Plastic Surgery Research Council

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The Effect of Quality Improvement Interventions in the Prevention of Pressure Injuries in Critically Ill Patients
Jillian M. McLaughlin, MD, Samee A. Hameed, BS, Jacquelynn P. Tran, MD, Dell E. Roach, MSN RN CNML CNS, Victor Z. Zhu, MD, Blake B. Sparks, MD, Jared L. Potts, MD, Ludwik K. Branski, MD, Douglas S. Tyler, MD, FACS, Aristides P. Koutrouvelis, MD, Linda G. Phillips, MD, FACS.
University of Texas Medical Branch, Galveston, TX, USA.

PURPOSE: Pressure injuries cause a significant health and economic burden. Quality improvement projects focusing on pressure injury prevention have been effective in reducing pressure injury in critically ill patients. The purpose of this project was to implement evidence based quality improvement interventions in critically ill patients and prospectively evaluate whether this led to a decrease in significant pressure injury incidence.
METHODS: A combined retrospective and prospective cohort study was performed in the surgical intensive care unit (SICU). Retrospective data served as control (pre-intervention). Data obtained prospectively allowed for assessment of intervention effectiveness (post-intervention). Variables collected during both study periods included: demographics, pressure injury risk assessment, and daily pressure injury grading. Significant pressure injury was defined as pressure injury grades of 3, 4, unstageable, or deep tissue injury. The intervention bundle consisted of a multimodal approach that encompassed all five evidence-based interventions: leadership initiatives, visual tools, pressure injury staging, skin care, and nutrition. Compliance with implementation of interventions was assessed via self-reported questionnaires and staff feedback was collected anonymously for protocol optimization. Differences between pre-intervention versus post-intervention were assessed with 2-sample t-test for continuous variables or by Fisher's exact test or chi-square test for discrete variables with p-value = 0.05. Cox proportional hazards model was used to explore risk factors associated with development of pressure injuries.
RESULTS: 505 patients were admitted to the SICU during the 12 month study period, 172 patients in first 4 months prior to and 333 patients in remaining 8 months following implementation of interventions (Table 1). Patients in the post-intervention cohort were significantly older and had significantly higher rates of vasopressor use and shock or need for resuscitation upon admission. Despite the higher number of risk indicators and higher age of the post-intervention group, a decrease in significant pressure injury incidence was observed from pre-intervention to post-intervention (Figure 1). SICU staff reported compliance with implementation of interventions 80% of the time. After adjusting for time-dependent covariates and baseline differences, the following variables were found to be significant in pressure injury development: shock or resuscitation (HR = 2.4, p = 0.016), vasopressor use (HR = 2.5, p = 0.012), history of diabetes mellitus (HR = 2.6, p = 0.005), serum glucose levels on admission (HR = 2.7, p = 0.007), and total Braden scale score (HR = 0.79, p = <0.0001).
CONCLUSION: Several unavoidable comorbidities were associated with higher risk of pressure injury development while higher Braden scale score was associated with a lower risk of pressure injury development. Implementation of evidence based quality improvement interventions for pressure injury prevention were effective in decreasing significant pressure injury incidence in critically ill patients. Further studies are needed to assess the effectiveness of the interventions long-term.

Table 1. Patient Characteristics (n = 505)
Pre-Intervention t = 4 months (n= 172)Post-Intervention t= 8 months (n= 333)p-value
Age, yrs, mean, +/- sd53 +/- 1757 +/- 170.01*
Male, n (%)95 (55)207 (62)0.15
BMI, mean +/- sd29 +/- 929 +/- 70.67
Length of ICU stay, days, mean +/- sd7 +/- 87 +/- 80.88
Braden Scale Score, mean +/- sd13 +/- 313 +/- 30.68
Glucose (mg/dL), mean +/- sd152 +/- 70154 +/- 1080.83
Shock or Resuscitation, n (%)28 (16)112 (34)<0.001*
Vasopressor Use, n (%)26 (15)99 (30)<0.001*
Diabetes Mellitus, n (%)53 (31)97 (29)0.76



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