Pressure Injury as a Quality Indicator: Literature Review and PDSA Cycle

This essay explores pressure injury as a quality indicator, literature review surrounding pressure injury and use of plan, do, study and act cycle in improvement of pressure injury and its evaluation. The patient is the focus in nursing care and healthcare in general. The quality of care delivered to the patient should be at optimum and should be one that can be measured.

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QUALITY INDICATORS
Pressure injury is among the hospital-acquired complications according to the (Standard, 2012).
Hospital-acquired complications form part of the quality indicators of patient healthcare among
others. This essay will explore pressure injury as a quality indicator, literature review
surrounding pressure injury and use of plan, do, study and act cycle in improvement of pressure
injury and its evaluation.
The patient is the focus in nursing care and healthcare in general. The quality of care delivered to
the patient should be at optimum and should be one that can be measured. According to
(Mainz,2014) clinical indicators not only measure quality of care provided to the patient and its
outcomes but also support quality improvement and accountability in the health care system. The
plan does study act cycle (PDSA) is a performance improvement tool used in quality
improvement. According to(Australian Commission on Safety and Quality in Health Care
(ACSQHC),(2012) the rate of hospital-acquired pressure injuries in Australian hospitals was 9.7
per 10000 hospitalizations in 2015.The pressure injuries increase discomfort to the patient and
pain, prolong hospitalization and increased financial burden in treatment of the injury.
(ACSQHC,2012) states that pressure injury as a clinical indicator is diagnosed by three features
including stage III ulcer, stage IV ulcer and unspecified decubitus ulcer.
A pressure injury refers to injury caused by excess pressure over bony prominences and can also
result due to shear and friction. This especially when the patient is pulled using the sheets against
the mattress rather than lifting. According to (World Health Organization, 2013) pressure injuries
are classified into five. Stage I includes an area of skin which has persistent redness erythema
without skin loss. Stage II includes a blister and partial loss of epidermis and dermis. Stage III

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involves skin loss involving subcutaneous tissue and fascia. Stage IV involves full thickness loss
plus muscle and tendons. Finally, the unspecified pressure area without stage specification. Risk
factors contributing to pressure injury include immobility, incontinence, obesity, malnutrition,
patients with diabetes and neurological disorders. According to(Clinical excellence
commission,2017) prevalence of pressure injury in Australian hospitals is between 9.5 to 17.6%
while in nursing homes it is 8.9%.The economic impacts of treating pressure injury in Australia
in 2012 was A$983 million per annum and the total number of bed days lost was
524661(Nguyen, Chaboyer and Whitty,2015).Pressure injury is an avoidable injury if
appropriate measure are taken and would save patients so much pain and discomfort.
Pressure injury is a quality indicator which can be reduced by quality improvement via
implementation of clinical expertise and resources (Elliott, McKinley, and Fox (2013). The
expected outcomes were a decrease in the number of patients who developed pressure injury
within the hospital. In my hospital setting an orthopedic ward, there was a report of five hospital-
acquired pressure injuries three months after hospitalization.
LITERATURE REVIEW
Pathophysiology of pressure injury involves increased pressure on the skin which leads to
decreased blood supply due to occlusion of blood vessels. This then causes tissue death which
then leads to necrosis. According to (Grey, Harding and Enoch,2014) pressure injury from shear
force results when movement of bone and subcutaneous tissue and the skin is restrained leading
to increased pressure over the site. Friction results when the patient is pulled rather than lifted
using the bed sheets resulting in blisters which may progress to ulcers with more force. Increased
moisture is a contributing factor to pressure injury which includes incontinence and wound

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drainage. Moisture leads to increased chances of tissue destruction. (Grey et.al ,2014) states the
effects of friction are five times worse in presence of moisture. This emphasizes the need of
immediate diaper change in patients who are immobile or those who are unconscious. Advanced
pressure ulcers become more difficult to treat and increase mortality rates. (Brem et.al ,2013)
states that the costs of treating a stage IV pressure ulcer was great and earlier detection of a
pressure injury would save lives and decrease expenditure used in treatment of pressure injury.
One of the most critical areas in improving pressure injury occurrence is the risk assessment tool.
There are various pressure risk assessment tools in Australia including Braden scale, Waterlow
Score,Glamorgan tool and the Norton scale. (Pancorbo‐Hidalgo, Garcia‐Fernandez, Lopez‐
Medina and Alvarez‐Nieto, 2013) state that in comparison to Waterlow and Norton Braden scale
in better in prediction of pressure injury. These tools are used by nurses to predict the patients at
high risk of developing pressure injury and act swiftly on preventing it. (Australian Wound
Management Association AWMA, 2012) states that the Waterlow tool is used for adults while
the Glamorgan tool is used for pediatrics. The patients should be assessed on admission and after
eight hours. (Pancorbo-Hidalgo et al, 2013) states that Braden and Norton are accurate compared
to nurses judgemental skills.
Resources such as pressure reducing mattress, self-adjusting mattress, pressure reducing
overlays, special beds, pressure reducing chair, cushions and positioning devices are used in
prevention of pressure injuries. This act by redistribution of pressure. Some of the mattress are
also designed to provide alternation which is thought to increase blood flow to the organs after
pressure injury. Increased blood flow leads to oxygenation of the tissue and removal of toxic
wastes which enhances healing of the pressure injury. According to (Perneger, Héliot, Rae, Borst

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& Gaspoz, 2013) the incidence of pressure ulcers in patients who used preventive devices such
as cushions and alternating mattress was highly reduced.
Turning of patients every two hours is a prophylactic measure to avoid pressure injury. This
relieves pressure on bony prominences and enhances blood circulation. If the patient is able to
turn themselves they should be taught how to do it and the importance of doing it. For critically
ill patients there is need for the nurses to be more vigilant and turn them more frequently as they
are at higher risk of developing pressure injury. (Defloor, De Bacquer, & Grypdonck, 2013)
states the reduction of pressure injuries on turning patients while using protective mattresses. It is
important to engage in this practice since pressure injuries are avoidable. According to (Nuru,
Zewdu, Amsalu, & Mehretie, 2015) nursing attitudes towards prevention of pressure injury were
negative, especially regarding low nursing staff. Increased nurse to patient ratio will discourage
turning of patients since there is heavy workload hence there should be enough nursing staff in
the ward.
Ensuring optimal nutrition among patients will reduce pressure injury occurrence Patients who
are malnourished and those feeding via nasogastric tubes are at risk of developing pressure
injury. According to (AWMA, 2012) these patients should have high protein and arginine
supplements. Action must be taken to identify patients who are at risk of malnutrition since they
are twice likely to develop pressure injury (Banks, Bauer, Graves& Ash, 2014). The nurse should
be the advocate of the patient who may be unconscious, aged and the critically ill.

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PDSA CYCLE
According to (Spath, 2013) the plan do study act cycle is the most effective tool in quality
improvement and quality management. It involves observing a gap in delivery of healthcare
services, planning objectives on changing the gap, implementing the changes, analyzing data
before and after and planning on next cycle. In my case, the quality indicator to be improved is
pressure injury, implementing changes such as educating nurses on risk assessment tool, proper
use of preventive equipment and carrying out the turning two hourly policy with the nurses.
EDUCATING NURSES ON RISK ASSESSMENT TOOL
PLAN
In my orthopedic ward, there was five hospital-acquired pressure injuries after an audit of
patients who develop pressure injuries after admission. The planning phase in the PDSA cycle
according to (Spath 2013) involves data collection to ascertain if desire change was achieved. In
my planning phase, I intend to educate the nurses through continuous medical education
seminars on the various aspects of different pressure injury risk assessment tools and why some
are preferred over others in various situations. This will involve other stakeholders such as
medical doctors and governmental organizations such as Australian wound management
associations. The desired objective is reduction of pressure injury to at least one or none three
months after hospitalization in the next clinical audit. The nurses in the orthopedic ward will be
informed on this strategy and will fill in questionnaires on knowledge of different risk
assessment tools before the seminar.
DO

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The do phase in PDSA cycle involves gathering data from the planning phase, carrying out the
change and documenting any problems encountered (Spath, 2013). In my ward, the
questionnaires filled in by the nurses indicated about 50% had knowledge of existence of
pressure injury risk assessment tools. However, majority did not know the protocol of using the
tools in preventing pressure injury. The nurses were taken through a seminar on risk assessment
tools, their various aspects and how to use the tools to identify at-risk patients. At the end of the
three days seminar, there groups of five nurses in a focused group discussion to collect data and
they also filled in post questionnaires. The nurses also participated in open interviews.
STUDY
The study phase involves analyzing data and comparing the data the expected results. The
qualitative data was collected through interviews and focused group discussions while
quantitative data was collected through questionnaires. There was an improvement in the post-
questionnaires regarding risk assessment tools. The nurses indicated their willingness to use the
tools in pressure injury assessment. The Braden tool was the most preferred one.
ACT
This phase involves evaluating if the cycle is successful it is implemented in large scale and if
not, it is modified and repeated till the desired results are achieved (Spath, 2013). The outcomes
of teaching nurses on risk assessment tools were positive and this would now kick-start a training
program for nurses in the orthopedic ward every three months until there were zero pressure
injuries.
EVALUATION

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(Harvey& Wensing, 2013) state that evaluation is used to identify issues in the quality
improvement so that it is redesigned. The evaluation was conducted by mixed designs such as
focused group discussions, interviews and questionnaires. The change of educating the nurses on
the risk assessment tools was positive.
TURNING PATIENTS
PLAN
According to (Gillam & Siriwardena, 2014) planning phase involves changes to be implemented,
collecting data to measure the change. In my ward, I mobilized the nurses on the importance of
turning patients to prevent pressure injury. The change to be implemented involved turning
patients two hourly. The importance of turning the patients two hourly was to increase blood
flow and to decrease pressure on the bony prominences. The data would be collected via
observation and surveys. The nurses in the orthopedic ward agreed to turn the patients two
hourly while at the same time educating the patients who were able to turn themselves to do it
and its importance. The observation would enable me to assess whether the turning was feasible
for the nurses and regarding the number of staff available while the surveys would be filled in to
assess the nurse’s attitudes towards turning, the effectiveness of turning the patient and the
challenges encountered.
DO
According to(Gillam & Siriwardena, 2014) the do phase includes implementing the change while
collecting data as to how the change was taking place.The nurses embarked on the two hourly
turning policy to prevent bed sores.At first, it proved to be a difficult task since the nurse to

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patient ratio was high and this increased the workload on the nurses.The nurses would divide
themselves on who will continue with the current task as at two hours while the others turned the
patients.The turning was also documented in the patient’s records.My observation was
sometimes the nurses were unable to turn all the patients every two hourly.
STUDY
According to (Gillam & Siriwardena, 2014) the study phase includes data analysis comparing the
before and after data, reflecting on impact of the change and the lessons picked up from it. The
nurses filled in the survey which was online and some of the major lessons picked was that the
nursing staff was minimal to implement this change. The nurses also expressed increased fatigue
but they were optimistic that the turning was a great measure in prevention of pressure injury.
My observation was the patients who had been educated also turned themselves while the nurses
were doing their level best to turn the patients although not 100%.
ACT
According to (Gillam & Siriwardena, 2014) the act cycle involved implementing changes on
small-scale till there was improvement then head to implementing it on large scale. My
experience was turning two hourly was very important in prevention of pressure injury but in my
ward, there was decreased nursing staff and therefore it was quite difficult to implement the
change since the staff had other nursing duties to attend to. However, on the positive side, the
patients who had undergone education on turning were doing it. Hence there was need to repeat
it but by altering the nurse-patient ratio to increase outcome
EVALUATION

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Evaluation of this change was through qualitative data in observation while quantitative data by
nurses filling in the online surveys. There was need to increase the number of staffs in the
orthopedic ward and the PDSA cycle would be repeated to increase positive patient outcomes.
PREVENTIVE EQUIPMENT
PLAN
In the planning phase, the change to be implemented was providing all the at-risk patient with
pressure reducing mattress. I ensured the nurses were duly informed on the use of pressure
reducing mattress. The nurses in the orthopedic ward will be involved in monitoring patients
using the pressure reducing mattress. The change to be implemented is nursing staff to use the
pressure reducing mattress for all newly admitted patients. The nurses would then be required to
journal weekly any changes and how they felt on using the pressure mattress. The nurses would
then fill in questionnaires on their knowledge on the use of different preventive equipment used
in pressure injury prevention. The nurses would be educated on how to journal their diaries while
questionnaires were analyzed.
DO
The nurses were involved in implementing changes for use of pressure reducing mattress. All
new admissions were nursed on pressure reducing mattresses. The patients were informed on the
importance of these mattresses. The nurses were involved in journaling diaries over the next
week. Different problems encountered involved some nurses were unable to journal daily
making the data collection process difficult.
STUDY

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The questionnaires filled in by the nurses revealed that they were aware of the different
preventive equipment available to prevent pressure injury but they were not available in the
hospital environment except the pressure reducing mattress. There was no development of
pressure injury on all new admissions three months after admission. The nurses exuded positive
feedback on the use of pressure reducing mattresses.80% who had previously nursed patients
using the pressure reducing mattress said they were positive that the new admissions would not
develop pressure injury in combination with other pressure reducing interventions.
ACT
The act phase which includes a successful change cycle to be modified as necessary and
implemented at a large scale and repeated. The use of pressure reducing mattress proved to be a
positive step and was successful. This would now be modified by ensuring all patients in the
orthopedic ward had pressure reducing mattress but in coordination with hospital administration
policy.
EVALUATION
The evaluation phase of the quality improvement is through clinical audit. The data was
collected by reflective journals and questionnaires. The use of pressure monitoring mattress
proved to be a positive success in the PDSA cycle.

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REFERENCES
Australian Commission on Safety and Quality in Health Care. (2012). National safety and
quality health service standards. Australian Commission on Safety and Quality in Health
Care.
Australian Wound Management Association. (2012). Pan Pacific clinical practice guideline for
the prevention and management of pressure injury. Osborne Park, WA: Cambridge
Media, 1-124.
Banks, M., Bauer, J., Graves, N., & Ash, S. (2014). Malnutrition and pressure ulcer risk in adults
in Australian healthcare facilities. Nutrition, 26(9), 896-901.
Brem, H., Maggi, J., Nierman, D., Rolnitzky, L., Bell, D., Rennert, R., ... & Vladeck, B. (2013).
High cost of stage IV pressure ulcers. The American Journal of Surgery, 200(4), 473-477.
Clinical Excellence Commission, 2017, 2016 NSW Pressure Injury Point Prevalence Survey
Report (2017), Sydney: Clinical Excellence Commission
Defloor, T., De Bacquer, D., & Grypdonck, M. H. (2013). The effect of various combinations of
turning and pressure reducing devices on the incidence of pressure ulcers. International
journal of nursing studies, 42(1), 37-46.
Elliott, R., McKinley, S., & Fox, V. (2013). Quality improvement program to reduce the
prevalence of pressure ulcers in an intensive care unit. American journal of critical
care, 17(4), 328-334.

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Gillam, S., & Siriwardena, A. N. (2014). Quality improvement in primary care: the essential
guide. Radcliffe Publishing Ltd..
Grey, J. E., Harding, K. G., & Enoch, S. (2014). ABC of wound healing: pressure ulcers. BMJ:
British Medical Journal, 332(7539), 472.
Harvey, G., & Wensing, M. (2013). Methods for evaluation of small scale quality improvement
projects. BMJ Quality & Safety, 12(3), 210-214.
Mainz, J. (2014). Defining and classifying clinical indicators for quality
improvement. International Journal for Quality in Health Care, 15(6), 523-530.
Nguyen, K. H., Chaboyer, W., & Whitty, J. A. (2015). Pressure injury in Australian public
hospitals: a cost-of-illness study. Australian Health Review, 39(3), 329-336.
Nuru, N., Zewdu, F., Amsalu, S., & Mehretie, Y. (2015). Knowledge and practice of nurses
towards prevention of pressure ulcer and associated factors in Gondar University
Hospital, Northwest Ethiopia. BMC nursing, 14(1), 34.
Pancorbo‐Hidalgo, P. L., Garcia‐Fernandez, F. P., Lopez‐Medina, I. M., & Alvarez‐Nieto, C.
(2013). Risk assessment scales for pressure ulcer prevention: a systematic
review. Journal of advanced nursing, 54(1), 94-110.
Perneger, T. V., Héliot, C., Raë, A. C., Borst, F., & Gaspoz, J. M. (2013). Hospital-acquired
pressure ulcers: risk factors and use of preventive devices. Archives of internal
medicine, 158(17), 1940-1945.
Spath, P. (2013). Introduction to healthcare quality management (Vol. 2). Chicago, IL: Health
Administration Press.

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Standard, Q. I. G. (2012). Australian Commission on Safety and Quality in Health Care.
World Health Organization. (2013). International statistical classification of diseases and
related health problems (Vol. 1). World Health Organization.