February Wound Ostomy Journal
Achieving 1,000 Days with Zero Hospital-Acquired Pressure Injuries on a Medical-Surgical Telemetry Unit
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Bethany Sobesto 3/10/19
ReplyDeleteHow does this research article compare to our practice, policy and/or procedure?
The interventions and procedures used in this article are similar to the practices used at PSJMC. Things they did in this study, which we also do at PSJMC include use of the Braden scale for assessing skin risk, use of absorbancy pads instead of diapers, specialized mattresses and overlays, early mobility, staff education about pressure ulcer prevention, and unit skin champions. The only notable differences are that when a HAPI is documented in their computer system a wound care consult is automatically triggered, and new arrivals on the floor have their skin assessed by two RNs.
Describe the method used by the author.
They used an internal reporting system to track new pressure ulcers on a 32 adult medical-surgical telemetry unit.
I work on a telemetry unit. As with the above mentioned study, the acuities are high and there are many co-morbidities. The bundles that are established at this hospital mentioned in the article are near identical to the practices at our hospital, specifically on my unit. The approach is comprehensive and focuses on prevention. We use the Braden scale as a tool to help assess potential skin breakdown and the areas that may require focus such as moisture, friction, nutrition, activity, sensory perception, and mobility. Ancillary services and staff including wound ostomy nurses, physical therapists, and registered dietitians can be consulted in order to address deficient areas. Two nurses are also used to conduct an initial skin assessment when patients are admitted or transferred to the unit. Photos are then captured and maintained on the electronic medical record. Skin care products including preventative dressings and barrier creams, special support surfaces, mobility equipment and training with the help of staff education at Annual Skills Fairs are in place. Support from Nurse Managers and assistant nurse managers are also readily available.
ReplyDeleteWith this said, the limitations that were mentioned in the study are also the same hurdles that our hospital faces. The specific unit I work on has piloted a study that utilizes a special surface in addition to the established support surface on the bed. With more emphasis on changes in Medicare reimbursement Float nurses from other floors and more-so registry nurses from outside agencies create a potential fault because they are not always aware of the specifics of unit or facility. Finally, there is also the preferences of the patient and/or family (which may not be controllable) that can hinder any process that is established in order to prevent injury. I support the practice of patient/family/visitor education. It always comes back to patient safety and trying to ensure the best outcomes.
1. How does this research article compare to our practice, policy and or procedure?
ReplyDeleteMedical surgical telemetry unit in this study had 1000 days without HAPI on patients with multiple risk factors. This was achieved by implementing six strategies. All Six strategies are implemented in our facility.
1. Improve risk assessment.
Braden scale is the standard tool used in comprehensive skin assessment. The assesment was also performed in the presence of a second nurse. PSJMC also uses the Braden scale. A patient with a score of 10-12 is considered high risk of developing HAPI. On admission and transfer, the skin is assessed in the presence of a second nurse usually the charge nurse. Wound care consult is also ordered for proper pressure injury staging in treatment.
2. Individualized Pressure injury risk factor reduction.
Incontinence diapers are no longer used. Instead, one absorbency pad is placed between the patient and the sheet. This pad pull moisture away from the skin promoting dry skin.
3. Specialized prophylactic products and support surface.
Application of Allevyn, an absorbing self adhering foam dressing, is being applied on the sacrococcyx and other bony prominent area for prophylaxis or treatment. Waffle mattress is also used for high-risk patients.
4. Early mobility
Patients are encouraged to ambulate to promote circulation and to offload pressure area. Early mobility is a fundamental component and the goal to prevent each HAPI.
5. Staff education.
During the annual skills fair, there is a section for the skin and pressure ulcer. Nurses are educated and updated on the current treatment modality of HAPI and pressure ulcer.
5. The unit skin champion role
Every unit has a skin champion or champions. Others call it the SWAT team. They conduct monthly skin prevalence. It is done every third Tuesday of the month. They check the skin, take photos, and update the unit of the last HAPI.
2. Discuss the sample size used in the study.
No specific number of subject was discussed. Instead, prevalence data were collected monthly using the pressure injury survey tool from the NDNQI.
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Limitations
ReplyDeleteAlthough the unit introduced a new process for HAPI prevention such as bundled interventions, required annual education for RNs and CCPs, display of quality dashboards so that staff see their performance, constant reminders during huddles, introduction of HAPI initiative in new staff orientation, and education of patient and family to care practices, they did encounter limitations.
The challenges they encountered were when RNs and CCPs floated to their unit and they were not familiar with the practice, then the staff would need to be sure to educate them so that they knew the expectations. There was patient and family resistance to recommended care at times and lastly there were the uncontrollable factors such as suboptimal nutritional status and vulnerability of aged skin.
Method
The method used was a Continuous Quality Improvement (CQI) model using FOCUS-PDCA. The team addressed six strategies for HAPI prevention: improved risk assessment, reduction of pressure injury risk factors, specialized prophylactic skin products and support surfaces, early mobility, staff education, and unit skin champions. During HAPI prevalence meetings challenges were reviewed, gaps were indentified, resources were addressed, and opportunities for continuous improvement were discussed. With this process in place the unit achieved 1,000 days with zero HAPIs.
Ariel Glaze, RN
ReplyDelete1. Advantages and disadvantages of proposed recommendation:
Advantages:
- Total member involvement. Use of unit champions, unit director, assistant unit director, clinical nurse specialist, and certified wound stony continence nurse afford a body of knowledge capable of studying the current challenges and offering comprehensive solutions customized for that particular unit.
- Expected reduced hospitalization costs.
- Mitigate or eliminate harm to patients.
- Improve quality of nurse practice and increase their evidence-based knowledge
- Improved identification of patients at risk
- pro-active approach to problem solving pressure ulcer incidences
Dissadvantages:
- If "cookie cutter" approach is used generically for all units, it might not work. (i.e.: units that run on less staff than project requires.
- Hard to measure initially cost of training versus reduced cost of pressure ulcer incidents. Even if this is the case, patient care take priority making the effort well worth it for the hospital.
2. Method used:
Prevalence data was collected monthly using pressure injury survey tool from the National Database of Nursing Quality Indicators (NDNQI). Data on new HAPI was tracked through an internal reporting system and evaluated by the skin champions, unit leaders, and certified wound stony continence nurse.
This was performed in a 32-bed adult medical-surgical telemetry unit in an urban academic, magnet designated teaching hospital.
Melissa Bautista
ReplyDelete1) How does this research article compare to our practice, policy and/or procedure?
In reducing the rate of HAPI's the facility mentioned in this article created a new pressure injury prevention plan. To improve skin assessments the unit began to perform two RN check skin assessments upon admission and transfer. This is part of the nursing practice on some units at PSJMC including 3N. The study also states that the unit eliminated diaper use to help in preventing pressure injuries we follow the same practice at PSJMC. Pressure injury prevention products like the foam dressing used at PSJMC were utilized in this study.
2) What are the advantages and disadvantages to the proposed recommendations in the article?
The article mentions that the unit used a team of "skin champions" that completed monthly skin prevalence surveys similar to the SWAT team at PSJMC. These skin champions also updated a quality board on their unit showing days since last HAPI to increase awareness of HAPI prevention as a unit goal. I think its a big advantage to have active members of the unit staff promoting HAPI prevention and skin awareness. It is a good way to motivate fellow coworkers to be active in preventing pressure injuries and reaching unit goals.