Numerous medical devices used in rehabilitation settings-cervical collars, knee immobilizers, nasal cannula, extremity slings, and continuous positive airway pressure masks, for example-put patients at risk for hospital-acquired pressure injuries (HAPIs). The measurement of HAPIs is standard work of nursing in the prevention and assessment in both acute care and rehabilitation settings. Despite an institutional pressure injury protocol, two patients experienced unit-acquired pressure injuries over a 4-month period on our inpatient rehabilitation unit (IRU); one involved a knee immobilizer, and the other involved a continuous positive airway pressure mask. Our interprofessional work group met with our wound, ostomy, and continence nursing clinician (WOCN) to determine standard work including treatment order sets and specific assessments of patients admitted with medical devices. The meeting discussion led to the planning and implementation of a quality improvement project to align best practices and strategies for maintaining skin integrity for patients having medical devices.

The goal of this quality improvement project was to reduce device-related HAPIs to zero and to sustain that success over time. We initiated the project in our IRU setting, a 26-bed unit within a 900-bed tertiary care center located in New England. Patients in this setting require around-the-clock nursing care 7 days a week with 3 hours of therapies 5 days a week. The average length of stay during the year-long period of the project was 12-14 days. Patient ages ranged from 45 to 64 years. Primary diagnoses were stroke, trauma, and spinal cord injury.

After a review of relevant resources (Benisco et al., 2019; European Pressure Ulcer Advisory Panel, National Pressure Injury Advisory Panel, & Pan Pacific Pressure Injury Alliance, 2019; Lewis et al., 2021), the team developed a project toolkit and huddle board with visual drivers to be used for daily HAPI audits. The toolkit included four yes/no questions:

* Does the patient have a device? If yes, is there an order?

* Was the electronic health record flowsheet parameter for devices and wounds added?

* Was the "four-eyes" (two RN) admission skin assessment documented in the flowsheet on admission?

* If the patient has a pressure injury present on admission, were the wound measurements completed?

The unit resource nurse completed an audit guided by the project toolkit within 24 hours of admission for every new patient. The use of a visual driver on the huddle board represented the organization's lean model (D'Andreamatteo et al., 2015) for change.

Between February 2021 and February 2022, we used the project toolkit to guide 600 HAPI audits. As an organization that uses a lean improvement model, we used our huddle board to keep track of practice deviations for use in real-time peer feedback. After audit completion, the resource nurse shared outcomes during the interprofessional huddle. The number of audit deviations per month decreased from six to one over the period of the project. The most frequent deviations included missed "four-eyes" practice and omitted flowsheet device entries. Nursing compliance for conducting audit items increased from 90% to 98%. The unit achieved zero HAPIs for 15 consecutive months. This project was recognized for a Full Circle Award at the organization's leadership forum.

Decreasing and sustaining zero device-related HAPIs was the goal of this quality improvement project. With an interdisciplinary and collaborative approach, practice standardization for patients with devices admitted to the IRU ensured patient safety and quality of care. Establishing a toolkit to guide clinical practice was safe and feasible without additional staffing resources.

This process improvement can be replicated in other care settings, including acute care settings. At this time, discussions continue for implementation in other clinical settings within our organization. Lessons learned included aligning best practice strategies for promoting staff engagement, increasing problem-solving opportunities for bedside clinicians, real-time peer feedback, and strong leadership support. Since completing our project, the outcomes of our work have been accepted for oral and poster presentations at regional and national forums.

Conflict of Interest

The authors declare no conflict of interest.

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