Are Quality Improvement Projects Improving Health Outcomes?

Quality improvement projects such as pressure injury prevention does improve health outcomes for patients.https://digitalcommons.misericordia.edu/research_posters2020/1056/thumbnail.jp

Pressure Injury Prevention in the Inpatient Setting

abstract: Background: Pressure injuries inflict a major, preventable burden onto hospital systems, healthcare providers, and patients. The purpose of this evidence based project was to evaluate the impact of a pressure injury prevention education program on nursing staff knowledge and pressure injury rates in an Arizona post-cardiac care unit. Method: A single group pre-test post-test design was utilized to evaluate nursing staff knowledge before and after an education program on pressure injury prevention. Staff knowledge was evaluated using a modified version of the Pressure Ulcer Knowledge Assessment Tool 2.0. Participants completed pre- and post-education surveys. Rates of hospital acquired pressure injuries were obtained via chart review. Results: Pre- and post-education scores were analyzed in participants who completed both surveys using a paired t-test. Post-education scores (M = 0.73, SD = 0.07) were significantly higher than pre-education scores (M = 0.59, SD = 0.09); t(7) = -5.39, p = .001. Pre- and post-education median scores of all participants were analyzed using two-tailed Mann-Whitney U test. Post-education scores (Mdn = 0.71) were significantly higher compared to pre-education scores (Mdn = 0.56); U = 102.5, z = -4.05, p = .001. Monthly incidence of pressure injuries on the unit increased following education. Discussion: Increase in scores from pre- to post-education surveys indicate staff knowledge improved. The increased incidence of pressure injuries is thought to be secondary to staff’s increased ability to detect pressure injuries. Staff education is recommended, but more research is needed regarding the impact on pressure injury rates

Repositioning for pressure injury prevention in adults

BACKGROUND: A pressure injury (PI), also referred to as a 'pressure ulcer', or 'bedsore', is an area of localised tissue damage caused by unrelieved pressure, friction, or shearing on any part of the body. Immobility is a major risk factor and manual repositioning a common prevention strategy. This is an update of a review first published in 2014. OBJECTIVES: To assess the clinical and cost effectiveness of repositioning regimens(i.e. repositioning schedules and patient positions) on the prevention of PI in adults regardless of risk in any setting. SEARCH METHODS: We searched the Cochrane Wounds Specialised Register, the Cochrane Central Register of Controlled Trials (CENTRAL), Ovid MEDLINE, Ovid Embase, and EBSCO CINAHL Plus on 12 February 2019. We also searched clinical trials registries for ongoing and unpublished studies, and scanned the reference lists of included studies as well as reviews, meta-analyses, and health technology reports to identify additional studies. There were no restrictions with respect to language, date of publication, or study setting. SELECTION CRITERIA: Randomised controlled trials (RCTs), including cluster-randomised trials (c-RCTs), published or unpublished, that assessed the effects of any repositioning schedule or different patient positions and measured PI incidence in adults in any setting. DATA COLLECTION AND ANALYSIS: Three review authors independently performed study selection, 'Risk of bias' assessment, and data extraction. We assessed the certainty of the evidence using GRADE. MAIN RESULTS: We identified five additional trials and one economic substudy in this update, resulting in the inclusion of a total of eight trials involving 3941 participants from acute and long-term care settings and two economic substudies in the review. Six studies reported the proportion of participants developing PI of any stage. Two of the eight trials reported within-trial cost evaluations. Follow-up periods were short (24 hours to 21 days). All studies were at high risk of bias. Funding sources were reported in five trials. Primary outcomes: proportion of new PI of any stage Repositioning frequencies: three trials compared different repositioning frequencies We pooled data from three trials (1074 participants) comparing 2-hourly with 4-hourly repositioning frequencies (fixed-effect; I² = 45%; pooled risk ratio (RR) 1.06, 95% confidence interval (CI) 0.80 to 1.41). It is uncertain whether 2-hourly repositioning compared with 4-hourly repositioning used in conjunction with any support surface increases or decreases the incidence of PI. The certainty of the evidence is very low due to high risk of bias, downgraded twice for risk of bias, and once for imprecision. One of these trials had three arms (967 participants) comparing 2-hourly, 3-hourly, and 4-hourly repositioning regimens on high-density mattresses; data for one comparison was included in the pooled analysis. Another comparison was based on 2-hourly versus 3-hourly repositioning. The RR for PI incidence was 4.06 (95% CI 0.87 to 18.98). The third study comparison was based on 3-hourly versus 4-hourly repositioning (RR 0.20, 95% CI 0.04 to 0.92). The certainty of the evidence is low due to risk of bias and imprecision. In one c-RCT, 262 participants in 32 ward clusters were randomised between 2-hourly and 3-hourly repositioning on standard mattresses and 4-hourly and 6-hourly repositioning on viscoelastic mattresses. The RR for PI with 2-hourly repositioning compared with 3-hourly repositioning on standard mattress is imprecise (RR 0.90, 95% CI 0.69 to 1.16; very low-certainty evidence). The CI for PI include both a large reduction and no difference for the comparison of 4-hourly and 6-hourly repositioning on viscoelastic foam (RR 0.73, 95% CI 0.53 to 1.02). The certainty of the evidence is very low, downgraded twice due to high risk of bias, and once for imprecision. Positioning regimens: four trials compared different tilt positions We pooled data from two trials (252 participants) that compared a 30° tilt with a 90° tilt (random-effects; I² = 69%). There was no clear difference in the incidence of stage 1 or 2 PI. The effect of tilt is uncertain because the certainty of evidence is very low (pooled RR 0.62, 95% CI 0.10 to 3.97), downgraded due to serious design limitations and very serious imprecision. One trial involving 120 participants compared 30° tilt and 45° tilt with 'usual care' and reported no occurrence of PI events (low certainty evidence). Another trial involving 116 ICU patients compared prone with the usual supine positioning for PI. Reporting was incomplete and this is low certainty evidence. Secondary outcomes No studies reported health-related quality of life utility scores, procedural pain, or patient satisfaction. Cost analysis Two included trials also performed economic analyses. A cost-minimisation analysis compared the costs of 3-hourly and 4-hourly repositioning with 2-hourly repositioning schedule amongst nursing home residents. The cost of repositioning was estimated at CAD 11.05 and CAD 16.74 less per resident per day for the 3-hourly or 4-hourly regimen, respectively, compared with the 2-hourly regimen. The estimates of economic benefit were driven mostly by the value of freed nursing time. The analysis assumed that 2-, 3-, or 4-hourly repositioning is associated with a similar incidence of PI, as no difference in incidence was observed. A second study compared the nursing time cost of 3-hourly repositioning using a 30° tilt with standard care (6-hourly repositioning with a 90° lateral rotation) amongst nursing home residents. The intervention was reported to be cost-saving compared with standard care (nursing time cost per patient EUR 206.60 versus EUR 253.10, incremental difference EUR -46.50, 95% CI EUR -1.25 to EUR -74.60). AUTHORS' CONCLUSIONS: Despite the addition of five trials, the results of this update are consistent with our earlier review, with the evidence judged to be of low or very low certainty. There remains a lack of robust evaluations of repositioning frequency and positioning for PI prevention and uncertainty about their effectiveness. Since all comparisons were underpowered, there is a high level of uncertainty in the evidence base. Given the limited data from economic evaluations, it remains unclear whether repositioning every three hours using the 30° tilt versus "usual care" (90° tilt) or repositioning 3-to-4-hourly versus 2-hourly is less costly relative to nursing time

Utilization of Pressure Injury Prevention Team in Long-Term Care Settings

In addressing the role that pressure injury prevention (PIP) teams can have in prevention and reduction of pressure ulcers for older adult patients in long-term care settings, this PICOT question is asked: In adults aged 65 and over in long-term care settings with a diagnosis of Type II Diabetes, does implementing weekly skin assessments performed by a pressure injury prevention (PIP) team to standard PIP strategies, compared to just standard PIP strategies, prevent or reduce pressure injury development over 6 months? Pressure injuries are a preventable complication that can lead to detrimental outcomes, including patients being “2.8 times more likely to die during their hospital stay, [and] 1.69 times more likely to die within 30 days after discharge,” (Tschannen & Anderson, 2019, p. 1399). Along with standard interventions, an interdisciplinary approach has become increasingly utilized. The search for research articles was conducted within PubMed and CINAHL using the terms pressure injury, pressure injury prevention, diabetes, and wound care team. Search inclusion criteria required articles to have been published between 2017 and 2022, address all three keyword phrases, and included peer-reviewed, full-text articles published within the past five years. Exclusion criteria involved evidence-based articles that were irrelevant to pressure injuries in the older adult population. Eleven key articles were reviewed. Research suggests continued skin assessment and prevention strategies in combination with standard PIP decrease the mortality, morbidity, and cost associated with pressure injuries

The Creation of a Critical Care Admission Pressure Injury Prevention Cart to Reduce Hospital-Acquired Pressure Injuries

The goal of this process improvement initiative is to reduce hospital-acquired pressure injuries related to Covid-19 with Critical Care patients. Critically ill and ventilated patients require prone position therapy and prolonged ventilator times place the patient at risk for hospital acquired conditions and pressure injuries. The Critical Care team created a Critical Care Admission Pressure Injury Prevention Cart that contains preventative dressings for all pressure areas at risk. The Critical Care Admission Pressure Injury Prevention Cart has significantly reduced the pressure injury rate. With the emergence of the pandemic and additional surges, pressure injuries continued to be on the rise due to prone position therapy. The Critical Care team worked with the system and developed prone position protocols, which included preventative dressings for all areas at risk. Prior to the implementation of the admission cart, Critical Care ended fiscal year 2022, quarter one, with fifty-three hospital acquired pressure injuries. Last December and early January 2022 there was another surge of Covid-19. The Critical Care team implemented the admission cart in January 2022. From January 2022 through September 2022, there has been an 98% reduction. The cart has been successful for Critical Care, and Baptist Hospital implemented the cart in all high acuity areas. This cart was a multidisciplinary practice, which consists of nursing, the wound and skin team, respiratory care, and leadership working together towards the goal of patient safety and pressure injury prevention

DNP FINAL REPORT: PRESSURE INJURY PREVENTION PATIENT INITIATIVE (PIPPI)

Background: Pressure injuries have been known to affect approximately 2.5 million patients each year, with roughly 60,000 patients dying as a direct result of a pressure injury. Associate healthcare costs are between $9.1-$11.6 billion per year in the United States. The cost of individual patient care was estimated between $20,900 and$151,700 per pressure injury. During the last three years, pressure injury prevalence has risen within the local long-term care organization. Pressure injury prevention interventions have been developed to improve healthcare outcomes, cut costs, and increase revenue for long-term care organizations. Purpose: Deliver evidence-based educational intervention that incorporates strategies for consistent pressure injury prevention to improve the desired outcomes of improving quality of care and decreasing pressure injuries in long-term care facilities. Methods: An educational program focused on consistent use of pressure injury risk assessments methods, effective interdisciplinary teamwork strategies, increasing communication through team huddles, and accurate documentation of pressure injury prevention strategies was implemented over twenty weeks with long-term care staff. Results: Staff knowledge of the Pressure Injury Prevention Patient Initiative increased after initial education. Implementation of pressure injury prevention strategies also increased, and pressure injury rates and costs decreased over the period of the project

Hospital Acquired Pressure Injury Prevention: A Quality Improvement Project

Abstract Hospital Acquired Pressure Injuries (HAPI) can be costly for the hospitals and devastating for the patients. Most pressure injuries are considered preventable, but despite that a lot of Americans die from pressure injury related complications each year. Hospitals spend billions of dollars on pressure injuries which can be used for other treatments. A quality improvement project was created to address these concerns and improve patient care. There were 5 cases of HAPIs on the telemetry/stroke unit prior to the start of this project. Interventions were created to improve the outcome. After careful review of the related literature, HAPI prevention bundle was implemented on the telemetry/stroke unit. The bundle included: skin assessment every shift and a double RN skin check for every patient upon admission and transfer to and from the unit; wound care consult; skin picture upon admission and uploaded in patients’ hospital record; repositioning every two hours and the use of waffle cushion for all patients at risk for skin injuries. The staff were educated on the HAPI bundle and audits were performed to check effectiveness. The project was carried out over 6 months. The results supported a decrease in the number of HAPIs by more than 50% during the implementation of this project. Furthermore, there was only 1 case of HAPI on the telemetry/stroke unit after implementing the project. The data identified opportunities for improvement and the project showed the impact of the HAPI prevention bundle on preventing HAPIs on the telemetry/stroke unit

Hospital Acquired Pressure Injury Prevention on an Inpatient Unit

Abstract The aim of the project is to improve the process and delivery of care with established and accepted standards by implementing evidence-based change. The plan is to create a HAPI prevention plan with the main expected outcome to reduce the HAPI occurrences on the unit to zero by July 30, 2018. This will be accomplished by increasing awareness among nursing staff members through education and diligent monitoring of prevention practices and treatments. The education portion of the plan will include reviewing basic pressure injury education and HAPI prevention and management in the form of visual aids provided by the WOCN and a standard operating procedure, also known as a standard work, that will be used as a guide to HAPI prevention on the unit. A self-evaluation tool will also be used to allow nursing staff to rate their understanding prior to and after in-services of the information are provided. The monitoring portion of the plan includes the creation of monitoring tools to properly track compliance of the interventions, such as a Turning Wheel to monitor repositioning and chart reviews to monitor documentation and use of skin care prevention products. The expected objectives include (1) increased awareness of the importance of HAPI prevention, (2) a clear understanding of HAPI prevention methods, and (3) increased confidence in HAPI education and management. The organization serves 9 million enrolled Veterans and their families every year. While mental health is a strong area of focus where suicide, homelessness, and trauma exceed the national rate of the general population, this patient population that consists of primarily men ages 60+ also suffer from multiple co-morbidities, such as congestive heart failure, diabetes, pulmonary issues, and cancer. Therefore, this population is at risk for developing health issues that can have a significant impact on patients’ lives and hinder the ability of the healthcare clinician to provide high quality care (JCAHO, 2016). Positive outcomes include an 80% completion rate of the turning wheels and documentation as well. There has been a noticeable increase in the use of skincare prevention products. Also, the HAPI occurrence rate has been at zero since the implementation of the project, which is due to increased staff awareness and support and collaboration between the WOCN, unit skin champions, and management. Concurrently, it has been reported by multiple staff members that team morale is increased as goals are being achieved due to the strong teamwork that this project has created for staff to prevent HAPI occurrences on the unit. There was an 80% completion rate of the turning wheels and documentation as well. References Joint Commission (2016). Preventing pressure injuries. Retrieved from https://www.jointcommission.org/assets/1/23/Quick_Safety_Issue_25_July_20161.PDF US Department of Veterans Affairs (2018). Veteran Population. Retrieved from https://www.va.gov/vetdata/veteran_population.as

Enhancing a Pressure Injury Prevention Bundle in a Skilled Nursing Facility

Problem: The purpose of the project was to address the increase in pressure injuries in a skilled nursing facility, which had risen from 6% to 10% despite the implementation of a prevention bundle. The project aimed to evaluate and enhance the effectiveness of existing interventions. Aim of the Project: The aim was to add evidence-based interventions to the existing pressure injury prevention bundle. The desired outcome was to decrease the number of acquired pressure injuries. Review of the Evidence: Research indicated that pressure injury prevention bundles were more successful when incorporating offloading interventions. These offloading measures, including frequent turning and repositioning of patients, utilizing air mattresses for individuals with a Braden score of 14 or below, and implementing a reminder strategy, have proven to be beneficial in reducing pressure injuries. Project Design: The quality improvement framework guided this practice change project, with the Plan-Do-Study-Act cycle facilitating the testing of changes. Four cycles were conducted to identify and mitigate any barriers. The OhioHealth Change Management Model played a crucial role in communication and addressing potential obstacles. Intervention: Modifications to the pressure injury prevention bundle involved changing the Braden Scale score cut-off to 14 for air mattress issuance and adding frequent turn and repositioning to nursing duties. This was enabled by making it a standing order and inserting reminders in the electronic medical record. Nursing leaders monitored implementation in weekly meetings. Significant Findings/Outcome: The incidence rate, which represents the number of patients developing new pressure injuries after admission over a specific time, was 6.2% prior to implementation. After implementation, this rate significantly decreased to 1.74%, a 72% reduction from the baseline. This demonstrates that reviewing and modifying the pressure injury prevention bundle to incorporate evidence-based practices effectively reduced the occurrence of acquired pressure injuries. Implications for Nursing: Implementing evidence-based interventions for preventing acquired pressure injuries is in alignment with the objectives of the Institute for Healthcare Improvement Triple Aim. This approach not only reduces the incidence of pressure injuries, enhancing patient health and satisfaction, but also curtails care costs. Moreover, it adheres to the Six Aims for Healthcare Improvement by incorporating effective and safe offloading measures to mitigate the occurrence of pressure injuries

INTroducing A Care bundle To prevent pressure injury (INTACT) in at-risk patients: A protocol for a cluster randomised trial

Background Pressure injuries are a significant clinical and economic issue, affecting both patients and the health care system. Many pressure injuries in hospitals are facility acquired, and are largely preventable. Despite growing evidence and directives for pressure injury prevention, implementation of preventative strategies is suboptimal, and pressure injuries remain a serious problem in hospitals. Objectives This study will test the effectiveness and cost-effectiveness of a patient-centred pressure injury prevention care bundle on the development of hospital acquired pressure injury in at-risk patients. Design This is a multi-site, parallel group cluster randomised trial. The hospital is the unit of randomisation. Methods Adult medical and surgical patients admitted to the study wards of eight hospitals who are (a) deemed to be at risk of pressure injury (i.e. have reduced mobility), (b) expected to stay in hospital for ≥48 h, (c) admitted to hospital in the past 36 h; and (d) able to provide informed consent will be eligible to participate. Consenting patients will receive either the pressure injury prevention care bundle or standard care. The care bundle contains three main messages: (1) keep moving; (2) look after your skin; and (3) eat a healthy diet. Nurses will receive education about the intervention. Patients will exit the study upon development of a pressure injury, hospital discharge or 28 days, whichever comes first; transfer to another hospital or transfer to critical care and mechanically ventilated. The primary outcome is incidence of hospital acquired pressure injury. Secondary outcomes are pressure injury stage, patient participation in care and health care costs. A health economic sub-study and a process evaluation will be undertaken alongside the trial. Data will be analysed at the cluster (hospital) and patient level. Estimates of hospital acquired pressure injury incidence in each group, group differences and 95% confidence interval and p values will be reported. Discussion To our knowledge, this is the first trial of an intervention to incorporate a number of pressure injury prevention strategies into a care bundle focusing on patient participation and nurse–patient partnership. The results of this study will provide important information on the effectiveness and cost-effectiveness of this intervention in preventing pressure injuries in at-risk patients. If the results confirm the utility of the developed care bundle, it could have a significant impact on clinical practice worldwide