Prevention of Pressure Injuries
Pressure injury prevention requires an interprofessional team approach and organiza- tional support (National Database of Nursing Quality Indicators, 2019). Early nursing care interven- tions play a significant role in pres- sure injury prevention and manage- ment across the healthcare setting. The National Pressure Ulcer Ad – visory Panel (NPUAP, 2016) recom- mended performing skin assess- ments within 8 hours of patient admission using a risk assessment tool (e.g., Braden Scale for Pre – dicting Pressure Sore Risk; Pre – vention Plus, 2016) to identify per- sons at risk for pressure injury. In addition, a skin assessment should be completed every shift in the acute care setting. According to the NPUAP, patients who are consid- ered at risk for pressure injuries include those who are bedfast or chairfast, or have fragile skin, previ- ous or existing pressure injuries, decreased blood flow to the extrem- ities, and pain in pressure points. Prevention of Pressure Injuries
An individualized plan of care should be developed for patients based on their risk assessments. For example, if decreased mobility is a current problem, the plan of care should include turning and reposi-
Continuous Quality Improvement
The performance improve- ment process was used to develop and implement a ded- icated Turn Team to decrease the incidence of unit-acquired pressure injuries. Outcomes as a result of the change are reviewed.
• Repositioning of individuals at risk for pressure injuries is performed to reduce the length of time and amount of pressure over vulnerable body areas and to contribute to comfort, hygiene, dignity, and functional ability (National Pressure Ulcer Advisory Panel, European Pressure Ulcer Advisory Panel, and Pan Pacific Pressure Injury Alliance, 2014). Prevention of Pressure Injuries
• Studies demonstrate the implementation of a dedicated Turning Team decreases the incidence of pressure injuries (Harmon, Grobbel, & Palleschi, 2016; Still et al., 2013).
• Pressure injuries are associated with an estimated excess mortality rate of 72 deaths per 1,000 and excess costs of $18,000/case (Agency for Healthcare Research and Quality, 2019).
• In addition to the high cost of treatment, pressure injuries have a great impact on patients’ lives and caregivers’ ability to provide appropriate care (The Joint Commission, 2016).
• Patients with hospital-acquired pressure injuries (HAPI) incur longer length of stay compared to patients without HAPI (Australian Commis – sion on Safety and Quality in Health Care, 2018; Ling & Shin, 2017).
Plan, Do, Check, and Act (Mann, 2014)
Quality Indicator with Operational Definitions & Data Collection Methods
• Unit-acquired pressure injury data encompassed the 12 months before implementation of Turn Teams and 12 months after team implemen- tation. Prevention of Pressure Injuries
• Weekly skin assessment audits were performed on all patients at risk for developing pressure injuries over a 12-month period after Turn Teams implementation.
51-bed medical-surgical unit in a hospital in the southeastern United States
Decrease unit-acquired pressure injuries by 50%.
July-August 2019 • Vol. 28/No. 4258
tioning the patient at regular inter- vals, and using a support surface. In addition to performance of a risk assessment, guidelines address skin care, nutrition, mobilization, and education as part of pressure injury prevention (NPUAP, 2016). Reposit – ioning and mobilization interven- tions require nursing staff to turn and reposition all individuals at risk for pressure injury, choose a fre- quency for turning, avoid position- ing the individual on areas with an existing pressure injury, and ensure the patient’s heels are offloaded. At the medical-surgical unit that was the site for this quality improve- ment project, multiple interven- tions were followed without achiev- ing a marked decrease in pressure injury occurrence. For example, appropriate support surfaces were in place and skin care products were used consistently, including pH-bal- anced skin cleansers and moisture barrier creams. Nutrition consulta- tion, assess ment of adequacy of oral intake, and nutrition supplementa- tion were implemented as needed. A literature review on the imple- mentation of Turning Teams for pressure injury prevention was con- ducted by the unit’s Patient Out – comes Facilitators (POFs). Study results suggested a decrease in the incidence of pressure injuries after the implementation of a team dedi- cated to turning patients every 2 hours (Harmon, Grobbel, & Palleschi, 2016; Still et al., 2013). Thus, the decision was made by the POFs in collaboration with the unit’s Shared Governance Council to focus on turning and reposition- ing patients on this unit. Prevention of Pressure Injuries
Project Site and Reasons for Change
The Joint Commission (2016) reported immobility as a major con- tributing factor to the development of pressure injuries. The NPUAP (2016) published Pressure Injury Prevention Points that recommended turning and repositioning at-risk patients at a scheduled frequency if not contraindicated. Patients at risk for pressure injuries represented a
substantial portion of patients on the project unit, with patients aver- aging age 65 with 6-day length of stay. The most common patient diagnoses on the unit were gastro – intestinal-related disorders (17%), kidney/urinary tract-related disor- ders (10%), sepsis (8%), and celluli- tis (4%) (E. Butler, personal commu- nication, May 18, 2018). Prevention of Pressure Injuries
This project unit had an aver- age of two to six unit-acquired pres- sure injuries each quarter before project implementation in April 2015. The repositioning of at-risk patients was not being done consis- tently due to staffing assignments, high patient acuity, and competing priorities. However, the policy at this institution recommended turn- ing at-risk patients every 2 hours. These variables contributed in part to an increase in the number of unit-acquired pressure injuries for 2014 and the first quarter of 2015. The purpose of this project was to decrease the incidence of pressure injuries by 50% on this medical-sur- gical unit Prevention of Pressure Injuries