Critical Evaluation of Nova Scotia’s Provincial Prevention of Pressure Injuries Policy

 Critical Evaluation of Nova Scotia’s Provincial Prevention of Pressure Injuries Policy

Table of Contents

 Introduction…………………………………………………………..3

Historical context …………………………………………………….5

Pressure injuries……………………………………………………….6

Problem Definition……………………………………………………7

 Indicators of the problem……………………………………………….8

Analysis of Goals and Objectives…………………………………….9

Analysis of Instruments and Implementation………………………………..10

Outcome Evaluation and Analysis…………………………………..10

 Adequacy…………………………………………………….10

 Suitability…………………………………………………….11

 Accessibility…………………………………………….……12

 Sustainability…………………………………………………12

 Summary of analysis of criteria……………………………….12

Proposed method of Impact Evaluation……………………………….13

Summary and Future Recommendations…………………….……….14

INTRODUCTION

Healthy social policies are put in place to improve the health conditions of the people, to reduce morbidity and mortality rate such as government policy on prevention of pressure injuries and wound care treatment in Nova Scotia following a mortality issue in long term care. Pressure ulcer prevention protocol for long-term care settings was updated to challenge injustice that affected older adults in long term care (vulnerable group). The policy came into existence following the death of a lady in one of the long-term cares in Nova Scotia which occurred because of infected pressure injuries. This policy really interests me as a health professional in Nova Scotia.

The prevention and management of pressure injuries continues to be a concern in the Canadian long-term facilities. In 2003, Canadian Association of Wound Care (Wounds Canada) reported that the overall prevalence of pressure injuries across all long-term care settings was 26%, with approximately 70% of these pressure injuries was preventable by clinical practice, expert opinion, using best practices and use of appropriate equipment. Despite the focus on prevention to date, pressure injury incidence rates have not significantly reduced in Nova Scotia when compared with other provinces. A comprehensive approach focused on prevention is required across all areas of the health-care system to make a significant difference in incidence rates of pressure injuries. For the policy to be effective, interprofessional teams need to be integrated to include the person at risk of or with a pressure injury along with their families and departments such as purchasing and housekeeping. The cost of treating Pressure injuries is expensive. The lowest cost for treating a deep-tissue injury or Stage 1 or 2 wound is approximately $2,450 per month, while an uncomplicated Stage 3 or 4 is $3,616 per month Pressure injuries complicated by osteomyelitis cost approximately $12,648 per month to treat. The resources involved in the prevention of pressure injuries are less expensive than the cost of treatment.

The recommendations in the prevention of pressure injuries policy are based on the best available evidence and are intended to support the health care professional in planning and developing best practices in the prevention and management of pressure injuries.

Five priority action steps which are known as Wound prevention and management cycle were identified in the Policy; (1) Assess and Re assess- This serves as baseline information and helps in planning. Assess the resident, the wound, environmental and system challenges. Also, identify risk and causative factors that may affect skin integrity and wound healing. (2) Set Goals on prevention, healing, quality of life and symptom control. (3) Assemble the team, select membership based on resident need. (4) Establish and implement a plan of care that addresses the environment, system, the resident, the wound. Ensure effective communication among all members of the team. (5) Evaluate Outcomes. Ensure sustainability if goals are met and Re assess if goals are not met.

The policy’s objectives and directives are primarily focused on health care professionals and

clinicians to ensure that actions are carried out that will prevent pressure injuries throughout the province.

• To examine the effectiveness of this policy, I will use an inclusion lens. An inclusion lens is used to determine if a policy is inclusive of all older adults, in particular those who belong to vulnerable populations, those who are disadvantaged, or who have been discriminated against by other policies or by society in general (Kwong., Lau, Lee, & Kwan, 2011). Saunders, Kraus, Peters, and Reed (2010) found out that the risk of developing pressure injuries increases with age. This is because aging comes with decreased skin elasticity, texture, circulation, cell replacement level and scarring process, and reduced peripheral sensitivity. Therefore, in evaluating this policy, I will look to see if older adults are included as effectively as those who are not disadvantaged or vulnerable and to determine if the policy has its intended benefits and effects on older adults.

The following criteria will be used to evaluate the prevention of pressure injuries policy; adequacy (i.e. are the measures being taken capable of solving the problem and of reaching the intended objectives and goals?); suitability (i.e. are the measures suitable for the older adults’ population; sustainability (i.e. can this policy effectively deal with the problem over a long period) and; accessibility (i.e. are the benefits of this policy accessible to all residents of long term facilities in the province of Nova Scotia?). Additionally, using these criteria I will conduct an outcome evaluation to determine if the policy is being effective in meeting its desired objectives (i.e. prevention of pressure injuries) in Nova Scotia.

Historical Context

Before delving further into the policy and beginning an evaluation, it is necessary to consider the history of prevention of pressure injuries in Nova Scotia.

In May 2016, the National Pressure Ulcer Advisory Panel updated the term pressure ulcer to pressure injury. The update was done to clarify that both Stage 1, stage 2 and Deep Pressure Injuries refer to intact skin while stage 3 and 4 are referred to as Open skin. Prevention of pressure injuries was part of the curriculum for teaching health care professionals in different level of studies. In 2012, Protocol document on prevention of pressure ulcers in long term care, Nova Scotia was developed by Department of Health and Wellness continuing care in collaboration with Nova Scotia Health Authority Provincial Wound Prevention and Management Program and Northwood as part of quality improvement initiative, the purpose of the policy is to enhance continuity of care and knowledge and build capacity of health workers to enhance pressure injury prevention and management in long term care facilities. The policy was updated in July 2018 following the death of a lady in one of the long-term cares in Nova Scotia which occurred because of infected pressure injuries.

Pressure Injuries

Woodbury (2014, p. 5) defined Pressure injuries (bed sores) as “injury to the skin and underlying tissue”. These injuries ranges from mild reddening of the skin to severe tissue damage and sometimes sepsis, cellulitis and infection that extends into muscle and bone. Government of Alberta (2018, P.1) described Pressure injuries in four stages:

• Stage 1: there is skin discolouration, sores are not open wounds. The skin may be painful, but it has no breaks or tears. The skin appears reddened and does not blanch (lose colour briefly when you press your finger on it and then remove your finger). In a dark-skinned person, the area may appear to be a different colour than the surrounding skin, but it may not look red. Skin temperature is often warmer. And the stage 1 sore can feel either firmer or softer than the area around it.
• At stage 2, the skin breaks open, wears away, or forms an ulcer, which is usually tender and painful. The sore expands into deeper layers of the skin. It can look like a scrape (abrasion), blister, or a shallow crater in the skin. Sometimes this stage looks like a blister filled with clear fluid. At this stage, some skin may be damaged beyond repair or may die.
• During stage 3, the sore gets worse and extends into the tissue beneath the skin, forming a small crater. Fat may show in the sore, but not muscle, tendon, or bone.
• At stage 4, the pressure injury is very deep, reaching into muscle and bone and causing extensive damage. Damage to deeper tissues, tendons, and joints may occur.

Braden scale is an important component in prevention of pressure injuries as it helps in predicting pressure injuries risk among older adults. The Braden scale uses six criteria which includes: Moisture, activity, friction shear, sensory perception, moisture and mobility. Each criterion is rated on a scale of 1 to 4, except the ‘friction and shear’ criteria which is rated on a 1-3 scale which makes the possible total of 23 points. Higher score means a lower risk of developing a pressure ulcer and lower score means a higher risk of developing pressure ulcer (NSHA, 2018). The Braden Scale assessment score scale:

• Very High Risk: Total Score 9 or less
• High Risk: Total Score 10-12
• Moderate Risk: Total Score 13-14
• Mild Risk: Total Score 15-18
• No Risk: Total Score 19-23

Problem Definition

Saunders et al. (2010) found out that the risk of developing pressure injuries increases with age. This is because aging comes with decreased skin elasticity, texture, circulation, cell replacement level and scarring process, and reduced peripheral sensitivity. Also, Lannering, Ernsth, and Johansson (2017) reported that poor nutritional status is a major contributor to development of pressure injuries in older adults. If someone is not taking the required amount of nutrients the body needs, it makes the body to be more vulnerable to wear and tear. In the same vein, Long-term care residents may not be able to take enough food due underling medical conditions like difficulty with swallowing, lack of appetite, or because they are living with dementia which has made them to lose interest in eating or the knowledge of how to feed themselves. In addition, Woodbury (2014) identified Diabetes as one of the risk factors for developing pressure injuries. For instance, many residents with diabetes have poor circulation to the feet. If such resident develops an ulcer on the foot, it may not heal due to lack of oxygen. Furthermore, long term facilities staffing policy which has not increased since 1988 has made it stressful for staffs of long-term facilities to effectively care for residents in order to prevent pressure injuries such as engaging in regular turning of residents, assessment of wounds.

Indicators of the problem

To evaluate this policy, we can use different ways which may include:

how well the policy has been implemented and if its implementation is appropriate for the policy

goals and tools utilized; whether long-term care facilities are actually delivering the policy

consistently and appropriately along with analysis of the policy’s components (process

evaluation), a cost-benefit analysis or whether the policy is achieving its goals and

making a difference (outcome evaluation).

Unfortunately, Nova Scotia Health Authority has not published recent data on the province pressure injuries. The data I used in this paper was gotten from one of the NSHA new employee orientation slides as I have the privilege of getting hired recently. The following indicators will be used to evaluate the goals of prevention of pressure injuries policy in Nova Scotia; Incidence (percentage of residents with a new pressure injury in a 6-month period)- In April to October 2018, Long term facilities reported a total of 291 bedsores — with 52 at the severe stage 3 and 4 levels. Prevalence (percentage of residents with a pressure injury in a 6-month period)- In October 2018, the prevalence rate for pressure injuries averaged seven per cent for the province. Percentage of residents with a healed pressure injury in a 12-week period, percentage of residents with a healed pressure injury who were diagnosed with a secondary pressure injury within 1 year (recurrence), percentage of residents with a pressure injury who had a diagnosed wound infection in a 6-month period , and percentage of residents with a pressure injury in a 12-month period who reported high satisfaction with the care provided.

Analysis of the Goals and Objectives

The overall goal of the prevention of pressure injuries policy in Nova Scotia is quality improvement initiative. Its objective is to enhance continuity of care and knowledge and build capacity of health workers to enhance pressure injury prevention and management in long term care facilities. This is to reduce morbidity and mortality rate among residents of long-term care facilities ( Woodbury & Houghton, 2014).

When considering the definition of the problem, high incidence of pressure injuries in Nova Scotia, part of the contributing factor is the staffing policy that have not increased since 1988 when the long-term facilities had fewer residents and now when they have more residents to take care.

Additionally, the best way to achieve this is by increasing the long-term staff strength, retraining of health care workers on wound care management and prevention of pressure ulcers, turning bedridden residents every hour, application of barrier ointment to prominent bony prominences’, adequate hydration of residents, and improved documentation and reporting.

However, the policy is not a specific to a group of people but, rather a general approach and knowledge to all race, ethnicity, religion, sex, gender, age, mental and physical disability.

Analysis of Instruments and Implementation

Department of Health and Wellness continuing care in collaboration with Nova Scotia Health Authority Provincial Wound Prevention and Management Program and Northwood developed a protocol document that involves steps and directives to be followed by health care professionals that will purportedly lead to decreased incidence of pressure injuries and prevention of pressure injuries in Nova Scotia. Thus, the primary instrument utilized by the policy is regulation.

These regulations which is more of education do not apply to the residents and their families but rather to health care professionals. These regulations include retraining of health care workers on wound care management and prevention of pressure ulcers, turning bedridden residents every hour, application of barrier ointment to prominent bony prominences’, adequate hydration of residents, improved documentation and reporting.

Outcome Evaluation and Analysis

 Earlier it was mentioned that to evaluate this policy, an outcome evaluation would be conducted

considering four criteria: adequacy, suitability, sustainability and accessibility. These have been

touched on in previous sections, but it is now appropriate to look at each in more detail.

 Adequacy

Is this policy adequate; are the instruments employed capable of effecting the change that

we are looking for? In theory, all bases are covered by regulation, public information and

government/non-government partnerships and accompanying programs. Residents and families are made aware of the benefits of prevention of pressure injuries. Long term care facilities are required to share this information with Residents and their families. As earlier mentioned, the policy consists of five priority action steps which are known as Wound prevention and management cycle. Health care professionals’ partner with Resident and families to achieve optimum results. Proper documentation and reporting of new cases of pressure injuries will help in determining if the policy is adequate or not.

Suitability

 Are the programs within this policy suitable for all residents of long term facilities (race, ethnicity, religion, age, sex, gender, mental and physical disability) across the province? To truly

answer this question, it would be necessary to conduct a focus group interviews among health care professionals, Residents and families to determine the suitability of the policy. Studies found out that people with low economic status are at higher risk of developing pressure injuries compared to people with high economic status. Possible explanations for this, is that high income class can afford some resources that might help to prevent pressure injuries such as customized wheel chair and heel protectors and take good balanced diet that help in prevention of pressure ulcers. I think since prevention of pressure injuries is education driven, it provided an equal access for people from both low and high economic status. With or without availability of customized wheelchair or heel protectors, irrespective of socio-economic status, all residents that are bed ridden need to be assessed, turned every hour, application of barrier creams and heel should be elevated using pillows.

Accessibility

 Are the programs implemented in this policy accessible to all residents of long-term facilities in the province? I think since prevention of pressure injuries is more of education for health care professionals, the protocol on prevention of pressure injuries would be accessible to all residents of long-term facilities in Nova Scotia. Everyone is to be treated the same way in order to prevent pressure injuries.

Sustainability

 Finally, is the instruments, and policy programs sustainable? In addition, is our health care system in Canada sustainable? given that many of the programs that are part of this policy are free and are offered through the Department of Health and wellness for the province. However, that is too much to get into for the purpose of this paper. Of the three instruments utilized by this policy, the most sustainable are the directives. Partnerships with professional bodies such as college of Registered Nurses, College of Licensed Practical Nurses, College of Physicians to incorporate prevention of pressure injuries as part of requirements for annual license renewal will enhance sustainability of the policy. Also, engaging the media to sensitize the general public on prevention of pressure injuries will help to sustain the policy

Summary of criteria analysis

In conclusion, I feel that this policy is a positive step towards prevention of pressure injuries

in the province of Nova Scotia, but having a policy alone is not enough. All the

instruments employed, from the directives, to the public awareness, to the partnerships with professional bodies and programs must be continually assessed to ensure that they are meeting the

changing needs of Nova Scotia population.

Proposed Method of Outcome Evaluation

 To conduct an outcome evaluation, using these criteria I will conduct an outcome evaluation to determine if the policy is being effective in meeting its desired objectives (i.e. prevention of pressure injuries) in Nova Scotia.

we need to know if the policy and the policy have had their intended effects. That is, is the policy successfully achieving its desired objectives and goals (i.e. prevention of pressure injuries in Nova Scotia?). In this case the overall aim is prevention of pressure injuries in long term care facilities in Nova Scotia and, a decrease in overall incidence and prevalence of pressure injuries.

The following indicators will be used to evaluate the goals of prevention of pressure injuries policy in Nova Scotia; Incidence (percentage of residents with a new pressure injury in a 6-month period) , Prevalence (percentage of residents with a pressure injury in a 6-month period), percentage of residents with a healed pressure injury in a 12-week period, percentage of residents with a healed pressure injury who were diagnosed with a secondary pressure injury within 1 year (recurrence), percentage of residents with a pressure injury who had a diagnosed wound infection in a 6-month period , and percentage of residents with a pressure injury in a 12-month period who reported high satisfaction with the care provided. Proper reporting and documentation by health care professionals of long-term care facilities will enhance the success of these indicators.

Summary and Future Recommendations

 In the last six months, incidence of pressure injuries in long term care facilities in Nova Scotia have greatly reduced by 4.3 percent (Chronicle Herald news: 04.09.18). For some reasons, although statistics regarding the number of pressure injuries in Nova Scotia are not officially published by the Government so little information is known about the number of individuals in Nova scotia who have pressure injuries. Such information is important to assess the scope and healthcare costs of pressure injuries and develop public policies (Woodbury, 2014). To obtain estimated pressure injuries prevalence rates in Nova Scotia, existing data (gathered between 2008 and 2018) from different long-term care settings across the province were obtained from peer-reviewed published studies and from unpublished studies provided by individuals and pressure injuries support.

Policy’s primary instruments and their implementation have been very well executed overall across the province, there are still some areas that needs improvement. Most especially, the area of reporting and documentation as this is important to determine the success of the policy.

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