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Saint Francis Hospital and Medical Center, a 617-bed hospital in Hartford, CT, reduced hospital-acquired pressure injuries by more than 60 percent using an ������Ƶtoolkit. Preventing Pressure Ulcers in Hospitals: A Toolkit for Improving Quality of Care was central to the hospital’s effort to prevent an estimated 114 pressure ulcers and avoid nearly $2 million in excess hospital costs.

For Saint Francis, the toolkit provided a roadmap to reducing pressure injuries, which are painful sores that can develop on the skin, particularly if the patient is confined to a bed. Pressure injuries are painful, can lead to serious deep tissue infections, and can affect clinicians’ ability to provide appropriate treatment. They are also associated with increased costs and longer hospital stays.

“We followed and implemented the ������Ƶtemplate with rigor,” said Amanda R. Safer, D.N.P., director of nursing professional practice, education, and research for the hospital. “We embraced change, followed the toolkit, and implemented everything ������Ƶsuggested.”

This started with a “deep dive” to understand the extent of the problem. The hospital surveyed nurses and other clinical staff to get a sense of current practices and how pressure injuries were measured and reported. This involved working with the hospital’s quality and data staff to make sure common terms and measurement tactics were used. An interdisciplinary intervention team evaluated, piloted, and selected practices. Then it was time to implement the ������Ƶtoolkit.

Major steps included:

• Measuring staff’s knowledge of and attitude about pressure injuries.
• Implementing new policies and procedures in two hospital units—critical care and medical-surgical—which had the highest number of pressure injuries.
• Educating clinical staff, with a focus on nurses and certified nursing assistants.
• Staging pressure injuries on a 1-4 scale.
• Using “skin rounds” to check skin condition for high-risk patients.

The heightened awareness included having two nurses conduct a skin assessment within 24 hours of admission. “The two-RN assessment might not seem significant, but it helped with perfecting practice at the bedside,” Dr. Safer said. “If one nurse thought there was a pressure injury, we required confirmation from a second RN. The conversation about the two assessments would reinforce procedure and make sure we were treating patients appropriately.”

At Saint Francis, pressure injuries identified as Stage 2 (characterized by partial loss of skin at the bedsore) or worse went from a rate of 1.36 per 1,000 patients admitted in early 2015 to just 0.54 per 1,000 patients 2 years later.

“Our people have been hyper-vigilant. If anything, they’re over-reporting pressure injuries,” Dr. Safer said. “We’re hoping to get back toward the middle on that, but we’re still way below the benchmark, which is where we want to be.”

Saint Francis implemented the toolkit as part of an AHRQ-sponsored Hospital Pressure Ulcer Training Program, in which hospitals received technical assistance. Eleven hospitals across the Nation participated in the program, which ran from 2015 to 2017.