Intensive & Critical Care Nursing Essay

Severe acute and chronic diseases, invasive medical procedures, care
dependency and disability are often associated with an increased risk to
develop pressure ulcers/injuries. Indeed, pressure ulcers/injuries have
been described for thousands of years in animals and man and without
doubt they remain major healthcare and patient safety challenges today.
Evidence-based medicine (or healthcare) “… is the conscientious,
explicit, and judicious use of current best evidence in making decisions
about the care of individual patients” [1] and Clinical Practice Guidelines (CPGs) are useful tools to support these individual decisions to
improve patient care and outcomes. Intensive & Critical Care Nursing Essay. For more than 10 years the European Pressure Ulcer Advisory Panel (EPUAP), the National Pressure
Injury Advisory Panel (NPIAP) and the Pan Pacific Pressure Injury
Alliance (PPPIA) have worked successfully together to develop, to update, to disseminate and to implement CPGs for the prevention and
treatment of pressure ulcers/injuries [2–4]. In 2019, the third edition of
the international CPG was released [5].
Since the first publication in 2009, substantial methodological improvements have been implemented; consumer involvement was
strengthened and many more individuals and 14 professional societies
around the globe have contributed [3]. The Guideline Governance
Group, the methodologist and Small Working Group members spent
thousands of hours in reviewing literature, completing data extraction
tables and evidence-to-decision frameworks, drafting chapters and recommendations and collecting critical feedback from over 700 stakeholders. This work not only produced the most up-to-date and
comprehensive evidence-based guidance for clinicians caring for patients with (or at risk of) pressure ulcers/injuries, but also helped to
summarize and discuss key questions in the field such as how pressure
ulcers/injuries develop; what is most important for consumers; and what
are the most pressing research needs from a truly international
perspective. These questions are partially addressed in the full CPG
version, but a more in-depth discussion will provide additional insights
for guideline users, researchers and practitioners in the field of pressure
ulcer/injury prevention. We are grateful that the Journal of Tissue
Viability offered a platform for sharing these insights in the form of an
International Guideline based article series. We started in 2019 with an
article that described the guideline development methods [3] and discussed how to best classify pressure ulcers/injuries [6]. An update of
pressure ulcer/injury aetiology; results of the international consumer survey; a discussion of the current state of the science and future research needs; and barriers and facilitators to guideline implementation will be discussed in future issues of the Journal of Tissue Viability. Intensive & Critical Care Nursing Essay.

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Funding sources
The International Guideline Development was supported by the
National Pressure Injury Advisory Panel, the European Pressure Ulcer
Advisory Panel, and the Pan Pacific Pressure Injury Alliance.
Declaration of competing interest
All authors were involved in the development of the Clinical Practice
Guidelines for the Prevention and Treatment of Pressure Ulcers/Injuries
2019.
Acknowledgements
We thank all volunteers who participated in the Small Working
Groups, Associate Organizations, and the stakeholders and consumers
who contributed to the development of the Prevention and Treatment of
Pressure Ulcers/Injuries: Clinical Practice Guideline (2019).
References
[1] Sackett DL, et al. Evidence based medicine: what it is and what it isn’t. BMJ 1996;
312(7023):71–2.
Contents lists available at ScienceDirect
Journal of Tissue Viability
journal homepage: www.elsevier.com/locate/jtv
https://doi.org/10.1016/j.jtv.2020.09.003
Received 14 September 2020; Accepted 14 September 2020
Journal of Tissue Viability 29 (2020) 225–226
226
[2] Haesler E, et al. The 2014 international pressure ulcer guideline: methods and
development. J Adv Nurs 2017;73(6):1515–30.
[3] Kottner J, et al. Prevention and treatment of pressure ulcers/injuries: the protocol
for the second update of the international Clinical Practice Guideline 2019. J Tissue
Viability 2019;28(2):51–8.
[4] Kottner J, Haesler E. The dissemination of the prevention and treatment of pressure
ulcers clinical Practice guideline 2014 in the academic literature. Wound Repair
Regen 2020;28(4):580–3.
[5] European Pressure Ulcer Advisory Panel. National pressure injury advisory Panel,
and Pan pacific pressure injury alliance, Prevention and Treatment of Pressure lcers/
injuries: clinical Practice guideline. 2019.
[6] Kottner J, et al. Pressure ulcer/injury classification today: an international
perspective. J Tissue Viability 2020;29(3):197–203.
Jan Kottner*
Charit´e-Universitatsmedizin ¨ Berlin, Department of Dermatology and Allergy,
Germany
Ghent University, Faculty of Medicine and Health Sciences, Belgium
Janet Cuddigan
University of Nebraska Medical Center, College of Nursing, Omaha, NE,
USA
Keryln Carville
Silver Chain Group, Curtin University, School of Nursing, Midwifery and
Paramedicine, Australia
Emily Haesler
Curtin University, School of Nursing, Midwifery and Paramedicine,
Australia
LaTrobe University, Australian Centre for Evidence Based Aged Care, School
of Nursing and Midwifery, Australia
Australian National University, ANU Medical School, Academic Unit of
General Practice, Australia
* Corresponding author. Intensive & Critical Care Nursing Essay. Charit´e-Universitatsmedizin ¨ Berlin,
Department of Dermatology and Allergy, Germany.
E-mail address: [email protected] (J. Kottner).

With an aging patient population, high acuity and comorbidities, and changes
in government-mandated payment
incentives, hospital-acquired pressure
injury (HAPI) remains one of the
biggest challenges faced by healthcare
organizations. Increased attention
has been focused on HAPI prevention. Incidence of HAPI has been
reported to be about 0.28% (Dreyfus,
Gayle, Trueman, Delhougne, &
Siddiqui, 2018). Authors also noted
patients with HAPI experience longer
hospital lengths of stay (LOS) of
approximately 13 days compared to
patients who do not develop HAPI.
Readmission rates within 30 days of
discharge also are higher in patients
developing HAPI. The mortality rate
in patients with pressure injuries is
approximately 9%, significantly higher than in patients without pressure
injuries (Bauer, Rock, Nazzal, Jones, &
Qu, 2016). Despite existing cost variation, the excess cost of a hospital stay
for each HAPI is estimated to be
greater than $43,000 (Agency for
Healthcare Research and Quality,
2014).
Nursing-sensitive indicators
(NSIs) such as HAPI prevalence were
implemented by the American
Nurses Association as measures of
safety to evaluate the quality of
nursing care delivered by healthcare
facilities and improve patient outcomes (Montalvo, 2007). NSIs
Continuous Quality Improvement
Bertram Vita Amon
Alexandria G. David
Van Hong Do
Donna M. Ellis
Derek Portea
Patrick Tran
Betty Lee
Causes of pressure injuries are multi-factorial. A comprehensive,
hospital-acquired pressure injury prevention program with bundled
interventions was effective in achieving zero pressure injuries for
over 2 years on a medical-surgical telemetry unit.
specifically identify processes and
outcomes that are influenced by
nursing care. The project facility
participates in monthly HAPI prevalence surveys, with results reported
to the National Database of Nursing
Quality Indicators (NDNQI). These
surveys allow staff on each patient
care unit to have a clear understanding of their HAPI prevalence
and target efforts to identify gaps,
resources, and opportunities for
continuous improvement. One
unit’s implementation of a comprehensive pressure injury prevention
program is described, including its
success in attaining prevalence and
incidence rates of 0 for 1,000 days.
Project Site and Reason for
Change
Patients on the project unit
were admitted from home and
other care facilities with acute and
chronic medical conditions. Al –
though the LOS ranges from 3 to 5
days, patients may remain hospitalized on the unit for several weeks
and months. Staff consisted of registered nurses (RN) and clinical care
partners (CCP), a classification com-
18 January-February 2019 • Vol. 28/No. 1
prised of certified nurse assistants
and licensed vocational nurses.
The organization had been
using the Braden scale (Bergstrom,
Braden, Laguzza, & Holman, 1987)
to conduct standardized patient
skin assessments. Intensive & Critical Care Nursing Essay. The Braden scale applies a score to subscales of sensory perception, moisture, activity,mobility, nutrition, and friction and
shear. The unit previously implemented preventive strategies outlined in the hospital skin careguideline, and integrated an interprofessional approach that involvedthe patient’s entire care team. Intensive & Critical Care Nursing Essay.
Nevertheless, HAPI prevalence rates
in 2013 and 2014 ranged from 1.1%
to 2.3%, exceeding the NDNQI
benchmark, and did not meet unit
performance goals. Incidence rates
were 0.4% to 1.5%. Variability in
nursing practices and gaps in
knowledge of HAPI prevention may
have contributed to the high prevalence. The goal of this project was
to decrease HAPI prevalence and
incidence through comprehensive
prevention practices.
Program
Treatment of pressure injuries
always has been a priority for medical-surgical telemetry patients. In
June 2014, the unit shifted the
focus toward prevention. A team
was established to include unit
champions, unit director, assistant
unit director, clinical nurse specialist, and certified wound ostomy
continence nurse (CWOCN). Using
FOCUS-PDCA methodology, the
team formulated an improvement
plan with a bundled approach to
address six strategies for HAPI prevention comprehensively.
Improved Risk Assessment
The standard hospital practice
for the RN was to conduct a comprehensive skin assessment using
the Braden scale. In the new prevention plan, the unit adopted a
practice of performing thorough
skin assessments with a second RN
to improve accuracy for patients on
admission or transfer to the unit.
This careful initial examination of
the patient’s skin by two RNs
helped identify any pressure injury
that may have been unnoticed in
one assessment and improve accuracy of staging the injury.
Once a HAPI was identified and
documented, a wound care consultation referral was triggered in the
electronic health record. The
CWOCN collaborated with the RN
to implement an individualized
plan of care for prevention and
treatment. Consultation by the
CWOCN also provided valuable
real-time bedside education.
Individualized Pressure
Injury Risk Factor Reduction
The prevention plan addressed
reduction of pressure injury risk factors. Certain conditions (e.g., in –
continence) posed a unique challenge in maintaining moisture control and skin integrity. Team members determined the use of incontinence diapers might have been a
contributor to moisture-associated
skin damage. With the introduction
of a new absorbency pad to hospital-approved products, the unit
eliminated diaper use in early 2015.
The new absorbency pad effectively
pulled moisture away from the skin
and held a large volume of fluid,
thus promoting dry skin for the
patient. Any patient with incontinence only received a diaper when
transported from the unit, during
ambulation, or according to family
Continuous Quality Improvement
Literature Summary
• Hospitalized patients are vulnerable to the development of hospitalacquired pressure injury (HAPI). Multi-factorial risk factors include
patient’s advanced age, co-morbidities, malnutrition, and limitations
in sensory and mobility (National Pressure Ulcer Advisory Panel
[NPUAP], European Pressure Ulcer Advisory Panel, & Pan Pacific
Pressure Injury Alliance, 2014). Intensive & Critical Care Nursing Essay.
• HAPIs affect patients’ quality of life by contributing to increased risk
of infection, pain, and a decline in health (NPUAP et al., 2014).
• Incidence of HAPI negatively impacts hospital length of stay, mortality
rates, readmissions, and healthcare cost (Bauer, Rock, Nazzal, Jones, &
Qu, 2016; Dreyfus, Gayle, Trueman, Delhougne, & Siddiqui, 2018).
• Pressure injury prevention programs should be developed using a
multi-faceted approach that addresses the patient’s individualized risk
factors and needs (NPUAP et al., 2014).
CQI Model
FOCUS-PDCA (Batalden, 1992)
Quality Indicator with Operational Definitions & Data Collection
Methods
• Prevalence data were collected monthly using the pressure injury survey tool from the National Database of Nursing Quality Indicators
(NDNQI).
• Data on new HAPIs were tracked through an internal reporting system
and evaluated by the skin champions, unit leaders, and certified
wound ostomy continence nurse.
Clinical Setting
32-bed adult medical-surgical telemetry unit in an urban academic,
Magnet®-designated teaching hospital
Program Objective
Decrease HAPI prevalence to below the national NDNQI monthly mean
through a bundled intervention program.
January-February 2019 • Vol. 28/No. 1 19
Achieving 1,000 Days with Zero Hospital-Acquired Pressure Injuries on a Medical-Surgical Telemetry Unit
preferences. In the latter situation,
staff educated patient and family
about effects on skin breakdown
and discouraged diaper use.
Specialized Prophylactic Skin
Products and Support
Surfaces
The cache of available skin
products and support surfaces was
evaluated continually by the
CWOCN. Over the years, various
specialized skin products were
introduced into the hospital supply
for protection of pressure points
and bony prominences. Since 2014,
a new absorbent, self-adherent, bordered foam dressing product was
available; it was easy to apply to
vulnerable areas for prophylaxis.
The optimal support surface
provided risk reduction through
pressure redistribution. Organiza –
tional leaders committed financial
support to ensure current models of
specialized support surfaces, such as
static air mattress overlays and lowair-loss mattresses, were outfitted
throughout the facility. The pa –
tient’s Braden score, individual
needs, and hospital skin care guideline facilitated clinical decision
making about use of an appropriate
product or support surface.
Early Mobility
Decreased mobility in the hospitalized patient may contribute to
negative outcomes such as HAPI
development (Boynton et al., 2014). Intensive & Critical Care Nursing Essay.
In 2014, a safe patient handling
(SPH) program was implemented to
facilitate safe patient mobilization. In
2016, a comprehensive early mobility program was adopted with use of a
nurse-administered validated tool for
assessing mobility level. The Banner
Mobility Assessment Tool provided a
standard RN assessment of the
patient’s mobility and a guide for the
use of SPH equipment (Boynton et
al., 2014). Early mobility was promoted as an organizational patient
care priority and fundamental component in the goal to prevent HAPI.
Staff Education
Nursing leaders supported skin
care education. The RNs and CCPs
were required to attend annual hospital classes about HAPI identification, prevention, and treatment.
The RNs also completed annual
NDNQI Pressure Injury Training.
The Unit Skin Champion
Role
For many years, the unit used a
team of skin champions. Skin champions included RNs and CCPs from
day and night shifts. This diverse
group reinforced the focus of HAPI
prevention as a combined effort.
They completed the monthly skin
prevalence survey. On prevalence
day, the CWOCN updated the skin
champions about pressure injury
data, trends, issues, and the latest
products or equipment used in the
hospital. On the unit, skin champions served as resources and helped
validate findings or answer questions
from staff. Skin champions updated a
quality dashboard showing days since
last HAPI to increase awareness of
HAPI prevention as a unit goal.
Evaluation and Action Plan
Unit skin champions met
monthly to perform a pressure
injury survey using the NDNQI
tool. They evaluated outcomes by
reviewing monthly prevalence data.
New HAPIs were detected through
shift assessments and consultation
requests were made to the CWOCN.
New HAPIs were tracked using an
internal reporting system and evaluated by the champions, unit leaders, and CWOCN. This process
resulted in a dramatic decline in the
number of HAPIs since June 2014.
Results and Limitations
The unit’s process improvement plan for HAPI prevention was
implemented in 2014, and new
strategies were introduced through
cycles of continuous improvement.
Prevalence and incidence of HAPI
decreased to zero. Annual education and use of quality dashboards
raised staff knowledge and awareness of HAPI prevention. Decreased
HAPIs may be attributed to use of
bundled interventions rather than
any single strategy. The unit
achieved a milestone of 1,000 days
without HAPIs (see Figures 1 and 2).
Efforts to sustain the success
have required constant attention.
The champions and unit leaders
continually review data collection,
process improvement steps, and evidence-based strategies. The annual
education curriculum has evolved as
the CWOCN addresses clinical
trends and new interventions. Case
studies and huddles help to enhance
staff understanding of pressure
injuries. Emphasis on this patient
initiative was incorporated in new
staff orientation. Staff also engaged
patient and families about pressure
injury prevention when strategies
were implemented.
Despite the improved rates, the
unit encountered some challenges
for sustaining best practices. Al –
though HAPI prevention was a hospital initiative, staff noticed RNs
and CCPs who floated to the unit
often were unfamiliar with the unitspecific implementation of new
HAPI prevention practices. This
required staff to introduce the unit
program to them. Occasionally,
staff encountered resistance from
patients or family members who
refused the recommended care due
to personal preferences. Addi –
tionally, some clinical limitations
were difficult to overcome, such as
suboptimal nutritional status or
vulnerability of aged skin.
Lessons Learned/Nursing
Implications
Use of preventive strategies
identified by the team and the focus
on decreasing HAPI now have been
sustained for over 3 years. With the
knowledge gained from the continuous improvement process, preventive interventions were integrated
as standard of care and were implemented proactively on all unit
admissions. Although HAPI prevalence is a nurse-sensitive indicator
that reflects the nurse’s professional
role in delivering care and influencing outcomes, unit staff also recognized HAPI prevention required a
team effort to reach the goal. Leader
and staff support were vital for the
project’s success. Patient outcomes
were achieved because team mem-
20 January-February 2019 • Vol. 28/No. 1
Continuous Quality Improvement
FIGURE 1.
Prevalence of Hospital-Acquired Pressure Injuries (HAPIs) from First Quarter of 2013 to
Fourth Quarter of 2017
Number of HAPIs HAPI prevalence rate
0.0
0.5
1.0
1.5
2.0
2.5
3.0
3.5
Prevalence Rate (%) of HAPI
0.0
2.3
0.0 0.0 0.0
1.1
0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0
1Q 2013
2Q 2013
3Q 2013
4Q 2013
1Q 2014
2Q 2014
3Q 2014
4Q 2014
1Q 2015
2Q 2015
3Q 2015
4Q 2015
1Q 2016
2Q 2016
3Q 2016
4Q 2016
1Q 2017
2Q 2017
3Q 2017
4Q 2017
Quarters (Q)
3
2
1
0
Number of HAPI Prevalence
FIGURE 2.
Incidence of Hospital-Acquired Pressure Injuries (HAPIs) from First Quarter of 2013 to Fourth Quarter of 2017 Incidence Rate (%) of HAPI
0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0
1Q 2013
2Q 2013
3Q 2013
4Q 2013
1Q 2014
2Q 2014
3Q 2014
4Q 2014
1Q 2015
2Q 2015
3Q 2015
4Q 2015
1Q 2016
2Q 2016
3Q 2016
4Q 2016
1Q 2017
2Q 2017
3Q 2017
4Q 2017
Quarters (Q)
4
3
2
1
0
Number of HAPI Incidence
0.0
0.5
1.0
1.5
2.0
0.4 0.4
0.0 0.0 0.0
1.5 1.5
Number of HAPIs HAPI prevalence rate
January-February 2019 • Vol. 28/No. 1 21
bers identified a clinical problem,
selected a quality improvement
process to analyze the problem,
implemented a plan, and continually evaluated the plan. The unit
achieved improved patient outcomes through use of bundled
interventions adopted over time to
ensure best practices.
The success and sustainability
of the HAPI prevention program
required ongoing support, adherence, and accountability. HAPI prevention was embraced by administrators and staff as a patient safety
priority. Tools and resources were
available to staff for early risk identification and patient management.
With CWOCN guidance, unit
champion advocacy helped drive
change and sustain improvement
efforts. Unit leader oversight
through active rounding helped
ensure accountability with a focus
on staff commitment, awareness of
the problem, and reduced practice
variability. Educating staff narrowed
the knowledge gap and translated
knowledge to practice, while educating patients and families facilitated their adherence to HAPI prevention based on their understanding of risk for HAPI development.
For a medical-surgical telemetry
unit with patients presenting with
multiple risk factors, reaching 1,000
days without a HAPI was an impressive achievement. Unit leaders celebrated the 1,000th day as a successful milestone. The chief nursing
officer, medical director, and
CWOCN attended the celebration
to congratulate unit staff. The hospital newsletter highlighted the
story. Recognizing the achievement
served as reinforcement for the program’s continuation.
These outcomes helped enculturate increased vigilance for HAPI
prevention among staff. The interventions developed from the
improvement process elevated unit
expectations for HAPI prevention.

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Unit performance data were presented to staff so they could remain
engaged with the process. Processes
were shared so practices could be
standardized throughout the hospital. With publicly reported quality
metrics, this achievement reflected
the quality of nursing care and provided reassurance to patients of the
hospital’s commitment to patient
safety.
Conclusion
A comprehensive HAPI prevention program, increased staff awareness, and interprofessional collaboration were effective in reducing
HAPI and decreasing associated
costs. The unit culture has shifted to
a comprehensive, preventive focus.
Efforts continue to sustain and
spread these practices. Unit staff
assess challenges and barriers at the
patient, staff, and hospital levels to
maintain attention on HAPI prevention. Data collection and monitoring provide feedback to the staff
and organizational stakeholders.
This program fostered knowledge of
HAPI prevention and awareness of
HAPI as a constant challenge in the
care of the hospitalized patient.
REFERENCES
Agency for Healthcare Research and Quality.
(2014). Preventing pressure ulcers in
hospitals. Are we ready for change?
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Batalden, P.B.Intensive & Critical Care Nursing Essay.  (1992). Building knowledge for
improvement – an introductory guide to
the use of FOCUS-PDCA. Nashville, TN:
Quality Resource Group, Hospital
Corporation of America.
Bauer, K., Rock, K., Nazzal, M., Jones, O., &
Qu, W. (2016). Pressure ulcers in the
United States’ inpatient population from
2008 to 2012: Results of a retrospective
nationwide study. Ostomy Wound
Management, 62(11), 30-38.
Bergstrom, N., Braden, B.J., Laguzza, A., &
Holman, V. (1987). The Braden scale for
predicting pressure sore risk. Nursing
Research, 36(4), 205-210.
Boynton, T., Kelly, L., Perez, A., Miller, M., An,
Y., & Trudgen, C. (2014). Banner mobility
assessment tool for nurses: Instrument
validation. American Journal of Safe
Patient Handling & Movement, 4(3), 86-
92.
Dreyfus, J., Gayle, J., Trueman, P.,
Delhougne, G., & Siddiqui, A. (2018).
Assessment of risk factors associated
with hospital-acquired pressure injuries
and impact on health care utilization and
cost outcomes in US hospitals. American
Journal of Medical Quality, 33(4), 348-
358. doi:10.1177/1062860617746741
Montalvo, I. (2007). The National Database of
Nursing Quality Indicators (NDNQI).
OJIN: The Online Journal of Issues in
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National Pressure Ulcer Advisory Panel
(NPUAP), European Pressure Ulcer
Advisory Panel, & Pan Pacific Pressure
Injury Alliance. (2014). Prevention and
treatment of pressure ulcers: Quick reference guide. Osbourne Park, Western
Australia: Cambridge Media.
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