NURS3046 Nursing Project

Problem

The problem caused by this issue is the formation of pressure ulcers in elderly patients during their stay in the hospitals. Pressure ulcers are considered localised injuries, which occur due to unrelieved pressures on the underlying skin and tissues. Despite effective preventive approaches, pressure ulcers can be unavoidable in some cases. Even it has been observed that pressure ulcer rate among elderly people has increased over time. Hence it is necessary to propose a specific guideline to analyse effective service provision in consideration of patient safety and care quality.

Context

Pressure ulcers essentially result in areas of bony prominences, like sacrum, heels, greater trochanters, lateral malleoli and ischial tuberosities. As reported by Wang, Walker and Gillespie (2018), 70% of the people who suffer from these ulcers belong to the age range of 65 years or above. This result is prevalent in approximately 21% of patients in the nursing homes and 28% of residents in hospitals in the United Kingdom. Bryant and Nix (2015) denote external as well as internal risk indicators for checking the formation of pressure ulcers. External risk parameters involve constant pressure that can give rise to immobility. In addition to this, excessive moisture or shear forces on patients can be the causes of ulcers. Internal risk parameters malnutrition and involve reduced sensory perception.

Background

Prognosis for effective treatment of pressure ulcers are further hindered by a drop in the service provisions rendered by service providers. However, note at least 70% of secondary stage ulcers are seen to heal after applying appropriate intervention for 6 months (Qaseem et al. 2015). Similarly, 50% of tertiary stage ulcers as well as 30% of final stage ulcers can also heal within approximately a similar period as given above. As mentioned in the problem statement formation of ulcers in elderly patients can cause a series of secondary comorbidities. As stated by Ackley, Ladwig and Makic (2016), Braden scale is a prominent checklist that adjuncts risk assessment in case of bed-bound patients. Skin infections, scabies or further laceration can occur from continual wear and tear and inappropriate wound management (Mir et al. 2015). Service providing organisations should therefore target prevention and treatment of pressure ulcers.

Figure 1: Stages of Pressure Ulcers

(Source: Given by Researcher)

An efficient approach that can be used for management of pressure ulcers is prevention. Utilisation of need-based dynamics can prevent ulcer formation in case of immobile patients. Nursing caregivers often debride or clean ulcers until they can view granulation tissues. Application of extensive dressings can maintain moist environment around the wound that can pace ulcer formation (Sheehan et al. 2016). Fluid, protein and calorie intake are also responsible for influencing the formation rates. Preventive measures for these ulcers involve reducing pressure through frequent repositioning, avoiding shear forces, and utilising pressure-reducing static devices. According to Cereda et al. (2015), the aforementioned static devices involve water, foam, air or gel mattresses for its construction. In other cases mattress overlays, heels and joints pads, and foam wedges are also used. In some cases dynamic devices can be sought to help if the patient is unable to reposition themselves.

Service improvement and prevalent policies

Service improvements in terms of ulcer prevention, care and management can be employed in a patient-centred approach. This can provide a holistic provision of care that in turn can mandate empathetic care for aged people, considering their prevalent needs and preferences. A prominent threat in the management of pressure ulcers is that they are likely to occur in a very fast rate, essentially within 6 hours after heavy loading. As per Health and Social Care Act (2012), Pressure Ulcer Prevention Policy has been designed by NHS. Similarly, NICE guidelines also designate an ECT2550 Pressure Ulcer Prevention and Treatment Policy.

DMAIC model of service improvement

DMAIC methodology offers efficiently governed methodical process that can deliver complete measurable outcomes. The present protocol is thereby segregated in the following phases. [Refer to Appendix A]

Define: The definition phase involves brainstorming to successfully enumerate the threats that can be posed by an issue (Beeckman et al. 2014). In this case, ulcer formation in bedridden elderly patients is defined as the threat.

Measure: The measurement of ulcer formation rates is done through Braden Scale to identify risk exposure of patients in consideration of pressure ulcer development.

Analyse: One-Way data analysis of revealed critical factors of ulcer formation are heel protectors and compliance to incontinence protocols. Braden score of 23 to 18 can identify lower risk, while 12 or less resembles high risk exposure.

Improve: 60% reduction in cognitive nosocomial rate of pressure ulcer can result in approximately £80,000 cost avoidance per annum.

Control: Nosocomial rates must be monitored each month to focus on patient-based care indicators to maintain performance.

PDSA model of ulcer management

Plan: The plan conforms to manage pressure ulcers by applying therapeutic intervention after its occurrence. This plan is based on timely washing and documentation of ulcer development in elderly patients. [Refer to Appendix B]

Do: Bryant and Nix (2015) state appropriate washing techniques must be utilised for each stage of pressure ulcer (soap wash for stage 1, saline wash for stage 2 ulcers). Stage 3 and 4 ulcers can rarely be treated permanently; hence nurses should maintain effective protocols to prevent further infections.

Study: During the treatment, frequent observations should be made and documented to analyse the reduction rate pressure ulcers (Qaseem et al. 2015). The documentation charts can be aided with weekly photographs to measure the diameter, depth and tenderness of the ulcers.

Act: Further modifications can be implemented in the prevalent cycle by utilisation of therapeutic drugs for stage 1 and stage 2 pressure sores. Amoxicillin-potassium clavulanate can be used to induce a faster healing process in case of infected ulcers in elderly patients.

Principles of lean management

The researcher proposes utilisation of lean management strategies on elderly patients to understand its efficacy in the present issue. The practices that can be conducted are tabulated in the given representation with their probable rates of implementation and success. As commented by Posthauer et al. (2015), documentation of specific practices can help carers as well as the management to understand efficacy of each approach in the current scenario.

Table 1: Implementation of lean management practices

(Source: Given by Researcher)

Inclusion of weekly audits based on skin documentation can enable clinical teams to devise efficient chart review tools. Wang, Walker and Gillespie (2018) suggest these tools can be reviewed each week to understand the development of ulcer on the criteria of condition of the surrounding skin and wound tenderness. Overall assessment of hydration and nutrition levels can be implemented for daily maintenance of cognitive well-being of the elderly patients, on the basis of the needs.

Overall, these three frameworks are suggested by the researcher in consideration of effective wound management in a professional healthcare ambience. Additional parameters that can be utilised to increase success rates are monthly pilot studies and comparative analysis of cohort based observation driven by contrasting medication.

Literature review

Concepts of DMAIC model

Application of six sigma strategies and relevant DMAIC model have facilitated healthcare over the last decades. According to Thomas and Compton (2014), extrapolation of above-mentioned outcomes can extend the application of DMAIC approach in the healthcare sector. As stated by Cereda et al. (2015), clinicians are more prone to embrace DMAIC model due to its utilisation of familiar paradigms and in the presence of sustainability and scientific rigor. The ability to clearly outline and manage healthcare ambience presents a massive organisational benefit. Beeckman et al. (2014) opine DMAIC improves the measurable outcomes of an activity through response variables. This is in consideration of a common issue in aged residents of nursing home, which contribute to care mortality and morbidity. Rates of pressure ulcers can thus be controlled through implementation of six sigma DMAIC practices.

Figure 2: Effective outcome attainment

(Source: Given by Researcher)

The response variables in healthcare sector can be segregated into quality improvement and technical strategies. The prominent medication error and its reduction can be achieved by DMAIC in consideration for improvement at patient safety. As stated by Clark (2018), management of cost and revenue enhancement can help to enhance satisfaction among patients and care providers. Significant modifications can also be exhibited in supply chain management with increase in opportunities of marketing growth. As commented by Wang, Walker and Gillespie (2018), development of intrinsic leadership skills can streamline and optimise technologies that can be related to workflow management. Achievement of regulatory and compliance requirements can be mandated by successful implementation of the DMAIC model in ulcer and wound care management. Pressure ulcers are prevalently managed through preliminary hygiene care in a clinical ambience.

Governing theories of PDSA model

The cyclic model of PDSA accounts for an integral part of cognitive healthcare improvement concepts. As stated by Ladwig and Makic (2016), this approach is an uncomplicated yet effective tool to accelerate quality enhancement. This process initiates with an appropriate establishment of an objective, which guides the following protocol in terms of its membership establishment. The PDSA cycle develops appropriate measures for determining possible impacts of a change on a clinical ambience. Boyko et al. (2018) state this helps to create a simulation for the strategic implementation in next step is to test necessary modifications in a real world setting. As care for pressure ulcer involves complex efforts to enhance prevention rates, this requires system-based approach that involves distinct organisational changes (Qaseem et al. 2015). Bringing due changes in healthcare organisations can be hindered by multiple obstacles when that includes simultaneous improvements to communication, decision making and workflow.

Figure 3: Relationship of interdependent initiatives in PDSA model of ulcer care

(Source: Given by Researcher)

As per the consideration of initiative of pressure ulcer prevention, assessment failure in can induce changes on multiple tiers that result to unanticipated complications in the implementation stages. Posthauer et al. (2015) state PDSA cycle is an effective testing method that can planning and implements a change as well as takes critical decisions based on observing its outcomes. The significance of growing needs can be considered for clinical audits owing to integral portions of clinical practices (American Hospital Association, 2018). These practices essentially highlight better data management in the healthcare sectors. Indeed, processes of clinical audits can ultimately be made retrievable through by-products of routine care therapies to modify quality care and continuous improvements.

Appraisal and application of lean management approaches

This segment ensures analysis and implementation of lean management to promote maximum progress in clinical sectors. Lean management provides certain operating guidelines that can induce value maximisation in case of patients through reduction in waste and waiting time. Patient needs consideration through additional employee involvement can bring continuous improvement in healthcare organisations (Institute for Healthcare Improvement, 2018). The conceptual paradigm of lean management is originally provided by production system of Toyota through continuous improvement strategies. Whitehead and Trueman (2018) state the strategies of lean management can fundamentally transform organisational values and thinking styles. Ackley, Ladwig and Makic (2016) state lean is driven by a process-based methodology of improvisation and management.

This modification can be responsible for transformation of organisational culture and behaviour. A basic tenet can be considered for existing clinical taskforce. This can be studied with the help of Toyota model and its capacity to allocate different resources as per priorities. The utilisation can shed light on the added values mediated for patients. The recent study of Boyko et al. (2018) evaluates demonstrations of lean in healthcare management and successful outcomes that can be applicable in Australian Ministry of Health. However, Thomas and Compton (2014) argue implementation of lean can be patchy, fragmented and pragmatic. Implementation of lean in healthcare sector can be evaluated from a holistic perspective such as overall transformation of the organisational strategy. Nevertheless, lean thinking is driven by design and research on sustainability in healthcare.

Methodology for sustaining change

Theory

The guiding theory for lean management condenses around the approach of sustainable organisational management in support of continuous improvement. This strategy recognises long-term working approaches that can methodically seek to attain small, but considerable changes to enhance quality and efficiency.

Figure 4: Research methodology

(Source: Bryman, 2016)

Hypothesis

The hypothesis of the proposed research is given in the form of null (h0) and alternative (h1) assumptions.

• H0: Application of lean management and six sigma strategy cannot reduce the rates of pressure ulcer formation in elderly patients.
• H1: Utilisation of lean management and six sigma strategy can effectively reduce the rates of pressure ulcer formation in elderly patients.

Research design

A mixed research design will guide this study, which is a blend of both qualitative and quantitative methods. As stated by Bryman (2016), qualitative data will help to understand the perceptions of patients as well as the healthcare service providers in the given issue of pressure ulcer formation. In addition, quantitative data will provide empirical information that can be used as ample evidence for the qualitative opinions obtained.

Concept measurements

Concepts would be measured with the help of secondary data. This information will facilitate evaluating prevalent trends in elderly healthcare sector in the UK. On the contrary, secondary data from published literature can evaluate the established paradigms on the basis of their efficiencies.

Data collection and processing

Secondary data will be accumulated from databases and government healthcare reports. The researcher will ensure utilisation of valid and credible information by retrieving them from reliable sources, such as NCBI, SCOPUS, ProQuest and CINAHL. The accumulated data will be analysed thematically in consideration of appropriate lean management and six sigma strategies.

Process mapping

Process mapping has helped to analyse the process that has been followed by the researcher during this process. Pre and post measurement maps have been given in the appendix that provides a graphical flow to the protocol. The baseline measurement of the proposed project is the original medication that is prescribed to the patients. [Refer to Appendix C]

Analysis and interpretation of main finding

Analysis of the accumulated data can give rise to the formulation of the main finding. This will give rise to the strategic design of implementing lean and six sigma management strategies in a fast-paced clinical workplace. As stated by Bryant and Nix (2015), analysis of the data can shed light on patient needs and the efficacy of recommended strategies to meet the aforementioned requirements. This will also facilitate drawing a definite conclusion about the affectivity of one of the two hypotheses. Data documentation will be done in compliance with Copyright Act 1968 (Cth) to ensure information is cited with their authentic sources. This can avoid presence of legal charges pertaining to copyright protection of the original works.

Possible solutions

Principles of lean system management and six-sigma can be implemented in a healthcare setting to reduce the rates of elderly patients developing pressure ulcers. These recommendations are used to introduce improvisations in quality care of the elderly patients and enhance their experience.

Table 2: Possible solutions

(Source: Given by Researcher)

Recommendation

Holistic approach of clinical service is the main recommendation in the given scenario. Pressure ulcers can increase financial burden on patient family by enhancing substantial costs of medication and treatments. Utilisation of the DMAIC model as stated above can widen the documentation phase to enhance turnaround time for patients. PDSA audit can also influence the modification in the database management systems of the hospital. This, in turn, can help nurses to keep track of the information systems that can be give rise to better and faster service deliveries. Lean strategies can implement expert-driven continuous cycle of learning for in healthcare processes.

Conclusion

Based on the given information, it can be concluded that the proposed research will enumerate the effects posed by lean management and six sigma strategies on the quality of care. The aforementioned care services are applicable for elderly patients who are exposed to a risk of developing pressure ulcers as co-morbidity to hospital stay. The proposed research hypotheses frameworks are driven by DMAIC and PDSA models of six-sigma. In addition to this, lean management strategies have influenced the recommendation that motivates a rise in care quality. A prominent limitation of these strategic frameworks for implementing quality care is that they require effective change to be introduced in the organization. In case of clinical bodies, change is not usually accepted in high emergency working environment such as hospitals and nursing homes. Management thus has to carefully handle human resource and mitigate issues that may arise with the help of an appropriate change management.

References

Ackley, B.J., Ladwig, G.B. and Makic, M.B.F., (2016) Nursing Diagnosis Handbook-E-Book: An Evidence-Based Guide to Planning Care. London: Elsevier Health Sciences.

American Hospital Association (2018) Pressure Ulcer Reduction using Lean Six Sigma, Viewed on 12 September 2018 <https://www.hpoe.org/resources/iha-case-studies/2526>

Beeckman, D., Van Lancker, A., Van Hecke, A. and Verhaeghe, S., (2014) A systematic review and meta?analysis of incontinence?associated dermatitis, incontinence, and moisture as risk factors for pressure ulcer development. Research in nursing & health, 37(3), pp.204-218.

Boyko, T.V., Longaker, M.T. and Yang, G.P., (2018) Review of the current management of pressure ulcers. Advances in wound care, 7(2), pp.57-67.

Bryant, R. and Nix, D., (2015) Acute and chronic wounds. London: Elsevier Health Sciences.

Bryman, A., 2016. Social research methods. UK: Oxford university press.

Cereda, E., Klersy, C., Serioli, M., Crespi, A. and D’andrea, F., (2015) A nutritional formula enriched with arginine, zinc, and antioxidants for the healing of pressure ulcers: a randomized trial. Annals of internal medicine, 162(3), pp.167-174.

Clark, M., (2018) Microclimate: Rediscovering an Old Concept in the Aetiology of Pressure Ulcers. In Science and Practice of Pressure Ulcer Management, pp. 103-110.

Institute for Healthcare Improvement (2018) Available at: https://www.ihi.org/resources/Pages/ImprovementStories/RelievethePressureandReduceHarm.aspx (Accessed: 9th october, 2018).

Mir, T.P., Qaseem, A., Starkey, M. and Denberg, T.D., (2015) Risk assessment and prevention of pressure ulcers: a clinical practice guideline from the American College of Physicians. Annals of internal medicine, 162(5), pp.359-369

Posthauer, M.E., Banks, M., Dorner, B. and Schols, J.M., (2015) The role of nutrition for pressure ulcer management: national pressure ulcer advisory panel, European pressure ulcer advisory panel, and pan pacific pressure injury alliance white paper. Advances in skin & wound care, 28(4), pp.175-188.

Qaseem, A., Humphrey, L.L., Forciea, M.A., Starkey, M. and Denberg, T.D., (2015) Treatment of pressure ulcers: a clinical practice guideline from the American College of Physicians. Annals of internal medicine, 162(5), pp.370-379. https://annals.org/aim/fullarticle/217350

Sheehan, K.J., Sobolev, B., Chudyk, A., Stephens, T. and Guy, P., (2016) Patient and system factors of mortality after hip fracture: a scoping review. BMC musculoskeletal disorders, 17(1), p.166. https://doi.org/10.1186/s12891-016-1018-7

Thomas, D.R. and Compton, G.A., (2014) Pressure ulcers in the aging population. New York: Humana Press.

Wang, I., Walker, R. and Gillespie, B.M., (2018) How well do perioperative practitioners implement pressure injury prevention guidelines? An observational study. Wound Practice & Research, 28(1).

Whitehead, S.J. and Trueman, P., (2018) To what extent can pressure relieving surfaces help reduce the costs of pressure ulcers?. Senior nurse, 4, p.21. https://www.nursingtimes.net/clinical-subjects/wound-care/to-what-extent-can-pressure-relieving-surfaces-help-reduce-the-costs-of-pressure-ulcers/5017910.fullarticle