Megan W Miller1, Rebecca T Emeny2, Gary L Freed3. 1. Department of Wound Care Services, Dartmouth Hitchcock Medical Center, Lebanon, NH. 2. The Dartmouth Institute for Health Policy & Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, NH. 3. Department of Plastic Surgery, Dartmouth Hitchcock Medical Center, Lebanon, NH.
Abstract
INTRODUCTION: Hospital-acquired pressure injuries (HAPIs) increase patient mortality and length of stay (LOS). Twenty-eight full-thickness HAPIs occurred in fiscal year 2015 (FY15), and that trend continued into FY16 with 14 injuries on multiple units throughout a tertiary acute care center with 400 beds. To address this trend, a multidisciplinary Pressure Injury Prevention (PIP) team was created. OBJECTIVE: This report is a description of ongoing, hospital-wide efforts to understand the common factors of HAPI causality and to establish corrective action plans institutionally to prevent similar events in the future. METHODS: The team goals were to document the occurrence of HAPIs across all hospital units, reduce preventable full-thickness PIs to zero, and recommend institution-wide changes as those opportunities were recognized. RESULTS: Since the committee's inception in July 2015, an 89% reduction of full-thickness HAPIs, with only 2 full-thickness HAPIs in FY17 and 3 in FY18, has been seen. This effort has been hospital wide with involvement of all inpatient units and perioperative areas (including the operating rooms). Opportunities remain for improvement around the prevention of deep tissue and partial-thickness HAPIs. CONCLUSIONS: The data demonstrate that the formation of a multidisciplinary PIP team of engaged clinicians can reduce the number of preventable full-thickness HAPIs.
INTRODUCTION: Hospital-acquired pressure injuries (HAPIs) increase patient mortality and length of stay (LOS). Twenty-eight full-thickness HAPIs occurred in fiscal year 2015 (FY15), and that trend continued into FY16 with 14 injuries on multiple units throughout a tertiary acute care center with 400 beds. To address this trend, a multidisciplinary Pressure Injury Prevention (PIP) team was created. OBJECTIVE: This report is a description of ongoing, hospital-wide efforts to understand the common factors of HAPI causality and to establish corrective action plans institutionally to prevent similar events in the future. METHODS: The team goals were to document the occurrence of HAPIs across all hospital units, reduce preventable full-thickness PIs to zero, and recommend institution-wide changes as those opportunities were recognized. RESULTS: Since the committee's inception in July 2015, an 89% reduction of full-thickness HAPIs, with only 2 full-thickness HAPIs in FY17 and 3 in FY18, has been seen. This effort has been hospital wide with involvement of all inpatient units and perioperative areas (including the operating rooms). Opportunities remain for improvement around the prevention of deep tissue and partial-thickness HAPIs. CONCLUSIONS: The data demonstrate that the formation of a multidisciplinary PIP team of engaged clinicians can reduce the number of preventable full-thickness HAPIs.
Authors: Laurel B Moyer; Denise L Lauderbaugh; Katherine Worten; Chelsea Carter; Peggy Holub; Rose A Santos Manrique; Judy H Bergman; Mary Anne Dilloway; Marisha Hamid; Linda Glenn Journal: Pediatr Qual Saf Date: 2022-06-14