Maintaining Patient Skin Integrity Requires Identification of Knowledge, Practice and Product Gaps

The University of Chicago Medicine team with the 3M Award for Excellence in Skin Safety. From left to right: Jenny Sala, Kathleen Hudson, Susan Solmos, Foluke Omosule, Marianne Banas.

Skin integrity is a building block of infection prevention, with pressure injuries and wound-related complications posing as a major threat to good patient outcomes.

In May, 3M and the Wound, Ostomy and Continence Nurses Society (WOCN®) announced that the University of Chicago Medicine’s successful “Countdown to Zero” skin integrity program had received the sixth annual 3M Award for Excellence in Skin Safety. The program was honored for reducing the number of preventable skin injuries – including an 83 percent reduction in pressure injuries – within the academic medical center.

Susan Solmos, MSN, RN, CWCN, manager of nursing clinical services at University of Chicago Medicine, explains that the majority of acute-care institutions are aware of their hospital-acquired pressure injury rate as a part of their overall patient skin integrity monitoring. "Most hospitals track hospital acquired pressure injury (HAPI) rates particularly since reimbursement penalties were implemented by the CMS in 2008."

The Countdown to Zero program began in 2014 after an analysis of nursing practices and available products was conducted to understand factors contributing to the system’s higher- than-average hospital-acquired pressure injury rate. A monthly auditing program was established to help lower the point prevalence of pressure injuries, incontinence-associated dermatitis (IAD), intertriginous dermatitis (ITD) and friction injuries.

Pre-program analysis uncovered that some clinicians were unable to distinguish between certain types of skin injuries, which could lead to improper treatment. Therefore, clinician education became a cornerstone of the Countdown to Zero program.

"Nursing practice, including staging and differentiation of pressure injuries versus other common skin injuries continues to evolve," says Sol-mos. "It’s necessary for experts to integrate new knowledge into their practice and determine while also disseminating to frontline nursing staff.

An intensive yet accessible education program was created at University of Chicago Medicine, offering learning opportunities about skin injuries in a variety of formats – new hire orientation, computer-based programs, formal 30-minute in-services and informal five-minute in-services conducted right at the bedside. Since the program’s implementation, the medical center has seen reductions in all targeted preventable skin injuries.

Ongoing, regular clinician education is critical to good patient outcomes, and as Solmos emphasizes, "In order to integrate new knowledge into practice it’s necessary to provide knowledge in a format that nurses can immediately use, such as soundbites. This can be followed with practice prompts and efforts to ensure new knowledge is integrated into practice."

Solmos attributes the success of the Countdown to Zero program to "expert identification of knowledge, practice and product gaps" as a cornerstone. "Data analysis of monthly prevalence studies and direct observation of practice is used to continually determine where improvement is needed," she says. "Unit-based champions (RNs and NSAs) reinforce practice reminders and prompts to integrate and reinfuse knowledge and/or practice. The percent effort by the expert in sustaining and improving practice has been equal or greater than the percent effort to implement the program." She continues, "Through our skin-care team’s hard work, our preventable skin injury rates continue to improve year-over-year. In fact, we recently met our ultimate goal – recording zero instances of Stage 2 and above pressure injuries in all patients surveyed, which included critically ill adult and pediatric patients – which is incredible. By prioritizing skin integrity education and continuous evaluation, we have been able to enhance our standard of care system-wide in a very tangible way for our patients."

Other healthcare systems can model programs after UChicago's project, but only if the institution can secure senior leadership support, Solmos says.
"In addition, the expert is responsible for continuous evaluation and integration of new knowledge, practice or products for optimal results," she adds.
The take-away message for infection preventionists and clinicians regarding the importance of patient skin integrity relating to HAI prevention and other associated complications is that "pressure injuries can lead to serious consequences including osteomyletis, sepsis and septic shock; therefore, prevention is a priority," Solmos says.

In terms of evaluating skin integrity-related products, Solmos advises, "Products should be critically evaluated to determine if their perfor-mance meets the needs of the patient population and program. Products should also be evaluated to determine if they are designed to reduce the risk of medical device related pressure injuries."

The award was made possible by a partnership between the WOCN Society and 3M, who together aim to recognize the most innovative and inspiring individuals or healthcare facilities that have implemented a program to improve patient skin integrity and skin health.

“UChicago Medicine and its dedicated staff are truly at the forefront of prioritizing, implementing and sustaining skin injury prevention,” says Leslie McDonnell, vice president of global marketing at 3M. “It’s an honor each year to learn about and acknowledge outstanding facilities, like UChicago Medicine, that truly understand the importance of skin integrity in patient care.”

In order to win, the program must demonstrate measurable and sustained results that are achieved through prevention, senior leadership engagement, product formulary and interdisciplinary participation.

“Through this award program partnership with 3M, we’re frequently reminded of the exceedingly profound contributions made by nurses dedicated to pressure injury prevention, because it isn’t an easy task,” says Carolyn Watts, MSN, RN, CWON, president of the WOCN Society. “And we have no doubt that other medical facilities are making significant strides in prioritizing skin integrity as this year we received a record number of award submissions. UChicago Medicine stood out because of its exemplary fulfillment of each requirement, going above and beyond each year of the program, and we commend their team.”