In healthcare, pressure injuries are a serious problem that cannot be overlooked. Pressure injuries carry a psychological, financial, and physiological burden to patients and a financial burden to healthcare organizations. The Agency for Healthcare Research and Quality developed a toolkit for reducing pressure injuries. Over an eight-week period, the toolkit was used in four intensive care units, with a focus on fidelity of comprehensive skin assessments. Through increased adherence to the toolkit components, the four ICUs, which had 374 patients and 1,530 patient days, saw a decrease in pressure injury rate, incidence, and prevalence.
Problem: Nationally, pressure injuries are a problem that over 2.5 million people develop annually. CMS can financially penalize hospitals for advanced pressure injuries staged at 3, 4, and unstageable. In the acute care facility, there were 156 pressure injuries in 2022, six were reportable to CMS.
Measurement: The project outcome was to be considered successful if the rate of post-intervention pressure injuries was lower than the pre-intervention rate. To measure the rate, the number of injuries was divided by the number of patient days and then multiplied by 1000. A control chart showed a trendline of success.
Analysis: The data abstracted pre-implementation included the location, type, and severity of all pressure injuries. An FMEA analysis was also performed for interventions within the AHRQ toolkit for pressure injury reduction that were missing in any cases of pressure injuries. This uncovered a lack of fidelity in performing comprehensive skin assessments.
Implementation: Daily formative evaluations of fidelity to the intervention with color-coded charts handed to staff of patients who did not have a comprehensive skin assessment within the previous 24 hours. By doing this daily, it was designed to hard-wire this practice into the nurse’s routine by the end of 8 weeks.
Results/Discussion: Through increased adherence to the toolkit components, the four ICUs, which had 374 patients and 1,530 patient days, saw a decrease in pressure injury rates from 4.875 to 2.61. The incidence decreased from 285.71% to 187.17%, and prevalence decreased from 253.97% to 106.95%.
