Safety Solutions Wound care Journey to zero

Safety Solutions Wound care Journey to zero harm Using apparent and systemic cause analysis to reduce HAPIs By Sarah Kaplan, MSN, RN-BC, CPHQ; Diane Maydick-Youngberg, EdD, APRN, ACNS-BC, CWOCN; Julieann Liao, MSN, ANP-BC, CWON; and Kathleen Francis, DNP, FNP-BC, CWOCN Hospital-acquired pressure injuries (HAPIs) are a serious complication that can hinder inpatient hospitalization. The Agency for Healthcare Research and Quality reports that more than 2.5 million people in the US develop pressure injuries, which are associated with pain, infection risk, and increased healthcare utilization. A pressure injury is defined as “localized damage to the skin and/or underlying tissue usually over a bony prominence or related to a medical or other device” that occurs “as a result of intense and/or prolonged pressure or pressure in combination with shear.”1,2 Development of a pressure injury during the hospital course is considered to be patient harm and reported as a quality indicator. Stage 3, 4, and unstageable pressure injuries are considered “never events” by the Centers for Medicare and Medicaid Services, and care rendered as a result of these complications isn’t reimbursed.3 52 November 2019 Nursing Management www.nursingmanagement.com Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved. Risk assessment instruments have been adopted to assess a patient’s risk of developing a pressure injury and guide interventions to mitigate the risk. The Braden Scale, a common pressure injury risk assessment tool, measures levels of risk in sensory perception, skin moisture, physical activity, nutritional intake, friction and shear, and the patient’s ability to change or control position.4 A score of 18 or below identifies the patient as being “at risk” for pressure injury development. The Braden Scale is completed every shift, and nurses use the risk factors identified in each Braden Scale subscale to develop an individualized plan for pressure injury prevention. (See Braden Scale risk assessment.) Although risk assessment tools and evidence-based prevention practices have been adopted by many institutions, including ours, patients continue to develop HAPIs. Our facility engages in continuous quality improvement efforts for better patient outcomes, especially the reduction of HAPIs. To help decrease HAPIs, we implemented the processes of apparent cause analysis (ACA) and systemic cause analysis (SCA). The ACA process starts with a unit-based debrief after a HAPI is reported. During the debrief, the group discusses the case and identifies barriers and challenges, and education on strategies to prevent future HAPIs is provided to the interdisciplinary team on the affected unit. If trends are identified during the ACA process, an SCA workgroup is convened to determine potential systems issues that may have contributed to the HAPI and discuss Braden Scale risk assessment • Skin assessment • Care plan • Device rotation • Appropriate support surface • Seating cushion • Appropriate linen usage • Moisture management • Ensure that head-of-bed elevation is at a 30-degree angle • Turning and repositioning possible solutions. The SCA takes a broader view of the issue and leads to hospital-wide improvements.5 The use of ACA and SCA encourages the early identification and reporting of problems, rapid process improvement, and increased ownership and engagement of the interdisciplinary team in all aspects of HAPI prevention. Apparent cause analysis Discovery. The ACA process starts with the identification of a HAPI on the unit. After a HAPI is identified, the RN or healthcare provider consults the wound, ostomy, and continence nursing (WOCN) team. Validation. The WOCN team validates that the injury is, in fact, a HAPI. There are some alterations in skin integrity that may be mistakenly identified as a pressure injury, such as moistureassociated skin damage or a skin tear. The validation from the WOCN team ensures that we’re differentiating another skin injury from a true HAPI. Once the WOCN has confirmed the HAPI, the team notifies the unit’s nurse manager and the nursing quality specialist. Chart review. The nursing quality specialist reviews the affected patient’s chart using a standardized data collection instrument. The chart is reviewed primarily to check for documentation regarding pressure injury prevention bundle elements. Additional data, such as the patient’s age, length of stay, diagnosis, hospital course, and Braden Scale risk scores, are also collected. ACA scheduled. The nursing quality specialist coordinates a time with the nurse manager for the ACA. The goal is to conduct the ACA within 7 days of the patient developing the HAPI. A calendar invite is sent to nursing leadership, the WOCN team, healthcare provider leadership, and the nutrition department. If the HAPI is device-related, the involved discipline is invited. For example, an invite for a HAPI involving a ventilator or oxygen mask will include the respiratory therapy team. ACA. The ACA is conducted on the unit in which the patient developed the HAPI. In addition to the invitees, all RNs, nursing assistants, and ancillary staff members who are working on the unit on the day of the ACA attend. The ACA begins with discussing the patient and the HAPI occurrence using the information collected from the chart review. All members then discuss barriers, challenges, and opportunities both specific to the patient and regarding pressure injury prevention in general. Follow-up. Following the ACA, the nursing quality specialist summarizes the discussion and emails the summary to all invitees. This closes the loop for all who were invited, even if they were unable to attend. Finally, www.nursingmanagement.com Nursing Management November 2019 53 Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved. Safety Solutions Wound care the nurse manager emails a summary of the ACA to all RNs who cared for the patient before the HAPI developed. Systemic cause analysis The guiding principle behind an SCA is simple: Multiple similar events occurring throughout the hospital must have a systemic cause, and the events will continue to occur unless the cause is identified and corrected. The SCA is an ad hoc workgroup of key stakeholders and decisionmakers from the departments involved in the HAPI. Attendees may include nurse leaders, clinical nurses, and physician leaders. If the trend involves a medical device, such as a respiratory therapy device or an orthopedic brace, the ancillary department also participates. The ACAs related to the trend are reviewed and potential systemic causes and solutions are identified. The group proposes solutions, agrees on an implementation plan, and determines the next steps, including whether a subsequent meeting is needed. During the SCA, it’s vital to have decision makers in the room to approve any suggested intervention. This quick turnaround enables us to rapidly implement a solution, study its effectiveness, and modify as needed. The group continues to meet until the HAPIs are no longer occurring. If there’s a recurrence of a specific type of pressure injury, the group will reconvene to examine the process and determine what’s needed to prevent further patient harm. Sometimes, further education on the new processes is needed. Other times, it may be determined that the process isn’t working as intended and additional interventions are needed. Depending on the scope of the issues identified, the group will agree on a meeting schedule. If a further redesign of the process is needed, the group may require a monthly or bimonthly meeting. Smaller issues, such as re-education or clarification of the process, can be resolved in a single meeting. The SCA process has been especially useful in our efforts to combat medical device-related pressure injuries. Any medical device that comes into contact with the skin can potentially cause a pressure injury. Devices that are applied by ancillary departments, such as braces and respiratory devices, represent an opportunity for collaboration on pressure injury prevention. The ACAs and SCAs have provided an opportunity to increase risk awareness and educate members of these ancillary departments on assessment, escalation, offloading, and cushioning areas where devices come into contact with the skin. Our interdisciplinary SCA workgroups have established the need for stocking preventive supplies on all units to aid staff in quickly implementing interventions. We’ve also adopted several types of dressings to cushion and protect the skin over bony prominences and where devices come in contact with the skin. Assessing the results Since initiating the ACA and SCA process in 2017, our incidence of HAPIs has almost been cut in half. Approaching HAPIs as an interdisciplinary care challenge makes all team members accountable and promotes comprehensive interventions across disciplines. Engaging the interdisciplinary team in preventing HAPIs—an issue that’s traditionally been nursing-centric—has improved patient outcomes, prevented patient harm, and empowered all members of the interdisciplinary care team to contribute to HAPI prevention.

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