Preventing Hospital-Acquired Sacral Pressure Injuries With Silicone Foam Dressing

the implementation phase. In addition, a laminated adherence checklist was created and posted in each patient’s room. Finally, the project manager and nursing manager partnered with the hospital central supply team to increase the unit par of silicone foam dressings to ensure availability.

Educating staff on the implementation process was crucial for the intervention to succeed. The project manager distributed the assessment algorithm to understand the state of current RN and ICU technician knowledge, deliver re-education on staging PIs, and reviewed proper use of the evidence-based Braden scale risk skin assessment tool. The staff was then instructed on the (a) inclusion and exclusion criteria for the project, (b) dressing type and application, (c) assessing the skin beneath the dressing daily, (d) the length of time the dressing should remain on the sacrum, (e) documentation, and (f) completion of the adherence checklist. The project manager and HAPI interdisciplinary team were present daily to provide and receive feedback on the implementation.

Each day, the project manager completed an electronic medical record (EMR) review to identify all newly admitted patients and the presence of a documented comprehensive skin assessment, adherence checklist’s utilization, and compliance with the appropriate dressing and skin assessment documentation per policy/project protocol. The project manager participated in a daily unit safety huddle, just-in-time education, and observational rounds daily to facilitate one-on-one discussions with staff. The instructions for applying the silicone foam dressing were delivered daily during safety huddles by the team leads, the project manager, CNS, wound care specialist, nursing management, charge nurses, or skin care champions. Throughout the eight weeks, the project manager’s presence ensured the support of frontline nurses by establishing relationships and rapport. The project manager was accessible by phone and email during all shifts.

Measures

Pre- and post-implementation data were obtained from chart reviews, observations, and the units quality scorecard. Data was collected using chart audits/reviews in the pre-implementation phase to establish current state. Data included in the collection process were (a) skin integrity on admission, (b) Braden risk assessment on admission, (c) HAPI assessment, and (d) documentation. Additional data collected during the review process were gender, race, ethnicity, type of surgery, nutritional status, post-arrest status, mobility, comorbidities, and vasoactive medication use. In addition, the project team reviewed the chart for PI stages and treatment options ordered for the different stages. The outcome measures were based on the monthly report conducted by the wound care specialist, nursing staff accuracy in the documentation of skin ad provided care, and adherence to the project checklist. The wound care specialist and project manager conducted a monthly assessment in the unit and completed chart reviews on the patients identified as high risk for developing sacral PIs.

The HAPI rate was calculated in two ways: prevalence and incidence. The prevalence rate depicts the percentage of patients who have a PI specific time (Agency for Healthcare Research and Quality [AHRQ], 2017). Prevalence data was collected on the first Wednesday of each month per hospital practice. The incidence rate represents the percentage of patients that develop a new PI in the hospital or a specific unit during a particular time (AHRQ, 2017).

Analysis

To implement the silicone foam dressing, the project manager collected data pre-implementation via chart review to assess HAPIs in the SICU. The post-implementation data were collected using the compliance checklist, chart review, and observation of staff activity. “Yes” and “No” responses separated the data items on the compliance checklist and observation activities. The statistical plan to analyze the data included determining if a silicone foam dressing reduced HAPIs compared to the existing standard interventions. The data analysis method for the evidence-based intervention was the chi-square test. Additional demographic variables were collected to ensure the pre-implementation patient sample was similar to post-implementation.

ethical Considerations

The intervention was considered an improvement to the standard of care to augment patient care outcomes. Therefore, no consent was required for this QI project. Patient information was protected for obscurity and confidentiality, and the Health Insurance Portability and Accountability Act (HIPAA) was followed. Data collection and patient data were passwordprotected, patient information was de-identified, and only room numbers were used during the implementation phase.

Results

The pre-implementation data was collected over eight weeks during the second quarter (Q2) of 2021. In the pre-implementation group, 58.6% (n = 85) were male and 41.4% (n = 60) were female with an average age of 64.7 (SD = 15.5). Participants were 35.2% (n = 51) Hispanic, 34.5% (n = 50) white, 22.8% (n = 33) Black, and 7.6% (n = 11) Asian. A majority (39.3%, n = 57) of patients were admitted to the SICU post-operatively. Other common admitting diagnoses were hypotension or respiratory distress from the emergency department (ED) (13.1%, n = 19), COVID-19 (9%, n = 13), and gastrointestinal bleed (GIB) (8.3%, n = 12). The other 30.3% (n = 44) were admitted for cardiac arrest, transplant, and acute decompensation on a lower level of care. All patients received the current standard of care and evidencebased PI interventions per hospital policy and unit guidelines that did not include applying the silicone dressing to the sacral area within 24 hours of admission. During the eight weeks of pre-implementation data collection, 145 patients were admitted to the unit and four patients developed a HAPI (2.6%).

The post-implementation group consisted of 142 patients. Of these, 40.8% (n = 58) were female and 59.2% (n = 84) were male with an average age of 62 (SD = 15.8). Participants were 36.6% (n = 52) Hispanic, 35.2% (n = 50) white, 23.9% (n = 34) Black, and 4.2% (n = 6) Asian. Most patients (58.5%, n = 81) were admitted to the SICU postoperatively. Other common admitting diagnoses were acute respiratory decompensation (6.3%, n = 9), ED admission for hypotension and respiratory distress (4.9%, n = 7), GIB (4.2%, n = 6), and cardiac arrest (1.4%, n = 2). The remaining 32.9% (n = 37) of patients were admitted for other miscellaneous medical reasons (see Table 1). A total of 92% (n = 131) of SICU patients received preventative treatment for a sacral HAPI in the post-implementation group. This consisted of applying a silicone foam dressing to a patient’s sacral skin within 24 hours, assessing beneath the dressing daily, and changing and reapplying the dressing

Percentage of Patients With a Sacral HAPI Preand

Discussion

This project utilized an evidence-based intervention to reduce the sacral HAPI rate in the SICU. Applying a silicone foam dressing to the sacral area within 24 hours of admission, assessing beneath the dressing daily, and changing and reapplying the dressing every third day demonstrated a significant reduction in HAPI rates in critically ill patients. This QI project was aligned with other peer-reviewed scholarly articles in its findings that these interventions reduce sacral HAPI rates (Aloweni et al., 2017; Forni et al., 2018; Fulbrook et al., 2019; Gaspar et al., 2019; Gazineo et al., 2020; Hahnel et al., 2020; Lee et al., 2018; Oe et al., 2020; Stankiewicz et al., 2019; Teo et al., 2018). Consistent use of formative evaluation and regular staff education may have impacted the positive outcome of this project. The evidence made it abundantly clear that continuous education is required for the continued reduction of HAPI (Forni et al., 2018; Hahnel et al., 2020; Lee et al., 2018). Although results were statistically significant, the sample size was small and homogenous. Therefore, the external validity of these results should be applied with caution. Furthermore, since this was a QI project, the generalizability of the findings is specific to the practicum site and ICU population.

Potential barriers

Note. HAPI = hospital-acquired pressure injury every third day to prevent the development of a sacral HAPI. Eleven (8%) patients in the post-implementation group were excluded from the project for not meeting inclusion criteria.

During the first three weeks of implementation, 85% (n = 43) of nurses completed the bedside checklist, 78% (n = 40) documented it in the EMR, and 22% (n = 11) of nurses needed to be reminded to document assessments and/or interventions. Compliance for the remaining five weeks of the intervention checklist and documentation were 100% (N = 51). Of the 131 patients included in the post-implementation data, 0% developed a sacral HAPI. A Chi-squared test was used to identify statistical significance in the reduction of sacral decrease in sacral HAPI from pre- to post-implementation. The 2.6% decrease was a statistically significant ( p = 0.044) in the post-implementation group (see Figure 1).

Potential barriers to implementing an evidence-based intervention included workload and task burden for staff (e.g., checklist completion, dressing application, increased documentation). The SICU team was usually resistant to workflow changes unless augmented with an improved staffto-patient ratio (Correa-de-Araujo, 2017). The workflow concerns were remedied by clustering care and collaborating with the ICU technicians to assess skin integrity and dressings during care rounds. The project manager and stakeholders collaborated with central supply to ensure that silicone foam dressings were readily available to the staff to reduce inefficiencies during project implementation.

Finally, to change the organization’s culture, the project manager utilized numerous strategies to implement the evidence-based intervention successfully. Effective communication and shared leadership were essential in strategic planning; transparency throughout the planning and preparation phases of the project fostered communication. The project team was available to clarify and answer questions via email, phone, and face-to-face meetings. Providing guidance and support to frontline staff was essential during this phase. The wound care specialist, clinical nurse specialist (CNS), and nurse manager assisted with education and attended safety huddles and meetings to enhance the projects implementation and success. Collaboration with the unit staff and the leadership team assisted in capitalizing on the facilitators and mitigating barriers (Belkadi et al., 2017).

Limitations

The limitations of the QI project include success based on frequent oneto-one educational sessions, follow-ups, and continuous feedback to staff. These efforts could pose a challenge in a larger project setting. The project had a small sample size, and in order to provide substantial, consistent evidence, a larger sample is needed. Longer project duration would reveal more conclusive evidence on intervention effectiveness. Risk factors that could potentially lead to the development of sacral HAPIs were not addressed in the QI project, such as vasoactive medication use. Finally, the project only looked at one type of silicone foam dressing to prevent sacral HAPIs.

Conclusions

A HAPI is a direct and preventable threat to patient morbidity and mortality and poses a tremendous financial burden to treat within the healthcare system. This is especially true for patients in the ICU. Many studies, including this QI project, demonstrate that utilization of a silicone foam dressing within 24 hours of admission can reduce sacral HAPI rates.

Therefore, implementation of this intervention in conjunction with standard PI prevention can improve patient care outcomes (Forni et al., 2018; Fulbrook et al., 2019; Gaspar et al., 2019; Gazineo et al., 2020; Hahnel et al., 2020; Lee et al., 2018; Oe et al., 2020; Stankiewicz et al., 2019; Teo et al., 2018). While this QI project indicates positive results, additional research requiring a more rigorous methodology is needed to strengthen its generalizability to nursing practice.

Nursing educational opportunities are vital to improve nursing practice. Clinical nurse educators, CNSs, and nursing management can enhance nursing skills and reinforce expert knowledge to enculturate safety and evidence-based strategies into practice. According to Trautman et al. (2018), working with inter- and intra-disciplinary teams to bring change to nursing practice directly improves patient care and outcomes. This preventative intervention can improve nursing practice by enhancing assessment skills and communication within teams.

Sustainability

To maintain post-project success, the institution needs an updated policy and procedure to reflect the change in practice. Staff education is vital to the sustainability of a practice change, and well as continued surveillance of compliance. In this instance, the SICU created a system of continued education and competency assessment during bi-yearly skills days. Other barriers such as insufficient EMR documentation must be addressed to ensure success and accurate data abstraction.

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