NUR 590 Prevention Of Pressure Ulcers In Palliative Patients In Hospitals

Prevention of Pressure Ulcers for End of Life Patients in Hospitals: Adoption of an Evidence-Based Pressure Ulcers Risk Assessment Protocol for Standing Orders 

1.0 Background 

The philosophical literature on good death supported the early framework of achieving a natural death free from medical intervention at home surrounded by friends and family (Campbell, 2020).

This traditional way of conceptualizing good death, particularly outside the hospital setting, places palliative care in opposition to mainstream healthcare services (Robinson et al.,2016). However, Palliative care, to help provide relief from symptoms and offer support to patients and their family members at the end of their lives, is expected to be offered in all care settings (4th edition of the National Consensus

Project’s Clinical Practice Guidelines for Quality Palliative Care). Similarly, palliative care policy in England emphasizes that high-quality care should be available wherever the person may be: at a hospital, in home, in a care home, in a hospice, or elsewhere (Leadership Alliance for the Care of Dying People, 2014 and NHS, 2008). 

This focuses on solving the problem associated with the hospital as a place of palliative care and end-of-life. Also, in 2012, the NHS identified pressure ulcer prevention as a quality improvement target, which was in furtherance of the Department of Health set a target of an annual reduction of at least 5-10% in the incidence of pressure ulcers in 1994

(Department of Health (DH), 2012. 

However, as there was no requirement for trusts to provide data relating to this target, there is no evidence to suggest this has been addressed. Likewise, there is no requirement for data to be collected about the needs or outcomes of services used by patients of acute hospitals, resulting in a significant lack of such literature in the United Kingdom (Kerrison and Pollock, 2001). 

Therefore, despite the attention given to the area of pressure ulcer prevention, what remains uncertain is what constrains hospitals from implementing national guidelines on pressure ulcer prevention ((National Institute for Clinical Excellence (NICE), 2001; 2003; DH, 2001; 2003)) and the evidence-based recommendations of the International Pressure Ulcer Prevention and Treatment Guidelines (National Pressure Ulcer Advisory Panel (NPUAP) et al, 2019) in terms of improving the outcomes for patients. This study aims at addressing some of these gaps.

Particularly, the researcher would be working closely with the staff in one of the placement hospitals to identify the barriers to change and then to work with the healthcare professionals and management to implement best practices in pressure ulcer prevention. In addition, considering the increasing population of patients requiring palliative care in acute hospital (Cruz-Oliver, 2017; Etkind, S.N., Bone, A.E., Gomes, B. et al. 2017;, 2014) amid established evidence that: i) end-of-life patients are susceptible to pressure ulcer (Ferris, Price & Harding, 2019; Carville, 2018), ii) 

Some 80 to 95% of pressure ulcers are preventable (Institute for Healthcare Improvement, 2021; Ebi, Hirko & Mijena, 2019; NHS, 2015), and iii) hospital settings are inadequate in providing palliative care (the Mid Staffordshire NHS Foundation Trust, 2013; Gardiner et al., 2011), this area requires systematic application of evidence-based practice research. The existing end-of-life and palliative care in hospitals in England fit a proposed practice change given its inadequacy in terms of coverage, variation in practices, and sustainability (Ó Coimín et al., 2019). For instance, dying in hospital in the UK is characterized by a deficit of vital end-of-life care because of the lack of specialist support available out of hours and at weekends.

Those who die overnight or at the weekend may be denied the right care because only some (11%, 2016 End of Life Care Audit – Dying in Hospital) of hospital trusts in

England provides face-to-face specialist palliative services round the clock 1 Monday to Sunday, as the majority of trusts offer a specialist telephone helpline. Though most healthcare professionals giving end-of-life care do it to a very good standard when things start to go wrong out-of hours in the middle of the night and at weekends, then the nurses that need access to specialists in palliative care are without it, patients with complex problems like pressure ulcers may not get the care they need.

Which is a problem. Consequently, practice research toward improving the prevention of pressure ulcers among end-of-life patients in an acute hospital is needed to ensure improved patient outcomes, including symptom control and quality of life, and family outcomes, such as decreased anxiety. The purpose of this study is, therefore, to describe the process of a nurse-led practice improvement project to implement an evidence-based standing order set for risk management of pressure ulcers in a hospital-based palliative care setting using patients’ experience data as an evaluative component. 

Considering the progressive end-stage deterioration of the skin usually experienced by patients receiving palliative care, ongoing regular assessment of pressure ulcer risk is required (NPUAP et al, 2019). The Marie Curie Centre Hunters Hill Risk Assessment Tool (Chaplin, 2000), is identified in literature as a recommended tool that can be used in conjunction with clinical judgment to conduct a broad pressure ulcer risk assessment in patients under the end of life and palliative care (NPUAP et al, 2019). In this light, the underlying elements of the PICO model: Patient / Problem, Intervention,

Comparison and Outcome being considered will be as follows: Table 1: PICO Process Population/Patient/Problem Intervention Comparison Outcome In end-of-life patients and Prevention of Comparison between Make a difference in among family members of pressure ulcers in old and new standing meeting the care patients individuals receiving orders need of patients and palliative care significantly reduce in-hospital using pressure ulcer evidence-based risk incidence in hospital assessment management 2.0 Methods:

The steps of the Iowa Model for Evidence-Based Practice Change will be utilized for this practice implementation project. Survey data will be conducted as a proxy for assessing the intervention effectiveness. The Iowa Model of Evidence-Based Practice The Iowa

Model of Evidence-Based Practice for organizational scientific evidence as described by Spellman (2016) provides the framework for identification of a relevant topic for clinical inquiry, team formation appraisal and synthesis of the relevant best evidence, application of changes, evaluation and dissemination. 

It involves identifying practical issue of concern and formulation of research questions; determining how much of a problem the priority issue is for the organization; determine if the evidence is sufficient – otherwise, search; but if the evidence is sufficient and the changes are appropriate, conduct 2 a pilot study to change the practice; evaluate pilot results, disseminate results and implement change (Camargo et al.,2017). 


  • Campbell, S.M. (2020) Well-Being and the Good Death. Ethical Theory Moral Prac 23, 607–623. 
  • Robinson, J., Gott, M., Gardiner, C. & Ingleton, C. (2016) The ‘problematization’ of palliative care in hospitals: an exploratory review of international palliative care policy in five countries. BMC Palliative Care 15:64. doi 10.1186/s12904-016-0137-0 
  • Department of Health (2012) Using the Commissioning for Quality and Innovation (CQUIN) Payment Framework: Guidance on New National Goals for 2012–13 London: Department of Health, London. 
  • NHS (2008), High Quality Care for All. NHS Next Stage Review Final Report No. CM 7432, Presented to Parliament by the Secretary of State for Health by Command of Her Majesty.