Pressure Injuries in the Healthcare Setting

Abstract

Background: The ultimate goal and purpose of healthcare is to improve health while preventing morbidity and mortality. The optimal approach to this is through teamwork using a reliability framework. Upon review of our institution’s 2012 patient safety culture survey data, we noted that the teamwork domain of the Agency for Healthcare Research and Quality (AHRQ) assessment was in the lowest decile. Our institution implemented the Crimson Analytics tool in 2013, and an analysis of inpatient mortality data revealed higher than expected mortality statistics. Objective: Hospital systems and team-based care are more developed during daytime hours, leaving patients more vulnerable to adverse events (morbidity and mortality) during the overnight period. Our objective was to develop optimal transitions of care and proactive risk identification/mitigation through an interprofessional team-based approach, with resultant decrease in patient harm and improvement in safety culture. Methods: In a community hospital, standardize transitions to identify “at risk” patients for nurses, physicians, and respiratory techs with subsequent interprofessional review of care plans/patient status in a centralized midevening standup briefing, subsequent proactive rounding on “at risk” patients, use of error prevention behaviors aimed to mitigate cognitive bias, and end-of-shift reflection process. Results: Inpatient mortality rates fell from a baseline level of 2.08% in April 2013–March 2015 to 1.56% during the intervention period from April 2015–March 2018. The observed/expected mortality ratio fell from 1.04 to 0.76. AHRQ safety culture data improved in the team-work domain from 81% to 83%. A custom survey for this intervention was developed and found significant improvements in risk awareness and mitigation response, teamwork, efficiency, and—potentially—joy at work. Conclusion: An interprofessional approach to high-quality transitions in care, risk identification, and mitigation, along with structured huddles and proactive rounding, can improve patient safety at night while simultaneously improving staff satisfaction, joy, and safety culture.