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Temple University Hospital (Philadelphia, Pennsylvania)

CSI Summary

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CSI Presentation

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CSI Toolkit

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Project Topic:

Hospital-acquired pressure injury (HAPI) prevention

Hospital Unit:

Cardiovascular Intensive Care Unit (CICU)

Video Presentation

View this CSI team's project presentation video to earn CERPs.

CSI Participants:

  • Lauren Hayes, BSN, RN, CCRN
  • Alessia Rossillo, BSN, RN
  • Marymarion Trindle, MSN, RN
  • Erica Zabala, BSN, RN

Project Goals/Objectives:

  1. Decrease hospital-acquired sacral pressure injuries (HAPI) 50%
  2. Increase staff engagement as evidenced by:
    1. Compliance with repositioning
    2. Compliance with proper bed-making with gel pad placement
    3. Improvements in documentation

Project Outcomes:

  1. Decreased new HAPIs 700% (from seven to zero) during project implementation
  2. Increased staff documentation compliance 75%
  3. Attained 100% compliance with staff education on all shifts
  4. Achieved consistent, proactive gel pad placement preoperatively or immediately postoperatively with increased acceptance as a sustained standard of care

Project Overview:

Between November 2020 and May 2021, seven non-device-related sacral pressure injuries occurred in CICU patients. With a cost of $14,506 per injury, these occurrences cost our hospital $101,542 cost over 6 months. The HAPIs occurred in patients receiving extracorporeal support and/or post-cardiovascular or post-cardiothoracic surgery. A contributing factor is that many of post-surgery patients are profoundly hemodynamically unstable and unable to tolerate side-to-side repositioning.

HAPIs prolong acute/critical care length-of-stay secondary to infection, injury-specific treatment and depleted physiologic reserve, affecting recovery and ICU-related risks. Reducing HAPI incidence in vulnerable populations promotes recovery and decreases costs and length-of-stay.

To tackle this challenge, our CSI team identified the most vulnerable population as patients who are post-surgery, severely hemodynamically unstable and receiving extracorporeal support. Next, we focused on team-building and engagement, identifying interventions to prevent HAPIs and developing education to share with staff at our kickoff event.

After kickoff, staff placed a silicone-based gel pad on each patient’s bed either prior to surgery or post-supportive device placement. This protocol required intensive education of the both CICU and OR staff as well as planning and tracking of the staff and patient documentation. At the halfway mark, our CSI team provided re-education for redosing and to encourage inter-departmental collaboration.

Permission to Reuse Materials
The materials associated with this AACN Clinical Scene Investigator (CSI) Academy project are the property of the participating hospital noted above, not AACN. Requests to use content contained in the CSI team’s summary, presentation or toolkit should be directed to the hospital. We suggest reaching out to the hospital’s Communications, Marketing or Nursing Education department for assistance.

The AACN CSI Academy program supports change projects based on quality improvement methods. Although CSI teams seek to ensure linkage between their project and clinical/fiscal outcomes, data cannot be solely attributed to the project and are estimations of impact.