The decision to select the unit to pilot the bundle was based on its incidence of HAPIs. There were 9 HAPIs on the pilot unit during the 14-month pre-intervention period (January 2017 to February 2018); this represented a HAPI rate of 3.4. The 14-month pre-intervention period rate was determined using the calculation (pressure injuries / patient care days) × 1000.20
The unit chosen for PIP bundle implementation had a high incidence of HAPIs during the pre-intervention period. Pre-intervention data were obtained from WOC nurse consults and quarterly prevalence surveys. The unit was an 11-bed adult CCU in a 652-bed, tertiary, acute care hospital in New York City. Most patients are acutely ill with cardiac disease but medical and surgical intensive care overflow patients are also admitted. The delivery of care model was primary nursing, with a registered nurse (RN) to patient ratio of 1:2, and a patient care associate (PCA)/nursing assistant to patient ratio of 1:11. The average daily patient census was 9 and fluctuated throughout the day, with an average length of stay of 5 to 6 days.
During the PIP bundle initiative, the WOC nurses collaborated with nursing management and staff to obtain feedback regarding ease of use of, and adherence to, the bundle. Staff provided valuable feedback, which resulted in multiple revisions of the bundle. Audits were also conducted to assess adherence.
An interdisciplinary team was established to address HAPIs. The team consisted of 2 WOC nurses, 1 nurse manager, assistant nurse managers, RNs, respiratory therapists, and PCAs.
A Population Intervention Comparison and Outcome (PICO) question was used to outline the clinical question and consisted of:
(P) Patients in an adult CCU at risk
(I) Implementation of a PIP bundle
(C) Lack of standardized practice
(O) Decrease HAPIs
A review of the literature was conducted to identify EBPs to reduce HAPIs. PIP bundles have been associated with a reduction in HAPIs.2,5,7,15 A bundle provides structure and standardization of evidence-based interventions to promote positive patient outcomes. Information garnered from the literature review as well as plans to develop and pilot the PIP bundle to reduce HAPIs were shared with key stakeholders, which included senior nursing leadership, the unit nurse manager, assistant nurse managers, RNs, respiratory therapists, and PCAs. Providing evidence to support the use of the bundle fostered commitment and adherence. Insight and input from stakeholders were vital to the development of the multidisciplinary PIP bundle. Staff involvement in the development and implementation of initiatives fostered engagement and success of the initiative.
The implemented PIP bundle included use of the Braden scale. Bergstrom et al21 developed the Braden scale to promote early identification of the risk of pressure injury development. The Braden scores for patients who had HAPIs in the unit chosen for the initiative ranged from 8 to 14 (average, 12). The standard bed on the CCU allowed for continuous lateral rotation of the patient. A repositioning system was also used for patients with Braden scores of 18 or less. The bundle consisted of 2 sections (Figure 1). The WOC nurses divided the PIP bundle into 2 categories to easily identify the standard interventions from the high-risk interventions. Section 1 outlined standard interventions for patients with a Braden score of 19 or greater. Interventions in section 1 included a 2-RN skin assessment conducted together on all patients upon admission, transfer to the unit, and PIP strategies to reduce the risk of MDRPI development. Section 2 delineated the PIP interventions for patients with a Braden score of 18 or less. Components of section 2 included applying prophylactic dressings for prevention of pressure injuries, turning, positioning devices, and repositioning every 2 hours. Additional interventions included nutrition consultations, adjusting the head of the bed to 30 degrees or less (unless contraindicated), early mobility, a WOC nurse consultation for all HAPIs, and tips on documentation.
An audit tool (Figure 2) was developed to assess adherence to the PIP bundle. Audits were initially performed by the resource nurse daily and then weekly. The WOC nurses collected the data and disseminated the results to the nursing leadership and during quality council meetings. The WOC nurses provided additional teaching when needed. Adherence to the bundle was reinforced by the WOC nurses, nurse manager, assistant nurse managers, and resource nurses.
Pre-intervention period. Prior to bundle implementation, meetings were held with the unit nurse manager, assistant nurse managers, staff nurses, PCAs, and respiratory therapists to discuss development of the PIP bundle. These meetings encouraged staff involvement in the planning and development processes. The PIP bundle was shared with senior nursing leadership to engage them in the process. Research has shown that nurse leadership engagement is vital to successful implementation of and adherence to a bundle.5,14,16,19 Additionally, the WOC nurses met with quality improvement specialists as well as the quality and education councils. The meetings served to disseminate information regarding the PIP bundle and the pilot.
Quality improvement staff assisted in the development of the audit tool. Two (2) staff nurses volunteered to be resource nurses.
Intervention period. Throughout the month of February 2018, in-service programs were held by the WOC nurses during morning briefs to educate staff on the elements of the PIP bundle. Education included potential patient complications arising from a single pressure injury to foster commitment to use of the bundle. Morning briefs provided an opportunity to meet with morning and night staff working 12-hour shifts. The WOC nurses also met with the evening PCAs, because their work schedule is composed of 8-hour shifts. While in-service programs were held, the WOC nurses conducted daily and then weekly rounds to foster understanding and use of the PIP bundle. Rounds were also conducted by the nurse managers and assistant nurse managers. The bundle was incorporated into change-of-shift briefs as a reminder to implement the appropriate strategies. To further support the bundle, the resource nurses completed the audits and encouraged adoption of the bundle. Results of the audit tools were reviewed by the WOC nurses and disseminated to nursing leadership, nurse managers, and nursing executive leadership. Laminated copies of the PIP bundle and turn clocks were posted in all rooms for ease of reference and accessibility.
WOC nurses conveyed to staff the importance of their involvement and the value of their feedback. Staff was receptive and committed to reducing HAPIs on the unit. Staff and the resource nurses provided constructive feedback regarding the bundle. Feedback included concerns regarding perceived additional time required to implement the bundle. Assistant nurse managers supported staff at the bedside when needed to ensure that the bundle was being used when appropriate.
HAPI incidence was reported on a daily basis by the resource nurse or the bedside nurse through a WOC nurse consult. Pressure injury consults were also generated by physicians or physician’s assistants. HAPIs may have been identified during skin care rounds with WOC nurses or during quarterly prevalence surveys.
Data management/analysis. The HAPI data were collected daily and reported monthly. The WOC nurses recorded monthly pressure injury data electronically in a pressure injury database, which was developed internally by the WOC nurses with assistance from a data analyst. The HAPI index was determined using the calculation (pressure injuries / patient care days) × 1000.20 The pressure injury database is a repository for pressure injuries at the author’s facility and generates a pressure injury index. The monthly pressure injury index is then reported to the hospital health care system.
The pre-intervention HAPI index was 3.4. This included all stages of HAPIs on the unit over a period of 13 months. The post-intervention HAPI index decreased to 0.48 over a period of 10 months.