In the US, 2.5 million people develop a pressure injury while hospitalized.1 Pressure injuries are localized to the skin and/or underlying tissue (usually over bony prominences) and result from pressure or in combination with shear and friction.2 The number of pressure injuries in healthcare facilities continues to rise, even though many of them are preventable.2
The American Nurses Association established the National Database of Nursing Quality Indicators(R) (NDNQI(R)) in 1998.3 Used by over 2,000 hospitals, the NDNQI(R) is the largest database for unit-level performance.4 The NDNQI(R) allows hospitals to compare themselves to similar hospitals at state, regional, and national levels, including 95% of Magnet(R)-recognized facilities.4,5 The NDNQI(R) is the only national database for nurses that provides quarterly and annual reporting of structure, process, and outcome indicators that can be used to evaluate practice at the nursing unit level.3
The NDNQI(R) prevalence and incidence study enables hospitals to ascertain facility-wide and unit-specific pressure injury occurrence, and examine the association among performed nursing assessments, interventions, and the development of pressure injuries.6 Hospitals conduct NDNQI(R) prevalence and incidence studies quarterly.6 Most of the time, patients are surveyed by direct care nurses who are part of the skin care champion team. For each patient surveyed, the champion is required to gather data by assessing the patient and collecting information from the electronic health record (EHR) using a paper collection form provided by the NDNQI(R). The data collected are then entered into the NDNQI(R) database individually for each patient surveyed, which is a time-consuming process. The size of the hospital, eligible units included in the survey, and the census for the date of the survey can impact the number of entries each quarter.
Leveraging a streamlined process
A 341-bed, rural, Magnet-recognized community hospital set a goal in 2022 to develop a streamlined and efficient process for collecting and entering data for the quarterly NDNQI(R) prevalence and incidence study. This technology-driven, innovative approach would allow the hospital to use the Excel upload process for the first time. The Magnet team began brainstorming in early January in preparation for the first survey of the year, which was scheduled for March 2022.
The Magnet team consisted of the Magnet program director, the manager of nursing quality and patient experience (who completed the manual entries each quarter), and the hospital's nursing project manager. The team wanted to ensure the process would be seamless for both the person uploading the data and the direct care nurses who would be collecting the information. This new process would require the direct care nurses to electronically fill out the questions that historically had been filled out on paper when surveying patients. Buy-in from the direct care staff was vital for successful implementation of this process.
The health system had recently updated to Office 365, giving the team access to many Microsoft products. The Magnet team determined that the Microsoft Forms application would host the digital version of the survey. Microsoft Forms lets users create surveys to which others can be invited to respond using almost any web browser or mobile device. Submitted results can be seen in real time and can also be exported into an Excel file.7 The use of a Microsoft Form would enable direct care nurses to seamlessly enter data in real time when completing the study each quarter. The data could then be exported into an Excel file, requiring minimal data manipulation, allowing for a harmonious upload to the NDNQI(R) database.
This was a huge undertaking for the team and a major change in the way the study was conducted at the hospital. Buy-in from direct care nurses was imperative to ensure successful adoption of this technology. Technology adoption would give more time back to the direct care nurses to operate at full capacity because they'd be selecting answers rather than writing them on paper. Electronic collection would also provide more accurate documentation. The data could be quickly checked for each unit after completion, and there would be less risk of errors by eliminating the possibility of illegible handwritten information from staff.
Electronic data collection would also save time for the site investigator uploading the data to the NDNQI(R) quarterly because they wouldn't have to manually enter each form. On average, the hospital prevalence and incidence study took the NDNQI(R) site coordinator 8 to 16 hours to enter data manually after direct care nurses completed the study. Each direct care nurse averaged 4 hours to complete the survey on paper on the day of the prevalence and incidence study.
Streamlined implementation
To prepare for this streamlined transition, the team began to develop a Microsoft Form that followed the same path as the paper format for the prevalence and incidence study. However, the form also incorporated branching logic, which is used so the survey can change according to the response to a specific question.7 Questions will only appear if they're relevant to the previous response. If the response doesn't apply, the respondent is directed to a different set of questions or skips a set of questions altogether.7
The method of branching was added to certain sections of the form to allow direct care staff to only answer appropriate questions based on each surveyed patient. For example, if a staff member selected that the patient wasn't in restraints, it would bring them to the next appropriate question to answer. This process let direct care nurses complete required information for patients more efficiently, eliminating confusion if the nurse was unsure if a question should be answered.
After analyzing what was required for the Excel file data upload to the NDNQI(R), the Magnet team decided that it would be ideal for staff to have two forms to complete each quarter: the unit breakdown of patients and the unit census. This would allow the site investigator to upload two separate Excel files for a summary of the unit and details of patients surveyed for pressure injuries and restraints. The direct care nurse would fill out the unit breakdown of patients first, followed by the unit census survey.
The questions on the unit breakdown of patients were all the questions the nurse would need to answer while assessing the patient and looking in the EHR. This form included a question asking for the unit and room number of the patient to ensure the data collectors accounted for all rooms. The second survey detailed the unit census at the start of the survey and the number of patients included in the survey, as well as the reasons why a patient may not have been included (such as off unit for testing or patient refused). After completing each form, the team tested its validity multiple times to ensure the branching was correct throughout both forms.
It was imperative to educate direct care nurses and gain buy-in on the process for completing the survey. The manager of nursing quality and patient experience met with the skin care champions at the monthly skin care champion meeting in February 2022 to discuss the new process and gather input prior to the launch of the first electronic prevalence and incidence study. Key stakeholder involvement is essential for change to increase buy-in.1 Direct care nurses suggested the additional question asking the room number of each patient. This question was vital in the seamless successful validation by the Magnet team after direct care nurses completed the study. The Magnet team also provided education to direct care nurses who couldn't attend the skin care champion meeting to ensure they felt comfortable with the new study format.
On the day of the prevalence and incidence study, the skin care champions met in the nursing education department to get their unit census sheet and start the study. The Magnet team provided a tip sheet that explained the electronic survey process, including links and QR codes. At the end of study, staff members were instructed to report back to the nursing education department. The team would then work with staff members from each unit to ensure the correct number of entries were recorded on both forms and verify that the staff hadn't accidentally entered a room twice. All patients' ages were double-checked as well to ensure each patient was correctly matched to their room. Using this process, the team could ensure that data were correct in real time when the nurse who completed the survey was still present.
Streamlined success
The first prevalence and incidence study of 2022 was successful. All direct care nurses seamlessly answered the questions on the form. At the end of the study, the Magnet team collected each census sheet so they could easily match rooms with the appropriate patients if issues arose with the data upload portion. Previously, direct care nurses averaged 4 hours to complete the survey, but with the electronic version, the average completion time was 2 hours. Many direct care nurses described an ease in completing the electronic survey compared with the paper format that was previously used.
In addition, the team could access the study data in real time. All pressure injuries present on admission and hospital-acquired were reviewed for accuracy with the manager of nursing quality and patient experience in collaboration with the wound care nurse at the hospital. This ensured that all of the information was accurate prior to uploading to the NDNQI(R). Previously, this took much longer to review with handwritten forms.
The team worked together to successfully upload the files to the NDNQI(R) quickly. The total time spent uploading data for Q1 2022 for the prevalence and incidence study for pressure injuries and restraints was a few hours compared with 8 to 16 hours. The data were exported into an Excel spreadsheet that could be copied into the NDNQI(R) Excel file upload template provided on the NDNQI(R) website. All the unit names needed to be changed to the NDNQI(R) unit code to meet the requirements for the upload. It was easy to include the unit codes by adding a new column and using a VLOOKUP function. This allowed the Magnet team to populate the unit codes quickly and efficiently in the spreadsheet. Completing this after data collection from staff eliminates any confusion and the possibility that direct care nurses would enter the incorrect unit code.
Overcoming barriers
One major barrier the team encountered was with QR code technology. During the first survey, the team quickly realized that the QR codes couldn't be scanned by the hospital's smartphones, which were enabled with the Epic Rover application to support the hospital EHR. All direct care staff were provided QR codes and a URL, so for Q1 2022, all staff members used the links to complete the data collection. The Magnet team worked closely with the informatics team to ensure all staff members could use this method. After meeting with the informatics staff, it was decided it would be best to have both surveys added as a home screen application on all Rover phones throughout the health system. This would be critical, as the plan was to implement this process at the other hospitals throughout the health system in the future. The informatics team added the links on the phones for the Q2 prevalence and incidence study.
Each quarter the study has been completed, the average completion time has decreased. Direct care nurses rave about how easy it is for them to collect the data. In addition, many have expressed that the new process reduces confusion related to which questions are required and which ones can be skipped. With the paper survey, staff would often respond to questions they weren't required to answer, adding time to overall data collection on units. At times, this also led to confusion when checking and entering data into the database.
Ongoing leadership engagement has been shown to increase the success of change.8 The Magnet team remains available throughout the entire length of the prevalence and incidence study each quarter, checking data with direct care nurses in real time.
Expansion of streamlined process
After successful implementation of this innovative approach, it was discussed at the health system's nursing excellence council for hospitals interested in implementing this new process. The manager of nursing quality and patient experience worked with a 104-bed community hospital and a 576-bed, large, urban Level I trauma hospital in the network to successfully implement this approach in Q3 2022. The Magnet team worked with informatics team members to ensure the surveys could be used for any other hospital within the health system by adding a question to identify the hospital where the survey was being conducted. Once the hospital was selected, the form would branch to the units for that specific hospital.
At the community hospital, their wound care nurse completed the quarterly study, so it only required buy-in from one nurse. This was an easy transition and successful in Q3. At the large urban Level I trauma hospital, the manager of nursing quality and patient experience met virtually with all direct care nurses during their monthly skin care champion meeting to explain the process. In addition, the team member went on-site at the hospital for the prevalence and incidence study to help ensure a seamless process for all direct care nurses. The team member also met with the lean coach responsible for data entry of the prevalence and incidence study at the hospital to successfully complete an Excel file upload of the information for Q3 2022.
Implications for nurse leaders
The NDNQI(R) prevalence and incidence study needs to be conducted at least quarterly for hospitals throughout the US who utilize the NDNQI(R). Streamlining this innovative approach and incorporating technology that's already available within a health system is key to successful implementation. Buy-in from direct care nurses is essential to ensure successful data collection for upload quarterly.
According to the US Bureau of Labor Statistics, it's projected that more than 275,000 additional nurses will be needed in 2030 and more than 1 million nurses will retire from the profession by 2030.9 With the current nursing shortage, it's now more imperative than ever to develop approaches that support technology adoption and streamlined efficient processes.
When implementing this process, nurse leaders need to consider a survey platform that their hospital uses, such as Microsoft Teams, Qualtrics, Redcap, or SurveyMonkey. The platform must allow certain questions to be skipped based on answers provided and responses required. The platform ultimately should support the Excel download, so the person performing the data upload to the NDNQI(R) can conveniently manipulate the data.
The health system's use of Epic Rover-enabled smartphones allowed for a seamless transition to put the surveys on mobile devices for the nurses to complete. Nurse leaders should assess the current resources available at their hospital for direct care nurses to complete this survey. Hospitals could use electronic tablets or a workstation on wheels for staff members to complete the survey if smartphones enabled with the needed technology aren't available. However, health systems should consider a mobile device so the direct care nurse can answer questions in real time while looking up information in the EHR. Additionally, the use of a mobile device integrated in the health system's EHR could allow direct care nurses to capture real-time pictures of any new wounds and the progression of existing wounds when completing the survey.
Leveraging technology in innovative ways is invaluable to creating sustainable efficient systems for data collection. Many hours of time have been saved for both direct care nurses and those entering data each quarter into the NDNQI(R). As this project shows, this streamlined process can easily be implemented at other hospitals and health systems throughout the nation for easier data collection and upload to the NDNQI(R). The process has served as a prototype for other Excel file templates, including one for falls, which demonstrated similar reductions in the amount of time needed to complete the information in the NDNQI(R) database. Although there's some upfront technical work required to set up the process, in the long run, the time invested is worth the reward. It would benefit all organizations to consider adopting innovative strategies such as this to support modernization of data collection and entry.
INSTRUCTIONS Leveraging technology to drive the NDNQI(R) prevalence and incidence study
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