Wound Practice and research Vol. 16 no. 2 MaY 2008
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Evidence-basedbestpracticeinmaintaining
skin integrity
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Introduction
Maintaining skin integrity in hospitalised patients is one of
the most fundamental and critical goals of nursing practice.
Measures to prevent, restore or heal skin breakdown illustrate
the convergence of clinicians’ knowledge, critical thinking
and caring skills. They are also instrumental to hospital risk
management strategies, one of the most important elements
of the current quality and safety agenda. High quality, safe
care also relies on the use of best evidence as a defensible
foundation for practice. Developing an institutional culture
of evidence-based practice (EBP) helps ensure that clinicians
participate in generating or using research findings as a basis
for achieving quality improvements and clinical goals
1, 2
as well
as enhancing their professional status and job satisfaction.
The study reported here outlines the development and
impact of a comprehensive skin integrity programme. It
was designed to reflect the commitment to developing an
interdisciplinary EBP culture in one private hospital in
Western Australia, primarily in generating clinically relevant
research findings that would be useful to clinicians, managers
and others involved in decision making for patient care.
The overarching objective of the programme was to promote
best practice in maintaining patient skin integrity, ensuring
consistency of clinical practices related to prevention and
management of skin breakdown. Specific objectives were to:
• Conduct a scoping study of skin breakdown, and map
current policies and practice in maintaining skin integrity.
• Compare current policies and practice with existing
clinical guidelines and best practice in Western Australia,
interstate and internationally.
• Developaskinintegrityqualityimprovementtrialwitha
focus on:
– maintaining best practice in preventing skin
breakdown in relation to mobility, skin condition, diet
and hydration, hygiene and elimination;
– managing patients at risk for skin breakdown, including
analysis of the relative quality and clinical outcomes of
products, practices and appropriate documentation.
The findings of this initiative were expected to provide a basis
for the development of policies and protocols for clinical care,
discharge planning and staff development.
Abstract
The study reported here describes a 1 year programme to promote best practice in maintaining skin integrity, ensuring consistent
clinical practices in relation to skin care, and managing skin breakdown. The analysis included baseline data on skin breakdown;
comparisons of policy and practice with clinical guidelines and best practice locally, interstate and internationally; a quality
improvement trial focusing on mobility, skin condition, diet and hydration, hygiene and elimination; and implementation of
best practice, including analysis of the relative quality and clinical outcomes of products, practices and documentation strategies.
Product evaluation by nurses and patients showed that all mattresses trialled were effective in minimising or preventing skin
breakdown. All chair cushions were rated effective in preventing breakdown – some were easier to use than others, although all
were rated highly by patients.
A retrospective chart audit indicated substantial improvements in consistent use of the Braden scale, and the number of risks
identified. Completed risk assessments increased by 19.6% to 70%. Initial assessment increased from 16.5% to 44.6%, with
identification of dietary insufficiency increasing from 3.4% to 10.6%. Hospital acquired pressure lesions were reduced from 6.4%
to 5.8%. The most notable improvement (from 1.3% of patients to 43.9%) occurred in the completion of subsequent pressure risk
assessments, with a modest increase in repositioning. The use of overlays and special mattresses increased, with heel raisers
increasing from 11% to 82.4%. The project demonstrated the value of a comprehensive team approach to clinical care and
demystified evidence-based practice (EBP).
Gardiner L et al. Evidence-based best practice in maintaining skin integrity
GardinerL,LampshireS,BigginsA,McMurrayA,NoakeN,vanZylM,VickeryJ,
WoodageT,LodgeJ&EdgarM
