1. Improving Communication of Skin Integrity Risk Factors: A Quality Improvement Project
Amanda Carlson-Dondero, DNP, RN
Allison Erzberger, DNP, RN, CMSRN, AGCNS- BC
Ann Colburn, BSN, BSW, RN
Katie Vos, BSN, RN
Froedtert & the Medical College of Wisconsin Froedtert Hospital
Wisconsin Association of Clinical Nurse Specialists
CNO/CNS/Shared Governance Breakfast
September 6, 2019

2. Background and Significance ~To Nursing and Shared Governance~
Hospital Acquired Pressure Injuries (HAPIs) prevalence annually
1 to 2.5 million HAPIs
Costs hospitals hundreds of thousands of dollars a year (Meddings et al., 2015)
HAPI decreases patient health outcomes, patient satisfaction, and increase infections leading to sepsis (Mallah et al., 2015)

3. Background and Significance cont.
Multiple High Acuity Criteria (MHAC):
Mechanically ventilated
OR time greater than 6 hours
2 or more vasopressors
ECMO or VAD
Polytrauma victims
The literature review confirmed these common risk factors (Cox et al., 2015; Coyer et al., 2015; Zuo et al., 2015; Cooper, 2013).

4. Problem: Hospital Specific
Opportunity for communicating MHAC and pressure injury interventions performed in ICU upon transfer to the acute care unit
Hand-off report note between critical care and acute care did not include skin-related information

5. Project Overview Purpose-To improve nursing handoff communication of
MHAC
Braden Scale score
Current skin integrity
Intended outcomes were to increase implementation of the Pressure Injury Prevention (PIP) bundle interventions and to decrease the number of HAPIs.

6. Framework
A quality improvement (QI) study based on the Plan-Do-Study-Act (PDSA) model
Setting: SICU (21- bed unit) & CVICU (20-bed unit) and 2NT (32- bed surgical unit) & 3NW step down cardiac unit (30-bed unit)
Method:
Sample- convenience sample of transfer patients between February 1, 2019 and March 31, 2019
84 transfers between SICU and 2NT
154 transfers between CVICU and 3NW

7. Project Description Education was conducted:
staff meetings, weekly s, staff huddles, and reminder signs posted on the units
A pre and post education survey was completed
Nurse rounding on the units
Magnets placed on the patient board and outside the patients’ room
Collaborative effort between nursing staff, CNS, shared governance, and leadership

8. Transferring a patient?
Reminder Signs
Transferring a patient?
Include the following in your note and report:
1) Current Braden Scale Score
2) Any Current Skin Integrity Issues
3) Multiple High Acuity Criteria
-Vasoactive medication use
-OR time >6 hours
-Mechanical ventilation
-ECMO or VAD

9. Project Results
Improved communication regarding MHAC, skin integrity and Braden Scale score
Decreased HAPIs during project implementation and data collection
Increased documentation of PIP Bundle implementation on all transferred patients

10. PIP Bundle Documentation- 3NW

11. PIP Bundle Documentation 2NT

12. Pressure Injury

13. Project Discussion Education and frequent rounding
Real time feedback helped to strengthen the project implementation
Note: Pressure injury prevention techniques were implemented on all patients, not just those with MHAC present
Floor nursing perspective- improved awareness for nursing and support staff about the importance of implementing the interventions on all patients, not just the ones with MHAC present

14. Implications for Nursing Practice
Evaluate MHAC on other units
Estimate nursing hours in the care of a pressure injury
Education regarding MHAC to nursing staff across hospital
Barriers: smart text transfer note and number of new staff starting on 3NW and 2NT
Communication about skin integrity skin factors could help decrease HAPIs across the entire organization

15. Conclusion
Improved communication about MHACs in addition to Braden score between ICU and acute care units can help prevent HAPIs
Acknowledgements:
Thank you to the staff and leadership teams of CVICU, 3NW, SICU, and 2NT for helping to make the project a success!

16. References
Alderden, J., Cummins, M., Pepper, G., Whitney, J., Wilson, A., Butcher, R., … Thomas, D. (2017). Mid-range Braden subscale scores are associated with increased risk for pressure injury development among critical care patients. Journal Wound Ostomy Continence Nurs, 44(5),
Agency for Healthcare Research and Quality. (2014). Preventing pressure ulcers in hospitals. Retrieved fromhttps://
He, J., Staggs, V., Bergquist-Beringer, S., & Dunton, N. (2013). Unit-level time trends and seasonality in the rates of hospital- acquired pressure ulcers in US Acute Care Hospitals. Research in Nursing & Health, 36,
Mallah, Z., Nassar, N., & Badr, L. (2015). The effectiveness of a pressure ulcer intervention program on the prevalence of hospital acquired pressure ulcers: Controlled before and after study. Applied Nursing, 28(2),
Meddings, J., Reichert, H., Rogers, M., Hofer, T., McMahom, L., & Grazier, K. (2015). Under pressure: Financial effect of the hospital- acquired conditions initiative- A statewide analysis of pressure ulcer development and payment. JAGS, 63,
Moran, K., Burson, R., & Conrad, D. (2017). The doctor of nursing practice scholarly project: A framework for success. Burlington, MA: Jones and Bartlett. Chapter 6, pp. 139.
National Pressure Ulcer Advisory Panel. (2016). National Pressure Ulcer Advisory Panel (NPUAP) announces a change in terminology from pressure ulcer to pressure injury and updates the stages of pressure injury. Retrieved from
Olshansky, K. (2016). Organ failure, hypoperfusion, and pressure ulcers are not the same as skin failure: A case for a new definition. Advanced Skin Wound Care, 29(4), 150.
Qaseem, A., Mir, T., Starkey, M., & Denberg, T. (2015). Risk assessment and prevention of pressure ulcers: A clinical practice guideline from the American College of Physicians. Annals of Internal Medicine, 162(5),

17. Contact Information
Allison Erzberger, DNP, RN, CMSRN, AGCNS- BC
Amanda Carlson-Dondero, DNP, RN