Alternating Mask
Alternating Masks Noninvasive ventilation is a much needed option for patients in the critical care setting, but prolonged use and multiple comorbidities can lead to pressure of the face and head. Alternating the nasal/oral mask with the full face mask could help decrease the risk of skin breakdown or lessen the severity of wounds that do develop. “A full facial mask has the potential for greater redistribution of pressure because it covers the forehead and a larger area of the cheek/side of face than other masks.” (Schallom et al., 2015, p. 350)
Change Model Overview The Johns Hopkins Nursing Evidence-Based Practice Process “occurs in 3 phases and can be simply described as Practice question, Evidence, and Translation (PET)”. …show more content…
(Dearholt & Dang, 2012, p. 42) Each phase is described by a number of steps that have to be taken. These steps include find a team to assist, finding evidence and evaluating outcomes among other things.(Dearholt & Dang, 2012, p. 42) Nurses and researchers should use this process because it essentially walks the researcher through the steps of the process to ensure valid and reliable results. A nurse needs to know that the changes that are made come from in depth research and study.
Practice Question
Step 1: Recruit Interprofessional Team The team members of this project other than the team leader include the wound care nurse, a respiratory therapist, the charge nurse, the nurse educator, and the pulmonary physician/intensivist. As a stakeholder, the company that supplies both types of masks would need to be involved to ensure correct usage of the mask and adequate supply for the study.
Step 2: Develop and Refine the EBP Question The population focused on in this study are critical care patients who are on noninvasive ventilation. The intervention that this study is focusing on is alternating the full face mask with the nasal/oral mask every 12 hours versus the comparison of using one or the other without alternating. The desired outcome for this project is a decrease in the number of pressure ulcers related to the noninvasive ventilation mask or decrease in severity of breakdown that does occur.
Step 3: Define the Scope of EBP The issue seen with the use of noninvasive ventilation in critical care is that patients are often using it for longer periods of time without adequate breaks due to the severity of their condition.
Also, many critical care patients have multiple comorbidities that increase the occurrence of skin breakdown and decreased healing. According to articles done by Conti G., Marino, P., Cagliati, A. et al; Atonelli M, Conti G , Pelosi P, et al; and Schettino G, Altobelli N, Kacmarek R.M. (as cited in Schallom et al., 2015), “Published rates for the incidence of facial pressure ulcers associated with noninvasive ventilation masks range from 10% to 31%”. (p. 350) This problem impacts healthcare because it not only increases the cost of care by thousands, but also increases the patient’s length of stay. As stated by Lyon (as cited in Cooper, K.L., 2013), a stage three or four ulcer can cost “between $5,000 and $50,000”. (p. 57) A pressure ulcer obtained in the hospital is no longer covered by the Center for Medicare and Medicaid Services (CMS), because they believe this is a truly preventable …show more content…
problem.
Step 4 and 5: Determine the Responsibility of Team Members The wound care nurse is trained in assessing for and preventing pressure ulcers in those at risk. This member would assess the patients daily and anytime skin breakdown arises. They would also be able to stage and treat any wounds or breakdown that does occur. A respiratory therapist would be involved because they would be able to make sure that the mask is on correctly and with the correct fit. They would also make sure that the patient on noninvasive ventilation is gaining full benefit from the therapy during the research process. The charge nurse would ensure that the primary nursing team and all others involved are monitoring correctly and helping answer questions as they arise. The charge nurse would do scheduled rounding to assess patient comfort and ask if there are any questions or concerns from the staff involved. A nurse educator would be involved to help educate the interdisciplinary team of the process and answer any questions prior to the study and anytime a need arises. This would include anyone who would come in contact with the patient who is not already on the team, such as the nurses on the unit who will care for the patient. The pulmonary physician/intensivist would be involved daily to monitor and make sure that the patient is stable on both masks and to help the team decide when to exclude the patient from the study due to unforeseen circumstances.
Evidence
Step 6 and 7: Conduct Internal/External Search for Evidence and Appraisal of Evidence The research found for this study includes peer reviewed articles and a case studies as well as some literature review. Quantitative and quasi-experimental research comprises the majority of the information. The evidence found is considered high quality as a whole based on the appraisal tools provided by Dearholt and Dang because they are dependable and show at least “fairly definitive conclusions”. (2012, p. 240)
Steps 8 and 9: Summarize the Evidence The research obtained for this study is relevant to the research question, because it brings to light the prevalence of pressure ulcers with the use of noninvasive ventilation. Schallom et al. (2015) found that pressure ulcers developed “as early 1.25 hours after nasal-oral mask application” and multiple risk factors can contribute to this such as “local tissue anoxia from hypotension, reduced skin turgor from hypovolaemia and thin skin, a consequence perhaps of long-term corticosteroid therapy”. (Ahmad, Venus, Kisku, & Rayatt, 2013, p. 87) With the patient in a critical care setting, these risks factors are very real. In a study done by Yamagitu et al. (2014), it was found that “the development of SB (skin breakdown) was observed in 50 subjects receiving NIV via ONM (42%), but in only 4 subjects receiving NIV via TFM (1.6%).” Adding the plan of alternating masks along with other critical tasks such as removal of the mask for mouth care can greatly impact the outcome positively. Research done by Tayyib, Coyer, and Lewis (2015), shows that “the use of the PU bundle can reduce PU incidence, severity, and total number of PUs per patient” which involves the use of multiple efforts to prevent skin breakdown.
Step 10: Develop Recommendations for Change Based on Evidence All of the evidence found points to the recommendation of alternating the nasal/oral mask and the full face mask. This should be every 12 hours at shift change so that the departing nurse and the oncoming nurse can assess the skin together and change. The fact that there are people who received pressure ulcers with the total face mask indicate the need to alternate masks rather than picking just the total face mask alone. Some patients will no doubt develop breakdown no matter the preventative steps taken so this plan may also decrease the seriousness of those ulcers.
Translation
Steps 11, 12, and 13, 14: Action Plan The action plan will consist of having a meeting with the team a few days before the start date and make sure that there will be enough of both types of masks to complete the study. At this meeting there will be a discussion on the procedures and assigning roles. The week before there will be education by all members of the team to the staff on the unit that will be taking care of these patients. The study will start on the first day of the month. As patients are admitted or started on noninvasive ventilation, the team will do an initial assessment involving the team to make sure the patient is able to be in the study. Every other patient started will be on nasal/oral mask only while the others will be alternating masks in order to have a control group. The team would make rounds in the morning to check for any sign of skin breakdown or impending breakdown on all of the participants. Every 12 hours the mask would be changed by the oncoming and outgoing primary nurse and then the respiratory therapist would check for proper mask fit. This would continue until the trial is over and as long as the patient is tolerating the mask. The trial would last a total of 30 days and anyone started toward the end has to complete the trial by the 30 days to be counted. All information would be gathered and divided into who developed breakdown and what mask they were wearing. Also, time frames would be noted and categorized to assess for length of wear time. Then the percentage would be taken for each group and who did and did not develop breakdown.
Steps 15 and 16: Evaluating Outcomes and Reporting Outcomes The desired outcome will be that the people who are alternating masks would have a reduced incidence of skin breakdown compared to the nasal/oral mask only. Any breakdown that is reported would be staged by the wound care nurse in order to report severity of breakdown and divided into groups as well and the hope is that the people who do get breakdown are not as severe with the alternating mask method. The results will be made into a table and chart for easy visibility and understanding of the results. The information would be drawn up and given to the representative from the company who supplies the masks. The team members will discuss the results and begin to decide whether the alternation of masks is appropriate.
Steps 17: Identify Next Steps To implement the plan, first there would need to be education. All nurses and respiratory therapists on units with noninvasive ventilation would need to be able to learn and understand what is being and done and why. They would be shown the same charts and table with the results that the team members see. The plan would be written up and sent to the policy and procedures committee to evaluate for a new policy. In order for this plan to become permanent, there would have to be monitoring and proper implementation of the plan at all times to ensure consistent and desirable results.
Step 18: Disseminate Findings To communicate these findings throughout the hospital, emails will be sent and flyers will be placed to educate the staff and public. In order to communicate externally, the study will be sent to be published in scholarly nursing magazines.
Conclusion
As nurses, the outcome of all studies should be for better understanding as a way for change.
In critical care, the nasal/oral mask can be on for long periods of time which can lead to skin breakdown and a higher cost, monetarily and physically, for the patient. Forming the practice question is the first step and is also an important one. You can’t find proper evidence and come to a conclusion if your practice question is not well defined. Knowing that there is a risk with the noninvasive ventilation masks can help nursing understand the need to change and to find a means to do so. In this case, it would be alternating the nasal/oral and full face
mask.
Change Model Overview The Johns Hopkins Nursing Evidence-Based Practice Process “occurs in 3 phases and can be simply described as Practice question, Evidence, and Translation (PET)”. …show more content…
(Dearholt & Dang, 2012, p. 42) Each phase is described by a number of steps that have to be taken. These steps include find a team to assist, finding evidence and evaluating outcomes among other things.(Dearholt & Dang, 2012, p. 42) Nurses and researchers should use this process because it essentially walks the researcher through the steps of the process to ensure valid and reliable results. A nurse needs to know that the changes that are made come from in depth research and study.
Practice Question
Step 1: Recruit Interprofessional Team The team members of this project other than the team leader include the wound care nurse, a respiratory therapist, the charge nurse, the nurse educator, and the pulmonary physician/intensivist. As a stakeholder, the company that supplies both types of masks would need to be involved to ensure correct usage of the mask and adequate supply for the study.
Step 2: Develop and Refine the EBP Question The population focused on in this study are critical care patients who are on noninvasive ventilation. The intervention that this study is focusing on is alternating the full face mask with the nasal/oral mask every 12 hours versus the comparison of using one or the other without alternating. The desired outcome for this project is a decrease in the number of pressure ulcers related to the noninvasive ventilation mask or decrease in severity of breakdown that does occur.
Step 3: Define the Scope of EBP The issue seen with the use of noninvasive ventilation in critical care is that patients are often using it for longer periods of time without adequate breaks due to the severity of their condition.
Also, many critical care patients have multiple comorbidities that increase the occurrence of skin breakdown and decreased healing. According to articles done by Conti G., Marino, P., Cagliati, A. et al; Atonelli M, Conti G , Pelosi P, et al; and Schettino G, Altobelli N, Kacmarek R.M. (as cited in Schallom et al., 2015), “Published rates for the incidence of facial pressure ulcers associated with noninvasive ventilation masks range from 10% to 31%”. (p. 350) This problem impacts healthcare because it not only increases the cost of care by thousands, but also increases the patient’s length of stay. As stated by Lyon (as cited in Cooper, K.L., 2013), a stage three or four ulcer can cost “between $5,000 and $50,000”. (p. 57) A pressure ulcer obtained in the hospital is no longer covered by the Center for Medicare and Medicaid Services (CMS), because they believe this is a truly preventable …show more content…
problem.
Step 4 and 5: Determine the Responsibility of Team Members The wound care nurse is trained in assessing for and preventing pressure ulcers in those at risk. This member would assess the patients daily and anytime skin breakdown arises. They would also be able to stage and treat any wounds or breakdown that does occur. A respiratory therapist would be involved because they would be able to make sure that the mask is on correctly and with the correct fit. They would also make sure that the patient on noninvasive ventilation is gaining full benefit from the therapy during the research process. The charge nurse would ensure that the primary nursing team and all others involved are monitoring correctly and helping answer questions as they arise. The charge nurse would do scheduled rounding to assess patient comfort and ask if there are any questions or concerns from the staff involved. A nurse educator would be involved to help educate the interdisciplinary team of the process and answer any questions prior to the study and anytime a need arises. This would include anyone who would come in contact with the patient who is not already on the team, such as the nurses on the unit who will care for the patient. The pulmonary physician/intensivist would be involved daily to monitor and make sure that the patient is stable on both masks and to help the team decide when to exclude the patient from the study due to unforeseen circumstances.
Evidence
Step 6 and 7: Conduct Internal/External Search for Evidence and Appraisal of Evidence The research found for this study includes peer reviewed articles and a case studies as well as some literature review. Quantitative and quasi-experimental research comprises the majority of the information. The evidence found is considered high quality as a whole based on the appraisal tools provided by Dearholt and Dang because they are dependable and show at least “fairly definitive conclusions”. (2012, p. 240)
Steps 8 and 9: Summarize the Evidence The research obtained for this study is relevant to the research question, because it brings to light the prevalence of pressure ulcers with the use of noninvasive ventilation. Schallom et al. (2015) found that pressure ulcers developed “as early 1.25 hours after nasal-oral mask application” and multiple risk factors can contribute to this such as “local tissue anoxia from hypotension, reduced skin turgor from hypovolaemia and thin skin, a consequence perhaps of long-term corticosteroid therapy”. (Ahmad, Venus, Kisku, & Rayatt, 2013, p. 87) With the patient in a critical care setting, these risks factors are very real. In a study done by Yamagitu et al. (2014), it was found that “the development of SB (skin breakdown) was observed in 50 subjects receiving NIV via ONM (42%), but in only 4 subjects receiving NIV via TFM (1.6%).” Adding the plan of alternating masks along with other critical tasks such as removal of the mask for mouth care can greatly impact the outcome positively. Research done by Tayyib, Coyer, and Lewis (2015), shows that “the use of the PU bundle can reduce PU incidence, severity, and total number of PUs per patient” which involves the use of multiple efforts to prevent skin breakdown.
Step 10: Develop Recommendations for Change Based on Evidence All of the evidence found points to the recommendation of alternating the nasal/oral mask and the full face mask. This should be every 12 hours at shift change so that the departing nurse and the oncoming nurse can assess the skin together and change. The fact that there are people who received pressure ulcers with the total face mask indicate the need to alternate masks rather than picking just the total face mask alone. Some patients will no doubt develop breakdown no matter the preventative steps taken so this plan may also decrease the seriousness of those ulcers.
Translation
Steps 11, 12, and 13, 14: Action Plan The action plan will consist of having a meeting with the team a few days before the start date and make sure that there will be enough of both types of masks to complete the study. At this meeting there will be a discussion on the procedures and assigning roles. The week before there will be education by all members of the team to the staff on the unit that will be taking care of these patients. The study will start on the first day of the month. As patients are admitted or started on noninvasive ventilation, the team will do an initial assessment involving the team to make sure the patient is able to be in the study. Every other patient started will be on nasal/oral mask only while the others will be alternating masks in order to have a control group. The team would make rounds in the morning to check for any sign of skin breakdown or impending breakdown on all of the participants. Every 12 hours the mask would be changed by the oncoming and outgoing primary nurse and then the respiratory therapist would check for proper mask fit. This would continue until the trial is over and as long as the patient is tolerating the mask. The trial would last a total of 30 days and anyone started toward the end has to complete the trial by the 30 days to be counted. All information would be gathered and divided into who developed breakdown and what mask they were wearing. Also, time frames would be noted and categorized to assess for length of wear time. Then the percentage would be taken for each group and who did and did not develop breakdown.
Steps 15 and 16: Evaluating Outcomes and Reporting Outcomes The desired outcome will be that the people who are alternating masks would have a reduced incidence of skin breakdown compared to the nasal/oral mask only. Any breakdown that is reported would be staged by the wound care nurse in order to report severity of breakdown and divided into groups as well and the hope is that the people who do get breakdown are not as severe with the alternating mask method. The results will be made into a table and chart for easy visibility and understanding of the results. The information would be drawn up and given to the representative from the company who supplies the masks. The team members will discuss the results and begin to decide whether the alternation of masks is appropriate.
Steps 17: Identify Next Steps To implement the plan, first there would need to be education. All nurses and respiratory therapists on units with noninvasive ventilation would need to be able to learn and understand what is being and done and why. They would be shown the same charts and table with the results that the team members see. The plan would be written up and sent to the policy and procedures committee to evaluate for a new policy. In order for this plan to become permanent, there would have to be monitoring and proper implementation of the plan at all times to ensure consistent and desirable results.
Step 18: Disseminate Findings To communicate these findings throughout the hospital, emails will be sent and flyers will be placed to educate the staff and public. In order to communicate externally, the study will be sent to be published in scholarly nursing magazines.
Conclusion
As nurses, the outcome of all studies should be for better understanding as a way for change.
In critical care, the nasal/oral mask can be on for long periods of time which can lead to skin breakdown and a higher cost, monetarily and physically, for the patient. Forming the practice question is the first step and is also an important one. You can’t find proper evidence and come to a conclusion if your practice question is not well defined. Knowing that there is a risk with the noninvasive ventilation masks can help nursing understand the need to change and to find a means to do so. In this case, it would be alternating the nasal/oral and full face
mask.