We conducted a quality improvement project in order to evaluate the effect of nurse-to-nurse bedside "rounding" as a strategy to decrease hospital-acquired pressure ulcers (HAPU) in a surgical intensive care unit. We instituted weekly peer-to-peer bedside skin rounds in a 17-bed surgical intensive care unit. Two nurses were identified as skin champions and trained by the hospital's certified WOC nurse to conduct skin rounds. The skin champion nurses conducted weekly peer-to-peer rounds that included discussions about key elements of our patients' skin status including current Braden Scale for Pressure Sore Risk score, and implementation of specific interventions related to subscale risk assessment. If a pressure ulcer was present, the current action plan was reevaluated for effectiveness. Quarterly HAPU prevalence studies were conducted from January 2008 to December 2010. Nineteen patients experienced a HAPU: 17 were located on the coccyx and 2 on the heel. Ten ulcers were classified as stage II, 3 PU were stage IV, 5 were deemed unstageable, and 1 was classified as a deep tissue injury. The frequency of preventive interventions rose during our quality improvement project. Specifically, the use of prevention surfaces increased 92%, repositioning increased 30%, nutrition interventions increased 77%, and moisture management increased 100%. Prior to focused nursing rounds, the highest HAPU prevalence rate was 27%. After implementing focused nursing rounds, HAPU rates trended down and were 0% for 3 consecutive quarters.
Introduction
The prevention of hospital-acquired pressure ulcers (HAPU) is a nursing quality outcome measure used to evaluate the effectiveness of nursing care and optimal patient outcomes.1-3 In October 2008, the Centers for Medicare & Medicaid Services added prevention of HAPU to the National Patient Safety Initiatives.4 Preventing HAPU remains a focus for improving the quality care in the current Healthy People 2020 objectives.5 Despite the increased focus on prevention of HAPU, prevalence rates range from 14% to 17% and incidence rates range between 7% and 9%.6-8 An estimated 60,000 patients die of pressure ulcer (PU)-related complications each year.9 The average cost of PU care per patient has been estimated at $43,180 per hospital stay5 with an annual cost of approximately $11 billion.10 A significant body of evidence is available to guide clinical practice to reduce the prevalence and incidence of PU.11,12
Local Problem and Intended Improvement
Prevention of HAPU begins with a nursing assessment of PU risk using a valid risk instrument.12,13 While there is insufficient evidence to conclude that the use of a risk assessment scales decreases PU incidence,14 their use has been shown to aid nurses in designing and implementing an individualized prevention plan.15 Completing a PU risk assessment is a standard of care in our surgical intensive care unit (SICU). We complete a Braden Scale score16 on admission to the unit, and every 12 hours. We complete this assessment more frequently when a change in the patient's condition indicates that reassessment is indicated. While chart audits demonstrated that the standard of care was being completed, it was not known if SICU nurses were linking these assessments to an individualized plan of care to prevent HAPU. This concern was prompted by a rising HAPU rate in our SICU. Therefore, a quality improvement project was initiated by 2 bedside nurses (skin champions-A.K. and A.M.) in coordination with the hospital's certified WOC nurse, the unit clinical nurse specialist (CNS), and the unit nurse manager. The primary goal of this quality improvement project was to decrease the HAPU prevalence in the SICU through peer-to peer bedside nursing rounds under the clinical leadership of unit-based skin care champions. A secondary goal was to increase the use of preventive interventions.
Nursing rounds were used as a primary intervention because evidence suggests that they provide an opportunity for nurses to increase their understanding of interventions and reasoning for care decisions.17 Clinical rounds have been described in various settings and are generally used to improve the use of evidence in practice providing a forum to model expertise and develop clinical decision-making skills.18 In this quality improvement study, we combined the expertise of the certified WOC nurse, CNS, and skin care champions to implement nursing rounds to improve PU prevention knowledge and prevention interventions.
Practice Setting
This quality improvement project was conducted in a 17-bed SICU that is part of a 413-bed quaternary referral academic medical center in Colorado. The SICU provides care to a variety of critically ill patients including trauma, cardiothoracic surgery, general surgery, and transplant surgery/bridge-to-transplant patient populations. Patients in the SICU are typically high-acuity individuals characterized by long operative times, sustained periods of hemodynamic instability, aggressive fluid mobilization, excessive moisture from drains, third spacing of fluid, and fecal incontinence. Each of these factors is known to contribute to an increased risk of pressure ulceration.12,19
Intervention Planning and Study
The hospital has a skin champion team consisting of certified WOC nurses, a nurse researcher, clinical dietician, and bedside nurses. The purpose of the skin champions is to continually review current best practice for optimal skin care to include prevention of HAPU. The team develops evidence-based clinical decision tools to guide nursing practice relative to skin care, wound care, and PU prevention and management. The SICU has 2 bedside nurses as representatives on this team. The SICU unit skin champion RNs began to embrace their role with the initiation of the Skin Prevention Assessment Management hospital-wide campaign that was launched in September 2008. A teaching tool in the form of a pocket guideline was distributed to each bedside nurse. The tool included information on body anatomical pressure points, our PU prevention protocol and intervention algorithm, PU staging, measuring, and documentation, along with a Braden Scale risk assessment scorecard with treatment guidelines. The unit skin champion RNs were responsible for ensuring staff education about the Skin Prevention Assessment Management program for HAPU prevention.
Despite these educational efforts, HAPU prevalence in our SICU remained a concern. The SICU skin champions hypothesized that hospital-wide training might not have resulted in meaningful practice changes within the SICU practice environment. Thus, a focused, extensive case study was developed to enhance teaching on skin assessment, prevention, and documentation in this critical care unit. The case study was reviewed through informal peer-to-peer teaching, presentations at staff meetings, and a detailed poster display. In spite of these efforts, the PU prevalence rate continued to be above benchmark prevalence rates published by the National Database of Nursing Quality Indicators (NDNQI) for SICU in academic hospitals.
In an effort to improve patient outcomes and reduce the unit HAPU prevalence rates, the 2 unit skin champion RNs met with the certified WOC nurse, unit manager, and unit CNS to develop a more effective method to engage staff in aggressive PU prevention. The root of the problem was identified as a lack of application of the subscales of the Braden Scale for subscale-specific interventions. Lynn and colleagues20 suggested that bedside rounds provide systematic, data-guided activities designed to bring about immediate improvements in health care delivery. The SICU team decided to implement PU bedside rounds as a focused intervention to bring about rapid improvement in the nurses' knowledge of PU risk assessment. Rounds were also created to bridge assessment of PU risk via the Braden Scale and application of daily nursing care.
In quarter 6, the certified WOC nurse, unit manager, unit CNS, and unit skin champion RNs began weekly PU bedside rounds. The idea was not to examine the patients, but to engage the unit RNs in a discussion of their patients' PU risk factors. Rather than asking the RN to state the Braden Scale (eg, number), nurses were asked to apply their knowledge of the Braden Scale subscales to preventive interventions driven from the specific subscale risk assessment. For example, if the RN stated that the patient was consistently moist from incontinence, the intervention would be to use the moisture wicking underpads, regular application of a skin protectant, and exploration of the cause of excessive moisture.
We used a specific question format to guide discussions with RN colleagues (Table 1). In addition to this set group of questions, patient specific risks such as compromised hemodynamics or specific orders were discussed. For example, if the physician ordered strictly limited patient mobility, the bedside RN was encouraged to discuss the rationale of the order, methods to relieve pressure points without full position changes, and the ongoing need for this restriction when the patient's medical condition improved. The RN was also encouraged to investigate the need for an alternative support surface such as a low air loss or immersion surface, a nursing-driven decision in our hospital.
At times, the certified WOC nurse, the unit manager, and the unit CNS were not able to be present for PU bedside rounds. However, as the unit skin champion RNs developed increased comfort with rounding, they exerted ownership and continued rounds independently. If a problem or concern was not resolved during peer-to-peer bedside rounds, the unit skin champions contacted the certified WOC nurse for further evaluation. The unit skin champion RNs were able to expand the process to include nights and weekends within their own schedules, thus increasing consistency of rounds between all shifts. Over time it was noticed that bedside RNs were more engaged in conversations about PU prevention within the context of this peer-to-peer approach. Over time HAPU prevalence rates diminished and the frequency of PU bedside rounds was decreased to bimonthly and then monthly.
Methods of Evaluation
We measured quarterly HAPU prevalence in our SICU in order to measure the effect of peer-to-peer nursing rounds based on NDNQI standards. Both skin care champions completed the NDNQI PU training modules (available at https://www.nursingquality.org/ndnqipressureulcertraining/default.aspx) on how to collect and report data. Pressure ulcer prevalence studies were collected on a single day, once a quarter. Data were compiled through a chart review and visual skin assessment. Pressure ulcer staging system used was defined by the National Pressure Ulcer Advisory Panel.21 We include all stages of PU (eg, stages I through IV), unstageable, and suspected deep tissue injury. Hospital-acquired pressure ulcers found during the prevalence study were validated by the certified WOC nurse. To evaluate the effectiveness of PU bedside rounds, unit-acquired PU and interventions were tracked based on these prevalence data.
Our evidence-based skin care team met and reviewed the data on a quarterly basis, in order to enable unit skin champions to return to their units and intervene while the patient remained in the SICU. In addition, a NDNQI report comparing our SICU's unit to benchmarked data was generated. These data were shared with the rest of the RN staff and medical director through bulletin board posting, e-mails, and staff meeting presentations.
Outcomes
We monitored HAPU prevalence over a 36-month period, which we divided into 12 quarters (Q1-Q12). Each quarter consisted of a 3-month time frame. We observed episodic spikes in our SICU PU prevalence rates, but the prevalence tended to be lower following the intervention (Figure). One hundred eighty patients were included in the prevalence studies; the prevalence of HAPU was 10.6% (19 patients). The average number of patients included in each quarterly prevalence study was 15 (range, 12-17). The average age of patients with a HAPU was 57.9 +/- 16.7 years (mean +/- SD); their mean Braden Scale score was 13 +/- 1.2 (range, 9-17). The mean age of patients without a HAPU was 58.6 +/- 13.9 years. Pressure ulcer stage and location were tracked; 17 were located on the coccyx and 2 were on the heel. Pressure ulcer stages included 10 stage II ulcers, 3 stage IV PU, 5 unstageable ulcers, and 1 suspected deep tissue injury. The quarters with the highest prevalence rate during this time period were Q5 and Q8; 4 patients experienced a HAPU during each of these quarters (Table 2). Q9, Q10, and Q11 had a HAPU prevalence rate of 0. The overall trends in the SICU HAPU prevalence rates showed a consistent downward trend after the implementation of peer-to-peer bedside rounds. We also tracked the frequency that preventive interventions were implemented (Table 3).
Discussion
We believe that the outcomes we tracked suggest that peer-to-peer bedside rounds by the unit skin champions have the potential to diminish HAPU prevalence rates in a SICU such as ours. These rounds were developed to encourage clinical discussion of specific skin care management interventions. We hypothesize that the process of refocusing the bedside RN's assessment to look more closely at the subscales of the Braden Scale and using direct care interventions led to greater utilization of preventive interventions and, ultimately, fewer HAPUs.
While PU prevalence rates tended to be lower after initiating peer-to-peer bedside rounds, the unit experienced 2 spikes in prevalence data. In Q8, the HAPU prevalence was 27%, representing 4 ulcers. The majority of our patients were deemed to be at moderate to high risk for developing a PU, with Braden Scale scores ranging from 10 to 14. We also found an unusually high patient acuity during that period. The critically ill patient is at increased risk of PU because of the patient's severity of illness as well as variables of immobility, hemodynamic instability, excessive moisture, advanced age, and suboptimal nutrition.12,19,22-24 Recently the National Pressure Ulcer Advisory Panel released a statement that not all PUs are avoidable.12 The panel of experts agreed that certain situations create conditions such as hemodynamic instability seen in patients in critical care units, may influence turning or reposition, and lead to unavoidable PUs.12 This statement, however, does not mean that PU assessment risk and prevention strategies should be minimized. Rather, the critically ill patient is at greatest risk of PU; thus, critical care nurses need to be vitally involved in the prevention of PU through ongoing skin and PU risk assessment and initiating interventions to minimize patients' risk for developing a HAPU.
In Q12, the prevalence rate was also high at 6%, representing 1 HAPU. This wound was an unstageable PU located on the coccyx. Preventive interventions in this patient included a low air loss bed, fecal containment device, and enteral feeding. Nevertheless, repositioning remained a challenge because of prolonged hemodynamic instability and we believe that this may have contributed to the development of an HAPU.
We found that peer-to-peer discussions during bedside rounds were perceived to be more effective and meaningful to critical care nurses than were typical educational strategies of online education modules and classroom staff in-service education. Throughout this quality improvement project, adjustments in peer-to-peer rounds were made to address new initiatives launched by the evidence-based practice skin team and to specifically address nursing interventions for prevention of PU in the SICU. While the direct impact of rounds and improved nursing knowledge was not measured in this project, we believe that peer-to-peer rounds improved RN ownership of PU-prevention strategies.
The introduction of clinical nursing rounds has been found to be an innovative strategy that supports an environment of mutual learning that shares the expertise of senior nurses,17 in this case, peer SICU nurses (eg, unit-based skin champions). Nursing rounds provide a forum to facilitate collaborative problem identification, clinical decision making, and incorporation of evidence at the point of care to promote individualized patient-centered evidence-based nursing practice.18 Pressure ulcer rounds by peers allowed sharing of clinical information and PU-prevention education that was seen as immediately meaningful to critical nurse peers.
We acknowledge that other factors during the 36 months of data collection might have influenced the prevalence of HAPU. For example, new intensive care unit beds and mattress surfaces were purchased during the data collection period. In addition, we introduced a wicking incontinence underpad product. The results of this project are also limited by the use of quarterly prevalence rates as opposed to incidence rates. NDNQI prevalence studies provide data only 4 times a year. However, data collection was scheduled in a consistent manner in an effort to standardize the process.
Conclusion
We applied peer-to-peer bedside skin rounds in order to improve the HAPU prevalence rates in our SICU and increase the implementation of preventive interventions. Two unit-based skin care champions were able to engage in dialogue with critical care nurse colleagues in the context of individual patients. Pressure ulcer bedside rounds provided an opportunity to explore the RN's knowledge of Braden Scale score subscales through discussion of the patient assessment and how the nurse determined the patient's risk for skin breakdown. Despite the high risk for skin breakdown in this patient population, the SICU has continued to have a decreased prevalence rate. Further research is needed to demonstrate the efficacy of nursing rounds as an intervention to improve RN knowledge of PU risk and patient outcomes.
KEY POINTS
Peer-to-peer nurse rounds were associated with an increased use of preventive interventions and a decline in the quarterly prevalence of HAPU in our SICU.
Our experiences suggest that peer-to-peer rounds are especially useful in the critical care unit because they are perceived as providing more immediate and clinically relevant knowledge about current patients than traditional in-service staff education.
ACKNOWLEDGMENTS
We thank our unit clinical nurse specialist, Shannon Johnson Bortolotto, RN, MS, CNS, CCNS, and our 2 certified WOC nurses Paula Gipp, BSN, RN, CWOCN, and Anne Pirzadeh, BSN, RN, CWOCN, for their mentorship with this quality improvement project.
References