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3 women, one bandaging foot
As Krembil Nursing Award Mentor Natasha Briggs (C) looks on, Patient Care Assistant Anjel Henry (L) volunteers as a pretend patient so her colleague Kadiatu Kamara can demonstrate proper application of a dressing that prevents pressure injuries. (Photo: UHN)​

Though it's now referred to as Caring Safely, reducing preventable harm to patients has long been a focus at UHN and has taken different forms over the years. Teams across the organization are always looking for ways to incorporate harm reduction in everything they do.

At Toronto Western Hospital (TW), work on two in-patient units to reduce pressure injuries (PIs) has gone on for years and yielded great results.

On 3B Fell's in-patient unit, a combination of staff communication and specific interventions has contributed to the team recently celebrating 250 consecutive days without a PI originating on the floor.

"We address each patient's skin health at the time of admission," says Adassa Wilson, Patient Care Coordinator (PCC) of the mixed Cardiology/General Internal Medicine (GIM) unit.

"If they are at risk of developing a PI, we immediately take action to reduce that risk."

One intervention is to order a gel or air therapeutic mattress. The former helps redistribute a patient's weight and reduce pressure on any bony areas, the latter assists with management of moisture. Both of which can cause a PI.

The team also assesses the patient's nutrition; protein is important to help skin heal and, if a patient isn't eating, that puts them at risk of a PI.

Additionally, staff make sure patients move around to the maximum of their ability.

"Mobilization is very important, even if we only help them to sit up in bed and dangle their legs over the side," says Velma Bailey, Nurse Manager for the unit.

Members of 3B Fell in-patient unit
Members of 3B Fell in-patient unit at TW say a combination of staff communication and specific interventions has contributed to the team recently celebrating 250 consecutive days without a pressure injury originating on the floor. (Photo: UHN)

The team has found new ways to prioritize skin health over the years. It started as part of a Do No Harm Board that monitored several risk factors for patients including PIs, and evolved to being a staple in the team's work flow as part of daily discussion during their quality huddles and hourly rounding.       

"We're really committed to maintaining good skin health on the unit," says Gerry Ann Nepomuceno, a registered nurse on 3B Fell. "Frequent discussion during huddles encourages the team to take the necessary measures to prevent PIs."

A few floors up on 9A Fell's in-patient unit caring for orthaepedic surgery patients, a Krembil Nursing Award project overachieved its PI reduction goals through peer education and inter-department collaboration.

Earlier initiatives had improved skin health for 9A's patients in general as it fostered a culture similar to that on 3B. But there are many aspects to PIs, and the team is always looking for ways to improve.

"As a team, we focus really hard on PIs – we're always trying to identify what we can do better, what is the next thing to improve," says Anne Vandeursen, 9A's Nurse Manager. "Everyone is learning a different aspect of PI for their patient group and sharing that learning with their colleagues."

Nurses Kadiatu Kamara and Tatiana Velasquez worked together to put in place measures that would reduce the risk of PIs among specific fracture patients on their floor.

Data collected to inform their project showed that an average of two to three patients a month had a pressure injury in 2017. Mobility, a key factor in reducing PIs, was challenging for these patients, so Tatiana and Kadi looked at what else they could do for prevention.

Raising awareness about skin health

They implemented a coccyx dressing that could be applied near the bottom of the spine. The dressing acts as a cushion for the skin, helping reduce PIs for theses fractures. Initially, the dressing was only used to decrease risk of PI around the coccyx, however, it has also been found to be effective when used on the heel, another area prone to PIs.

With Nurse Practitioner Natasha Briggs as their Krembil Nursing Award Mentor, they reached out to extend PI prevention to departments they worked with regularly such as the ED – raising awareness and providing education to ED staff to build the practice of getting the dressing applied to hip/pelvic fracture patients as soon as possible.

"We wanted our ED colleagues to call us as soon as they identified these patients so that a 9A nurse could go down to the ED to apply the dressing," says Kadi.

"We talked to the ED nurse educator, the charge nurse, used the department newsletter and attended their daily Safety Huddle to build awareness about the initiative," adds Tatiana.

When the project was launched in March 2018, the goal was to reduce PIs in hip/pelvic fracture patients by 50 per cent, but by the fall, the team achieved 100 per cent reduction. Now they want to build relationships with more departments like the Operating Room teams and physicians to raise awareness about skin health.

This groundwork by both units has complemented well with the launch, in 2017, of Caring Safely's Hospital Acquired Conditions (HAC) bundles that aim to reduce the occurrence of conditions that cause harm to patients but are preventable – including PIs.

As efforts to reduce harm at UHN move to its next chapter, these teams have all the tools to take PIs head on.​

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