Describe the methods for monitoring solution implementation using the steps of the model you chose.

Write a paper in implementing a project proposal to reduce pressure ulcers in an acute hospital.
The proposed project to be implemented is by adding an electronic documentation system that recorded harm events and documented initial pressure ulcer risk assessment among all admitted cases. In the new program, staff charge nurses will conduct pressure ulcer assessments in admission. Instead of documenting in paper form, they will directly record these findings on an initial risk assessment electronic form and simultaneously make an e-referral to the wound consult nurse if a patient has a pressure ulcer that is a stage 2 or higher.
The

Use the attached article as one of the references:
Pittman, J., Beeson, T., Kitterman, J., Lancaster, S. and Shelly, A. (2015). Medical device?
related hospital-acquired pressure ulcers. Development of an evidence-based position
statement. Journal Wound Ostomy Continence Nurse, 42(2), 151-154.
DOI: 10.1097/WON.0000000000000113

The assignment should have 4 main sections. Use the attached example as a template.
Please use subheadings to identify each section (see APA 6.0 for formatting heading levels). Do not forget to include the appendix – copy and paste it, do not attach as a separate document.
1) Monitoring

Describe the methods for monitoring solution implementation using the steps of the model you chose.
2) Evaluation

Describe the methods to be used to evaluate the solution.
3) Outcome Measure

Describe an outcome measure that evaluates the extent to which the project objective is achieved. A copy of the measure must be included in the appendix. For example: If your problem is falls or CAUTIs, then your objective would be to reduce the rate/numbers and the outcome measure is the form or graph you track the number of falls or number of CAUTIs. If your problem is the lack of knowledge of your nurses regarding lateral violence, then your outcome measure could be a pre and posttest.
The outcome measure for this propose project is: The expected result of the change implementation in California Health Medical Center (CHMC) is to have a reduction in the incidence of newly acquired pressure ulcers development from the current rate of 15% to 10% in all patients in the hospital within six months.

Describe the ways in which the outcome measure is valid and appropriate for use in this proposed project.

4) Evaluation Data Collection

Describe the methods for collecting outcome measure data and the rationale for using those methods.
Identify resources needed for evaluation.
Discuss the feasibility of the evaluation plan.

Format your paper consistent with APA 6.0 guidelines.
Include a minimum of 4 scholarly references
Minimum word count of 800.

J Wound Ostomy Continence Nurs. 2015;42(2):151-154.
Published by Lippincott Williams & Wilkins
WOUND CARE
Copyright ? 2015 by the Wound, Ostomy and Continence Nurses Society? J WOCN ? March/April 2015 151
Patient safety and prevention of harm are foundational
principles of healthcare, and nursing in particular, yet patients
continue to develop pressure ulcers while under our
care. Hospital-acquired pressure ulcers (HAPUs) cause pain,
loss of function, and infection, extend hospital stays, and
increase costs. The cost of treating these wounds is approximately
$11 billion a year. In spite of progress in wound
care products, support surfaces, and prevention methods,
occurrences of pressure ulcers persist. 1 Medical device-related
HAPUs are common in both adults and children in
the acute care setting.
Medical Device?Related HospitalAcquired
Pressure Ulcers
Development of an Evidence-Based Position Statement
Joyce Pittman Terrie Beeson Jessica Kitterman Shelley Lancaster Anita Shelly
? ABSTRACT
Hospital-acquired pressure ulcers (HAPUs) are a problem
in the acute care setting causing pain, loss of function,
infection, extended hospital stay, and increased costs. In
spite of best practice strategies, occurrences of pressure
ulcers continue. Many of these HAPUs are related to
a medical device. Correct assessment and reporting of
device-related HAPUs were identifi ed as an important
issue in our organization. Following the Iowa Model
for Evidence-Based Practice to Promote Quality Care,
a task force was created, a thorough review of current
evidence and clinical practice recommendations was
performed, and a defi nition for medical device-related
HAPU and an evidence-based position statement were
developed. Content of the statement was reviewed by
experts and appropriate revisions were made. This position
statement provides guidance and structure to accurately
identify and report device-related HAPU across our
18 healthcare facilities. Through the intentional focus on
pressure ulcer prevention and evidence-based practice in
our organization and the use of this position statement,
identifi cation and reporting of device-related HAPUs
have improved with a decrease in overall HAPU rates
of 33% from 2011 and 2012. This article describes the
development and implementation of this device-related
HAPU position statement within our organization.
KEY WORDS: Evidence-based , Iowa Model , Medical devicerelated
pressure ulcers , Position statement
A pressure ulcer can occur wherever external pressure
impairs circulation to the skin. Pressure ulcers have been
defi ned by the National Pressure Ulcer Advisory Panel
(NPUAP) as ?a localized injury to the skin and/or underlying
tissue usually over a bony prominence, as a result of
pressure, or pressure in combination with shear.? 2(p6) This
defi nition is helpful but many pressure ulcers occur as a
result of external pressure from medical devices that do not
completely fi t this defi nition. The NPUAP addressed devicerelated
HAPUs, which develop on mucosal membranes by
issuing a statement describing the inappropriate use of staging/category
classifi cation due to anatomical differences
between mucosal membrane with skin structures. The
National Database of Nursing Quality Indicators recommends
using the term ?indeterminate? when classifying
HAPUs over mucosal membranes when reporting HAPU. 3,4
However, neither of these recommendations provides a
clear and concise defi nition for all device-related HAPUs.
Hospital-acquired pressure ulcer development is considered
a quality indicator across healthcare systems. 5
Healthcare facilities are required to track and report HAPU
rates. In our large academic healthcare system, prevention
and accurate identifi cation and classifi cation of HAPUs are
a high priority. Monthly skin audits within our facility
found that a high percentage, often more than 50%, of
HAPUs are device related. In addition, the identifi cation,
Joyce Pittman, PhD, ANP-BC, FNP-BC, CWOCN, Indiana University
Health?Methodist, Indiana University School of Nursing, Indianapolis.
Terrie Beeson, MSN, RN, CCRN, ACNS-BC, Indiana University
Health- University Hospital, Indianapolis.
Jessica Kitterman, BSN, CWOCN, Indiana University Health- Ball
Hospital, Muncie.
Shelley Lancaster, MSN, CNS, CWOCN, Indiana University HealthWest
Hospital, Indianapolis.
Anita Shelly, MSN, CNS, CWOCN, Indiana University Health- Riley
Hospital, Indianapolis.
The authors declare no confl icts of interest.
Correspondence: Joyce Pittman, PhD, ANP-BC, FNP-BC, CWOCN,
Indiana University Health?Methodist, Indiana University School of
Nursing, 1701 Senate Blvd, Room B651, Indianapolis, IN 46202
( Jpittma3@iuhealth.org ).
DOI: 10.1097/WON.0000000000000113
Copyright ? 2015 Wound, Ostomy and Continence Nurses Society?. Unauthorized reproduction of this article is prohibited.
JWOCN-D-14-00006_LR 151 WOCN-D-14-00006_LR 151 21/02/15 2:01 PM 1/02/15 2:01 PM
152 Pittman et al J WOCN ? March/April 2015
defi nition, and reporting of these types of HAPU are inconsistent
with high variation across this organization?s
acute care facilities. Therefore, a task force was created and
given the directive to explore this issue. The purpose of
this article is to describe the process this task force used to
address this important issue.
? Development of the Project
When examining a practice issue or problem, it is helpful to
use a model that provides a guide to identify areas of clinical
inquiry through synthesis and application of research fi ndings.
6 One such model is the Iowa Model of Evidence-based
Practice to Promote Quality Care (Figure 1). It provides guidance
for nurses to use research fi ndings for improvement of
patient care. Using this model, we fi rst created a task force
that included members of our Pressure Ulcer Prevention systemwide
committee. Task force members represented 4 of
our adult acute care facilities and our childrens? hospital.
Four of the task force members were certifi ed WOC nurses,
3 were also masters prepared and/or a clinical nurse specialist,
and 1 member was doctorally prepared. Using the Iowa
Model of Evidence-based Practice to Promote Quality Care,
the task force identifi ed medical device-related pressure ulcers
as a problem-focused trigger, a clinical problem, and a
priority of the healthcare organization. This was an important
fi rst step because a topic that is aligned with the strategic
goals of the organization and embraced by staff has a
high likelihood of being adopted by those providing care. 6
In addition, connecting the knowledge gained from research
to an organizational initiative that has relevance to both the
organization and the WOC nurse creates an opportunity
and environment for support that might not be available if
the topic were chosen to fulfi ll local interests alone. 7
Developing a well-formulated purpose statement is
benefi cial once the topic or problem is identifi ed. The
purpose statement directs the evidence search, helps focus
reading, and defi nes the boundaries and limits around the
work to be accomplished. Finally, we advocate formulating
a clear and concise purpose statement to assist with
developing an appropriate implementation and evaluation
plan. The task force was charged with developing a
standardized, evidence-based defi nition for device-related
HAPU, which would support appropriate identifi cation
and reporting of these pressure ulcers.
The next step in the Iowa Model is to appraise the evidence
related to the question or purpose statement. In
order to fi nd the most current new knowledge related to
device-related pressure ulcers, a search was conducted of
the current relevant literature. We searched the MEDLINE
electronic database. Key search strategies were: (1) time
frame: 1996 to September 2012; (2) exp *?Equipment and
Supplies?/ (312834); (3) exp *Pressure Ulcer/ep, et
[Epidemiology, Etiology] (851); (4) 1 and 2 (84); (5) limit 3
to (English language and humans) (78); and (6) from 4
keep 2?4, 6, 13, 16?17, 20, 23?24, 26?31, 35?39, 53?54, 64,
69?71, 76?78 (30). This search identifi ed 30 references,
which were reviewed by our team.
The task force identifi ed the defi nition of medical devices
by the Food Drug & Cosmetic Act as integral to developing
a defi nition of device-related HAPUs. The US
Food and Drug Administration defi nes a medical device as
??an instrument, apparatus, implement, machine, contrivance,
implant, in vitro reagent, or other similar or related
article, including a component part, or accessory
which is: recognized in the offi cial National Formulary, or
the United States Pharmacopoeia, or any supplement to
them, intended for use in the diagnosis of disease or other
conditions, or in the cure, mitigation, treatment, or prevention
of disease, in man or other animals, or intended
to affect the structure or any function of the body of man
or other animals, and which does not achieve any of its
primary intended purposes through chemical action
within or on the body of man or other animals and which
is not dependent upon being metabolized for the achievement
of any of its primary intended purposes.? 8(p1)
Another important piece of evidence was that of the
NPUAP and its work surrounding pressure ulcers. The
NPUAP hosted a consensus conference in 2010 and again in
2014 to discuss the complexities of avoidable versus unavoidable
HAPUs. As a result of this work, NPUAP has led
efforts of the wound and pressure ulcer expert community
in identifying key components related to pressure ulcer development
and the complexities surrounding these wounds.
This work is in its initial stages, but a state of the science
article was published recently describing unavoidable pressure
ulcer incidence and the key risk factors that infl uence
them. 9 One of these key risk factors identifi ed is that of medical
devices. Medical device-related pressure ulcers are diffi –
cult to prevent as they are necessary for treatment. They are
also challenging to assess due to the inability to remove
them in certain instances, and they may produce compromise
of underlying tissue due to moisture or edema.
Many states are recognizing the importance of HAPUs
and are requiring the reporting of prevalence of HAPUs as
a quality measure. Minnesota used data collected through
mandatory statewide adverse health events reporting system
to identify trends in causative factors for device-related
pressure ulcers. An interdisciplinary team convened
to develop best practices for prevention of pressure ulcers
related to the use of medical devices. 10 Although the fi ndings
from this report are helpful, no defi nitive defi nition
for device-related HAPUs was described.
? Implementation of the Project
Using the US Food and Drug Administration defi nition for
medical devices, evidence-based guidelines, and position
statements from various organizations, and results of an expert
review, the task force defi ned device-related skin injury
to those devices that were medical and external. The task
force identifi ed 2 critical elements to be included in the
Copyright ? 2015 Wound, Ostomy and Continence Nurses Society?. Unauthorized reproduction of this article is prohibited.
JWOCN-D-14-00006_LR 152 WOCN-D-14-00006_LR 152 21/02/15 2:01 PM 1/02/15 2:01 PM
J WOCN ? Volume 42/Number 2 Pittman et al 153
Assemble Relevant Research & Related Literature
Critique & Synthesize Research for Use in Practice
Yes No
Yes
Is Change
Appropriate for
Adoption in
Practice?
Yes Institute the Change in Practice
No
Continue to Evaluate Quality
of Care and New Knowledge
No
Disseminate Results
Problem Focused Triggers
1. Risk Management Data
2. Process Improvement Data
3. Internal/External Benchmarking Data
4. Financial Data
5. Identification of Clinical Problem
Knowledge Focused Triggers
2. National Agencies or Organizational
Standards & Guidelines
3. Philosophies of Care
4. Questions from Institutional Standards Committee
1. New Research or Other Literature
Consider
Other
Triggers
Is this Topic
a Priority
For the
Organization?
Form a Team
Is There
a Sufficient
Research
Base?
Pilot the Change in Practice
1. Select Outcomes to be Achieved
2. Collect Baseline Data
3. Design Evidence-Based
Practice (EBP) Guideline(s)
4. Implement EBP on Pilot Units
5. Evaluate Process & Outcomes
6. Modify the Practice Guideline
Base Practice on Other
Types of Evidence:
1. Case Reports
2. Expert Opinion
3. Scientific Principles
4. Theory
Conduct
Research
Monitor and Analyze Structure,
Process, and Outcome Data
? Environment
? Staff
? Cost
? Patient and Family
The Iowa Model of Evidence-Based
Practice to Promote Quality Care
DO NOT REPRODUCE WITHOUT PERMISSION Revised April 1998 ? UIHC
= a decision point Titler, M.G., Kleiber, C., Steelman, V.J., Rakel., B. A., Budreau, G., Everett, L.Q.,
Buckwalter, K.C., Tripp-Reimer, T., & Goode C. (2001). The Iowa Model Of EvidenceBased
Practice to Promote Quality Care. Critical Care Nursing Clinics of North America,
13(4), 497-509.
REQUESTS TO:
Department of Nursing
University of Iowa Hospitals and Clinics
Iowa City, IA 52242-1009
FIGURE 1. The Iowa Model of Evidence-Based Practice to Promote Quality Care. Reprinted with permission from the University
of Iowa Hospitals and Clinics and Marita G. Titler, PhD, RN, FAAN, Copyright 1998. For permission to use or reproduce the model,
please contact the University of Iowa Hospitals and Clinics at 319-384-9098 or uihcnursingresearchandebp@uiowa.edu
Copyright ? 2015 Wound, Ostomy and Continence Nurses Society?. Unauthorized reproduction of this article is prohibited.
JWOCN-D-14-00006_LR 153 WOCN-D-14-00006_LR 153 21/02/15 2:01 PM 1/02/15 2:01 PM
154 Pittman et al J WOCN ? March/April 2015
defi nition of device-related HAPUs: (1) NPUAP defi nition of
pressure ulcers provides the basis of the defi nition and (2)
device-related HAPUs will be limited to external medical devices.
After a thorough review of the evidence and using
clinical practice expertise, an evidence-based device-related
HAPU defi nition for adults and pediatrics was developed. A
device-related HAPU is defi ned as a localized injury to the
skin and/or underlying tissue including mucous membranes,
as a result of pressure, with a history of an external medical
device at the location of the ulcer, and mirrors the shape of
the device. This defi nition provides needed guidance, structure,
and process to assist with prevention, identifi cation,
reporting, and treatment of medical device-related HAPU.
The task force used this evidence-based defi nition to develop
the Medical Device-Related Pressure Ulcer Position
Statement. Following the format example of the Wound,
Ostomy and Continence Nursing Society and other organizations,
a position statement was developed. In order to
improve the content validity of the position statement, experts
in wound management and pressure ulcers were asked
to review the content. Based on their recommendations,
appropriate revisions were incorporated into the document.
The next step in the Iowa Model is to move the evidence
into practice. Effective dissemination of evidence
includes mindful communication among opinion leaders,
change champions, core groups of infl uence, and academic
detailing. Opinion leaders were defi ned as those colleagues
who are viewed as important and respected sources
of infl uence among their peers. Change champions
embrace and demonstrate the persistence necessary to promote
the adoption of evidence.
The task force disseminated the position statement by
informing various systemwide leadership groups involved
in patient quality/safety, systemwide pressure ulcer prevention
committee, facility-specifi c WOC nurse experts,
and facility-specifi c direct-care nurse wound teams.
Dissemination continues as the use of the Medical DeviceRelated
Pressure Ulcer Position Statement is integrated
into the process of conducting our monthly facility-wide
pressure ulcer prevalence surveys.
? Conclusion
A pressure ulcer may occur wherever external pressure impairs
circulation to the skin. Pressure ulcers cause pain, loss
of function, and infection, extend hospital stays, and increase
cost. In addition, pressure ulcer development is considered
a quality indicator across healthcare systems. 5
Increased scrutiny and reduced payment or nonpayment
for HAPU by the Centers for Medicare & Medicaid Services
has made the prevention and early detection of pressure
ulcers a prominent quality improvement initiative of
healthcare systems across the country. A key component in
prevention and detection of pressure-related injury is an
accurate skin assessment. In order to perform an accurate
skin assessment, an evidence-based defi nition for devicerelated
pressure ulcers is crucial. Our Device-Related
Pressure Ulcer Position Statement guides practice, education,
and research within this healthcare organization. This
defi nition is used when identifying, reporting, treating, and
developing prevention strategies for device-related HAPU.
It has proven useful for distinguishing between pressure
ulcers resulting from an external medical device versus
nonmedical device. Through the intentional focus on pressure
ulcer prevention and evidence-based practice in our
organization and the use of this position statement, identi-
fi cation and reporting of medical device-related HAPUs
have improved with a decrease in overall HAPU rates of
33% from 2011 and 2012. This concise and evidence-based
position statement supports appropriate and consistent
identifi cation and reporting of medical device?related pressure
ulcers. Staging of these ulcers continues to follow the
staging recommendations of NPUAP and National Database
for Nursing Quality Indicators reporting instructions.
? References
1. Ayello E , Lyder C . Protecting patients from harm: preventing
pressure ulcers . Nursing 2007 ; 37 : 36-40 .
2. EPUAP/NPUAP . European Pressure Ulcer Advisory Panel and
National Pressure Ulcer Advisory Panel. Treatment of Pressure
Ulcers: Quick Reference Guide. Washington, DC : National
Pressure Ulcer Advisory Panel ; 2009 .
3. Berquist-Beringer S , Davidson J . NDNQI: Pressure Ulcer Training.
2013 . Accessed December 18, 2014 . at https://members.nursing
quality.org/NDNQIPressureUlcerTraining/
4. NPUAP. Mucosal Pressure Ulcers: An NPUAP Position Statement
2012. Accessed December 18, 2014 at http://www.npuap.org/
wp-content/uploads/2012/03/Mucosal_Pressure_Ulcer_
Position_Statement_fi nal.pdf
5. Centers for Medicare & Medicaid Services. Hospital-Acquired
Conditions and Present on Admission Indicator Reporting
Provision. Accessed December 18, 2014 at http://www.cms
.gov/Outreach-and-Education/Medicare-Learning-NetworkMLN/MLNProducts/Downloads/wPOAFactSheet.pdf

6. Titler M , Kleiber C , Steelman V , et al. The Iowa model of
evidence-based practice to promote quality care . Crit Care Nurs
Clin North Am. 2001 ; 13 ( 4 ): 497-509 .
7. Stanley T , Sitterding M , Broome M , McCaskey M . Engaging and
developing research leaders in practice: Creating a foundation
for a culture of clinical inquiry . J Pediatr Nurs. 2011 ; 26 : 480-488 .
8. Food and Drug Administration . Is the product a medical device
? http://www.fda.gov/MedicalDevices/DeviceRegulation
andGuidance/Overview/ClassifyYourDevice/ucm051512.htm .
Published 2013. Accessed December 16, 2013.
9. Edsberg LE , Langemo D , Baharestani MM , Posthauer ME ,
Goldberg M . Unavoidable pressure injury: state of the science
and consensus outcomes . J Wound Ostomy Continence Nurs.
2014 ; 41 ( 4 ): 313-334 .
10. Apold J , Rydrych D . Preventing device-related pressure ulcers:
using data to guide statewide change . J Nurs Care Qual.
2012 ; 27 ( 1 ): 28-34 .
The CE test for this article is available online only at the journal website, jwocnonline.com, and
the test must be taken online at NursingCenter.com/CE/JWOCN.
Copyright ? 2015 Wound, Ostomy and Continence Nurses Society?. Unauthorized reproduction of this article is prohibited

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