Case study: Increase in Pressure Injuries Acute Care Setting There have been 5 cases of pressure injuries in the last month. The previous month there was one case. In all cases, the patients were older than 60 years old and had limited mobility. The QI committee has created the following Aim statement: Aim Statement: In our setting, there will be zero pressure injuries to any patient in the next month
Introduction
Pressure injuries, also known as pressure ulcers or bedsores, are a common and preventable condition that often occurs in older adults with limited mobility. These injuries can result in significant morbidity and healthcare costs, making their prevention a critical priority in healthcare settings. In this case study, we will examine the increase in pressure injuries in an acute care setting and propose strategies to achieve the aim of zero pressure injuries in the next month.
Background
Pressure injuries are localized areas of damage to the skin and underlying tissue, primarily caused by prolonged pressure on the skin. Common risk factors for pressure injuries include immobility, advanced age, malnutrition, and incontinence. The consequences of pressure injuries can be severe, leading to pain, infection, slow wound healing, and even death.
The Problem
In the last month, there have been five cases of pressure injuries in the acute care setting, a significant increase compared to the previous month’s single case. All the affected patients were older than 60 years old and had limited mobility, which aligns with known risk factors for pressure injuries. Such a sudden surge in pressure injuries is concerning and indicates a failure in the current prevention strategies or an unforeseen change in patient care practices.
Aim Statement
To address this issue, the Quality Improvement (QI) committee has created the following aim statement: “In our setting, there will be zero pressure injuries to any patient in the next month.” This aim reflects the desire to eliminate pressure injuries entirely within a specified timeframe. Achieving this aim would require a comprehensive and coordinated approach, involving various stakeholders, including healthcare providers, nursing staff, administrators, and patients.
Analysis
To effectively address the increase in pressure injuries, it is essential to conduct a detailed analysis of the contributing factors. Possible causes for this sudden surge in pressure injuries could include inadequate risk assessment, insufficient staffing, inadequate training of healthcare providers, inappropriate documentation and monitoring, or insufficient resources for implementing preventive measures.
Risk Assessment: Conducting a thorough risk assessment is crucial in identifying patients at risk for pressure injuries. In this case study, the fact that all the affected patients were older than 60 and had limited mobility indicates a failure in properly identifying and addressing their specific needs and vulnerabilities.
Staffing: Adequate staffing is fundamental to provide optimal patient care and prevent pressure injuries. Inadequate staffing levels can lead to rushed care, incomplete documentation, and inadequate monitoring, potentially contributing to the development of pressure injuries.
Training: Healthcare providers and nursing staff need to receive appropriate education and training on pressure injury prevention strategies. This includes knowledge about risk assessment, repositioning techniques, support surface selection, and skin care practices. If there are gaps in training or updates in best practices, it could lead to suboptimal preventive measures.
Documentation and Monitoring: Accurate and timely documentation of risk assessments, preventive interventions, and changes in the patient’s condition is critical for effective pressure injury prevention. Inadequate documentation may result in missed opportunities for intervention or inadequate monitoring of the patient’s progress.
Resources and Preventive Measures: Adequate resources, such as pressure-relieving support surfaces, dressing supplies, and access to specialist wound care services, are necessary to implement preventive measures effectively. If there are resource gaps or limitations, it may impact the implementation of evidence-based strategies.
Conclusion
The sudden increase in pressure injuries in the acute care setting necessitates immediate action to address this issue. The aim of achieving zero pressure injuries within a month is ambitious but achievable with a comprehensive approach that focuses on identifying and addressing contributing factors such as risk assessment, staffing, training, documentation, and resources. Implementing evidence-based practices and promoting a culture of safety can help prevent pressure injuries and improve patient outcomes in the acute care setting.