Authors: Jocelyn Price, Hilary Weatherby
Hilary Weatherby is a Registered Nurse working as a Patient Safety & Quality Improvement (QI) Specialist. Hilary helps teams apply QI methodology to organization-wide projects and reviews patient safety events for the purposes of continuous quality improvement across a large, downtown Toronto, hospital system.
You are a medical student seeing patients on a medicine unit at your local community hospital. One of your patients is an 81-year-old female with Parkinson’s disease who was admitted for the management of aspiration pneumonia. You conduct a physical exam and upon inspection, you notice a lesion overlying the sacrum that appears to be red, deep, and open. You estimate that she has a stage III pressure injury. On your way to consult with the attending physician, you wonder how this happened. Could this have been prevented? What prevention measures are currently in place?
What is a Pressure Injury?
A pressure injury (PI) is localized damage to the skin and/or underlying soft tissue, usually over a bony prominence, and may be related to medical and other devices. The injury usually occurs as a result of intense or prolonged pressure, sometimes in combination with shear. (1) There are a variety of risk factors that increase the likelihood of pressure injuries such as decreased mobility, poor nutrition, deficits in sensory perception, and incontinence. (1) There are four main stages of pressure injuries, classified based on severity, as seen in Figure 1.
Why Does it Matter?
The prevention of pressure injuries is crucial given their association with adverse patient outcomes. In addition to causing patients pain, pressure injuries have been associated with an extended length of stay, the development of infections, and even mortality. (1) Stage III and IV pressure injuries acquired after admission are therefore considered ‘never events’ in hospital care across Canada. This acknowledges the serious harm they can cause to patients and the fact that they are preventable with appropriate organization level policies and procedures. (2) Canadian data on pressure injuries is variable, with one 2015 Canadian study noting the prevalence of PIs across all healthcare settings to be around 13%. (3)
Additionally, hospital acquired pressure injuries are associated with a large economic burden. Models based on US data estimate that hospital-acquired pressure injuries cost an average of just under $11,000 USD per patient, amounting to nearly $26.8 billion annually. (4) Despite being a low proportion of all hospital acquired pressure injuries, stage 3 and 4 PIs are responsible for nearly 60% of these costs. (4) The good news is that these events are preventable through a variety of efforts. One large community hospital showed a reduction of the prevalence of hospital-acquired pressure injuries by 17% across two years in non-ICU patients, associated with an estimated $3.7 million in cost savings. (5)
What are the current best practices?
The Institute for Healthcare Improvement has outlined six steps considered essential in pressure injury prevention. The first two steps focus on identifying patients at an increased risk of pressure injuries, while steps three through six are prevention strategies that can be used in patients identified to be at higher risk, as seen in Figure 2. (1) Healthcare teams should strive to adopt these steps as part of routine patient care.
Additionally, providing patients and families with pressure injury prevention materials and teaching ensures patients are partners in their care and that they know their own risk of developing a pressure injury. The importance of appropriate wound debridement, infection management, surgical consultation, and well-coordinated transitions in care for patients who have developed pressure injuries are also emphasized in quality standard guidelines. (6)
An Organizational Approach to Reducing Pressure Injuries
Applying QI and prevention strategies in the organizational setting adds another layer of complexity. One example is the University Health Network’s (UHN’s) approach in 2017. UHN began an organization-wide approach to reducing hospital acquired pressure injuries. It took time to understand, develop, and improve pressure injury reporting so that they could monitor progress and improvement. There have been many strategies used and learnings along the way, some of which are outlined below:
Establishing Accountability: A framework for governance and accountability for pressure injury prevention was established.
Reducing variability, and building reliability: In collaboration with key stakeholders and subject matter experts, an evidence-based pressure injury prevention “bundle” was developed, as seen in Figure 3.
Collaboration with clinicians: Engagement with front-line clinicians and collaboration with the inter-professional skin health steering committee was integral to the scale and spread of pressure injury prevention work.
Focused quality improvement work: A comprehensive analysis of pressure injury data helped identify root causes.
Improving pressure injury documentation: The timely electronic documentation for wound assessments was streamlined within 24 hours of admission.
Improving pressure injury safety event reporting: a pressure injury safety event form was created to support stage III and above being considered a serious safety event and a universal “never event”.
A continuous focus on pressure injury prevention at all levels: UHN’s daily unit huddle supports the review of patients with existing pressure injuries, patients at risk for developing pressure injuries, and provides the opportunity to discuss the care plans in place for each of these patients.
Pressure injuries are an important patient safety issue that should be considered across all healthcare settings in Canada. Given the detrimental impact on patients, healthcare providers and institutions should strive to adopt evidence-based strategies for PI prevention, as outlined above. A reduction in the prevalence of pressure injuries not only leads to better patient outcomes but also can reduce the associated economic burden. More work needs to be done to bring the number of hospital acquired pressure injuries to as near zero as possible, improving patient health outcomes both during hospital admission and beyond.
After doing some background reading on pressure injuries, you are surprised to learn about how many strategies can be implemented to prevent pressure injuries from occurring in the first place! You are determined to share your knowledge with your team and learn more about what is currently being done in your hospital so that the evidence-based strategies you have learned about can be implemented and contribute to an improvement in patient safety longer term.
Senior Editor: Lucas Chartier
Copyedited by: Jocelyn Price
Institute for Healthcare Improvement. How-To Guide: Prevent Pressure Ulcers. Cambridge, MA. Published 2011. Available from: www.ihi.org
Canadian Patient Safety Institute. Never Events for Hospital Care in Canada. Published September 2015. Available from: www.patientsafetyinstitute.ca
Woo KY, Sears K, Almost J, Wilson R, Whitehead M, VanDenKerkhof EG. Exploration of pressure ulcer and related skin problems across the spectrum of health care settings in Ontario using administrative data. International wound journal. 2017 Feb;14(1):24-30.
Padula WV, Delarmente BA. The national cost of hospital acquired pressure injuries in the United States. Int Wound J 2019 16 (3), 634-640
Goodman L, Khemani E, Cacao F, Yoon J, Burkoski V, Jarrett S, Collins B, Hall TN. A comparison of hospital-acquired pressure injuries in intensive care and non-intensive care units: a multifaceted quality improvement initiative. BMJ Open Quality. 2018 Oct 1;7(4):e000425.
Health Quality Ontario. Pressure Injuries: Care for Patients in All Settings. Published 2017. Available from: www.hqontario.ca