Multidisciplinary Surgical Team Approach To Decrease Sacral Hospital Acquired Pressure Injuries: A Retrospective Study 1 BS ,
Shelby Isaacs,
Tamir Pinhasov,
1 BA ,
1,2,4 MD ,
3 RN , Amit
Alisha Oropallo, Mary Brennan, Agrell-Kann, RN3, and Timmy Li, PhD5
Rao,
1 MD , Gregg
Landis,
2,4 MD , Marie
1Department
of Surgery, Comprehensive Wound Care Healing and Hyperbarics, Northwell Health, Lake Success, NY 11042, USA 2Deparmtent of Vascular Surgery, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY 11550, USA 3Department of Nursing, North Shore University Hospital, Manhasset, NY 11030, USA 4Department of Vascular Surgery, North Shore University Hospital, Manhasset, NY 11030, USA 5Department of Emergency Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY 11550, USA
Background Hospital-acquired pressure injuries (HAPIs) are ”localized injuries to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear.”1 Not only are HAPIs painful and potentially fatal, but they are also costly, both monetarily and in patient perception of quality of care.2-4 As life expectancy continues to lengthen, the approximately 2.5 million people who develop pressure injuries in acute care settings each year is expected to increase, as well as the cost of treatment.5-7 Despite efforts to reduce the incidence of HAPIs, the ultimate goal of HAPI elimination has not yet been reached. In particular, sacral HAPIs do not respond as well as other areas of the body to conventional efforts of prevention as these patients are typically prone to higher incidences of malnutrition, have inadequate ability to offload, and are faced with comorbidities that impair wound healing.
Figure 1: Incidence of Sacral Healthcare-Associated Pressure Injuries by Year
Methods In 2012, a three-pronged intervention was implemented and yearly incidence of sacral HAPIs before and after implementation of the intervention were tracked • (1) Multidisciplinary Surgical Team: clinicians from multiple specialties, including wound care specialists and vascular/general surgeons, reviewed daily consults and rounded on at-risk patients within 24 hours of a nurse reporting a suspected sacral HAPI • (2) Enhanced Education for Nursing Staff: champion nurses were selected - they attended classes on proper staging of wounds and differential diagnosis, went to seminars, and completed a pressure injury module once a year • (3) Enhanced quality data reporting: increased emphasis on accurate quality data reporting
The implementation of a three-pronged intervention consisting of a multidisciplinary surgical team, enhanced education for nursing staff, and enhanced quality data reporting reduced the incidence of sacral HAPIs from 0.310% in the pre-intervention period to 0.019% in the post-intervention period. Through the use of a multidisciplinary surgical team, a holistic evaluation of the patient can be achieved, and thus information that may not be addressed with standard assessment tools can be accounted for.
Limitations/Future Direction
Hypothesis Systematic reviews have elucidated the effectiveness of multiintervention programs in decreasing the prevalence of HAPIs compared to a single intervention approach.8 For this reason, we hypothesized that the yearly incidence of HAPIs would decrease following the implementation of a three-pronged intervention.
Conclusions
Results
Note: Vertical dotted line represents the year 2012, in which the intervention was implemented. Years 2010 to 2011 represent the preintervention period and years 2013 to 2017 represent the postintervention period.
From 2010 – 2011, the pre-intervention years, the mean incidence of sacral HAPIs was 0.310% - a total of 294 cases. In the postintervention years, from 2013 – 2017, the mean incidence of sacral HAPIs was reduced to 0.019% - a total of 49 cases (p<0.0001). In addition, there was a statistically significant decrease in the median hospital length of stay in the post-intervention period compared to the pre-intervention period (13 days vs. 19 days, p=0.0096). Figure 7: Independent CRISPR knockout of CDK4 or CDK6 does not cause dropout in most breast cancer cell lines studied.
Patients in the pre and post intervention periods were similar with respect to age, sex, ethnicity, total Charlson Comorbidity Score, and readmission or mortality within 90 days after hospital discharge . However, race and HAPI staging differed among patients in the preintervention and post-intervention time periods.
There are several limitations of this study to acknowledge. As this was a single-centered study, it may not be generalizable to other institutions. This is of notable importance as the multidisciplinary surgical team implemented for this study was comprised of staff from numerous specialties, and smaller institutions may not have the resources or staff to implement this intervention. Second, our intervention consisted of three separate components, and it is therefore difficult to determine whether all three interventions were necessary, and which component played the largest role in decreasing the incidence of sacral HAPIs. Lastly, there are certain differences in the data (particularly differences in race distribution) that were attributed to small sample size in the post-intervention period. Future, multi-center studies should attempt to recruit a larger patient population for the post-intervention period.
Resources 1Edsberg
LE, Black JM, Goldberg M, McNichol L, Moore L, Sieggreen M. Revised National Pressure Ulcer Advisory Panel pressure injury staging system: revised pressure injury staging system. Journal of Wound, Ostomy, and Continence Nursing. 2016;43(6):585. 2Gefen A, Kolsi J, King T, Grainger S, Burns M. Modelling the cost-benefits arising from technology-aided early-detection of pressure ulcers. Wounds Int. 2020;11(1):22-9. 3Meddings JA, Reichert H, Hofer T, McMahon LF. Hospital report cards for hospital-acquired pressure ulcers: how good are the grades? Annals of internal medicine. 2013;159(8):505-13. 4Whitty JA, McInnes E, Bucknall T, Webster J, Gillespie BM, Banks M, et al. The cost-effectiveness of a patient centered pressure ulcer prevention care bundle: Findings from the INTACT cluster randomised trial. International journal of nursing studies. 2017;75:35-42. 5Padula WV, Delarmente BA. The national cost of hospital-acquired pressure injuries in the United States. International wound journal. 2019;16(3):634-40. 6Brem H, Maggi J, Nierman D, Rolnitzky L, Bell D, Rennert R, et al. High cost of stage IV pressure ulcers. The American Journal of Surgery. 2010;200(4):473-7. 7Cano A, Anglade D, Stamp H, Joaquin F, Lopez JA, Lupe L, et al., editors. Improving outcomes by implementing a pressure ulcer prevention program (PUPP): going beyond the basics. Healthcare; 2015: Multidisciplinary Digital Publishing Institute. 8Gaspar S, Peralta M, Marques A, Budri A, Gaspar de Matos M. Effectiveness on hospital-acquired pressure ulcers prevention: a systematic review. International wound journal. 2019;16(5):1087-102