PICO(T) Framework and Development of Evidence-Based Care Practices

PICO(T) Framework and Development of Evidence-Based Care Practices

Identifying the right question is central to any research undertaking that seeks to be effective (Salcido, 2017). The research question dictates the trajectory of the activity, from planning, implementation, analysis, evaluation, and finally, reporting. The PICO(T) acronym is critical in the toolkit for the implementation of evidence-based medicine. PICO(T) describes the specific area for key knowledge areas: Population or patient (P), Intervention (I), Control or comparison (C), and Outcome (O). The timeframe format includes the Time (T) aspect and sets out to consider the time when comparing the effectiveness of interventions over specified periods. Therefore, the PICO question will be: In hospitalized spinal injury patients with diminished mobility (P), how does adoption of the standard pressure injury prevention protocols (I), compared to repositioning patients only (C), resulting in reduced development of pressure ulcers, in 21 days (T)? The PICO(T) approach will help to interrogate and critically appraise the existing literature in an orderly and systematic process to arrive at new knowledge and best practices in managing impaired skin integrity for these patient populations. The standardized pressure injury prevention protocol consists of six components: patient repositioning, protective dressings, surface modification using mattresses, nutritional support, patient assessment, and staff education (Cruz, 2020).

Evidence Answering the PICO(T) Question

Identifying sources of evidence was conducted to identify evidence to answer the PICO(T) question for this task. The search was conducted on four different databases. These include PubMed, CINALH, Google Scholar, and the Cochair Library. The whole subheading of “risk of impaired skin integrity in immobilized spinal injury patients” and specific key search words were used. Key terms in the search strategy were “pressure ulcers,” “pressure sores,” “impaired skin integrity,” and “spinal injury.” Literature sources included in the study were only those published in English, published within five years, and the full text was accessible. Identified articles were included in this review.

Findings From Articles

Nursing practice that complies with international guidelines for best practice effectively reduces Hospital Acquired Pressure Injuries (HAPI) that result in impaired skin integrity (Padula & Black, 2019). The guidelines specify different nursing care practices ranging from skin review and risk assessment, skin care, nutritional support, pressure-relieving techniques, and reduction in shear and friction.

The U.S. Agency for Healthcare Research and Quality introduced practice protocols for managing pressure ulcer prevention (Padula & Black, 2019)). These protocols are updated every three to five years by the National Pressure Ulcer Advisory Panel. Hospitals adopt these guidelines into their daily routine. This quality improvement concept supports using new technologies such as prophylactic dressings, repositioning, and nutrition to prevent pressure ulcers. These interventions were found to reduce the cumulative incidence of pressure ulcers (Tayyib et al., 2021; Lavallée et al., 2019). The article gives evidence of both the financial and immediate quality improvements of adopting these care protocols.

Findings by Raynaldo (2020) revealed that evidence-based preventive measures against pressure sores effectively reduced their severity. A literature review of seven articles by the author determined that the pressure injury preventive bundle adopted and strategically implemented resulted in a reduction of pressure ulcer severity from stage two to one. The article made recommendations supporting continuous medical education and training for staff toward the application of bundle interventions supported by evidence. As a result, this will ensure a positive outcome in reducing the severity and incidence of HAPI. Cruz (2020) reported a 7.37% reduction in pressure ulcer incidence after 30 days of the pressure bundle implementation program. These findings show a clinically significant improvement in impaired skin integrity outcomes by adopting standardized, evidence-based protocols to prevent HAPI.

Analysis of Relevance of the Identified Sources

The findings and conclusions from the reviewed articles are relevant to the PICO(T) question as they provide evidence of the efficacy of the pressure prevention protocols. Pressure injuries are predictable and can be prevented and remain disproportionately frequent in ICU immobilized patients, such as spinal injury patients. The initial step to avoiding pressure injuries is accurate and timely risk assessment (Cruz, 2020). The Braden scale has been identified to be effective in this step. It assesses the risk of impaired skin integrity based on friction, range of mobility, sensory perception, nutritional status, level of activity, and moisture (Padula & Black, 2019). The tool is validated and has a sensitivity of 71% to 100% to identify at-risk patients (Cruz, 2020). The assessment should be undertaken on admission, at every shift change in the intensive care unit, and in the context of any at-risk patients. The risk assessment and skin structure should be done every shift change for these patients. The step is crucial as it determines the choice of interventional strategies for the patient.

Nursing interventions to relieve intense and chronic pressure for identified at-risk patients follow the first step. Different strategies have been adopted, including prophylactic dressings, pressure redistribution systems, skincare, and patient repositioning. The articles reviewed provide evidence on the suitability and effectiveness of these interventions in preventing pressure injury. The use of five-layer sacral dressings to cover traumatic skin injuries helps to reduce the loading forces and thus prevent HAPIs ( Padula & Black, 2019; Tayyib et al., 2021). An observational research study that included over one million patient samples found a 34% reduction in HAPI rates using these dressings alongside other protocol interventions.

Bed and support surfaces are the most common interventions in many hospitals (Cruz, 2020). However, the current literature does not provide specific data on the effectiveness of this intervention or the need for alternating support surfaces over constant low-pressure surfaces. Critically ill immobilized patients like hospitalized spinal injury patients who cannot be turned should have alternating pressure surfaces (Padula & Black, 2019). Air mattresses were better than conventional mattresses found in most hospitals (Cruz, 2020). Delays in modifying these surfaces result in increased incidence rates of pressure ulcers.

Patient repositioning systems are the most traditional nursing intervention for immobilized patients (Padula & Black, 2019). According to Lavallée et al. (2019), data collected from 462 patient bed days, repositioning was the only documented nursing intervention for managing HAPI in nursing homes. The adherence to repositioning charts was 74% at the pre-intervention phase with pressure ulcers with stage one, two, and three ulcers reported in hip and back regions. Over 1180 patient bed days were managed using the pressure protocols during the intervention phase, and no HAPIs were reported (Lavallée et al., 2019). The challenge is that nurses may be reluctant to reposition patients as they fear displacing medical devices involved in care (Tayyib et al., 2021). According to Padula & Black (2019), there was a 45%, 52%, and 27% reduction in HAPI incidence in cardiovascular, surgical, and medical ICUs when fluidized repositioning techniques were used.

The other components of the interventional bundle include nutritional consults, education, and staff training. Determining the nutritional status of the spinal injury patient on admission is essential in the early screening and nutritional support. Risk factors of HAPIs include the patient’s poor nutrition status. Nutritional assessment is usually done with the identified risk assessment tools. A vital step to implementation is staff training and education. Nurses should be competent in skin assessment, assessment of injury magnitude, and bundle implementation and evaluation.

Conclusion

Spinal cord injured patients possess a high risk of developing pressure ulcers. They have reduced mobility, skin changes, increased hospital bed days, and motor and sensory impairments. HAPIs result in reduced quality of life, severe pain, increased risk of infections, and high healthcare costs. Realization of the significant problem of HAPIs in the healthcare system led to adopting repositioning to reduce their incidence and effects. However, using repositioning techniques alone is not recommended, as HAPIs still occur (Lavallée et al., 2019). Adopting a standardized skincare bundle to eliminate HAPI dramatically improves patient outcomes in preventing and managing pressure ulcers. The protocol considers skin inspection and risk assessment, nutritional support, modification of support surfaces, and repositioning techniques in managing HAPI. Evidence shows that the compound approach has an immediate impact on HAPI across the globe (Padula & Black, 2019). Therefore, evidence answers the PICO(T) question. The use of a standardized pressure injury prevention bundle results in a significant reduction in HAPI incidence compared to repositioning alone. Hospitals should adopt the use of this approach as a quality improvement program. Ultimately, it will result in increased patient safety and high-quality of, cost-effective care.

References

Cruz, C. P. (2020). Reducing the incidence of pressure injuries in adult ICU patients at McAllen Medical Center with the implementation of a pressure injury prevention bundle: A quality improvement project.

Lavallée, J. F., Gray, T. A., Dumville, J., & Cullum, N. (2019). Preventing pressure ulcers in nursing homes using a care bundle: A feasibility study. Health & Social Care in the Community, 27(4), e417–e427. https://doi.org/10.1111/HSC.12742

Padula, W. V., & Black, J. M. (2019). The Standardized Pressure Injury Prevention Protocol for improving nursing compliance with best practice guidelines. Journal of Clinical Nursing, 28(3–4), 367–371. https://doi.org/10.1111/JOCN.14691

Raynaldo, M. C. (2020). Implementing hospital-acquired pressure injury (HAPI) prevention program.

Salcido, R. (2017). Evidence-based medicine: A FINER PICO analysis. Advances in Skin and Wound Care, 30(7), 294. https://doi.org/10.1097/01.ASW.0000520707.06374.44

Tayyib, N., Asiri, M. Y., Danic, S., Sahi, S. L., Lasafin, J., Generale, L. F., Malubay, A., Viloria, P., Palmere, M. G., Parbo, A. R., Aguilar, K. E., Licuanan, P. M., & Reyes, M. (2021). The effectiveness of the SKINCARE bundle in preventing medical-device related pressure injuries in critical care units: A clinical trial. Advances in Skin and Wound Care, 34(2), 75–80. https://doi.org/10.1097/01.ASW.0000725184.13678.80

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Assessment 3 Instructions: PICO(T) Questions and an Evidence-Based Approach

Create a 3-5 page submission in which you develop a PICO(T) question for a specific care issue and evaluate the evidence you locate, which could help to answer the question.

Introduction

PICO(T) is an acronym that helps researchers and practitioners define aspects of a potential study or investigation.

It stands for:

P – Patient/population/problem.
I – Intervention.
C – Comparison (of potential interventions, typically).
O – Outcome(s).
T – Time frame (if time frame is relevant).
The end goal of applying PICO(T) is to develop a question that can help guide the search for evidence (Boswell & Cannon, 2015). From this perspective, a PICO(T) question can be a valuable starting point for nurses who are starting to apply an evidence-based model or EBPs. By taking the time to precisely define the areas in which the nurse will be looking for evidence, searches become more efficient and effective. Essentially, by precisely defining the types of evidence within specific areas, the nurse will be more likely to discover relevant and useful evidence during their search. When applying the PICO(T) approach, the nurse can isolate the interventions of interest and compare to other existing interventions for the evidenced impact on the outcome of the concern.

You are encouraged to complete the Vila Health PICO(T) Process activity before you develop the plan proposal. This activity offers an opportunity to practice working through creating a PICO(T) question within the context of an issue at a Vila Health facility. These skills will be necessary to complete Assessment 3 successfully. This is for your own practice and self-assessment and demonstrates your engagement in the course.

Reference
Boswell, C., & Cannon, S. (2015). Introduction to nursing research. Jones & Bartlett Learning.

Professional Context

As a baccalaureate-prepared nurse, you will be responsible for locating and identifying credible and scholarly resources to incorporate the best available evidence for the purposes of enhancing clinical reasoning and judgement skills. When reliable and relevant evidence-based findings are utilized, patients, health care systems, and nursing practice outcomes are positively impacted.

PICO(T) is a framework that can help you structure your definition of the issue, potential approach that you are going to use, and your predictions related to the issue. Word choice is important in the PICO(T) process because different word choices for similar concepts will lead you toward different existing evidence and research studies that would help inform the development of your initial question. When writing a PICO(T)-formatted research question, you want to focus on the impact of the intervention and the comparison on the outcome you desire.

Scenario

For this assessment, please use a health care issue of interest from your current or past nursing practice.

If you do not have an issue of interest from your personal nursing practice, then review the optional Case Studies presented in the resources and select one of those as the basis for your assessment.

Instructions

For this assessment, select a health care issue of interest and apply the PICO(T) process to develop the research question and research it.

Your initial goal is to define the population, intervention, comparison, and outcome. In some cases, a time frame is relevant and you should include that as well, when writing a question you can research related to your issue of interest. After you define your question, research it, and organize your initial findings, select the two sources of evidence that seem the most relevant to your question and analyze them in more depth. Specifically, interpret each source’s specific findings and best practices related to your issues, as well explain how the evidence would help you plan and make decisions related to your question.

If you need some structure to organize your initial thoughts and research, the PICOT Question and Research Template document (accessible from the “Create PICO(T) Questions” page in the Capella library’s Evidence Based Practice guide) might be helpful.

In your submission, make sure you address the following grading criteria:

Define a practice issue to be explored via a PICO(T) approach. Create a PICO(T)-formatted research question
Identify sources of evidence that could be potentially effective in answering a PICO(T) question (databases, journals, websites, etc.).
Explain the findings from articles or other sources of evidence as it relates to the identified health care issue.
Explain the relevance of the findings from chosen sources of evidence to making decision related to a PICO(T) question.
Communicate using writing that is clear, logical, and professional with correct grammar and spelling using the current APA style.
Example Assessment: You may use the following to give you an idea of what a Proficient or higher rating on the scoring guide would look like:

Assessment 3 Example [PDF].
Additional Requirements
Your assessment should meet the following requirements:

Length of submission: Create a 3-5-page submission focused on defining a research question and interpreting evidence relevant to answering it.
Number of references: Cite a minimum of four sources of scholarly or professional evidence that support your findings and considerations. Resources should be no more than 5 years old.
APA formatting: Format references and citations according to the current APA style.
Portfolio Prompt: Remember to save the final assessment to your ePortfolio so that you may refer to it as you complete the final capstone course.

Competencies Measured

By successfully completing this assessment, you will demonstrate your proficiency in the course competencies through the following assessment scoring guide criteria:

Competency 1: Interpret findings from scholarly quantitative, qualitative, and outcomes research articles and studies.
Explain the findings from articles or other sources of evidence that are relevant to the health care issue.
Competency 2: Analyze the relevance and potential effectiveness of evidence when making a decision.
Identify sources of evidence that could be potentially effective in answering a PICO(T) question.
Explain the relevance of the findings from chosen sources of evidence to making decision related to a PICO(T) question.
Competency 3: Apply an evidence-based practice model to address a practice issue.
Define a practice issue to be explored via a PICO(T) approach and develop a PICO(T)-formatted research question.
Competency 5: Apply professional, scholarly communication strategies to lead practice changes based on evidence.
Organize content so ideas flow logically with smooth transitions; contains few errors in grammar/punctuation, word choice, and spelling.
Apply APA formatting to in-text citations and references exhibiting nearly flawless adherence to APA format.