Development of an Evidence-based Specialty Support Surface Decision Tool
The decision to use a specialty support surface for the prevention or treatment of skin breakdown is becoming increasingly complex.
As technology advances, a growing array of surface choices has become available. In addition, an aging patient population and the higher acuity level now seen in hospitals can present healthcare professionals with increasingly difficult care management issues. The focus on financial stewardship in healthcare also necessitates careful attention to appropriate resource use without the loss of care quality. These factors, along with growing concerns about patient safety and professional liability, highlight the importance of making appropriate decisions about skin and ulcer care using support surfaces.
With these issues in mind, a project was undertaken in a large, urban facility to evaluate and revise an existing specialty support surface decision tool based on current published literature and expert opinion. The revised tool was pilot tested and updated where necessary.
Setting. The project was initiated in a 600-bed tertiary care hospital in a large urban center in western Canada — a regional referral center caring for high acuity patients and recognized for its leading-edge programs in emergency care, women’s health, ophthalmology, internal medicine (including innovative acute geriatric care services), interventional cardiology, critical care, and surgery. Interdisciplinary collaboration and innovation are commonplace in many program areas, making this a viable setting to undertake a project of this nature.
Original instrument. A decision support tool for the use of specialty surfaces had been developed in 2000 and was in use throughout the relevant care areas. Elements included in the tool were the patient’s Braden Score,1,2 mobility/activity indicators, and identification of existing skin breakdown. The tool allowed considerable latitude in decision-making based on other clinical factors and established professional practices and had not been formally evaluated. Although hospital staff were familiar with the tool, review of appropriate use was necessary in light of escalating support surface rental costs and confusion caused by the multifactorial nature of skin maintenance and the pace of technological advancement.
Personnel. The project was initiated and led by the senior operating officer of patient care and managed by a project coordinator who ensured that all critical project tasks were completed. The nurse practitioner for geriatric services, who also chairs the hospital’s Skin and Wound Care Committee, provided clinical expertise.
Purpose. The project aimed to review and evaluate the existing decision tool, ensure that current evidence was incorporated into an updated decision tool, allow for broad professional input into the development of the new tool, and achieve cost savings while recognizing the importance of specialty support surfaces in preventing and treating skin breakdown in institutionalized patients.
Project approach. To accomplish the goals, the following strategies were incorporated into the project plan:
• The literature review completed to create the first instrument would be updated to focus on developments in the topic area during the last 3 years.
• A sample of completed existing decision tool forms would be audited to determine compliance with the guidelines and identify areas where the tool no longer conformed to the evidence or was unclear in its direction.
• Current decision makers and users of the existing algorithm (Skin and Wound Committee members, nurse educators, unit managers, physicians) would be interviewed regarding current practice and issues in the decision-making process.
• The vendor representative would be consulted for input on support surface use and the choices available under the current rental contract.
• A new decision tool would be developed based on evidence gathered.
• The new decision tool would be pilot tested and evaluated for its effectiveness.
A search of the literature accessible through CINAHL, PubMed, Cochrane Database of Systematic Reviews, and Medline was conducted using the following search terms: pressure relief beds, decubitus ulcer — diagnosis and treatment, pressure ulcers — diagnosis and treatment, and specialty support surfaces. The search was limited to English articles published since 2000. Articles from the literature search conducted during the creation of the existing decision tool (in 2000) also were reviewed and utilized when not replaced by more current literature. Not surprisingly, the literature reflected the complexity and confusion perceived by hospital staff with regard to skin integrity and the prevention and treatment of skin breakdown using support surfaces.
Considerable deficits in the literature on support surfaces were identified. While individual studies have been conducted to examine the effectiveness of certain surfaces, no comprehensive set of clinical trials evaluates the relative effectiveness of specialty support surfaces. A published systematic review of 37 randomized clinical trials (RCTs)3 and another review of 45 RCTs4 on the use of support surfaces revealed similar findings. Generally, evidence seemed to indicate that air-fluidized beds and low-air-loss beds improve healing rates3,4 and high specification foam mattresses are superior to standard hospital foam mattresses.3 Studies comparing different types of alternating pressure supports and other low-pressure devices revealed no difference in effectiveness.3 Finally, no studies evaluated the effectiveness of low-air-loss beds in comparison to alternating pressure surfaces.3,4 The authors of both reviews conclude that determining the most effective surface for either prevention or treatment is nearly impossible because the relative merits of the various surfaces are unclear.3,4
Two studies not included in the above-mentioned systematic reviews evaluated the relative effectiveness of low-air-loss surfaces and other surfaces. The goal of one of these studies, described as a prospective, randomized clinical trial (n = 20),5 was to determine if the rental cost of low-air-loss beds was justified. The researchers found that wound healing was actually better on the static study mattress than on the low-air-loss surface. The second study6 also suggests that low-air-loss beds can be outperformed in terms of promotion of healing, in this case by an alternating pressure surface.
Given the lack of clear evidence to guide the decision about support surface use, patients may receive care on surfaces that do not meet their individual needs. However, Arblaster6 cautions that support surface selection still should be based on the best available evidence rather than on alternate reasons such as persuasive marketing, tradition, or even cost.
The experiences of other institutions in dealing with the question of support surface selection can be helpful. Several examples of support surface selection tools exist in the published literature.7-10 Commonly, the development of these decision tools was motivated by concerns about costs and inconsistencies in practice as well as by the recognition of the need to support clinical decision-making in a bewildering area. Typical elements in these example decision tools include assessment of patient risk using an established risk assessment scale, determining treatment goals, and matching patients to surfaces based on assessment findings and care objectives. Alignment of decision tools with hospital policy and care guidelines and thorough education of patient care providers are stressed. Three of the tools also recommend establishing a project manager position or wound/skin care team to monitor and/or control usage, respond to consultation requests, and facilitate staff education.8-10
The Braden Scale1,2 is widely recognized as one of the leading instruments for early identification of patients at risk of pressure ulcer formation.11 The scale is composed of six subscales (sensory perception, moisture, activity, mobility, nutrition, and friction/shear) that reflect the multivariable nature of skin breakdown. Patients are given a rating on each of the subscales; an overall risk score based on the sum of the subscale scores. A higher score indicates lower risk. Researchers studied the predictive value of the Braden scale11 and found that while Braden Scale use has limitations, the Braden subscales — especially nutrition, mobility, and friction/shear — provide predictive value. Researchers caution that the use of risk assessment scales can oversimplify the complex set of factors that produce pressure ulcers. Warren et al9 also indicate that over-reliance on a decision tool based on a risk assessment, such as the Braden Scale, can lead to decision errors because other contributing factors are not considered. Nevertheless, the use of a predictive scale is recommended. In addition, the Braden Scale is used more reliably by registered nurses than by less skilled nursing staff.1,12
In addition to the literature review, data were gathered to assess use of the existing decision tool and compare decisions made to current evidence. An audit was performed of approximately 90 readily available decision tool forms completed on actual patients. Although many justifiable decisions were made using the tool, it lacked the detail required to match individual patient assessment findings to appropriate support surface treatment options. In addition, all available surface choices were not included; new options had been added since the development of the tool. Overall, too much latitude was allowed in decision-making, leading to situations where patients were unnecessarily placed on a support surface.
The input of care providers (nursing and rehabilitation staff) was sought to ascertain their opinions and needs regarding decision support for specialty support surfaces. Generally, caregivers were confused about the range of surfaces available and wanted the new tool to include more detail for matching patient assessment to indications for the various surface options. They also suggested that improved follow-up and reassessment of patients on surfaces would lead to higher quality and more cost-effective care. Physician input represented a range of opinion from conservative use of surfaces to widespread use as a preventative and therapeutic strategy. In most cases, however, physicians supported a collaborative decision-making process based on the needs of individual patients.
Tool Development and Trial
Findings from the literature and the audit of examples involving the existing tool were considered along with feedback from users in order to create an algorithm that would be acceptable in this particular institution.
The goals of the new tool were to:
• Build on the familiar as much as possible
• Incorporate research findings
• Specify a wider range of products and indications
• Guide nurses to select the lowest tech surface that would still provide evidence-based protection and treatment for patients
• Use generic surface names to prevent confusion in the event of a vendor change (although the piloted tool included a legend to allow staff to match generic names to the more familiar trade names in use at the time of the pilot)
• Be applicable in a range of clinical areas
• Specify goals of care/therapy.
A draft tool was prepared and offered for review to approximately 14 key users, including 10 on the Skin and Wound Care Committee, plus one unit manager and one clinical nurse educator each in medicine and surgery. Minor revisions were made based on discussions and the tool (see Figure 1) was implemented for a trial period on all medical and surgical units in the hospital (13 units), as well as the general medical/surgical critical care unit. Nursing and rehabilitation staff on the participating units were informed of the project and the use of the new tool at short, unit-based educational sessions led by their unit-based nurse educators. Unit managers were informed about the project and the tool by the project coordinator at meetings held before the trial period.
For the trial period, unit managers were asked to collaborate with direct caregivers to determine the need for a specialty support surface for specific patients based on the guidance offered by the new decision tool. Relevant assessment criteria included risk category, patient weight, presence of existing skin breakdown/number of ulcers, flap surgery, pulmonary complications, palliative care, positioning, and Braden scale score. The elements of the patient assessment were drawn from examples and findings in the literature.7-12 Although risk categories, based on the Braden score, are somewhat arbitrary and setting-dependent, they give an initial indication of the potential extent of required care.12 Patient weight, for example, may be a factor in a patient’s mobility and limited activity levels can increase a patient’s risk score. Because specific support surfaces for care of the obese patient are available, weight assessment is important. Existing ulcers, recent flap surgery, pulmonary complications, and spinal cord injuries are additional key reasons for utilizing a support surface.7-9
When multiple ulcers exist, positioning options can be limited. The pain and inactivity associated with terminal illness are indications for specialty support surface use in this institution. In addition, the risk of shear injuries can increase when head-of-bed elevation is required, such as with continuous tube feeds, making this another indication for a surface that reduces patient sliding. Even though friction and shear are part of the Braden assessment, this particular application was specifically noted on the piloted decision tool for clarity. Finally, the mobility subscale of the Braden Scale was highlighted because of its value in predicting risk11 and because it is the aspect of skin management targeted by the use of specialty support surfaces.
Caregivers selected the appropriate surface based on a patient’s unique assessment findings. Reassessment of patients on surfaces took place daily, although as the trial period progressed, this was reduced to Monday, Wednesday, and Friday. This change ensured that unit managers (17 — 13 from med/surg units and four from critical care) would consistently complete the reassessment (as opposed to weekend charge nurses who were, at times, unfamiliar with the new process). Clinical assessment findings and the surface selection decision were logged on a daily tracking sheet that was submitted to the project coordinator on a weekly basis for audit.
Regular communication, both face-to-face and via e-mail, was maintained among the senior operating officer, the project coordinator, the clinical experts, and the users in order to gather ongoing feedback about the acceptance and utility of the new tool. This also provided an opportunity to respond to questions and issues and to maintain awareness that the trial was ongoing.
The new tool was evaluated on several levels. Formative evaluation involved auditing the daily tracking sheets, which monitored adherence to the tool and revealed areas where greater specificity was needed in the tool to enhance decision-making. Generally, adherence was high and only minor revisions were required. For three units, it was found that >10% of logged decisions varied from the tool. Meetings were held between the project coordinator and the unit manager of each of these units to determine the reason for the variances and to encourage compliance with the tool. In two cases (one medicine unit and one surgery unit), the meetings were successful in generating a renewed commitment to the project. The third situation involved the critical care unit where diverse and complex patient needs made adhering to a standard guideline (better suited to a more stable medical/surgical environment) difficult. Nevertheless, the critical care staff members remained fully committed to the project and to using the tool to the extent possible. For all units, it was demonstrated that the tool needed greater detail regarding the treatment of early skin breakdown, including the option of more conservative approaches (such as position devices offered through the rehabilitation department). This revision was made and communicated near the end of the trial period.
At the conclusion of the pilot, feedback was again solicited from the Skin and Wound Care Committee, the nurse educators, and the unit managers. Comments were positive, indicating that the tool and the tracking sheet ensured consistent follow-up and reassessment, provided an effective teaching tool, offered clear decision support in a complex care area, and led to decisions that were acceptable to the nursing and rehabilitation staff.
The project background, rationale, and findings; the new decision tool; and information about skin care devices available through rehabilitation also were presented at nursing rounds — a regular educational session for front-line nursing staff — shortly after the completion of the trial period. Evaluations collected after this educational session indicated a fairly high level of interest in the topic but also revealed that many nurses in this institution already were familiar with the project and the new tool and that the information was not new to them — a positive sign of interest and awareness among staff.
Cost and Quality Indicators
Cost and quality indicators also were monitored at points throughout the trial period and compared to pre-pilot data. It was assumed that patient populations before and during the pilot were equivalent (no changes to service delivery occurred that would have altered the types of patients cared for in the programs included in the pilot). Final numbers were collected and reviewed at the completion of the project pilot.
Average monthly rental costs for specialty support surfaces were calculated and compared for the year before the trial period and for the trial period (6 months). Cost savings were achieved in all program areas (see Table 1).
In addition to achieving cost savings, ensuring and demonstrating that this project did not interfere with the quality of patient care was important. For this reason, the incidence of hospital-acquired pressure ulcers also was tracked for the pilot period during which the decision tool was tested. The Health Records Department provided a count of patients who had a hospital-acquired pressure ulcers discharged from each of the pilot areas by month. The average was determined by totaling the number of patients affected and dividing by the number of months for the period in question (the total number of patients discharged from each of these areas was not provided). The averages offered a snapshot of pressure ulcer incidence in one time period relative to another time period. Only slight changes in numbers of hospital-acquired pressure ulcers occurred during the pilot phase as compared to the pre-pilot phase (see Table 2). It should be noted that fluctuations in the incidences of pressure ulcers within the individual programs are most likely attributable to the effect that one or two incidences of pressure ulcer formation can have when a small total is averaged over a relatively short period of time. It should also be noted that parameters of patient acuity or diagnosis were not measured with the pilot so fluctuations in pressure ulcer incidence may be due to patient characteristics rather than mattress use. In evaluating the quality aspect of the project, it was determined that the overall incidence was a more reliable indicator of quality because it balanced out the more noticeable effects seen in the individual program averages.
The effects of changing surfaces on the healing rates of existing ulcers were not evaluated as part of this project. It is expected that this indicator will be tracked as part of the ongoing monitoring of support surface utilization. This is important to understanding the efficacy of various types of surfaces and should be the topic of future research.
Based on the cost and quality indicators tracked for this project, using the new decision tool for specialty support surfaces appeared to successfully control costs while ensuring a continuing standard of quality. The tool also appears to have met the expectations and needs of the user group.
As a result of the initial success in the trial phase, the new specialty support surface decision tool will continue to be used throughout the institution. Program areas will assume the responsibility of auditing usage and monitoring costs. Ongoing success also will depend on maintaining the level of awareness regarding decision-making and re-assessment. Program areas and unit management are best positioned for maintaining the profile of this issue.
An important step in the ongoing care of patients with or at risk of skin breakdown will be to develop leadership and expertise and to coordinate skin/wound care. To this end, it has been proposed that a clinical nurse specialist be added to the leadership team to provide expertise, promote research and evidence-based care, and coordinate efforts to monitor and improve quality. The need for leadership and coordination in this area is supported by the literature.8-10
The use of specialty support surfaces is one facet, albeit a costly aspect, of the care of patients with or at risk of skin breakdown. Despite the lack of clear guidance in the literature, institutions have been able to devise evidence-based, user-friendly, effective decision support tools such as the one presented here. It must be noted, however, that the use of support surfaces must go hand-in-hand with skilled and attentive nursing care. Additionally, a commitment to ongoing evaluation research and technology assessment in order to shed more light on a very complex topic and offer the best possible care to our patients will be necessary to keep the tool current and practical.