Reducing Hospital-Acquired Pressure Injuries During the COVID-19 Pandemic.

Abstract

Assessment and prevention of pressure injuries is both a challenge and a responsibility for critical care nurses. A large body of evidence exists to guide practice, but effective translation of pressure injury prevention (PIP) at the bedside can be difficult. In our 16-bed intensive care unit, the incidence of preventable hospital-acquired pressure injuries (HAPIs) increased significantly at the beginning of the COVID-19 pandemic. A culture shift was noted in which PIP was no longer prioritized and evidence-based standards for care of patients with pressure injuries were not consistently met. The pressure injury prevention bundle was revised to reflect best current evidence. An evidence-based practice initiative led by an intensive care unit (ICU) staff nurse and a clinical nurse specialist was developed to reengage the ICU team in interventions to reduce the rate of HAPIs.Rates of HAPI are indicators of nursing and hospital quality. Overall, such rates have increased since 2014.1 Currently, approximately 3 million HAPIs occur annually in the United States.2 Considered a preventable condition, HAPIs result in decreased financial reimbursement, with an average estimated cost of $21 767 per injury.2 The occurrence of a HAPI is associated with increased risks of in-hospital mortality and readmission, increased length of stay, and complications such as pneumonia.2 Patients who experience HAPIs report increased pain and decreased quality of life and may develop chronic wounds requiring prolonged treatment.3Evidence-based HAPI prevention strategies have been issued by the European Pressure Ulcer Advisory Panel (EPUAP), the National Pressure Injury Advisory Panel (NPIAP), and the Pan Pacific Pressure Injury Alliance (PPPIA).4 Many care factors influence the potential for the occurrence of pressure injuries. Nursing practices that have been shown to prevent HAPIs include performing comprehensive skin, risk, and nutrition assessments; ensuring adequate protein intake; keeping skin clean and dry; frequent repositioning; and heel offloading.4Our mixed ICU in the Rocky Mountain region saw a sharp increase in preventable HAPIs over a 4-month period, from March through June 2020. Nine HAPIs were identified during that period, compared with 4 in the previous 4 months, an increase of 125%.A baseline review of PIP standards found no formal policy or educational program addressing HAPI prevention specific to ICU patients. Inconsistency in PIP care was believed to stem from lack of education on best practices. A perceived “culture shift” in the unit, corresponding with a high staff turnover rate and stress related to the COVID-19 pandemic, had resulted in a lower priority for PIP in care delivery. Random audits found inconsistent use of protective foam dressings, repositioning, and appropriate mattress settings.The EPUAP/NPIAP/PPPIA clinical practice guideline4 informed the ICU-specific PIP program (see Table). The Iowa Model of evidence-based practice5 was used to guide implementation. Pressure injury prevention bundle interventions focused on consistent use of 4 prevention strategies4: (1) turn the immobile patient every 2 hours; (2) adjust mattress settings on every shift; (3) apply a foam dressing on the coccyx for every patient; (4) float heels if applicable. The tagline “Every patient, every time!” was used to promote consistency (Figure 1).Given the stressors of COVID-19 and staff dynamics, a multimodal approach was determined to be the most effective strategy for providing education and empowering the nursing staff to make practice changes in real time. A “just-in-time” training model was developed to improve PIP best practices.6,7 Ongoing education was considered essential to continually update nurses’ knowledge and promote change.The team held an underlying belief that bedside staff performance was the most important factor in the prevention of HAPIs. The bedside nurse is responsible for assessing the patient for risk factors and pressure injuries as well as initiating prevention and treatment strategies.6 Implementing and sustaining a HAPI prevention program during the COVID-19 pandemic was especially challenging given the stressors associated with care for this patient population.Education and promotion of the ICU-specific PIP bundle was performed in 2 waves, encompassing different methods of integration. The first wave consisted of education on the PIP bundle elements by the unit clinical nurse specialist. Flyers were placed around the unit describing the interventions, and turn clocks were placed outside of rooms to remind staff members of the need to turn the patient every 2 hours. Real-time audits of interventions allowed for just-in-time training if the appropriate procedures were not in place.The second wave, approximately 6 weeks later, was designed to maintain momentum and enthusiasm about improving PIP practice. Trivia questions were asked during shift huddles, with prizes of candy given. Assignment sheets identified which patients require assistance with every-2-hour turning. The unit clerks rounded on the unit every 2 hours to assist with turns.Audits of interventions were completed on a shift-by-shift basis for 1 month. Appropriate mattress settings and every-2-hour turning were reported as occurring most often, with deficits noted in the use of foam dressings and heel off-loading. As shown in Figure 2, HAPI data indicated that during the intervention period, only 1 HAPI occurred in the ICU, compared with 9 HAPIs in the previous 4 months, a reduction of 89%.Reducing the incidence of HAPIs is essential to the delivery of excellent patient care. Our practice change resulted in an impressive reduction in the HAPI rate and provided nursing staff members with a sense of accomplishment during an especially challenging time for the provision of high-quality care.One of the major barriers to lowering the HAPI rate was the high degree of turnover and the continual addition of new staff members during the intervention period. It was difficult to access all float nurses to ensure that they received the proper education. This deficiency was noted and brought to the attention of hospital educators, with a recommendation to consider providing a brief PIP bundle educational program as part of new staff members’ orientation, even for agency, traveling, and float nurses. The overwhelming consequences of HAPIs require that PIP be considered an integral part of the role of every bedside nurse.Providing evidence-based education and resources, tackling barriers, and developing a unit culture of embracing evidence-based practice to support change all take time, energy, and hard work. Empowering staff members and providing resources to assist with HAPI prevention strategies helped keep patients safe and maintain nursing quality at a high level. Even during times of significant stress in the health care field, returning to expected evidence-based standards for practice helped nurses achieve meaningful practice change.The authors thank the intensive care unit leaders, nursing staff, and unit clerks who assisted with data collection and implementation of this project, and especially Mary Potter, MS, RN, CCNS, ACCNS-BC, CCRN, for her assistance with this project and her service as a mentor.