Post Event Huddle to Decrease Hospital Acquired Pressure Injuries

Topic: Post Event Huddle to Decrease Hospital Acquired Pressure Injuries

Purpose: The goal was to reduce hospital acquired pressure injury rates by engaging bedside staff in identifying barriers to care and implementing changes in pressure ulcer prevention techniques according to the findings through the development of a PIRATE (Pressure Injury Review AcT and Educate) huddle.  Hospital acquired pressure injuries (HAPIs) are considered a nursing sensitive quality indicator. HAPIs are a serious cause of morbidity and mortality, increase length of stay, decrease quality of life and increase burdens on the healthcare system.  

Objectives: To reduce HAPIs, the PIRATE huddle was developed. In the event of an HAPI, all interdisciplinary team members involved in the care of the patient are required to attend the scheduled PIRATE huddle. The PIRATE huddles proceeds through a formal, consistent process of data verification and feedback, open discussion to consider the care provided, and development of action items. Team members are identified to drive the initiative of change through a PDSA (Plan Do Study Act) cycle. 

Outcomes: Multiple action items have been identified and implemented including: nursing staff education on medical device related pressure injury prevention, WOC nurse rounding on patients with Braden scale < 14, bedside "4 eye" assessment during nursing rounds, and staff nurse driven implementation of PI prevention interventions based on the Braden scale score (such as application of preventive dressings and utilization of specialty support surfaces).

A paired-samples t-test was conducted to determine the significance in implementing PIRATE meetings to reduce HAPIs. There was a significant decrease in HAPIs between 2016, when PIRATE meetings were not implemented (mean (M) = 0.0033, standard deviation (SD) = 0.002) to 2017, when PIRATE meetings were being implemented (M = 0.0015, SD = 0.002); t(1)=0.004 p < 0.05.