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A HAPI Opinion Commentary

Brennan, Mary R. MBA, RN, CWON; Grahn, Elizabeth MSN, NP-C, CWOCN; Oropallo, Alisha MD, FACS, FAWPCA; Probst, Nicole MS, RN, AGNP-C, CWOCN; Reynolds, Deborah BA, RN, CWOCN; Rivera, Julie MSN, RN, NPD-BC, CWOCN

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doi: 10.1097/01.ASW.0000792936.94123.e7
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Of the many challenges faced by wound care specialists, mitigating the risks of hospital-acquired pressure injuries (HAPIs) and differentiating pressure injuries (PIs) from other conditions continue to be significant issues of concern. Additional challenges include changes in patient safety indicators and correctly coding PIs. These efforts require multifaceted strategies. The strategies incorporated by the Northwell Health Pressure Injury Prevention Task Force include the use of HAPI prevention guidelines, interdisciplinary staff education, and collaboration among multisite wound care specialists.

Northwell Health is a nonprofit quaternary healthcare network that is New York State’s largest healthcare provider and private employer, with more than 74,000 employees in 2020. Northwell Health consists of 23 hospitals and more than 830 outpatient facilities, as well as the Donald and Barbara Zucker School of Medicine at Hofstra/Northwell including the Feinstein Institute for Medical Research.

Since 2007, the Northwell Health Pressure Injury Task Force has met quarterly to review patient care policies, procedures, and issues; guidelines from state and regulatory sites; quality and legal issues affecting specific specialties, materials, and therapies; procurement input with formulary additions; and current standards of care. A wound care specialist from each of the sites of care serves on the Task Force. Further, our internal quality department, the Krasnoff Quality Institute, has been integrated into the meetings.

The focus of the Task Force has been to support excellent patient care and provide guidelines, policies, and procedures for staff to follow in the prevention, assessment, management, and treatment of patients with and without PIs. Over the years, we have created an internal intranet toolkit available to all staff. This toolkit comprises a resource for nurses including definitions, educational links, guidelines, and pictorial guides for staging and differentiating skin changes. In addition, internal mandatory PI learning modules have been created and are accessed by internal staff and new hires each year.

Within the Northwell system, each hospital site of care provides monthly incidence and prevalence data to Krasnoff for submission to state and federal agencies. Part of the Task Force’s duties is to review these data to understand the system-wide picture and determine what interventions are undertaken to reduce the incidence of PIs. Because Nursing Quality Indicators are always on the agenda, participants discuss their efforts toward prevention and share success stories with each other. Unfortunately, despite all these efforts, the Task Force identified an increase in PIs documented by staff beginning in mid-2018. Clearly, the focus needed to be on understanding why the increase in HAPIs had occurred and what our efforts would be to reduce these numbers.

We met as a working group in late 2018 to discuss our issues and concerns regarding HAPIs. We had previously changed our nasal oxygen tubing to all silicone tubing and looked at many of the tube holders to ensure we had the best quality products for our patients. We introduced a urinary management system to aid in reducing incontinence-associated dermatitis and moisture-associated skin damage in all patients with continence issues. We reviewed our prevention protocols, including bed systems, and could not identify any weakness in our process. Given these and other efforts, it appeared we had done what we could, and yet we still noted increases in our HAPI rates.

One of the first factors we noted after discussions with our quality colleagues was that we were seeing the impact of coding changes in Patient Safety Indicator (PSI-3) reporting within our sites of care. That is, the data from each site were not in line with the numbers noted by our coding teams, which was our first point of concern. The coders reported higher numbers than those noted on our monthly incidence reports. Prior to the PSI-3 changes, wound ostomy and continence nurses were the point persons for PIs, and physicians were guided by the nurses’ documentation. With the introduction of PSI-3, our coders were now beginning to identify and code for the documentation of PIs by our many providers. Any HAPI documented by a provider (accurately or not) was now counted in our numbers. Additional changes included counting actively dying patients and patients at end of life and/or with skin failure who developed a PI. Prior to this change, we did not count those patients in our HAPI numbers. Further, we had previously instructed staff on medical device-related PIs (MDRPIs), which also resulted in increased reporting of HAPIs.

The Task Force decided to undertake a literature review to see what others may have found, help determine what was potentially affecting our scores, and ascertain whether there were interventions we had not considered or implemented. A comprehensive literature search conducted by one of the health system librarians encompassed practice issues, regulatory and coding concerns, and PI classification.1–26

Much of the literature that was identified focused on developing an understanding and a clinical definition of what constitutes a HAPI and what does not; why some HAPIs are unavoidable; and the difference between a HAPI and what is currently termed “skin failure,” particularly among geriatric patients and those in the ICU. Twenty-six articles were reviewed. We divided the articles among our group and delegated the review process. We asked for each article to be evaluated for its study design, methodological concerns, approach in addressing the research question of interest, and types of published articles in PubMed concerning this topic. Each reviewer was then to report their full critique of the article to the group for further discussion. We agreed to meet and discuss the findings in late 2019.

The findings (or paucity of findings) for each of the articles were discussed, and we identified commonalities in the studies, which consisted of the following:

  1. Many of the National Pressure Injury Advisory Panel guidelines do not meet level A or B evidence, and there is a need to support further research. Additionally, there is a paucity of evidence-based medicine regarding skin failure. With the incidence of PIs among actively dying patients now counting as HAPIs, we see the need to continue research in this area. Could skin failure be the etiology of skin changes seen in the actively dying patient?
  2. Acute care hospitals are penalized for skin failure; however, if skin failure occurs in the home care setting, there is no such penalty. Is that because of the wording and choices in the Outcome and Assessment Information Set D document?27
  3. Skilled nursing facility guidelines encompass “unavoidable” terminology. Further, the CMS allows for “unavoidable” injuries in long-term care if all efforts to prevent a PI were adhered to by staff. This is not true in acute care hospital settings.
  4. Discrepancies in terminology exist, such as the use of “preventable” and “nonpreventable” instead of “avoidable” or “unavoidable.”
  5. The definition of skin failure is not clearly defined by consensus, even in the palliative care literature. Skin failure appears to be differentiated into acute, chronic, and terminal (end-stage) skin failure.
  6. It is difficult to compare acute care hospital outcomes if risk adjustment does not factor in hospital size, social risk adjustments, case mix, data source, and so on.
  7. The incorporation of medical devices into PI frameworks (ie, MDRPIs) has not been clearly defined, and MDRPIs are challenging to prevent even with the use of preventive dressings.
  8. A patient’s LACE (L, length of stay; A, acuity; C, Charleston Comorbidity Index; E, ED visits during the last 6 months) score may be associated with HAPIs through a root-cause analysis. (LACE scores range from 1 to 19 and predict the rate of readmission or death within 30 days of discharge.)
  9. There is an opportunity to develop improved interprofessional communication and education regarding skin failure.
  10. There is an opportunity to examine the National Pressure Injury Advisory Panel’s guidelines in terms of the clinical implications of PI staging and its relationship to treatment rendered.
  11. There may be an opportunity to develop an algorithm for best practice of skin failure from a clinical perspective.
  12. Additional research regarding skin changes associated with end of life and critical illness (and now, COVID-19) is essential to address these gaps in the literature.

With these commonalities established, the Task Force began to identify areas of focus. However, this work was quickly interrupted. During the COVID-19 crisis beginning in March 2020, the New York area experienced high morbidity and mortality among patients. Our staff had to adapt to increasing numbers of patients requiring intensive care and face large numbers of patient deaths, despite all the care being rendered. During these months, we saw heroic efforts on the part of our staff caring for patients with heightened needs for respiratory equipment and structured proning programs. With the necessity of intubation and respiratory support, the incidence of MDRPIs increased, and staff scrambled to obtain equipment to protect not only their patients from the respirators but also themselves from the multiple masks they wore for 12 hours or more a day.

When Task Force meetings resumed in late 2020 (now virtual), we discussed the soaring numbers of patients developing HAPIs from these medical devices. What were the options? We struggled as a group to prevent these unavoidable device-related injuries. However, the penalties for these HAPIs did not go away during the pandemic. Frustration was evident as Task Force members spoke of the work they had done late in 2019 and how these same issues continued to impact patients, albeit now with additional challenges.

Preventable PIs should not occur, and providers should be held accountable for them and implement changes in care. Our frustration lies with increased federal regulations with little recognition that not all PIs are preventable or avoidable. How can providers be punished when we as a discipline are still questioning risk factors, prevention protocols, and useful interventions, much less the very definitions of skin failure and end of life? We need to use equipment to address respiratory distress, and despite our efforts to protect the face and ears from this necessary equipment, we see skin alteration occurring. Should we mandate that manufacturers provide equipment that does “no harm?”

We have seen recently published articles such as Delmore et al28 and Cox et al8 reviewing risk predictors of PIs in ICU patients and Pittman and colleagues’29 review of unavoidable HAPIs. With these studies and opinions, we are hopeful that discussion and potential changes will begin to occur in what is defined as a preventable PI. We need a way to clearly define “unavoidable” PIs and to impress upon legislators and the CMS that these wounds cannot always be prevented. Acute care facilities should not be penalized for the dying skin of our very ill patients, just as they are not penalized for the dying heart or kidney or lungs of very ill patients, so long as all efforts are made to preserve and protect those organs. Distinguishing between skin that is injured because of poor care and skin that is injured because of the natural dying process, critical illness, or COVID-19 manifestations is a huge task that requires knowledge and a deep sense of responsibility for those individuals who are entrusted to our care.


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