Research has indicated pediatric patients in all hospital settings of all age groups, are at- risk for developing HAPIs, while the science behind pressure injury (PI) etiology still remains understudied. With a continually growing amount of literature examining hospital-acquire pressure injury (HAPI) rates among hospitalized children, there remains a wide national prevalence, ranging from <1% to over 27%. Half of all reported HAPIs in children are attributed to medical devices, nearly 20% higher than that of adult patients.
From its inception in 2006, the ST has been instrumental in organizational efforts aimed at eliminating HAPIs. However, as the team grew in size and popularity, it became clear that a restructuring of the ST was necessary to improve the clinical competence of its members, and achieve improved patient outcomes through a reduction in HAPI rates, specifically those caused by medical devices. This undertaking would rely on a multidisciplinary approach, improving prevention strategies and awareness to frontline staff.
Relevance/Significance
Reflecting on historical hospital-acquired pressure injury (HAPI) prevalence data, our institution averaged 2.74% yearly HAPI prevalence rates. 15 serious harm events (stage 3, 4, and unstageable (UTS) HAPIs) had been observed in 2015, a drastic increase from previous years. HAPI prevention bundle compliance had only been partially implemented, two of the five elements, in two of our 10 inpatient units (pediatric and cardiac intensive care units).
A restructure in 2016, of the nurse-led Skin Team (ST) became necessary. Keeping pace with national benchmarks set by the National Database of Nursing Quality Indicators (NDNQI) and recommendations from Solutions for Patient Safety (SPS), a robust Skin Team (ST) program, emphasizing highly reliable collective competence, became critical in decreasing harm to all patients who came through our doors.
Through a monthly structured skin and wound program, education, prevention, and interdisciplinary collaboration became the pillars the new Skin Team was built upon. HAPI prevention bundle implementation became the first NSI to become fully aligned and fully spread institution wide. The strategic programmatic changes created and implemented, proved instrumental in radically decreasing HAPIs rates in all inpatient, non-inpatient, perioperative services, and the ambulatory clinics.
Strategy/Intervention
From its inception in 2006, the ST has been instrumental in organizational efforts aimed at eliminating HAPIs. The initial team consisted of 12 members, most were nurses, focusing on addressing skin related issues throughout the organization.
First attempts at data collection occurred in 2009, through participation in the Child Health Corporation of America (CHCA) collaborative, a collective collaborative aimed at HAPI reduction in intensive care units (ICUs). Huge successes resulted from this collaboration, decreasing our HAPI prevalence rates from 29% to 2.2%. Due to success of the CHCA collaborative, the decision was made to implement HAPI prevalence institute wide in 2010, growing membership to 25 on the ST. This decision was historical for the ST, making it the organizations first nursing-led team to tackle a NSI.
Regardless of the growing popularity of the ST, a steadily decreasing prevalence rate, there continued to be an increase in serious harm events and medical device-related pressure injuries (MDRPIs). The now 50 member ST required creative solutions to address current challenges. The 2016 redesign, which reviewed historical prevalence and ST data, focused efforts on education, prevention, and interdisciplinary collaboration. This growing team of 50 members committed to 4-8 hour monthly skin, wound, and PI educational days that incorporated: NDNQI prevalence studies, PI prevention bundle audits, inter-rater reliability exercises, interactive continuing educational activities, and unit-based and delivered case studies on patients with complex skin care needs. Our institution surpassed standards set by NDNQI through engagement of frontline patient care technicians (PCTs), the addition of non-inpatient units and ambulatory clinics, as well as “floating” team members from nursing education and nursing research/quality outcomes to float between the 10 inpatient units where extra expertise was necessary. These new initiatives provided for more rigorous assessments of our HAPI prevention efforts, while creating a cadre of unit-based skin and wound care experts across all clinical areas.
Outcomes
Since the 2016 restructure, a reduction of 49% in HAPI prevalence has been noted, with a yearly reduction of 11% from 2016-2017 and 15% from 2017-2018. 4 months recorded prevalence rates less than 1%, 3 months were less than 0.5%, and 1 month, April 2017, the hospital was able to report its first 0% prevalence rate. A mark we were not sure was achievable, but has become the quality care we strive to provide our patients.
The ST became the organization’s first NSI group to become fully aligned and spread with the SPS recommended PI prevention bundle elements. Our organization decided to preform 24 hour look backs on 5 elements, with 22 combined documentation points with in the electronic medical record, one missing documentation point meant a non-compliant bundle. Despite continued struggle to consistently remain greater than 90% with preventative bundle compliance, through focused efforts, a yearly increase in identification of at-risk patients has been noted, with 347 at-risk for PI patients identified in 2016, 407 and 651 in 2017 and 2018 respectively. Early identification of at-risk patients has led to increased prevention methods and continued decreases in hospital wide HAPI prevalence.
Through interdisciplinary taskforces addressing the institutes top two medical devices, EEG leads and respiratory equipment, resulting in MDRPI organization-wide practice changes were implemented. 6 months post EEG interventions aimed at decreasing PIs noted a 90% reduction, 41 to 4 MDRPIs, of those 4 EEG-related PIs, none occurred on patients who were turban-less. In the two years (2017, 2018) since the EEG taskforce was initiated a sustained 85% reduction in overall EEG-related HAPIs has been noted. 7 EEG-related PIs were documented in both 2017 and 2018. More impressively, there have been zero EEG-related PIs on patients who are turban-less. Respiratory devices, like EEG leads had a drastic post intervention reduction of 81%, from 37 MDRPIs to 7 in the 6 months post intervention.
In the two years (2017, 2018) since the respiratory taskforce formation, a dissolving of that original taskforce occurred due to organizational changes and movement of staff within the respiratory department. Where an initial 50% sustained reduction (N 26 to 13) was noted in 2017, the same cannot be stated for 2018, where a drastic increase in respiratory device-related HAPIs has occurred (N 32). Currently respiratory devices account for 35% (32/91) of our MDRPIs. A new dedicated respiratory device taskforce has been formed with members’ of the ST, the RT educator and manager, and RTs, aiming to build on the initial successes of our earlier partnership. Additional didactic and hands on education was provided to all RTs on preventative padding of respiratory devices.
The backslide in respiratory device-related PIs highlights the necessity of constant vigilance and preventative padding on all hospitalized patients with medical devices, for the prevention of HAPIs. Additionally, this highlights the importance of a robust interdisciplinary partnership.
Implications for Practice
Reduction in HAPIs is achievable through creative solutions involving interdisciplinary collaboration, novel prevention strategies, and system-wide leadership support.
Institutions striving to implement best practices can benefit from learning how one institution restructured their ST, leading to a sustained reduction in HAPIs and serious harm events, increased interprofessional collaboration, and structured education pertaining to wound and skin health.
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