Pressure

Injuries
Andrea Alarcia, Sylvia Kim, Steven Pedroza, Abeba Tesfa, Phet
Tran
March 26, 2018
 Background
●  Pressure injuries are injuries to the skin and
underlying tissue from prolonged pressure or
shear to the skin
●  Can be staged I-IV
●  Risk Factors include a sedentary state,
impaired skin integrity, lack of adequate
nutrition
●  Prevention includes regular repositioning and
assessment (Huether & McCance, 2017)
Manpower Method
s

Effect –
what
went
wrong?

Machine Material
s
 Kaiser Ontario
●  KP Ontario’s rate of HAPI is 0.497 per 1,000 patients
●  Clinical Experiences
◦  Bariatric Patient
◦  Window/Door Turning schedule
◦  Head board
◦  Lack of additional staff

(The Leapfrog group, 2017)

 Root Cause Analysis
Hospital acquired pressure injury (HAPI)

Immobile/impaired patient not turned frequently

Staff was busy/forgot

Staff relies on memory to know which direction to turn patients

No regulation or standardizations in place

Problem: No turning regulation or standardization for HAPI prevention

PLAN DO
Implement an in-room turning
schedule Keep a turning log in the room

PDSA
STUDY
ACT
Logs were inconsistently being
Promote the use of logs utilized
 PDSA: Aim
To address no turning
regulation or
standardization for
hospital acquired
pressure injury
prevention
PDSA: Plan
Tasks Person When Where
responsible
Create and post turning log (Cano et al., 2015) Unit secretary Upon pt Beside the
(create) admission computer
Nurse (post) screen in the
room

Promote turning logs (Cano et al., 2015) Charge Nurse During nurses’ On the unit
huddle

Follow-up on log usage (Sving, 2017) Charge Nurse, During change Pt room
Oncoming Nurse of shift
 PDSA: Plan
Prediction Measures to determine if prediction
succeeds

Turning logs will be created and posted (Cano et al., Have at least 20 turning log templates printed by
2015) the beginning of the unit secretary’s shift. Charge
nurse checks to make sure there is a new turning
log posted in the room for each new admission

Turning logs will be utilized (Cano et al., 2015) Charge nurse checks to make sure there is a new
turning log posted in the room for each new
admission

Nurses will keep each other accountable for log If logs are incomplete, the nurse will get a strike.
usage (Sving, 2017) After 3 strikes, the nurse will receive a write-up
 PDSA: DO
●  Turning logs will
incorporate the
time, direction,
and staff initial
●  Logs will be
implemented for 2
weeks on the ICU
 PDSA: Study
Prediction Outcome
Turning logs will be created and posted (Cano et al., Turning logs were created and
2015)
posted upon pt admission.

Turning logs will be utilized (Cano et al., 2015)
Nurses will keep each other accountable for log
usage (Sving, 2017)
There was an inconsistent use of
turning logs at certain time periods
(e.g. morning meds, rounds,
breaks).
Not all nurses/staff utilized turning
logs
Some nurses felt overwhelmed by
the additional task
 PDSA: Study
Problem Solution
Nurses underutilizing turning logs Retrain nurses/staff on log use and importance
of preventing HAPI

Inconsistencies among log use Encourage staff to use team reminders in using
logs properly and to take initiative to fill logs
correctly after performing repositioning

Summary of findings:
●  Not all nurses/staff utilized the turning logs
●  There was an inconsistent use of turning logs at certain time periods
(e.g. morning meds, rounds, breaks)
●  Family helped to remind nurses to use the turning logs
●  Some nurses felt overwhelmed by the additional task
 PDSA: Act
●  Promote the use of logs
(announcements during huddle,
place logs by the computer)
●  Create an incentive for complete
logs
●  Recheck log use in 2 weeks
●  Ask for feedback on use of logs
from unit nurses
 Stakeholder Analysis
●  Internal (unit) stakeholders
◦  Employees
◦  Administrators
◦  Board members
◦  Investors
●  External stakeholders
◦  Patients
◦  Family
Force Field Analysis
Forces FOR Forces AGAINST
Change Change
(Driving Forces) (Resisting Forces)
Staff compliance Time consuming/Tedious

Cost-effective
Turnin Staff noncompliance

g Double charting

logs
Easily implemented

May encourage
Family involvement falsification
 References
Cano, A., Anglade, D., Stamp, H., Joaquin, F., Lopez, J. A., Lupe, . . . Young, D. L. (2015). Improving
outcomes by implementing a Pressure Ulcer Prevention Program (PUPP): Going beyond the
basics. Healthcare, 3, 576-585. doi:10.3390/healthcare3030574
Huether, S. E., & McCance, K. L. (2017). Understanding pathophysiology (6th ed.). St. Louis, MO:
Elsevier.
Sving, E., Fredriksson, L., Gunningberg, L., & Mamhidir, A. (2017). Getting evidence-based pressure
ulcer prevention into practice: A process evaluation of a multifaceted intervention in a hospital
setting. Journal of Clinical Nursing, 26(19-20), 3200-3211. doi:10.1111/jocn.13668
The Leapfrog Group. (2018). Retrieved from http://www.leapfroggroup.org/