Analyzing Reporting of Hospital Acquired Pressure Injuries in the Acute Care Setting

This project was conducted at a level one trauma center, acute care hospital consisting of 459 beds. With more patients than wound care nurses, hospital-acquired pressure injuries (HAPIs) have become a significant problem for this hospital. A gap between reporting in the Safety and Quality Information System (SQIS) and the reporting that takes place in electronic health record (EHR) with wound care consults has been observed. A root cause analysis (RCA) was used to identify discrepancies. The accurate collection of data was identified as paramount providing information necessary to create improvements and lower the occurrence of HAPIs. The conceptual framework which guided this project to decrease the incidence of inaccurate HAPI documentation was the PDSA model/cycle. The Lewin Change Model was applied as the leadership theory. The cost of one HAPI is $14,506 and can potentially cost the hospital$2,088,864 per year. With the proper education to prevent HAPIs from occurring, the medical center can save on average $1,044,432 per year. The plan is to educate nurses on the prevention, correct staging, and proper documentation of HAPIs. Using process and balance measures, the team can study the effectiveness of the interventions. Additionally, nurses who attended educational sessions completed pre and post tests to assess their knowledge which was then compared through a bar chart. With all these efforts, expected outcomes are to sustain a 50% decrease in HAPIs at this hospital

Reducing HAPI in High-Risk Patients: A Quality Improvement Project

Executive Summary Introduction: Pressure injuries (PI) are wounds caused by pressure, friction, or sheer on the skin and the underlying structures, resulting in cell death (Berlowitz et al., 2014). When hospital-acquired pressure injuries (HAPI) occur, they severely affect a patient\u27s quality of life. It is estimated HAPI is the cause of death in 41 out of every 1000 patients (AHRQ, 2017). Annual costs related to HAPI in the United States are estimated at $26.8 billion (Padula & Delarmente, 2019). HAPI prevention is a priority in the hospital setting as it is a quality indicator. There is emerging evidence that foam dressings over the sacrum, as an addition to the standard of care, may further reduce the incidence of HAPI. Problems and Purpose Statement: Currently, nurses use foam dressings as PI prevention as an independent practice decision at the project hospital. The purpose of this project was to determine whether the application of sacral foam dressings over intact skin by hospital staff RNs as PI prevention would reduce the incidence of HAPI in high-risk adult patients. Eligibility criteria included a) \u3c24 hours admission to the unit; b) Braden score ≤18; c) Braden sub-category moisture \u3e2; d) no tape allergy; e) intact sacral skin, no history of sacral PI, or sacral scar; f) continent or contained urine/stool; g) no diarrhea even if continent. After implementation, additional exclusion criteria included patients who became incontinent, those with a history of noncompliance with care, and patients who refused skin assessment. Specific aims included a reduction in the incidence of HAPI, and successful adoption of the intervention by nursing staff on the project unit. Though evidence supports the use of foam dressings as HAPI prevention, the overall goal of this study was to incorporate the intervention into hospital policy to help standardize the practice and improve patient safety. Methods: The project was implemented in one inpatient unit at the project hospital. Lewin\u27s Change Theory (Lewin, 1947) and the Plan-Do-Study-Act (PDSA) framework guided the project (IHI, 2020). Patients and nurses were considered participants. All nurses and a convenience sample of all eligible high-risk patients from May through June 2021 were eligible to participate. Nurses charted skin assessment, dressing application, and interventions using an existing wound tracking flowsheet in the EHR. Additional chart data was collected regarding interventions reflecting the standard of care for PI prevention. The RN Unit Post Satisfaction Survey was used to assess whether the project protocol was acceptable and feasible to the nursing staff on the unit as a measure to promote sustainability. Results/Outcomes: Of the 243 patients admitted to the unit during the project, 23 met eligibility criteria, with 6 enrolled in the project. Most of those eligible were excluded. The sample included 3 males and 3 females, ages 53 to \u3e90 years, with Braden scores ranging from 16-18. No patients developed a pressure injury during the project. Though low enrollment, the foam dressing showed promise in mitigating pressure injury, which is in line with the research. Anecdotally, 2 of the 6 patients exhibited improved skin under the dressing when compared to the surrounding skin. Whether the standard of care for pressure injury had been met was poorly understood by staff and the project lead. While there were aspects of nurse charting which were measurable, time-sensitive, and could be quantified (e.g., assessments and hourly rounding) due to the complexity and the intradisciplinary nature of PI interventions, the measure of standard of care was unknown to nursing staff. The RN Unit Post Satisfaction Survey included 5 questions with 5-point Likert type survey response sets, plus space for comments. The survey was available for two weeks post-intervention, was anonymous, and open to every RN regardless of experience with a patient in protocol. With 64 nurses assigned during the project period, 30 responses were returned (47%). Participant responses showed variability, which may be an indicator of thoughtful responses rather than socially desired answers. Results considered favorable were those marked as either agree or strongly agree. Unfavorable results were marked disagree or strongly disagree. There was also a neutral option. The items related to the protocol intervention were favorable: a) understanding the inclusion criteria (97%); b) availability of dressings (83%); c) low impact on time management (82.7%), and d) understanding the charting protocol (76%). When asked if nurses were more aware of PI prevention because of the project, 83% responded favorably as well. Sustainability: Though the project had the support of nurses, there were barriers to sustainability that would need to be addressed in future projects. The inclusion/exclusion criteria should be simplified. Though nurses endorsed the necessity of a tracking tool for the prevention dressing, using the existing EHR wounds flowsheet was cumbersome and complex. Time was also a factor noted in the survey. With chronic short-staffing related to Covid-19 as a global concern, adding a new process would be challenging as even the best ideas need front-line support. Understanding whether the standard of care for PI interventions had been met remained poorly understood. Though nurses and CNAs were actively engaged in PI prevention, the measure at the staff level remained unclear. Additional education on how to pair Braden scores with specific interventions may bring clarity. Limitations: Limitations included implementing a QI project during the Covid-19 global pandemic, which had already placed unprecedented stress on healthcare systems, including critical staffing shortages. Though the survey results supported the project, the project lead was aware from 1:1 conversations that staff were burdened by the extra work the project was generating. In response, the project lead took on more responsibility which impacted sustainability. Implications: Implications for practice suggest creating a new protocol during the stressors related to the ongoing Covid-19 pandemic may be poor timing. However, despite pandemic-related complications, the study results showed the nursing staff were able to successfully adopt the intervention, though some aspects were confusing at times. Despite promising results both for patients and adoption by nurses, challenges remain in integrating the protocol steps into a usable model. However, nurses who are well versed in evidence-based practice may be more willing to use a simple to implement protocol where the benefits are easily understood. Finally, these results show there is value in doing a unit-based QI project as participation can elevate knowledge of this practice or others. Here, 83% of nurses agreed they had increased knowledge of pressure injury prevention because of exposure to the project. Even those nurses who were not directly involved with patients in protocol received the secondary benefit of deeper understanding regarding HAPI prevention practices. Future endeavors might consider this secondary benefit when planning evidence-based practice projects and find ways to engage staff even during times of extreme challenges in the healthcare setting. References: Agency for Healthcare Research and Quality [AHRQ]. (2017). Partnership for patients. https://www.ahrq.gov/hai/pfp/index.html Agency for Healthcare Research and Quality[AHRQ]. (n.d.). 5. How do we measure our pressure ulcer rates and practices? https://www.ahrq.gov/patient- safety/settings/hospital/resource/pressureulcer/tool/put5.html Berlowitz, D., VanDeusen, C., Niederhauser, A., Silver, J., Logan, C., Ayello, E., & Zulkowski, K. (2014, October). Preventing pressure ulcers in hospitals: A toolkit for improving quality of care. Agency for Healthcare Research and Quality. https://www.ahrq.gov/sites/default/files/publications/files/putoolkit.pdf Institute for Healthcare Improvement [IHI]. (2020). Plan-Do-Study-Act (PDSA) worksheet: IHI. http://www.ihi.org/resources/Pages/Tools/PlanDoStudyActWorksheet.aspx Lewin, K. (1947). Frontiers in group dynamics: Concept, method and reality in social science; social equilibria and social change. Sage Journals - Human Relations. https://doi.org/10.1177/001872674700100103 Padula, W. V., & Delarmente, B. A.. (2019). The national cost of hospital‐acquired pressure injuries in the United States. International Wound Journal, 16(3), 634–640. https://doi.org/10.1111/iwj.130

Protecting the Skin of Older Adults Through Surveillance and Pressure Ulcer Prevention Beginning in Emergency Services

ED (emergency department) personnel are admitting to inpatient services increasing numbers of elderly clients who are at risk for skin breakdown. The ED environment is designed for short term care in response to emergent situations. Pressure related injuries originating in the ED lead to both physical suffering and financial burdens. Pressure relief strategies have been actively employed on an inpatient basis without translation to the ED environment. Evidence for best practice in PUP (pressure ulcer prevention) in the ED is not widely embraced. Prevention of PUs is primarily within the scope of nursing practice and amenable to improvements in the standard of care. Therefore, the purpose of this project is to translate current evidence for PUP from the literature to sustainable best practice in emergency nursing. Synthesis of existing literature revealed the most effective strategies for PUP focused on enhanced support surfaces, patient positioning, moisturizing dry skin, restricting head of bed (HOB) elevation, and timely removal of backboards. These measures reflect current evidence and were proposed as innovative strategies in the ED. A logic model was utilized to guide planning and evaluation of the program. The theory of planned behavior, the consolidated framework for implementation research, and polarity thinking were employed to ensure theory driven practice. Following an organizational assessment and IRB approval, the project was implemented at a 254 bed community hospital in the Midwestern United States with a 20 bed ED. A significant challenge to implementation was the culture of ED nursing which was focused upon stabilization and disposition versus prevention. The timeline for the project involved data collection, intervention, and evaluation over a four month period. A chart review was conducted to establish current practice of skin assessments and ED interventions directed at maintaining skin integrity. Nursing and support staff participated in an educational intervention addressing the relationship between routine care and the unintended consequence of skin breakdown. Evidence for best practice in prevention was reviewed and realistic measures for PUP presented for adoption. Learning was evaluated in pre-test/post-test format. Nurse\u27s intention to implement best practice measures and perceived barriers/facilitators were identified. The post intervention evaluation period lasted two months and documented utilization of skin moisturizer from ED supply. The terminal outcome was repeat chart audit of vulnerable elderly patients which assessed for increased documentation of skin assessments and identified PU strategies. Follow up chart audit revealed a 56.6% improvement in the frequency of nursing documentation of integumentary assessments. Documentation of prevention measure improved less dramatically. Inventory analysis, however, demonstrated actual use of recommended products. Nursing knowledge regarding pressure ulcer identification, staging, and prevention increased in 93% of participants. All four evidence-based strategies were embraced with greater than 70% of participants reporting intent to implement. The most frequently identified barriers to implementing prevention measures were time and staffing. The most common facilitators were availability of supplies and visual reminders. Recommendations include revision of the electronic health record to facilitate documentation of strategies by staff and inclusion of the protective dressing in the bedside treatment carts

Unavoidable Pressure Ulcers: An Ethnonursing Study

Catherine M. Clarey-Sanford Loyola University Chicago UNAVOIDABLE PRESSURE ULCER: AN ETHNONURSING STUDY In an effort to improve patient safety and the quality of care in the acute care setting, there has been an increased focus on the prevention of adverse events believed to be avoidable. Hospital-acquired pressure ulcers (HAPU) have been listed as one of those adverse events, and hospitals are no longer reimbursed for related costs. However, there are patient conditions and clinical situations in which a pressure ulcer can be deemed unavoidable. In acute care, unavoidable means that the patient developed a pressure ulcer even though the provider had: evaluated the patient’s pressure ulcer risk factors; defined and implemented interventions that were consistent with recognized standards of practice; monitored and evaluated the impact of the interventions; and revised the approaches as appropriate. Despite these guidelines, the implementation and documentation of pressure ulcer prevention has been inconsistent, making it difficult to identify a HAPU as unavoidable. There is a lack of research exploring the acute care nurses’ perspective of implementing and documenting pressure ulcer prevention interventions. Using an ethnographic qualitative method, information was collected through observation, informal conversations, interviews, and field notes. Data collection took place in a regional medical center located in the mid-west of the United States over a seven month period and included 23 participants: 7 acute care medical-surgical nurses who had provided direct care to a patient who developed a HAPU and 16 multidisciplinary health care members who had knowledge of pressure ulcer prevention interventions and documentation. A systematic, rigorous, and in-depth qualitative analysis was completed using the Leininger Data Analysis Guide. Four themes emerged from the data regarding the culture of care of adults experiencing a HAPU: incomplete skin assessments were influenced by priority setting and kinship relationships; an inability to implement pressure ulcer prevention interventions was influenced by economical staffing; diverse documentation regimes were influenced by care rationing practices and technical factors; and diverse multidisciplinary collaborative pressure ulcer prevention efforts were influenced by silo social structures. The findings of this study not only have implications for nursing practice, administration, and education, but are vitally important in the identification of a HAPU as avoidable or unavoidable

The Influence of Continuity of Nursing Care in the Acute Care Setting on Readiness for Discharge and Post-Discharge Return to Hospital

Background: Promoting continuity of nursing care has the potential to increase patient readiness for discharge, which has been associated with fewer readmissions and emergency department (ED) visits. The few studies that have examined nursing continuity during acute care hospitalizations did not focus on discharge or post-discharge outcomes.Objectives: The aim of this research study was to examine the association of continuity in nurse assignment to patients prior to hospital discharge with return to hospital (readmission and ED/Observation visits), including exploration of the mediating pathway through patient readiness for discharge and moderation effects of unit environment and unit nurse characteristics.Methods: In a sample of 18,203 adult, medical-surgical patients from 33 Magnet hospitals participating in a randomized clinical trial evaluating implementation of discharge readiness assessments, regression analysis with simultaneous equation modeling was used to evaluate the impact of nurse continuity on readmissions and ED/Observation visits within 30 days after hospital discharge and the mediating pathway through discharge readiness measured by patient self-report and nurse assessments. Moderating effects of unit environment and nursing characteristics were examined across quartiles of unit environment (nurse staffing hours per patient day) and unit nurse characteristics (education and experience). Analyses were adjusted for patient characteristics, hospital fixed effects, and clustering at the hospital level.Results: Continuous nurse assignment on the last 2 days of hospitalization was observed in 6,441 (35.4%) patient discharges and was associated with a 0.85 absolute percentage point (95% CI [-0.0166, -0.0004], p\u3c0.05) reduction (7.8% relative reduction) in readmissions. There was no significant association with ED/Observation visits. Sensitivity analysis revealed a stronger effect in patients with higher Elixhauser Comorbidity Indexes. Readiness for discharge was not a mediator of the effect of continuity on return to hospital. Unit characteristics were not associated with nursing continuity. No moderation effect was evident for unit environment and nurse characteristics. Discussion: Continuity of nurse assignment on the last 2 days of hospitalization can reduce readmissions. Staffing for continuity may benefit patients and health care systems, with greater benefits for high comorbidity patients. Nurse continuity should be a priority consideration in assigning acute care nurses to augment readmission reduction efforts

Improving the Accuracy of Publicly Reported PSI Rates through Enhanced Internal Documentation Review

Patient Safety Indicators, or PSIs, are used by several healthcare related federal agencies and third-party payers to determine the quality of care being delivered by a healthcare provider. A composite PSI, PSI-90, includes a group of PSIs that are publicly reported as quality indicators for a provider, and that are used as part of the Value Based Purchasing calculation. Poor PSI-90 rates directly influence healthcare services reimbursement rates by CMS and may be considered an indication of a quality of care problem by potential patients and third party payers. This research is a case study on the effectiveness of a program implemented by the Medical University of South Carolina (MUHA) to improve the accuracy of their reported PSI-90 composite score

2022 - The Third Annual Fall Symposium of Student Scholars

The full program book from the Fall 2022 Symposium of Student Scholars, held on November 17, 2022. Includes abstracts from the presentations and posters.https://digitalcommons.kennesaw.edu/sssprograms/1026/thumbnail.jp

Patient Safety and Quality: An Evidence-Based Handbook for Nurses

Compiles peer-reviewed research and literature reviews on issues regarding patient safety and quality of care, ranging from evidence-based practice, patient-centered care, and nurses' working conditions to critical opportunities and tools for improvement

Human Resource Strategies for Improving Organizational Performance to Reduce Medical Errors

Preventable medical errors are the third leading cause of death in the United States. Healthcare leaders must consistently promote the delivery of quality and safe care of patients to reduce unnecessary errors and prevent harm. The purpose of this case study was to explore human resource strategies for improving organizational performance to reduce medical errors. The study included face-to-face interviews with 5 healthcare clinical managers who work within a multifaceted health system in the Midwestern region of the United States. Complex adaptive systems theory was used to frame this study. Interview notes, publicly available documents, and audio recordings were transcribed and analyzed to identify themes regarding strategies used by managers to find effective ways for improvement. Four themes emerged: addressing seminal/never events, ongoing training programs, communication/collaboration, and promoting a culture of safety and quality. Results may directly benefit healthcare managers by facilitating successful strategies to reduce preventable medical errors through education, feedback, innovation, and leadership. Implications for social change for healthcare managers include continued training, building a culture of safety, and using collaborative and communicative efforts while making contributions to the best practices within healthcare organizations to reduce the likelihood of medical errors

The Impact of Daylight and Window Views on Health and Recovery: A Quash-Experimental Study of Patients with Heart Disease in a Cardiac ICU

Heart disease is the leading cause of death in the United States. Being diagnosed with heart disease can lead to depression, anxiety, sleep disruption, and delirium symptoms, which can cause prolonged hospital stays among patients. Evidence suggests that the presence of daylight and window views can influence these symptoms positively. However, no studies to date have differentiated the impact of daylight from window views on heart disease patients or addressed how window use can impact patient recovery in cardiac intensive care units (CICUs). This IRB-approved study employed a retrospective and prospective quasiexperimental approach to investigate CICU rooms of the same size with daylight and views (patient bed parallel to the full-height, south-facing window), rooms with daylight and no views (patient bed perpendicular to the window), and windowless rooms. The first phase of the study entailed analyzing retrospective data between 2015 to 2019. In the second phase, 21 CICU patients were recruited through purposive sampling. Data regarding depression/anxiety, sleep quality, and lighting were collected prospectively through questionnaires, actigraphy, and data loggers. Linear regression models were developed for each outcome of interest to control for confounding variables. Based on the results, rooms with windows supported patient recovery in general; however, rooms with daylight and views significantly reduced patients’ typical CICU LOS compared to the windowless rooms. While room type was not significantly associated with mortality and delirium, patients receiving palliative care and opioid medications in rooms with daylight and views had significantly lower odds of mortality and delirium than other iii patients. In phase two, the availability of daylight in windowed rooms significantly improved CICU patients’ perceived sleep quality. Patients in windowed rooms also reported a lower average anxiety/depression score; however, the difference was not statistically significant. Moreover, higher light levels in rooms significantly reduced analgesic intake and improved actigraphic sleep efficiency among patients. This study helps architects with design decisions regarding CICU room layouts by indicating the bed orientation that best supports patient recovery. Identifying the type of patients who benefit most from direct access to daylight and views can also help CICU stakeholders with patient assignments and hospital training programs