Presentation
HE22 - Under Pressure: Understanding the Difference Between Work as Imagined and Work as Done in Pressure Injury Assessment
SessionPoster Session 2
DescriptionHospital acquired pressure injuries (HAPI) are a significant and complex problem facing US hospital systems, substantially increasing mortality risk and decreasing quality of life (Wassel et al., 2020) for 2.5 million patients per year (Agency for Healthcare Research and Quality, 2014). Incidence rates, which vary widely based on location and care setting, are estimated between 0.4% and 12% (Wassel et al., 2020), with more recent data suggesting an incident rate of 5.85% in critical care (Cox et al., 2022). Pressure injuries are estimated to have an incremental cost of $32,292 in intensive care units (ICUs; Wassel et al., 2020). Many factors may contribute to a patient developing a HAPI, including, but not limited to, immobility, poor nutrition, reduced blood supply, age, incontinence, and medical device usage (Rondinelli et al., 2018; Cox et al., 2022). Despite adoption of evidence-based PI prevention programs HAPI rates have become not decreased in recent years (Cox et al, 2022), with Agency for Healthcare Research and Quality (2020) data suggesting a 6% in rates between 2014 and 2019, indicating that prevention of their development must be prioritized.
METHODS
Data Capture. The Human Factors and Innovations (HF&I) interdisciplinary team adopted a system’s-based method to understanding the current state of pressure injury prevention through gathering qualitative and quantitative data. This work was conducted in a large midwestern hospital system to analyze what additional steps could be taken to prevent adult patients from developing pressure injuries. Qualitative data collection focused on observing how work is done by nurses and nurse technicians in intensive care units (ICU), medical-surgical units (med/surge), and the emergency department (ED). Additionally, wound care and ostomy nurses (WOCN) workflows were observed to understand the role that they play in caring for patients who have developed pressure injuries. Although the role of a mobility technician was discontinued during the project, initial observations were included in the analysis. Interviews were also conducted with clinical team members on ICU and med/surge units.
Data Visualization. The patient care process was mapped using the Functional Resonance Analysis Method (FRAM; Hollnagel et al., 2014). This patient care process followed from arriving to the ED to being admitted on a unit, having their skin assessed by their care team, what prevention steps their care team performed, and what treatment they might receive upon the development of a pressure injury. The FRAM allowed the human factors team to identify places where work as imagined (WAI) via the policy, differed from how the work as done (WAD) in the real world in the prevention of pressure injuries.
RESULTS
Work-As-Done Prevention Gaps. Understanding WAD allowed the HF&I team to identify where there were gaps in current pressure injury prevention practices. For the purposes of prevention of HAPI, there was a large discrepancy between WAI and WAD. Staff indicated that daily skin assessments were often not feasible as imagined, which led them to reasonably complete skin assessments in smaller portions as accommodated by visibility during other tasks. It was also observed that prevention techniques such as turning were limited in effectiveness and utilization of prescribed devices, as well as frequency due to patient condition and other factors.
Pain Point Identification. Qualitative data were synthesized to come up with a list of several different pain points that underlie why prevention of pressure injury work was not being completed or was being completed ineffectively. Pain point areas included: a lack of interdisciplinary engagement in skin health, not having enough staff to complete all of the patient related care tasks, significant time to complete tasks related to skin care in an understaffed environment, a lack of efficiency in skin care processes, a lack of training related to pressure injuries, especially for a complex issue, a lack of access to tools to prevent pressure injuries, and risk scoring not driving prevention activities.
OUTCOMES
The HF&I team then brainstormed potential solutions around these pain points, which were refined and ranked with an interdisciplinary team of key stakeholders to determine which solutions would be most impactful while balancing cost and time to implement. The proposed solutions are currently under review and awaiting potential implementation.
The findings of this project suggest that how work is imagined to be done for pressure injury prevention does not line up with how work is being done by clinical staff. This indicates that prevention of pressure injuries may not be done as expected, or at an impactful level, leaving patients vulnerable to development of HAPIs. Identifying innovative and sustainable solutions that integrate well into current workflows or offload work from overburdened clinicians is essential to reduce pressure injury rates in hospital patients.
Hollnagel, E., Hounsgaard, J., & Colligan, L. (2014). FRAM-the Functional Resonance Analysis Method: a handbook for the practical use of the method. Centre for Quality, Region of Southern Denmark.
Agency for Healthcare Research and Quality. (2020, July) Declines in Hospital Acquired Conditions. https://www.ahrq.gov/data/infographics/hac-rates_2019.html
Cox, J., Edsberg, L. E., Koloms, K., & VanGilder, C. A. (2022). Pressure injuries in critical care patients in US hospitals: results of the International Pressure Ulcer Prevalence Survey. Journal of Wound Ostomy & Continence Nursing, 49(1), 21-28.
Rondinelli, J., Zuniga, S., Kipnis, P., Kawar, L. N., Liu, V., & Escobar, G. J. (2018). Hospital-acquired pressure injury: risk-adjusted comparisons in an integrated healthcare delivery system. Nursing research, 67(1), 16-25.
Agency for Healthcare Research and Quality. (2014, October). Preventing Pressure Ulcers in Hospitals. https://www.ahrq.gov/patient-safety/settings/hospital/resource/pressureulcer/tool/pu1.html
Wassel, C. L., Delhougne, G., Gayle, J. A., Dreyfus, J., & Larson, B. (2020). Risk of readmissions, mortality, and hospital‐acquired conditions across hospital‐acquired pressure injury (HAPI) stages in a US National Hospital Discharge database. International wound journal, 17(6), 1924-1934.
METHODS
Data Capture. The Human Factors and Innovations (HF&I) interdisciplinary team adopted a system’s-based method to understanding the current state of pressure injury prevention through gathering qualitative and quantitative data. This work was conducted in a large midwestern hospital system to analyze what additional steps could be taken to prevent adult patients from developing pressure injuries. Qualitative data collection focused on observing how work is done by nurses and nurse technicians in intensive care units (ICU), medical-surgical units (med/surge), and the emergency department (ED). Additionally, wound care and ostomy nurses (WOCN) workflows were observed to understand the role that they play in caring for patients who have developed pressure injuries. Although the role of a mobility technician was discontinued during the project, initial observations were included in the analysis. Interviews were also conducted with clinical team members on ICU and med/surge units.
Data Visualization. The patient care process was mapped using the Functional Resonance Analysis Method (FRAM; Hollnagel et al., 2014). This patient care process followed from arriving to the ED to being admitted on a unit, having their skin assessed by their care team, what prevention steps their care team performed, and what treatment they might receive upon the development of a pressure injury. The FRAM allowed the human factors team to identify places where work as imagined (WAI) via the policy, differed from how the work as done (WAD) in the real world in the prevention of pressure injuries.
RESULTS
Work-As-Done Prevention Gaps. Understanding WAD allowed the HF&I team to identify where there were gaps in current pressure injury prevention practices. For the purposes of prevention of HAPI, there was a large discrepancy between WAI and WAD. Staff indicated that daily skin assessments were often not feasible as imagined, which led them to reasonably complete skin assessments in smaller portions as accommodated by visibility during other tasks. It was also observed that prevention techniques such as turning were limited in effectiveness and utilization of prescribed devices, as well as frequency due to patient condition and other factors.
Pain Point Identification. Qualitative data were synthesized to come up with a list of several different pain points that underlie why prevention of pressure injury work was not being completed or was being completed ineffectively. Pain point areas included: a lack of interdisciplinary engagement in skin health, not having enough staff to complete all of the patient related care tasks, significant time to complete tasks related to skin care in an understaffed environment, a lack of efficiency in skin care processes, a lack of training related to pressure injuries, especially for a complex issue, a lack of access to tools to prevent pressure injuries, and risk scoring not driving prevention activities.
OUTCOMES
The HF&I team then brainstormed potential solutions around these pain points, which were refined and ranked with an interdisciplinary team of key stakeholders to determine which solutions would be most impactful while balancing cost and time to implement. The proposed solutions are currently under review and awaiting potential implementation.
The findings of this project suggest that how work is imagined to be done for pressure injury prevention does not line up with how work is being done by clinical staff. This indicates that prevention of pressure injuries may not be done as expected, or at an impactful level, leaving patients vulnerable to development of HAPIs. Identifying innovative and sustainable solutions that integrate well into current workflows or offload work from overburdened clinicians is essential to reduce pressure injury rates in hospital patients.
Hollnagel, E., Hounsgaard, J., & Colligan, L. (2014). FRAM-the Functional Resonance Analysis Method: a handbook for the practical use of the method. Centre for Quality, Region of Southern Denmark.
Agency for Healthcare Research and Quality. (2020, July) Declines in Hospital Acquired Conditions. https://www.ahrq.gov/data/infographics/hac-rates_2019.html
Cox, J., Edsberg, L. E., Koloms, K., & VanGilder, C. A. (2022). Pressure injuries in critical care patients in US hospitals: results of the International Pressure Ulcer Prevalence Survey. Journal of Wound Ostomy & Continence Nursing, 49(1), 21-28.
Rondinelli, J., Zuniga, S., Kipnis, P., Kawar, L. N., Liu, V., & Escobar, G. J. (2018). Hospital-acquired pressure injury: risk-adjusted comparisons in an integrated healthcare delivery system. Nursing research, 67(1), 16-25.
Agency for Healthcare Research and Quality. (2014, October). Preventing Pressure Ulcers in Hospitals. https://www.ahrq.gov/patient-safety/settings/hospital/resource/pressureulcer/tool/pu1.html
Wassel, C. L., Delhougne, G., Gayle, J. A., Dreyfus, J., & Larson, B. (2020). Risk of readmissions, mortality, and hospital‐acquired conditions across hospital‐acquired pressure injury (HAPI) stages in a US National Hospital Discharge database. International wound journal, 17(6), 1924-1934.
Event Type
Poster Presentation
TimeTuesday, April 14:45pm - 6:15pm EDT
LocationFrontenac Foyer