Can We Talk?: Prevention Intervention Problems

     Experts agree that prevention measures are essential to reducing the occurrence of pressure ulcers. Still, the literature suggests that implementation of prevention interventions is not always what it should be,¹ is sometimes unrelated to risk assessment data,² and at times is haphazard and erratic.³ Although somewhat loosely described, prevention intervention problems (PIPs) are obvious.

     The Institute of Medicine Report on Keeping Patients Safe⁴ suggests that preventable conditions such as pressure ulcers might occur as a result of errors of planning (not knowing what to do) or errors of execution (knowing but not implementing a plan of action). Whether PIPs occur as a consequence of errors of planning, errors of execution, or some combination of both is not entirely clear. Moreover, little is known about PIPs beyond the fact that they continue to occur despite widespread (and often creative) efforts to introduce pressure ulcer prevention protocols and educate caregivers in their use.      Curious, we wondered whether PIPs for specific pressure ulcer preventive interventions varied in terms of over- and undertreatment across and within categories of risk per Braden score — ie, generally not at risk, mid-level risk, and high/very high risk. To satisfy our curiosity, we carefully examined data from a recent inter-rater reliability study⁵ in which expert raters, trained in using the Braden Scale for Predicting Pressure Sore Risk and collecting risk-based prevention intervention data, provided useful information on 100 hospitalized acute care patients. Briefly, expert raters completed a Braden Scale assessment then immediately identified measures that should be implemented and those that actually were implemented from a list of commonly used pressure ulcer prevention interventions. The interventions included posting a whole body repositioning schedule in the room or chart, using a 30° lateral side-lying angle to avoid positioning onto sacral and trochanteric body prominences, using pillow or foam positioning wedges to maintain body position, using a pressure-reducing support surface while in bed, floating/suspending heels off of the bed, using a pressure-reducing chair cushion, placing a pad between bony prominences (eg, knees, ankles), consulting a dietitian, and protecting skin from moisture, and friction-shear. Data were used to determine whether, in the experts’ judgment, the implementation of an intervention represented “appropriate treatment,” “undertreatment,” or “overtreatment.”
     We were surprised to find that:
     •    Great variability existed in the proportion of PIPs observed across and within levels of risk
     •    For every intervention, PIPs indicating undertreatment of patients at mid- and high/very high levels of risk were always greater than PIPs indicating overtreatment
     •    The proportion of PIPs was greater for patients at mid-levels of risk on 8 out of 10 interventions compared to the proportion of PIPs made on patients at high/very high risk. 

     We acknowledge that the undertreatment rates reported might be inflated because our expert raters used an aggressive approach (any level of risk warranted implementation of a risk-based prevention intervention). Also, we acknowledge our concern regarding extensive undertreatment among patients at mid-levels of risk. Most importantly, the results of this exercise suggest a pressing need for greater specificity in reporting and classifying PIPs. We worry that unless and until we have data sufficient to adequately describe and classify PIPs, the challenge of developing targeted corrective programs might be forever beyond our reach.

1. Salvadalena GD, Snyder ML, Brogdon KE. Clinical trial of the Braden Scale on an acute care medical unit. J ET Nurs. 1992;19(5):160–165.

2. Richardson GM, Gardner S, Frantz RA. Nursing assessment: impact on type and cost of interventions to prevent pressure ulcers. J WOCN. 1998;25(6):273–280.

3. Moore AZ, Price P. Nurses’ attitudes, behaviours and perceived barriers toward pressure ulcer prevention. J Clin Nurs. 2004;13(8):942–951.

4. Institute of Medicine: (2003) Keeping Patients Safe. Priority areas for National Action: Transforming Health Care Quality. Available at http://www.iom.edu. Accessed July 28, 2008.

5. Magnan MA,  Maklebust J. The effect of Web-based  Braden Scale training on the reliability and precision of Braden Scale pressure ulcer risk assessments. J WOCN. 2008;35(2):199–208.