Safety and Pressure Ulcers

It may come as no surprise to some, but pressure ulcers are among the only hospital-acquired conditions that have been on the rise in recent years. Other hospital-acquired conditions—such as adverse drug events, falls, and catheter-associated urinary tract infections—have decreased, according to a statement by the Agency for Healthcare Research and Quality in January of this year.¹ The Joint Commission also focused on this issue in an October 2018 online newsletter,² where they revealed a current collaborative project of a few hospitals that aim to find consensus on pressure ulcer reduction efforts that can be reproduced in other hospitals. The project will wrap up this summer and, once The Joint Commission analyzes their findings, we'll hear more.

Image provided by the Agency for Healthcare Research and Quality.

  Acquired pressure ulcer incident increases of this magnitude make us cringe. We're proud of our care, facilities, and the services we offer. We're also proud of all the initiatives we're putting in place to achieve no-harm environments. Even if these data don't surprise you, you've probably seen situations arise that warrant closer attention and adjustments to prevention practice. It can seem a daunting task to launch a house-wide prevention program, especially because these practices should affect every discipline and filter into every area of your facility, including the operating room, intensive care unit, nursing units, radiology, acute rehabilitation unit, and your off-campus partners, such as hospice and home health. My hospital recently took this journey, and this blog is a glimpse at our experience.

Essential Elements in Pressure Ulcer Reduction Efforts

During our recent pressure ulcer prevention project launch, we chose to utilize an Agency for Healthcare Research and Quality toolkit.³ We found it to be a sound structure on which to base practices that we could truly hardwire that also allowed for organic execution. These are the highlights of what we found especially useful, as well as a few of our own ideas:

Reflective, insightful leaders

Partnership with directors throughout the process of implementation is invaluable. Unit directors know the routines on their unit better than anyone. They know the unique needs of their patients and areas of opportunity for their staff. If the beginning of your efforts includes a gap analysis and/or process mapping, the unit directors must be involved so you can identify barriers to doing the right things. The unit directors are also vital to accountability by reporting pressure ulcer incidents (acquired or present on admission) at daily leadership huddles and quarterly safety meetings.

Wheelchairs and Pressure Injuries: What Do We Know?

Administrative support

This support allows aspirations to take shape. Administration can certainly set the tone for expectations by tying your initiative to the bigger strategic focus, offer course correction when needed, and provide the means to acquiring assets for implementing better practices.

Select, meaningful changes in practice

Because the changes you'll implement are so far reaching throughout your hospital, you'll want to identify the few key pieces that will make the most impact toward reducing incidents. For most hospitals, the initiative is based on hardwired assessment routines, standardized repositioning schedules, and individualized treatment plans. There should be no doubt about when and how often skin and risk assessments are expected to be accomplished and documented. Establishing a uniform way to reposition compromised patients provides benefit for both the patient and nurses who can be on different units yet the same approach is used. Individualized treatment plans are the ideal responses to the vast array of variables that may compromise a patient. This piece takes a bit more time because rewrites in the electronic medical record can take time, but this will allow for specific interventions to populate on worklists as the needs are identified during assessment.

Closing communication gaps

For us, another key focus was communication. We wanted to ensure that everyone touching a patient was aware of current pressure ulcers through the use of colored identification bands.

Analyzing product formulary

This analysis involves a thorough review of everything from support surfaces to wound dressing materials. This can take some time but is worth doing.

• Support surfaces include mattresses, seat cushions, and heel protectors. Seat cushions often are overlooked but are a significant area of opportunity.
• Skin care products and dressings are not all created equal, but options can be reduced to an agreeable product line that will increase compliance and reduce waste.
• Repositioning systems are a good way to minimize the use of layered sheets and disposable bed pads and reduce employee back injuries.

Routine check-ins

Creating a pressure ulcer committee that meets monthly goes a long way to keeping the initiative alive and certainly to keeping a pulse on pain points as they arise. Topics such as documentation errors and recent acquired incident review should be regular agenda items with this group.

Creating resource venues

Your teams will need resources to sustain the initiative when they have questions or when there's turnover on the floors.

• Policy/protocol outlining the framework for the essential expectations toward assessments, prevention, and documentation
• Educational opportunities that occur during the initiative rollout, annually and at the time of new hire
• Director's guide that serves as a quick reference tool for reportable incidents
• Huddle document that serves as a mini onsite RCA tool the team can debrief from
• Audit tool that shift leaders can reference to quickly round with to spot and correct deviance from established protocol

Conclusion

Launching this initiative takes diligence and time. Many facilities will spend upward of one year implementing all the pieces and parts to make it work well. Mirroring another program, such as your falls program, is another way of ensuring success through familiarity. Finally, dig into the enormous volumes of reference material out there for guidance.

References

1. Agency for Healthcare Research and Quality. Declines in hospital-acquired conditions. Reviewed May 2019. https://www.ahrq.gov/data/infographics/hac-rates_2019.html. Accessed July 31, 2019.

2. The Joint Commission . Center launches project to address hospital-acquired pressure injuries. 2018. Accessed July 17, 2019.

3. Agency for Healthcare Research and Quality. Preventing pressure ulcers in hospitals. 2014. https://www.ahrq.gov/professionals/systems/hospital/pressureulcertoolki…. Accessed July 31, 2019.

Image Declines in Hospital-Acquired Conditions. Content last reviewed May 2019. Agency for Healthcare Research and Quality, Rockville, MD. https://www.ahrq.gov/data/infographics/hac-rates_2019.html

About the Author

Kelly Byrd-Jenkins currently serves in the Texas Hill Country as Director of Wound Care, having a diverse background in both clinical and operational aspects. She was selected in 1993 for specialty training in wound care and hyperbaric medicine by the US Air Force. She earned her CHT and DMT during active duty years while supporting clinical, research and emergency treatment teams as well as chamber operations and maintenance. Over the many years in the specialty, she is proud to have earned her CWS. She has been privileged to work with some of the physician "giants" of the wound care and hyperbaric specialty and continues to advocate for physician led programs that preserve patient's quality of life and dignity.