Safety and Quality Improvement in the Hospital

Ahead of this post- this is an expansion on a paper I wrote for my masters program.  I chose this post today because tomorrow is Florence Nightingale's birthday and the cumulation of nurses week.  Hopefully next week I'll post more about safe staffing.

Problem Statement and Literature Support

 Pressure ulcers are considered an easily preventable nursing error caused by poor quality nursing care. The Agency for Healthcare Research and Quality (AHRQ) states that pressure ulcers affect 2.5 million patients per year (Agency for Healthcare Research and Quality [AHRQ], n.d., figure 1.1). In Minnesota there were 104 pressure ulcers reported via centralized reporting in 2015 (Tingle, 2016, p. 274). A United Kingdom study by Collier (2015) found that in 2014 there were 610 hospital acquired pressure ulcers (HAPU) reported in the Lincolnshire Hospital reporting tool (table 1). The Lincolnshire Hospital Trust in the United Kingdom and Minnesota in the United States are some of the few places requiring reporting of HAPUs. Ma and Park (2015) demonstrated that increased quality of care provided by nurses as demonstrated by achieving and maintaining the Magnet Status designation, reduced the number of pressure ulcers that patients received while hospitalized. (p. 566). Literature exploring the cause of HAPUs in retrospective studies as well as those examining prevention innovations and methods is considerably limited. A brief search of CINAHL (Cumulative Index of Nursing and Allied Health Literature) using the term pressure ulcer retrieved over 5,000 results. When the term hospital acquired was added to the search, either prior or after the phrase pressure ulcer, the search returned no results.

Further and of significant concern to this nurse, was the lack of long-term randomized control trials into the routine of turning and repositioning a patient every two hours.  Even the Cochrane database, considered the gold standard for instituting evidenced based practice changes, has very few reviews of the basic nursing behavior.  Using the search term "pressure ulcer" resulted in 65 overall reviews, and of those five looked at interventions not directly related to treatments (i.e. wet to dry dressing, honey, etc), rather organizational support and other staffing needs to provide safe and appropriate patient care.

There is a secondary concern with the lack of long term research into the turning cycle used by nursing staff.  During a patient's awake time repositioning every two hourse is easy on the nursing staff and makes logical sense when a shift is an even number of hours long. However, sleep cycles have been demonstrated to be 90 minutes long, and restful sleep, specifically the delta, non-dreaming deep sleep phase, has been demonstrated for tissue healing. If the nursing staff continues to reposition patients every two hours without regard to the patient's sleep cycle, are we, as nurses, actually contributing to the problem.

Rational

Much of the research done on pressure ulcer reduction and prevention has been done at the single acute care hospital setting with few studies resulting in interventions that can be easily implemented in other facilities. Additionally, those studies that examine more general views on preventing HAPUs and empirically examine HAPUs are primarily done in Europe and Asia. A study done in one hospital demonstrated that most of the hospital staff involved with pressure ulcer prevention have an average level of knowledge about general pressure ulcer prevention practices and a negative viewpoint towards pressure ulcer prevention (Kaddourah, Abu-Shaheen, & Al-Tannir, 2016). Chaboyer, Gillepsie et. al. (2014) found that there are limited randomized controlled trials for best practice for pressure ulcers internationally, which limits the implementation of best practices. Even the current best practice, turning and repositioning every two (2) hours, which is considered practical, has not been tested with randomized controlled trials. Two well designed studies specifically focused on reduction of healthcare acquired pressure ulcers (HAPU) in their facilities. The first study focused on HAPU reduction in the hospital’s intensive care unit, achieving a 69% reduction in HAPUs in the hospital’s intensive care unit during that time frame (Swafford, Culpepper, & Dunn, 2016, p. 152). The second study was hospital wide and focused on nurse led interventions. This facility achieved an 80% reduction in their incidence of HAPU since the introduction on the interventions (Fabbruzo-Cota et al., 2016, p. 110). Both of those studies would be difficult to expand to other health facilities, but what is learned can be applied in the design of future hospital specific programs.

Plan Design

The initial stages of a plan to decrease HAPUs in the hospital involve (1) data collection of the rates of HAPUs within the organization (2) educational assessment of the staff and (3) equipment assessment. The next stage would include researching and discussing means of improvement and reduction rates with staff. The third stage is implementing a plan, followed by evaluation. If the plan does not result in reduction of pressure ulcers, the process will start again at educational assessment. If the plan does result in a reduction, the evaluation should continue and modifications should be made as additional information about the development and prevention of HAPU’s become available to ensure that best practices continue. Godlock, Christensen, and Feider (2016) recommend the FOCUS-PDCA model for instituting any systemic change.

FOCUS-PDCA consists of nine steps:

• Find a process to improve
• Organize a team
• Clarify the current process
• Understand variations in the current process
• Select process improvement
• Plan the improvement
• Do the improvement
• Check for improvement
• Act to hold gains

If the nursing staff is not on board with a change, as many know, change cannot be implemented even if the current methodology is fragmented and is likely to cause patients or staff harm.  In using a method such as the FOCUS-PDCA method, there is room for staff involvement, and this will make change smoother.

In implementing a HAPU reduction program that would be scalable to other facilities and even across a hospital, there are a few considerations. First, is the issue of culture, including the nurse’s thoughts about pressure ulcers and staffing should be considered. Staff with excellent knowledge as to pressure ulcer formation and prevention can result in significant decline in pressure ulcers. Swafford, Culpepper, and Dunn (2016) achieved a sixty-nine percent (69%) decline in pressure ulcer formation in the presence of an approximately twenty-two percent (22%) in admissions in that same time period (p. 152). Swafford, Culpepper and Dunn (2016) credit some of the reduction to education of the staff. (p. 152). Additionally, in a whole hospital implementation of a HAPU reduction program education showed to contribute to an eighty percent (80%) decline in HAPUs (Fabbruzo-Cota et al., 2016, p. 110). Both studies emphasized the importance of education through the process, including the education in the use and importance of the tools. Additionally both the small ICU only study and the larger hospital study demonstrated that providing their staff with adequate and appropriate equipment and management support encouraged staff to use the equipment and work towards best practices in their own personal practice.

Other concerns that need to be addressed in terms of HAPU improvement includes staffing levels.  Many nurses in active practice whom I have spoken with state their primary barrier to pressure ulcer prevention- even current practice- is staffing levels.  The nurses state that they do not have time to do comprehensive head to toe assessments or ensure that those with continence issues are clean and dry more than once or twice a shift.  In a twelve hour shift, those with positioning issues, and continence issues should be checked and repositioned a minimum of 6 times by assorted staff members.
It would be simple to say that adding more nurses and more support staff will solve the problem, a complete HAPU reduction plan will include appropriate staffing, education of the staff, and equipment to prevent staff and patient injury. None of this is cheap, but the long run savings in prevented pressure ulcers, as well as increased reimbursement from Medicare and Medicaid would offset any losses suffered by the hospital in not only the initial cost of implementing such a program but maintaining the program.

Based on the general success of previously implemented best practices within a single unit as well as whole hospital settings, it can be expected that a well instated HAPU reduction program should see a reduction in HAPUs of fifty percent (50%) or better over a one year period. Godbold et. al. (2016) emphasized the importance of continued ongoing monitoring (A- Act to hold gains) as key in making sure that the reduction holds.  If the hospital wants to continue to reduce HAPUs or maintain the decreased risk of HAPUs in their facilities, then the hospital cannot start to reverse what has been done. This includes not decreasing staffing levels, keeping equipment in good repair, and ensuring that their nursing staff has access to and participate in an evidence based practice system.

References

Agency for Healthcare Research and Quality. (n.d.). Preventing pressure ulcers in hospitals: Are we ready to change. Retrieved from http://www.ahrq.gov/professionals/systems/hospital/pressureulcertoolkit/putool1.http://www.ahrq.gov/professionals/systems/hospital/pressureulcertoolkit/putool1.html

Chaboyer, W., Gillespie, B., McInnes, E., Kent, B., Whitty, J., & Thalib, L. (2014, April 3). Repositioning for pressure ulcer prevention in adults. Cochrane Database for Systemic Reviews. http://dx.doi.org/10.1002/14651858.CD009958.pub2

Collier, M. (2015, October). The development and benefits of 10 year’s experience with an elctronic monitoring tool (PUNT) in a UK hospital trust. European Wound Management Association, 15(2), 15-20. Retrieved from http://survey.hshsl.umaryland.edu/?url=http://search.ebscohost.com.proxy-hs.researchport.umd.edu/login.aspx?direct=true&db=c8h&AN=110787594&site=ehost-live

Fabbruzo-Cota, C., Frecea, M., Kozell, K., Pere, K., Thomspon, T., Thomas, J. T., & Wong, A. (2016). A clinical nurse specialist-led interprofessional quality improvement project to reduce hospital-aquired pressure ulcers. Clincal Nurse Specialist, 110-116. http://dx.doi.org/10.1097/NUR.0000000000000191

Godlock, G., Christiansen, M., & Feider, L. (2016, January/February ). Implementation of an evidence-based patient safety team to prevent falls in inpatient medical units. MedSurg Nursing, 25(1), 17-23.

Kaddourah, B., Abu-Shaheen, A. K., & Al-Tannir, M. (2016, February 24). Knowledge and attitudes of health professionals towards pressure ulcers at a rehabiliation hospital: a cross-sectional study . Biomed Central Nursing , 15(17). http://dx.doi.org/10.1186/s12912-016-0138-6

Ma, C., & Park, S. H. (2015). Hosptial magnet status, unit work enviornment, and pressure ulcers. Journal of Nursing Scholarship, 47, 565-573. http://dx.doi.org/10.1111/jnu.12173

Swafford, K., Culpepper, R., & Dunn, C. (2016). Use of a comprehensive program to reduce the incidence of hospital aquired pressure ulcers in an intensive care unit. American Journal of Critical Care, 25(2), 152-155. http://dx.doi.org/10.4037/ajcc2016963

Tingle, J. (2016). Patient safety perspectives from other countries: the Minnesota system. British Journal of Nursing , 25(5), 274-275. Retrieved from http://eds.b.ebscohost.com/ehost/pdfviewer/pdfviewer?sid=ce6c281a-f5d9-4cdb-9dba-83a2b3582523%40sessionmgr102&vid=0&hid=111