Turning Pressure into Progress

Participants

Ashley Perkins, clinical nurse specialist, Corewell Health, Grand Rapids, Mich.

Teresa Johnston, clinical outcomes manager with quality, Ohio Health, Grant Medical Center

Trisha Conn, WCC, Ohio Health, Berger Hospital, Circleville, Ohio

Midwest-based Clinical Nurse Specialist

Despite decades of innovation, pressure injuries continue to affect both clinical and financial outcomes. We wanted to hear from some of you about your successful strategies to prevent pressure injuries from starting or from getting worse. We gathered four clinical specialists and quality leaders from several Midwest hospital systems to share how their organizations embed pressure injury prevention into daily routines.

Our panelists explore the ways that culture, creativity and accountability intersect to drive improvements—and how they’re still learning from each other. We hope you’ll take away a few new, actionable insights to drive your own prevention goals.

Clinical Connection: How do you embed pressure injury prevention into your everyday facility culture?

Ashley Perkins, clinical nurse specialist, Corewell Health, Grand Rapids, Mich.: We use the term ‘operational alignment,’ and it’s really a focused set of different quality initiatives that each unit tackles. These initiatives are always aligned with what we call ‘metrics that matter,’ which are strategic goals. Because of PSI 03s, we are very intentional about pressure injuries being the focus at the unit level with our bedside nurses.

On that point, our bedside nurses often come up with creative ideas based on what they’re seeing as their trends in HAPIs each month and identifying opportunities—is it medical device-related? Is it turning surfaces?—That gives them ownership of the outcomes, and they see that improvement month to month.

CC: Can you give us an example of a creative approach?

Perkins: One unit was focusing on bathing, and they had a month-long competition with each other where they intentionally focused on bathing every patient every day, using rubber duckies to sign off that the patient was bathed. We know documentation is always an opportunity, but this was a way for them to have that visual cue to show, ‘OK, we have achieved this on X number of patients today.’

Teresa Johnston, clinical outcomes manager with quality, Ohio Health, Grant Medical Center: I worked on the floor and then wound care and then moved to quality. And so sometimes I have a unique perspective in that I feel like the units forget about a quality person, and how we can track trends and help them with those things. So from a system perspective, we implemented a four eyes skin assessment and made some tweaks to Epic so we can be a little more accountable on that.

We’re also using skin champions and encouraging them to use the Braden Scale, because we want them to understand they need to pair those pieces, that it’s more than just what you’re visually seeing. And then we share this at a system HAPI group where we can show how we’re linking what the system’s goals are and what we’re doing at our individual units’ HAPI meetings.

I think it’s definitely interesting to figure out how all those meetings and pieces go together. But it can be a challenge to get back down to that granular unit level and individual nurse. What are you capable of? What are your understandings and your gaps?

CC: Do any others have skin health advocates? How has that impacted outcomes at the bedside over time?

Midwest-based Clinical Nurse Specialist: We use the champion model here, and I’m aware of every pressure injury we have institutionally, and we do track trends. We have unit-based clinical nurse specialists that review every pressure injury and then report back to the pressure injury committee on what they found, whether our standard of care was met or not, and what contributing factors existed. Our skin champions participate in our prevalence study and are given time to enter their data into our online data collection system and then attend education specific to what trends we’re seeing.

Our skin champions also complete NPIAP modules for pressure injuries and are part of our focus group for writing and updating our policies and bringing forward suggestions for initiatives. We really lean into those frontline staff who are their unit-based resource for all things pressure injury prevention.

Trisha Conn, WCC, Ohio Health, Berger Hospital, Circleville, Ohio: We don’t have any responsibilities for skin champions outside of participating in the quarterly prevalence. Definitely something that we need to invest some time in. I think with Berger being a smaller hospital and having one inpatient nurse, most days, I can manage it, and I’m very visible to all of the staff. We have also implemented the four eyes assessment, and we have Rovers that are taking photos of every single wound.

CC: What strategies have been the most effective for educating on PI prevention? Any creative ways that have really worked best?

Conn: Hands-on education has been the most effective here. If I’m noticing something and ask the nurse managers to put that in the huddle, they’ll do that every shift change. So that’s nice because it’s coming from management and not just me. When I’m seeing patients, the nurses are engaged in what I’m doing. They’ll come into the room with me. They want to watch me do what I’m doing. And so as I’m doing it, I’m having that lowkey conversation with them, like, ‘OK, it’s good that you placed the wedges, but maybe let’s put them so that the sacrum is offloaded.’

Perkins: I absolutely echo what Trisha said about the wedges. Wedge placement is complex. Nurses have to spend so much time and effort to turn a patient, and the little amount of time that’s ever focused on education to turn a patient is really inadequate. We’ve done a lot of skills reviews and skills fairs focusing on problem areas like offloading and external urinary devices, things that we’ve seen impact with around pressure injuries. It’s great when you focus on it, but as soon as you take away that focus, you see the problem arise again. So that sustainability piece is quite complex.

CC: Do you communicate the prevalence data to the frontline staff? And if so, how does that help?

Perkins: The human factors team members are not clinicians. They know a lot about healthcare, but that is not their expertise. But they’re able to have really in-depth conversations with our bedside nurses with no judgment and understand if they are actually doing what we hope they are doing, and what does that look like, and then what are their recommendations for improving it?

Clinical Nurse Specialist: We recently had Medline do a Discovery Assessment to confirm some of what we thought was happening versus what is actually happening. And it was really eye-opening. One of the the proud points of that, though, is that 100% of the staff they talked to knew their unit’s prevalence numbers. So we’re doing a good job of getting our information out to our staff and where we’re having struggles.

CC: What are some of those struggles?

Clinical Nurse Specialist: Storing some of the equipment that we’re using for our pressure injury prevention initiatives has been a challenge. So, finding storage space is one of the things we wanted to highlight with that Discovery Assessment. Another thing I wanted to do is confirm our variation in care, and then take that information to the C-suite to say, we really need to standardize this work in some way. I don’t want to take away everybody’s options, but we have about five different kinds of soap and maybe three different ways to CHG bathe the patient, and I think standardization clears up some of the confusion that our staff have at the front line. We had a 21% decrease in HAPIs over last year, so we’re moving in the right direction, for sure. But now it’s really time to focus on the less low hanging fruit and find those focused areas.

CC: What has been some low hanging fruit for you?

Clinical Nurse Specialist: When I got into place, the only education that our skin champions was given was the NDNQI modules. They did not feel like they were prepared to lead that work at the bedside. So we instituted monthly education sessions for them, and we also did a sort of Lean process with them, but I don’t like them to know that’s what we’re doing. So we sneak in questions like, ‘What is your practice? What are the gaps? What are your challenges? What things are you celebrating with your staff?’ Like a gap analysis without it being that formal. It’s more of a conversation, and people feel comfortable sharing. And then we were able to put that into a document and present it to the leadership where we needed support both financially and from staffing.

CC: What about different kinds of education to help the staff be aware of pressure injuries on all skin tones?

Johnston: We were able to get wound models in both dark and light skin tones for the units. And we’re trying to provide additional information on photos about what wounds look like on dark skin or what you can look for. But I definitely think that’s a difficult education lift for people because we’re already struggling to get that education out.

Clinical Nurse Specialist: We landed on thermography, because with our darker pigmented patients, it’s often not until a deep tissue injury has formed and that top layer of skin has come off that staff can see blatant pink or red and recognize that that’s what it is. So we’re hoping that the thermal imaging will do better. We’ve thought about a sub epidermal moisture scanner, but it’s based on multiple scans over multiple days to really give you a good delta.

CC: What are some ways you’ve celebrated the wins?

Perkins: We’ve done what we call fun rounding, really highlighting what they’ve done well. We just did one that we called “HAPI hour,” and we served non-alcoholic margaritas to our nurses on our cardiac progressive unit and our MICU to celebrate their HAPI reduction while they were piloting some technology for us.

On Worldwide Pressure Injury Prevention Day, we did some intentional rounding and wore peach costumes, passed out peach stickers and had peach cookies for the skin champions. Really focusing on keeping the conversation going, keeping the engagement there, hearing feedback from the nurses on what’s going well and what’s not, and reminding them that these are focused problems that we want to continue to work through together. And we brought a smile to their faces with our peach costumes.