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Introduction

This proposal for a change in practice intends to implement a skin traction care plan for pressure injury prevention in the orthopaedic ward. This proposal lays forth an early strategy to track and spot any degradation in skin quality. In order to improve the quality of treatment given and patient outcomes, the goal is to prevent pressure points from arising, make it easier to recognise deterioration early and promote safe practice.

A literature evaluation will provide background information on the need for this suggested practice change as well as details on the related financial cost and resource requirements. A technique of project performance evaluation will be proposed, and the effectiveness of the implementation will be discussed. In conclusion, it will be demonstrated that this little, straightforward innovation will improve the standard of care provided in orthopaedic wards.

Background

Patient safety is defined by the Australian Commission on Safety and Quality in Health Care (ACSQHC) as the prevention of errors and unfavourable effects related to medical care, and quality is defined as how much health care services for people and populations boost the chance of intended health outcomes and are compatible with knowledge in the field (ACSQHC 2023). Moreover, a total of 112,000 hospitalisations in public hospitals (2.1 per 100 hospitalisations) and 34,700 hospitalisations in private hospitals (0.9 per 100 hospitalisations) had one or more hospital-acquired complications (HACs) (Australian Institute of Health and Welfare [AIHW] 2023).

Pressure injuries are described as skin integrity degradation caused by pressure. This might happen if the prominence of the bone is in constant contact with an outside surface (Al Aboud and Manna 2018). Infections and higher mortality are linked to PIs, as well as longer admission times and greater assessment and treatment resource expenditures (Barakat-Johnson et al. 2021). In acute care settings, the prevalence rate varies between 6% and 18.5% among nations. A comprehensive review and meta-analysis of African research revealed a point prevalence that ranged between 3.4% and 18.6%, while a systematic review and meta-analysis of European studies indicated that, depending on the country, PI rates ranged from 4.6% to 27.2%. According to large research from various nations, the prevalence rates were reported to be 8.7% in Australia, 9.2% in the United States and Canada, 5.76% in Portugal and 17% in Italy (Tervo‐Heikkinen et al. 2022).

Pressure injuries cost Australian public hospitals a total of $9.11 billion, based on an incidence of 12.9%. The potential cost of the excessive length of stay totalled $3.60 billion, and treatment expenditures totalled $3.59 billion, accounting for the two most significant shares of costs. $493 million is the productivity loss cost by pressure injuries. Pressure injuries that occur in hospitals cost $5.50 billion overall, compared to $3.71 billion for pressure injuries that occur during admissions (Nghiem et al., 2022).

Treatment aims to facilitate wound healing, prevent infection, and alleviate discomfort. Approaches include offloading to reduce pressure, wound care, nutrition optimisation, and surgical intervention as needed (Brimelow and Wollin 2018. The role of nurses is paramount in pressure injury management, as they are often responsible for implementing preventative measures, conducting regular assessments, and providing hands-on wound care (Barakat-Johnson et al. 2019).

In specific cases, skin traction could be considered as a component of treatment. Skin traction involves applying controlled pulling forces on the skin's surface to address deformities or reduce friction (Nadaph et al. 2023). Its potential role in pressure injury management includes minimising friction by lifting the skin away from surfaces and aiding in correcting bony deformities or joint contractures, which can contribute to pressure injury development (Jiao et al. 2022). However, using skin traction for pressure injuries is not standard practice and requires careful evaluation by healthcare professionals (Kheiri et al. 2023). Nurses play a vital role in assessing the appropriateness of skin traction, ensuring its safe application, and monitoring patient response. Their expertise in wound care, patient positioning, and treatment coordination makes them essential contributors to comprehensive pressure injury management strategies (Sammut 2021).

Skin traction care is not covered by a care plan in the clinical setting, and documentation in notes frequently omits key details regarding the evaluation of findings. Common patient complaints include discomfort, extended wait times for imaging approval, and insufficient pressure during care.

Opportunities to improve outcomes are identified through the study of needs and the identification of practice gaps (Alasaireh et al. 2020). This project will guarantee that Actions 5.10 and 5.12 of the National Safety and Quality Health Service Standards, Comprehensive Care are followed, which motivate clinicians to evaluate and evaluate discomfort, continue dermal inspections, and identify individuals who are at risk using a proven risk assessment technique. (ACSQHC 2019).

Primary Goals and Objectives

The purpose of this is to advance patient-centred care via suitable, better, and financially viable healthcare delivery by paying attention to consumer needs, looking into them, and delivering successful patient results. To minimise dermal degradation and enable early detection of PI, this will be accomplished by requiring all patients using skin tractions to receive a validated dermatological evaluation in the acute setting, thereby lowering the risk of mortality and morbidity. Through the implementation of a skin traction care plan (STCP) that includes skin assessment, documenting of skin change, care that is commenced, and results evaluation, the main goal of this project is to lower the chance of PIs developing conditions as a direct result of the insertion of skin traction. Reduced nurse time spent assisting with dressing changes, a decrease in the amount of money spent on dressings related to PI, and a reduction in patient suffering are all secondary goals.

Outcomes of the Project

A decrease in detected PIs related to skin traction will indicate the success of the project, as will data analysis of the Incident Management System+ (IMS+), a practical instrument used by NSW Health and developed by the Clinical Excellence Commission (CEC) NSW Health 2020). Staff members who are involved in the implementation of this STCP must sign up for a safety briefing on its use. Data will be added to staff members' individual portfolios and uploaded to the online learning platform, documenting continuous professional development (CPD). Ensuring personnel are knowledgeable about and competent in using the STCP will increase staff capability. Along with the six-month post-project implementation survey, a pre-and post-safety huddle survey will help evaluate the results.

Staff members participate in a safety seminar to become familiar with the Skin Traction Care Plan's (STCP) usage, which is documented on a sign-in sheet. Data will then be added to staff members' individual portfolios and uploaded to the online learning platform, creating a thorough record of their continuous professional development (CPD). This methodical technique ensures staff members are aware and confident when using the STCP, ultimately improving their general proficiency. Pre and post-safety huddle questionnaires and a follow-up survey six months after implementation will be used to evaluate the effects of the STCP. Additionally, the STCP will be included in the patient's bedside folder, assuring compliance and facilitating simple STCP audits. The STCP will also include measures made to lessen discomfort and assessments of pain, thereby increasing patient satisfaction with their care. Through focused and auditable interventions, this multifaceted model strengthens staff capabilities and improves patient experiences.

Implementation Framework

The Canadian Institutes of Health Research (CIHR) established the Knowledge to Action (KTA) framework as an all-encompassing strategy to make it easier to translate research findings into usable applications in healthcare settings (Schlager 2019). This paradigm recognises the gap that frequently occurs between research findings and their application in actual healthcare environments, and it provides an organised procedure to close this gap efficiently. The knowledge production and action cycle phases make up the KTA framework's two primary sections (Nilsen 2020).

Researchers engage in knowledge inquiry during the knowledge development phase by selecting research topics that address gaps in healthcare practice. Utilising systematic reviews, meta-analyses, and other research techniques, existing data is synthesised and consolidated to produce knowledge products, including clinical guidelines, decision aids, and teaching materials. This stage seeks to convert study findings into useful information that can direct healthcare professionals (Graham et al. 2018). For instance, Garritty et al. (2021) strongly emphasise the value of synthesising research information to provide useful guidelines that guide clinical decision-making.

Implementing evidence-based practices in healthcare settings constitutes the second step of the KTA framework or action cycle. This phase, which is iterative and adaptive, is concerned with comprehending the local situation, identifying obstacles, and choosing specialised solutions to overcome these obstacles (Spooner et al. 2018). The adoption of evidence-based practices is facilitated by the use of strategies, including education, training, and modifications to organisational policy. The implementation process must be monitored and evaluated in order to determine its efficacy and effect on patient outcomes (Arajo-Soares et al. 2018). In order to improve and optimise treatments, Arajo-Soares et al. (2018) stress the action cycle's cyclical character and the necessity of continuing review.

In order to effectively integrate evidence-based practices into normal treatment, the KTA framework places an emphasis on collaboration between researchers, healthcare professionals, policymakers, and patients. This strategy encourages a comprehensive awareness of the implementation's obstacles and enablers by taking into account things like patient preferences, the availability of resources, and the organisational culture of healthcare settings (Tucker et al. 2021). In order to ensure the applicability and viability of evidence-based practices, Tucker et al. (2021) also emphasise the significance of collaborations between researchers and knowledge users.

Skin traction is a fundamental orthopedic procedure that involves applying a controlled pulling force to a limb, aiding in fracture reduction and the alignment of bones (Dhurvas et al. 2019). The successful implementation of this technique hinges on a thorough understanding of the clinical evidence substantiating its efficacy and benefits (Duperouzel et al. 2018). Extensive research has explored the utility of skin traction in orthopedic settings. For instance, a study by Mobed et al. (2022) investigated the effects of skin traction in patients with hip fractures. The study's findings demonstrated that skin traction effectively alleviated pain and improved fracture alignment, underscoring its clinical relevance and positive outcomes. Throughout the project plan, the SMART framework is used to make sure timelines and assessment dates are noted, encourage staff involvement to aid in project compliance as the project moves forward and provide an opportunity for inquiries, if necessary. The MyHealth Learning skin traction care program is recommended for nurses to finish. Consequently, the project will last six months. There are identified important junctures (see table 2).

Table 1 - Stakeholders

Stakeholder

Action

The APRN Team

Clinical Nurse Specialists provide hands-on patient care and services using advanced skills.

 They diagnose, treat, and manage complex medical conditions within their specialty.

The team implements up-to-date nursing practices based on the latest medical research.

 They work with other healthcare professionals to design comprehensive care plans tailored to patients.

Regular sessions are held to discuss care plans, addressing concerns and improving practices.

They use email and follow-up to ensure effective communication and address nursing staff needs.

Head of Orthopaedic Ward

Responsible for approving or modifying proposed nursing practice changes.

Review proposed changes' impact on patient care, feasibility, and alignment with goals.

Consult the APRN Team, nursing staff, and executive nurses for insights before authorization.

Nursing Staff

Finish the pre-project survey.

Complete Learning module for MyHealth

Attend the safety briefing

Complete the 6-month post-project implementation survey Complete the Post-project survey Document care on STCP

Executive Nurses

Oversee nursing practices to ensure alignment with the organisation's mission and standards.

Provide direction to ensure consistent patient care and evaluate proposed practice changes.

Evaluate the implications of changes on resources, training, and patient satisfaction.

Their buy-in is essential for successful and sustainable practice change.

Intern and Fellow Nurses

Junior nurses actively participate in patient care under the guidance of the APRN Team and experienced staff.

Assist in procedures, medication administration, and patient monitoring to gain practical experience.

Offer fresh perspectives during feedback sessions, enriching care plan discussions.

Witness the integration of evidence-based approaches into real patient care scenarios

Table 2 - Key Milestones GANTT Chart

Structure of Actions to be taken

September

October

November

December

January

February

Literature review and proposal drafting

Involvement with stakeholders

Support and provision of My health learning module

Creation of flyers and survey to evaluate the awareness of nurses

Implementation of STCP.

Commencing new changes

Auditing and collection of data

Sending a request through email to the nursing staff for a 6-month survey

Compile the findings from the pre- and post-surveys, the IMS+ data, and the audit reports.

NUM and the Head of the Orthopaedic Division should get the results and reports from the project's efficacy review.

Update the STCP policy for skin traction care in coordination with the Executive Nurses.

Table 3 - Barriers and Strategies for Mitigation

Barrier

Mitigation Strategy

Lack of awareness among nursing staff

Conduct workshops/presentations explaining rationale and benefits.

Use flyers and emails to communicate key points.

Limited participation in pre-project survey

Clearly explain survey importance.

Ensure user-friendly survey design.
- Offer incentives for completion.

Difficulty in scheduling daily safety huddles

 Plan huddles for different shifts.

 Use varied communication methods (in-person, video, written summaries).

Resistance to change among nursing staff

 Provide comprehensive education and address concerns.

Involve staff in decision-making.

Incomplete/delayed post-survey completion

Regularly remind staff to complete post-survey.

Highlight the post-survey's role in evaluating practice change.

Difficulty in assembling and analysing project data

Design surveys and reports systematically.

Use data management tools/software for efficient analysis.

Lack of support from higher management

Present a well-structured proposal emphasising benefits.

Highlight positive impact on patient outcomes.

Inadequate collaboration with NEs

Schedule regular meetings with NEs for coordination.

 Define clear roles and responsibilities for NEs.

Unforeseen challenges during implementation

 Develop a contingency plan outlining alternative approaches.

 Maintain open communication with stakeholders.

Table 4 - Financial Factors

Item

Resource Type

Amount

APRN Time/Wages:

Make a proposal.

Create and distribute flyers

Create the STCP, then print

Create a 6-month survey and a pre- and post-safety short survey.

Every day for a week, safety huddle education sessions

Examine IMS+

Consider pre- and post-surveys.

assemble presentation materials and audit reports.

Review any updated policies.

30 hours @ $48.41

0.5 hours @ $48.41

1 hour @ $48.41

1 hour @ $48.41

Attended in working hours

1 hour @ $48.41

1 hour @ $48.41

4 hours @ $48.41

2 hour @ $48.41

$1452.30

$24.20

$48.41

$48.41

$0

$48.41

$48.41

$193.64

$96.82

NE STCP assessment and policy alterations

2 hours @ $50.36

$100.72

Number of data and report reviews

2 hour @ $64.13

$116.72

Orthopedic services director analysis of the data and reports

2 hour @ $58.36

$128.26

TOTAL

$2306.30

According to the NSW Nurses and Midwives Association (NSWNMA 2021), APRN, NE, and NUM earnings are displayed.

Evaluation

Analysis of nursing practices, the ability to uphold those practices, and analysing results to influence nursing practices are all covered in national guidelines describing expectations (Harvey et al. 2019). Evidence, as was already established, is a critical component of the KTA framework (Spooner et al, 2018). This can help bridge the gap between the evidence and the context by providing education, support, problem-solving, and creating a shared vision for change (Dopp et al. 2020). Table 5 lists the outcomes. To determine the success of the suggested practice shift, three assessment methods will be used.

When the 6-month mark is achieved, the initial strategy entails nurses taking part in a micro-level survey, as well as the pre-and post-safety huddle brief surveys. Through the use of both qualitative and quantitative questions, this six-month survey will include inquiries regarding participants' understanding, perceptions, and experiences during the project's trial phase. A recent study by Pittman et al. (2022) identified nurses as stakeholders and used web-based surveys to assess the effect of a hospital EBP centre on nursing rules. With these polls, we hoped to understand how decisions, happiness, and possibilities for development were influenced. The positive impact of EBP on outcomes was recognised and the results enabled prompt policy changes. Limitations were noted, nevertheless, such as the reliance on response quality and potential bias.

The second approach entails STCP audits by evaluating STCP documentation quality and examining IMS+ reporting of identified skin traction-linked PIs. The use of audits in the creation of safety legislation has grown. However, there are still factors to take into account, such as organisational position, the audit team's level of expertise, and attitudes toward auditing, all of which must be encouraged (Hut-Mossel et al. 2021). It will be clear that the project has improved patient outcomes if there is a decrease in IMS+ skin traction-linked PIs. Completing the online MyHealth learning module will count as the third approach to attending the safety brief, which will be documented on a sign-in sheet and uploaded to the online learning platform. This data can be used to assess skin traction care knowledge and skill objectively and support CPD. 

Table 5 - Outcomes

Measure

Outcome

Reporting

Safety huddle for nurses

Obtain knowledge about the endeavor

Get educated

Clarification on the change in practice is desired.

Attendance record with a signature CPD points

Brief survey findings from before and after the safety huddle undertaking a six-month survey

Hospital IMS+ recording audit

KPIs related to the decline in skin traction PIs that were recorded

IMS+ review

Pre-post survey audit findings

The 6-month survey's audit findings

Improved patient experience

Lessening the discharge delay

Reports of decreased pain

Reduced mortality and morbidity

Audits completion

Staff surveys

Decreased rates of traction-associated injuries seen on STCPs

Improved staff satisfaction

Improved Skin-traction confidence

NE availability reiterated

CPD points for signing in to the safety huddle

Learning history in MyHealth

Audits based on surveys

Improved documentation

Accurately documenting the provision of skin traction treatment

Auditing of STCPs

Conclusion

The project will become institutionalised as a result of the creative, simple practice change plan mentioned, which calls for stakeholder involvement and NE support in a progressive workplace culture that is strengthened through leadership and management. Moreover, the KTA approach, is a useful method for implementing evidence-based practices in healthcare settings. PI reduction is a shared objective that will improve patient outcomes, care delivery quality, and practice safety. To justify institutionalisation, it is underlined the importance of conducting a critical evaluation of the results. A modest financial investment is required for assisting with investigation in terms of resources and time, but constant needs would be minor and would contribute to efficient and thorough patient care, leading to improved health and well-being

References

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Alsaraireh, M. and Eshah, N.F., 2020. Factors that influence the quality of pain management in patients with skin traction. International Journal of Orthopaedic and Trauma Nursing, 36, p.100713. https://doi.org/10.1016/j.ijotn.2019.100713

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Tervo‐Heikkinen, T.A., Heikkilä, A., Koivunen, M., Kortteisto, T.R., Peltokoski, J., Salmela, S., Sankelo, M., Ylitörmänen, T.S. and Junttila, K., 2022. Pressure injury prevalence and incidence in acute inpatient care and related risk factors: A cross‐sectional national study. International Wound Journal19(4), pp.919-931.  https://doi.org/10.1111/iwj.13692

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