A Unit-Based Project to Reduce Hospital-Acquired Pressure Injuries

In May 2019, the prevalence of hospital-acquired pressure injuries (HAPI) Stage 2 and above on the 3 Medical-Surgical Unit at Cleveland Clinic Avon Hospital increased to 4%. Realizing that this was above national benchmarks for similar units, Sarah Khan, MSN, RN, CMSRN, nurse manager of the 42-bed unit, teamed up with skin care resource nurses to tackle the problem and decrease HAPIs. They used resources offered enterprise-wide by the Cleveland Clinic health system as well as interventions devised specifically for their unit.

Enterprise-wide focus on HAPI prevention

In June 2019, the 3 Medical-Surgical Unit was invited to participate in a Cleveland Clinic performance-based pressure injury education plan to improve HAPI Stage 2 and above results. Based on a three-tiered approach, the plan outlines educational opportunities and activities for units depending on their prevalence rates:

• Red Tier – Units with a 3% or higher prevalence
• Yellow Tier – Units with 1 – 2.9% prevalence
• Green Tier – Units with less than 1% prevalence

Based on 1Q 2019 data, the 3 Medical-Surgical Unit was identified as a yellow unit. “There were certain interventions that needed to be done, one of which was to evaluate and increase the number of skin care resource nurses on the unit,” says Khan. In August, the unit added another skin care resource nurse for a total of four.

In addition, the med-surg unit implemented several other strategies to reduce HAPIs, most of which fell under one of three areas: ongoing caregiver education, practice changes and communication methods.

Ongoing caregiver education

The health system’s plan emphasizes the importance of caregiver education for all tiers. Adhering to the plan, Khan asked all clinical nurses on the med-surg unit to complete an online learning module related to skin care and skin prevalence. In addition, she assigned all nurses a self-guided learning module titled “NDNQI Pressure Injuries and Staging Module I” as part of yearly competencies. The module covers several topics, including normal skin versus damaged skin, definitions and examples of Stage 1 through 4 pressure injuries, common pressure injury locations and pressure injury healing.

Clinical nurses on the med-surg unit also were encouraged to attend a hands-on wound care education session hosted by Cleveland Clinic. Two paired caregivers rotate through six simulated bed spaces with manikins that have synthetically made pressure injuries located somewhere on the body. The caregivers determine a Braden score and assess, measure and describe the wound. Then they determine appropriate nursing interventions.

In addition to these formal educational opportunities, Khan stressed the importance of reviewing monthly materials provided by skin care resource nurses, such as information on new skin care products, pressure injury staging tips and two-hour turning for patients with a Braden Score of 18 or less. Nurses sign off when they have reviewed the materials.

Practice changes

The 3 Medical-Surgical Unit also made changes to practice to reinforce education and reduce HAPIs. One of the biggest changes was requiring verification of two clinical nurses on the initial skin assessment performed upon patient admission.

The unit also increased the number of skin prevalence days from once a month to bimonthly. During one of the days, skin care resource nurses and a nurse practitioner specializing in wound, ostomy and continence care round on patients. On the second prevalence day, a skin care resource nurse rounds with a clinical nurse from the unit. “These rounds promote skin care awareness for nurses on the unit and provide exposure to pressure injuries,” says Khan.

Working alongside a skin care resource nurse also helps nurses build relationships with experts, whom they feel comfortable turning to later for assistance. One of the skin care resource nurses on the unit, Sulay Toledo, RN, has served in the role since Avon Hospital opened in 2016. “She has taken other nurses under her wing to help get them engaged, and nurses really look to her as the skin expert on the unit,” says Khan.

Communication methods

The final component in the effort to reduce HAPIs is constant communication about skin breakdown and care. The 3 Medical-Surgical Unit reviews routine interventions and prevention strategies during change-of-shift huddles and staff meetings. The unit added “Date of Last HAPI” to its Professional Practice Model board for daily caregiver review during huddles. “This increases awareness not only about the patient who sustained a skin injury, but for all at-risk patients,” says Khan.

In August 2019, Khan began emailing a weekly update to unit caregivers titled “A Thorough Inspect Will Help You Detect.” Skin care resource nurses contribute content to the updates, which discuss care of the patient with skin breakdown, the Cleveland Clinic Nursing Institute Pressure Ulcer Prevention Protocol and pointers from skin care resource nurses.

The collective effort of the education, practice changes and routine communication helped the 3 Medical-Surgical Unit achieve its goal to reduce HAPIs. The unit’s prevalence of hospital-acquired pressure injuries (HAPI) Stage 2 and above in September, October and November 2019 was 0%.

“Of course we are concerned about meeting metrics,” Khan acknowledges. “But ultimately it’s about providing high-quality patient care so they don’t have any more complications.”

She also stresses that the initiative to decrease HAPIs wasn’t a one-time project. “You can never get complacent,” says Khan. “We had great results, but we have to learn from the initiative and make sure it’s applied beyond the project and into routine patient care.”

A focus on decreasing pressure injuries across the system

Solutions to pressure injuries are top of mind among nurses across the health system. Deborah Styskel, BSN, RN, CMSRN, a nurse on Cleveland Clinic Marymount Hospital’s medical surgical unit and a member of the Skin Care Committee, had seen painful immobility-related injuries that prolonged hospital stays. With the help of her manager, Styskel purchased hand-held mirrors and wrote “Reflect to Inspect” on them to remind nurses the importance of using the mirrors for skin assessments. She then educated staff to use the mirrors to assess hard-to-see areas, such as heals, for all patients during skin assessments.

Using this method improves nurses’ ability to perform thorough inspections without moving the patient more than a few inches. Since the “Reflect to Inspect” method was introduced in August 2018, there have been no pressure injury incidents on the units that have used the assessment method. Styskel received third place in Cleveland Clinic Nursing Institute’s annual Nursing Innovation Inventory for her dedication to improving patient care.