Reducing hospital acquired pressure ulcers in intensive care

A retrospective analysis of adverse events reported by Tunisian intensive care units' professionals

INTRODUCTION

Adverse events (AEs) that occur in hospitals remain a challenge worldwide, and especially in intensive care units (ICUs) where they are more likely to occur. Monitoring of AEs can provide insight into the status and advances of patient safety. This study aimed to examine the AEs reported during the 20 months after the implementation of the AE reporting system.

METHODS

We conducted a retrospective analysis of a voluntary ICU AE reporting system. Incidents were reported by the staff from ten ICUs in the Sahloul University Hospital (Tunisia) between February 2020 and September 2021.

RESULTS

A total of 265 reports were received, of which 61.9% were deemed preventable. The most frequently reported event was healthcare-associated infection (30.2%, n = 80), followed by pressure ulcers (18.5%, n = 49). At the time of reporting, 25 patients (9.4%) had died as a result of an AE and in 51.3% of cases, the event had resulted in an increased length of stay. Provider-related factors contributed to 64.2% of the events, whilst patient-related factors contributed to 53.6% of the events. As for criticality, 34.3% of the events (n = 91) were unacceptable (c3) and 36.3% of the events (n = 96) were 'acceptable under control' (c2).

CONCLUSIONS

The reporting system provided rich information on the characteristics of reported AEs that occur in ICUs and their consequences and may be therefore useful for designing effective and evidence-based interventions to reduce the occurrence of AEs.

Considerations in wound care of patients living with dementia

The prevalence of wounds and comorbidities such as dementia increases with age. Given projected rises in population ageing and growth, the likelihood of encountering an overlap in these conditions in clinical practice has increased. Clinicians provide wound care for patients in a variety of settings, drawing on different evidence-based clinical guidelines. Most research into wound care has excluded patients with dementia. Therefore, the aim of this review is to provide safe strategies and methods of implementation in those patients living with dementia.

Quality Improvement Intervention Bundle Using the PUPPIES Acronym Reduces Pressure Injury Incidence in Critically Ill Patients

OBJECTIVE

To assess whether a quality improvement bundle focusing on prevention is effective in reducing pressure injury (PI) incidence or costs or delaying PI onset.

METHODS

A combined retrospective/prospective cohort study was performed at an academic tertiary care ICU on all patients admitted with a length of stay longer than 48 hours and Braden scale score of 18 or less. Following retrospective data collection (preintervention), a multimodal quality improvement bundle focusing on PI prevention through leadership initiatives, visual tools, and staff/patient education was developed, and data were prospectively collected (postintervention).

RESULTS

Statistical and cost analyses were performed comparing both cohorts. A total of 930 patients met the study inclusion criteria (preintervention, n = 599; postintervention, n = 331). A significant decrease in PI incidence was observed from preintervention (n = 37 [6%]) to postintervention (n = 7 [2%], P = .005). This led to a predicted yearly cost savings of $826,810. Further, a significant increase in time to PI occurrence was observed from preintervention (mean, 5 days) to postintervention (mean, 9 days; P = .04). Staff were compliant with the bundle implementation 80% of the time.

CONCLUSIONS

Implementation of the quality improvement bundle focused on multimodal PI prevention in critically ill patients led to a significant reduction in PI incidence, increased time to PI occurrence, and was cost-effective.

Predicting open wound mortality in the ICU using machine learning

BACKGROUND

Open wounds have a significant impact on the health of patients causing pain, loss of function, and death. Labeled as a comorbid condition, open wounds represent a "silent epidemic" that affect a large portion of the US population. Due to their burden of care, open wound patients face an increased risk of ICU stay and mortality. There is a dearth of studies that investigate mortality among wound patients in the ICU. We sought to develop a model that predicts the risk of mortality among wound patients in the ICU.

METHODS

Random forest and binomial logistic regression models were developed to predict the risk of mortality among open wound patients in the Medical Information Mart for Intensive Care III (MIMIC-III) database. MIMIC-III includes de-identified data for patients who stayed in critical care units of the Beth Israel Deaconess Medical Center between 2001 and 2012. Six variables were used to develop the model (wound location, gender, age, admission type, minimum platelet count and hyperphosphatemia). The Charlson Comorbidity Index (CCI) and Elixhauser Comorbidity Index were used to assess model strength.

RESULTS

A total of 3,937 patients were included with a mean age of 76.57. Of those, 3,372 (85%) survived and 565 (15%) died during their ICU stay. The random forest model achieved an area under the curve (AUC) of 0.924. The CCI and Elixhauser models resulted in AUC of 0.528 and 0.565, respectively.

CONCLUSIONS

Machine learning models may allow clinicians to provide better care and management to open wound patients in the ICU.

Age-Friendly Health Care: A Systematic Review

Background: Health care provided to older adults must take into account the characteristics of chronic diseases and the comorbidities resulting from ageing. However, health services are still too oriented towards acute situations. To overcome this problem, the World Health Organization (WHO) proposed a set of Age-Friendly Principles that seek to optimize the provision of health care for this population. This article aims to understand how such Principles are considered in the implementation of age-friendly health care worldwide. Methods: A systematic review was conducted to synthesize the literature on age-friendly health care in accordance with the PRISMA recommendations in the PubMed, Web of Science, and Scopus databases. Results: The research identified 34 articles, with only seven recognizing the WHO Principles and only four using the implementation toolkit. In addition, in the context of primary care, three studies recognize the WHO Principles, but only two use the toolkit. Conclusions: The WHO Principles are being implemented in health care, but in a smaller scale than desired, which reveals possible flaws in their dissemination and standardization. Thus, a greater scientific investment in age-friendly health care should be considered, which represents a greater operationalization of the Principles and an evaluation of their effectiveness and impacts.

Pressure injury data in Australian acute care settings: A comparison of three data sets

Hospital-acquired pressure injuries (HAPIs) represent a serious clinical and economic problem. The cost of treating HAPIs in Australian public hospitals was recently reported at AUS$983 million per annum. There are three main sources of data for documenting pressure injury (PI) occurrence in Australian hospitals: incident reporting, medical record coded data, and real-time surveys of pressure injury. PI data reported at hospital level and to external agencies using these three different sources are variable. This reporting issue leads to inaccurate data interpretation and hinders improvement in accuracy of PI identification and PI prevention. This study involved a comparison of the three different data sources in selected Australian hospitals, to improve the accuracy and comparability of data. Findings from this study provide benchmark areas for improvement in PI documenting and reporting. Better understanding the agreement between the three data sets could lead to a more efficient and effective sharing of data sources.

Lessons Learned From Medical Malpractice Claims Involving Critical Care Nurses

BACKGROUND

Medical malpractice data can be used to improve patient safety.

OBJECTIVE

To describe the types of harm events involving nurses that lead to malpractice claims and to compare claims among intensive care units (ICUs), emergency departments, and operating rooms.

METHODS

Malpractice claims closed between 2007 and 2016 were extracted from a national database. Claims with a nurse as the primary provider were identified and then compared by location of the harm event: ICU, emergency department, or operating room. Multivariable regression was used to determine predictors of claims payment.

RESULTS

Of 54 699 claims, 314 involved ICU nurses as the primary provider. The majority (59%) of claims involving ICU nurses resulted in death or permanent injury. The most common allegation of claims involving ICU nurses was failure to monitor (47%), which was higher than among claims against nurses in the emergency department (9%) or the operating room (4%) (P < .001). The most common diagnosis in claims involving ICU nurses was decubitus ulcers (26%). Despite equivalent numbers of defendants per claim, the median indemnity for paid claims involving ICU nurses was higher ($125 000) than that paid for claims originating in the emergency department ($56 799) or operating room ($43 910) (P < .001). In multivariable regression, 2 variables increased the risk of claim payment: ICU location (odds ratio, 1.79 [95% CI, 1.29-2.48]) and permanent injury (odds ratio, 1.50 [95% CI, 1.07-2.09]).

CONCLUSIONS

Malpractice claims involving ICU nurses were distinct from claims in comparably fast-paced settings. Focusing harm-prevention efforts in the ICU on skin integrity and monitoring of patients would most likely mitigate many highly severe harms involving ICU nurses, which would benefit both patients and nurses.

Improving the quality of pressure ulcer management in a skilled nursing facility

Pressure ulcers (PUs) are a serious health care problem for nursing home residents and a key quality metric for regulators. Three initiatives were introduced at a 128-bed facility to improve PU prevention. First, a Quality Assurance and Performance Improvement project and a Root Cause Analysis were conducted to improve the facility's wound care programme. Second, a digital wound care management solution was adopted to track wound management. Third, the role of skin integrity coordinator was created as a central point of accountability for wound care-related activities and related performance metrics. Improvements in PU prevention were tracked using Centers of Medicare and Medicaid data, specifically (a) the percentage of long-stay high-risk residents with PUs and (b) the percentage of short-stay residents with PUs that are new or have worsened. PU prevalence for long-stay high-risk residents was 12.99% (Q4 2016), and upon implementation of these initiatives, the facility saw continued reductions in PU prevalence to 2.9% (Q4 2017), while PUs for short-stay residents were maintained at zero throughout this period. This study highlights the power of effective management combined with real-time data analytics, as enabled by digital wound care management, to make significant improvements in health care delivery.

Quality of reporting of outcomes in trials of therapeutic interventions for pressure ulcers in adults: a protocol for a systematic survey

Pressure ulcers (PUs) have a high incidence, especially in hospital units. Randomised clinical trials (RCTs) of therapeutic interventions for PU should include a clear description of the outcomes and results to enhance transparency and replicability.

OBJECTIVES

The primary objective of this study is to assess the completeness of the descriptions of the outcomes of therapeutic interventions in RCTs in adult patients with PU. The secondary objectives are to evaluate the types of reported primary outcomes, measurement methods or tools used to evaluate the outcomes and the results of reported outcomes.

METHODS

We will conduct a systematic survey of RCTs published from January 2006 to April 2018. The selection process of the studies will be done in two stages of screening: title and abstract, and full text revision, always by two researchers independently. The completeness of the outcome will be assessed according to five criteria: domain (outcome title), specific measurement or technique/instrument used, specific metric or format of the outcome data that will be used for analysis, method of aggregation (how data from each group will be summarised) and time-points that will be used for analysis. The quality of the results of the outcome will be classified as either complete, incomplete or unreported. We will conduct a descriptive analysis of the number, type and degrees of outcome specification in the included RCTs. The frequency of categories in each domain of the outcomes will also be reported. The median and IQR will be estimated for each element of the specified outcome (out of five).

ETHICS AND DISSEMINATION

This will be the first systematic assessment of the outcomes of therapeutic interventions used for pressure ulcers. After completion, this review will be submitted to a peer-reviewed journals.

Reducing the incidence of pressure ulcers in critical care units: a 4-year quality improvement

Quality problem

Critical care patients often have several risk factors for pressure ulceration and implementing prevention interventions have been shown to decrease risk.

Initial assessment

We identified a high incidence of pressure ulcers in the four adult critical care units in our organization. Therefore, avoiding pressure ulceration was an important quality priority.

Choice of solution

We undertook a quality improvement programme aimed at reducing the incidence of pressure ulceration using an evidence-based bundle approach.

Implementation

A bundle of technical and non-technical interventions were implemented supported by clinical leadership on each unit. Important components were evidence appraisals; changes to mattresses; focussed risk assessment alongside mandating patients at very high risk to be repositioned two hourly; and staff training to increase awareness of how to prevent pressure ulcers.

Evaluation

Pressure ulcer numbers, incidence and categories were collected continuously and monitored monthly by unit staff. Pressure ulcer rates reduced significantly from 8.08/100 patient admissions to 2.97/100 patient admissions, an overall relative rate reduction of 63% over 4 years. The greatest reduction was seen in the most severe category of pressure ulceration. The average estimated cost saving was £2.6 million (range £2.1-£3.1).

Lessons learned

A quality improvement programme including technical and non-technical interventions, data feedback to staff and clinical leadership was associated with a sustained reduction in the incidence of pressure ulceration in the critically ill. Strategies used in this programme may be transferable to other critical care units to bring more widespread patient benefit.

Measuring the quality of pressure ulcer prevention: A systematic mapping review of quality indicators

The aim of this study was to provide a systematic overview of available pressure ulcer prevention quality indicators and to evaluate the underlying empirical evidence. A systematic mapping review was conducted with combined searches in Embase and Medline, and websites of relevant institutions and organisations. The eligibility criteria were clear use of the term "quality indicator" regarding pressure ulcer prevention; English or German language; and all settings, populations, and types of resources, including articles, brochures, and online material. In total, n = 146 quality indicators were identified. Most indicators were published in the United States (n = 50). The majority of indicators was developed for the hospital setting (n = 102). Process indicators were the most common (n = 71), followed by outcome indicators (n = 49). Less than half of identified indicators appeared to be practically used. Evidence supporting the validity and reliability were reported for n = 25 and n = 30 indicators respectively. The high number of indicators demonstrate the importance of measuring pressure ulcer prevention quality. This is not an indicator of our ability to accurately measure and evaluate this construct. There is an urgent need to develop evidence-based and internationally comparable indicators to help improve patient care and safety worldwide.

Prevention and treatment of skin lesions associated with non-invasive mechanical ventilation. Recommendations of experts

INTRODUCTION

In the last two decades, non-invasive mechanical ventilation (NIV) has been consolidated as an initial strategy for the management of respiratory failure in critical adult and paediatric patients.

OBJECTIVES

To identify risk factors and preventive strategies to reduce the incidence of skin lesions associated with clinical devices (LESADIC) related to NIV, as well as the most effective treatment for injuries that cannot be avoided.

METHODOLOGY

Review in the MEDLINE, CINAHL and Cochrane databases of studies published in the last 10years to reach consensus through an expert panel.

RESULTS

Knowledge about how to measure correct mask size and protection of the skin with foam or hydrocolloids dressings are factors related to the incidence of LESADIC, as it conditions the degree of pressure-friction and shear that the interface exerts on the skin. The interface that causes fewer LESADIC and is better tolerated is the face mask. When there are injuries, the first thing is to remove the interface that causes pressure on damaged skin, recommending a Helmet^® hood as an alternative, treating the infection, managing the exudate and stimulating perilesional skin.

CONCLUSIONS

The mask of choice is the facial, always using foam or hydrocolloid dressings on the nasal bridge. Evaluate the condition of the skin under the interface and harness every 4hours (recommended) and 11hours (maximum). Evaluate the rotation strategy of the interface at 24hours if the NIV is still needed on an ongoing basis.

Quality improvement in health care: how to do it

This article outlines the steps to success in quality improvement and explains how quality improvement can help you, your patients and your institution. Although many tactics can be used to drive quality improvement, some tactics deliver results that are short term and unsustainable and that fail to embed a culture of quality improvement within organizations. Consensus is emerging that a bottom-up approach may be better - where the intrinsic motivations of clinical staff are harnessed to drive quality improvement. This is an ideal opportunity for clinical staff at all levels to join in. The steps involved in quality improvement include choosing a topic, choosing tools to measure the problem, using plan, do, study, act cycles to drive improvement, and then writing up and sharing the project. Quality improvement projects can achieve multiple outcomes including improved patient experience and saved costs.