Improving the Discovery and Care of Pressure Injuries in the Emergency Department

The problem.

Hospital-acquired conditions, particularly pressure injuries (PIs), increased at alarming rates during the COVID-19 pandemic. Hospital isolation precautions and infection prevention practices limited clinician time at the bedside. How does a nurse regularly turn and position a patient if they are unable to enter the room as often as they did prior to the pandemic? In addition, hospitals often operated with high percentages of their workforce out sick.

While Covid may be less of a threat by now, the number of patients admitted to EDs continues to increase while nurse staffing shortages intensify the pressure on nurses to maintain patient safety standards. With patient boarding in EDs becoming more common, the risk of hospital-acquired PIs grows as well, even in the ED. Traditional ED care focuses on rapid screening, assessment, and stabilization, followed by discharge or admission. But the reality is that medical–surgical inpatient care has become more necessary in the ED.

A central element of nursing care is the identification of PIs upon entry to the hospital, PI prevention, and care of existing PIs. Patients who are boarded in the ED, particularly older patient populations with underlying diseases and long length of stays, are at especially high risk for pressure ulcers or may present with existing pressure ulcers. All of this occurs in the context of regulatory governance that ranks hospitals in terms of quality outcomes and affects reimbursements for care.

Making a plan.

Our chief nursing officer, Jill Goldstein, and senior director of nursing quality and education, Daniella Stephen, brought this important issue to the senior director of nursing, nurse managers, and clinical RNs in the ED, inspiring us to develop a quality improvement project to improve the discovery of community-acquired PIs on our unit. Through our shared governance meetings and unit based practice council, we developed the plan:

• We created a PI cart and assigned nurses in four-hour blocks to perform skin rounds, with a goal of 16 hours per 24-hour period (4 hours per 8-hour cycle).
• The designated skin nurse utilized a novel PI rounding tool and followed a tiered priority approach: the first tier included all admitted patients 65 years of age or greater; the second, all admitted patients; and the third, all patients 65 years of age or older, regardless of admission.
• The tool encompassed 11 categories: Medical record number (MRN), Age, Date, Time of assessment, 2 RN check with primary RN, Length of stay at assessment, Findings, CAPI present (yes or no), LDA (line, drain, airway) status and electronically recorded occurrence, Prevention actions, and Additional comments.
• The tool was scanned to a secure drive daily so the leadership team could review regularly and retrospectively for quality assessment.

Our ED nursing leadership team routinely supported the ability to staff the pilot, made rapid adjustments as needed, and celebrated the results displayed on our daily management board.

A decline in hospital-acquired PIs.

Prior to our skin pilot, the ED averaged a discovery of three community-acquired PIs per month. During our pilot period, the rate of discovery increased 90%, to an average of 27 community-acquired PIs per month. Post-pilot, we now discover an average of 16 community-acquired PIs per month. Since the initiation of the pilot, zero hospital-acquired PIs have been attributed to lack of discovery or documentation in the ED setting (24-hour documentation rule).

As a result, the hospital has seen a rapid decline in hospital-acquired PIs. Over the two-month pilot period, followed by four months of standard work, ED nurses discovered 102 community-acquired PIs. The literature notes that a single hospital-acquired PI can cost an average of $10,000 in reimbursement and resources.

It is important to add two unanticipated results.

• Even when a skin nurse was not scheduled, the primary nurses in the ED were aware that every patient was assessed for community-acquired PIs. Our ED nursing practice has made improving skin care for a vulnerable patient population a priority.
• Our inpatient nurse colleagues recognized the work being done in the ED, which further supported the demands of their work. This has strengthened teamwork between the two services.

The skin care project of our ED nurses has reinvigorated our hospital’s zero harm efforts.

To learn more about our work, contact: Jonathan Nover: jonathan.nover@mountsinai.org

Authors: Jonathan Nover, MBA, RN, senior director of nursing, emergency department & critical care services, Mt. Sinai Queens; Bernadette Springer, MS, RN, FNP-BC, nurse manager, emergency department, Mt. Sinai Queens; Eric Peterson, BSN, RN, clinical nurse & magnet champion, Mt. Sinai Queens.