Post-Event Huddle to Decrease Hospital-Acquired Pressure Injuries

Purpose: The goal was to reduce hospital-acquired pressure injury rates by engaging bedside staff in identifying barriers to care and implementing changes in pressure injury prevention techniques according to the findings through the development of a PIRATE (Pressure Injury Review AcT and Educate) huddle. Hospital-acquired pressure injuries (HAPIs) are considered a nursing sensitive quality indicator. HAPIs are a serious cause of morbidity and mortality, increase length of stay, decrease quality of life, and increase burdens on the health-care system.

Objectives: To reduce HAPIs, the PIRATE huddle was developed. In the event of an HAPI, all interdisciplinary team members involved in the care of the patient are required to attend a scheduled PIRATE huddle. The PIRATE huddle proceeds through a formal, consistent process of data verification and feedback, open discussion to consider the care provided, and development of action items. Team members are identified to drive the initiative of change through a PDSA (Plan, Do, Study, Act) cycle.

Outcomes: Multiple action items have been identified and implemented, including: staff education on medical-device-related pressure injury prevention, WOC nurse rounding on patients with Braden scale < 14, bedside “4 eyes” assessment during nursing rounds, and staff nurse driven implementation of PI prevention interventions based on the Braden scale score.

A paired-samples t-test was conducted to determine the significance in implementing PIRATE meetings to reduce HAPIs. There was a significant decrease in HAPIs between 2016, when PIRATE meetings were not implemented (mean (M)=0.0033, standard deviation (SD)=0.002), and 2017, when PIRATE meetings were being implemented ((M=0.0015, SD=0.002); t(1)=0.004 p<0.05).