Since its beginning the Skin Care Committee at Texas Health Presbyterian Hospital Dallas has been driven by a goal to decrease the incidence of Hospital Acquired Pressure Ulcers (HAPU) below national benchmarks.
The team found that studying the literature and developing actions plans could not be successful without continuously increasing the knowledge and expertise of all caregivers in skin assessments and interventions.
"The defining moment occurred in the 2nd Quarter 2011 when the quarterly Skin Prevalence Study revealed a hospital wide HAPU rate of 0.8 percent," Debbie Kelp, RN, chair of the Skin Committee, wrote in her essay to ADVANCE.
"This was a phenomenal decrease from a rate exceeding 10 percent in 4 Quarter 2009. This allowed the team to visualize a new goal of 0 percent HAPU."
The Skin Committee, composed of a majority of direct care RNs, meets monthly to evaluate data and develop tools and interventions. The team is responsible for introducing and supporting the use of strategies for RNs hospital wide to identify pressure ulcers present on admission and prevent further skin breakdown while patients are hospitalized.
Kelp designated a portion of this meeting to develop the expertise of these nurses so that they may lead hospital wide process improvement. The team partnered with the Wound Ostomy and Incontinence Nurses (WOCN), physical therapy and nutrition department and studied the literature to identify best practices.
The group was charged with extending this expertise to other direct care RNs and so a new role of Skin Resource Nurses was developed. Each unit designated a direct care nurse that would become the Skin Care Champion for that unit. These nurses began to meet once a quarter and received education from the WOCN's, physician wound specialist, and vendors who provided the skin care products used at the hospital.
These nurses also conducted quarterly Skin Prevalence Studies, a designated day they fanned out over the hospital and assessed the skin of every adult in-patient on campus.
In addition, Skin Resource Patient Care Technicians were identified on each unit and became partners in patient care with the Skin Resource RNs. They participated in the Quarterly Skin Prevalence studies and received specialized training in early detection of skin breakdown and what to report to the nurse assigned to the patient.
Since many nurses are hands on learners, rather than more education, it was determined that a unit that did not meet the benchmarks on a skin prevalence study would conduct monthly skin prevalence studies, Kelp added.
If not at benchmark by the next quarterly study, the skin prevalence studies were increased to weekly. The repetition of the new processes and best practices successfully increased awareness and accountability on the units that struggled with below benchmark results.
In 2nd quarter 2010, an additional intervention utilized the expertise of the WOCNs. To insure inter-rater reliability of the Skin Resource Nurse's assessment, the WOCNs conducted a second assessment later in the day of each HAPU identified in the quarterly prevalence study. Some HAPU initially identified were found to be positional skin irritation that had resolved at the time of the WOCN assessment. This supported a continued decrease of HAPU prevalence.
On top of the measures mentioned above, a comprehensive web based training module was developed to advance the skills of RNs to assess and detect the earliest stage of skin break down. 90 percent of all RNs completed this training.
The prevalence of HAPU began to decline, but so did the national benchmark. A consensus statement was released by the National Pressure Ulcer Advisory Panel in March 2010 that defined some pressure ulcers as "unavoidable" based on specific factors and variables in the patient's condition, Kelp noted.
Other evidence based practice literature proposed that HAPU should be a "never event" and CMS was developing payment structures to withhold payment for HAPU occurrences. It was noted that similar hospitals were reporting 0 percent occurrence of HAPU.
"This team was not content to 'just meet the benchmark,' but accepted the premise that our hospital treated some of those patients who would develop "unavoidable" HAPU," Kelp wrote. "They questioned "if" and "what" advanced expertise could continue to decrease the incidence of HAPU?"
Best practices identified and implemented included:
- "Turning Buddies"- nurses partnering with their colleagues on the unit to establish an every 2 hour turning schedule.
- Referral for nutrition screening if a patient was identified as at risk for skin breakdown on admission.
- Taking pictures of all skin breakdowns and importing pictures to the electronic health record.
- Established new work flow changes that required 2 nurses to assess skin on admission.
- Coordinated in-patient and outpatient wound care patient records and integrated the Skin Care Protocol in the electronic health record.
"Maintaining these improvements and hardwiring these practices for consistency and predictability became the emphasis for this team. A new determination dawned and a belief arose: HAPU could be a never event at our hospital," Kelp emphasized. "This fueled a new level of commitment and accountability."
The 4th Quarter Prevalence Study revealed the benefits of consistently increasing knowledge and expertise throughout the nursing care staff, HAPU prevalence hospital wide was 0 percent.