Reducing Hospital Acquired Pressure Injuries Using the Braden Sub Scale at a Large Safety-Net Hospital

Hospital-acquired pressure injuries (HAPIs) contribute to high cost of treatment, increase morbidity and hospital length of stay [1]. In fiscal year (FY) 2014/2015, executive leadership at ZSFG selected HAPI’s as one of the hospital’s priority metrics of causing no harm. We utilized the A3 process, a Lean management problem-solving tool, to implement multiple tests of change using the Plan-Do-Study-Act (PDSA) module. We retrospectively looked at the total Braden score upon admission for patients who acquired a reportable HAPI in FY2016/2017. Our analysis revealed that 31% of patients who acquired a HAPI were assessed and documented as having a no/mild risk (≤14) on the Braden Scale. Even though ≤14 is the threshold for being at risk, nurses were not consistently implementing interventions in order to prevent HAPI’s from developing, decreasing the reliability of the Total Braden Score. These findings led us to focus on a Braden Scale Subcategory PDSA. The PDSA was conducted over a 13-week period on a medical-surgical unit, where we introduced various resources including: presenting audit data, case studies, peer-to-peer nurse rounding, a wound lexicon, and an electronic health record revision to reflect a stronger emphasis on the Braden subcategories. In order to measure improvement, we defined the compliance rate as the percentage of interventions documented by nurses when any of the 6 Braden Scale subcategories were scored as ≤2. Baseline data showed that nurses documented interventions 41% of the time when the Braden Scale subcategory was scored ≤2, which increased to 64% in week 13. Two years post PDSA we continue to see sustainable reduction of reportable HAPIs in Medical-Surgical Units – with an 80% decrease from our baseline. Amid the COVID-19 pandemic, our reportable HAPIs continue to remain low with 1 reportable in Medical-Surgical to date in FY19/20, despite limitations in practice and new disease specific challenges.

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References (if applicable): Ayello, Elizabeth A., and Courtney H. Lyder. “A New Era of Pressure Ulcer Accountability in Acute Care.” Advances in Skin & Wound Care, vol. 21, no. 3, 2008, pp. 134–140., doi:10.1097/01.asw.0000305421.81220.e6.