An Interdisciplinary Team Approach to Decrease Sacral Hospital-acquired Pressure Injuries: A Retrospective Cohort Study

A hospital-acquired pressure injury (HAPI) is a “localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear.”¹ One of the most common iatrogenic events in health care, HAPIs are not only painful and potentially fatal, but also are costly in both monetary terms and in patient perception of quality of care. A descriptive study with matched odds ratio comparisons found that pressure injuries were reported as a cause of death in 114,380 individuals over an 11-year period, with 18.7% having pressure injuries listed as the underlying cause.²  In addition, 1 prospective cohort study found that the hospital costs ($37,288 vs $13,924; P = .0001) as well as mean length of stay (30.4 days vs 12.8 days; P = .0001) for patients who developed pressure ulcers during hospital admission were both significantly increased.³ In regard to individuals who live with pressure ulcers, an international systemic review including adults with pressure injuries in acute, community, and long-term care settings concluded that many aspects of patients’ lives, including general health, psychological health, health care professional–client relationships, and financial impact, were significantly affected by the diagnosis.⁴

In the United States, patients in whom HAPIs develop have longer hospital stays, higher readmission rates, and substantial financial burdens. Any individual experiencing strong, sustained pressure over the skin is at risk of the development of underlying ischemia and subsequent pressure injury formation, but those who are recovering from surgery or are paralyzed are at a higher risk. A cohort study of 3225 surgical patients reported a statistically significant association between pressure ulcer development and both total surgery time (P < .001) and the number of surgeries during admission (P < .001).⁵ In addition, a secondary data analysis study of patients with quadriplegia, paraplegia, and hemiplegia in long-term care facilities found higher pressure ulcer rates in these patients compared to residents without paralysis (33.9% for patients with quadriplegia, 47.4% for patients with paraplegia, and 9.6% for patients with hemiplegia).⁶ Further risk factors for the development of pressure ulcers were elucidated in a retrospective medical record review in an academic teaching hospital, some of which include advanced age, female sex, anemia, and hypertension.⁷

Despite efforts to reduce the incidence of HAPIs, including provider-patient shared decision-making and the implementation of prevention programs based on staff education, there has been an interval reduction with eventual potential for the elimination of HAPIs.^8,9 A systematic review in which 86% of studies reviewed elucidated the effectiveness of multi-intervention programs in decreasing the prevalence of pressure injuries compared to a single invention approach.¹⁰ For this reason, it is hypothesized that the number of pressure injuries may be significantly decreased through the establishment of an interdisciplinary team to assist in the identification of such injuries, in addition to educating staff and implementing evidence-based practices in the management of underlying disease.

Although pressure injuries can occur throughout the body, including mucous membranes and skin overlying soft tissue, the most common location is at bony prominences such as the sacrum or heels.^11,12

In 2012, the authors implemented a 3-pronged intervention involving 1) creation of an interdisciplinary team, 2) enhanced education for nursing staff, and 3) enhanced quality data reporting with the goal of decreasing the incidence of sacral HAPIs in hospitalized patients. The purpose of this study was to assess the yearly incidence of sacral HAPIs before and after the intervention period. The hypothesis was that the yearly incidence of HAPIs would decrease following the intervention.

Study design. This study was a retrospective pre- and post-analysis of a 3-pronged intervention implemented in 2012. All patients who were admitted to North Shore University Hospital (NSUH), Manhasset, NY, during the pre- and post-intervention periods were included in the study population. The pre-intervention period, which included data from 2010 and 2011, was used to establish baseline incidence of sacral HAPIs. The post-intervention period included data from 2013 to 2017. Data from 2012 were considered to be the “washout period.” A medical record review of the hospital electronic medical record system (Sunrise Clinical Manager; Allscripts, Chicago, IL) was completed and included all persons with diagnosed sacral HAPI occurring during hospitalization. These data were then cross-referenced with data gathered by the in-house wound care team from their consultation lists. The review included demographic information (age, sex, race, and ethnicity), body mass index, staging of sacral HAPIs, Charlson comorbidity score, length of hospital stay, and readmission and/or mortality, and was completed for all patients who had a sacral HAPI. All data collected were entered into a Research Electronic Data Capture (REDCap) database (Vanderbilt University, Nashville, TN). The study was approved by the health system’s institutional review board and deemed exempt.

Study setting and population. In 2012, NSUH, a 738-bed quaternary care academic hospital, adopted the National Quality Forum and National Database of Nursing Quality Indicators standards for the management and prevention of pressure injuries, in addition to enforcing their metrics and definitions.¹³ All patients admitted to the hospital and all patients in whom a sacral HAPI developed were included in the calculation of annual incidence of sacral HAPIs during the study period. Due to the large number of patients in the pre-intervention period who had a sacral HAPI, a random sample of patients from the pre-intervention period was selected so that the demographic and clinical characteristics of patients who had a sacral HAPI in the pre-intervention period could be compared with the 49 patients who had HAPIs in the post-intervention period. To maximize power, the authors selected a 5:1 ratio¹⁴ of pre-intervention patients to post-intervention patients. Therefore, 245 pre-intervention patients were selected for analysis. Each patient in the pre-intervention group was assigned a number in accordance with the month and year of diagnosis, and 122 to 123 patients were arbitrarily chosen from a list containing only subject medical record numbers and dates of admission per pre-intervention year.

Intervention. A 3-pronged intervention program involving 1) creation of an interdisciplinary wound care team, 2) enhanced education for nursing staff, and 3) enhanced quality data reporting was implemented in 2012 with the goal of reducing the incidence of HAPIs and properly treating wounds and identifying etiology.

During the study period, NSUH employed approximately 1900 registered nurses with various levels of knowledge and experience regarding pressure injuries. The authors’ first step was to gain an understanding of how the nursing staff assessed and documented pressure injuries. During spot checks with nursing staff, it became apparent that the nursing staff appeared to count all alterations in skin integrity as pressure injuries and that, regardless of etiology, wounds on the sacrum were being documented as pressure injuries. An internal decision was made to have the wound, ostomy, and continence (WOC) nurses conduct a 2-hour educational class, with both evening and day shifts, on differentiating pressure injuries from various dermatitis, fungal, and moisture-related wounds.

To help with proper assessment and documentation, the authors identified that assisting the nurses at a patient’s bedside, as well as providing small group educational sessions, increased the number of properly documented wound pathologies.

Interdisciplinary wound care team. Board-certified nursing wound care specialists, vascular and general surgeons, podiatrists, physical therapists, certified WOC nurses, nurse practitioners, and physician assistants were part of the multidisciplinary team. Within 24 hours of a nurse reporting a suspected sacral HAPI, the patient was screened. A team of 6 clinicians from different specialties (wound care, vascular, wound care nursing, physical therapy, podiatry, and advanced care) reviewed consultations daily and saw at-risk patients during rounds (although not all at the same time). At-risk patients were those who were exhibiting an alteration in skin integrity and/or at high risk of skin breakdown.

The Braden scale was used to evaluate pressure injury risk, and patients with a score ≤ 18 were considered at risk of pressure injury development, as per the hospital policy. If a sacral HAPI was identified, a full assessment of the patient was performed by the wound care team at the time of the consultation, including a physical examination with an emphasis on examining the peripheral vascular system as well as wound staging. After the consultation was completed, nursing specialists educated the staff to help them understand the pathophysiology of the wound to guide best practices as well as appropriate interventions and treatments. In addition, a registered dietician either joined the team while assessing the patient or was available to recommend a dietary plan to support the nutritional needs of the patient; this input was incorporated into the plan of care.

Enhanced nursing education. Due to the large number of nursing staff at NSUH, the authors sought to additionally educate unit-based skin champions, volunteers who desired further education or were recommended by the management team of the nursing unit. Ideally, the goal was to have 2 champions per unit per day shift and at least 1 overnight. Each nursing staff member on orientation when first employed by the hospital completed a 3-part module on pressure injury prevention, assessment, and treatment. The nursing staff was mandated to complete yearly modules available from the National Database of Nursing Quality Indicators. The modules focused on pressure injury description, assessment, and early intervention. The skin champions were focused on supporting and aiding staff members with their knowledge of care. These champion nurses, who were available on all shifts, attended a 9-hour class on proper staging of wounds and differential diagnosis review to gain additional knowledge and, therefore, served as great assets and resources for wound assessment and documentation. These champions were able to support staff by addressing questions and issues that arose, especially during those hours and days when no WOC nurse was readily available.

The WOC nurses held frequent, small (5 to 7 nurses) “lunch and learn” seminars on pressure injuries and incontinence-associated dermatitis to review how to differentiate between the two and establish parameters for documentation. Differentiating between a stage 2 pressure injury and incontinence-associated dermatitis presented some confusion to younger nurses, who were not comfortable with their own experience and expertise in the beginning of their careers. Implementation took approximately 4 months (May to August 2012), and by the end of that time frame approximately 60% of the 1900 nurses at NSUH had attended the classes; the majority of nurses who did not receive this additional education were those in administrative and leadership roles.

Improved quality data reporting. With a new chief nursing officer, there was an emphasis on accurate quality data reporting; additionally, each nurse manager was required to be familiar with the data of their unit for all nursing-sensitive quality indicators. These same indicators were discussed at bimonthly nursing and patient care meetings to identify and discuss opportunities for improvement.

Outcome measure. The primary outcome measure of this study was incidence of sacral HAPIs reported on an annual basis. Incidence was expressed as a proportion and calculated by dividing the number of sacral HAPI cases by the total number of admissions for that year multiplied by 100.¹⁵ All patients who had a sacral HAPI during the study time periods were included in the calculation of incidence.

Data analysis. The incidence of sacral HAPIs for the years 2010, 2011, 2013, 2014, 2015, 2016, and 2017 were reported. Descriptive statistics were used to describe characteristics of all patients who developed a sacral HAPI during the post-intervention period and the random sample of patients who developed a sacral HAPI during the pre-intervention period. Medians and interquartile ranges were reported for continuous variables, frequencies, and proportions for categorical variables. Differences in characteristics among patients who had a sacral HAPI in the 2 periods were assessed using Wilcoxon rank sum tests for continuous variables and chi-square or Fisher’s exact tests for categorical variables. A 2-sample t-test was performed to assess overall difference in mean incidence of sacral HAPIs between the pre- and post-intervention periods. Race was dichotomized into White and Non-White due to small cell sizes. Length of stay (in days) was calculated by subtracting the discharge date from the admission date for each patient. All other variables were analyzed the way they were documented in the medical record. Statistical significance was P < .05. Data were analyzed using SAS 9.4 (SAS Institute; Cary, NC).

As shown in Figure 1, during the pre-intervention period, there were 54,982 and 54,301 admissions in the years 2010 and 2011, respectively. During the post-intervention period, there were 51,524; 51,191; 52,950; 54,414; and 52,751 admissions in the years 2013, 2014, 2015, 2016, and 2017, respectively. In the pre-intervention period, incidence of sacral HAPIs was 0.353% (n = 194), and 0.267% (n = 145) in the years 2010 and 2011, respectively. In the post-intervention period, incidence of HAPIs was 0.033% (n = 13), 0.043% (n = 22), 0.008% (n = 4), 0.007% (n = 4), and 0.004% (n = 2) in the years 2013, 2014, 2015, 2016, and 2017, respectively. The mean incidence of sacral area HAPIs was 0.310% (339 HAPIs of 109,283 admissions) in the pre-intervention period and 0.019% (48 HAPIs of 262,830 admissions) in the post-intervention period; the mean incidence proportions were statistically significantly different between the 2 periods (2-sample unpaired t-statistic: 11.5937; P < .001).

Demographic and clinical characteristics of patients who had a sacral HAPI in the post-intervention period (n = 49) and the random sample of patients (n = 245) who had a sacral HAPI in the pre-intervention period are shown in Table 1, Part 1 and Part 2. Patients in the pre- and post-intervention periods were similar with respect to age, sex, ethnicity, total Charlson Comorbidity Index score, and readmission or mortality within 90 days after hospital discharge. However, race, hospital length of stay, and HAPI stage differed among patients in the pre-intervention and post-intervention periods. There were more White patients in the post-intervention period (n = 35; 71.43%) compared with the pre-intervention period (n = 94; 38.37%) (Chi-square, 18.1248; P < .0001).

The distribution of HAPI stage also was different between the 2 periods. In the pre-intervention cohort, 27.76% (n = 68) of HAPIs were stage I, 61.63% (n = 151) were stage II, 0.41% (n = 1) were stage III, 0.00% (n = 0) were stage IV, and 10.20% (n = 25) were unstageable; however, in the post-intervention cohort, 46.94% (n = 23) were stage I, 18.37% (n = 9) were stage II, 0.00% (n = 0) were stage III, 2.04% (n = 1) were stage IV, and 32.65% (n = 16) were unstageable (chi-square, 38.8560; P < .0001).

Hospital length of stay, defined as admission date to discharge date, for patients who developed a sacral HAPI was shorter in the post-intervention period (13 days; interquartile range [IQR], 6, 28) compared with the pre-intervention period (19 days; IQR, 12, 31) (Wilcoxon rank sum test, 5812.000; P = .0096).

There was no statistically significant change in readmission or mortality rates within 30 days of discharge in the post-intervention group compared with the pre-intervention group (40.00% vs 27.06%; P = .3530).

Implementation of the 3-pronged intervention reported in this study reduced the incidence of sacral HAPIs, and there was no statistically significant change in readmission or mortality rates within 30 days of discharge in the post-intervention group compared with the pre-intervention group. There was a statistically significant decrease in the median hospital length of stay in the post-intervention period compared with the pre-intervention period. There also was an increase in the proportion of White patients in the post-intervention period compared with the pre-intervention period. This finding may be attributed to the small sample size in the post-intervention period (n = 49) or to changes in the way the hospital’s medical record system captures racial information.

However, the distribution of HAPI staging was significantly different between the pre- and post-intervention periods. Certified WOC nurses play a vital role in enhancing the knowledge of the nursing staff and implementing protocols to ensure best practices in the treatment and prevention of sacral HAPIs. The success of classes led by WOC nurses to differentiate pressure injuries from various dermatitis, fungal, and moisture-related wounds was seen in the post-intervention period when the number of pressure injuries (notably stage 1 and stage 2) decreased. The increase in the overall proportion of stage 1 HAPIs in the post-intervention period can be attributed to heightened awareness by the staff leading to more accurate diagnoses. In addition, staff changed their method of counting any darkening of the tissue on a Non-White patient as a pressure injury. Critical thinking by the staff fostered an environment in which they were encouraged to look closely at the patient to rule out causes for skin darkening (ie, bruising related to a fall) and assess for other wound etiology prior to a wound care team consultation request for a potential HAPI.

The wound care team was vital in data collection by identifying trends in HAPI occurrence to find changes that have been successful in reducing the incidence of HAPIs. Additionally, the authors believe that wound care training and nursing protocols provided a strong foundation that was critical in the decreased incidence of HAPIs. The implementation of unit audit tools to ensure proper documentation and data reporting greatly contributed to rapid identification and subsequent treatment in patients with HAPIs.

To the authors’ knowledge, interventions to reduce the incidence of sacral HAPIs specifically have not been studied extensively. Shieh et al¹⁶ performed a similar intervention in 2 acute care facilities in California, in which patients who were at high risk of pressure injury development were identified through a pink paper reminder system. That intervention resulted in a significant reduction in the incidence of pressure injuries in 2 hospitals, although the hospitals were much smaller than that of the current authors; nevertheless, those results further demonstrated that the identification of patients who are at risk of HAPI development is crucial to decrease incidence. The present study and the study by Shieh et al¹⁶ are 2 of the few published studies reporting on successful interventions to decrease the incidence of sacral HAPIs. Although the current intervention involved more resources and personnel than the intervention by Shieh et al,¹⁶ their low-cost intervention also resulted in a significant reduction in the incidence of HAPIs.

There are several limitations to the current study. First, because this was a single-center study, it may not be generalizable to other institutions. This is notable because the interdisciplinary team was composed of staff from numerous specialties, and smaller institutions may not have the resources or staff to implement this intervention. For this reason, additional studies are needed to determine whether a smaller care team can reduce the incidence of HAPIs. Second, the current intervention consisted of 3 separate components, and it is therefore difficult to determine the role of each intervention in decreasing the incidence of sacral HAPIs. Third, there are certain differences in the data (particularly differences in race distribution) that were attributed to small sample size in the post-intervention period. Future multi-center studies should attempt to recruit a larger patient population for the post-intervention period. Fourth, the classification of DTI and unstageable HAPI were not able to be separated based on the method of data collection. Thus, the increase in the proportion of suspected DTIs could not be explained.

plementation of a 3-pronged intervention consisting of the creation of an interdisciplinary pressure injury team, enhanced education for nursing staff, and enhanced quality data reporting significantly reduced the incidence of sacral HAPIs from 0.310% in the pre-intervention period to 0.019% in the post-intervention period. Through the use of an interdisciplinary team, a holistic evaluation of the patient was achieved by implementation of greater clinical analysis by the bedside nursing staff. Knowledge bases increased in understanding the evolution of pressure injury versus other causes of skin changes. In addition, certified WOC nurse champions played a vital role in enhancing the knowledge of the nursing staff and implementing protocols to ensure best practices in the treatment and prevention of sacral HAPIs. Additional studies are needed to address the limitations of this study and confirm these findings at other institutions and in other patient populations.

SI and TP contributed equally to this work. Ms. Isaacs and Mr. Pinhasov are visiting scholars, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY. Dr. Oropallo is a director, Department of Surgery, Comprehensive Wound Care Healing and Hyperbarics, Northwell Health, Lake Success, and an associate professor, Department of Vascular Surgery, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY. Ms. Brennan is an assistant director for wound & ostomy care, Department of Nursing, North Shore University Hospital, Manhasset, NY. Dr. Rao is a research coordinator, Department of Surgery, Comprehensive Wound Care Healing and Hyperbarics, Northwell Health, Lake Success, NY. Dr. Landis is a vice chairperson, Department of Vascular Surgery, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY. Ms. Agrell-Kann is a nursing wound specialist, Department of Nursing, North Shore University Hospital, Manhasset, NY. Dr. Li is an assistant professor, Department of Emergency Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY. Address all correspondence to: Alisha Oropallo, MD, Northwell Health Comprehensive Wound Healing & Hyperbaric Center, 1999 Marcus Avenue, Suite M6, Lake Success, NY 11042; tel: (516) 233-3780; email: aoropallo@northwell.edu.