An easy-to-use worksheet that combined an assessment scale designed to identify critically ill patients at risk for developing a pressure injury with specific interventions to address each risk contributed to a decrease in healthcare-associated pressure injuries (HAPIs) for patients in a New York hospital’s cardiothoracic intensive care unit (ICU). Findings from the performance improvement project are published in Critical Care Nurse (CCN).
“Reducing Hospital-Acquired Pressure Injuries in a Cardiothoracic Intensive Care Unit” details a nurse-led quality improvement project in a 10-bed ICU at Catholic Health Long Island’s Good Samaritan University Hospital, West Islip, New York. Most of the patients in the specialty unit were recovering from open heart surgery and transcatheter aortic replacement. Other patients had complex cardiac conditions that often required mechanical support devices such as intra-aortic balloon pumps (IABPs), ventricular assist devices (VADs) and extracorporeal membrane oxygenation (ECMO).
Cardiac patients are at especially high risk for developing HAPIs, and the unit’s average prevalence rate was 11.01% for the 24-month period prior to the initiative, higher than national benchmarks. The rate was despite the hospital’s standard of care for HAPI prevention: assessing the patient’s skin and risk factors at each nursing shift with the widely used Braden scale and addressing the identified risk factors with the SKIN care bundle (surface, keep turning, incontinence care and nutrition).
For the project, the team designed a simple tool that linked bundled HAPI prevention interventions to risks identified by the Cubbin-Jackson scale, a pressure injury risk-assessment scale specifically for ICU patients. Nurses completed a paper version of the tool in addition to performing the existing standard of care.
Author Sunday Caldwell, DNP, NP, ANP-BC, NE-BC, is a nurse practitioner and director of cardiac intensive care at the hospital. She previously presented the performance improvement project at the American Association of Critical-Care Nurses’ conference, the National Teaching Institute & Critical Care Exposition, in 2024.
“We developed a tool to guide nurses to implement a preventive intervention bundle for each specific risk factor identified, allowing them to tailor care to each patient’s individual needs,” she said. “The combination resulted in a decrease in HAPIs, improving patient outcomes and avoiding a variety of costs.”
The intervention group consisted of all patients admitted to the cardiothoracic ICU during an eight-week period. The rates of HAPIs were then compared with a retrospective review of medical records from a preintervention group of all patients admitted during the preceding eight weeks. Each group consisted of 102 patients, and nurses completed the Cubbin-Jackson assessment for 89 patients in the intervention group.
In the preintervention group, four patients experienced HAPIs, of whom three had sacral HAPIs. In the intervention group, three patients developed HAPIs, of whom only one had a sacral HAPI that developed quickly, within 72 hours of an 11-hour surgery.
The prevalence rate fell 67.84% (from 22.2% to 7.14%), and the incidence rate decreased 36.43% (from 13.56% to 8.62%), which isn’t considered statistically significant due to the small number of patients with HAPIs.
Although medical device-related pressure injuries are clinically concerning, sacral deep tissue injuries are the most concerning given their potential to advance to higher-stage pressure injuries; therefore, the decline in this type of injury is clinically significant.
A total of 29 nurses completed a preintervention questionnaire, and 18 completed one after the intervention. Before the intervention, 82.75% of the respondents agreed or strongly agreed that the Braden scale was a useful tool in preventing HAPIs, and 89.66% agreed or strongly agreed that the SKIN care bundle was also useful. After the intervention, only 55.56% agreed or strongly agreed that the Braden scale was useful, and 77.78% agreed or strongly agreed that the SKIN care bundle was useful. Meanwhile, after the intervention, 83.33% agreed or strongly agreed that the Cubbin-Jackson scale with the linked interventions was useful in preventing HAPIs.
Since completion of the project, the unit has continued to use the Cubbin-Jackson scale with linked HAPI prevention interventions, and the results have been sustained over time.
As AACN’s bimonthly clinical practice journal for acute and critical care nurses, CCN is a trusted source of information related to the bedside care of critically and acutely ill patients. Access the article abstract and full-text PDF by visiting the CCN website at http://ccn.aacnjournals.org.
About Critical Care Nurse: Critical Care Nurse (CCN), a bimonthly clinical practice journal published by the American Association of Critical-Care Nurses, provides current, relevant and useful information about the bedside care of critically and acutely ill patients. The award-winning journal also offers columns on traditional and emerging issues across the spectrum of critical care, keeping critical care nurses informed on topics that affect their practice in acute, progressive and critical care settings. CCN enjoys a circulation of about 130,000 and can be accessed at http://ccn.aacnjournals.org/.
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