Improving Hospital-Acquired Pressure Injury Outcomes by Overcoming Barriers to Implementing Patient Positioning Devices

Approximately 2.5 million cases of hospital-acquired pressure injuries (HAPIs) occur annually in the United States, with the cost of treatment averaging $11 000.1 An extensive study of critical care patients in US hospitals indicated a HAPI prevalence rate of 5.85%.2 Further analysis showed that 33.2% of those patients developed pressure injuries on the sacrum or coccyx, followed by 14.8% on the buttocks.2 Pressure injuries impose a significant burden on the patient, including increased morbidity, mortality, and pain.3 Because most pressure injuries are preventable, their financial and quality-of-care implications for hospitals are significant. Therefore, introducing care innovations to improve patient outcomes is crucial. This project to improve the outcomes of patients with HAPIs began before the onset of the COVID-19 pandemic. However, the products and procedures implemented helped achieve and sustain improved pressure injury outcomes despite the multitude of challenges posed by the crisis care environment, including a reduction in available nursing personnel.The fiscal year 2019 goal at our large midwestern academic medical center was achieving top-decile clinical quality excellence. Despite considerable efforts, however, the surgical intensive care unit (SICU) continued to experience a high incidence of sacral, coccyx, and buttock skin breakdown among at-risk adult surgical patients. A nurse-led unit skin team identified practice opportunities to improve nursing care efficiency while decreasing the friction, shear, and pressure that contribute to HAPIs. This Magnet-designated institution recognizes and values nurses’ feedback. All views including the frontline perspective, unit leadership concerns, and wound ostomy continence nurse (WOCN) expert guidance were balanced to achieve sustainable, data-driven solutions. A lean process improvement framework—combined with the principles of value stream, flow, “pull,” and seeking perfection—was used to improve patient outcomes and nursing satisfaction.4,5Overcoming barriers in quality improvement projects requires product innovation, which in turn requires understanding of institutional goals and appropriate metrics and measurements. In addition, workflow analysis and change management strategies are critical to achieving full project implementation while maintaining patient-centered goals. In 2019, the European Pressure Ulcer Advisory Panel, National Pressure Injury Advisory Panel, and Pan Pacific Pressure Injury Alliance released revised guidelines stressing the importance of frequent patient repositioning while minimizing skin exposure to friction and shear forces.3 Before this project began, the nurses in our institution turned and positioned patients using pillows and reusable wedges. A literature review performed by the unit skin team uncovered a study demonstrating the value of patient-specific positioning devices, which resulted in more sustained and effective turns than those achieved with pillows.6 In addition, the study showed that use of patient positioning devices required fewer staff resources, less physical effort, and less time.6 However, translating this evidence into practice required overcoming implementation barriers, as hospital decision-makers viewed the desired new products as expensive compared with the current practice.Nurses voiced concern that the current reusable wedges were ineffective for positioning patients and posed the risk of nosocomial infection. In addition, because the reusable wedges tended to travel with the patients from unit to unit, they tended to get lost within the system, resulting in an insufficient supply. The current transfer devices were regarded as inefficient and inconsistently used, as they could not remain in place under the patient. The current practice was to roll the immobile patient side to side, placing and replacing the product under the patient for each boost in bed or lateral transfer. Review of the literature and a benchmarking process confirmed that the current positioning products did not support best practices in reduction of pressure, shear, and friction.Using a lean process improvement framework and mapping the value stream enabled identification of types of waste and inefficiency related to the current products and processes (Table 1).4 This strategy revealed the need to evaluate new products and workflows to improve patient outcomes related to HAPIs.Striving to improve practice, skin team nurse leads partnered with the unit team, clinical nurse specialists, and WOCNs to benchmark and identify the best techniques and products. This process identified a patient-specific glide sheet product that included a set of wedges. The patient benefits from the glide sheet remaining beneath them, reducing skin friction or related injury during boosting and lateral transfers. This feature also increases the efficiency of nursing practice by decreasing repetitive work. The wedges prevent slipping and overturning and reduce infection risk by limiting use to a single patient. Even when a new product has clear benefits, its adoption by an organization requires buy-in from decision makers among supply chain, finance, and nursing executives, who must understand the product’s cost-benefit value and the return on investment. Table 2 summarizes strategies for navigating cost concerns and resistance to change when making nursing practice improvements.Once the product is approved, setting the pilot program up for success includes developing system supports that create product “pull,” which means ensuring that the right product is available and is used at the right time and for appropriate patients. Overuse of a product with high costs may contribute to poor trial results. Therefore, before the product pilot, it was essential to establish workflow details and standard work guides. The Figure shows the chart that was used to guide staff members to use the product only for high-risk patients. Unit champions must be empowered to make decisions such as standardizing product location, planning for obtaining staff feedback, and capturing practice gains such as measuring compliance (more adequate turns), workflow (fewer steps), and time saved. Establishing a cadence for rounding during the trial by unit leaders, clinical nurse specialists, and WOCNs allowed collection of real-time patient and family feedback and helped identify early barriers to implementation. Forming close partnerships with supply department leaders and monitoring utilization reports supported projections of annual use after the trial. After product pilot workflows are established, the final step is training staff on the product and processes.A 2-week trial during the spring of 2018 resulted in positive feedback from patients and nurses. After metrics showed positive gains in practice, the nursing executive team approved the product for rollout in the SICU in September 2019. After approval, the focus shifted to ensuring the sustainability of improved outcomes. Partnerships with product vendors, supply chain executives, WOCNs, and informatics and environmental services personnel were important for the continuous pursuit of excellence. Strategies for seeking perfection and achieving sustainability included monitoring monthly HAPI incidence reports, adding documentation fields to the electronic medical record for nurses to document product use, WOCN rounding to ensure appropriate product use, monitoring product use and requesting adjustments as necessary, and holding quarterly education sessions led by the product vendor to reduce the chances of “practice drift.”Six months after product implementation, the SICU incidence of sacral, coccyx, and buttock skin breakdown was zero compared with other critical care units where these pressure injuries continued to occur. The improved staff satisfaction, better patient outcomes, and demonstrated cost-effectiveness led to approval for expansion of the program to all critical care units in May 2020. This timing coincided with the increased complexity of care during the COVID-19 pandemic. Since the new product implementation, all 4 critical care units have experienced substantially reduced incidences of HAPIs. The SICU has sustained a rate of zero sacral, coccyx, and buttock pressure injuries since August 2020.Reducing waste by applying innovations to inpatient care is essential to meet rising quality expectations during a time of decreasing resources. The use of multiple metrics to capture the value of practice improvements can help overcome implementation barriers and gain hospital decision-makers’ buy-in, leading to increased nurse satisfaction and enhanced patient outcomes.The authors thank Angelique Richard, SVP Hospital Operations, CNO for Rush University Medical Center, and CNE Rush University System for Health; Shonda Morrow, Vice President, Patient Care Services, Hospital Affairs, Rush University Medical Center; Mark Serain, Manager, Business Operations and Finance, Division of Nursing, Rush University Medical Center; Andrea Pekofske, Strategic Sourcing Manager, Rush University Medical Center; Timothy Rog, Assistant Unit Director, cardioscience intensive care unit, Rush University Medical Center; Jaclyn Zasaitis, registered nurse, cardioscience intensive care unit, Rush University Medical Center; and Katherine Barclay, registered nurse, cardioscience intensive care unit, Rush University Medical Center.