Hospital-acquired pressure injuries (HAPIs) are a nurse sensitive indicator (NSI), measuring the causative relationship between nursing cares provided to patient outcomes. Adverse events, like pressure injuries (PIs), are subject to the non-payment rule by the Centers for Medicare & Medicaid Services (CMS), making HAPI prevention a high priority.
Monthly PI prevalence studies, combined with focused education for unit-based Skin Team (ST) members’ [registered nurses (RNs) and patient care technicians (PCTs)] is essential in the reduction of HAPIs among hospitalized children. Didactic education, augmented with hands on application requires a realistically structured approach, to include: early identification of at-risk patients, PI prevention strategies, and treatment optimization.
With increasing attention towards development of HAPIs in the pediatric population, there is a recent increase in literature reporting HAPI incidence and prevalence rates among this specific patient population range from 0.25% to 27%, and upwards of 73% in patients admitted to intensive care units (ICUs) or who have spina bifida. 13% to 50% of those HAPIs were attributed to medical devices. Potential detrimental effects of PI development include: increased risk of infection, altered thermoregulation, and residual psychosocial effects.
Education and skill development for unit-based Skin Team (ST) experts, in addition to active PI surveillance, is essential to mitigate adverse patient outcomes.
Relevance/Significance
Incidence of hospital acquired pressure injury (HAPI) is considered a nurse sensitive indicator of care quality. Therefore prevention of pressure injuries (PI) in hospitalized patients is a high priority. The early identification and prevention of pressure injuries in hospitalized patients is an important nurse- sensitive indicator of patient care quality.
Despite a downward trending HAPI prevalence rate, our institution faced increased medical device related injuries (MDRIs), unstageable (UTS) PIs, and incomplete PI preventative bundle compliance, leaving us vulnerable. Adhering to 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 crucial to protect a vulnerable population of hospitalized children.
Professional development and education is achieved through integration of topic specific education combined with skill competencies for clinical nursing staff. The active educational strategy employed during monthly PI prevalence activities is aligned with adult learning principles wherein didactic content is paired with an opportunity for application in real-time by way of return demonstration, oral response, and patient assessments.
Strategy/Intervention
Regulatory requirements for HAPI reporting, as well as quality improvement (QI) documentation standards, are used to structure the monthly PI prevalence data collection and education. Quarterly topics guide inter-rater reliability exercises, SPS prevention bundle compliance, interactive continuing educational activities, and unit-delivered case study presentations.
Skin 101 lectures are brief educational sessions designed to highlight a specific area of skin health, reviewing the pathophysiology of the related topic, compounding on learning from month to month. These lectures are completed prior to each prevalence study and aim to advance the knowledge base of ST members and promote an evidence based approach to problem solving and treatment recommendations by understanding the basics of how skin functions. Inter-rater reliability exercises immediately prior to data collection reinforce ST members knowledge related to accurate assessment, staging, prevention strategies, and evidence based treatment options.
Ongoing active surveillance and prevention of HAPIs for all hospitalized children is achieved through monthly (4-8 hours) prevalence studies which include all inpatient and non-inpatient units, perioperative services, and a handful of ambulatory clinics. These monthly prevalence studies are augmented with education to members of the Skin Team (ST), covering skin and wound management competence, unit-based case presentations on disease specific pathophysiology as it relates to alterations in skin integrity, treatment optimization, and didactic presentations by content experts.
Monthly didactic and hands-on learning sessions by content experts, are awarded continuing nursing education (CNE) hours; objectives are guided by quarterly topics and issues related to skin and wound management for hospitalized pediatric patients. Evaluation levels I-IV are incorporated for monthly prevalence activities: level I- self-reported satisfaction and achievement of objectives; level II- return- demonstration of skills; level III- real-time audience response and prevalence data collection audits and level IV- monthly PI prevalence rates and nursing professional development.
Outcomes
This novel approach to HAPI prevalence has provided for more rigorous assessments of our HAPI preventive efforts, and created a cadre of unit-based skin and wound care experts across all clinical and ambulatory settings. Monthly HAPI prevalence studies, combined with 4 to 8 hour educational days have yielded an aggregated yearly prevalence rates decline of 49% over the last three years. The structured approach to HAPI prevalence surveillance provides regular opportunities for enculturation of QI for clinical staff as well as patients and families. Environments where there is collaboration between patients, families and care providers with clear communication about goals and risks have improved patient outcomes; the monthly HAPI prevalence studies provide such an opportunity as evidenced by the multiple impromptu consultations and just-in time education Skin Team members provide while on the clinical units collecting prevalence data.
ST members’ abilities to apply knowledge related to accurate assessment, staging and management of alterations in skin integrity is re-enforced monthly with inter-rater reliability activities immediately prior to prevalence data collection. The 4-hour introduction course has been held quarterly, and provided continued nursing education hours for more than 40 new ST members over 24 months. Prevalence days have provided 1.5 to 3.5 CNE hours each month for participants. Self-report level one evaluations of monthly prevalence education days reported scores of 4 or 5 on a 5-point Likert scale for satisfaction and achievement of objectives in > 94% of surveys received from an average of 30+ ST members monthly.
Implications for Practice
Continued declines in HAPI prevalence rates demonstrate the effectiveness of an organized prevention program. ST members are self-identified clinical nursing staff members who have committed to their individual professional development by working collaboratively to maintain quality care standards for the patients on their units.
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