Reduction of Hospital-acquired Pressure Injuries Using a Multidisciplinary Team Approach: A Descriptive Study

Introduction. Hospital-acquired pressure injuries (HAPIs) increase patient mortality and length of stay (LOS). Twenty-eight full-thickness HAPIs occurred in fiscal year 2015 (FY15), and that trend continued into FY16 with 14 injuries on multiple units throughout a tertiary acute care center with 400 beds. To address this trend, a multidisciplinary Pressure Injury Prevention (PIP) team was created. Objective. This report is a description of ongoing, hospital-wide efforts to understand the common factors of HAPI causality and to establish corrective action plans institutionally to prevent similar events in the future. Methods. The team goals were to document the occurrence of HAPIs across all hospital units, reduce preventable full-thickness PIs to zero, and recommend institution-wide changes as those opportunities were recognized. Results. Since the committee’s inception in July 2015, an 89% reduction of full-thickness HAPIs, with only 2 full-thickness HAPIs in FY17 and 3 in FY18, has been seen. This effort has been hospital wide with involvement of all inpatient units and perioperative areas (including the operating rooms). Opportunities remain for improvement around the prevention of deep tissue and partial-thickness HAPIs. Conclusions. The data demonstrate that the formation of a multidisciplinary PIP team of engaged clinicians can reduce the number of preventable full-thickness HAPIs.

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Pressure injuries (PIs) are costly to patients, health care institutions, and health care consumers. These are considered never events – medical errors that should never occur – and preventable harm to patients by the Centers for Medicare & Medicaid Services (CMS). A 2016 analysis of Medicare patients estimated that the cost of severe PIs to beneficiaries was $3069 per case.¹ Data further demonstrate higher readmission rates and increased in-hospital mortality for patients who develop hospital-acquired PIs (HAPIs).² Review of the literature has shown an increased length of stay from 3 to 7 days for patients with any type of HAPI.³ The true cost and magnitude of HAPI care and prevention is difficult to quantify. Codes for the International Classification of Diseases and clinical documentation are often inaccurate, as HAPIs are often not a primary hospital problem.⁴ Significant variability exists in reported incidence and prevalence data due to variability in data collection and injury recognition.⁵ Management of these injuries varies greatly by stage of injury and involves indirect costs, which are challenging to estimate. This usually includes an increased level of nursing care and follow-up management after discharge. Full-thickness HAPIs (stage 3, stage 4, and unstageable) may require multiple readmissions and place the patient at risk for infection and possible surgical intervention.

Several authors suggest a decrease in prevalence and incidence of HAPIs through the development of a multidisciplinary team.^6-9 With an average rate of 2 full-thickness HAPIs per month (28 total in fiscal year 2015 [FY15]) and with 186 HAPIs (all stages) in FY15, the authors worked with a multidisciplinary team to systematically address the HAPI rate.

This descriptive study was conducted to review the impact of a multidisciplinary pressure injury prevention (PIP) team designed to provide a diverse perspective of patient care and to operate as a vehicle for institution-wide implementation of best practice and data dissemination for HAPI reduction.

Setting
The institution is a 400-bed level 1 academic medical center (Dartmouth Hitchcock Medical Center, Lebanon, NH) serving New Hampshire and the surrounding rural areas of western Maine and southern Vermont. Previous work around PIP had focused on the creation of a best practice bundle, support surfaces, improving documentation, standardizing products, and building a team of certified wound care nurses. Additional PIP efforts implemented for this current project were inclusion of clinicians from various backgrounds; development of policy and procedures to standardize prevention practices and guidelines for refusal of care; development of equipment tracking for the operating rooms, including a replacement system; and ongoing review of skin care and prevention products.

Because this was a descriptive study that did not include patient–specific data, International Review Board approval was not required.

PIP team structure
A certified wound care nurse and a plastic surgeon, who direct the institution’s wound clinic, were co-leaders. Team members were from multiple practice areas and included physical and occupational therapy, nursing, clinical nurse specialists, quality and safety, process improvement, informatics, analytics, and supply chain/product analysis. The use of bedside clinicians was chosen for the PIP team to mirror work done in the Transforming Care at the Bedside approach to practice change.¹⁰ The theory was that clinicians providing care to the patients would be in the best position to inform the committee on gaps noted in practice.

Incidence tracking
Prior to the establishment of the PIP team, incidence data had never been collected in a systematic and formal way. The team reviewed all historic full-thickness HAPIs and developed a HAPI monitoring protocol based on the internal event reporting system. The actual count of new injuries per month was used as a substitute for true incidence, which is a rate. This allows the PIP team to look at trends among stages of HAPIs and patient care areas. The event reporting system was chosen because it is known that injuries are not always captured accurately in coding or in nursing documentation. The standard of care at the authors' institution requires event entry in the reporting system whenever a HAPI is discovered. Although this may still miss some injuries, the investigators believe it is the most accurate method of capturing data at this point. Data are collected continuously, and a report of the data is reviewed monthly. The data are available for the PIP team to review for trends in terms of injury type, body location, hospital units, or devices. The unit-based nursing safety champions also have access to the data to disseminate among their colleagues. This creates an awareness of what is happening on each unit and within the hospital. Prevalence data have been collected for years by the unit-based nursing safety champions, but a report of results has not been available to them. The data are now available through a shared internal website for all clinicians to access.

Safety champions
The safety champions are a group of nurses from each inpatient unit, perioperative services, and the emergency department. Nurses who have an interest in this role petition their manager to join the group. Once the manager approves participation, the champion completes online educational training through the National Database of Nursing Quality Indicators. The group of safety champions meets monthly, with sessions including didactic portions, skills sessions, or case studies. The expectation is that the champions will then take this information back to their unit and educate staff through bulletin boards, huddles, or during a staff meeting. Aside from education dissemination, the champions use the practice evaluation tools to audit bundle compliance. The champions have an electronic tool that focuses on Braden Scale scoring, moisture, sensory, assessment, repositioning, and devices. These tools provide a coaching format; if variants are found from best practice, then the champion has a framework to use to help with communication.

Event review process
The multidisciplinary PIP team reviewed all outcomes of full-thickness HAPIs and the subsequent corrective action plan to determine if each was a unique situation to one unit or if it was the result of a system or process gap that should be communicated hospital wide. Data collected as part of this review process were not previously available to the direct care staff.

The PIP team provides a forum for all disciplines to discuss their viewpoints and barriers. This open communication allows for problem solving.

Since implementation of the PIP committee in July 2015, the prevalence of all HAPIs has decreased with the rate ranging from about 4% in the fourth quarter of 2015 to approximately 0.2% in the first quarter of 2018 (Figure 1). The PIP team has focused on a modified form of incidence data, looking specifically at counts of new HAPIs at a monthly team meeting. The actual number of full-thickness HAPIs has decreased. Prior to the implementation of the PIP team, the institution measured an average of 1 to 2 full-thickness HAPIs per month. The institution had 28 full-thickness injuries in FY15, 18 in FY16, 2 in FY17, and 3 in FY18 (Figure 2; ^a The reported numbers do not always match the incidence data, which only reflect the initial stage of injury. For example, a DTI may evolve to unstageable at a later time point). The change in the count of stages 1, 2, and deep tissue injuries (DTIs) has been smaller (Figure 2). In FY15, the institution reported 88 DTIs, 88 in FY16, 62 in FY17, and 51 through May 2018. In FY15, there were 51 stage 2 injuries, 33 in FY16, 28 in FY17, and 16 through May 2018. There were 24 stage 1 in FY15, 23 in FY16, 18 in FY17, and 12 through May 2018. The proportion of DTIs decreased by 32%, stage 2 injuries decreased by 31%, and stage 1 injuries by 50% through May 2018.

Review of adverse events revealed that 3 of 18 cases from FY15-FY16 were attributed to the perioperative department. Chart reviews and the delayed nature of presentation of these types of injuries made ascertaining where the injury occurred difficult. A PIP program and culture shift in perioperative services was implemented around prevention, skin assessments, support surfaces, and handoffs. Work is beginning on standardizing documentation across the institution. The perioperative areas had 10 months with no HAPIs in 2017 through the first quarter of 2018.

Initially, the PIP team identified the following hospital-wide gaps in monitoring and procedures related to HAPIs: the root cause analysis/corrective action plan process was unit specific, incidence data did not exist, data in general were not readily available to the direct care clinicians, engagement was lacking from perioperative services, and clear/accessible communication of discipline-specific plans of care were not in use. The establishment of the systematic incidence tracking system, the repurposing and PIP-specific education of nurse safety champions, and the regular review of events all contributed significantly to the success of our efforts. Multiple events showed links to communication gaps, either gaps in provider to nursing communication around use of devices, nutrition services to provider, or therapy to nursing. Because of this, patients were not being ambulated, having devices left in place too long, or not receiving the appropriate nutrition.

The data collected over the past 3 years have allowed the PIP team to discuss targeted interventions for possible specific causes of the injuries. There has been an increase in sacral HAPIs since fourth quarter 2017, and the team is reviewing institutional bed maintenance procedures (Figure 3). In the first quarter of 2017, a rise in device-related injuries was noted. Devices were involved in almost half of the HAPIs during that time. The committee noted that the institution was not yet tracking the incidence of device-related injuries, and in May 2017, the institution began systematic monitoring. Increased monitoring had a profound effect, and the total percentage of device-related HAPIs decreased almost immediately (Figure 4). Most of these injuries involved the use of a respiratory device, which prompted the PIP team to engage respiratory therapy to join the effort (Figure 5).

The establishment of a multidisciplinary PIP team to systematically identify and monitor HAPIs as well as hospital-wide engagement to apply quality care was successful in reducing HAPIs over a 3-year time period. Pressure injuries cause a quantifiable cost to health care institutions and payers. Since 2008, CMS has refused to pay for costs incurred because of HAPIs; thus, institutions are incentivized to reduce their occurrence. The cost to patients is not as easily captured. Patients suffer from pain and the development of often disfiguring scars. The devastating nature of severe HAPIs cannot be adequately explained and should not be underestimated. Although the number of events may be lower than other hospital-acquired conditions, the per patient impact is very high. Pressure injuries also are hard to predict. A standard risk assessment tool is utilized on each patient; however, it lacks specificity in many patient populations. Due to the gaps in knowledge and assessment tools, a multidisciplinary PIP team to provide overarching insight and direction to institutional policy is paramount to the success of a PIP program.

In conducting this program, the PIP team was faced with several challenges and decisions (what to measure, the role of safety champions, how to educate and disseminate information). Most data concerning HAPIs are in the form of prevalence.⁵ This measurement is limited as it is collected at one point in time, thus trends or patterns cannot be inferred from this type of data.⁵ Incidence, the occurrence of new events, is a better measurement to analyze trends and review the effects of interventions and therefore was chosen as the measured outcome of interest.

Through this 3-year experience, the PIP team acknowledges that the role of the safety champions has high potential, though it has experienced many barriers to success such as lack of structured time to perform audits or education. Champions often must perform direct patient care in addition to their champion work. The position relies entirely upon the efforts and dedication of the individual who volunteers their time to this role. Institutional investment in support for such efforts would yield great returns.

As a direct result of the effectiveness demonstrated by the implemented PIP efforts, an institution-wide splint order was developed for providers to use around devices, rehabilitation services are currently piloting a report for nursing to find their plan of care for mobility, nutrition services developed standardized notes and closed loop communication, and a refusal-of-care algorithm (a protocol for clinical staff when a patient refuses to follow prevention recommendations) is now an institutional policy. Opportunities remain for a more robust system of communication and education.

The PIP team believes the decrease in full-thickness injuries is related to multiple factors, including earlier recognition of injuries before they evolve to full thickness and a greater awareness/shared responsibility of preventing injury before it occurs. Corrective action plans that were in place when the PIP team was established had been developed historically because of a specific event on a specific unit. However, the root cause usually was not unique to a single area of practice, and the lack of a coordinated hospital-wide system of communication resulted in lost opportunities to the institution. A direct measure of success of the present PIP program is reflected in the fact that all caregivers, from providers to nursing assistants and ancillary staff, are aware of the potential for HAPIs. Additional knowledge gained by the certified wound care nurses has included an increased understanding around the staging system and level of injury allowing for more consistent and accurate staging. Senior leadership engagement and sponsorship has helped move many initiatives forward. The next area of focus is on building a sustainable system of clinician education.

Future directions for the PIP team revolve around conducting apparent cause analysis for DTIs, review of common cause analysis at the committee level for trends among injuries, engagement in the emergency department, and building a robust data dissemination process. Education needs to be designed and delivered in a systematic and structured method. Statistical analysis for other potential predictors of injury revealed novel patient-specific factors that contributed to risk of HAPI that may allow for enhanced intervention strategies and targeted education to further protect patients.¹¹ The team continues PIP work and will next focus on understanding and decreasing the incidence of DTIs.

This work has several limitations. The use of the event reporting system as a measure of incidence will likely result in missed injuries. The system captures injuries at the stage of initial identification; if advancement in stage occurs, it is not reflected in the incidence data. Infrastructure support is currently lacking due to staffing constraints, which impedes the ability of the champion to focus on PIP work. In addition, education is not distributed systematically and is currently person dependent.

The implementation of a multidisciplinary PIP team has improved patient outcomes by decreasing the number of preventable full-thickness HAPIs. Institutional awareness has increased and caused a culture shift around the importance of skin assessments.

Note: The authors thank George Galev, Gabrielle Carrier, and Alison Mumford for compilation and organization of data.

Authors: Megan W. Miller, MSN, APRN, AGACNP-BC, CWON¹; Rebecca T. Emeny, PhD, MPH²; and Gary L. Freed, MD³

Affiliations: ¹Department of Wound Care Services, Dartmouth Hitchcock Medical Center, Lebanon, NH; ²The Dartmouth Institute for Health Policy & Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, NH; and ³Department of Plastic Surgery, Dartmouth Hitchcock Medical Center

Correspondence: Megan W. Miller, MSN, APRN, AGACNP-BC, CWON; mwmiller719@gmail.com

Disclosure: RTE was supported by award number UL1TR001086 from the National Center for Advancing Translational Sciences of the National Institutes of Health.