Evidence-Based Project, Critical Appraisal of Research
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TurnTeamsHowDoYouPreventPressureInjuries.pdf
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Maria Kahn, BSN, RN, CMSRN®, is Patient Outcomes Facilitator, Baptist Hospital of Miami, Miami, FL.
Evelyn Jonusas, BSN, RN, CMSRN®, is Patient Outcomes Facilitator, Baptist Hospital of Miami, Miami, FL.
Turn Teams: How Do You Prevent Pressure Injuries?
Maria Kahn
Evelyn Jonusas
P ressure injury prevention requires an interprofessional team approach and organiza- tional support (National Database of Nursing Quality Indicators, 2019). Early nursing care interven- tions play a significant role in pres- sure injury prevention and manage- ment across the healthcare setting. The National Pressure Ulcer Ad - visory Panel (NPUAP, 2016) recom- mended performing skin assess- ments within 8 hours of patient admission using a risk assessment tool (e.g., Braden Scale for Pre - dicting Pressure Sore Risk; Pre - vention Plus, 2016) to identify per- sons at risk for pressure injury. In addition, a skin assessment should be completed every shift in the acute care setting. According to the NPUAP, patients who are consid- ered at risk for pressure injuries include those who are bedfast or chairfast, or have fragile skin, previ- ous or existing pressure injuries, decreased blood flow to the extrem- ities, and pain in pressure points.
An individualized plan of care should be developed for patients based on their risk assessments. For example, if decreased mobility is a current problem, the plan of care should include turning and reposi-
Continuous Quality Improvement
The performance improve- ment process was used to develop and implement a ded- icated Turn Team to decrease the incidence of unit-acquired pressure injuries. Outcomes as a result of the change are reviewed.
Literature Review
• Repositioning of individuals at risk for pressure injuries is performed to reduce the length of time and amount of pressure over vulnerable body areas and to contribute to comfort, hygiene, dignity, and functional ability (National Pressure Ulcer Advisory Panel, European Pressure Ulcer Advisory Panel, and Pan Pacific Pressure Injury Alliance, 2014).
• Studies demonstrate the implementation of a dedicated Turning Team decreases the incidence of pressure injuries (Harmon, Grobbel, & Palleschi, 2016; Still et al., 2013).
• Pressure injuries are associated with an estimated excess mortality rate of 72 deaths per 1,000 and excess costs of $18,000/case (Agency for Healthcare Research and Quality, 2019).
• In addition to the high cost of treatment, pressure injuries have a great impact on patients’ lives and caregivers’ ability to provide appropriate care (The Joint Commission, 2016).
• Patients with hospital-acquired pressure injuries (HAPI) incur longer length of stay compared to patients without HAPI (Australian Commis - sion on Safety and Quality in Health Care, 2018; Ling & Shin, 2017).
CQI Model
Plan, Do, Check, and Act (Mann, 2014)
Quality Indicator with Operational Definitions & Data Collection Methods
• Unit-acquired pressure injury data encompassed the 12 months before implementation of Turn Teams and 12 months after team implemen- tation.
• Weekly skin assessment audits were performed on all patients at risk for developing pressure injuries over a 12-month period after Turn Teams implementation.
Clinical Setting
51-bed medical-surgical unit in a hospital in the southeastern United States
Program Objective
Decrease unit-acquired pressure injuries by 50%.
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tioning the patient at regular inter- vals, and using a support surface. In addition to performance of a risk assessment, guidelines address skin care, nutrition, mobilization, and education as part of pressure injury prevention (NPUAP, 2016). Reposit - ioning and mobilization interven- tions require nursing staff to turn and reposition all individuals at risk for pressure injury, choose a fre- quency for turning, avoid position- ing the individual on areas with an existing pressure injury, and ensure the patient’s heels are offloaded. At the medical-surgical unit that was the site for this quality improve- ment project, multiple interven- tions were followed without achiev- ing a marked decrease in pressure injury occurrence. For example, appropriate support surfaces were in place and skin care products were used consistently, including pH-bal- anced skin cleansers and moisture barrier creams. Nutrition consulta- tion, assess ment of adequacy of oral intake, and nutrition supplementa- tion were implemented as needed. A literature review on the imple- mentation of Turning Teams for pressure injury prevention was con- ducted by the unit’s Patient Out - comes Facilitators (POFs). Study results suggested a decrease in the incidence of pressure injuries after the implementation of a team dedi- cated to turning patients every 2 hours (Harmon, Grobbel, & Palleschi, 2016; Still et al., 2013). Thus, the decision was made by the POFs in collaboration with the unit’s Shared Governance Council to focus on turning and reposition- ing patients on this unit.
Project Site and Reasons for Change
The Joint Commission (2016) reported immobility as a major con- tributing factor to the development of pressure injuries. The NPUAP (2016) published Pressure Injury Prevention Points that recommended turning and repositioning at-risk patients at a scheduled frequency if not contraindicated. Patients at risk for pressure injuries represented a
substantial portion of patients on the project unit, with patients aver- aging age 65 with 6-day length of stay. The most common patient diagnoses on the unit were gastro - intestinal-related disorders (17%), kidney/urinary tract-related disor- ders (10%), sepsis (8%), and celluli- tis (4%) (E. Butler, personal commu- nication, May 18, 2018).
This project unit had an aver- age of two to six unit-acquired pres- sure injuries each quarter before project implementation in April 2015. The repositioning of at-risk patients was not being done consis- tently due to staffing assignments, high patient acuity, and competing priorities. However, the policy at this institution recommended turn- ing at-risk patients every 2 hours. These variables contributed in part to an increase in the number of unit-acquired pressure injuries for 2014 and the first quarter of 2015. The purpose of this project was to decrease the incidence of pressure injuries by 50% on this medical-sur- gical unit.
Program
Phase 1 The work team was led by the
unit’s two POFs. As a clinical regis- tered nurse, the POF supports the concept of evidence-based nursing practice and is responsible for facil- itating clinical improvement initia- tives. Other team members includ- ed the Unit Shared Governance Council, which consists of nurses, nurse assistants, and unit clerks. The work team’s first task was to develop a standardized method of turning and repositioning patients at risk for pressure injuries. Members determined staff needed a method to facilitate the process of turning patients every 2 hours. The decision was made to implement a designated turning team comprised of nurses and nurse assistants.
This institution uses green reposition magnets on the door- frames of patient rooms to identify patients who need to be reposi- tioned. After work team members determined the green magnets were
not being used on this unit, they decided the green magnets should be used as a visual identifier of patients who required reposition- ing. A Braden Scale score of 18 or below (out of a possible total score of 23) and the patient’s inability to turn in bed also were used as Turn Team criteria. A Turn Team schedule and assignment were developed to turn and reposition patients every 2 hours around the clock (see Figure 1). A trial was conducted over 2 days to determine the amount of time required to turn all patients identified as at risk for pressure injuries. Nineteen patients needed to be turned each day, with 20-40 minutes required to turn and repo- sition all patients. This time accounted for toileting in addition to turning and repositioning. After the trial, the work team determined the designated Turn Teams only would turn and reposition patients; they would notify each patient’s assigned nurse assistant if the patient required toileting.
Phase 2 Staff education on process was
completed via staff meetings, emails, and huddles. Registered nurses and nurse assistants identi- fied patients who were at risk for developing pressure injuries at the beginning of their shifts. A green reposition magnet was placed on the doorframe indicating each patient’s need to be repositioned. The nursing unit was divided in half and staff members were paired to turn and reposition at-risk patients at 2-hour intervals for each side. The Turn Team of nurses and nurse assistants received their scheduled turning assignments at the beginning of the shift. Unit clerks sent reminders to turn patients every 2 hours via text mes- sage. Each pair of team members turned and repositioned the identi- fied patients and offloaded heels, circled the position the patient was turned on the rounding log, and initialed the scheduled turn time.
Phase 3 POFs and Clinical Nurse Super -
visors rounded daily to collect
Continuous Quality Improvement
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adherence data and ensure the cor- rect process was followed. The inci- dence of unit-acquired pressure injuries decreased to an average of 0-1 per quarter after implementa- tion of Turn Teams (second, third, fourth quarters of 2015; first, sec- ond quarters of 2016) (see Figure 2).
Evaluation and Action Plan
Phase 4 The implementation of Turn
Teams decreased the incidence of unit-acquired pressure injuries by 54% (see Figure 3). This budget-neu- tral practice also had a positive effect on length of stay and finan- cial implications for patients at risk for pressure injuries. Turn Teams were implemented as a standard of care for patients at risk for pressure injuries on this medical-surgical unit. This performance im prove - ment measure was adopted by the organization as a best practice and
subsequently was implemented on other nursing units throughout the hospital.
Results and Limitations The number of unit-acquired
pressure injuries over a 12-month period was reduced by 54%. However, nurses did not communi- cate consistently during handoff report regarding patients who were at risk for pressure injuries. In some instances, the green reposition mag- nets were not in place even though the patient had been identified as at risk for pressure injuries. To aid nurses in discussing turning needs during handoff report, a Braden Score section was added to the report form. Occasionally, the nurs- es and nurse assistants forgot to turn their patients at the allotted times because they were distracted by other nursing tasks. Unit clerks then were to send reminder texts to the staff.
Lessons Learned/ Nursing Implications
Continuous staff education on the process was crucial to ensure Turn Teams became an automatic part of daily care routines. Staff feedback was positive, indicating the strategy improved teamwork. Nurse leaders’ ongoing surveillance of Turn Teams was crucial to ensure staff adherence to the correct process. The leaders of any quality improvement project should review data continuously to identify prob- lems and ensure positive patient outcomes are met consistently.
Inconsistencies were noted among nursing staff on identifica- tion of patients who should be placed on Turn Teams. Therefore, the POFs reviewed patients’ medical records and conducted daily rounds with registered nurses to assure patients who were at risk for devel- oping pressure injuries were placed on Turn Teams. If a facility does not
FIGURE 1. Turn Team Assignment
Time Rooms 1-25
Time Rooms 26-51
Registered Nurse Nurse Assistant Registered Nurse Nurse Assistant
8:30
Blocked time for Registered Nurse
Nurse Assistant 1 Nurse Assistant 2 8:30
Blocked time for
Registered Nurse
Nurse Assistant 3 Nurse Assistant 4
10:30 Nurse Assistant 1 Nurse Assistant 5 10:30
Nurse Assistant 2 Nurse Assistant 6
12:30 Registered Nurse 1 Nurse Assistant 3 12:30 Registered Nurse 3 Nurse Assistant 4
14:30 Registered Nurse 2 Nurse Assistant 5 14:30 Registered Nurse 4 Nurse Assistant 6
16:30
Registered Nurse 5 Registered Nurse 6
Blocked time for Nurse Assistant 16:30
Registered Nurse 7 Registered Nurse 8
Blocked time for Nurse Assistant
18:30 Blocked time for Registered Nurse
Each Nurse Assistant will
change and TURN his/her own
assigned patients
18:30 Blocked time for Registered Nurse
Each Nurse Assistant will
change and TURN his/her own
assigned patients
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Continuous Quality Improvement
have a POF, a designated nurse (e.g., patient care supervisor, wound care nurse, dedicated clinical nurse) can monitor pressure injury incidence and Turn Team function.
Despite having a standardized Turn Team process, many staff members did not turn patients con- sistently if they were not reminded by the unit clerks via text message. Reminder texts were essential for staff members to be prompted to turn their patients every 2 hours. If text messaging is not an option for a facility, reminders can be commu- nicated via overhead paging or a dedicated person can remind staff to turn patients.
Due to competing priorities, repositioning patients regularly becomes a challenge for nursing staff. On a 12-hour shift, a regis- tered nurse and nurse assistant would have to reposition their assigned patients an average of six times during their shift to comply with the hospital’s policy of turning every 2 hours. With the implemen- tation of Turn Teams, the task of repositioning was shared by staff for a particular shift. This resulted in staff members having to reposition patients no more than once or twice during their shift.
This project was intended to improve the process of turning patients at risk for pressure injuries and the delivery of a nursing inter- vention to prevent pressure injury occurrence. Having dedicated Turn Teams facilitates patient reposition- ing by decreasing the number of times a staff member has to turn, easing the staff workload and improving adherence to the turning schedule. Turn Teams can be imple- mented easily in other hospitals or healthcare settings to achieve simi- lar results without incurring addi- tional costs.
Conclusion Turn Teams are an effective way
to turn and reposition patients at risk for pressure injuries consistent- ly and timely (Harmon et al., 2016; Still et al., 2013). This had a positive effect on length of stay and other costs associated with pressure
FIGURE 2. Number of Unit-Acquired Pressure Injuries per Quarter
Quarter
0
1
2
3
4
5
6
7
20 16
A pr
-Ju n
20 16
Ja n-
M ar
20 15
O ct-
De c
20 15
Ju l-S
ep
20 15
A pr
-Ju n
20 15
Ja n-
M ar
20 14
O ct-
De c
20 14
Ju l-S
ep
20 14
A pr
-Ju n
20 14
Ja n-
M ar
N u
m b
er o
f P
re ss
u re
In ju
ri es
Baseline data January 2014-March 2015
Post-implementation data April 2015-June 2016
3 3 3
2 2
1 1 1
0
6
FIGURE 3. Pre- and Post-Implementation Pressure Injuries
0
2
4
6
8
10
12
14
April 2015 – March 2016April 2014 – March 2015
N u
m b
er o
f P
re ss
u re
In ju
ri es
Baseline April 2014-March 2015
Post-implementation April 2015-June 2016
13
6
July-August 2019 • Vol. 28/No. 4 261
injuries. This simple, budget-neu- tral practice can decrease unit- acquired pressure injuries for at-risk hospitalized patients. Continued surveillance has been vital to improve patient outcomes and maintain a reduction in unit- acquired pressure injuries.
REFERENCES Agency for Healthcare Research and Quality.
(2019). AHRQ national scorecard on hospital-acquired conditions. Retrieved from http://www.ahrq.gov/professionals/ quality-patient-safety/pfp/index.html
Australian Commission on Safety and Quality in Health Care. (2018). Hospital-acquired complication pressure injury. Retrieved from https://www.safetyandquality.gov. au/wp-content/uploads/2018/03/Pres sure-injury-detailed-fact-sheet.pdf
Harmon, L.C., Grobbel, C., & Palleschi, M. (2016). Reducing pressure injury inci-
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Ling, L.M., & Shin, A.Y. (2017). Impact of hos- pital-acquired pressure injuries on hospi- tal costs – experience of a tertiary hospi- tal in Singapore. Wound Practice and Research, 25(1), 42-47.
Mann, D., (2014). Creating a lean culture: Tools to sustain lean conversions (3rd ed.). Boca Raton, FL: Taylor & Francis Group, LLC.
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National Pressure Ulcer Advisory Panel (NPUAP). (2016). Pressure injury pre- vention points. Retrieved from http:// www.npuap.org/wp-content/uploads/ 2016/04/Pressure-Injury-Prevention- Points-2016.pdf
National Pressure Ulcer Advisory Panel, European Pressure Ulcer Advisory Panel and Pan Pacific Pressure Injury Alliance. (2014). Prevention and treat- ment of pressure ulcers: Quick reference guide. Retrieved from https://www. npuap.org/wp-content/uploads/2014/ 08/Updated-10-16-14-Quick-Reference- Guide-DIGITAL-NPUAP-EPUAP- PPPIA-16Oct2014.pdf
Prevention Plus. (2016). Home of the Braden scale. Retrieved from http://www.braden- scale.com/index.htm
Still, M.D., Cross, L.C., Dunlap, M., Rencher, R., Larkins, E.R., Carpenter, D.L., … Coopersmith, C.M. (2013). The turn team: A novel strategy for reducing pres- sure ulcers in the surgical intensive care unit. Journal of the American College of Surgeons, 216(3), 373-379. doi.org/10. 1016/j.jamcollsurg.2012.12.001
The Joint Commission. (2016). Quick safety: Pre venting pressure injuries. Retrieved from https://www.jointcommission.org/ assets/1/23/Quick_Safety_Issue_25_July _20161.pdf
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