Implementation and Sustainability of Pressure Injury Prevention and Management Strategies in the Geriatric Patient Population
Summary
Older adults presenting with multiple comorbidities in a post-acute setting are at an increased risk for developing pressure injuries (Jaul et al., 2018). These comorbidities may include but are not limited to immobility, incontinence, impaired sensory perception, and poor perfusion. These risk factors are undeniably common among the geriatric population here at Baycrest, and as such are important things to note to ensure that our efforts in the prevention and management of pressure injuries are effective.
Since 2016, Baycrest has been granted the designation of Best Practice Spotlight Organization by RNAO. In keeping with this designation and our commitment to better patient outcomes, Baycrest continues to provide its support to the professional growth of individuals who show interest in participating in initiatives such as the Advanced Clinical Practice Fellowship (ACPF) offered by the RNAO. In my case, I was fortunate to hear that my interest in wounds and further learning could be accomplished by tying together how wounds that develop from extended pressure, friction, and shear forces over time are analyzed and observed from a quality improvement perspective. In focusing on reviewing existing pressure injury prevention and management strategies, I was able to orient my fellowship projects towards not only sustaining but also improving the current organization wide initiatives in place at Baycrest.
My overall learning goal for this fellowship could be described as wanting to develop and enhance my knowledge and understanding of implementation and sustainability principles in the context of pressure injury prevention and management at Baycrest. It was specifically meant to uphold one of the currently implemented Best Practice Guidelines (BPG) here at Baycrest that focuses on pressure injuries, namely the “Assessment and Management of Pressure Injuries for the Interprofessional Team (3rd ed.)” guideline.
Having primarily practiced as a point-of-care nurse prior to the fellowship, I was curious about everything that I was about to experience for my learning. Considering what I had for my proposal, most of my time at the beginning was spent on literature reviews to consolidate my understanding of pressure injuries and how the interprofessional team work together to promote the best care for the patients.
What I understood from my different interactions with the advanced practice nurses and my peers here at Baycrest was that I work well as an independent learner, and that I was able to make effective use of my time given minimal guidance and direction. I had many opportunities to engage and interact with different disciplines here at Baycrest, and I appreciated all the support I was given in the form of having an active role during discussion groups that focused on pressure injury management.
I was led by example by my mentors, and had many chances to practice how to better communicate to staff across the different units. These experiences helped increase my self-confidence in particular going into the quality improvement meetings whereby I could also advocate on behalf of point-of-care nurses our concerns when we hear about the new projects that get proposed for our units. It was a unique and incredible experience being exposed to both sides of the project implementation and sustainability phases, from the point of view of bedside nursing to having a more involved role in determining resource allocation for education and change management.
Outcomes
The patients here at the hospital can be categorized into different post-acute care settings. My fellowship and the overall focus of all pressure injury initiatives here at Baycrest were concentrated on the complex continuing care (CCC) patients, as well as our slow stream rehabilitation (SSR) and transitional care unit (TCU) patients. Considering that most of the CCC units were already keeping a close watch on pressure injuries as many patients in those units have both healable and non-healing wounds, we were able to allocate more resources in determining gaps in the SSR and TCU environments. After determining these gaps through individual and focused group interviews, we were able to come up with strategies that promoted open dialogue and suggestions to overcoming the challenges that were identified.
For instance, one of the things that came up in conversation was about how each unit communicated to its team members when a new or worsening pressure injury was noted on a patient. We determined how each unit conveyed this information along the rest of the healthcare team, and identified ways to improve our current system to ensure that we were able to prevent any potential areas of concern from being missed.
In the previous years, much of the data collection with regards to prevalence and incidence data on pressure injuries had been primarily collected by advanced practice nurses. By enlisting a group of point-of-care nurses interested in participating in the pilot project to be trained in data collection and interpretation, we were able to expand our ability to more consistently collect data and also promote rapid knowledge exchange at patient bedside. Considering that the results of the previous pilot were overwhelmingly positive, part of my fellowship was made to be dedicated into expanding and strengthening this initiative. This program that consists of the “P&I Champions” saw an increase in the number of participants over the course of my fellowship, whom I was responsible for teaching as part of my facilitation activities. Other initiatives that have been started throughout the course of my fellowship also resulted in an improved toolkit and a new resource material being developed to promote documentation standards. The weekly progress and outcomes of these related activities were eventually shared to stakeholders during our quarterly lead/sponsor updates as part of our quality improvement plan discussions.
Overall experience
The ACPF experience has taken me to a whole new world of nursing. Having spent most of my career at bedside, the opportunity to get to know more outside the realm of direct patient care was a welcome experience, and one that I will not soon forget. Being able to take part in this fellowship journey and getting to know more about the barriers and facilitators to implementing change ideas has been a worthwhile challenge, and I am very grateful to have been supported by my wonderful mentors as well as by my peers.
One of the most interesting impressions that I can point out during this fellowship was the feeling of duality being in a position whereby I could directly guide the timelines of the project while concurrently working part time as regular staff at point of care. I could distinctly remember how the priorities of bedside staff like myself would be formulated and compared to viewing things from a project management perspective. It was later on when I was able to overcome this dichotomy that I was better able to see how both sides can be influenced to biased thinking about what is more important, and learned how to better unite the differences into something that was meaningful to both parties.
Being able to participate in this fellowship with another fellow in the same organization also added to the overall rich learning experience here at Baycrest. We had been able to connect frequently with one another, and were able to reflect and discuss our shared experiences with our mentors.
Overall, I believe that the entire fellowship experience provided many opportunities for my growth as an independent learner, as well as highlighted my leadership style in taking on project management.
References
Jaul, E., Barron, J., Rosenzweig, J. P., & Menczel, J. (2018). An overview of co-morbidities and the development of pressure ulcers among older adults. BMC Geriatrics, 18(1). https://doi.org/10.1186/s12877-018-0997-7
