Evidence

IN TR ODUCTION

MEET TH E PATIEN TS

VISIT TH E UN ITS

High Tide Health System Medical Center

Magnet Journey

Case Studies

Emergency Department

Orthopedic Unit

Operating Room

Surgical Trauma ICU

High Tide Health System Pressure Ulcer Case

Neuroscience Unit

Summary

High Tide Health System Medical Center

The HTHS Medical Center, a 400-bed inpatient facility with a Level 2 trauma center

designation, is part of the High Tide Health System.  It opened in 1974 as a result of a

partnership between Oceanfront Hospital and High Tide University.  It is located in an urban

setting with a largely indigent population.  

1 of 9

High Tide Health System Medical Center

 Visit the HTHS website to learn more about the Health System and Medical Center.

Website password:  ceomast

C O NT I NU E

High Tide has not previously been a Magnet designated facility, but the organization is

optimistic that its outstanding nursing engagement and positive patient outcomes will help

them achieve this recognition.  

Pressure Injury Prevalence

2 of 9

Magnet Journey

The hospital environment is especially energized

at this time, as team members on the recently

implemented Magnet Team are hard at work on

their Magnet document that will be ready for

submission in the upcoming quarter.  

One requirement to become a Magnet designated facility is to report a pressure injury

prevalence rate quarterly.  Fortunately, High Tide is currently performing a quarterly

prevalence study.  The quarterly prevalence rate falls below the national benchmark of 2.5%,

but the organization has been unable to consistently meet the internal stretch target of 1.5%. 

Often times there is a signi�cant rise in prevalence in between quarters for an unknown

reason.  

Members of High Tide Medical Center's Magnet Team review wound care data

The stretch target of 1.5% was proposed by the Wound Care Team in 2017 as a measurable

and attainable goal for hospital acquired pressure injury (HAPI) prevalence when the

organization was tasked with reducing hospital acquired pressure injuries by its hospital

board.  The stretch target was selected by analyzing and comparing High Tide’s performance

against other academic medical centers.  The organization has been given one year to make a

positive and consistent change.

Assessment and Education

Currently, the Wound Care Team at High Tide assesses patients with pressure injuries and

makes recommendations for care.  They provide prevention education for newly hired nurses.

 They also collect data for the quarterly pressure injury prevalence study.  This is a time

consuming task for the small Wound Care Team of 5 Wound and Ostomy certi�ed nurses.

 The team has often considered utilizing the knowledge and skills of bedside nursing sta� to

help collect this data.  Additionally, the team has exploring strategies to change the culture

from treatment to prevention.  It is to the bene�t of the patients and the organization to be

proactive rather than reactive.

Magnet Document Contribution

The Wound Care Team has contributed to the Magnet document with its work in wound and

ostomy care.  At a recent team meeting, a Wound Care Team member acknowledged that a

great deal of work for the Magnet document was created in collaboration with varying levels

of leadership and bedside sta�.  The Wound Care Team consulted with the Magnet team to

discuss how leadership support can be obtained and how the framework utilized for the

Magnet document can be used to successfully implement a comprehensive pressure injury

prevention program. The framework includes the following domains: 

Transformational Leadership

Structural Empowerment

Exemplary Professional Practice

New Knowledge, Innovation, and Improvement

It was also discussed at the team meeting that the culture among bedside sta� can often

re�ect skepticism of new processes. While bedside sta� at High Tide is highly engaged, they

often feel overwhelmed with growing expectations from the organization. Many team

members in the environment are aware that hospitals do not receive reimbursement for the

care of hospital acquired pressure injuries, but not all realize this is about more than money

or “checking a box” to meet a standard.  Instead, it is about taking excellent care of the

patients. As a result, the Wound Care Team posed the following question:

It appears that most of the hospital acquired pressure

injuries occur in the ICU and a large portion of these

injuries are caused by medical devices.   This is useful

information when planning pressure injury prevention

education.

Scene 1 Slide 1

How can we convince team members that this is not just about money or numbers, rather, it’s about providing the best possible care and preventing harm among our patients? 

Scene 1 Slide 2

Continue End of Scenario

Feedback

Scenario End

Add text here to let learners know your scenario is over. View

this tutorial to learn how to create branching scenarios.

START OVER



The Wound Care Team has previously met with leaders on the inpatient units to identify

barriers to prevention and to communicate the goal of decreasing the hospital acquired

pressure injuries, but the team is at times met with resistance.  Recent feedback has included

as shown below: 

“The organization is already doing what can be done to decrease pressure

injuries.”

- Valerie Sowards

“Units are already tasked with so many other key initiatives”

- Danny Coyle

“We do not have the sta� or the resources to achieve the goal of 1.5% HAPI

prevalence.”

- Kelly Herrmann

The Wound Care Team recognizes that additional resources are needed for sta�ng,

education, and implementation of best practice guidelines in order for the comprehensive

program to be successful.  

C O NT I NU E

In order to identify opportunities for improvement and determine root cause analysis, the

Wound Care Team pulled the list of patients who sustained a hospital acquired pressure injury

in July 2019.  This month was selected as this was the highest HAPI prevalence month in

2019.  Of the 17 patients with hospital acquired pressure injuries, 5 were selected for review.

 Additionally, two cases in which the patient was hospitalized for >100 days but sustained no

pressure injuries were also selected for review.  This could provide the team with information

as to what processes were in place to promote positive outcomes.

View the 7 cases below:

3 of 9

Case Studies

Case Study 1 –

UNIT:  MEDICAL RESPIRATORY ICU 51 YO Caucasian male, 86.4 kg, with Hx of: Dysphagia, Malnutrition, MRSA, COPD, DM, Aortoiliac disease, HTN, ESRD Pt in ICU for 115 days. NO evidence of pressure injury throughout stay. What went well? 

Pt was on the right surface

Pt was turned and repositioned appropriately

Nursing sta� aware of high risk for skin injury status (discussed as a team in daily huddle)

Appropriate prophylactic dressings were utilized

Pt’s family educated appropriately and engaged in patient’s care

Case Study 2 –

UNIT:  NEUROSCIENCE 81 YO African American male, 112.2 kg, with Hx of: HTN, HLD, DM, CHF, CAD, CVA In ICU for 185 days, no evidence of a pressure injury throughout stay. What went well?

Pt was on the right surface

Pt was turned and repositioned appropriately

Nursing sta� aware of high risk for skin injury status (discussed as a team in daily huddle)

Appropriate prophylactic dressings utilized

Family not present, but verbalized concern about patient’s skin on multiple occasions via telephone conference. This created a stressful environment for the bedside sta�, but it required them to be diligent with turning/repositioning and thorough skin assessment.

Case Study 3 –

UNIT ASSOCIATION: SURGICAL TRAUMA ICU 32 YO Caucasian male, 207 kg, with Hx of: HTN, Malnutrition, Obesity, Mental Illness, Multisystem organ failure, sepsis, use of vasopressors to maintain blood pressure.  Pt hospitalized for signi�cant injuries s/p MVC. Pt was incontinent of stool and had Foley catheter in place. Pt on bedrest. Pt sustained Stage 4 pressure injury to sacrum, unstageable pressure injury to occiput (due to C-Collar), and unstageable pressure injury to anterior neck (due to trach plate). When providing an explanation for the cause of the injury, nurses on the Surgical Trauma ICU noted that the Bariatric patient that was di�cult to turn and o�oad appropriately. The C- Collar utilized was the incorrect size for this patient. The trach plate was sutured tightly in place for 17 days and was not properly o�oaded.

Case Study 4 –

UNIT ASSOCIATION: EMERGENCY DEPARTMENT 62 YO African American female, 219 kg, with Hx of: HTN, DM, Obesity, Asthma, COPD, Tobacco use Pt arrived to ED c/o dyspnea and fever. Pt in ED for 21 hours awaiting room for admission. Pt laid on hospital stretcher for 21 hours prior to being transferred to hospital bed in room. While in the ED, the pt had requested that the head of the bed be elevated to at least 60 degrees due to SOB. Pt reports sleeping on multiple pillows at home to assist with her breathing. Pt had multiple episodes of urine incontinence while in the ED. Sta� in the ED were not always available to clean the patient’s skin after each episode of incontinence, so the patient’s skin and sheets were frequently soiled with urine for long periods of time. Pt found to have signi�cant pressure injuries to her sacrum and bilateral ischium 3 days into admission.

Case Study 5 –

UNIT ASSOCIATION: ORTHOPEDICS  72 YO Caucasian male, 76 kg, with Hx of: Asthma, CAD, DVT, HTN, Osteoarthritis Pt underwent L hip replacement due to osteoarthritis. Pt’s mobility limited during admission. Per physician order: Weight bearing 25% LLE. ROM: Flexion and extension only. Dilaudid for pain. Pt had requested Dilaudid frequently for pain. This contributed to his lethargy and his failure to reposition self in bed. Review of the documentation revealed that the pt’s left heel was placed in a heel protector boot. The RLE was not elevated and the right heel was not �oated. As a result, the patient developed a deep tissue injury to the right heel.  Upon questioning of the nurses, they stated they believed the patient was repositioning himself since he was mobile prior to surgery.

Case Study 6 –

UNIT ASSOCIATION: OPERATING ROOM 18 YO African American male, 63 kg, with Hx of: metastatic sarcoma, anxiety. Pt underwent abdominal surgery and was in OR for 22 hours. Pt was placed on a gel overlay during surgery. Pt had a gel donut pillow placed under head during surgery. OR nurse charted post-operative skin assessment consistent with pre-operative skin assessment. Pt not turned in PACU due to signi�cant abdominal pain. Pt was transferred back to ICU 3 hours after completion of surgery. Three days after surgery, pt found to have circular deep tissue injury to his occiput and a deep tissue injury to his right heel.

Case Study 7 –

UNIT ASSOCIATION: NEUROSCIENCE 28 YO Hispanic male, 71 kg, with no prior Hx. Pt admitted with to ICU with TBI and multiple fractures after motorcycle collision with car at high speed. Pt in ICU for 64 days. No pressure injuries noted during ICU stay. Pt admitted to Neuroscience unit on day 65. As a result of his initial injuries, pt was left with right sided hemiplegia. On day 72 of admission, pt was transferred to the recliner with maximum assistance and was left to sit for 8 hours. On day 75 of admission, nurses charted deep tissue injuries to coccyx and bilateral ischium.

C O NT I NU E

Entrance to High Tide Medical Center's Emergency Department

Unit Description 3 Sections: 

Red:  Trauma

Yellow:  Observation/Awaiting Admission

4 of 9

Emergency Department

Green:  Fast Track

Culture Moderate nursing turnover with recent changes in leadership

- Majorie Hansen, RN, AGACNP-BC 

- Barry Moore, PA-C 

“Our patients aren’t here long enough to get pressure injuries.”

“We don’t have time to think about pressure injury prevention. We

are saving lives down here in this high stress environment.”

High Tide Medical Center's Therapy Room

Unit Description 24 beds

Culture Moderate nursing turnover 

5 of 9

Orthopedic Unit

- Brandy Walters, RN 

“Our patients are often in signi�cant pain and are di�cult to

turn/o�oad due to recent surgeries and orthopedic devices.

Sometimes our patients get pressure injuries under their orthopedics

devices, but there is nothing we can do about that. Also, there are a

lot of activity restrictions, so that presents a challenge in pressure

injury prevention.”

High Tide Medical Center's OR

Unit Description 32 OR Rooms

Scheduled surgeries performed 7 days per week. Multiple surgical specialties present.

Culture

6 of 9

Operating Room

Minimal nursing turnover

- Yi Chien, MD 

“We don’t have a pressure injury problem here. Most of the time the

post-operative patient’s skin looks like it did when they arrived to

the OR.”

High Tide Medical Center's Surgical Trauma ICU

Unit Description 22 ICU beds, 4 step down beds

Scheduled surgeries performed 7 days per week. Multiple surgical specialties present.

Culture

7 of 9

Surgical Trauma ICU

High nursing turnover

- Sheryl Benfer, RN 

“Our patients are critically ill and have a lot of medical devices to

contend with. It is understood that they will get pressure injuries

frequently. At least we are keeping them alive.”

High Tide Medical Center's Neuroscience Unit

Unit Description 24 beds

Culture Moderate nursing turnover

8 of 9

Neuroscience Unit

“Our patients are usually total care. We take TBI patients, SCI

C O NT I NU E

- Carolyn Ruben, RN-ACACNP-BC 

patients, and CVA patients. It’s very challenging to prevent pressure

injuries in these patients because they are di�cult to turn and keep

o�oaded.”

Based on what you have learned about High Tide Hospital, how would you work with the

Wound Care Team to develop and implement a comprehensive pressure injury prevention

program?  What are key elements across all units that need to be considered for an

organizational plan to reach a goal?

9 of 9

Summary

You have completed this case.