Improving Patient Safety: Context and Nurses' Work Processes for Pressure Ulcers

提高患者安全：压疮的背景和护士的工作流程

• 批准号: 8088756
• 负责人: Lynn M Soban
• 金额: --
• 依托单位: VA GREATER LOS ANGELES HEALTHCARE SYSTEM
• 依托单位国家: 美国
• 财政年份: 2011
• 资助国家: 美国
• 起止时间: 2011-06-01 至 2014-06-30
• 项目状态: 已结题
• 来源: https://reporter.nih.gov/project-details/8088756
• 关键词: Accounting; Acute; Address; Adherence; Adverse event; Affect; Agreement; Area; Atlases; Attention; Authorization documentation; Beds; Budgets; Care given by nurses; Caring; Case Study; Characteristics; Clinical; Consensus; Cost Savings; Data; Data Analyses; Data Collection; Databases; Decubitus ulcer; Development; Diagnosis; Discipline of Nursing; Educational process of instructing; Environment; European; Family; Feedback; Future; Goals; Guidelines; Healthcare Systems; Hospital Nursing; Hospital Units; Hospitals; Incidence; Individual; Injury; Inpatients; Institute of Medicine (U.S.); Intensive Care Units; Intervention; Interview; Knowledge; Lead; Leadership; Learning; Measures; Medical; Medicare; Mentors; Methods; Minority; Modeling; Morbidity - disease rate; Nurse Administrator; Nurses; Nursing Process; Nursing Staff; Occupations; Operative Surgical Procedures; Organization administrative structures; Organizational Change; Outcome; Participant; Patient Care; Patients; Prevention; Preventive; Process; Published Comment; Publishing; Qualifying; Qualitative Methods; Quality of life; Registered nurse; Relative (related person); Reporting; Research; Research Design; Research Personnel; Research Priority; Research Proposals; Resources; Review Literature; Risk Assessment; Role; Sampling; Services; Shapes; Site; Site Visit; Skin; Specific qualifier value; Structure; Surface; Surveys; System; Testing; Time; Ulcer; United States Agency for Healthcare Research and Quality; Variant; Veterans; Woman; Work; Writing; base; cost; design; health administration; human subject; implementation research; improved; meetings; mortality; novel; patient safety; prevent; programs; response; safety practice; therapy design

DESCRIPTION (provided by applicant): Project Background/Rationale: Assuring patient safety in hospitals, and preventing the estimated million or more injuries that result from poor safety practices, is a top priority in our nation's health care system. Nurses and nursing processes for patient care are central to preventing adverse events and promoting patient safety in the hospital environment, yet have received comparatively little attention from patient safety researchers. Pressure ulcer prevention is a critical patient safety concern for which delivery of recommended care processes are substantially, independently shaped by nursing leadership, nursing units, and the individual nurses within the units. Nationally accepted guidelines specify nursing care processes for pressure ulcer prevention (e.g., risk assessments), yet evidence indicates low rates of nurse adherence. Care improvement requires interventions aimed at organizational change. Review of the literature on pressure ulcer quality improvement interventions directed at nurses reveals the need to understand the influence that hospital and nursing unit organizational features exert on pressure ulcer prevention. Objectives: To address this gap, we propose to conduct semi-structured interviews with nurse executives, nursing unit managers, and frontline registered nurses in six diverse VA hospitals. Our aims are to: Aim 1: Understand the relationships between organizational context and guideline-concordant pressure ulcer preventive care by: (Aim 1.1) describing variations in pressure ulcer preventive care (e.g., use of risk assessments) and their determinants within individual hospitals and units, and; (Aim 1.2) evaluating variations in pressure ulcer preventive care in relationship to organizational features: (a) nursing unit contextual features (e.g., teamwork, support services); (b) hospital contextual features (e.g., teaching status), and (c) barriers and facilitators to achieving pressure ulcer guideline concordance. Aim 2: Use our findings as the basis for an expert panel designed to inform future intervention design by assessing the importance and feasibility of different intervention strategies in the different contexts identified in the study. Methods: A team consisting of 2 researchers will conduct site visits to 6 medical units representing organizationally diverse VA hospitals. Semi-structured interviews of nursing leaders, nurse managers, and frontline nursing staff will be conducted. Interviews will focus on how hospital and unit features influence key pressure ulcer prevention processes as described in nationally-accepted guidelines. We will use Atlas.ti to perform content analysis of these data. Key findings, including organizational features perceived to promote or inhibit pressure ulcer prevention, will be presented to the study Advisory Board, with the goal of achieving consensus regarding the most important areas for future research. Brief Description of Proposal (Primary Reviewer only): Pressure ulcers are an expensive condition that impact mortality and morbidity. While there are guidelines for pressure ulcer prevention, evidence suggests that nurses are not adhering to the guidelines. The overall goal of this study is to examine the association between hospital and nursing unit organizational factors and pressure ulcer intervention. Specific aims include (1) To understand the relationships between organizational context and guideline-concordant pressure ulcer preventive care" and (2) Convene an expert panel to inform future intervention efforts. The proposed study includes six sites, where the investigators will conduct site visits and semi-structured interviews with nursing leaders, management, and front-line staff. The data will be analyzed using content analysis. The findings will be presented to an expert panel during a meeting where a modified dephi process will be employed to achieve consensus regarding research priorities. Review Criteria 1. Importance of the Problem Addressed. Strengths: * Pressure ulcers are a costly problem and result in increased mortality and morbidity. Inpatient pressure ulcers are usually preventable and developing strategies to decrease ulcers could increase quality of life and result in substantial cost savings. Weaknesses: * The proposal still does not include data about the incidence of pressure ulcers in acute medical units. There is one additional citation, but it includes LTC and SCI units. The VANOD data includes data for each facility organized by bed section (acute, long term, SCI). The investigators state that this data is not published or validated, but it is possible to obtain permission to use VSSC data for research and in research proposals. While this data may not have been validated by researchers, it should provide a reasonable approximation of the magnitude of the problem. 2. Contribution to VHA. Strengths: * Understanding the relationship between nursing unit characteristics and the provision of guideline-concordant care could decrease pressure ulcer incidence and inform other quality-improvement initiatives. Weaknesses: * The barriers that are identified could lead to novel interventions, but as noted in the last review the proposed work might be necessary to developing an intervention, but it will take a few years and additional studies before an intervention can even be tested. 3. Adequacy of Response to Previous Feedback Provided by HSR&D Regarding the Proposed Study. Strengths: * The investigators made a number of substantial changes in the proposal to address the previous comments, including a new conceptual framework and additional methodological changes that strengthen the proposal. Weaknesses: * There is still limited information about the magnitude of HA pressure ulcers in acute settings in VHA, and if the proposed research will ultimately lead to an intervention that is successful. 4. Methods. Strengths: * The sampling of the interview participants, recruitment and statistical analyses sections are well written and detailed. Weaknesses: * The revised proposal includes additional discussion about how complexity scores might be related to organizational factors that affect pressure ulcers, but the investigators do not provide a compelling argument about why the complexity factors would be better than VANOD data for choosing sites. The response memo indicates that "we anticipate capturing sites with varying levels of pressure ulcer incidence" and briefly mentions that VANOD data will be captured if possible, but no details are provided about how the investigators will proceed if there isn't much variation between sites or if there doesn't appear to be an association between complexity level and pressure ulcer incidence. 5. Adequacy of Data. Strengths: * The data collection plan is carefully designed and clearly explained; additional details were added to address some of the reviewers' concerns. Weaknesses: * In response to the VANOD data VANOD currently collects data about skin assessment and pressure ulcers, and these data are available through VSSC reports. These reports include information about skin assessments, daily inspections, and the number of pressure ulcers acquired during inpatient stays at VA facilities. This data could inform site selection, the construction of survey questions, and ultimately the development of the conceptual model from the expert panel, but is only mentioned as part of a future study. If there are reasons why these data would not inform the proposed research, they should be clearly addressed in the proposal. 6. Project Organization and Management. Overall, the project organization plan is detailed and appears to be appropriate. 7. Investigator Qualifications. The team is well-qualified. 8. Human Subjects. The discussion of human subjects was comprehensive. 9. Inclusion of Women and Minorities. No concerns. 10. Facilities and Resources. Excellent; there are extensive resources available through the COE. 11. Budget. Properly designed qualitative studies are expensive, and the investigators did a good job of justifying the budget. 12. Overall Strengths. * The investigative team and expert panel are very qualified and the mentoring plan is detailed * The proposal is well-written * The qualitative methods are described in detail 13. Overall Weaknesses. * Lack of background data addressing pressure ulcer incidence in VA medical units - the cited IG report is not specific to acute care units, and this data is available from VANOD. * VANOD includes a number of pressure ulcer measures that could inform the design of the study * It is still unclear if the quality improvement programs based on the proposed and future studies will decrease pressure ulcers Key Issues (Summary Points): 1. VANOD was not created for research, but many VA databases created for clinical purposes are used in studies especially when other data are not available. 2. As noted in the last review, the sampling and analyses plans are detailed and well-designed and the investigative team has excellent qualifications. 3. This is an important topic and the proposed research could eventually decrease pressure ulcer incidence in acute units, which would improve patient outcomes and decrease costs.

描述（由申请人提供）： 项目背景/理由：确保医院患者的安全，并防止因不良安全措施造成的估计数百万人或更多的伤害，是我国医疗保健系统的首要任务。患者护理的护士和护理流程对于预防不良事件和促进医院环境中的患者安全至关重要，但患者安全研究人员的关注相对较少。压疮的预防是一个重要的患者安全问题，因此推荐的护理流程的实施基本上是由护理领导层、护理单位和单位内的个别护士独立制定的。全国公认的指南规定了预防压疮的护理流程（例如风险评估），但有证据表明护士依从率较低。护理的改善需要针对组织变革的干预措施。对针对护士的压疮质量改善干预措施的文献回顾表明，有必要了解医院和护理单位的组织特征对压疮预防的影响。目标：为了解决这一差距，我们建议对六家不同的退伍军人管理局医院的护士主管、护理单位经理和一线注册护士进行半结构化访谈。我们的目标是： 目标 1：通过以下方式了解组织背景与指南一致的压疮预防护理之间的关系：（目标 1.1）描述各个医院内压疮预防护理的差异（例如，风险评估的使用）及其决定因素，以及单位，以及； （目标 1.2）评估压疮预防护理与组织特征相关的变化： (a) 护理单位背景特征（例如团队合作、支持服务）； (b) 医院背景特征（例如教学状况），以及 (c) 实现压疮指南一致性的障碍和促进因素。目标 2：将我们的研究结果作为专家小组的基础，旨在通过评估研究中确定的不同背景下不同干预策略的重要性和可行性，为未来的干预设计提供信息。方法：由 2 名研究人员组成的团队将对代表不同组织的 VA 医院的 6 个医疗单位进行实地考察。将对护理领导、护士经理和一线护理人员进行半结构化访谈。访谈将重点关注医院和单位特征如何影响国家认可的指南中所述的关键压疮预防过程。我们将使用Atlas.ti 对这些数据进行内容分析。主要研究结果，包括被认为促进或抑制压疮预防的组织特征，将提交给研究顾问委员会，目标是就未来研究的最重要领域达成共识。 提案简要说明（仅限主要评审员）： 压疮是一种昂贵的疾病，会影响死亡率和发病率。 虽然有预防压疮的指南，但有证据表明护士没有遵守这些指南。 本研究的总体目标是检查医院和护理单位组织因素与压疮干预之间的关联。 具体目标包括（1）了解组织背景与符合指南的压疮预防护理之间的关系”以及（2）召集专家小组为未来的干预工作提供信息。拟议的研究包括六个地点，研究人员将在其中进行实地考察对护理领导、管理层和一线工作人员进行半结构化访谈 数据将通过内容分析进行分析，结果将在会议期间提交给专家小组，会议将采用修改后的 DEPH 流程来达成共识。研究重点。 审核标准 1. 所解决问题的重要性。 优势： * 压疮是一个代价高昂的问题，会导致死亡率和发病率增加。 住院病人的压疮通常是可以预防的，制定减少溃疡的策略可以提高生活质量并节省大量费用。 弱点： *该提案仍不包括有关急性医疗单位压疮发生率的数据。 还有一项额外的引文，但其中包括 LTC 和 SCI 单位。 VANOD 数据包括按床位（急性、长期、SCI）组织的每个设施的数据。 研究人员表示，该数据尚未发布或验证，但可以获得使用 VSSC 数据进行研究和研究提案的许可。 虽然这些数据可能尚未得到研究人员的验证，但它应该提供问题严重程度的合理近似值。 2.对VHA的贡献。 优势： * 了解护理单位特征与提供符合指南的护理之间的关系可以降低压疮发生率，并为其他质量改进举措提供信息。 弱点： * 所确定的障碍可能会导致新的干预措施的出现，但正如上次审查中所指出的，拟议的工作可能是制定干预措施所必需的，但在对干预措施进行测试之前，还需要几年的时间和更多的研究。 3. 对 HSR&D 先前提供的有关拟议研究的反馈的回应是否充分。 优势： * 研究人员对提案进行了一些实质性修改，以解决之前的意见，包括新的概念框架和其他方法上的改变，以加强提案。 弱点： * 关于 VHA 急性情况下 HA 压疮的严重程度以及拟议的研究是否最终会导致成功的干预，信息仍然有限。 4.方法。 优势： * 访谈参与者抽样、招聘和统计分析部分写得很好且详细。 弱点： * 修订后的提案包括关于复杂性评分如何与影响压疮的组织因素相关的额​​外讨论，但研究人员没有提供令人信服的论据来说明为什么复杂性因素比 VANOD 数据更适合选择地点。 回复备忘录指出，“我们预计会捕获压疮发生率不同水平的地点”，并简要提到如果可能的话，将捕获 VANOD 数据，但没有提供有关如果地点之间没有太大差异，调查人员将如何进行的详细信息或者复杂程度和压疮发生率之间似乎没有关联。 5. 数据的充分性。 优势： * 数据收集计划经过精心设计并解释清楚；添加了更多详细信息以解决审稿人的一些担忧。 弱点： * 针对 VANOD 数据，VANOD 目前收集有关皮肤评估和压疮的数据，这些数据可通过 VSSC 报告获得。 这些报告包括有关皮肤评估、日常检查以及退伍军人管理局住院期间获得的压疮数量的信息。 这些数据可以为选址、调查问题的构建以及专家小组最终开发概念模型提供信息，但仅作为未来研究的一部分提及。如果存在这些数据无法为拟议研究提供信息的原因，则应在提案中明确说明。 6. 项目组织和管理。 总体而言，项目组织计划是详细且适当的。 7. 研究者资格。 该团队资质良好。 8. 人类受试者。 对人类主题的讨论是全面的。 9. 包容妇女和少数群体。 不用担心。 10. 设施和资源。 出色的; COE 提供广泛的资源。 11. 预算。 正确设计的定性研究是昂贵的，研究人员在证明预算的合理性方面做得很好。 12. 整体优势。 * 调查团队和专家小组资质雄厚，辅导计划详细 * 提案写得很好 * 详细描述定性方法 13. 总体弱点。 * 缺乏关于 VA 医疗单位压疮发病率的背景数据 - 引用的 IG 报告并非特定于急性护理单位，并且该数据可从 VANOD 获得。 * VANOD 包括许多压疮测量措施，可以为研究设计提供信息 * 目前尚不清楚基于拟议和未来研究的质量改进计划是否会减少压疮 关键问题（总结点）： 1. VANOD 不是为了研究而创建的，但许多为临床目的创建的 VA 数据库都用于研究，特别是在没有其他数据可用的情况下。 2. 正如上次审查所指出的，采样和分析计划详细、设计周全，调查团队素质优良。 3. 这是一个重要的课题，拟议的研究最终可能会降低急性病房压疮的发生率，从而改善患者的治疗效果并降低成本。