Methods: Order sets are lists of interventions that are recommended for specific clinical conditions (Idemoto, Williams, & Blackmore, 2016). Evidence-based order sets serve as a knowledge translation tool to promote evidence-based practice (Wilson, 2018). Order sets for the assessment and management of pressure injuries were embedded within the hospital’s electronic documentation system. These order sets were derived from the recommendations published in a reputable evidence-based clinical guideline.
The order sets were mapped to key guideline-based performance measures and to the International Classification for Nursing Practice (ICNP®), which is the standardized terminology language for describing the work that nurses do (International Council of Nurses, 2015). Mapping involves establishing formal relationships among similar or related concepts or terms. The ICNP-encoded pressure injury order sets were deployed to eleven in-patient units using a phased-in approach from September - October 2016.
The evaluation plan included seamless electronic data collection using the hospital’s electronic documentation system. Functionality within the system facilitated the retrieval of pertinent data using the ICNP codes to auto-populate an Excel spreadsheet that was uploaded into a nursing data system. This system was used to perform data analytics and generate reports to evaluate the following guideline-based performance measures:
- Assessment of pre-existing pressure injuries on admission
- Pressure reduction management
- Pressure injury incidence
- Evidence of healing for stage II-IV pressure injuries after 2-4 weeks.
- Healed stage II-IV pressure injury after 12 weeks.
Data was collected and submitted to the data system on a monthly basis beginning in October 2016 and continuing through to May 2017, when the formal quality improvement initiative was concluded. Reports were generated on a quarterly basis to support outcome evaluation. The hospital has continued to submit data to the nursing data system as part of a larger initiative from May 2017 until the present time.
A data quality framework was used to assess the quality of the data submitted by the hospital between October 2016 and October 2018 for three of the eleven in-patient units. The Framework is comprised of six dimensions: integrity, relevance, interpretability, coherence and timeliness (Grdisa et al., 2018). For this Project, two dimensions were used to assess the quality of the data: integrity and timeliness (Grdisa et al., 2018). Integrity determines whether the data represents the event, object or concept it was intended to measure. The assessment of data integrity includes but is not limited to completeness, consistency, accuracy and representativeness (Ibid., 2018). Timeliness refers to the currency of the data. It determines if the data is available when expected and needed. The assessment of data timeliness focuses on timing and frequency (Ibid., 2018).
Results: There was successful adoption of the evidence-based order sets by 382 nurses. Embedding the ICNP-encoded wound care order sets within the hospital’s electronic documentation system made it easy to foster evidence-informed decision-making among the nursing staff. In addition, the ICNP codes enabled the organization to collect data for key guideline-based performance measures as the nurses completed their electronic documentation. This implementation strategy also simplified the process of extracting meaningful data to evaluate the impact of using evidence-based practices for the assessment and management of pressure injuries.
During the evaluation period from October 2016 to May 2017, there was documented evidence that pre-existing pressure injuries were only assessed on admission 100% of the time during three of the eight months for which data was submitted. These findings highlighted the need for ongoing education and monitoring to ensure consistency of documentation. The monthly average of pressure reduction management ranged from 100% in October 2016 to 83% in May 2017. Overall, the incidence of patients developing a new stage II to IV pressure injury was very low. After the implementation of the order sets, the incidence of pressure injuries dropped from 4% in November 2016 to 0% in May 2017. The average rate of healing and healed pressure injuries ranged from 25-100% and 4-25% per month respectively. The relatively low rate of healed pressure injuries in the acute care sector was attributed to the average length of stay being shorter than 12 weeks (the timeline when healing would normally occur).
The assessment of data integrity from October 2016 to October 2018 for the three in-patient units analyzed revealed that data was consistently submitted for each month for all performance measures. There was also a significant decrease in the average percentage of missing data, errors and outliers on all three units immediately post implementation, which was sustained two years later. Lastly, the assessment of timeliness revealed that data was consistently submitted earlier than the required 90-day time frame.
Conclusions:
This Initiative has huge implications for health care organizations, nursing practice and patients. It demonstrates the potential benefits to be gleaned by health care organizations that leverage technology to promote evidence-based nursing practice through the use of standardized order sets derived from evidence-based clinical guidelines. This will ensure that patients receive safe, high-quality care informed by the best available evidence. It also provides a viable solution that can replace the inefficient, laborious manual data collection and retrieval processes used in health care organizations with automated processes that better support outcome evaluation and ongoing quality improvement. Lastly, this Initiative provides strategies to enhance and monitor data quality to better demonstrate the impact of evidence-based nursing practice on health outcomes.