• Eliminating Hospital Acquired Pressure Injuries: Prevention Bundles and Two Nurse Skin

      Snider, Victoria E.; Callender, Kimberly (2021-05)
      Problem: A Vascular Surgery Progressive Care Unit (VSPCU) in a large, academic medical center had a year-to-date hospital-acquired pressure injury (HAPI) incidence rate of 1.89 per 1000 patient days in 2019; fifty percent of these HAPI were avoidable. Purpose: The purpose of this quality improvement (QI) initiative was to eliminate HAPI incidence on a Vascular Surgery Progressive Care Unit through implementation of an evidence-based pressure injury prevention bundle (PIPB), including a two-RN skin assessment and co-sign component within 24-hours of patient admission or transfer. Methods: The Vascular Surgery Progressive Care unit consists of 12 beds and averages 53 admitted patients per month. A 16-week implementation period took place from August 31, 2020 to December 22, 2020. Head-to-toe, 2-RN skin assessment with electronic health record cosign and bundle documentation was implemented on the project unit for nurses to identify risks for HAPI, provide all admitted patients evidence-based prevention strategies, and to link staff with institutional skin prevention resources. The QI project was guided by Lippitt’s Change Theory. Staff-received project education was measured by a completion goal date. Nursing staff completed return-demonstration of 2-RN cosign and bundle note documentation within the electronic health record. Documentation of RN bundle compliance was measured by weekly chart audits. Unit HAPI incidence rates were measured by quarterly audits compiled and dispersed by the institutional Skin Integrity Committee. Data used for dissemination and discussion was comprised using run-chart analysis. Results: At Go-live 57% of RNs were PIPB trained (n = 30). A zero avoidable HAPI incidence was maintained during implementation (n = 194 patients). At week nine, 100% bundle compliance was achieved for five consecutive weeks. Conclusions: Implementation of a prevention bundle using a two-nurse skin assessment with cosign, for achieving zero unit-based HAPI is feasible and should be a care standard. Bundle compliance was associated with completed staff training, charge nurses as project champions, compliance email reminders, compliance data-sharing with staff, leadership availability and visibility, and continual team positive reinforcement.
    • Hospital Acquired Pressure Ulcer Prevention: Admission Bundle

      Hicks, Courtney Crane; Rowe, Gina (2019-05)
      Background: The development of a pressure ulcer is detrimental to the patient, their family, providers, and hospital-based systems. Pressure ulcer development is not only costly but they are associated with an increase in morbidity and mortality. Hospital acquired pressure ulcers (HAPUs) are prevalent nationally and their incidence was on the rise in the state of Maryland as of 2015. Local Problem: In 2017, a heart/vascular unit within a community hospital in Maryland identified the development of HAPUs among five patients, with one patient ultimately succumbing to their pressure ulcer due to sepsis from infection in their HAPU. In 2018 five HAPUs were identified prior to implementation in September 2018. Aims/Objectives: In order to reduce rates of HAPUs on this unit and improve patient care, an evidence-based admission bundle was implemented. Specific aims for this project included an increase in compliance with aspects of the bundle, and an increase in nurse knowledge and confidence post implementation of the bundle. Methods/Interventions: After a survey of current practice completed by staff revealed knowledge gaps and specific areas for improvement, an educational online module was developed and an evidence-based admission bundle was implemented. The admission bundle included a two-skin assessment upon admission with a turning schedule for every patient, with sacral preventative dressings and pressuring reducing mattresses recommended based upon a patient’s Braden Scale scores. The Plan-Do-Study-Act model was utilized to help facilitate implementation. Results: Prior to implementation of the bundle, there was 100% completion of education by the nursing staff. There was an overall 79.7% compliance with the two-nurse skin assessment and a 56.5% compliance rate with the use of sacral preventative dressings. In regards to the pressure reducing mattresses, 31 out of the 33 patients were either in a pressure reducing mattress at time of audit or had an order placed. This yielded a 93.9% compliance rate with this aspect of the bundle. There was a 54.5% compliance rate with the turning schedules posted in patient’s rooms. During the implementation period, six pressure ulcers were identified. Based on the postimplementation survey of current practice, there was little change in knowledge and confidence levels. Conclusions: Compliance rates with the admission bundle varied among the different aspects. There was higher compliance with the skin assessments and use of pressure reducing beds, however there were lower compliance rates with the sacral preventative dressings and turning schedules. Knowledge and confidence levels with HAPUs did not change dramatically post implementation with the HAPU admission bundle. There was an increase in HAPUs during the implementation period of this bundle which could correlate to low compliance with several aspects of the bundle as well as the low levels of change measured in nurse knowledge and confidence levels regarding pressure ulcer prevention. Implications: The use of a nurse-driven admission bundle can promote early identification of risk and lead to early implementation of preventative measures to stop HAPUs before they start.
    • Implementation of a Hospital-Acquired Pressure Injury Prevention Admission Bundle

      Berry, Mickaela E.; Callender, Kimberly (2021-05)
      Problem: Within a community hospital located in central Maryland, an adult intensive care unit (ICU) had an increased Hospital Acquired Pressure Injury (HAPI) incidence average rate of 2.2% per month during the months of July and August 2020. A potential cause identified was an inadequate nursing skin assessment on patient admission. Purpose: The purpose of this quality improvement project was to implement a HAPI prevention admission bundle that has been shown to reduce the number of HAPIs in an adult population. The bundle included four care components: completion of the Braden Scale score, performance of a two-nurse skin assessment, use of a pressure reducing surface, and application of a prophylactic sacral foam dressing. Methods: The adult ICU consisted of 30-beds and treated approximately 200 patients per month. The bundle was initiated by nursing staff at patient admission and all components were expected to be completed within 24-hours. Nursing education was administered and completed by the staff who worked in this unit. The use of the bundle was measured twice per week by chart audits. The HAPI rate was measured monthly by the hospital’s incident management system (RL6). Bundle documentation compliance and monthly HAPI rate were analyzed using run-chart analysis. Results: 86% of staff nurses were educated about the bundle. The documentation compliance of the bundle during the last four weeks of data collection was a 79% average. The post-implementation HAPI monthly incident rate average increased to 4.1%. Conclusions: The HAPI prevention admission bundle did not improve the average monthly ICU HAPI incident rate during a 14-week implementation effort. The documentation compliance of the bundle components improved over time, due to regular feedback of the chart audit results. COVID-19 precautions altered the standards of care during the implementation phase, which may have influenced the increased HAPI incidence rates during November and December. The HAPI prevention admission bundle was useful in increasing documentation compliance of four vital skin care components. A future quality improvement project should focus on adding additional evidence-based skin care components to the bundle and extending the implementation phase to ensure 100% of staff are educated to improve utilization of the bundle elements.
    • Implementation of an Algorithm to Prevent Pressure Injuries Among Immobile Residents

      Robinson, Maria Esther; Callender, Kimberly (2022-05)
      Problem: Pressure injuries (PI) stages II, III, and IV became a serious health problem at a long-term care (LTC) facility in Maryland during the unprecedented times of the Coronavirus 2019 (COVID-19) pandemic. The executive director reported that several immobile residents in each of the facility’s (n=12) three units developed PIs: seven sacral ulcers, stages II, III, and IV; five heels, consisting of two right outers; and three left outers, stages II and III. In addition, (n=2) PIs stage III became infected. Purpose: The purpose of this quality improvement (QI) project was to implement a PI algorithm for prevention and expeditious intervention for PIs. Methods: The QI project was implemented August-December 2021. Pre-implementation, in person, the DNP student educated change champions, registered nurses (RNs), licensed practical nurses (LPNs), and certified nursing assistants (CNAs)/geriatric nursing assistants (GNAs), on the algorithm. After the education session, a copy of the algorithm was laminated and posted at each nursing station in the three units. Additional strategies included training CNAs/GNAs on adhering to the turning schedule and filling out the log posted in each resident's room. In addition, each nursing staff member completed a pretest, then viewed an educational PowerPoint, and completed a post-test to evaluate knowledge of PIs. During implementation, the DNP student tracked structure, process, and outcome measures weekly through chart audits and PI prevention rounding audit tool. Results: A pie chart displayed structure measures; 80% (n=20) of nursing staff were trained on the algorithm. Zero new PIs stages II, III, and IV were reported during implementation of the algorithm. Sacral PIs stages II (n=7) improved. At week ten, 100% algorithm compliance was achieved; additionally, 90% was achieved at weeks twelve and thirteen. Conclusion: Implementation of the PI algorithm at the LTC facility during COVID-19 effectively improved residents' quality of life, prevented PIs, and decreased morbidity and mortality. Continuing education and training will be needed to maintain sustainability.
    • Implementation of Early Mobility Screening in the Surgical Intensive Care Unit

      Jones, Lindsay K.; Bundy, Elaine Y. (2021-05)
      Problem: A lack of early mobility screening in the adult critical care population may lead to adverse healthcare outcomes. In the past months preceding the practice change, a Surgical Intensive Care Unit (SICU) experienced seven hospital-acquired pressure injuries (HAPIs) and three inpatient falls. Purpose: The purpose of this quality improvement (QI) project was to implement and evaluate the effectiveness of early mobility screening via the Johns Hopkins Highest Level of Mobility (JH-HLM scale) in a 12-bed adult SICU in a community hospital setting. Methods: The JH-HLM scale was implemented over a 13-week period and was used to assess patient’s daily mobility level. Data on nursing compliance of use of mobility scale and improvement in mobility scores were collected via manual chart audits, and run charts were used to track and analyze results. Falls and HAPIs were also tracked. Results: Analysis of run charts for nursing compliance in use of the scale and improvement in mobility scores showed no shifts, trends, or non-random variation of runs, suggesting no effect due to the practice change. However, nursing compliance with use of the scale was consistently 85% to 100% and improvements in patient mobility occurred in 41 (35%) out of 116 patients screened. Although there was no decrease in patient falls, HAPIs decreased when compared to the previous eight months. Conclusion: The JH-HLM scale was found to be a safe and feasible screening tool useful by nurses in promoting early mobility in an acutely ill population. Additional QI projects are needed to determine if improved patient outcomes are associated with early mobility screening within 72 hours of ICU admission through discharge.
    • Prophylactic Sacral Dressings and Skin Assessments in Acute Care Emergency Surgery Patients

      Brown, Caroline; Satyshur, Rosemarie D. (2020-05)
      Problem & Purpose Statement: Hospital acquired pressure injuries (HAPIs) are a growing issue within the healthcare system. On average, 2.5 million people in the United States develop a HAPI. Annually, approximately $26.8 billion dollars is spent on treating HAPIs in the United States alone. Consequences of HAPIs include increased length of stay, decreased quality of life, increased morbidity and mortality, and decreased hospital reimbursement. The purpose of this quality improvement (QI) project is to decreased the incidence of HAPIs, in Acute Care Emergency Surgery (ACES) patients with Braden scores less than or equal to fourteen in the Surgical Intensive Care Unit (SICU) through the implementation of a prophylactic sacral dressing and nurse practitioner (NP) and registered nurse (RN) skin assessments. Methods: The QI project took place over a ten-week period, from September 2, 2019 to November 10, 2019 and was implemented in three phases. Phase I included identification of unit skin champions and education pertaining to the Braden Scale and preventing HAPIs. Phase II included the implementation of a prophylactic sacral dressing and NP & RN skin assessments. Phase III included data collection and analysis. In order to help with implementation, Lewin’s theory of planned change was utilized. Results: Prior to implementation, there was a total of six HAPIs, with Braden scores ranging from eight to fourteen, with an average of twelve. Post implementation, there were a total of zero HAPIs, with Braden scores ranging from ten to fourteen, with an average of thirteen. 96% (n=61) of ACES patients who met criteria had a prophylactic sacral dressing applied. 100% of ACES patients who met criteria had a skin assessment completed and documented by RNs, while 35% (n=22) of ACES patients who met criteria had a skin assessment completed and documented by ACES NPs. Data collection form compliance was 44% (n=35). Conclusion: Compliance rates among RNs and NPs varied in respect to the documentation, and completion of the data collection form. RNs had a higher compliance rate associated with skin assessment documentation in the electronic health record compared to NPs. There was a decrease in the incidence of HAPIs after implementation of a prophylactic sacral dressing and RN/NP skin assessments.
    • Reducing Unit-Acquired Pressure Injuries on a Cardiac Surgery Progressive Care Unit

      McGinn, Amy E.; Davenport, Joan (2019-05)
      Background: Consequences of pressure injuries can be emotional and physical, including pain, body image distortion, increased risk for infection, increased length of stay in the hospital, and death. Pressure injuries create a significant economic burden for organizations and individuals. Organizations that have the highest incidences of pressure injuries receive less reimbursement for services. Local Problem: Prior to project implementation, 3 pressure injuries were found on the cardiac surgery progressive care unit during a 13-week period. The cardiac surgery progressive care unit in a large academic medical center in the mid-Atlantic region was responsible for 66% of the pressure injuries. The purpose of this quality improvement project was to implement and evaluate the effectiveness of a pressure injury prevention bundle on a cardiac surgery progressive care unit over a 13-week period using the Model for Improvement as a framework for implementation. Intervention: The pressure injury prevention bundle consisted of four steps: the Braden score, a two-nurse skin assessment on admission, a pressure-reducing surface, and a consult to the wound, ostomy, and continence nurse. Two-hundred one subjects were evaluated (n=201). The intervention was evaluated by a before-after design, comparing the number of avoidable unitacquired pressure injuries before project implementation, to after implementation of the PUPB. Results: Post-implementation, 4 pressure injuries were found on the cardiac surgery progressive care unit, but only 25% of the pressure injuries were determined to be the unit's responsibility, and 75% of the pressure injuries were determined to have occurred prior to admission to the unit. A nurse did not complete the two-nurse skin assessment on the one patient who developed a pressure injury during this project timeframe. The pressure injury was discovered 25.5 hours after admission to the unit, deeming it the cardiac surgery progressive care unit's responsibility. Conclusions: The pressure injury prevention bundle should be a standard of care for all new patient admissions. When all of these factors are used together in a bundle, this project demonstrates that the unit could have zero unit-acquired pressure injuries.