QUALITY IMPROVEMENT Article Review

6 American Nurse Journal Volume 16, Number 7 MyAmericanNurse.com

THE Centers for Medicare and Medicaid Serv- ices report that pressure injuries (PIs) affect millions of patients each year, with incidence rates ranging from 2.2% to 23.9% in long-term care organizations. PIs occur as a result of in- tense or prolonged pressure in combination with shear and are affected by excessive heat and moisture, poor nutrition and blood circu- lation, chronic illness, and soft-tissue condi- tions (for example, an abrasion or sprain).

For 3 years, PI prevalence increased at a Texas long-term continuing care retirement com- munity that provides independent living, assisted living, memory care, and skilled nursing. The or- ganization faced several challenges, including the lack of a nurse educator and inconsistent continuing education for nursing staff.

To address these challenges, a PI quality improvement team, consisting of the director of nurses, an assistant director of nurses, an RN, a licensed practical nurse (LPN) and a certified nurse assistant (CNA), was created to develop an evidence-based practice (EBP) project of educational interventions and strategies for consistent PI prevention. The project was part of the author’s doctor of nursing practice (DNP) program.

First steps The QI team started the project by using the PICOT (Patient, population, problem; Inter- vention; Comparison, control; Outcome, ob- jective; Timeframe) mnemonic to develop this question: P: In LPNs caring for older adult residents in nursing homes, I: how will the implementation of a formal PI prevention program

Pressure injury prevention in

long-term care Follow the

evidence to improve

outcomes.

By Melissa De Los Santos, DNP, RN

L E A R N I N G O B J E C T I V E S

1. Describe strategies for preventing pressure injuries (PIs) in long-term care (LTC).

2. Discuss how to implement a project designed to prevent PIs in LTC. The author and planners of this CNE activity have disclosed no relevant financial relationships with any commercial companies pertaining to this activity. See the last page of the article to learn how to earn CNE credit.

Expiration: 7/1/24

CNE

1.6 contact hours

MyAmericanNurse.com July 2021 American Nurse Journal 7

C: compared to no formal program O: affect PI incidence T: over a 5-month period?

A systematic literature search was then completed across three databases (PubMed, CINAHL, and Cochrane Library). The search initially yielded more than 65,000 articles, but applying subject headings when possible and reviewing journal titles and abstracts nar- rowed the results to 51 articles. The inclusion criteria for those articles consisted of partici- pants 18 years of age and older, articles pub- lished within 10 years, and those written or translated in English. Exclusion criteria includ- ed treatment options such as redistribution de- vices, wound care products, non-English items, and articles published before 2008. Applying these criteria and removing duplicate articles reduced the number to 20 studies: four Level I studies, four Level IV studies, two Level V studies, seven Level VI studies, and three Lev- el VII studies from around the world. (See Hi- erarchy of evidence.)

On the basis of a study analysis, the team found a body of evidence indicating that for- mal PI programs with consistent PI preven- tion education, interdisciplinary techniques, standardized PI risk assessments, increased communication, consistent documentation, and ongoing monitoring can help decrease PI incidence.

Building the project Building the formal PI program required de- termining the stakeholders and establishing a timeline. Stakeholders Project stakeholders were the facility residents and their families, CNAs, staff RNs and LPNs, nursing administrators, and the organization’s leaders. The EBP project included all residents who were at risk for PIs, and all received pre- vention strategies. Timeline Preliminary discussions began in the fall of 2018 and concluded in the spring of 2019, when the project received approval by the university, the DNP program, and the long-term care organiza- tion (the project didn’t require institutional re- view board approval). By the end of 2019, QI team meetings were planned and support and resources were finalized.

A timeline with evidence-based interventions and outcomes organized, captured, and docu- mented three project implementation phases: educational intervention, implementation, and sustainment and dissemination. Health informa- tion collected as part of the project was de- identified.

I used a logic model as the framework for my project. (See Logic model in action.)

Launching the project The EBP project launched on July 1, 2019, with self-paced online PI education, risk assess- ments (weekly and Braden Scale assessments), interdisciplinary teamwork strategies, PI pre- vention strategy communication, and docu- mentation using PI identification communica- tion tools and repositioning charts to increase reporting and encourage ongoing monitoring.

I led four staff development sessions on all shifts to introduce the EBP project to nursing staff. Participants completed a pretest (to gauge current PI knowledge) before the on- line education program and a post-test after.

Phase 1: Educational intervention Phase one consisted of implementing three online, self-paced PI education modules from an outside vendor and developing the quality improvement team. The team’s responsibilities included increasing PI prevention communica- tion, promoting an effective multidisciplinary team, discussing goals in staff meetings, mon- itoring progress, assisting with accurate docu- mentation of PI prevention strategies, and pro- moting sustainability.

The 20-week nursing staff educational pro- gram focused on consistent use of PI risk assess- ment methods, effective interdisciplinary strate- gies, increased communication, and accurate documentation of PI prevention strategies. Inte- grated checklists served as reminders to consis-

Hierarchy of evidence Different types of studies provide different levels of evidence.

• Level I—Systematic review or meta-analysis of all relevant random- ized controlled trials (RCTs)

• Level II—Well-designed RCTs • Level III—Well-designed controlled trials without randomization • Level IV—Well-designed case control and cohort studies • Level V—Systematic reviews of descriptive and qualitative studies • Level VI—Single descriptive or qualitative study • Level VII—Opinions of authorities, reports of expert committees Source Mazurek Melnyk B, Fineout-Overholt E. Evidence-based Practice in Nursing & Health- care: A Guide to Best Practice. 4th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2018.

8 American Nurse Journal Volume 16, Number 7 MyAmericanNurse.com

tently implement the change based on current protocols. For example, RNs completed monthly comprehensive skin assessments; LPNs complet- ed quarterly and as-needed Braden Scale assess- ments; RNs and LPNs completed weekly skin as- sessments; and CNAs, restorative aids, and medication aids completed daily skin assess- ments during routine care.

Flyers posted in the breakroom, next to the time clock, and behind both nurses’ stations outlined the importance of implementing and documenting PI prevention. (See Promoting PI prevention.)

Phase 2: Implementation Phase two focused on PI prevention strategies, consistent use of the Braden Scale, and weekly skin assessments. Two project implementation

forms (a PI identification communication tool and a repositioning chart) previously used within the organization were resurrected for this project. Daily skin checks were document- ed on the PI identification communication tool, and PI prevention strategies, such as turn- ing residents on a schedule, were documented on repositioning charts.

Phase 3: Sustainment Phase three consisted of sustaining the pre- vention strategies, conducting team meetings, developing a skin algorithm, and incorporat- ing project implementation forms into the electronic health record. Analyzing outcomes Outcome analysis included educational inter-

Logic model in action A logic model is a graphic tool for planning, describing, managing, communicating, and evaluating a program or intervention. It consists of two main sections: process (inputs, activities, and outputs) and outcomes (short-, medium-, and long-term goals). Fre- quently, assumptions and contextual or external factors also are included. The author used the body of evidence and recommendations in the literature to create the model for the project described in the article. The process section helped guide implementation, and project outcomes were planned, outlined, and appraised through- out. External factors included the time it would take to complete training, and underlying assumptions included awareness of pre- vention strategies that will decrease PI risk.

CNAs = certified nursing assistants, ID = identification, LPNs = licensed practical nurse, MAs = medication aids, PI = pressure injury, PIP = pressure injury prevention, RAs = restorative aids Learn more about logic models at cdc.gov/dhdsp/docs/logic_model.pdf.

• Staff members (RNs, LPNs, CNAs, MAs, RAs)

• PIP online edu- cation on Braden Scale, PI ID Communica- tion Tool, and Repositioning Chart

• Access to resi- dent electronic charts and meeting rooms

Inputs

• By month 5, there will be a reduction of PI rates and costs associated with treat- ment in resi- dents

Outcomes

• Conduct training sessions for accurate implementation and documentation of Braden Scale

Activities

• Inservices or work- shops for staff lead- ing to better docu- mentation and increased reporting of skin alterations and PIs will occur

• PIP education will be completed during the first month of implementation and available online for reinforcement for future use

Outputs

• By the first month after training, there will be an increase of knowledge of PI risk factors as evidenced by consistent use of Braden Scale, PI ID Communica- tion Tool, and Repositioning Chart

• By month 3, there will be an increased proportion of staff implementing strategies to de- crease the risk of PIs as evidenced by consistent use of Braden Scale, PI ID Communica- tion Tool, and Repositioning Chart and de- creased incidence of PIs in residents

Long-term goalShort-term goal Medium-term goal

• Time to complete training

• Paid or unpaid train- ing

• Other protocols cur- rently being imple- mented

External factors

• Improve health outcomes by eliminating PIs

Impact

• Awareness of PIP strategies will decrease risk of PIs. • Consistent and accurate use of PIP risk assessments will decrease risk of PIs. • Increased understanding of PIP will decrease costs and improve health

outcomes. • Empowering staff will influence behaviors to improve health outcomes.

Assumptions

MyAmericanNurse.com July 2021 American Nurse Journal 9

vention, PI prevention strategies, PI rates, and cost savings.

Educational intervention The educational intervention yielded a 57% nurs- ing staff completion rate. Knowledge change was calculated by analyzing staff pretest and post-test scores. In the pretest, 61.5% of nursing staff scored 80 on the PI assessments and 42% scored 100. In the post-test, 13% of staff scored 80 and 87% scored 100 (a more than 50% in- crease in 100 scores).

PI prevention strategies In two-thirds of cases where CNAs had docu- mented abnormal skin concerns on the PI identification communication tool, RNs and LPNs responded by completing multiple Braden Scale assessments, even though there was no formal protocol requiring them to do so. The results confirmed the value of the tool.

Results also indicated the benefits of im- plementing multicomponent PI prevention initiatives, such as turning, repositioning, and mobilizing frequently, along with other inter- ventions (such as completing the Braden Scale, skin assessments, special mattresses, topical products, heel protectors, pillows, nu- tritional assessments and interventions, hy- dration, PI reporting, and communication). Analysis of Braden Scale score averages and repositioning frequency percentages showed that patients with a high-risk Braden Scale score (between 10 and 12) had a 71% reposi- tioning average; moderate risk (13 to 14) had a 59% repositioning average; at risk (15 to 18) had a 66% repositioning average. Inconsistent documentation affected the results, but repo- sitioning averages were at or above 59% con- sistently.

PI rates For 3 years, PI incidence rates at the organiza- tion had been rising steadly, from 0.67% in 2016 to 2.3% in 2017 and 5.3% in 2018. The national average was 7.2% to 7.3%. The EBP project achieved anticipated decreased PI rates. Between July and December 2019, four Stage II PIs were reported during the interven- tion (4% PI incidence rate in 2019), resulting in a 25% decrease in PI rates. Based on analy- sis, more consistent use of the PI identifiction communication tool with appropriate follow- up may have prevented more PIs.

Cost savings According to the Agency for Healthcare Re- search and Quality, PIs in the United States cost between $9.1 and $11.6 billion per year. Costs associated with legal action resulting from facility-acquired PIs add to the econom- ic burden. Based on the evidence, the EBP

Promoting PI prevention As part of the quality improvement team’s efforts to educate nursing staff about pressure injury (PI) prevention, they created a flyer to post through- out the organization. The flyer promoted staff empowerment through edu- cation and encouraged the use of a repositioning/skin inspection chart and a PI identification communication tool. At the end of each shift, completed charts and tools are submitted to the assistant director of nursing, who promptly reviews them to identify any new skin issues. Repositioning/skin inspection chart When developing the care plan, consider comorbid conditions, such as frailty and dementia.

• Change the patient’s position at least every 2 hours. • Reposition patients sitting in chairs every hour. • Inspect skin during activities of daily living. • Document the patient’s position and skin inspection every shift. (View a repositioning chart at myamericannurse.com/?p=258423.) PI identification communication tool • Complete on all residents daily during routine care every shift. • If the skin inspection reveals an area of concern, note it on the tool below. PI identification communication tool Date: Check all that apply:

Resident’s name: n No skin problem noted

Reporter’s name: n Bruise n Skin tear

n Reddened area

Place an “X” on the area of the body where you see a concern.

Reporter’s signature ______________________________________________ Nurse’s signature (if reporter is not a nurse) __________________________

10 American Nurse Journal Volume 16, Number 7 MyAmericanNurse.com

project was expected to reduce PI prevalence by at least 62%. This long-term care organiza- tion’s financial policies prohibited the discov- ery of direct costs, but because PI prevalence decreased by 25% between July and Decem- ber of 2019, it’s safe to assume some savings occurred. In addition, it’s reasonable to con- clude that decreased PI prevalence rates are viewed as desirable by potential residents, which could increase revenue from patient recruitment.

Sustaining the intervention To support sustainability and continued use of evidence for data-driven changes, the QI team developed a skin integrity algorithm. (See Skin integrity algorithm.) The team also rec- ommended to nursing leadership that the or- ganization continue to use Braden Scale and weekly skin assessments. The EBP project

prompted a culture change within the organi- zation, enhancing PI awareness and contin- ued use of the implementation forms by nurs- ing staff after the EBP project ended.

Closing the gap This EBP project used evidence to close the gap between knowledge and action. Contin- ued efforts include integrating implementation forms and the skin integrity algorithm into electronic formats for permanent use. Other recommendations are incorporating increased EBP into long-term care facilities for better outcomes and to increase the quality of care for all residents. AN Access references at myamericannurse.com/?p=258423. Melissa De Los Santos is a professor in the vocational nursing program at Austin Community College, Eastview Campus in Austin, Texas.

Skin integrity algorithm To ensure the pressure injury (PI) prevention evidence-based practice was sustained, the quality improvement team developed a skin integrity algorithm.

Weekly skin assessment

Abnormal findingNo abnormal finding

Continue Braden Scale assessments per protocol Nurse follow-up assessment and complete a Braden Scale assessment

Braden Scale risk scores*

Mild-risk scores (15 to 18) Encourage mobilization, turning, and repositioning; document on repositioning chart every shift. Assist with peri-care and ADLs as needed. Maintain hydration and nutrition.

Assist with mobilization, turning, and repositioning; document on repositioning chart every shift. Assist with peri-care and ADLs every shift. Implement consultations with physician, wound team, and dietician as needed.

Assist with mobilization, turning, and repositioning; document on repositioning chart every shift. Assist with peri-care and ADLs every shift. Consult with physician, wound team, and dietician for additional interventions.

Inspect, report, and document skin concerns on PI identification communication tool every shift.

Inspect, report, and document skin concerns on PI identification communication tool every shift. Assist with hydration and nutrition every shift.

Inspect, report, and document skin concerns on PI identification communication tool every shift. Assist with hydration, nutrition, and offer supplements every shift.

Moderate-risk scores (13 to 14)

High-risk scores (12 or below)

ADLs = activities of daily living, PI = pressure injury *For this project, the Braden Scale Score for very high risk (9 or below) was incorporated into the high-risk score.

MyAmericanNurse.com July 2021 American Nurse Journal 11

Please mark the correct answer online.

1. Harold*, your 88-year-old patient, enjoys sitting in his chair for the en- tire morning. How often should you reposition him?

a. Every 30 minutes

b. Every 45 minutes

c. Every 60 minutes

d. Every 90 minutes

2. You should document your inspec- tion of Harold’s skin every

a. hour.

b. shift.

c. day.

d. week.

3. Joan, a 78-year-old resident in a long-term care (LTC) facility, has a Braden Scale score of 16. You know that all of the following actions are appropriate except:

a. assisting with mobilization, turn- ing, and repositioning.

b. assisting with peri-care every shift.

c. assisting with activities of daily living every shift.

d. requesting a consultation with the wound care team and dietician.

4. Which of the following statements about PICOT is incorrect?

a. P = patient, population, problem

b. I = intervention

c. C = contrast, contractual

d. O = outcome, objective

5. You’re asked to spearhead a team to reduce PIs in the LTC setting where you work. The team is analyzing the results of a literature search, and some team members aren’t familiar with the levels of evidence used to guide the analysis. You explain that al- though the precise levels can vary, Level I typically includes

a. case control and cohort studies.

b. systematic review or meta-analy- sis of all relevant randomized controlled trials.

c. opinions of authorities and re- ports of expert committees.

d. a single descriptive or qualitative study.

6. Level VII typically includes

a. case control and cohort studies.

b. systematic review or meta-analy- sis of all relevant randomized controlled trials.

c. opinions of authorities and re- ports of expert committees.

d. a single descriptive or qualitative study.

7. Which of the following statements about logic models is correct?

a. It’s a graphic tool for planning, describing, managing, communi- cating, and evaluating a program or intervention.

b. It’s a written tool for planning, describing, managing, communi- cating, and researching a pro- gram or intervention.

c. It includes outcomes in the form of long-term goals.

d. The process section includes medium-term goals.

8. You’re assembling a team for a project to reduce PIs in your LTC set- ting. Whom would you include on the team?

______________________________

______________________________

______________________________

9. What would you anticipate the team would identify as activities that would help reduce PIs?

______________________________

______________________________

______________________________

10. What would be reasonable short-, medium-, and long-term goals for this project?

______________________________

______________________________

______________________________

*Names are fictitious.

POST-TEST • Pressure injury prevention in long-term care Earn contact hour credit online at myamericannurse.com/pressure-injury-prevention

Provider accreditation The American Nurses Association is accredited as a provider of nursing continuing professional development by the American Nurses Credentialing Center’s Commission on Accreditation.

Contact hours: 1.6

ANA is approved by the California Board of Registered Nurs- ing, Provider Number CEP17219. Post-test passing score is 80%. Expiration: 7/1/24

CNE: 1.6 contact hours

CNE

Concise Guide, 7th Edition

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See sample tables on the APA Style website.

Figures (Sections 7.22–7.32): Use a program appropriate for creating figures (e.g., Word, Excel, Photoshop, Inkscape, SPSS). Number figures in the order they are mentioned in the text. Within figures, check that images are clear, lines are smooth and sharp, and font is legible and simple. Provide units of measurement. Clearly label or explain axes and other figure elements.

All figures include three basic components: number, title, and image. Write the figure number above the figure title and image and in bold. Write the figure title one double- spaced line below the figure number and in italic title case. Write text in the figure image in a sans serif font between 8 and 14 points. Include a figure legend if needed to explain any symbols in the image. Position the legend within the borders of the figure, and capitalize it in title case. Include notes beneath the figure if needed to describe the contents. Start each type of note (general, specific, and probability) on its own line, and double-space it.

See sample figures on the APA Style website.

In-Text Citations (Chapter 8) Cite only works you read and ideas you incorporated into your paper.

Include all sources cited in the text in the reference list (exception: personal communications are cited in the text only).

Make sure the spelling of author names and the publication dates in the in-text citations match those of the corresponding reference list entries.

Paraphrase sources in your own words whenever possible.

For guidance on how to paraphrase sources, see the Paraphrasing pages.

Cite appropriately to avoid plagiarism, but do not repeat the same citation in every sentence when the source and topic do not change.

For guidance on appropriate citation, see the Appropriate Level of Citation page.

Write author–date citations according to seventh edition guidelines: Include the author (or title if no author) and year. For paraphrases, it is optional to include a specific page number(s), paragraph number(s), or other location (e.g., section name) if the source work being paraphrased is long or complex.

° One author: Use the author surname in all in- text citations.

° Two authors: Use both author surnames in all in-text citations.

° Three or more authors: Use only the first author surname and then “et al.” in all in-text citations.

For more information, including exceptions to basic in-text citation styles, see the Basic Principles of Citation pages.

Use either the narrative or the parenthetical citation format for in-text citations.

° Parenthetical citation: Place the author name and publication year in parentheses.

° Narrative citation: Incorporate the author name into the text as part of the sentence and then follow with the year in parentheses.

For works with two authors,

° use an ampersand (&) in parenthetical in-text citations: (Guirrez & Castillo, 2020)

° use the word “and” in narrative in-text citations: Guirrez and Castillo (2020)

For more information, see the Parenthetical and Narrative Citations page.

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When citing multiple works in parentheses, place the citations in alphabetical order. When multiple parenthetical citations have the same author(s), order the years chronologically and separate them with commas (e.g., Coutlee, 2019, 2020). When the authors are different, separate the parenthetical citations with semicolons (e.g., Coutlee, 2019, 2020; Ngwane, 2020; Oishi, 2019).

For more examples, see the Citation of Multiple Works page.

Limit the use of direct quotations. Include the author (or title if no author), year, and specific part of the work (page number(s), paragraph number(s), section name) in the citation.

° Short quotation (less than 40 words): Use double quotation marks around the quotation.

° Block quotation (40 words or more): Use the block format: Indent the entire quotation 0.5 in. from the left margin and double-space it.

For more information, see the Quotations page.

References (Chapters 9 and 10) Start the reference list on a new page after the text.

Center and bold the section label “References” at the top of the page.

Double-space the entire reference list, both within and between entries.

Use a hanging indent for each reference entry: First line of the reference is flush left, and subsequent lines are indented by 0.5 in. Apply the hanging indent using the paragraph- formatting function of your word-processing program.

All reference entries should have a corresponding in-text citation. The beginning of the reference entry (usually the first author’s surname) and year should match the corresponding in-text citation.

List references in alphabetical order according to seventh edition guidelines.

Create the appropriate reference entry for the type of work being cited, as described in Chapter 9 and shown in Chapter 10 and on the Reference Examples pages.

Do not create reference entries for personal communications and secondary sources.

For a list of works to include and exclude from a reference list, see the Works Included page.

Each reference entry includes four elements: author, date, title, and source.

See exceptions for references with missing information on the Missing Information page.

Use punctuation to group information and separate reference elements.

For more information, see the Basic Principles of References page.

List authors in the same order as the original source. Use initials for authors’ first and middle names. Put a comma after the surname and a period and a space after each initial (e.g. Lewis, C. S.). Put a comma after each author (even two authors). Use an ampersand before the last author.

For more information, including what to do when a work has more than 20 authors, see the Reference Elements page.

Capitalize titles in sentence case: Capitalize only the first word of the title, the subtitle, and any proper nouns. Format titles according to the type of work.

° Works that stand alone: Italicize the title (e.g., authored books, reports, data sets, dissertations and theses, films, TV series, albums, podcasts, social media, websites).

° Works that are part of a greater whole: Do not italicize or use quotation marks around the title (e.g., periodical articles, edited book chapters, TV and podcast episodes, songs). Write the title of the greater whole (e.g., journal or edited book) in italics in the source element.

For more information, including when to include bracketed descriptions for titles, see the References Elements page.

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Do not include database information for works retrieved from academic research databases. Do include database information for works retrieved from databases with original, proprietary content or works of limited circulation (e.g., UpToDate).

For more information, see the Database Information page.

Include a DOI or URL for any work that has one. If there is no DOI, include a URL if the work is retrieved online (but not from a database). Present DOIs and URLs as hyperlinks (beginning with “http:” or “https:”). Copy and paste DOIs and URLs directly from your web browser. Do not write “Retrieved from” or “Accessed from” before a DOI or URL. Do not add a period after a DOI or URL.

For more information, see the DOIs and URLs page.

© 2021

Last updated March 10, 2021

More information on APA Style can be found in the Publication Manual of the American Psychological Association (7th ed.) and the Concise Guide to APA Style (7th ed.).

CITE THIS HANDOUT:

American Psychological Association. (2021). Concise Guide, 7th edition student paper checklist. https://apastyle.apa.org/instructional-aids/ concise-guide-formatting-checklist.pdf

We thank Miriam Bowers-Abbott, of Mount Carmel College of Nursing, for providing the inspiration for this content.

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