Micro to Macro Approach: Using Data to Drive Change and Reduce Pressure Injuries

The organization implemented a Harm Prevention program which was built out from a macro and microsystem perspective for all harm indicators, laying the foundation for a streamlined and standardized approach to harm prevention organization-wide. With a dedicated team focused on improving harm, a dashboard was built for all indicators which had the capability of drilling down to the root cause including device-related vs. immobility related HAPI. The following sub-groups were created to reduce the rate of harm from the most frequently offending devices: tracheostomy, orthotic/braces, non-invasive positive pressure ventilation (NIPPV) and PIV. Following the creation of the HAPI orthotics-related subgroup, small tests of change were initiated including: education at safety huddles, clinical updates, and EPIC upgrades. The subgroup was able to decrease the rate of orthotic related pressure injuries by 50% from a baseline rate of 0.26 to 0.13. All patients in the Progressive Care Unit (PCU) have a tracheostomy so they decided to create a multidisciplinary committee to address the increasing rate of trach-related HAPI. Following the creation of the subgroup, small tests of change were initiated including: q shift neck checks under the strings, daily string change, rolling cart education, neck measurements, and staff try on strings. The cumulative results of the above changes have led to a 40% decrease in the rate of stage 2 or greater trach-related injuries from 4.61 to 3.06. Following the creation of the HAPI PIV subgroup, small tests of change were initiated including: consistent padding, dedicated VAS resources, nursing standard procedures updates, and education of IV placement. The cumulative results of the above changes have led to a 100% decrease in the rate of PIV reportable HAPI’s. Furthermore, the above changes have led to a 67% decrease in the overall HAPI rate from 0.03 to 0.01.