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Implementing Evidence-Based Pressure Injury Prevention Interventions: Veterans Health Administration Quality
Lisa Zubkoff1, Julia Neily, Shantia McCoy-Jones
1VA National Center for Patient Safety, White River Junction, Vermont (Drs Zubkoff, Young-Xu, and Mills and Mss Neily, Soncrant, and Boar); Geisel School of Medicine at Dartmouth, Hanover, New Hampshire (Drs Zubkoff and Mills); and Pressure Injury Prevention & Management FAC, Central Office, Washington, District of Columbia (Dr McCoy-Jones).
Background:
Pressure injury prevention is a persistent concern in nursing. The Veterans Health Administration implemented a creative approach with successful outcomes across the United States.
Problem:
Pressure injury prevention is a measure of nursing quality of care and a high priority in the Veterans Health Administration.
Methods:
A 12-month Virtual Breakthrough Series Collaborative utilizing coaching and group calls was conducted to assist long-term and acute care teams with preventing pressure injuries.
Interventions:
Interventions from the Veterans Health Administration Skin Bundle were implemented, including pressure-relieving surfaces, novel turning techniques, specialized dressings, and emollients to prevent skin breakdown.
Results:
The aggregated pressure injury rate for all teams decreased from Prework to the Action phase from 1.0 to 0.8 per 1000 bed days of care (P = .01). The aggregated pressure injury rates for long-term care units decreased from Prework to Continuous Improvement from 0.8 to 0.4 per 1000 bed days of care (P = .021).
Conclusion:
The Virtual Breakthrough Series helped reduce pressure injuries.
