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Preventing Hospital-Acquired Sacral Pressure Injuries With Silicone Foam Dressing

Carol Blagrove, DNP, MSN/NEd, RN, CCRN, MEDSURG-BC

n Abstract

Problem: A hospital-acquired sacral pressure injury is a preventable adverse event related to unsafe care that impacts patient outcomes. The institution’s hospital-acquired pressure injury rate was below the benchmark, but the 16-bed surgical intensive care unit (SICU) rate remained higher than the overall hospital rate.

Purpose: The quality improvement (QI) project aimed to reduce the hospital-acquired sacral pressure injuries rate using education and the application of a silicone foam dressing within 24 hours of patient admission.

Methods: Educational sessions were provided to nursing staff before project implementation. Outcomes were assessed by comparing pre- and post-implementation sacral pressure injury rates. Chi-square was used to analyze the data.

Interventions: Actions taken included applying silicone foam dressing to the sacral area within 24 hours of admission, assessing beneath the dressing daily, and removing and replacing the dressing every third day or when needed.

Results: No patients developed a sacral pressure injury during the eight weeks of project implementation. The chi-square test was statistically significant ( p = 0.044) between the pre- and post-implementation hospital-acquired sacral pressure injury rates.

Conclusions: The application of silicone foam dressing to the sacral area may reduce hospital-acquired pressure injuries in high-risk patients, improve quality patient care, and enhance staff assessment skills by implementing a preventative intervention.

Keywords: Hospital-acquired sacral pressure injury, silicone foam dressing, intensive care unit (ICU)

Preventing Hospital-Acquired Sacral Pressure Injury With Silicone Foam Dressing

Hospital-acquired pressure injuries (HAPI) are a patient safety issue that affects approximately 3 million people (Centers for Medicare & Medicaid Services [CMS], 2018). Individuals admitted to the intensive care unit (ICU) are at a 27% to 47% higher risk for HAPI (Fulbrook et al.,

2019; Gazineo et al., 2020; Stankiewicz et al., 2019) due to factors such as immobility, malnutrition, incontinence, excessive moisture, dehydration, multiple comorbidities, advanced age, lengthy surgical procedures, and educational deficits (Amoldeep et al., 2019; Ebi et al., 2019; Lin et al., 2020). Although the institution’s HAPI rate was below benchmark, the 16-bed surgical intensive care unit (SICU) prevalence rate remained high, specifically for sacral HAPIs. The evidence-based interventions implemented for all patients included turning and positioning every two hours, moisture cream barriers, fluidization beds, early mobilization, and early nutritional interventions. These interventions to reduce sacral HAPIs were ineffective at reducing prevalence; therefore, the following practice question served as the foundation for a quality improvement (QI) project at the practicum site: For the patients in the SICU, does the routine application of a silicone foam dressing to the sacral area impact the rate of sacral HAPI over an 8-week period in comparison to the rate of sacral HAPI with the current practice?

Available Knowledge

Pressure injuries (PI) form where skin covers boney areas of the body, including the occiput, ears, shoulders, elbows, sacrum and buttocks, trochanter, inner knees, and heels in the setting of unrelieved pressure from an external surface (Forni et al., 2018; Oe et al., 2020; Teo et al., 2018). PI are classified into different stages based on the degree and depth of injury to the skin and soft tissues. The PI staging guidelines, developed in collaboration by the National Pressure Injury Advisory Panel (NPIAP), the European Pressure Ulcer Advisory Panel (EPUAP), and the Pan Pacific Pressure Injury Alliance (PPPIA), guide both grading and the treatment of PIs.

Developing sacral HAPIs can result in life-threatening complications, increased morbidity and mortality, and have severe economic ramifications (Amoldeep et al., 2019; CMS, 2018; Lin et al., 2020; Padula et al., 2019) that can cost twice that of prevention strategies. Researchers have found that HAPIs cost organizations approximately $43,180 per patient to treat and manage annually, ranging from $20,900 to $151,700 per patient (CMS, 2018; Roberts et al., 2017). Organizations absorb the cost because they are not reimbursed for hospital-acquired condition (CMS, 2018). Treating subsequent pain from sacral PIs also adds to hospital expenditure. Therefore, early intervention to prevent or treat HAPIs is vital to the patient’s recovery, reduced length of stays (LOSs), and improving hospital expenditure (Lin et al., 2020; Roberts et al., 2017).

The PI-related mortality rate in the United States accounts for 11.6% of hospital deaths (Padula et al., 2019), or 60,000 deaths annually (Joint Commission Center for Transforming Health, 2021). According to an analysis by American Nurse Today (2018), HAPIs increased patient LOS by seven days and increased mortality rate from 1.8% to 9.1%.

Standard evidence-based interventions, including turning and positioning (T&P) patients at least every two hours, use of moisture cream barriers, fluidization beds, early mobilization, and early nutrition, alone have been ineffective in preventing sacral HAPIs. The additional evidence-based intervention of applying a silicone-foam dressing on to the patient’s sacral area within 24 hours of admission is recommended to reduce and/or prevent HAPI (Fulbrook et al., 2019; Gazineo et al., 2020).

Specific Aim

This QI project aimed to reduce the rate of sacral HAPIs in the SICU. The objectives were (a) to assess the current practice and its effect on HAPI prevention, (b) to educate staff on the application of the silicone foam dressing, and (c) to verify staff implementation of the intervention (dressing application within 24 hours of admission and daily skin assessment under the dressing) (Aloweni et al., 2017; Walker et al., 2017). Based on the organizational assessment data, patients in the SICU develop sacral HAPIs at a higher rate than those admitted to other comparable units.

Standard evidence-based interventions, including turning and positioning (T&P) patients at least every two hours, use of moisture cream barriers, fluidization beds, early mobilization, and early nutrition, alone have been ineffective in preventing sacral HAPIs.

Method

A silicone foam dressing was implemented over the span of eight weeks in a 16-bed SICU in a large, academic northeastern New York health system. Staffing skill mix included (a) RNs (bedside nursing staff, float pool RNs, traveling RNs, a certified wound care specialist, and a clinical nurse specialist); (b) ICU technicians; (c) nursing management; (d) medical providers (medical directors, residents, interns, and physician assistants); (e) physical therapist (PT); (f) occupational therapist (OT); and (g) registered dieticians (RD). Bedside nursing staff work 12.5-hour day or night shifts. The patient population in the SICU are adult patients over 18 years of age requiring a surgical procedure: transplant, gastrointestinal, thoracic, otolaryngologic, vascular, oncologic, and overflow cardiac. Other patients may include medicine overflow, acute decompensation from lower levels of care, and post-arrest patients. All patients are acutely ill, and many have multiple complex comorbidities and chronic conditions.

One hundred and forty-two patients were recruited for this project. Patients were assessed by trained staff RNs and the intervention was instituted for patients who met the following the inclusion criteria: adults 18 years and older, intact sacral skin, decreased mobility, and requiring assistance with T&P. Exclusion criteria were based on the literature review: patients with existing PI, allergy to silicone or adhesive, current diarrhea, and patients with a contraindication for inserting a rectal tube.

Intervention

Integrating evidence-based practice (EBP) into the daily routine of nursing care can improve the practice environment, patient outcomes, and safety. Standard practices such as T&P, proper skin products like barrier creams, specialty beds to aid wound healing, and early enteral nutrition were evident in the SICU, but ineffective at reducing HAPI prevalence. The expected outcome of early implementation of a silicone foam dressing in the sacral area is PI prevention (Teo et al., 2018).

The educational plan to reduce sacral HAPIs was a process that required leadership engagement, a cultural change, and the HAPI interdisciplinary team creation. The pre-implementation phase included acquiring buy-in from nursing and medical leadership by presenting the proposal to key stakeholders and the executive team. The ten weeks prior to project implementation consisted of using a data extraction tool (chart review) on skin assessment. Next, the project manager identified skin-care champions, prepared teaching tools, and organized information to disseminate during