The European Pressure Ulcer Advisory Group, the National Pressure Ulcer Commission, the Advisory Panel, and the Pan-Pacific Injury Pressure Alliance have developed Pressure ulcer/injury prevention and management: A quick reference guide. The latest edition was published in 2019 and had the most relevant recommendations for preventing pressure ulcers and injuries. However, Lakeside Hospital does not comply with a significant portion of the recommendations (see Appendix B). Therefore, one of the approaches to reducing the HAPI indicator from 1.25 percent to 0.7 percent is the implementation of the guide.
The guide contains evidence-based information and recommendations for the prevention and treatment of pressure ulcers for healthcare organizations. Key categories of recommendations are risk factor assessment, skin and tissue assessment, nutrition and treatment assessment, preventive skin care repositioning, and early mobilization (Haesler, 2019). These categories of preventive measures are defined as mandatory and have a set of specific aspects and factors that need to be taken into account. For example, assessing such factors as limited mobility, diabetes mellitus, perfusion and circulation deficits, oxygenation deficit, increased body temperature, and mental health status is mandatory to evaluate the risk of pressure ulcers (Haesler, 2019). Thus, the described categories of recommendations are strategies for preventing pressure ulcers and improving patient care quality.
In addition, the guide also provides recommendations for organizing the work of medical facilities, which acts as a preventive factor and limitation for the implementation of these recommendations. One of the essential preventive elements is the availability of such resources as special mattresses, medical-grade sheepskin, air fluidized beds, bariatric and air pressure redistribution cushions, and other devices for repositioning patients with postoperative trauma or limited mobility (Haesler, 2019). However, a potential challenge to this approach is its scale, which requires the involvement and motivation of staff. The guideline has recommendations for different areas of care; consequently, the plan requires many changes, including material resources to improve the hospital’s equipment. Nevertheless, the guideline provides specific and general recommendations for organizing a hospital’s work and the necessary care actions; hence, its implementation is a useful approach for the prevention of pressure ulcers.
Implementation of Electronic Health Records (EHR) prognostic tool
Electronic Health Records (EHR) is a technology that is increasingly being used in healthcare facilities to organize and systemize data and simplify and make staff’s work more efficient. Depending on the EHR system and platform, employees have access to different tools aimed at improving their work efficiency. The use of the EHR prognostic instrument is one approach to addressing the problem of the high rate of pressure ulcer cases at Lakeside Hospital.
The benefits of EHR are the accurate collection and storage of patient health records, which helps healthcare providers cover all the details for risk assessment. Numerous studies demonstrate that EHR-based instruments are effective and prospective tools for preventing pressure ulcers due to their high accuracy in assessing risks and reducing the number of human errors. For example, Cramer et al. (2019) determine that an EHR tool using machine learning is more accurate at predicting pressure ulcers than the Braden score. At the same time, Alderden et al. (2021) confirm this claim by noting the benefits of EHR-based analytics tools in the ability to include complex nonlinear relationships between variables, as well as proper documentation of all risk factors. Therefore, the use of this tool at Lakeside Hospital will improve the quality of the pressure ulcer risk assessment.
The main challenge for leaders, managers, and staff is to consistently and regularly use ERH to provide data for analysis. In other words, this approach requires leaders to acquire the tool and encourage staff to use it. Middle managers should play an assisting and supervising role to familiarize staff with the tool’s functions and ensure regular use of the ERH system. At the same time, nurses and physicians must perform the necessary patient assessments and document the factors appropriately.
Analysis of Potential Success
The approach selected to reduce the HAPI indicator from 1.25 percent to 0.7 percent is the implementation of EPUAP / NPIAP / PPPIA’s guide. This approach is more suitable for Lakeside Hospital as it has comprehensive methods to pressure ulcer prevention. Key categories of steps include both assessing different risk factors and taking practical steps to diminish them. Since Lakeside Hospital staff’s current work has problems in different areas of the organization from assessment to availability of resources, the use of a guide is essential. Moreover, the small size of the hospital and the number of staff created the conditions for interdisciplinary collaboration that facilitates faster implementation of changes.
However, there are also barriers to implementing this plan related to staff motivation and knowledge, as well as hospital resources. Lakeside Hospital is a small rural facility that lacks the resources to purchase special mattresses, beds, and pressure distribution devices, although the hospital has only 35 beds. In addition, some staff members lack the knowledge to apply the recommendations and properly conduct risk assessments. Simultaneously, since the hospital has limited staff, the employees’ workload hinders their motivation for education. Therefore, these barriers must be taken into account to implement the guide’s recommendations.
The theory selected to create the action plan is Lewin’s theory of change. This theory defines three stages of change in the organization, such as unfreezing, moving, and refreezing (Hussain et al., 2018). The first stage aims to identify and understand the problem and its delivery to all staff members, and the second stage includes building a plan and its implementation (Marquis & Huston, 2021). The refreezing phase means establishing and maintaining the adopted changes and continuing the implementation of the plan. However, Hussain et al. note (2018), that the implementation of these stages requires effective leadership to motivate employees, overcome fears and resistance to change, and analyze the problem accurately. At the same time, leadership style plays a significant role, since employees’ voluntary motivation and involvement are necessary to implement changes successfully.
This theory is most suitable for solving the Lakeside Hospital’s problem and implementing EPUAP / NPIAP / PPPIA’s guide. First, during the unfreezing phase, staff will be able to determine mistakes that lead to a high rating of pressure ulcers. Second, the theory foresees staff resistance to change, which is one of the barriers at Lakeside Hospital due to the lack of employees and time and the need for education. In addition, Lewin’s theory requires workers’ involvement in developing and implementing the plan, which is a simple task for a hospital with a small number of employees.
Quality Improvement Project Action Plan
A high level of hospital-acquired pressure injuries was identified in 2020. A proposal to reduce the HAPI level in 2021 was developed and presented to the Executive Team, which approved the initiative and appointed the senior manager of the hospital as leader of the project. An interdisciplinary team of nurses, general surgery, pharmacist, and a physician has been formed. A team meeting was held in January 2021 and was set to 1) share the problem and the goal of the project; 2) study EPUAP / NPIAP / PPPIA’s guide; 3) identify gaps in patient care using a cause and effect diagram (see Appendix B); 4) identify gaps in the provision of the hospital.
The team reviewed EPUAP / NPIAP / PPPIA’s guide and scientific literature to determine the gaps in inpatient care. The team set goals based on a cause and effect diagram to correct determined mistakes, and identify responsibilities and resources to achieve the goal. The practical implementation of the changes was to educate nurses on the rules and practices of caring for patients with reduced mobility to avoid HAPI.
The changes aimed to improve the quality and accuracy of assessing the risk factors for HAPI development and preventive measures such as nutritional changes, skincare, and patient repositioning. First, all nurses were trained to assess skin, nutrition, and other HAPI risk factors. Evaluation of skin and tissues includes examination for damage, oxygenation, and moisture of the skin, and its general condition. Evaluation of nutrition includes the determination of body mass index, energy intake, and dietary restrictions. Other risk factors are age, mobility, length of hospital stay, patient status, diabetes, or skin disease. Secondly, nurses were educated in preventive patient care. Among these measures were determining the optimal way of feeding (enteral or parenteral feeding), the number of calories, and the patient’s diet. The rules of skincare, including the use of barrier products against skin moisture, and the regulations for repositioning patients with different severity of the condition every 2 hours, were also studied. A separate measure was acquiring specialized furniture and equipment for repositioning and patient comforts, such as redistributing mattresses and cushions, supporting chairs, beds, and prophylactic dressings.
The surgeon, physician, pharmacist, and senior nurse were responsible for compiling training material and recommendations for the care of patients with specific risk factors, for example, postoperative trauma, diabetes, or metabolic diseases. The senior nurse was responsible for instructing the nurses, monitoring the implementation of the recommendation, and nurses reporting on applied preventive measures. The senior manager was responsible for controlling the performance of tasks by all team members, assessing needs and progress, and requesting the Executive Team to purchase equipment. The dean of the hospital was responsible for distributing funds and buying furniture and equipment.
The assessment plan was designed to correlate and monitor the change implementation process. Data was collected in January, February, March, and April 2021 (see Appendix D). The evaluation included such parameters as 1) patients admitted with pressure ulcers 2) patients assessed with a high risk of developing HAPI 3) preventive measures to improve nutrition 4) skincare, 5) patient repositioning 6) HAPI cases. Data will be further collected and evaluated monthly by a senior manager.
The project has not reached the freezing stage; however, nurses’ continued use of patient care practices is expected. The data on the effectiveness of the changes will be tracked and evaluated over 9-12 months. In addition, based on the information on the implementation of the recommendations, a system of rewards and punishments will be developed to motivate employees to comply with the rules of HAPI prevention.
For the analysis, data were collected and systematized from each stage of care necessary to prevent pressure ulcers. First, the number of patients admitted with pressure ulcers and the number of patients assessed with a high risk of developing HAPI were determined. Second, cases of taking preventive measures to improve nutrition, skincare, and patient repositioning, as well as HAPI cases, were assessed. In addition, such indicator as the availability of specialized furniture and equipment was also considered. All data was collected as part of the pretest and posttest.
A comparison of pretest and posttest data showed a significant improvement in the HAPI rate. While the number of patients hospitalized with pressure ulcers remained at the same level, patients assessed with a high risk of developing HAPI increased by 0,4, respectively (see Appendix C). The frequency of taking preventive measures such as improving nutrition, skincare, and repositioning also increased by 0,8, 0,7, and 0,7 respectively(see Appendix C). Although these rates may be influenced by the overall increase in the number of patients with adverse health conditioning, they most likely indicate a more frequent and accurate assessment of patients and the adoption of preventive measures.
At the same time, different types of preventive measures were used in almost the same proportion (see Appendix C). However, the amount of equipment and specialized furniture has grown by only a few units. These specific metrics cannot be compared with state and country benchmarks as they are not available. Nevertheless, the total number of HAPIs shows an approximation to the national benchmark of 0,65; the number of patients who required HAPI treatment decreased to 0,9 (see Appendix C). Consequently, the comparison of indicators demonstrates that the improvement in indicators is associated with an increase in employees’ quality of work but not a deterioration in the state of health of patients.
It can be noted that quality improvement plan implementation was successful in general by evaluating its results. First, there is an increase in patient care quality, since specialists more accurately and often assess the condition of patients, note the risks associated with the development of HAPI, and take measures to eliminate them. Second, while Lakeside Hospital has yet to meet its target, the significant downgrade in HAPI’s rate demonstrates that the organization is moving in the right direction.
The driving forces behind the implementation of the changes were the relatively small staff who collaborate and interact with each other daily. Thus, the hospital has an interprofessional interaction system that ensures a comprehensive approach to patient care. Consequently, employees quickly acquired the necessary knowledge to assess risks and select preventive measures by using the assistance and advice of colleagues. In addition, the small staff also contributed to the involvement of all employees in the development of the plan and decision-making, and close relationships with the leaders increased their influence on motivation.
At the same time, a slight increase in the number of specialized furniture and equipment demonstrates that the hospital has failed to overcome the barrier of limited resources. However, the hospital can turn to the local community for fundraising, since its citizens must be interested in the good conditions of hospital stay and also make a request to the local authority or health organizations. Since the hospital has only 35 licensed beds, the renovation cost is not high for most charities or sponsors. However, overcoming this barrier contributes to more efficient work of staff members and higher patient satisfaction.
Therefore, this quality improvement project was aimed at the problem of the high rate of hospital-acquired pressure ulcers. The analysis of the problem showed shortcomings in the organization of employees’ work and knowledge; hence, an approach to problem-solving was implementing the EPUAP / NPIAP / PPPIA’s guide for the prevention of pressure ulcers. The results showed that this approach has a high potential for practical application but requires the efforts of leadership, employees, and the involvement of resources. Nevertheless, this approach can be applied in practice in any healthcare facility, taking into account the specifics of the institution that needs improvement.
The implementation of the Guidelines for Prevention and Treatment of HAPI approach has many positive aspects; however, some recommendations need to be followed for its successful realization. First, this approach requires strong and effective leadership that motivates employees to change. Secondly, all team members’ involvement in the process is necessary for a detailed analysis of the problem and searching for a solution. This principle can be applied in small organizations through discussions, and extensive facilities can use questionnaires for employees. In addition, I recommend evaluating and allocating funds before starting the realization of the plan to ensure that its material component is implemented since the lack of funds is a significant barrier to improving the quality of work. These recommendations will enable organizations to assess their capabilities and take steps to prepare for this kind of quality improvement project.
Alderden, J., Drake, K. P., Wilson, A., Dimas, J., Cummins, M. R., & Yap, T. L. (2021). Hospital acquired pressure injury prediction in surgical critical care patients. BMC Medical Informatics and Decision Making, 21(1).
Cramer, E. M., Seneviratne, M. G., Sharifi, H., Ozturk, A., & Hernandez-Boussard, T. (2019). Predicting the incidence of pressure ulcers in the intensive care unit using machine learning. EGEMS (Washington, DC), 7(1), 49.
Haesler, E. (Ed.) (2019). Prevention and treatment of pressure ulcers/injuries: Quick reference guide. European Pressure Ulcer Advisory Panel, National Pressure Injury Advisory Panel and Pan Pacific Pressure Injury Alliance.
Hussain, S. T., Lei, S., Akram, T., Haider, M. J., Hussain, S. H., & Ali, M. (2018). Kurt Lewin’s change model: A critical review of the role of leadership and employee involvement in organizational change. Journal of Innovation & Knowledge, 3(3), 123–127.
Marquis, B.L., & Huston, C. J. (2021). Leadership roles and management functions in nursing : theory and application (10th ed.). Wolters Kluwer Health.