Reducing Hospital-Acquired Pressure Ulcers: A Quality Improvement Project Across 21 Hospitals

Incidence of hospital-acquired pressure ulcers in patients with "minimal risk" according to the "Norton-MI" scale

Introduction

Pressure ulcers (PUs) nowadays are a major health problem in society, associated with increased morbidity and increased health care costs. The incidence of HAPU is an indicator of health care quality.

Objective

To describe the profile of patients with minimal risk on the Norton-MI scale who developed PUs during hospitalization, and to identify the incidence of hospital-acquired pressure ulcers (HAPU).

Methods

Retrospective cohort study conducted between 2014 and 2017.

Study population

Patients over 18 years of age classified as "minimum risk" according to Norton-MI, admitted to acute hospital units of the Severo Ochoa University Hospital—Madrid-Spain. Patients were classified as patients with hospital-acquired pressure ulcers (PWHAPU) if they developed one or more new PU during their hospitalization.

Variables

Sociodemographic variables, hospitalization units, Morton-MI score and characteristics of the risk factors of HAPU were studied.

Results

The risk of PU was evaluated in 5530 patients, being 1260 patients classified as "minimum risk", with a median of 16 points in the Norton-MI scale. The average age was 76 years old and 52.5% were women. Principal causes of admission: traumatological pathologies (20.8%) and cardiovascular pathologies (20%). 129 HAPU were diagnosed in 112 patients, implying an incidence of HAPU of 8.89% (CI95%: 7.44–10.59). 106 PWHAPU (94.6%) presented up to 6 risk factors. The excess pressure and altered skin sensibility were identified as statistically significant risk factors as predictive factors of HAPU. In terms of severity, 55% of the HAPU were category I and 42.6% were category II, mainly with anatomical sacro-coxygeal location. In 65.2% of the patients the HAPU appeared in the first week of hospitalization.

Conclusion

In our study the incidence of HAPU in patients classified as minimum risk with Norton-MI scale was 8.89%. This elevated risk suggests for future investigations to develop new validity studies of the Norton-MI scale and to maintain a continuo training of professionals in the knowledge of PU risk assessment scales for their safe application in the patients, since it directs the practice of care in the prevention of PUs. It would be advisable to specially control the risk of PUs in care units, mainly in the first week of their hospital stay to minimize the HAPU incidence.

Effect of preventive care interventions on pressure ulcer rates in a national sample of rural and urban nursing units: Longitudinal associations over 4 years

BACKGROUND

Pressure ulcer rates are persistently high despite years of research and practice policies focused on prevention. Prior research found crosssectional associations between care interventions, hospital and nursing unit characteristics and pressure ulcer rates. Whether these associations persist over time is unknown. Finally, comparisons of quality measures across rural and urban location have mixed findings.

OBJECTIVE

Our study examined effects of care interventions on unit-acquired pressure ulcer rates over 4 years controlling for community, hospital, and nursing unit characteristics in rural and urban locations.

DESIGN

Guided by contingency theory a longitudinal study was conducted to examine associations between context, staffing, care interventions, nurse outcomes, and pressure ulcer rates, using unit-level data from the National Database of Nursing Quality Indicators^Ⓡ 2010-2013 (16 quarters) augmented with data on rural classifications and case mix index. Ulcer rates were measured as percentage of patients with a nursing unit-acquired pressure ulcer. The three care interventions were unit-percentage of patients receiving skin assessment on admission, receiving risk assessment on admission, and receiving any risk assessment before the pressure ulcer. Nursing unit characteristics were RN staffing, education, and experience. Nurse outcomes were job satisfaction and intent-to-stay.

PARTICIPANTS

We included 5761 units (332 rural and 5429 urban) in 772 hospitals (89 rural and 683 urban) that reported ulcer rates in two or more quarters during the study period.

METHODS

Rural and urban units were examined separately using multilevel binomial regression in which within-unit changes in pressure ulcer rates were related to the within-unit changes in the explanatory variables, controlling for region, hospital size, unit type, case mix index, and percentage of patients at risk for pressure ulcers.

RESULTS

An increase in the three care interventions, RN skill mix, and the two nurse outcomes were associated with a decrease in unit-acquired pressure ulcers. For example, in rural units a 10% increase in unit-percentage of any risk assessment and in urban units a 10% increase in skin assessment on admission were associated with a 21% and 5% decrease in the odds of developing an ulcer. A 10% increase in RN skill mix was associated with 17-18% and 5-6% decrease in ulcer rates in rural and urban units respectively.

CONCLUSION

Hospitals aiming to improve pressure ulcer prevention should focus on organizational structures that support improved nurses work environments and workflow that will enhance nursing care interventions. Future studies should include both contextual and patient characteristics along with care interventions.

Risk Adjustment for Hospital Characteristics Reduces Unexplained Hospital Variation in Pressure Injury Risk

BACKGROUND

Research investigating risk factors for hospital-acquired pressure injury (HAPI) has primarily focused on the characteristics of patients and nursing staff. Limited data are available on the association of hospital characteristics with HAPI.

OBJECTIVE

We aimed to quantify the association of hospital characteristics with HAPI and their effect on residual hospital variation in HAPI risk.

METHODS

We employed a retrospective cohort study design with split validation using hierarchical survival analysis. This study extends the analysis "Hospital-Acquired Pressure Injury (HAPI): Risk Adjusted Comparisons in an Integrated Healthcare Delivery System" by Rondinelli et al. (2018) to include hospital-level factors. We analyzed 1,661 HAPI episodes among 728,266 adult hospitalization episodes across 35 California Kaiser Permanente hospitals, an integrated healthcare delivery system between January 1, 2013, and June 30, 2015.

RESULTS

After adjusting for patient-level and hospital-level variables, 2 out of 12 candidate hospital variables were statistically significant predictors of HAPI. The hazard for HAPI decreased by 4.8% for every 0.1% increase in a hospital's mean mortality ([6.3%, 2.6%], p < .001), whereas every 1% increase in a hospital's proportion of patients with a history of diabetes increased HAPI hazard by 5% ([-0.04%, 10.0%], p = .072). Addition of these hierarchical variables decreased unexplained hospital variation of HAPI risk by 35%.

DISCUSSION

We found hospitals with higher patient mortality had lower HAPI risk. Higher patient mortality may decrease the pool of patients who live to HAPI occurrence. Such hospitals may also provide more resources (specialty staff) to care for frail patient populations. Future research should aim to combine hospital data sets to overcome power limitations at the hospital level and should investigate additional measures of structure and process related to HAPI care.

Hospital-Acquired Pressure Injury: Risk-Adjusted Comparisons in an Integrated Healthcare Delivery System

BACKGROUND

Although healthcare organizations have decreased hospital-acquired pressure injury (HAPI) rates, HAPIs are not eliminated, driving further examination in both nursing and health services research.

OBJECTIVE

The objective was to describe HAPI incidence, risk factors, and risk-adjusted hospital variation within a California integrated healthcare system.

METHODS

Inpatient episodes were included in this retrospective cohort if patients were hospitalized between January 1, 2013, and June 30, 2015. The primary outcome was development of a HAPI over time. Predictors included cited HAPI risk factors in addition to incorporation of a longitudinal comorbidity burden (Comorbidity Point Score, Version 2 [COPS2]), a severity-of-illness score (Laboratory-Based Acute Physiology Score, Version 2 [LAPS2]), and the Braden Scale for Predicting Pressure Ulcer Risk.

RESULTS

Analyses included HAPI inpatient episodes (n = 1661) and non-HAPI episodes (n = 726,605). HAPI incidence was 0.57 per 1,000 patient days (95% CI [0.019, 3.805]) and 0.2% of episodes. A multivariate Cox proportional hazards model showed significant (p < .001) hazard ratios (HRs) for the change from the 25th to the 75th percentile for age (HR = 1.36, 95% CI [1.25, 1.45]), higher COPS2 scores (HR = 1.10, 95% CI [1.04, 1.16]), and higher LAPS2 scores (HR = 1.38, 95% CI [1.28, 1.50]). Female gender, an emergency room admission for a medical reason, and higher Braden scores showed significant protective HRs (HR < 1.00, p < .001). After risk adjustment, significant variation remained among the 35 hospitals.

DISCUSSION

Results prompt the consideration of age, severity of illness (LAPS2), comorbidity indexes (COPS2), and the Braden score as important predictors for HAPI risk. HAPI rates may be low; however, because of significant individual site variation, HAPIs remain an area to explore through both research and quality improvement initiatives.

Health Behavior Theory for Pressure Ulcer Prevention: Root-Cause Analysis Project in Critical Care Nursing

The purpose of this project was to use a behavioral theory to examine pressure ulcer prevention by nurses in a critical care setting. A root-cause analysis approach was used, including an integrative literature review, operationalization of behavioral constructs into a survey, and root-cause analysis application in a cardiovascular intensive care unit. This article highlights an innovative approach to quality improvement in critical care.

Leading the Future We Envision: Nurturing a Culture of Innovation Across the Continuum of Care

In the Fall of 2012, this large integrated health care system located in Northern California, comprising 21 hospitals and employing more than 25 000 nurses across all inpatient, outpatient, and continuum of care areas, embarked upon a comprehensive initiative to further engage the "hearts and minds" of its nursing workforce while establishing a foundation for innovation in an era of health care reform. This article will outline the strategy employed to ensure that professional nurses across the continuum of care were made aware of the impact of the Affordable Care Act. Major shifts to value-based care and improved performance expectations focus our attention on quality, service, and affordability, also known as the "Triple Aim." Transitioning from a volume-focused model to a value-based care model requires measurable and sustainable improvements over current performance, reinforcing the importance of increased levels of engagement, shared accountability, and purposeful collaboration. Over a span of 18 months, the organization conducted 55 interactive educational forums for point-of-care care teams and leadership. These dynamic learning events helped recalibrate the working foundation for how leaders would nurture the process for innovation among care teams and transform care across the continuum of care.

A nursing information model process for interoperability

The ability to share nursing data across organizations and electronic health records is a key component of improving care coordination and quality outcomes. Currently, substantial organizational and technical barriers limit the ability to share and compare essential patient data that inform nursing care. Nursing leaders at Kaiser Permanente and the U.S. Department of Veterans Affairs collaborated on the development of an evidence-based information model driven by nursing practice to enable data capture, re-use, and sharing between organizations and disparate electronic health records. This article describes a framework with repeatable steps and processes to enable the semantic interoperability of relevant and contextual nursing data. Hospital-acquired pressure ulcer prevention was selected as the prototype nurse-sensitive quality measure to develop and test the model. In a Health 2.0 Developer Challenge program from the Office of the National Coordinator for Health, mobile applications implemented the model to help nurses assess the risk of hospital-acquired pressure ulcers and reduce their severity. The common information model can be applied to other nurse-sensitive measures to enable data standardization supporting patient transitions between care settings, quality reporting, and research.