INTRODUCTION

An average of approximately 60,000 deaths occur in the US each year as a result of community-acquired and hospital-acquired pressure injuries (HAPIs). An estimated 2.5 million people in the US are affected by pressure injuries (PIs) annually. As a result, the CMS estimates a total financial burden of $9.1 billion to $11.6 billion a year due to hospitalization costs related to PI care.1 These alarming PI-related death rates coupled with significant costs signal a call to action.

According to the National Pressure Injury Advisory Panel (NPIAP), a HAPI is a localized injury to the skin and underlying tissue during hospital admission.2 They develop from intense or prolonged pressure or pressure in combination with shear on bony prominences or under medical devices; friction has been named as a related factor, but not a sole etiology.2 In addition, the CMS added HAPIs to its list of “never events”3 (ie, events that should not occur in hospitals), owing to its advocacy for preventing patient harm.1 As healthcare facilities strive to reduce harm and provide safe environments and care for their patients, HAPI prevention has become a key component of quality control measures across systems.4 Thus, HAPI incidence is a vital quality indicator that is considered a clinically essential and preventable hospital-acquired condition.5

The current evidence-based literature strongly suggests that for HAPI rates to be reduced or driven to zero, facilities must engage in interdisciplinary collaboration and ongoing improvement of nursing skills through continuing education and promote a culture of engagement, practice-ownership, and accountability.1,5,6 Further, board-certified wound care specialists, known as wound, ostomy, and continence (WOC) nurses, play a vital role in healthcare facilities. High-performing hospitals have reduced their HAPI rates by hiring skilled wound care specialists to act as expert resources for nurses and members of the interdisciplinary care team.3

Wound, ostomy, and continence nursing traces its roots back to 1968.7 More than 50 years later, it is now a recognized specialty practice by the American Nurses Association owing to its rigorous certification process that involves formal education and training; WOC nurses are considered the foremost specialists in the field.7 Including board-certified wound care specialists as part of the interdisciplinary care team improves quality care outcomes, including improvements in PI rates.3 In addition, early interventions directed at PI prevention should be an essential component of the routine nursing workflow process, including Braden Scale risk assessment, regular skin assessment, frequent turning and repositioning, and use of prophylactic dressings.3,8 Today’s healthcare landscape needs a strong force of board-certified wound care specialists that will take the organizational lead to prevent PIs, thereby preventing patient harm.

Upon joining the institution in early 2019, the current lead WOC nurse specialist took on the role as the subject-matter expert and team leader in PI prevention and management; a second WOC nurse specialist was hired in October 2019. During early 2019, multiple HAPI occurrences were reported across the critical care and medical-surgical areas.

This quality improvement (QI) project was anchored on the goals of improving patient safety and care outcomes through harm reduction and minimization of length of stay. The authors aimed to design and implement an interdisciplinary program with multiple interventions to reduce the incidence of HAPI at the community hospital. The specific aims were to (1) implement an early identification system and accurate documentation of PIs present on admission; (2) increase staff competencies and engagement in PI assessment and management; (3) promote interdisciplinary collaboration for PI management; and (4) decrease the incidence of HAPIs. Moreover, this QI project leveraged the expertise of wound care nurse specialists as a consulting service rather than as a frontline staff team (eg, to provide direct wound and ostomy care management), while also achieving executive and leadership support that resulted in sustainable increases across different levels of care within the organization.

METHODS

An interdisciplinary and collaborative approach was implemented across both the critical care areas and adult medical-surgical units at the community hospital.

Project Design Structure

The project was designed to promote a collaborative, interdisciplinary team-based approach to PI prevention, identification, and management. This cultural change was facilitated by nurse engagement (eg, increase in wound care champions), education, and empowerment, resulting in a positive cultural change leading to reduction in HAPI rates. Key interventions were utilized from April 2019 to December 2020.

Sample/Participants and Project Setting

This project was part of a more extensive QI program involving cultural shifts, which included creating an interdisciplinary and collaborative team of medical providers, wound care specialists, and nursing staff from both the critical care and medical-surgical units of a local community hospital. The population of focus included all nursing staff who provide direct care for patients, the WOC nurse specialists, and the medical providers (eg, physicians, nutritionists, and physical therapists). Nursing leadership also aided in the oversight of the project and attended monthly updates involving the Skin Care Champion Committee.

Ethical Acknowledgment

This QI project was undertaken with the guidance of ethical principles derived from the Belmont Report, which was finalized in 1979. It emphasizes three major principles as its ethical framework for research: respect for persons, beneficence, and justice.9 Quantitative data were extracted from the National Database of Nursing Quality Indicators (NDNQI) data submitted quarterly on behalf of this institution. Concerning privacy and confidentiality, no specific patient identifiers were used. Beneficence and nonmaleficence are demonstrated through provision of interventions that lead to increased patient safety outcomes with an overall goal to prevent patient harm.

Implementation Model/QI Model/Change Model

The Donabedian model for quality of care was used for this QI project.10 The Donabedian model is a conceptual framework for examining health services and evaluating the quality of healthcare.11 According to the model, information about quality of care can be drawn from three categories: structure, process, and outcomes.11,12 Structure refers to the care settings involved, such as human resources and organizational structure. Process refers to the activities undertaken to implement patient care or quality initiatives. Outcomes refer to the effects of care on the health status of patients and populations. The model emphasizes links between these three categories. As the structure is instituted and examined, the sustainability of the structure improves the implementation of processes, which improves the likelihood of positive outcomes.11,12Figure 1 illustrates the model that was designed and implemented for this QI project.

Figure 1.:

COLLABORATIVE, INTERDISCIPLINARY, STAFF-DRIVEN APPROACH TO PI IDENTIFICATION AND MANAGEMENTAbbreviations: HAPI, hospital-acquired pressure injury; PI, pressure injury; WOC, wound, ostomy, continence.

Intervention

Using the Donabedian model as a structural framework, this QI project implemented a series of process and structural changes that improved the quality-of-care outcomes. Process changes involved a series of interventions to create a collaborative, interdisciplinary, staff-driven approach that included early identification, management, and treatment of community-acquired PIs (CAPIs), thereby preventing HAPIs. Figure 2 presents the process and structural changes that were implemented beginning in April 2019 and ending in December 2020.

Figure 2.:

IMPLEMENTATION TIMELINE FROM APRIL 2019 TO DECEMBER 2020Abbreviations: HAPI, hospital-acquired pressure injury; WOC, wound, ostomy, continence.

Skin care champion revitalization

This structural change was implemented as a component of the QI project’s second aim. Whereas WOC nurses are the facility’s subject-matter experts with regard to skin care management, skin care champions (SCCs) are unit-based RNs that act as expert skin care resources to their teams. Monthly SCC meetings were resumed in April 2019, after a 6-month gap. These meetings are led by the WOC nurses and aim to provide continuous training and staff engagement to SCCs. A proactive approach to staff recruitment was made through unit huddles and individual staff conversations to encourage participation. In addition to RNs, nursing support staff were also recruited to include patient care partners and certified nursing assistants. Meetings were held in person with an option for remote attendance via dialing in to allow night-shift and off-duty staff members to participate. With evolving needs due in part to the COVID-19 pandemic, these are now a monthly Zoom conference call, in addition to in-person meetings.

WOC nurse validation of all admitted patients with PIs

This process change was implemented in May 2019 as part of the QI project’s first aim, when the WOC nurses began to run a daily PI report. Historically, this was done only once a month, on the day of the NDNQI Pressure Injury Prevalence Survey. As part of this initiative, all admitted patients with identified CAPIs are reviewed, validated, and evaluated by the WOC nurses. Further, the WOC nurses review and validate a hospital-wide report that is extracted from the electronic health record to identify all admitted patients with PIs noted on admission. Subsequently, an individualized plan of care is discussed with the staff RNs along with treatment recommendations and documentation guidelines.

Staff empowerment and engagement

As a structure and cultural change, the QI project’s second aim was to transition from a WOC nurse-centered wound care approach toward a staff-empowered model, modeled after the theory of structural empowerment where authority is decentralized to increase staff engagement and participation.13 The WOC nurses worked to keep the staff RNs actively engaged and professionally empowered in the care of their patient’s wounds through thorough assessments with clear and concise treatment recommendations discussed with staff RNs. Staff RNs were also encouraged to perform continuous and routine wound care treatments after the wound care consult. They document all wound assessment and management tasks they perform every shift in the patient’s electronic health record. The primary approach was to encourage staff RNs to understand why a specific treatment was recommended, know how to properly perform it, and ensure that they can perform the treatment independently and proactively. As a result, staff RNs began seeing the WOC nurses as their expert resource that will help empower them to properly assess and independently perform wound care treatment modalities. When follow-up is needed, staff RNs are encouraged to place a reconsultation request to ensure appropriate wound care treatment and recommendations are implemented and communicated through an application-based communication system that is secure and compliant with Health Insurance Portability and Accountability Act requirements.

In addition to education, inclusion is an essential component of empowerment and engagement. Inclusion was leveraged to ensure that staff participated in all levels of care planning and project management.14 For instance, inclusion is demonstrated through staff nurse participation in shared governance and decision-making processes during the hospital’s monthly quality council meetings. Nurses’ voices and opinions are encouraged as part of this initiative. Further, staff RNs were empowered to become SCCs for their respective units.

A new HAPI case surveillance initiative

This process change addressed the first aim of this project and was initiated in December 2019 to begin tracking HAPI incidence. This marked a shift from prevalence to incidence tracking. The WOC nurses keep an incidence log of CAPIs to ensure that they are constantly monitored during a patient’s hospital stay. The Excel spreadsheet (Microsoft Inc) is kept on a secure, internal network that is accessible only to the WOC nurses and the nursing quality team. Structurally, the organization elects to report this data to the Agency for Healthcare Research and Quality and to the NDNQI quarterly. As part of this initiative, WOC nurses engage in the monthly hospital- and institution-wide quality and patient safety meetings to discuss HAPI rates and ongoing initiatives. This supports WOC nurses’ participation in leadership roles.

Early recognition of COVID-related skin manifestations

As an identified process change in the Donabedian model, this intervention addressed the project’s first aim. During the early stages of the COVID-19 pandemic, “atypical” PI-like skin lesions were first noted and studied by the WOC nurses. By the time the NPIAP released their initial guidelines in May 2020 regarding the occurrence of COVID-related skin manifestations such as lacelike purpuric skin lesions in nonbony prominences of patients with COVID-19,15 the WOC nurses had already identified several cases of this new phenomenon.

Skin care resource nurse class

In alignment with process change and the second aim, this 6.5-hour continuing education course was first offered to local staff in June 2020. The WOC nurses conduct this class using an approved and standardized continuing education curriculum. Because the first session filled up quickly, two additional classes were subsequently offered in July and November 2020. Nurses who participated in the class were asked to submit a course evaluation with closed-ended questions and an open-ended section for additional feedback.

Increasing awareness through participation in NPIAP advocacies

This process and structure change was implemented as part of the project’s second aim. The authors’ hospital first participated in the Worldwide Pressure Injury Prevention Day in November 2019. During that time, three SCCs were encouraged to serve as panel experts to teach their colleagues. This was the beginning of a peer-to-peer approach in wound care education. By November 2020, a total of 10 SCCs divided into two groups (ie, “Woundie” and “Stomie”) toured the units and served as peer experts educating their colleagues on wound and ostomy management principles.

Interdisciplinary and collaborative approach to wound care

This structure change addresses the project’s third aim. From July 2019 until June 2020, a series of collaborative meetings were held between the WOC nurse (eventually, the WOC nurses) and physicians, physician assistants, nutritionists, and physical therapists. The team discussed the impact of nutrition status, early mobility, and physical therapy; encouraged unified documentation across the disciplines; and discussed innovative approaches to wound care management. During the emergence of COVID-related skin manifestations, a roundtable discussion with both hospitalists and physicians was held to increase awareness and understanding of emerging treatment modalities regarding these lesions.

Concurrent chart reviews and validations with coders

This structure and process change was implemented to address the project’s first and third aims. Clinical documentation improvement specialists concurrently validate any potential occurrences of HAPIs with both the WOC nurses and the physicians while the patient remains admitted. If needed, group case discussions and consultations are held to ensure accurate identification and proper documentation.

Outcome Measurements

This QI project utilized both quantitative and qualitative measures of data collection. The authors collected HAPI prevalence rates as reported to the NDNQI from January 2018 to December 2020. As of December 2019, the WOC nurse team began collecting separate HAPI incidence data. Whereas PIs present on admission were classified as CAPIs and were not publicly reported, PIs that occurred within 24 hours after admission were identified as HAPIs and were reported to NDNQI.

The authors also collected and evaluated survey responses from the nurses who completed the skin care resource nurse class. This survey was completed at the end of each class and consisted of nine questions that asked respondents to reflect on the learning outcomes and educators of the course and was scored on a 4-point Likert-type scale ranging from 1 (poor) to 4 (excellent). In addition, the survey included nine open-ended, free-response questions for participant feedback, including (1) practice changes to be made as a result of this program and (2) comments and suggestions for future education programs.

Outcomes Analysis

Data collected for NDNQI HAPI prevalence rates were sent to a hospital statistician for analysis and submission quarterly. Further, HAPI incidence from December 2019 to December 2020 was analyzed by the WOC nurse team and sent to the director of nursing quality.

Survey responses collected from nurses were evaluated at the end of each course by the WOC nurses, who serve as course instructors, in addition to the director of nursing. Qualitative data, including participant responses and feedback, were analyzed by the team, the two WOC nurse facilitators, and the director of nursing. Subsequent courses were adapted based on participant feedback.

RESULTS

The primary outcome of this QI project is a reduction of HAPI rates. Figure 3 displays HAPI prevalence rates for the authors' hospital from January 2019 to December 2020. The interventions reduced HAPI rates from a peak of 5.3% in April 2019 to 0% incidences beginning September 2019 to December 2020. To date, the HAPI incidence remains at 0%.

Figure 3.:

HAPI PREVALENCE RATES FROM JANUARY 2019 TO DECEMBER 2020.Abbreviation: HAPI, hospital-acquired pressure injury.

A secondary outcome includes increased staff engagement and participation, as evidenced by an increase in SCCs from 0 in May 2019 to 30 by December 2020. The SCCs were graduates of three cohorts of skin care resource classes attained upon completion of a 6.5-hour continuing education course approved by both the New Jersey State Nurses Association and the American Nurses Credentialing Center.

After completing the class, 100% of participants (N = 30) completed the evaluation survey. All the responses had an overall score of 4 out of 4, equivalent to a rating of excellent on the Likert scale. Participants expressed that the knowledge and skills they learned were fully applicable to the practice setting to identify and manage PIs. This reflected a generalized increase in nursing skill set among staff nurses.

Additional outcomes included (1) the formation of an interdisciplinary team of clinicians who meet as needed to evaluate program outcomes, (2) WOC nurses engaging in active data tracking and surveillance of PI incidence, and (3) the development of program initiatives that are fully supported by nursing leadership and are continuously evaluated by both nursing leadership and the interdisciplinary care team. Further, COVID-related skin manifestations continue to be reported almost every day. The WOC nurses are seeing a steady rise in the occurrence of these lesions among patients who are positive for COVID-19. Early expert identification and proper differentiation of these lesions against true HAPIs have prevented the increase in HAPI rates at the authors’ community hospital despite the continued resurgence of COVID.

To ensure project sustainability, the program elements are regularly reviewed by the WOC nurses and nursing leadership to ensure that the results obtained through current interventions are maintained accurately. Continued leadership appraisal is part of the structure of this process change model to support ongoing initiatives for HAPI reduction to ensure sustainable outcomes are continuously achieved.

DISCUSSION

The results of this project revealed that with appropriate nursing empowerment and engagement, strengthened by an interdisciplinary and collaborative approach to PI prevention, identification, and management, HAPIs can be avoided and be maintained at a goal of zero incidences.

In a study conducted by Englebright et al,1 an evidence-based tool kit was implemented in a system of community hospitals that resulted in a 66.3% reduction in HAPI rates. Similarly, an interprofessional and collaborative approach to PI reduction was implemented by Amon6 and resulted in a reduction in HAPI rates coupled with decreased cost of hospitalizations. The results of the present QI project further strengthen the existing evidence-based literature advocating for a collaborative, team-based approach to PI identification, management, and prevention to ultimately reduce HAPI rates.

The value of investing in skilled specialists was reported by Padula et al,3 through a retrospective, observational cohort study of academic hospitals in the US. The authors indicated that the addition of one board-certified wound care specialist per 1,000 hospital beds resulted in a 17.7% reduction in PI rates. Midway through the implementation of this project, a second board-certified wound specialist was onboarded, and the HAPI rate reduction was sustained throughout the project.

Comprehensive patient assessments and increased staff education and awareness to properly delineate PIs from other similar wounds were advocated by Howell et al,16 when they reported 16 different skin and wound care presentations that may be inaccurately tagged as a PI. Similarly, this project increased staff knowledge through provision of several cohorts of skin care resource nurse classes that enabled nurses to accurately identify PIs.

Strengths and Limitations

A strength of this project was the organizational support and oversight from the professional expertise of two Wound, Ostomy and Continence Nursing Certification Board (WOCNCB)-certified wound care nurse clinicians who provided improved quality-of-care outcomes.3 In addition, supportive leadership and participatory staff engagement further improved nursing care interventions. Engagement of clinical staff and the interdisciplinary team and organizational investment in full utilization of the expertise of WOCNCB-certified nurses resulted in increased quality-of-care outcomes.

Limitations of this project include implementation at a single-site community hospital and implementation during the height of the COVID-19 pandemic. However, satisfactory care outcomes were sustained as evidenced by zero HAPI incidence despite the challenges of the ongoing pandemic. Future studies should use the same interdisciplinary approach to replicate these interventions at larger academic medical centers or long-term care facilities and specialized wound care centers with a focus on improving patient safety and quality-of-care outcomes.

Clinical Implications

This project impacted three clinical outcomes in particular. (1) Decreased HAPI rates reduce the cost of hospitalization leading to decreased burden of hospitalization and improved patient care outcomes.1 (2) Provision of opportunities for staff education and engagement paved the way for increased staff competencies related to PI identification, prevention, and management, ultimately leading to improved nursing care and better patient outcomes. (3) A cultural shift toward an interprofessional, collaborative, and team-based approach to PI management resulted in increased camaraderie and cooperation.

Lessons Learned

In conducting this project, several learning milestones were achieved. Leadership buy-in and involvement from project inception to project completion are vital in the success of any QI project. Further, staff engagement and teamwork are essential in introducing change but, more importantly, are key for sustaining interventions. Last, the rigor of data tracking can be reduced by using consistent, reliable, and sustainable tracking methodologies that lead to safe, secure, and comprehensive data management. Continued leadership and executive support, along with ongoing data tracking and maintenance of process changes, will ensure that ongoing initiatives continue to effect positive outcomes and that momentum and project sustainability are maintained.

CONCLUSIONS

Hospital-acquired PIs remain a vital indicator of nursing care and quality and directly impact patient safety and care outcomes. This QI project showed that through a collaborative, interdisciplinary, and staff-driven approach to PI prevention, identification, and management, in addition to expert oversight from WOCNCB-certified wound care clinicians, HAPIs can be prevented, thus improving patient safety and satisfaction, increasing employee engagement, and enhancing the quality of care.