A New York hospital reduced the incidence of medical device-related pressure injuries (MDRPIs) following a tracheostomy to zero for four years, according to a study published in AACN Advanced Critical Care.
The intervention used evidence-based resources from the Preventing Pressure Injuries Toolkit funded by the Agency for Healthcare Research and Quality, part of the U.S. Department of Health and Human Services.
A key part of the new clinical process was a revised PDT tracheostomy procedural kit and documentation. During insertion, a polyurethane foam dressing was placed under the tracheostomy flange and secured with sutures and a flexible holder. The foam dressing remained in place for seven days, with primary care nurses assessing the site at least every 12 hours. As clinically indicated, the dressing was changed to a standard nonwoven gauze drain sponge after seven to 10 days.
The results showed that suturing a foam dressing as part of PDT tracheostomy insertion can reduce the incidence of associated MDRPIs.
The authors are Hazel Holder, DNP, MSN, RN, ACCNS-AG, CCRN, and Brittany “Ray” Gannon, PhD, MSN, AGPCNP-BC. Holder is a critical care clinical nurse specialist at NewYork-Presbyterian Westchester, and Gannon is a nurse scientist at NewYork-Presbyterian Hospital, New York City.
“When COVID-19 increased demand for healthcare equipment, we were able to refine our processes, transition to a revised PDT tracheostomy kit and maintain the integrity of the initiative,” Holder says. “We took a multidisciplinary approach that engaged all related specialties, with surgical site assessment and any clinician concerns discussed during daily rounds.”
Before the initiative, in 2018, the incidence of healthcare-associated pressure injuries (HAPIs) was 1.39% for all ICU patients. Tracheostomy MDRPIs accounted for 0.19% of the incidents (15 HAPIs, including two MDRPIs in 1,077 patients). However, of the two PDT tracheostomies performed, both patients experienced MDRPIs.
In 2019, the overall HAPI incidence decreased to 1.30%, with nine tracheostomies and no MDRPIs. The tracheostomy MDRPI incidence remained at zero for the next three years.
During the four years of this project, 22 PDT tracheostomies were performed in the ICU, with the foam dressing placed at the point of insertion in all procedures.
The project was conducted with another unit-based program to address the overall rate of unit-acquired HAPIs, which may have contributed to increased vigilance.
The Beacon Award for Excellence lauds hospital units that employ evidence-based practices to improve patient and family outcomes. The award provides gold, silver, and bronze recognition to hospital units that exemplify excellence in professional practice, patient care, and outcomes. Recognition is for a three-year term.
AACN President Amanda Bettencourt, PhD, APRN, CCRN-K, ACCNS-P, praises the exemplary efforts of the unit teams who achieved the Beacon Award for Excellence.
“During the height of the COVID-19 pandemic, Beacon units were truly a light showing the way forward, as these teams demonstrated an ongoing and steadfast commitment to providing safe, patient-centered, and evidence-based care to patients and families,” she says. “This achievement is not only a tremendous honor, but it also provides meaningful recognition of their efforts to achieve excellence in patient care and create a healthy work environment.”
Results from AACN’s most recent national nurse work environment study indicate that nurses who work in Beacon units and units obtaining Beacon recognition report healthier work environments and higher quality of patient care than nurses who don’t work in Beacon units.
Recipients of a gold-level Beacon Award demonstrate staff-driven excellence in sustained unit performance and improved patient outcomes that exceed national benchmarks. Silver-level recipients demonstrate continual learning and effective systems to achieve optimal patient care. Bronze-level awardees successfully develop, deploy and integrate unit-based performance criteria for optimal outcomes.
Sixty-six units received gold-level Beacon awards, the program’s highest distinction. Among the 2022 recipients, Arnold Palmer Hospital for Children in Orlando, Florida, had five units recognized with gold-level awards. Morristown Medical Center, New Jersey, had three units earning gold-level honors, with another two earning silver-level awards. University Hospital in San Antonio, Texas, also had five units receive Beacon awards in 2022 – three silver and two gold. Eight other hospitals had two units recognized with gold-level awards.
The only international hospital recognized in 2022 was Fundación Santa Fe de Bogotá, in Colombia, a first for the country. Three units at the hospital received silver-level Beacon awards, and a fourth unit earned a bronze-level award.
A total of 34 hospitals had multiple units honored with an award in 2022, demonstrating a system-wide approach to caring for acutely and critically ill patients and their families.
Twenty-nine units at 18 Texas hospitals attained Beacon status in 2022, the most for any state.
The American Association of Critical-Care Nurses (AACN) updated its landmark standards for tele-critical care nursing practice, offering specific recommendations for developing and enhancing tele-critical care programs.
The consensus statement reflects current evidence, best practices, and the expert opinions of AACN’s nine-person Tele-critical Care Task Force. It underscores how the contributions of tele-critical care nurses continued to expand by embracing additional risk assessments, interventions, and patient safety measures.
During the pandemic, tele-critical care nurses addressed the loss of experienced nurses from the on-site team, leaving a knowledge gap. Their work includes mentoring on-site nurses, facilitating the ongoing development of newer nurses, and supporting excellent nursing care.
The AACN updated its landmark standards for tele-critical care nursing practice, offering specific recommendations for developing and enhancing tele-critical care programs
The initiative brought together tele-critical care nursing leaders from varied backgrounds to share their expertise and dynamic front-line perspectives, resulting in a comprehensive, patient-centric update. The task force was led by Theresa Davis, Ph.D., RN, NE-BC, CHTP, FAAN, and Lisa-Mae Williams, Ph.D., RN, CCRN-K, two national leaders in tele-critical care nursing.
“Tele-critical care programs have become more pervasive with advances in technologies and expansions in modalities, and the number of patients served,” Davis says. “We’ve seen significant growth in tele-critical care services, including expanding beyond traditional critical care areas, medical-surgical units and even home-care settings. This document offers a broader definition of the term ‘teleICU’ to reflect how these nurses contribute to care beyond intensive care units.”
“In addition to caring for patients, tele-critical care nurses are helping to address the experience gap by providing an extra layer of support and expertise to the on-site team,” Williams says. “Knowledge and expertise are precious commodities, especially when caring for critically ill patients. Mentoring a novice nurse, a float nurse, or traveling nurse can instill a greater sense of confidence, while peer-to-peer collaboration can help on-site colleagues feel more supported.”
The consensus statement’s practice recommendations include essential elements for tele-critical care nurses, nurse leaders, and their healthcare organizations.
The document includes clinical scenarios with real-world examples of how clinicians implemented each key recommendation in various environments, including natural disasters and the COVID-19 pandemic. An increased focus on the importance of equity, diversity, and inclusion has been integrated throughout the document, beginning with its first recommendation and continuing through the practice model and clinical vignettes.
The statement includes the AACN Tele-critical Care Nursing Practice Model, which provides the conceptual framework for implementing and evaluating tele-critical care nursing practice.
Patients critically ill with COVID-19 are at exceptionally high risk for developing healthcare-associated pressure injuries (HAPrIs). Therefore, nurses and other clinicians should be extra vigilant with assessments and protective interventions, according to a study published in AACN Advanced Critical Care.
The study is part of the research team’s ongoing work to develop ways to determine pressure injury risk among ICU patients more accurately. The researchers compared the Braden Scale for Predicting Pressure Sore Risk for patients with COVID-19 with patients who were negative for the disease and identified additional risk factors for device-related HAPrIs in critically ill patients with COVID-19.
“This study and others provide further evidence that patients with severe COVID-19 are at even greater risk for pressure injuries than the general ICU patient population,” says co-author Jenny Alderden, Ph.D., APRN, CCRN, CCNS, associate professor at Boise State University School of Nursing.
Accurately Determining Risk for Pressure Injuries
She says prevention begins with accurately determining risk, and clinicians must consider additional factors beyond those assessed with common classification tools.
Since its development in 1987, the Braden Scale has become the most widely used tool in the United States to determine pressure injury risk across all care settings. Still, a growing body of literature shows that it lacks predictive validity in the ICU population, finding that nearly all ICU patients are at high risk.
The study sample included 1,920 patients, and 407 patients were diagnosed with COVID-19. In the entire sample, at least one HAPrI developed in 354 patients (18%), with a third of those considered device-related. Among the 407 patients with COVID-19, at least one HAPrI developed in each of 120 patients (29%), with nearly half (46%) considered device-related.
The research team looked at data related to demographics, diagnoses, comorbidities, hospital length of stay, treatment interventions, laboratory tests, nutrition, and the results of skin assessments conducted by nurses.
Statistical analysis revealed two variables as potential risk factors for device-related HAPrIs: fragile skin and prone positioning during mechanical ventilation.
The researchers also point to the potential for machine learning methods and explainable artificial intelligence to improve the accuracy of HAPrI risk assessments to provide additional information for clinicians to incorporate into their patient care decisions
New research from the American Association of Critical-Care Nurses (AACN) underscores the ongoing impact of the COVID-19 pandemic on nurses and the benefits of creating and sustaining healthy work environments (HWEs) to support nurse staffing, retention and optimal patient care.
Results from AACN’s fifth national survey of nurses are now published online ahead of the October 2022 print issue of Critical Care Nurse (CCN). “National Nurse Work Environments – October 2021: A Status Report” includes key findings from AACN’s survey of more than 9,000 nurses, compares the results with previous studies and recommends areas for improvement.
The 2021 survey was conducted two years earlier than regularly scheduled in an effort to assess the pandemic’s impact on nurses and their work environments. Key findings from the AACN survey include the following:
The nurse staffing crisis has become significantly worse. Only 24% of the respondents said they have appropriate staffing more than 75% of the time, compared with 39% of respondents in 2018.
Nurses’ intent to leave their current nursing position increased. More than two-thirds (67%) of respondents stated they intend to leave their nursing position within three years, compared with 54% in 2018.
Among those who intend to leave, 36% plan to leave within the next year.
Among those who intend to leave, respondents said top items that could very likely influence them to reconsider include higher salary and benefits (63%, up from 46% in 2018) and better staffing (57%, up from 50% in 2018).
Satisfaction with being a nurse declined since the last survey. Only 40% of all respondents indicated they were very satisfied with being a registered nurse, compared with 62% in 2018.
Nurses aren’t feeling safe and valued. Only 47% of the respondents agreed with the statement “My organization values my health and safety,” compared with 68% in 2018. This item had the highest correlation to job satisfaction.
Study co-author and AACN Chief Clinical Officer Connie Barden, MSN, RN, CCRN-K, FAAN, said, “Not surprisingly, the 2021 survey showed a decline in the health of nurses’ work environments. Unchecked, this decline can cause permanent damage to nurse retention and the entire healthcare system.”
Barden said, “A bright spot is that the study indicated implementation of the six AACN Standards for Establishing and Sustaining Healthy Work Environments (HWE standards) can be a game changer. Focusing on these standards is crucial to support nurse well-being, staffing and retention, which are necessary for optimal patient care.” After examining several key nursing challenges, AACN notes that workplaces that had actively implemented any of the six HWE standards showed better results than those that had not. The following includes some insights from the 2021 survey:
In units that had implemented or were “well on their way” to implementing any of the six HWE standards, nurses’ perceptions of appropriate staffing were higher (44%) than in those that had not implemented the standards or had just begun (16%).
Respondents working in units that had implemented HWE standards were half as likely to say they intend to leave their position in the next 12 months (26%), compared with those in units without implementation (52%).
Fifty-five percent of nurses working in units that had implemented any of the HWE standards reported being very satisfied with being a nurse, compared with 34% of those working in units that had not.
Regarding satisfaction with their current position, 33% of nurses working in units that had implemented the HWE standards reported being very satisfied, compared with 6% of those working in units that had not.
“Our findings indicate that unit or institutional implementation of the AACN HWE standards may mitigate the pandemic’s negative impact on nurses, which may help ease the current staffing crisis,” said principal investigator Beth Ulrich, EdD, RN, FACHE, FAONL, FAAN. She added, “Creating and sustaining healthy work environments is everyone’s responsibility, and this requires changing longstanding cultures, traditions and hierarchies. The benefits of doing so are increasingly clear, as are the consequences of inaction.”
