a risk. Interest rate risk arises
from adverse changes in interest rates, causing higher interest
costs or lower investment income and therefore lower profits or
even losses. At any point when individuals see that a specific
speculation is more dangerous, they will expect a higher profit
for that venture as remuneration for bearing the hazard. A third
factor that can affect the interest rate is a liquidity preference
among investors. The term liquidity preference refers to the
general tendency of investors to prefer short-term securities
(Gitman & Zutter, 2012).
Part II:
One of the interesting topics of Chapter 7 and 8 was Going
Public. When a firm decides to sell its stock in the primary
market, there are three possible ways to do them: Either it can
be done with a public offering or with right offerings or with a
private placement. To go public, it is very important to get
approvals from their current shareholders because currently the
company is privately owned and issued stocks. After the
approvals, the next step is to get all the documents certified to
prove the legitimacy of the company and get investment banks
to underwrite the offerings. After this, a company gets
registered with SEC and the investment community can begin
analyzing the company’s prospects. At this point, all the

investment bankers and company executives start promoting the
company’s stock by road shows, media to attract potential
investors from all over the place. And at last after the
underwriter sets terms and prices the issue, the SEC must
approve the offering and it becomes public (Gitman & Zutter,
2012). Companies decide how they want to go public depending
on the level of involvement company wants from the market and
how much capital business needs. Recently Spotify went public
and they didn’t release additional shares, rather they simply list
existing shares directly on the NYSE without getting help or
relying on underwriters to help assess demand and set a price (
Disis & Fiegerman, 2018).
References:
Gitman, L., & Zutter, C. (2012). Managerial Finance. Boston:
Prentice Hall - Pearson.
Jill Disis and Seth Fiegerman, April 3, 2018. Spotify goes
public in an unconventional IPO. Retrieved
from: http://money.cnn.com/2018/04/02/technology/business/sp
otify-ipo/index.html
Interest Rate:
An interest rate is the price that lenders receive and borrowers
pay for debt capital (Brigham & Houston, 2016). Interest rates
can be influenced by a few macroeconomic factors such as
Federal Reserve Policy and federal budget deficits and
surpluses. In the United States, the Federal Reserve Board
controls the money supply. They can alter interest rates in
several ways. The Fed can buy and sell short-term securities
which will cause short-term rates to decline (Brigham &
Houston, 2016). They do this when increasing the money
supply. A larger money supply may lead to an increase in
expected future inflation, which will cause long-term rates to
rise as short-term rates fall. A budget deficit occurs when the
government spends more than it takes in as taxes (Brigham &

Houston, 2016). To cover the deficit, the government must
borrow funds. This increased demand for funds increases
interest rates. The government can also print more money. By
printing money inflation increases which increases the interest
rate as well.
In the industry that I am employed, the macroeconomic factor
that my industry is most sensitive is the Federal Reserve Policy.
I am employed in the banking industry and we deal with the
Federal Reserve Policy on a daily basis. When the government
stimulates the economy by increasing money supply, businesses
and customers deposit their money into our institution and
borrow funds from us. One example is our mortgage loan. Our
mortgage rates a very low right now, but if the Fed forecasts
inflation rate will begin to increase.
Stock valuation
Stock valuation is one of the common used mostly in financial
marketing. This term is referred to a method that is used in the
calculation of the theoretical worthiness and value of a given
company and what they have as their stock. Stock valuation is
important as it is used monitor and know the potential market
prices and at the same time helping to know the amount
expected as profit as a result of the movements experienced on
prices periodically. Stock valuation is also important as it is
used to identify the overvalued and undervalued stocks all in
relation to their theoretical value. The main aims of stock
valuation considering the fundamental analysis is to ensure that
the company has got its intrinsic value. This intrinsic value is
normally based on the future flow of cash and the expected
profitability of the corporate body. Sometimes these flows can
be interpreted more like the demand and supply in the market.
This is because it involves the future demand or flows of stock.
Different methods have been used by different stock experts
when doing stock valuation. One of the commonly used method
is known as the discounted cash flow (also known as income
valuation). This method is generally based on the discounting of
the profits that are obtained which includes the cash flows, the

dividends and earnings that this stock is expected to bring to the
shareholders. Based on the capital pricing model for this case,
one can also be able to come up with the risk premium which
forms part of the discounted rate.
Risk and Returns analysis
Conduction of return and risk investigation is an essential
advance in administration of portfolio and examination of the
arrival segments. There are stocks markets, currency markets
vehicle and securities with more noteworthy level of offers one
over the other. On the premise of the resilience of the financial
specialist's hazard is assessed. There is forceful hazard
resistance to the group and weight age is more to the weighted
normal security utilizing each of their beta. Recognizable proof
of the superior workers is finished by this procedure. With a
specific end goal to have the finish for the risk and examination
of the arrival the last hazard assessment is finished. Connection
between the macroeconomic factors and furthermore amongst
hazard and resistance is assessed which is the last subject to be
contemplated.
Amid the exchange of weights inside the arrangement of the
other the risk resilience level of the group is considered. The
group of portfolio administration settles on its decisions
between the stocks, at that point securities lastly currency
showcase instruments this denotes the last conclusion among the
different forceful hazard portfolio administration. With high
profit for the returned chance the stocks are having a high
renouncement of higher returned dangers. There are 70% stocks
in the portfolio and with a sheltered market ahead and slightest
dangers the securities may take 10% of the portfolio. Staying
20% is devoured by the currency showcase instruments.
References:
Brigham, E.F., & Houston, J.F. (2016). Fundamentals of
financial management (14th ed.). Boston, MA: Cengage
Learning.
Five Forces Shaping the Banking Industry. (n.d.). Retrieved

from https://www.atkearney.com/documents/10192/296636/Five
_Forces_Shaping_Banking.pdf/9a0bcd47-8572-4dba-9aa1-
8ec204ffbeac
Holland, D. M., & Myers, S. C. (1978). Trends in corporate
profitability and capital costs.
Kaplan, R. S. (2001). Strategic performance measurement and
management in nonprofit organizations. Nonprofit management
and Leadership, 11(3), 353-370.

Part 1 Interest RatesMacroeconomic factors that influence inter.docx

Recommended

Recommended

More Related Content

Similar to Part 1 Interest RatesMacroeconomic factors that influence inter.docx

Similar to Part 1 Interest RatesMacroeconomic factors that influence inter.docx (13)

More from ssuser562afc1

More from ssuser562afc1 (20)

Recently uploaded

Recently uploaded (20)

Part 1 Interest RatesMacroeconomic factors that influence inter.docx