NURS 716 Week 6 Assignment 4: Developing an Evidence-Based Practice Proposal Part 1 Example

Evidence-Based Practice Proposal, Part 1: Background, Problem, Purpose and Evidence for Prophylactic Silicone Foam Dressings in Surgeries of Three Hours or More

Section One: Background and Significance

Introduction

Pressure injuries are localized damage to skin and underlying tissue caused by pressure, or pressure combined with shear, usually over a bony prominence. Patients in surgery are especially vulnerable: they lie still for hours, cannot feel or report discomfort, and may be positioned in ways that concentrate load on the sacrum, heels and other points. Injuries that begin on the operating table often appear hours or days later on a surgical unit, which hides their origin and delays prevention.

Significance of the Problem

Perioperative pressure injuries are common enough to matter for any surgical service. In a prospective study of 218 patients undergoing urological surgery in the lithotomy position, 26.1% had a stage I pressure injury at the end of the operation (Karaca & Okgün Alcan, 2026). Among 367 adults in surgeries of three hours or longer, 30% developed device-related pressure injuries, almost all stage I (Adıgüzel Akbaba et al., 2026). In a national registry of 14,523 patients undergoing hip fracture repair, 4.3% developed a hospital-acquired pressure injury (Zhao et al., 2026). Although most perioperative injuries are early stage, each one causes pain, prolongs nursing care and signals that tissue was damaged, and deeper injuries can lead to infection, longer stays and penalties for the hospital.

Local Data

At the project hospital, a 350-bed regional medical center, last quarter's surgical quality report counted 14 new pressure injuries, appearing within three days of the operation, among 220 adults whose procedures ran three hours or longer, an incidence of 6.4%. Twelve of the 14 injuries were on the sacrum or heels, and most were first documented in the post-anesthesia care unit. Prevention currently consists of gel pads and conventional positioning; dressings are not used prophylactically, and skin is not formally inspected before the patient leaves the operating room.

Cost and Organizational Impact

The financial case strengthens the clinical one. A single prophylactic dressing costs a few dollars, while treatment of a hospital-acquired pressure injury requires additional nursing time, specialty dressings, wound care consultation and sometimes a longer stay, and deeper injuries can generate costs many times higher. Hospital-acquired pressure injuries are also a nurse-sensitive quality indicator reported to accreditors and, at advanced stages, subject to payment penalties. For the surgical services department, whose annual goals now include fewer pressure injuries, a reliable prevention practice protects patients, staff morale and the organization's reputation.

Stakeholders

The project affects several groups. Perioperative and post-anesthesia nurses will apply and inspect dressings and must be engaged early. Surgeons and anesthesia providers influence positioning and surgical time and need to understand that dressings will not interfere with sterile fields or monitoring. Supply chain staff must stock dressings in every operating room, and the wound and ostomy nurse will help with education and injury staging. Patients benefit directly and should be told about the dressings, and why they are used, as part of preoperative teaching.

Problem Statement

At the project hospital, adults whose operations run three hours or more develop sacral and heel pressure injuries at a rate that exceeds what current evidence suggests is achievable, because prevention relies on padding and positioning alone and does not include prophylactic dressings shown in randomized trials to reduce such injuries.

Purpose of the Project

The purpose of this evidence-based practice project is to introduce soft silicone foam as a routine prophylactic dressing for the sacrum and heels of adults in operations of three or more hours and to evaluate their effect on pressure injuries within 72 hours.

Clinical Question

For adults whose operations last three hours or more (P), will placing soft silicone multilayer foam over the sacrum and both heels before positioning (I), rather than relying on gel padding and positioning alone (C), lower the number of sacral and heel pressure injuries found in the first 72 postoperative hours (O)?

Section Two: Review of the Literature

Search Strategy

The search covered three databases, CINAHL, PubMed and the Cochrane Library, limited to peer-reviewed work from the past five years, combining terms for the surgical population, prophylactic and silicone foam dressings, and pressure injury or pressure ulcer, with subject headings where available. After duplicates were removed and titles, abstracts and full texts were screened against the question, ten articles were retained, supplemented by the current international guideline.

Appraisal

Articles were leveled with the hierarchy in Melnyk and Fineout-Overholt (2015) and appraised for validity, reliability and applicability. The set includes three level I syntheses, one level II randomized trial, one level III non-randomized controlled study, four level IV observational studies and one level VI qualitative study. The international guideline was appraised separately with AGREE II and judged suitable for use with local modifications.

Synthesis of the Evidence

Three themes emerge. The first is that silicone foam dressings reduce pressure injuries. Pooling ten randomized trials, Fu et al. (2025) found that silicone foam cut early sacral injuries by more than four-fifths and also reduced deeper sacral injuries and heel injuries. A network meta-analysis of 15 studies ranked silicone dressings above other prophylactic options (Al Jehani et al., 2026). In surgery specifically, a randomized trial of 134 adults found intraoperative injuries in 3.0% of patients with a sacral silicone dressing compared with 19.4% of those receiving standard care (Wang et al., 2026). When syntheses of many trials and a trial in the operating room agree, the question for a hospital is no longer whether the dressings work but how to use them well.

The second theme concerns which patients are at highest risk. Long procedures, lithotomy positioning, older age, higher body mass index, repositioning after induction and higher anesthesia risk class were associated with injury across the observational studies (Adıgüzel Akbaba et al., 2026; Hooper et al., 2026; Karaca & Okgün Alcan, 2026; Zhao et al., 2026). These findings define the population for the project and point to device contact points as a second target.

The third theme concerns implementation. Evidence-based guidance on perioperative prevention exists but is unevenly applied, and operating room nurses describe barriers and facilitators that shape adoption (Gao et al., 2026). A care bundle approach in orthopedic surgery suggests that packaging prevention measures together may support consistency (Eğilmez et al., 2026). Repositioning, the subject of an updated Cochrane review, remains part of standard prevention that dressings supplement rather than replace (Latimer et al., 2026).

Gaps in the Evidence

Few trials were conducted entirely in operating rooms, the one surgical trial protected the sacrum but not the heels, and most observational evidence comes from outside the United States. The project's local evaluation will add evidence from a US surgical service and include heel outcomes.

Definitions of Key Terms

For this project, a pressure injury is any localized damage to skin or underlying tissue over the sacrum or heels, staged with the National Pressure Injury Advisory Panel system. A long surgery is any procedure with an anesthesia time of three hours or more. Prophylactic dressing refers to a soft silicone multilayer foam dressing applied to intact skin before positioning. The outcome window, 72 hours after surgery, captures injuries that originate in the operating room but appear later.

Guiding Framework

The revised Iowa Model will guide the project (Iowa Model Collaborative, 2017). The trigger, the priority decision and the team have been established; the evidence has been assembled and judged sufficient; the next steps, designing and piloting the change, deciding on adoption and integrating and sustaining the practice, structure the methods in Part 2.

Anticipated Barriers

The implementation literature and the department's own history suggest three barriers. Dressings must be available in every room at the start of each case, which requires changes to preference cards and par levels. Some surgeons may worry that a sacral dressing will shift during positioning or interfere with grounding pads, which education and a short trial period can address. And the habit of inspecting skin only in recovery must change to inspection at the end of surgery, which will need a prompt in the intraoperative record and a brief handoff line for the recovery nurse.

Biblical Foundation

The project rests on the conviction that patients who cannot speak for themselves during surgery deserve protection. Proverbs tells the king to speak up for the mute and to defend those who cannot defend themselves (English Standard Version Bible, 2001/2016, Proverbs 31:8), and an anesthetized patient is as voiceless as any. Preventing harm they cannot report is a form of advocacy.

Summary

Perioperative pressure injuries are common and costly, and the project hospital's data show a local problem. Strong evidence supports prophylactic silicone foam dressings, observational evidence identifies who is at greatest risk, and implementation evidence shows what must accompany a new practice. Part 2 will describe the setting, participants, intervention, data collection, analysis, timeline, budget and ethical safeguards for the project.

References

Adıgüzel Akbaba, M., Uslu, Y., Aytar, F., & Eren, E. (2026). Intraoperative device-related pressure injuries in patients undergoing prolonged surgery. Advances in Skin & Wound Care. Advance online publication. https://doi.org/10.1097/ASW.0000000000000510

Al Jehani, M., Al Mazrou, F., Bafail, A., Alhwsawi, H., Albalawi, I., Alanazi, G., Halawani, I., Alhije, F., & Alalola, R. (2026). Prophylactic dressing in the prevention of bedsore: A network meta-analysis. Journal of Surgical Research, 317, 235-243. https://doi.org/10.1016/j.jss.2025.09.065

Eğilmez, H., Yava, A., & Koyuncu, A. (2026). Investigation of the effect of a pressure sore care bundle in reducing the development of operating room pressure injury in patients undergoing orthopedic surgery: A non-randomized controlled study. BMC Musculoskeletal Disorders, 27(1). https://doi.org/10.1186/s12891-026-10039-0

English Standard Version Bible. (2016). Crossway. (Original work published 2001)

Fu, T., Wu, X., & Yu, B. (2025). Efficacy of silicone foam dressings in preventing pressure injuries in the sacral and heel areas of patients: A meta-analysis. Frontiers in Medicine, 12, Article 1644290. https://doi.org/10.3389/fmed.2025.1644290

Gao, Y., Chen, J., Guang, W., Xu, W., Wei, Z., & Yang, H. (2026). A qualitative study of facilitators and barriers to intraoperative acquired pressure injury prevention implementation in operating room nurses based on the CFIR framework. Frontiers in Health Services, 6, Article 1877556. https://doi.org/10.3389/frhs.2026.1877556

Hooper, V., LaFond, C., & Perez, A. C. (2026). The performance of the Scott Triggers instrument in predicting perioperative pressure injury (PPI) development. Journal of PeriAnesthesia Nursing. Advance online publication. https://doi.org/10.1016/j.jopan.2026.06.012

Iowa Model Collaborative. (2017). Iowa Model of Evidence-Based Practice: Revisions and validation. Worldviews on Evidence-Based Nursing, 14(3), 175-182. https://doi.org/10.1111/wvn.12223

Karaca, M., & Okgün Alcan, A. (2026). Lithotomy position and intraoperative-acquired pressure injury: A prospective observational study. Advances in Skin & Wound Care, 39(8), 420-423. https://doi.org/10.1097/ASW.0000000000000501

Latimer, S. L., Chaboyer, W. P., Probst, S., Thalib, L., Palipana, D., Lapkin, S., McInnes, E., Downes, M. J., & Gillespie, B. M. (2026). Repositioning for pressure injury prevention in adults. Cochrane Database of Systematic Reviews, 2026(6), Article CD009958. https://doi.org/10.1002/14651858.CD009958.pub4

Melnyk, B. M., & Fineout-Overholt, E. (2015). Evidence-based practice in nursing and healthcare: A guide to best practice (3rd ed.). Wolters Kluwer.

Wang, C. Y., Liao, H. H., Hsieh, M. Y., & Lee, C. H. (2026). Soft silicone foam dressing for preventing intraoperative pressure injuries: A randomized controlled trial. Journal of PeriAnesthesia Nursing. Advance online publication. https://doi.org/10.1016/j.jopan.2026.08.022

Zhao, Y., Alderden, J., Missbrenner, N., Quon, A., & Tivis, L. J. (2026). Risk factors associated with hospital-acquired pressure injuries in patients undergoing surgical hip fracture repair. Journal of Wound, Ostomy, and Continence Nursing, 53(5), 369-375. https://doi.org/10.1097/WON.0000000000001311