Implementing a Pressure Injury Prevention Bundle to Decrease Hospital Acquired Pressure Injuries in Critical Care

Adult patients in the Intensive Care Units have a higher risk for developing Hospital Acquired Pressure Injuries (HAPI) because of hemodynamic instability requiring vasoactive medications, use of medical devices, immobility and malnutrition (Cooper, 2013). HAPI negatively impacts patient outcomes, patient/family experience, nurse satisfaction and financial implications (Chaboyer et al., 2016). Development of HAPI results in financial penalty because the Centers for Medicare and Medicaid Services (CMS) consider stage 3 pressure injuries as never events and will not reimburse the facility. Apart from financial penalty, the increased length of stay, cost of pressure injury treatment, and litigation potential, further increases healthcare cost (Tayyib & Coyer, 2016).

An increase in HAPI in the Cardiac Care Unit (CCU) in 2017, spearheaded the Collaborative Care Council in partnership with Wound Ostomy Continence Nurse (WOCN) to develop strategies to decrease HAPI. The collaborative care council reviewed the literature to identify best practices. Thus the Pressure Injury Prevention (PIP) bundle was implemented.

The PIP bundle encompass risk assessment, skin assessment, nutrition, repositioning, pressure redistribution surfaces, care of medical devices and education (Tayyib & Coyer, 2016). The risk assessment is completed upon admission to CCU and every shift, using the Braden scale (National Pressure Ulcer Advisory Panel, 2016). If the Braden scale is 19 or above, patient receives standard pressure injury prevention care. Patients with Braden scale 18 or less, are at high risk for developing HAPI and Pressure Injury Prevention bundle is implemented. Skin assessment is conducted every shift. Documentation of skin assessment is done upon admission and every shift. Clinical practice guideline is added to plan of care for risk of pressure ulcer.

A head to toe skin assessment is performed by two Registered Nurses (RN) s upon admission to the CCU. The primary RN documents skin assessment and name of collaborating RN who performed the skin assessment. Patients admitted with pressure injury receive wound consult as soon as possible. Patients without pressure injury have a foam dressing applied to bony prominences to prevent HAPI. The pad is lifted at least every shift to inspect the skin underneath. Patients are repositioned every two hours, at minimum. Micro turns may be ordered if the patient cannot be moved to alternate laterals.

Redistribution mattress, foam dressing to pressure points for prevention. Skin care using balanced pH cleansers as often as necessary and moisturizers daily. Key interventions include Nutrition consult, head of bed 30 degrees, unless contraindicated, turn and reposition every two hours, early mobilization. Wound consult for all pressure injuries. Provide education to patient and families.

An audit tool was developed to monitor compliance with adherence to PIP bundle. The bundle was disseminated during nursing leadership meetings and staff in-services. The wound champion and WOCN conducted daily rounds initially, then weekly rounds. The collaborative care council developed a project charter to document structure, process and outcomes (Tayyib & Coyer, 2016).

From January 2017 to January 2018 there were nine HAPI, index 3.4. PIP bundle was implemented March 2018. Eight months post implementation of PIP bundle there was one HAPI, index 0.95, which represents 89% reduction in HAPI. As a result of reduction in HAPI and improved patient outcomes and nurse satisfaction, the PIP bundle has been implemented in all other units of the hospital.