Editor's note: After COVID19, facilities faced nursing shortages, barriers to efficient documentation, and, subsequently, rises in hospital-acquired injuries (HAPI). In this interview from SAWC Fall 2023, Kim Cummings, MSN, RN, CWOCN, CFCN, WOCN discusses protocols used at her facility that significantly reduced the number of HAPIs.

Transcript

Hi, my name is Kim Cummings, I'm a certified Wound, Ostomy and Continence Nurse at Banner Del E Webb in Sun City West in Phoenix.

What inspired your facility to roll out these initiatives?

So, we did see a rise in our pressure injuries in 2017 and we started a pressure injury prevention push, and then we were really doing well and brought our pressure injuries down quite significantly, as evidenced by the data that's in the poster. And then when COVID came we started to see it increase and obviously a lot of our patients were really sick and there were a lot of proning patients so they developed a lot of facial injuries, so we had to rethink how we were going to continue to educate nurses.

So, we brought in our interventions, but we did them in a different way, you know, our education. And that education involved, instead of having classroom education, we had to revert to teams and have smaller groups of nurses rather than, you know, cohorts. And then we realized a lot of the nurses coming out actually didn't have any hands-on skills because they had to do their training in a virtual environment. So, we were noticing not only were we getting busier with critical patients, we were also having staff and nurses that really weren't really well equipped to look after those patients.

How have alternative trainings for new nurses during COVID19 impacted staff? Consequences of less hands-on learning?

Kind of covered that a minute ago. I mean, it's because the nurses have less hands -on training, then they're doing their training in a virtual environment, so they're not getting to see the patients until they're actually out there as a registered nurse. So it did impact negatively in as much as it put more pressure on the existing staff, and we were going through critical nursing staffing anyway because of COVID, and a lot of nurses were off sick or retired early, took early retirement. Then we had an influx of a lot of, and still do, nursing travelers and increase in new grads, and the attrition rate was quite poor, too. But I think we're coming through it now. This last year we've seen an improvement, and I think a lot of the nurses on the floor, we can still educate as Wound, Ostomy and Continence nurses because we do a lot of rounding, so we do a lot of one-on-one education.

So leadership support, we were able to still continue with bringing nurses out to do a shadow experience with us, so they'd come out for 4 hours a day for 1 day just to kind of see how we do things and to gain skills in nursing assessment and preventing pressure injuries and treating pressure injuries. And then we could still carry on with our new hire classes and then last 6 months we've been able to gain momentum with that now, so that's been a big improvement.

But the one thing is with the classes and education we've reverted to a teams approach, probably you know the virtual meetings, but we're now able to go back to having classroom and meetings you know proper meetings one-on-one. But it does seem like the teams approach has kind of taken over because a lot of leadership like to have them at the meeting on teams, but I think we prefer to do it You know having actual nurses doing hands -on, rather than in the teams culture because it's harder to do You know to do hands -on training through teams and that kind of platform. So we're back to the classroom and that and the nurses now are actually getting more clinicals We're getting more students coming through, so I think the next year we'll see you know the nurses gaining momentum you know, but it's put a lot of pressure on the last few years.

How have documentation practices been impacted?

Okay, so that's a good question. When COVID hit and we realized it was here for longer than we expected, then we went into, I think nationally, we went into emergency charting, which means that nurses were given kind of permission to only document what was absolutely necessary. So things like interventions weren't being documented, assessments still had to be documented.

But coming out of COVID, now it's hard to kind of get nurses to kind of continue to go back to how the nursing charting should be. So that leaves us wide open for litigation. Of course, when things are being investigated, you know, if you're intervention through in place, was it documented? Again, we're seeing small improvements, but this is, I think I noted a bit in the poster work, was it's probably our highest litigious area, because if you go back and do a chart review, it's poor. The charting is poor. But I think that's a stand, that's across the nation. But, you know, you just have to keep educating and keep going with that.

Could you briefly discuss what demarks a sacral wound as not being a pressure injury?

So, I'm going to direct you to the NPIAP website. But there is a wonderful paper, a white paper there that we refer to through, I think, when COVID came out and people start noticing these extensive sacral wounds, on the toes, and lower extremities and they put it down to the abnormal clotting that was occurring during COVID. And then also I think the other thing was you were realizing people were getting these wounds that looked like pressure injuries, deep tissue injuries, but they weren't actually laying in the same position for long periods of time. So the kind of didn't match the fact that these patients were getting these sacral wounds because they weren't really laying supine for that long, but you knew you had these clotting problems.

So we were able to work with our intensivists, especially in ICU, and talk about these wounds so we didn't kind of have to label them as pressure injuries or we'd be owning a lot more wounds than we should have been, so the NPIAP was a great resource for us at that time.

What are some tips for spotting a deep tissue pressure injury used at your facility?

Well, any patient that develops what looks like a pressure injury wound or any wound in general, we typically get consults. So if a patient comes in with a pressure injury, they consult us. If they come in with a wound, they'll consult, wound care. So we kind of educate through tip sheets what to look for.

So we have pictograms of, you know, heels and sacrums and what and what a deep tissue looks like in the early stages and in the more advanced stages but generally we want nurses just to consult us if they feel like there's any purple, dark red because they can get missed very you know easily, so we've we I think it's again we've it's in the poster, we have several tip sheets on of what to look for deep tissue injury. And then in patients who have orthopedic devices, orthotics and trachs and ET tubes and those kinds of equipment, to make sure they're looking all around the device because deep tissue injury is very common under those devices. So it's really assessing and consulting us as soon as they can when they see anything that's available not normal.

What are some strategies for preventing heel pressure injuries in the ICU?

This is an ongoing project and before COVID we were seeing an increase in pressure injuries in the ICU, our data, because we collect data continually every time we get a HAPI. We track it with quality and then, we've got like 5 or 6 years worth of data now.

And just before COVID came, we were really seeing a good reduction in heel pressure injuries. And what we were doing, we were making sure that all vented patients would be in an offloading boot. And if they couldn't use a boot, they'd have heel dressings for prevention, and then floated on pillows.

So we kind of did some audit, hands-on audits, where we would round and just see if they were following the protocol for that. And then we would discuss with leadership, before that, and then the education.

And we were doing well. Again, COVID came. It wasn't a priority so much. Everything was kind of turned around. And we were finding we were pruning a lot more patients. So the heel pressure injuries didn't actually become so much of a problem when you're proning patients. So, but we did still get a few pressure injuries, but once we started coming out of COVID, like last year, 2022, we really, you know, through 2021 -2022, we worked on still continuing with the audits, the education, and I think it might have been a little bit of luck too, but we ended up with zero pressure injuries in the ICU in 2022.

We are seeing a little rise up again because of a lack of compliance. You need to keep educating, educating, educating. And now again, since the education has been pushed up by leadership, by the managers on the floor, we haven't seen a heal pressure there for 2 or 3 months. So it just, again, it's amazing how much education you have to keep doing all the time. It's never a done deal.

And a lot of nurses don't realize that and managers will say, you know, “We've educated stuff, we keep talking about that in our meetings, they should know this by now.” But then you find your staff is changing so much that you just have to keep on it. And we notice that when education is put out there and the leaders get more involved with it, then you notice the compliance goes up and your pressure injuries come down. There's a correlation between that.

That surprised me a little bit, really, because it's how powerful education is, you know.

Did any part of these initiatives surprise you?

Yeah, I think going in a few years back, it was you think you can put things together like tip sheets and education programs and it's going to solve the problem. It does not.

And because of our rapid turnover, and you have seasoned nurses that stay a while for long term and are still with us now, and then you just have to keep re-educating all the new nurses that come and there's so many things in the nurses day, that they're overwhelmed. I mean how do you kind of put this up to the fore of importance and I think our pictures of pressure injuries that we show nurses in our meetings. We have a skin champion team, so you know, we kind of have them help to educate the nurses also, but when nurses start to see the pressure injuries that occur in your facility, you know, I think it brings that message home. But we see a lot more present or admission pressure injuries from nursing homes, skilled nursing facilities, and that's been really surprising. Well, I guess it's not surprising as such, but the last 2 years particularly we've, I think we've never seen so many pressure injuries as what we see now coming in to our facility. So, There's a lot of work that we have to do, it's about prevention.