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nosocomialinfection.pdf

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Background Nurses certified in wound, ostomy, and continence monitored an increasing incidence of hospital-acquired pressure injury of the nares due to medical devices, specifically nasogastric tubes, in a metropolitan hospital. A majority of these pressure injuries occurred in patients in the intensive care unit. The organization lacked formal guidelines for preventing such injuries. Objective To decrease the incidence of nasogastric tube–related hospital-acquired pressure injury. Methods The organization’s process improvement model, comprising steps to define, measure, analyze, improve, and control, guided the project. The incidence rate of nasogastric tube–related hospital-acquired pressure injury before the intervention was determined for calendar year 2015 and compared with data obtained after the intervention, for calendar year 2016. An interprofessional team created, implemented, and evaluated the effectiveness of evidence-based guidelines and surveillance strategies for preventing nasogastric tube–related hospital-acquired pressure injury. The team implemented guidelines using the simple mnemonic “CLEAN”: correct tube position, stabilize tube, evaluate area under/near tube, alleviate pressure, note date and time. Results The incidence rate of nasogastric tube–related hospital-acquired pressure injury (0.13 per 1000 patient days in 2015) decreased 100% (0.0 per 1000 patient days in 2016) after the guidelines were imple- mented in the organization. This rate was sustained for a full year, after which it increased slightly because temporary and new staff lacked knowledge of the guidelines. Conclusions The creation and implementation of clear and specific guidelines for assessing and secur- ing nasogastric tubes successfully reduced nasogastric tube–related hospital-acquired pressure injury. (Critical Care Nurse. 2019;39[6]:54-63)

Jessica Schroeder, BSN, RN, CWOCN Verna Sitzer, PhD, RN, CNS

Nursing Care Guidelines for Reducing Hospital-Acquired Nasogastric Tube–Related Pressure Injuries

N urses often use nasogastric tubes (NGTs), or “sump” tubes, when caring for critically ill

patients. Nasogastric tubes pass through a naris and into the stomach, and nurses use them

to decompress the gastrointestinal system, administer medications, and perform gastric

lavage. Nasoenteric tubes, also referred to as “feeding” tubes, are used for administering nutrition. Naso-

gastric tubes may be stiffer and have a larger diameter than nasoenteric tubes.1 Because of these charac-

teristics, nasogastric and nasoenteric tubes can contribute to the development of hospital-acquired pressure

injuries (HAPIs) to the epidermal tissue of the nares.2 For the purposes of this process improvement project,

we referred to them collectively as “NGTs.”

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Nasogastric tubes can contribute to the development of hospital-acquired pressure injuries.

Hospital-acquired pressure injuries are a costly and

often disfiguring problem. They can cause pain and

infection, increase a patient’s length of stay, and lead to

litigation.3,4 The cost of treating a single HAPI can range

from $21 000 to $152 000.5 Medical device–related pres-

sure injuries (MDRPIs) are defined as “pressure injuries

[that] result from the use of devices designed and applied

for diagnostic or therapeutic purposes.”6 In a study of

the prevalence and incidence of pressure ulcers among

2178 patients, 5.4% had a pressure injury, and 34.5% of

those injuries were due to medical devices.7 Among

stage 3 and 4 HAPIs reported in a Minnesota statewide

database, 29% were due to MDRPIs. Of those, 8% were

caused by NGTs.8 Patients in critical care units are at

high risk for MDRPI because they require many devices

for monitoring and treatment. In a study of patients in

intensive care units (ICUs), investigators attributed

32% of all HAPIs to medical devices2; of these MDRPIs,

1.6% were caused by NGTs.2 Health care organizations

are placing more focus on safety and thus are giving

greater attention to reducing preventable injuries such

as MDRPIs.

In 2008, the Centers for Medicare and Medicaid

Services ruled that facilities will not be reimbursed for

hospital-acquired conditions, including HAPIs, and that

they could in fact incur fines for stage 3 and 4 pressure

injuries that develop during a hospitalization.9 Because

of the potential financial implications, many organiza-

tions mobilized efforts and resources for surveilling and

preventing HAPIs.

This intervention occurred in a nonprofit acute care

Magnet hospital in southern California with 313 staffed

beds, an emergency department, and a level II trauma

center. Programs include comprehensive cardiac care,

cancer treatment, orthopedics, organ transplantation,

and rehabilitation. In this hospital, a team of certified

wound, ostomy, and continence (WOC) nurses tracks

HAPI incidence. In June 2015, the team noted an increas-

ing trend in the incidence of MDRPIs, specifically

nasogastric tube–related HAPIs (NGT-HAPIs). These

NGT-HAPIs all occurred to epithelial tissue and thus

were staged by using the National Pressure Ulcer Advi-

sory Panel (NPUAP) staging system.6 The incidence of

NGT-HAPIs was 0.09 per 1000 patient days in the previ-

ous quarter of that year, which had risen to 0.17 per

1000 patient days by June 2015. The team shared this

trend and its concern with hospital leaders, including

the chief nursing officer, during the hospital’s daily

high-reliability and operational huddle. The daily hud-

dle was created to identify and address safety events

and operational issues that occur throughout the hospital.

Identified events and issues are recorded and tracked,

and trends are identified, on a whiteboard.

A process improvement (PI) work group was recom-

mended to address the increasing number of NGT-HAPIs.

The PI work group was led by a certified WOC nurse and

included clinical nurse specialists (CNSs) and a regulatory

nurse. All members concurred that the problem-solving

format they

used to guide

their work

would be the

hospital’s cur-

rent PI framework. The team applied a framework com-

prising 5 stages—define, measure, analyze, improve,

and control—that aims to minimize variation and create

more reliable processes.10

In the define phase, the work group identified a

goal of reducing the incidence of NGT-HAPIs to 0.

The improvement question was, “Will the develop-

ment and implementation of evidence-based guidelines

for preventing NGT-HAPIs reduce their incidence?”

Methods Process improvement projects in this hospital do not

require PI teams to seek ethical approval for the use of

human subjects through the organization’s institutional

review board. Therefore, the PI project was exempt from

institutional review board approval. Most PI projects use

retrospective data and report aggregate data. Data collected

and used for the purpose of this project were considered

part of usual PI activities. No protected health information

was included in any progress summary reports during

the course of the project.

Authors Jessica Schroeder is the clinical lead of the Wound Healing Depart- ment, Sharp Memorial Hospital, San Diego, California.

Verna Sitzer is the Director, Professional Practice, Research and Innovation, Sharp Memorial Hospital.

Corresponding author: Jessica Schroeder, BSN, RN, CWOCN, Sharp Memorial Hospital, 7901 Frost St, San Diego, CA 92123 (email: [email protected]).

To purchase electronic or print reprints, contact the American Association of Critical- Care Nurses, 101 Columbia, Aliso Viejo, CA 92656. Phone, (800) 899-1712 or (949) 362-2050 (ext 532); fax, (949) 362-2049; email, [email protected].

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Knowing the point of care where NGTs were initially inserted and secured helped the team determine the scope of the project.

All members of the PI work group had the knowl-

edge and skills to apply the 5-stage framework in address-

ing the increased incidence of NGT-HAPIs. During the

project, the organization was continuing a journey of

cultural transformation to become a “highly reliable orga-

nization.” Highly reliable organizations strive to create a

culture in which providers and staff proactively address

potential safety issues to prevent harm to patients and

staff.11 Initiatives were under way to support continuous

PI, including a daily organization-wide reliability hud-

dle, unit-based safety huddles during each shift, PI and

highly reliable organization training for all staff, and a

frontline approach to problem-solving.

Define Another element in defining the problem or issue

was identifying the current process for preventing

MDRPIs, specifically to the nares. The work group

obtained and reviewed the organization’s critical care

nursing guidelines for preventing HAPIs related to devices.

The document contained information regarding general

assessment for preventing MDRPIs but nothing specific

for preventing NGT-HAPIs. In this organization, when

guidelines of care are not specified, nurses use approved

online nursing care references on the intranet, although

these references

are not specific

to preventing

NGT-HAPIs.

According to

current prac-

tice, staff move a tube slightly from side to side to assess

the skin beneath it. Staff use their preferred method to

secure the tube; this could include tape or a commercial

product. No existing organizational guidelines specified

when and how to secure an NGT.

Measure Certified WOC nurses track, identify trends in, and

report all HAPIs that occur in the organization. Although

it would be convenient to report these occurrences as

counts, it is important to provide incidence data to give

context and allow comparison with other data. The NPUAP

prefers incidence density, or the number of patients who

develop a HAPI divided by 1000 patient days, as the mea-

sure of quality improvement.12 Thus the PI work group

retrospectively reviewed HAPIs occurring during 2014

to determine the percentage of MDRPIs caused by NGTs.

In 2014, 33 of the 85 HAPIs (38.8%) were MDRPIs. Of

these MDRPIs, 10 (30.3%) were attributed to NGTs. The

incidence of NGT-HAPI was 0.11 per 1000 patient days.

In the beginning of July 2015, 16 of 47 HAPIs (34%)

were MDRPIs, 6 (37.5%) of which were due to NGTs.

The incidence of NGT-HAPI had risen to 0.13 per 1000

patient days.

The facility has 2 ICUs, 1 medical and 1 surgical,

each with 24 beds. The mean length of stay is 3.2 days

for patients in both ICUs. Of the 10 NGT-HAPIs that

occurred in 2014, 7 (70%) occurred in the ICUs. By July

2015, that value was at 50% (3 of 6 HAPIs). Establishing

a baseline was essential for determining the effectiveness

of the improvement efforts.

Analyze The PI work group analyzed the root cause of all

NGT-HAPIs (n = 16) from January 2014 to June 2015.

Although NGT-HAPIs occurred at all levels of care, 50%

(n = 8) occurred in the surgical ICU. Timing of the dis-

covery of an NGT-HAPI varied: 2 were discovered more

than 1 month into the patients’ hospitalizations, 9 were

found within a few days, and 4 were identified after 1

week. One NGT-HAPI was discovered in just more than

24 hours after the NGT had been inserted. These NGT-

HAPIs were discovered during nurse assessments, and

WOC nurses were then consulted to accurately stage

the injuries. Of the 16 NGT-HAPIs, 6 (38%) were staged

as deep-tissue injuries.

The root cause analysis revealed several inconsisten-

cies regarding the nursing management of NGTs. Docu-

mentation in the electronic medical record often did not

reflect that the skin beneath the devices had been assessed

at regular intervals. How the tube was secured and how

often it was changed varied. Case review also revealed

that nurses or physicians placed 7 NGTs contributing

to an NGT-HAPI in the emergency department, and an

anesthesiologist placed 2 in the operating room. Know-

ing the point of care where NGTs were initially inserted

and secured helped the team determine the scope of the

project and identify which departments and providers

would need to be included in the improvement project.

Members of the PI work group interviewed physicians

and nurses to obtain their perspectives on NGT manage-

ment and potential causes of NGT-HAPI. Interviews of

providers who recently cared for patients who sustained

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an NGT-HAPI revealed common themes. Some physi-

cians lacked awareness of or concern for this type of

injury, as they perceived it to be a minor issue when

compared with the complex problems critically ill patients

experience. Some nursing staff throughout the hospital

shared this sentiment. Many nurses described discomfort

and uncertainty regarding how to properly secure an NGT

without dislodging it. Staff interviews revealed a lack of

clarity regarding expectations for when tape should be used

to secure an NGT or when a device should be changed.

On the basis of root cause analysis, the work group

identifi ed a need for specifi c guidelines for the nursing

care provided to patients with an NGT. The guidelines

would include expectations for preventing NGT-HAPI,

including method of securement, frequency of assess-

ment and resecurement, and documentation.

Improve Guideline Development. The PI work group

reviewed the current literature to obtain MDRPI preven-

tion recommendations7,8,13-16 (see Table). Team members

also networked with other hospitals within and outside

the health care system to determine practices for pre-

venting NGT-HAPI. Through this information gather-

ing, the team discovered that no established community

standards existed for the type of securement device, the

Table Summary of literature review for recommendations Source Purpose Methods Recommendations Black

et al,7 2010

To quantify the extent and nature of, and identify risk factors for, MDRPI and to explore potential preventative strategies in hospitalized patients

Secondary data analysis from point prevalence studies conducted in a medical center

Frequent assessment for change in condition (edema causes increased risk for pressure)

Keep area dry (moisture increases risk for pressure) Interdisciplinary collaboration (necessary for

MDRPI prevention)

Apold and Rydrych,8 2012

To describe how data was used to identify trends in root causes for MDRPI and to develop best practices for prevention

Secondary analysis of data submitted to a statewide database

Routinely inspect and properly fit devices Create clear best practice guidelines for prevention

Fletcher,13 2012

To increase awareness and prevention of MDRPI

Review of the literature Appropriately fixate and stabilize devices Use thin barrier products to protect skin

beneath a device Repeatedly and thoroughly assess skin beneath a

device Loosen device at least once per shift for assessment

NPUAP et al,14 2014

To provide evidence-based recommendations for preventing and treating pressure ulcers

Comprehensive review and appraisal of available evidence at the time of literature search

Identify risk for MDRPI (patient with devices are at risk)

Select devices that causes least amount of pressure Secure devices to avoid dislodgment and

additional pressure Choose correct size of device (to reduce pressure) Inspect skin around device twice daily Reposition the device to decrease shear and

redistribute pressure Cushion and protect skin with dressings Remove or move device daily to assess skin

Coyer et al,15 2014

To describe characteristics of MDRPI in adult patients in the intensive care unit

Prospective, repeated-measure design using data collected from 2 metropolitan medical centers

Systematically assess high-risk areas daily Reposition devices daily

Dyers,16 2015

To provide tips for prevention of MDRPI

Review of the literature Assess risk Reposition device regularly, when possible Carefully fixate device while reducing pressure Create clear expectations Remove device as early as medically possible Monitor the appearance of skin and the presence

of pain Abbreviations: MDRPI, medical device–related pressure injury; NPUAP, National Pressure Ulcer Advisory Panel.

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The work group leader educated stakeholders, including frontline care providers, CNSs, and physicians.

frequency of assessment, or how often a securement

device was changed.

In an effort to address the NGT itself, a work group

member reached out to the manufacturer of the NGT

to determine whether a softer, more pliable alternative

was available. No such tube was currently available

from that manufacturer. The team member identified

a vinyl-based product, but it was more expensive and

staff would require special training on insertion. The

PI work group decided to continue with the current

product and to focus efforts on managing the medical

device to prevent NGT-HAPI.

A valuable resource in establishing a standard of care

for preventing MDRPI was the NPUAP.14 The work group

used the NPUAP recommendations and other best prac-

tices described in the literature to draft the hospital’s

guideline for preventing NGT-HAPI. The guideline tar-

geted many of the practice inconsistencies uncovered

during the root cause analysis, such as a lack of stan-

dardization of the securement device, skin assessment,

resecurement frequency, positioning of the NGT within

the naris, and documentation requirements.

To facilitate knowledge and implementation of the

new guidelines, the work group developed the mnemonic

“CLEAN”: correct tube position, stabilize tube, evaluate

area under/near tube, alleviate pressure, note date and

time. These guidelines included a recommendation to

reapply the NGT securement device every 24 hours,

which would allow nurses to thoroughly assess the skin

beneath or in contact with the NGT and an opportunity

to reposition

the tube to alle-

viate pressure

and to provide

nares hygiene

(if needed). To address a concern about the potential

for “critical” NGTs (difficult placement or medical

condition) to become dislodged, the team added a

statement to the CLEAN guideline related to the recom-

mendation to reposition the tube: “Unless otherwise

specified by physician’s order.”

Guideline Approval. The work group leader dis- seminated a draft of the guidelines to stakeholders within

the organization and system-wide so they could provide

feedback and suggest improvements. After the team

made minor revisions, the organization’s CNS group

approved the final guidelines for care, as did the health

care system’s CNS committee. This latter group is respon-

sible for establishing, revising, and disseminating nursing

guidelines of care. The approved guidelines were subse-

quently integrated into the respective acute care and

critical care nursing guidelines of care.

Guideline Implementation. To facilitate guide- line implementation, the work group incorporated the

CLEAN mnemonic into a nares HAPI prevention slogan:

“Is your patient’s nose CLEAN?” The work group leader

contacted and partnered with the selected securement

device manufacturer to create an educational poster of

the guidelines. The poster includes the slogan, a detailed

description of the CLEAN mnemonic, and step-by-step

instructions for applying the commercial securement

device (Figure 1).

The surgical ICU CNS work group member had

assumed responsibility for educating staff and imple-

menting the guidelines in the unit. As the surgical ICU

had the highest incidence of NGT-HAPI, an expecta-

tion was established for assessment and resecurement

of NGTs every 12 hours. Patient care during rounds

focused on assessing the naris beneath an NGT and

ensuring that securement devices were changed and

labeled with the date and time.

Because NGTs are omnipresent throughout the

organization, the PI work group determined that

widespread education was needed. The work group

leader assumed responsibility for educating the organi-

zation’s stakeholders, who include frontline care pro-

viders, CNSs, and physicians. The work group leader

presented to the organization-wide interprofessional

clinical practice council to raise awareness of the

problem and educate staff on the new evidence-based

guidelines. Every care provider has an opportunity to

observe a patient’s face and nose during their interac-

tions and can thereby assist by speaking up if they

recognize what might be an injury. Care providers

such as registered dieticians, physical therapists, and

occupational therapists were encouraged to speak up

when they noticed that an NGT was improperly posi-

tioned or appeared to be pulling or causing patient

discomfort. Clinical nurse specialists throughout the

organization also received the new guideline informa-

tion so they could educate the nurses in their respec-

tive units.

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Figure 1 CLEAN guidelines.

Evidence-Based Practice for Preventing Nares HAPUs

C L E A N ?

Is your patient’s nose

C: Correct tube position L: stabiLize tube E: Evaluate area under/near tube A: Alleviate pressure N: Note date and time of tape

Remove liner from first tab and adhere to nose (Figure 2).

Remove liner from second tab and adhere to nose (Figure 3).

Wrap around tube and pinch the two halves together, adhesive to adhesive (Figure 5).

NasoGastric tube is now fully secure (Figure 6).

Remove remaining liner from bottom tab and adhere tab to back of tube (Figure 4).

EVERY SHIFT: K e e p n o s e

CLEAN Correct tube position

• Ensure tube free flowing in naris

stabiLize tube • Ensure tube secured

properly

Evaluate area under/near tube • Look for discoloration,

abrasion, blister, etc.

Alleviate pressure • Reposition tube if not free

flowing*

Note date &time • Place on tape and in Corner

when retaped or repositioned

*Unless otherwise specified by physician’s order

Thoroughly perp application area per hospital protocol. Allow to dry completely.

Position securment device behind tubing (Figure 1).

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For anesthesiologists, a presentation was provided at

the monthly supervisory committee meeting and included

case studies and the new guidelines of care. In addition

to the education, the work group leader partnered with

the operating room educator to ensure all intubation

carts contained the recommended NGT securement

device. The work group leader reviewed case studies

and the CLEAN mnemonic/guideline with emergency

department leadership, giving particular attention to

tube placement and securement.

Arrangements were made with the commercial secure-

ment device representative to provide in-service training

on appropriate application of the device. Having the com-

mercial device representative available helped to address

nurses’ discomfort regarding proper securement. The

representative was able to provide training in all areas,

including the emergency department and operating room.

Control The PI work group identifi ed strategies to monitor

the implementation and effectiveness of the new guide-

lines. One strategy involved working with a clinical infor-

maticist to create a report from the electronic medical

record, which compiled a list of all hospitalized patients

with an NGT. This report was sent each morning to the

certifi ed WOC nurse team, which reviewed the list for

accuracy, created an audit slip for each unit, and distrib-

uted the appropriate audit slip to the charge nurse of

each unit (Figure 2). Creating daily audit sheets raised

awareness of the issues with NGT-HAPI and reminded

nursing leadership to pay particular attention to NGTs

as high-risk medical devices.

Because the certified WOC nurse team monitored

and analyzed trends in the incidence of all pressure inju-

ries, they became the process owners for the PI project

surveillance. During routine consultations for other

wound and ostomy issues in patients with an NGT in

place, certifi ed WOC nurses reinforced or provided edu-

cation on the guidelines. Together with the bedside

nurses, they ensured that patients’ noses were “CLEAN.”

By owning the surveillance process, the certifi ed WOC

nurse team validated the implementation and effec-

tiveness of the guidelines in preventing NGT-HAPI.

Results By the end of 2015, the guidelines had been fully imple-

mented, and the incidence of NGT-HAPI immediately

decreased to 0 in the ICUs and, consequently, throughout

the entire organization. The incident rate of NGT-HAPI

in the organization decreased 100% (0.13 per 1000 patient

days in 2015 to 0.0 per 1000 patient days in 2016), and this

decrease was sustained throughout 2016 (Figure 3). The

initial and sustained success was attributed to increased

awareness, standardized expectations, a simple yet catchy

mnemonic, and the surveillance process. Attaining an

NGT-HAPI incidence of 0 through this PI project greatly

contributed to decreasing the MDRPI and overall HAPI

incidences in the organization (Figure 4). The organiza-

tion achieved a 56.4% change in all HAPI from 2014 to

2016, and a 44.6% change from 2015 to 2016. The inci-

dence of NGT-HAPI increased slightly in 2017 (Figure 3).

Only 1 of the 4 NGT-HAPI in 2017 occurred in an ICU.

During root cause analysis of 3 of these NGT-HAPIs, the

PI work group discovered that new or temporary staff

had not followed the CLEAN guidelines. The fourth case

involved a critical NGT that could not be repositioned or

resecured. These cases highlight the need for continued

education and surveillance outside the ICU and for all

new and temporary staff.

Discussion The outcome attained from the PI project highlights

the need for guidelines based on the best available evi-

dence for the care of patients with a medical device, par-

ticularly those with an NGT in an ICU.8,17 A prospective

study of 175 patients in an ICU found that 40% developed

an MDRPI.17 In another prospective study, although the

Figure 2 Nosy Notes audit form.

Time to

Get Nosy!

Please round on these patients with nasogastric tubes on your unit today!

Date: Unit:

Rooms:

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prevalence of MDRPI was just 3.1%, 40% of those injuries

were caused by NGTs.15 Our PI project revealed similar

high percentages of NGTs contributing to MDRPI. In

2014, 33 of 85 HAPIs (38.8%) were MDRPIs, of which

10 (30.3%) were due to NGTs. In 2015, 27 of 69 HAPIs

(39.1%) were MDRPIs, of which 12 (44.4%) were due to

NGTs. Focusing specifi cally on preventing NGT-HAPI is

critical. Nurses in the ICU must be aware of the increased

risk for all MDRPIs among their patient populations and

should implement preventive measures, such as those

developed and presented in this PI project, for managing

NGTs for NGT-HAPI.

The guidelines established expectations based on sev-

eral inconsistencies found in practice. It was important

to standardize the method of securement, and we chose

a commercial device that was available in the organiza-

tion. Use of a commercial securement device has decreased

NGT-HAPI incidence.18 After choosing a standardized

device, we reviewed the device manufacturer’s guidelines

to determine the frequency of resecurement. In the absence

of a clear recommendation from the manufacturer, we

adapted the general NPUAP best practice recommenda-

tions for medical devices to apply to NGT management.14

This PI project created a process for using the best

evidence to improve nursing practice. A statewide database

Figure 3 Nasogastric tube–related hospital-acquired pressure injuries (NGT-HAPIs) per 1000 patient days from January 2014 through December 2017.

N G

T- H

AP Is

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Figure 4 Incidence of hospital-acquired pressure injuries by year, 2014-2017. Abbreviations: MDRPI, medical device–related pressure injury; NGT-HAPI, nasogastric tube–related hospital-acquired pressure injury.

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62 CriticalCareNurse Vol 39, No. 6, DECEMBER 2019 www.ccnonline.org

Figure 5 A naris with a nasogastric tube–related pressure injury (unstageable).

revealed that 63% of MDRPIs had no evidence of regular

skin assessment or repositioning to redistribute pressure.

Three-quarters of these MDRPIs were full-thickness

upon discovery.8 Creating expectations for care and doc-

umentation in order to prevent NGT-HAPI contributes

to the dearth of information and specifi c recommenda-

tions currently available in the literature.

Organizational complexity contributed to some diffi -

culty in developing and implementing these guidelines.

Because our organization is part of a health care system,

proposed additions or revisions to nursing guidelines

of care require approval from a system-wide CNS group.

This process can lengthen the overall timeline for an

improvement project. However, innovations from one

hospital can affect others. The CLEAN guidelines were

distributed to the other hospitals in the system to assist

with their education efforts. One hospital that imple-

mented the CLEAN guidelines as a component of its

MDRPI prevention process also saw a reduction in the

incidence of NGT-HAPI.

To address perceptions regarding the presumed

insignifi cant nature of NGT-HAPI, organizational case

studies and a photograph of a patient with an NGT-

HAPI were presented with the new guidelines (Figure 5).

The deidentifi ed photograph was powerful in changing

clinician perceptions because the case had occurred

within the organization. The presumed insignifi cance

of NGT-HAPI is consistent with fi ndings from a prospec-

tive study of 606 nurses that addressed perceptions of

MDRPI.19 In that study, 53% of nurses did not believe

that NGTs posed a risk for pressure injury. The strategy

of including actual organizational case studies with the

new guidelines addresses the need for nurses to receive

education about the risk for NGT-HAPI and what specif-

ically they can do to prevent them.

The organization’s journey to become highly reliable

created a culture in which safety issues could be identi-

fi ed and proactively addressed. The structure of a daily

reliability huddle led by administrators and attended by

interprofessional leaders provided a platform that paved

the way for creating awareness of the issue and assigning

process improvement, ownership, and accountability for

resolving the problem. Favorable outcomes in preventing

pressure injuries necessitate the involvement of an inter-

professional team.20 A work group with the right mem-

bers and skill sets to lead PI projects promotes a culture

of continual improvement.

A certifi ed WOC nurse led and championed the PI

project. In our organization, a team of certifi ed WOC

nurses is assigned to oversee wound and ostomy care on

specifi c units. For this PI project, certifi ed WOC nurses

provided ongoing surveillance, and they reinforced the

CLEAN guidelines with staff in their assigned units. The

framework of certifi ed WOC nurses collaborating with

administrators and frontline staff has been described as

a matrix of hierarchical leadership integral in translating

evidence into practice.21

Limitations This PI project was conducted in a hospital with a

high reliability culture and appropriate and adequate

resources. The intent of the project was to improve

practice related to NGT management in preventing

pressure injury by using a particular PI framework,

which limits the generalizability to other organiza-

tions. Although an increased number of NGT-HAPIs

was noticeable within the organization, accounting for

12 of the 69 HAPIs (17%) in 2015, it was a relatively

small sample. Root cause analysis of a small sample

may not include all possible patient and caregiver fac-

tors that could contribute to injury.

The literature inconsistently classifi es pressure inju-

ries to the nares as either mucosal or epithelial. Mucosal

injuries are described by NPUAP as “pressure ulcer[s]

found on mucous membranes with a history of a medi-

cal device in use at the location of the ulcer.”6 Mucosal

injuries cannot be described by using the classic staging

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www.ccnonline.org CriticalCareNurse Vol 39, No. 6, DECEMBER 2019 63

definitions, as mucosal tissue is histologically different

than epithelium. When a pressure injury occurs to epi-

thelial tissue, it is to be staged according the classic

NPUAP staging definitions, which describe depth. One

survey asked certified WOC nurses to classify photos

of injuries caused by NGTs at nares openings; the results

indicated that up to 69% of respondents categorized the

injuries as mucosal.22 It can be difficult to ascertain exactly

where the mucosal tissue of the inner nares ends and the

skin begins. In this PI project, all injuries that occurred

along the edge of or outside the opening of a naris were

not classified as mucosal, as they were not present on

mucosal tissue, and were staged appropriately.

Future research and guidelines are needed to assist

clinicians in consistently and accurately describing NGT-

HAPIs as either mucosal or classic epithelial pressure

injuries.22 Development of medical devices that allow for

easier assessment of the underlying skin and are made of

products less harmful to tissue will be essential in reduc-

ing NGT-HAPIs in the future.

During root cause analysis, it was evident that many

of the patients who developed an NGT-HAPI were in criti-

cal condition and had multisystem organ failure. In these

cases, the development of HAPIs seemed unavoidable,

and current staging classifications do not allow for this

type of formal designation. As organizations move toward

a goal of 0 HAPIs, future research and guideline formation

are necessary regarding unavoidable pressure injuries.

Conclusion This PI project demonstrates how culture, leadership,

and PI focused on safety can attain a goal of 0 injuries to

patients and can support an organization’s quest to become

highly reliable. The commitment of administrative lead-

ership to support a frontline PI work group allowed us

to create and implement guidelines for preventing NGT-

HAPIs in the ICUs and throughout the organization.

Understanding and addressing root causes was neces-

sary to establish an effective strategy. Ownership and

accountability were key in achieving the goal of 0 inju-

ries to patients. CCN

Financial Disclosures None reported.

See also To learn more about pressure injuries, read “Reducing Tracheostomy- Related Pressure Injuries” by Dixon et al in AACN Advanced Critical Care, Winter 2018;29:426-431. Available at www.aacnacconline.org.

References 1. Hodin RA, Bordeianou L. Inpatient placement and management of

nasogastric and nasoenteric tubes in adults. UpToDate. https://www .uptodate.com/contents/inpatient-placement-and-management-of -nasogastric-and-nasoenteric-tubes-in-adults. Updated December 4, 2018. Accessed November 22, 2017.

2. Amirah MF, Rasheed AM, Parameaswari PJ, Numan OS, al Muteb M. A cross-sectional study on medical device-related pressure injuries among critically ill patients in Riyadh, Kingdom of Saudi Arabia. WCET J. 2017;37(1):8-11.

3. Pittman J, Beeson T, Kitterman J, Lancaster S, Shelly A. Medical device- related hospital-acquired pressure ulcers: development of an evidence- based position statement. J Wound Ostomy Continence Nurs. 2015;42(2): 151-154.

4. ECRI Institute. Medical devices’ role in causing pressure ulcers. https:// www.ecri.org/components/PSOCore/Pages/PSONav0814.aspx?tab=2. August 1, 2014. Accessed August 5, 2015.

5. Agency for Healthcare Research and Quality. Preventing pressure ulcers in hospitals: 1. Are we ready for this change? https://www.ahrq.gov /professionals/systems/hospital/pressureulcertoolkit/putool1.html. Created April 2011. Reviewed October 2014. Accessed August 5, 2015.

6. National Pressure Ulcer Advisory Panel. NPUAP pressure injury stages. https://npuap.org/page/PressureInjuryStages. April 2016. Accessed November 27, 2017.

7. Black JM, Cuddigan JE, Walko MA, Didier LA, Lander MJ, Kelpe MR. Medical device related pressure ulcers in hospitalized patients. Int Wound J. 2010;7(5):358-365.

8. Apold J, Rydrych D. Preventing device-related pressure ulcers: using data to guide statewide change. J Nurse Care Qual. 2012;27(1):28-34.

9. Centers for Medicare and Medicaid Services. Hospital-acquired condi- tions. https://www.cms.gov/Medicare/Medicare-Fee-for-Service -Payment/HospitalAcqCond/Hospital-Acquired_Conditions.html. Page modified August 30, 2018. Accessed August 5, 2015.

10. National Pressure Ulcer Advisory Panel. Pressure ulcer incidence density as a quality measure. http://web.archive.org/web/20190221213347 /www.npuap.org/pressure-ulcer-incidence-density-as-a-quality-measure. Accessed September 10, 2019.

11. George, M. Lean Six Sigma for Service. New York, NY: McGraw-Hill; 2003. 12. Chassin MR, Loeb JM. High-reliability health care: getting there from

here. Milbank Q. 2013;91(3):459-490. 13. Fletcher J. Device related pressure ulcers made easy. Wounds UK. 2012;

8(2):1-4. 14. National Pressure Ulcer Advisory Panel; European Pressure Ulcer Advi-

sory Panel; Pan Pacific Pressure Injury Alliance. Prevention and Treatment of Pressure Ulcers: Quick Reference Guide. 2nd ed. Emily Haesler, ed. Perth, Australia: Cambridge Media; 2014.

15. Coyer FM, Stotts NA, Blackman VS. A prospective window into medical device-related ulcers in intensive care. Int Wound J. 2014;11(6):656-664.

16. Dyers A. Ten top tips: preventing device-related pressure ulcers. Wounds Int. 2015;6(1):9-13.

17. Hanonu S, Karadag A. A prospective, descriptive study to determine the rate and characteristics of and risk factors for the development of medi- cal device-related pressure ulcers in intensive care units. Ostomy Wound Manage. 2016;62(2):12-22.

18. Ambutas S, Staffileno BA, Fogg L. Reducing nasal pressure ulcers with an alternative taping device. Medsurg Nurs. 2014;23(2):96-100.

19. Karadag A, Hanönü S, Eyikara E. A prospective, descriptive study to assess nursing staff perceptions of and interventions to prevent medical device-related pressure injury. Ostomy Wound Manage. 2017;63(10):34-41.

20. Delmore BA, Ayello EA. CE: Pressure injuries caused by medical devices and other objects: a clinical update. Am J Nurs. 2017;117(12):36-45.

21. Padula W, Makic MF. Formal and informal leadership translating evidence-based practices for pressure injury prevention in the hospital setting. J Wound Ostomy Continence Nurs. 2017;44(2):153-154.

22. Richbourg L. Meet me in the nasal vestibule: a view from here. J Wound Ostomy Continence Nurs. 2017;44(6):513-514.

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