WSHA Hospital Safety & Quality Priorities: Historical Programs
The WSHA Safety & Quality team is a trusted and collaborative partner supporting Washington hospitals on several key quality and patient safety improvement programs. Historically, WSHA’s initiatives have aligned to support federal programs and support hospitals in achieving national patient safety aims such as:
- Hospital Engagement Network (HEN) and Hospital Improvement Innovation (HIIN)
- The Joint Commission Sentinel Events (CAMLAB_19_SE (jointcommission.org)
- Center for Medicare Services (CMS) Hospital-Acquired Condition Reduction Program | CMS
- National Quality Forum (NQF) endorsed ’27 Serious Reportable Events’ NQF: List of SREs (qualityforum.org)
When a program achieves milestones, objectives and industry standards of care that are widely adopted in our hospitals, our WSHA Board re-evaluates and re-prioritizes these initiatives. If a program has been successful in reducing patient harm, improving, and sustaining clinical quality outcomes in our hospitals, it may be considered ‘historical’ and no longer a key priority topic area.
The Safety & Quality team recognizes that tools, resources, and access to materials for these historical programs and are still valuable to our members.
Hospital-acquired Pressure Injuries
Pressure injuries continue to be a top health care focus, affecting approximately 2.5 million adults within acute care facilities each year. Many patients who suffer from pressure injuries are those who are elderly, malnourished, or who have been in the hospital for longer periods of time. Patients who have multiple devices in use, hemodynamic instability and/or are under the use of vasoactive medications are also at risk of pressure injury development. Following the development of a pressure injury, patients may suffer from severe pain, chronic wound management and even the risk of death. Pressure injuries may be associated with severe pain and about 60,000 patients die as a direct result of a pressure injuries each year. The development of pressure injuries can interfere with the patient’s functional recovery which than can contribute to longer hospital stays, with an average of an additional 2 days attributed to the length of stay secondary to the pressure injury.
Pressure injuries cost $3.3-$11.6 billion per year in the U.S. Additionally, CMS reported that the cost of the care for chronic pressure injury care was noted to be $22 billion. The development of Stage 3 and 4 and unstageable pressure injuries is currently considered by the Washington Department of Health as a Serious Reportable Event. As of 2008, the Centers for Medicare and Medicaid Services (CMS) announced it will not pay for additional costs incurred for hospital-acquired pressure injuries.
Pressure injury prevention requires an interdisciplinary approach to care. Certain aspects of pressure injury prevention care are highly routinized, but the care must also be tailored to the specific risk profile of each patient. Pressure injury prevention can be a shared opportunity to empower patients and their family through education, prevention, and treatment strategies.
Several evidence-based practices have been shown to be effective in reducing the occurrence of pressure injuries. They include:
- Early identification, including a complete and comprehensive skin inspection by 2 RN’s within 4 hours following admission, transfer, or if the patient is away from the unit for >4 hours.
- Patient & family engagement in plan of care.
- A dedicated, multidisciplinary team that meets frequently to identify trends and continuous improvement opportunities.
- Standardized, evidence-based education to clinical team on how to identify, stage and document pressure injuries.
- Standardized pressure-relieving surfaces across the continuum.
- Effective communication and team-based coordinated care.
Toolkits & Resources
The following toolkits and resources support our hospitals with implementing best practices in the prevention of pressure injuries and draw upon the most current and evidence-based literature.
NPIAP: Free Resource Materials
NPIAP: Position Statement on Staging – 2017 Clarification
NPIAP: Pressure Injury and Stages
NPIAP: (S32): Terms and Definitions Related to Support Surfaces
NPIAP: Pressure Injury Prevention – PIP Tips for Prone Positioning (NEW)
