Hospital-acquired pressure injuries are a significant patient safety concern. The Centers for Medicare & Medicaid Services tracks hospital-acquired pressure injuries as a patient safety indicator. Health care organizations with higher-than-expected rates may incur penalties.
The pressure injury prevalence rate in a cardiothoracic intensive care unit was above the National Database of Nursing Quality Indicators benchmark. The current standard of care—use of the Braden scale for pressure injury risk assessment and the SKIN (surface, keep turning, incontinence care, and nutrition) care bundle—may not adequately address the needs of the intensive care unit population. In addition, cardiac patients present a special challenge because of their disease process and the mechanical support devices used to treat patients in cardiogenic shock, which place them at risk for the development of hospital-acquired pressure injuries.
A performance improvement project was carried out in the cardiothoracic intensive care unit to reduce the prevalence and incidence of hospital-acquired pressure injuries. A preintervention convenience cohort was compared with a postintervention cohort. The intervention consisted of use of the Cubbin-Jackson scale, an intensive care unit–specific risk-assessment tool, with linked interventions to prevent pressure injuries.
The preintervention and postintervention cohorts consisted of 102 patients each. The pressure injury prevalence and incidence rates decreased by 67.84% and 36.43%, respectively, from before to after the intervention.
The use of an intensive care unit–specific risk-assessment tool with linked interventions to prevent pressure injury can help reduce hospital-acquired pressure injuries in an intensive care unit.
This article has been designated for CE contact hour(s). The evaluation tests your knowledge of the following objectives:
Identify risk factors that contribute to the development of a pressure injury in the critical care population.
Describe unique risk factors that can contribute to the development of pressure injuries in the cardiac critical care population.
Describe how linking interventions to a risk assessment tool can reduce pressure injuries in the cardiac critical care population.
To complete CE activity C2521, visit aacnjournals.org/ccnonline/ce-articles. No CE fee for AACN members. See CE activity page for details and expiration date.
A hospital-acquired pressure injury (HAPI) is an injury to the skin as a result of pressure, friction, or moisture. The Centers for Medicare & Medicaid Services (CMS) has designated HAPIs as a patient safety indicator as part of its Hospital-Acquired Condition Reduction Program.1 The costs of treatment for HAPIs are not reimbursed by CMS, and a health care organization may incur additional penalties if it fails to meet quality measures related to HAPIs. In addition, a health care organization’s HAPI rates affect the grade it is given by the Leapfrog Group, a national nonprofit organization that reports to consumers on health care quality and safety.2 The American Nurses Association has identified HAPIs as a nurse-sensitive quality indicator.3 Such quality indicators are tracked by the National Database of Nursing Quality Indicators (NDNQI), which provides benchmarks against which health care organizations can measure themselves. HAPIs increase medical costs, length of stay, and rates of readmission and mortality.4 In addition, HAPIs are often the subject of litigation, making them a major liability for a health care organization. Therefore, HAPIs have a substantial impact on patient outcomes as well as health care organization financial stability.
Patients in intensive care units (ICUs) are at the greatest risk of developing HAPIs because of the acute nature of their illness, comorbidities, and the medical devices that are necessary for their care. The DecubICUs study found that 1 in 4 ICU patients experience a pressure injury during their stay.5 Prevalence rates of HAPIs in ICUs range from 10% to 45.5%, with incidence rates as high as 41%.6–8 Rates of 4.5 to 6.0 per 1000 cumulative patient days have also been reported.9 HAPIs remain a nurse-sensitive quality indicator, even though in 2014 the National Pressure Ulcer Advisory Panel determined that nonmodifiable risk factors may influence the development of a pressure injury, making some injuries unavoidable.6
The Braden scale is a risk-assessment scale that is currently widely used to identify patients who are vulnerable to pressure injuries. The risk level found determines which preventive measures are implemented. The SKIN (surface, keep turning, incontinence care, and nutrition) care bundle is commonly used to implement interventions designed to prevent pressure injury (see Table). Recent research has shown the Braden scale to be inaccurate when used in critical care patients, with low specificity and positive predictive value.8 Studies have indicated that the use of a risk-assessment scale and pressure injury prevention bundle can significantly decrease HAPI rates.8,10 Rivera et al9 implemented an evidence-based pilot initiative in an 11-bed cardiac care unit using a pressure injury prevention bundle that included the use of the Braden scale. The initiative was conducted over a 10-month period and resulted in a reduction of the HAPI index (pressure injuries divided by patient care days multiplied by 1000) from 3.4 before the intervention to 0.48 after the intervention.9
The SKIN (surface, keep turning, incontinence care, and nutrition) care bundle is commonly used to implement interventions designed to prevent pressure injury.
The Cubbin-Jackson scale is a pressure injury risk-assessment scale that was specifically designed for ICU patients. (The Cubbin-Jackson scale and the Jackson/Cub-bin scale are both referenced in this article. The Jackson/Cubbin scale is a revised version of the Cubbin-Jackson scale, with minor changes.) The scale’s components are age, body mass index, medical history, hemodynamics, respiration, oxygen requirements, mental condition, nutrition, incontinence, general skin condition, hygiene, and mobility. The results of studies comparing the Cubbin-Jackson and Braden scales have been mixed, with some showing better performance of the Cubbin-Jackson scale and others showing greater sensitivity of the Braden scale.11 In a direct comparison in critical care patients, Delawder et al11 found that the 2 scales had similar predictive validity, with both demonstrating poor specificity and positive predictive value. In a comparative study of the Jackson/Cubbin and Braden scales in a trauma-surgery ICU, Higgins et al8 found that the Jackson/Cubbin scale demonstrated superior predictive properties and discrimination. These results supported those of an earlier study performed in Korea that found the Cubbin-Jackson scale to be most effective of numerous risk assessment tools in predicting pressure injuries in the surgical ICU population.12 Another study performed in Turkey compared the Braden scale with the Jackson/Cubbin scale and found that both scales were reliable and valid but that the Jackson/Cubbin scale had better predictive ability.13
In 2013, García-Fernández et al14 published the results of a systematic review with meta-analysis conducted to determine which risk-assessment scales used in ICUs were valid, predictive, and reliable. They determined that the Cubbin-Jackson scale had been validated but with small samples and that it required further testing in larger numbers of patients. In 2016, Park and Lee15 reported on a systematic review and meta-analysis that evaluated 17 studies involving 5185 patients and numerous pressure injury risk-assessment scales, including the Cubbin-Jackson scale. The authors recommended that, given the various strengths and weaknesses of existing tools, a new or modified scale be developed to improve patient care.15 A subsequent systematic review and diagnostic test accuracy meta-analysis reported in 2021 by Zhang et al16 evaluated numerous pressure injury risk-assessment scales. The review included 6 prospective studies of the Cubbin-Jackson scale. The authors found that the Cubbin-Jackson scale had good diagnostic accuracy, whereas the Braden scale had only moderate diagnostic accuracy, and they recommended that the latter be modified for ICU patients. They concluded that, although the Cubbin-Jackson scale was valid, it could be further improved.16
Local Problem
Patients who have cardiac diseases or are undergoing cardiac surgery are at especially high risk for HAPIs. Chello et al17 found that almost one-third of cardiac surgery patients experience a HAPI. Lee et al18 highlighted the unique risks faced by cardiac surgery patients, including prolonged operative time that increases exposure to pressure and use of a cardiopulmonary bypass machine, which can lead to hypotension, blood loss, and microcirculatory perfusion disturbances resulting from the nonpulsatile flow state. In a study involving patients with acute myocardial infarction, the researchers found that age and left ventricular ejection fraction were strong independent predictors of HAPIs.19
The standard of care for HAPI prevention at my organization is use of the Braden scale and SKIN care bundle. If a patient develops a HAPI, an apparent cause analysis is performed using a software tool available from The Joint Commission. However, validation of this tool has not been reported in the literature. Despite this standard of care, the HAPI prevalence rate in the organization’s cardiothoracic ICU was above the NDNQI benchmark: according to the most recent data, from the third quarter of 2020 to the second quarter of 2022, the unit’s average prevalence rate was 11.01%, compared with the NDNQI benchmark of 6.22%. Therefore, a performance improvement project was warranted.
Cardiac patients are especially vulnerable to HAPIs because, in addition to having conditions typically seen in the ICU population, they are often in cardiogenic shock. Cardiogenic shock results in low cardiac output, which leads to poor tissue perfusion that may contribute to the development of HAPIs. The Cubbin-Jackson scale assesses for treatments used in cardiogenic shock, such as use of inotropes and vasopressors. Other treatments for cardiogenic shock include mechanical support devices such as intra-aortic balloon pumps (IABPs), ventricular assist devices (VADs), and extracorporeal membrane oxygenation (ECMO), which contribute to immobility, the greatest risk factor for HAPIs.20
The purpose of this performance improvement project was to decrease HAPI rates through adoption of an additional ICU-specific risk-assessment scale with linked interventions to prevent pressure injury. In a systematic review published in 2016, Tayyib and Coyer21 noted that there was no evidence that the use of a risk-assessment scale, with or without protocol interventions, could reduce pressure injuries in an ICU. This performance improvement project aimed to address this gap. The Cubbin-Jackson scale is a validated risk-assessment scale that was developed specifically for the ICU population. In addition, it has been shown that the implementation of evidence-based pressure injury prevention bundles can decrease pressure injury rates.20 Therefore, this performance improvement project involved design of a tool to link bundled pressure injury prevention interventions to the risks identified by the Cubbin-Jackson scale. The new tool combines an ICU-specific risk-assessment scale, the Cubbin-Jackson scale, with corresponding pressure injury prevention bundled interventions for each risk identified (Figure 1). The current standard of care—the use of the Braden scale with the SKIN care bundle alone—was compared with these measures plus the use of the Cubbin-Jackson scale with linked pressure injury prevention interventions in the cardiothoracic ICU patient population to determine whether this combination of tools could decrease HAPI rates and thereby improve patient outcomes.
Methods
Project Design and Setting
As a performance improvement project, this initiative did not require review by the health care organization’s institutional review board. The standard of care was maintained, the intervention posed no more than minimal risk to participants, and the magnitude of patient harm or discomfort anticipated during the project was not greater than that ordinarily encountered in the ICU.
The project design involved a convenience cohort with Kotter’s change theory23 used during the implementation phase. This cardiothoracic ICU is located within a 437-bed university teaching hospital with a level I trauma center in the northeastern United States. The unit is a 10-bed ICU for cardiac patients after open heart surgery and transcatheter aortic replacement, as well as patients with complex conditions who often require ECMO, VADs, or IABPs. The ratio of nurses to patients is 1:1, 2:1, or 1:2, with a ratio of nurse technicians or nursing assistants to patients of 1:8. The standard bed used for all ICU patients is a dynamic pressure redistribution mattress. All patients admitted to the cardiothoracic ICU were included in the study. Patients with HAPIs that were acquired before admission or in another hospital unit were excluded.
The preintervention group, which was reviewed retrospectively, consisted of all patients admitted to the cardiothoracic ICU during the 8-week period before implementation of this project. The intervention group consisted of all patients admitted to the cardiothoracic ICU during an 8-week period. The rates of HAPIs in the 2 groups were compared. The HAPI prevalence rates were drawn from the NDNQI monthly prevalence study of unit-acquired pressure injuries. The prevalence rate is calculated as the number of patients with pressure injuries classified as stage 2 or above divided by the number of patients surveyed, multiplied by 100, which is the standard formula used by the NDNQI.3 The incidence rate is calculated as the number of patients with pressure injuries divided by patient days, multiplied by 1000. Descriptive statistics were obtained for the patients’ demographic data including age and sex as well as type of cardiac condition and ICU length of stay and the groups compared to assess for homogeneity.
Use of the new tool linking pressure injury prevention interventions to components of the Cubbin-Jackson scale was added to the existing practices.
Interventions
The institution’s standard of care, which included skin assessment at each nursing shift, risk assessment using the Braden scale, and use of the SKIN care bundle protocol, was maintained. Use of the new tool linking pressure injury prevention interventions to components of the Cubbin-Jackson scale was added to the existing practices. Nurses used a paper version of the new tool for each patient during each shift.
In addition, an electronic questionnaire was created using SurveyMonkey and sent via email to all of the nurses working in the cardiothoracic ICU before implementation of the intervention in which they were asked to rate the usefulness of the Braden scale and SKIN care bundle in helping them prevent pressure injuries. The same questionnaire was administered after implementation of the intervention, along with additional questions about whether they found the new tool useful in pressure injury prevention (Figure 2). Answering the questionnaire was voluntary, and all responses were submitted anonymously.
Statistical Analysis
Statistical analysis was performed by means of a t test, a χ2 test, and correlations. G*Power version 3.1.9.7 software was used to conduct a priori power analysis, with an effect size of 0.4, 2-tailed significance testing with a chosen α of .05, and a power level of 0.8 for all inferential comparisons. Independent-sample t tests were used to compare groups with continuous outcomes. A χ2 test for independence and a Fisher exact test were conducted to analyze discrete data if more than 20% of cells had expected counts less than 5. To achieve a power level of 0.8, to detect a medium effect size, a minimally sufficient sample size was 87 observations in each group for discrete outcomes and 64 observations in each group for continuous outcomes.
Results
Data were collected from 102 patients during the 8-week period before implementation of the intervention. This preintervention group had an average age of 69 years; the average length of stay was 3 days, with a cumulative total of 295 patient days. Eleven patients required cardiac mechanical support, continuous renal replacement therapy (CRRT), or both. The average Braden scale score was 14.
The intervention group also consisted of 102 patients. The average age was also 69 years; the average length of stay was 3 days, with a cumulative total of 348 patient days. Eleven patients required cardiac mechanical support, CRRT, or both. The average Braden scale score for this group was also 14. The average Cubbin-Jackson scale score was 35. Of the 102 patients, 89 (87%) had the Cubbin-Jackson risk assessment completed. The Cubbin-Jackson assessment was to be completed during each nursing shift, and the compliance rate was 81%.
Although the intervention group had a higher percentage of complex cardiology cases, there was no significant difference between the groups in IABP, VAD, or CRRT days. Only 1 patient in the preintervention group received ECMO, and none received it in the intervention group.
In the preintervention group, 4 patients experienced HAPIs, of whom 3 had sacral HAPIs. In the intervention group, 3 patients experienced HAPIs, of whom only 1 had a sacral HAPI. From before to after the intervention, the prevalence rate fell from 22.20% to 7.14% (a decline of 67.84%), and the incidence rate fell from 13.56% to 8.62% (a decline of 36.43%). These differences were not statistically significant because of the small number of patients with pressure injuries. The sample size of 102 patients both before and after the intervention was sufficient to show that there were no statistically significant differences in demographic data between the 2 groups except for the complex cardiology cases. Comparison of the total number of pressure injuries in the preintervention and postintervention groups showed a clinically significant decrease, with the preintervention group having 13 pressure injuries and the intervention group having 3. In the preintervention group, 1 patient had 9 pressure injuries related to cooling pads, 1 patient developed both a mucosal membrane injury and a sacral deep tissue injury, and another 2 patients had sacral deep tissue injuries. In the intervention group, 2 patients had mucosal membrane injuries and 1 patient had a sacral deep tissue injury. The patient with the sacral deep tissue injury developed it within 72 hours of an 11-hour operation. The reduction from 13 to 3 pressure injuries is a decline of almost 77%. Although medical device–related pressure injuries of the mucosal membrane are clinically concerning, sacral deep tissue injuries are the most concerning given their potential to advance to higher-stage pressure injuries; therefore, the decline in this type of injury is clinically significant.
A total of 29 nurses completed the preintervention questionnaire and 18 completed the postintervention questionnaire. Before the intervention, 82.75% of the respondents agreed or strongly agreed that the Braden scale was a useful tool in preventing pressure injuries, and 89.66% agreed or strongly agreed that the SKIN care bundle was useful in preventing pressure injuries. After the intervention, only 55.56% agreed or strongly agreed that the Braden scale was useful, and 77.78% agreed or strongly agreed that the SKIN care bundle was useful. Meanwhile, after the intervention, 83.33% agreed or strongly agreed that the Cubbin-Jackson scale with the linked pressure injury preventive interventions was useful in preventing pressure injuries.
Discussion
This project aimed to fill the gap identified in the literature by Tayyib and Coyer,21 who found little evidence that use of a risk-assessment scale with or without bundled care decreased HAPIs. The combination of an ICU-specific pressure injury risk-assessment scale with linked bundled pressure injury prevention interventions resulted in a decrease in HAPIs in this cardiothoracic ICU. The new tool guides nurses to implement a preventive intervention bundle for each specific risk factor identified, allowing them to tailor care to each patient’s individual needs.
Each time a HAPI is prevented, a variety of costs are avoided. First, elimination of a hospital-acquired condition results in a decrease in CMS penalties. Moreover, the considerable costs associated with treating a HAPI are saved. It has been estimated that the incremental cost to hospitals of treating a HAPI is $10 708 per patient.24 Also, the ability to tailor care to the individual patient means that funds are not wasted on interventions that are not needed. Most importantly, the patient’s pain and suffering associated with a HAPI are avoided.
One limitation of this performance improvement project was the use of a paper tool. The paper tool was used to avoid a delay in implementation of this project given that the electronic medical record system approval and buildout process at this health care system can be lengthy. However, because nurses were used to document in the electronic medical record, the addition of a paper tool may have contributed to the compliance rate. In addition, this project involved only 1 of the 4 adult ICUs in this institution, which specifically houses patients who have undergone open heart surgery and those with complex cardiac conditions.
An ICU-specific pressure injury risk-assessment scale with linked bundled pressure injury prevention interventions resulted in a decrease in HAPIs.
Conclusion
This performance improvement project resulted in a decrease in both the prevalence and incidence of HAPIs in a cardiothoracic ICU. The Cubbin-Jackson scale is a validated pressure injury risk-assessment tool, and the results of this project support its use. In addition, the literature supports the use of bundled care. This project took a unique approach by directly linking pressure injury prevention interventions to the risk factors on the risk-assessment scale, thus allowing care to be tailored to each patient’s individual needs. Compared with the Braden scale and SKIN care bundle, more nurses agreed or strongly agreed that the Cubbin-Jackson scale with linked pressure injury prevention interventions was useful in the implementation of pressure injury prevention interventions.
The Cubbin-Jackson scale with linked pressure injury prevention interventions continues to be used in this cardiothoracic ICU, and the results of the initial performance improvement project have been sustained over time. It is recommended that this project be duplicated in other ICU settings to investigate the usefulness of the new tool in other ICU populations. In addition, the tool should be incorporated into the electronic medical record to facilitate its use.
Acknowledgments
The author thanks Patricia Eckardt, PhD, RN, for her assistance during this performance improvement project and publication process.
References
Footnotes
To purchase electronic or print reprints, contact the American Association of Critical-Care Nurses, 27071 Aliso Creek Rd, Aliso Viejo, CA 92656. Phone, (800) 899-1712 or (949) 362-2050 (ext 532); fax, (949) 362-2049; email, [email protected].
Financial Disclosures
None reported.
See Also
To learn more about pressure injuries in the critical care setting, read “Improving Skin Care Protocol Use in the Intensive Care Unit to Reduce Hospital-Acquired Pressure Injuries” by Fischbein in AACN Advanced Critical Care, 2023;34(1):16-23. Available at www.aacnacconline.org.