Project to curb pressure injuries in hospitals shows promise

The quality-improvement arm of the Joint Commission is seeing success in a project focused on reducing pressure injuries at hospitals by identifying their root cause. The project uses Lean and Six Sigma change management systems to maintain focus and ongoing improvement.

The Joint Commission Center for Transforming Healthcare began more than two years ago working with three hospitals to find root causes and solutions to pressure injuries. From May 2018 to December 2019, the hospitals saw an average 55% reduction in pressure injuries in the intensive-care unit. And from January to April 2020, the hospitals reported an average 62% reduction. Together, the hospitals saved $15.3 million, according to the center.

The three participating hospitals—Johns Hopkins Hospital in Baltimore, Kaiser Permanente South Sacramento (Calif.) Hospital and Memorial Hermann Southeast Hospital in Houston—volunteered for the pilot and regularly share their findings. 

“One of the things that came out early on as we met with these organizations was, we made improvement in the past when it came to pressure injuries but we weren’t able to sustain it,” said Klaus Nether, executive director of high reliability service delivery at the Joint Commission Center. By using Lean and Six Sigma processes, front-line caregivers own the work and implement it, which encourages long-term sustainability, he said.

Pressure injuries have risen in recent years. The most recent data from the Agency for Healthcare Research and Quality shows the preliminary national rate of pressure injuries was 23 per 1,000 discharges in 2017, which is a 6% increase from 2014 when the national rate was 21.7. Hospitals continue to struggle with controlling the injuries, Nether said. 

In 2008, CMS stopped paying for care related to treating a hospital-acquired pressure injury, determining they were “reasonably preventable based on the application of published, evidence-based guidelines.” One pressure injury can cost a hospital anywhere from $500 to more than $70,000.

The Joint Commission project found pressure injuries typically happen for the following reasons: lack of education on how they’re likely to occur; issues with identifying poor skin integrity; problems with assessing and documenting pressure injuries; and use of medical devices.

Analysis at Kaiser Permanente South Sacramento showed that medical devices were often the root cause for pressure injuries in the intensive-care unit. ICU patients typically have devices such as catheters or ventilators that put pressure on the skin, making it vulnerable to sores. In response, Kaiser created a device rounds team, consisting of a nurse leader and bedside nurse who check all ICU patients who have a device once daily. 

The nurses examine if the device has a protective barrier, typically a foam dressing, between the skin and the device. If there isn’t one, the nurses discuss it with the bedside nurse, educating them about the importance of using skin barriers. Nurses were also educated on the lifelong side effects of pressure injuries for patients. 

Nurses previously believed pressure injuries were an unavoidable side effect of care in the ICU, said Rachel Wyatt, clinical adult services director for Kaiser Permanente South Sacramento Medical Center. Since the project began, there has been a culture shift where nurses “are doing everything in their power to prevent pressure injuries,” she said. 

The 200-bed community hospital has sustained its nearly 60% reduction in pressure injuries even through the COVID-19 pandemic when patients in the ICU are typically hooked up to devices for weeks, Wyatt said. 
The hospital plans to expand the project to all other units in the next few months. 

The Joint Commission Center also plans to expand the project to more hospitals and other care settings by the first quarter of 2021. About five to eight organizations will likely be part of it, Nether said.