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Clinical Nurse SpecialistA Copyright B 2016

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Feature Article

A Clinical Nurse SpecialistYLed


Interprofessional Quality Improvement Project
to Reduce Hospital-Acquired Pressure Ulcers
Christina Fabbruzzo-Cota, MN, RN CON(C) n Monica Frecea, MScN, RN, CETN(C) n
Kathryn Kozell, MScN, RN, CETN(C) n Katalin Pere, MN, RN, CCN(C), APCF n
Tamara Thompson, PTA/OTA n Julie Tjan Thomas, RN, MN, CETN(C) n Angela Wong, MScOTReg. (Ont.)

Purpose: promote evidence-based practice for PU prevention. Initiatives


The purpose of this clinical nurse specialistYled interprofessional such as documentation standardization, development of staff
quality improvement project was to reduce hospital-acquired education and patient and family educational resources,
pressure ulcers (HAPUs) using evidence-based practice. initiation of a hospital-wide inventory for support surfaces,
Background: and procurement of equipment were implemented to improve
Hospital-acquired pressure ulcers (PUs) have been linked to PU prevention and management across the organization.
morbidity, poor quality of life, and increasing costs. Pressure Outcome:
ulcer prevention and management remain a challenge for An 80% decrease in HAPUs has been achieved since the
interprofessional teams in acute care settings. implementation of best practices by the Best Practice
Rationale: Guideline Pressure Ulcer working group.
Hospital-acquired PU rate is a critical nursing quality indicator Conclusion:
for healthcare organizations and ties directly with Mount The implementation of PU prevention strategies led to a
Sinai Hospital’s (MSH’s) mission and vision, which mandates reduction in HAPU rates. The working group will continue
providing the highest quality care to patients and families. to work on building interprofessional awareness and
Description: collaboration in order to prevent HAPUs and promote an
This quality improvement project, guided by the Donabedian organizational culture that supports staff development,
model, was based on the Registered Nurses’ Association of teamwork and communication.
Ontario Best Practice Guideline Risk Assessment & Prevention Implications:
of Pressure Ulcers. A working group was established to This quality improvement project is a successful example of
Author Affiliations: Clinical Nurse SpecialistYSarcoma (Ms Fabbruzzo- an interprofessional clinical nurse specialistYled initiative that
Cota); Clinical Nurse Specialist, Enterostomal Therapy Department impacts patient/family and organization outcomes through
(Mss Frecea and Thomas); Clinical Nurse Specialist/Manager, Rachel Flood the identification and implementation of evidence-based
Education Program (Ms Kozell); Clinical Nurse Specialist, Medicine
and Cardiology (Ms Pere); Physiotherapist Assistant and Occupational nursing practice.
Therapist Assistant (Ms Thompson); Occupational Therapist (Ms Wong), KEY WORDS:
Mount Sinai Hospital, Toronto, Ontario, Canada. clinical nurse specialist, evidence-based practice, pressure
This work is part of the Best Practice Spotlight Organization Initiative, ulcer, prevention, quality improvement
funded by the Ontario Ministry of Health and Long-term Care. For more
information about the Registered Nurses’Association of Ontario Best Prac-

T
tice Spotlight Organization Initiative, please visit www.RNAO.ca. he impact of pressure ulcers (PUs) on patients and
The authors report no conflicts of interest. their caregivers is related to decreased quality of
Correspondence: Monica Frecea, MScN, RN, CETN(C), Mount Sinai Hos- life, increased morbidity and mortality and prolonged
pital, 600 University Avenue, Room 1401C, Toronto, Ontario, Canada length of stay in hospital.1Y4 Pressure ulcers are 1 of the
M5G 1X5 (mfrecea@mtsinai.on.ca).
major drivers of escalating healthcare costs, with millions
Supplemental digital content is available for this article. Direct URL cita-
tions appear in the printed text and are provided in the HTML and PDF of dollars spent annually on treating and managing patients
versions of this article on the journal’s Web site (www.cns-journal.com). with this condition.1 Hospital-acquired PUs (HAPUs) are a
DOI: 10.1097/NUR.0000000000000191 nurse-sensitive indicator that provides data about the

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quality of care provided by nurses. In Canada, approximately champions (SWNCs), enterostomal therapy nurses, a phys-
1 in 8 patients in acute care hospitals experience PUs.5 iotherapist (PT), and a registered dietitian. Ad hoc membership
Increasing evidence suggests that patient care outcomes includes representatives from plastic surgery, pharmacy
can be improved through strengthening leadership behav- and the hospital’s buying group. Nursing participants rep-
iors of nurses and that prevalence and incidence (P&I) rates resent the following departments: emergency, operating
of PUs can be reduced through a nurse-led interprofessional room, medicine, surgery, obstetrics/gynecology, and the
team approach.6 intensive care unit. Table 1 summarizes resources devel-
oped by the SWCSC.
BACKGROUND Quarterly PU P&I audits implemented since 2010 provide
Mount Sinai Hospital in Toronto, Ontario, Canada, is a a snapshot of the hospital’s real-time PU rates. Part of this
442-bed academic healthcare science facility where reg- process includes reviewing charts and care plans of patients
istered nurses practice in a shared governance structure. identified with preexisting and HAPUs. Data pertaining to con-
This structure empowers nurses to have a greater influence tributing factors such as medical comorbidities, location and
on decision-making processes that contribute to increased categorization of PUs, use of pressure redistribution surfaces,
quality of patient care and improved outcomes. In 2012, and implemented preventative measures are collected and
MSH was selected by the Registered Nurses’ Association of analyzed. These results are used to guide QI initiatives related
Ontario (RNAO) as a candidate to become a Best Practice to PU prevention and management. The Graph, Supplemen-
Spotlight Organization. Through this partnership with the tal Digital Content 1, http://links.lww.com/NUR/A8, presents
RNAO, MSH embarked on a multifaceted initiative to im- the yearly aggregated results.
prove patient care outcomes through the implementation With the groundwork laid by the SWCSC and ongoing
of selected RNAO’s best practice guidelines (BPG), includ- support from senior nursing leadership, the partnership
ing the Risk Assessment and Prevention of Pressure Ulcers.7 with the RNAO served as a further impetus toward the
This article describes an advanced practice nurseYled inter- implementation of best practice for PU prevention. The
professional initiative from 2012 to 2014 to prevent HAPUs development of a BPG PU working group, which is led by
through the implementation of interventions aimed at stan- 2 CNSs, was established with the objective to implement inter-
dardizing processes of care and providing frontline clinicians ventions aimed at reducing HAPUs using an interprofessional
with tools and resources to facilitate evidence-based practice. approach. The working group is composed of 5 CNSs, an
SWNC, a registered dietitian, a PT, an occupational therapist,
FRAMEWORK and a PT assistant. Members were chosen for their clinical
This quality improvement (QI) project was guided by the expertise and their ability to provide strong leadership.
Donabedian healthcare quality model that provides a
framework for assessing quality of care by investigating Organizational Processes
the structure of the organization, the existing processes, The BPG PU working group recognized the need for stan-
and patient- and system-level outcomes.8 This structure- dardized methods to prevent PUs in a way that would
process-outcome framework is closely aligned with the foster interprofessional collaboration as well as promote
Professional Practice Model developed by the Gerald P. interventions guided by best practice principles. The work-
Turner Department of Nursing at MSH (Figure). The Pro- ing group identified gaps between current practice and
fessional Practice Model anchors nursing practice to the recommended evidence-based practices for PU prevention,
organization’s structures and processes to provide the assessed strengths and deficiencies in current practices, and
highest quality care to patients and families. determined what changes needed to take place and what
specific practices, tools, and resources will be needed to im-
Organizational Structures plement change. The group reviewed the Risk Assessment
This initiative is in alignment with MSH’s mission and vision, and Prevention of Pressure Ulcers best practice guideline7
which identify the goal of providing the highest quality care and selected 3 recommendations aimed at clinical interven-
and experience to patients and families through advances tions that would have the greatest impact on HAPU rates.
in professional practice, education, leadership, and new The targeted interventions focused on using pressure redistri-
knowledge. It is well documented that a strong organi- bution surfaces, implementing a repositioning schedule, and
zational infrastructure is imperative to achieve positive accessing interprofessional expertise.
outcomes when creating a clinical practice or behavior
change.9Y11 Through the leadership of the Skin and Wound Recommendation 3.1a
Care Steering Committee (SWCSC), MSH had preexisting A hospital-wide inventory of support surfaces was conducted
processes and resources in place regarding PU prevention to facilitate the implementation of this recommendation. The
and management. The committee which is led by clinical working group used the expertise of an external consultant, a
nurse specialists (CNSs), consists of skin and wound nurse registered occupational therapist nationally recognized for

Clinical Nurse Specialist A


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Feature Article

FIGURE. The Best Practice Guidelines Pressure Ulcer working group’s framework demonstrates the alignment of Mount Sinai
Hospital_s core values, Professional Practice Model, and the Donabedian model.
her work on therapeutic support surfaces and PU prevention tice guideline recommends that an individualized approach
and management. All support surfaces from inpatient units needs to be applied and that repositioning of patients should
were assessed and graded according to their condition. occur every 2 to 4 hours.7 To cultivate a standardized ap-
The inventory led to immediate replacement of support proach to the repositioning of patients, a decision tree for
surfaces that were in poor condition and the development positioning patients at risk of developing a PU was devel-
of a protocol for replacing all other support surfaces over a oped. Literature indicates that PU risk is best predicted by
3-year period. A final report by the external consultant pro- total Braden score in conjunction with Braden subscale
vided recommendations that are being used to develop a scores.12,13 Braden subscales provide important informa-
centralized system for procurement, maintenance, and dis- tion about the patients’ positioning profile and guides the
tribution of support surfaces. Through the implementation clinician to specific implementation strategies to address
of this recommendation, MSH ensures that proper pressure each profile. The decision tree guides the nurses to consider
redistribution surfaces are available. not only the total Braden score but also the subscores to help
them implement PU preventative measures that focus on
Recommendation 3.1b identified deficits.
Frequent repositioning of patients to prevent PUs has been The BPGs indicate that risk factors for PU development
standard practice among clinicians at MSH. The best prac- in acute care settings are different on each unit. The working

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Table 1. Skin and Wound Care Resources
Resources Description

Skin and wound care policies Updated and revised policies and procedures to reflect best practice, including assessment
and procedures and treatment of pressure ulcers, Braden Scale for predicting pressure ulcer risk with preventative
measures, classification prevention and treatment of skin tears, irrigations wound/sinus, negative
pressure wound therapy, support surfaces active and reactive.
Level I skin and wound care Updated and revised mandatory Level I E-learning modules, including anatomy and physiology,
E-learning modules phases of wound healing, principles of wound management, Braden Scale and pressure
ulcers prevention, skin tears, basic and advance dressings, and wound care documentation.
New Level I skin and wound New E-learning modules created and added to the Skin and Wound Care educational series, including
care E-learning modules moisture-associated skin dermatitis, medical device pressureYrelated injuries, mucous membrane,
and cartilage pressure ulcers.
Level II skin and wound care Title: A Holistic Approach to Skin and Wound Care. Interprofessional education provided by clinical
conference days nursing leadership, a registered dietitian, a certified enterostomal therapy nurse, staff nurses,
plastic surgeons, an occupational therapist, patient, and industry partners. Lecture topics include Best
Practice Spotlight Organization, moisture-associated skin dermatitis, nutrition and wounds, pressure
ulcer prevention and management, debridement and wound care from a patient_s perspective.
Hands-on sessions include assessment and management of skin tears, identification and classification
of wounds, negative pressure wound therapy, therapeutic surfaces, and compression therapy.
Electronic health record Updated and revised the electronic health record to reflect best practice to include revision of
pressure ulcer preventative measures, wound care products and, treatment options.
Skin and wound nurse champions 26 registered nurses completed standardized education in clinical knowledge, skill, and professional
competencies. Working collaboratively with advanced practice nurses, this group serves as a
resource in noncomplicated wound presentations using the opportunity to educate and problem
solve with nursing colleagues. Lecture topics include acute and chronic wound identification,
incontinence-associated dermatitis, Braden subscales, positioning and transferring a patient with
pressure ulcers, skin tears staging, and management.
Hands-on sessions include assessment, classification, and treatment of various wound presentations such
as pressure ulcers, skin tears, and intravenous extravasationYrelated injury wounds.

group reviewed the published risk factors and invited nursing sion making and the development of appropriate PU
staff and advanced practice nurses to select risk factors that prevention plans.
best represent their patient population. Selected unit-specific The BPG PU working group provided educational sessions
risk factors enhance a clinician’s ability to consider and assess to nursing leadership and frontline clinicians to review the
specific risks for PUs in each specialty area such as the inten- educational bundle and discuss strategies for implementa-
sive care unit, medicine, and surgery. tion. All resources were made available electronically for
It is also important for patients and families to under- easy access. For these interventions to be successful and
stand PU risk and what they can do to minimize this risk. for the desired outcomes to be reached, a shared involve-
To involve patients and families in PU prevention, the work- ment from the aforementioned stakeholders was necessary
ing group developed an education pamphlet for patients at to reinforce use of the PU prevention educational bundle
risk of developing a PU. A turning clock tool posted at the hospital-wide.
bedside alerts members of the healthcare team that the
patient has been identified as being at risk for PUs. The Recommendation 3.3
positioning clock also serves as a reminder to staff, patients, The rehabilitation members of the BPG PU working group
and family members that the patient should be repositioned were instrumental in providing strategies to reduce pressure,
at each 2-hour interval. The patient and family education friction, and shearing forces in patient positioning and han-
pamphlet and the positioning clock are tools for patients, dling. To assess current practice regarding positioning and
family, and clinicians to use as they partner in education transferring techniques and the use of equipment, a needs
and PU prevention strategies. assessment survey was distributed to all inpatient reha-
The decision tree for positioning patients at risk of de- bilitation and nursing staff. Results identified that the
veloping a PU, the unit-specific risk factors for developing gaps between current practice and best practice were
PU, the educational pamphlet for patient and family, and largely attributed to lack of available pressure redistribu-
the positioning clock are incorporated into the Pressure tion equipment. Having the necessary equipment, such
Ulcer Prevention Education Bundle. The education bundle as seating cushions, positioning wedges, and transfer
(Table 2) promotes awareness and supports clinical deci- sheets, is fundamental in pursuing decreased HAPU

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Feature Article

Table 2. Pressure Ulcer Prevention Education Bundle


Tools Description

Positioning Decision Tree for Patients at Risk Uses Braden Scale subscores (sensory, perception, nutrition, mobility, activity,
friction and shear, and moisture) to predict patients_ level of risk and provides
preventative positioning interventions
Unit-Specific Risk Factors for Pressure Ulcer Provides unit-specific risk factors based on the Registered Nurses_ Association of
Development Ontario Best Practice Guidelines for Risk Assessment and Prevention of Pressure
Ulcers (Supplement 2011)
Are You at Risk for Getting Pressure Ulcers? Pamphlet for patients and families
Topics include the following: Facts About Pressure Ulcers, How I Can Prevent
Pressure Ulcers, Tips for Good Skin Care, Take the Pressure Off, I Am Caring for a
Family Member, Am I at Risk of Getting a Pressure Ulcer?, Nutrition and
Hydration, Resources for Patients and Families
Repositioning clocks Visual tool to prompt care providers to reposition patient every 2Y4 h and to
serve as communication tool to facilitate continuity of care between staff,
patients, and families

rates. The procurement of new equipment was achieved Synthesizing, critiquing, and applying research are cen-
through the successful application to the Hospital’s Pa- tral to the CNS role and contributed to the success of this
tient Safety Fund. project. In an effort to promote best practice, the PU BPG
A review of the PU P&I results over the previous 3 quar- was reviewed and applicable recommendations were chosen
ters and taking into consideration unit-specific risk factors for implementation across the organization. Leadership, con-
for PU development, pressure redistribution equipment sultation, and education were also demonstrated by the
was strategically allocated to the various patient care units working group. Practice changes in PU prevention were
to benefit vulnerable populations. Education on the proper identified and addressed, such as standardizing the fre-
use of the new equipment through hands-on training and quency that nurses would complete a PU risk assessment.
in-services was organized for rehabilitation and nursing Collaborative partnerships were developed, and commitment
staff. To encourage the incorporation of the equipment into from key stakeholders was obtained to facilitate and manage
daily practice, the rehabilitation staff provides ongoing change. The working group assumed the role of change
support and training. A supplemental chart was also pro- agents and educators by planning, initiating, and coordi-
vided to all patient care units, including a list of allocated nating educational sessions across all clinical units to
equipment, infection control procedures, and indications promote evidenced-based strategies for PU prevention.
for use to provide staff with a clinical decision making tool. The use of these domains facilitated the successful im-
In addition, this education has been incorporated into plementation and outcomes of this project. There has
new hire orientation and training with the supplemental been an 80% reduction in HAPUs since the implementa-
goal of reducing workplace injuries incurred from patient tion of best practices by the BPG PU working group. The
handling. immediate replacement of unsatisfactory support sur-
faces occurred in the first quarter of fiscal year 2013Y2014.
Outcomes The replacement of support surfaces contributed to the re-
The 5 domains of practice associated with the role of the CNS duction in HAPU rate from 0.24% in the first quarter to
were evident within this interprofessional QI project. 0.08% in the second quarter. This outperformed the Canadian
These domains include clinical practice, consultation, educa- Institute for Health Information benchmark of 0.15% for
tion, research, and leadership.14 The CNS-led interprofessional Canadian acute care hospitals (see Graph, Supplemental
team integrated clinical experience with theory, research, Digital Content 2, http://links.lww.com/NUR/A9). The rate
and expert opinion in the development of assessment was measured calculating the total number of nosocomial
and intervention strategies for the prevention of PUs at PU divided by the total number of patient discharges.
MSH. Clinical practice competencies were evidenced by To measure the uptake of change in clinical practice
leading an initial environmental scan including an assess- related to the implementation of the Pressure Ulcer Preven-
ment of current nursing documentation, surface review, tion Education Bundle, audits were conducted concurrently
and equipment needs assessment. Intervention strategies with the quarterly PU P&I study. Sixty-three percent of all
included equipment and mattress replacement program, patients at risk of developing a PU, as determined by their
changes to nursing documentation standards, and the de- Braden scores, had a turning clock posted at the bedside.
velopment of a PU prevention education bundle. Furthermore, all clinical inpatient units had the Positioning

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Decision Tree for Patients at Risk available for reference to teams and senior leadership, hospital-wide inventory and
guide staff in clinical decision making. These results are replacement of support surfaces, development and imple-
encouraging and show opportunity for improvement. Pre- mentation of the PU prevention education bundle, securing
vention of PU has become further embedded in the culture funds and purchasing patient repositioning equipment,
at MSH with evidence of increased staff engagement and and mandatory staff education.
accountability. Registered nurses have demonstrated their
involvement and commitment to PU initiatives through a Planning for the Future
variety of forums: As we celebrate our successes, we are cognizant of the
n Twenty-eight registered nurses volunteered to become challenges faced when implementing a hospital-wide PU
SWNCs, with representation from various clinical areas prevention program. All patient care areas embrace our
including the operating and emergency departments. core value of patient- and family-centered care; however,
Their commitment included a 2-year term and the com- the philosophical and structural support required to shift
pletion of mandatory educational programs designed from a unit-based PU management approach to a systemic,
to prepare the nurse champion with wound care knowl- hospital-wide program must include organizational ac-
edge, skill, and professional practice competencies; countability, responsibility, and a financial shift from unit
n During the pilot of the Positioning Decision Tree for spending to corporate investment. Under the collective ef-
Patients at Risk for Pressure Ulcers, registered nurses forts of our Professional Practice Model, these challenges
from the medical and surgical units provided important are beginning to redirect our initiatives toward several
feedback, which reflected practical challenges related opportunities and a sustainable PU prevention program.
to workflow and translating theory to practice. This Some of these opportunities include the following:
resulted in the complete redesign of the tool. The out- n Implementation of a dedicated centralized system
come demonstrated a standardized interpretation of that includes the purchase, storage, tracking, repair
the tool with 100% consistency in its implementation; and maintenance, and transporting of patient handling
n The lecture series Level 2 (Advanced Skin and Wound equipment, some of which are for PU prevention and
Care) had a mean satisfaction rating of 4.7 of 5 from the management;
registered nurses. This comment exemplifies the im- n Implementation of the Braden Scale for the assessment
pact of this session, ‘‘I really appreciated that the guest of PU risk in the operating room and the emergency
speakers were experts in varied areas and disciplines. department;
This added valuable insight into the ‘holism’ of our prac- n Continuing with the implementation of best practice
tice and the way our practice can grow and is growing.’’ recommendations for the bed- and chair-bound pa-
n Two frontline nurses became standing members of tient; and
the SWCSC; and n Standardization of an evaluation tool to measure con-
n During the celebration of Nurses’ Week, posters tinued clinical practice uptake of prevention strategies,
displaying unit best practice initiatives related to the the utilization of the education bundle and the patient
prevention and management of PUs were presented. handling equipment and mobilization products, quar-
terly P&I for PUs and patient/family satisfaction related
CONCLUSION to the care of PUs.
The purpose of this QI project is to reduce HAPU quarterly The BPG for Risk Assessment and Prevention of Pressure
rates with a CNS-led interprofessional team using evidence- Ulcers has been a driving force for the implementation of
based practice. Although significant work on PU prevention positive change in our interprofessional management of
was already occurring in our organization, the need for HAPUs. This initiative aimed to reduce HAPU rates and to
further improvement through the implementation of best support professional nursing practice, education, and lead-
practice was recognized. Endorsed by senior leadership, ership. We have focused on providing support, tools, and
the BPG PU working group was established with focus on resources required by nursing staff to implement best
HAPUs prevention. The mandate of the BPG PU working practice in PU prevention. We will continue to move for-
group was augmented by many structural pillars of support, ward toward a collaborative, hospital-wide focus that
including the SWCSC, the Department of Nursing profes- will reinforce organizational accountability for PU preven-
sional practice model, the mission and vision beliefs of tion and improved patient care outcomes.
MSH, and the RNAO Best Practice Spotlight Organization
candidacy designation.
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Feature Article

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