Effectively Addressing Hospital-Acquired Pressure Injuries With a Multidisciplinary Approach

Abstract

Background: Hospital-acquired pressure injuries (HAPIs) result in patient harm, discomfort, and even death, with an estimated 2.5 million HAPIs occurring annually in the United States. These pressure injuries from prolonged pressure on the skin and deeper tissues cause reduced blood flow and the breakdown of skin and tissues, resulting in wounds. Additionally, these injuries contribute to longer hospital stays and increased health care costs. Hospitals have programs aimed at reducing HAPIs as well as ongoing surveillance to identify new trends early on. This ongoing monitoring revealed a trend early at our institution that HAPIs were 66% higher than the national HAPI rate of 3.5% of observed patients. In rapid response, a multidisciplinary team was formed to address and improve the HAPI rate via a quality improvement project.

Methods: To achieve the goal of decreased pressure injuries or ulcers, a team of nurses, patient care technicians, nutritionists, infectious disease specialists, radiologists, surgeons, vascular technicians, supply chain administrators, case management and social workers, hyperbaric medicine specialists, and wound care experts was created. The team completed a gap analysis and discovered inconsistencies in documentation and care practices that led to HAPI rates above the national average. The team then standardized a policy, standardized documentation of wounds, and provided staff education. Measures were implemented to proactively prevent pressure injuries.

Results: There was a 4.2 percentage point decrease in HAPIs from the beginning of the project (5.76%) to the last survey (1.59%). However, this difference was not statistically significant (P = .07). Overall, there were 6 fewer patients (8 vs 2 patients) with hospital-onset observed injury. Additionally, the length of stay decreased by 46%. Documentation of skin assessments within 24 hours of admission improved to 100%.

Conclusion: We implemented a quality improvement program across 10 service lines, monitoring pressure injuries, HAPI incidence, and length of stay in 480 patients over 2 years. Although the reduction in HAPI was not statistically significant (P = .07), our program positively impacted the hospital's response to pressure injuries and warrants further replication.

Keywords: HAPI; patient safety; pressure injury; prevention; quality improvement; wound care.

Figure 1

Number of stage III and IV HAPI events based on HAC-reported data, shows the trend per quarter from 2021 to 2024.

Figure 2

The timeline of quarterly changes in the percentage of patients with a HAPI are shown relative to the implementation of different phases of the prevention initiative from 2022–2024. * New department organization: New Wound Care Director was hired, outpatient clinic opens, and inpatient wound care staff reorganized. Phase 1: We found: (1) HAPI(s) were not always being documented as present upon admission (POA); (2) No consistency with Braden skin assessment(s) across units; (3) The number of layers between a patient’s skin and the surface they were laying on were often > 4 (> 3 layers is the national standard/goal); (4) Confusion on evidence-based offloading techniques and available resources; (5) Skin champions appeared not engaged from hospital departments and/or not assigned. Phase 2: We implemented (1) Monthly audits (30 patients per department or if less than 30 pts, 100% of patients). Audits included (A) documentation of Braden Skin Assessment within 24 hours of admission, (B) offloading devices used, (C) number of layers present. (2) Mandatory skin champions assignment to all departments. Skin champions were required to (A) attend monthly Skin Champion Meeting(s), (B) create and teach to trifold posters outlining three key performance indicators (KPIs) off documentation of skin assessment, offloading techniques, and layers initiative, (C) monthly education to a poster, (D) monthly activity log. Phase 3: Continued education with (1) monthly Skin Champion meeting, (2) quarterly educational pieces, (3) trauma Grand Round/oncology, etc, (4) huddle topics, (5) Braden Skin Assessment policy updates.

Figure 3

Monthly auditing compliance trends of clinical units, including skin care practices, off-loading techniques, clinical assessment of wounds, and clinical documentation are shown to identify potential problem areas contributing to HAPIs.

Figure 4

Hospital HAPI rate trends compared to IPUP/IPIP^™ moving benchmarked data are shown for each IPUP/IPIP^™ survey from 2022–2024.