Evaluating the effects of implementing a hospital-acquired pressure injury risk assessment hand-off tool

Abstract

More than 2.5 million patients suffer from pressure ulcer injuries each year, estimating that 60,000 die from complications (Joint Commission Center for Transforming Healthcare, 2021). Hospital acquired pressure injuries (HAPI) present as skin and muscle damage, slowed healing, and increased pain and infections that result from delayed wound care and treatments to fragile areas. Reports from Rondinelli et al. (2018) showed that implementing a HAPI risk assessment hand-off tool worked to reduce such events.

In 2021, a coastal community hospital located in Southeast Texas recorded 5% HAPI events, which resulted in the creation of a student developed HAPI risk assessment hand-off tool. The aim of this quality improvement (QI) project was to decrease HAPI events in the Cardiothoracic IMU to 0% by February 2022. Kurt Lewin's Change Theory was used to guide project interventions.

After receiving project approval, four changes were implemented. A unit champion, responsible for monitoring the accuracy of Braden Score documentation was designated. Nurses implemented interaction-based patient repositioning every 2 hours and participated in monthly HAPI prevention and education meetings. Lastly, nurses completed the hand-off tool to verify staff compliance. Chart audits and a student developed questionnaire was used to determine the usefulness of the HAPI risk assessment hand-off tool. After one month of chart audits, and use of the hand off tool, the HAPI occurrence rate decreased to 3%. This project concluded that the student developed HAPI risk assessment hand-off tool had no significant effect on the reduction of HAPI occurrences within the cardiothoracic IMU.