By Jay Kumar
Editor’s note: The fourth annual PSQH Innovation Awards recognize healthcare organizations who overcame patient safety or quality improvement challenges. In this article, we highlight the winning submission selected from SCL Health in Broomfield, Colorado. Thanks to Patricia McGaffigan, RN, MS, CPPS, vice president of safety programs at the Institute for Healthcare Improvement, for her help in evaluating the submissions.
As the COVID-19 pandemic took hold in 2020, healthcare organizations had to look for creative solutions to new problems that arose as a result. SCL Health in Broomfield, Colorado, found that it needed to come up with a better way to conduct patient proning, which involves placing patients with acute respiratory distress syndrome (ARDS) on their stomachs to allow better distribution and air volume in their lungs. SCL’s process transformation has been selected as the winner of the fourth annual PSQH Innovation Awards.
In SCL’s award submission, Nancy McGann, PT, CSPHP, CPPS, Manager of Clinical Associate Safety at SCL Health, detailed the steps taken to respond to this issue.
“In April 2020, we noted a large increase in hospital-acquired pressure injury (HAPI) in our COVID-19 patients that were vented and proned for the treatment of ARDS. We had 28 HAPIs systemwide related to proning in March and April 2020 and only one proning-related HAPI in all of 2019. We also noted two patient-handling overexertion injuries to our critical care nurses while proning patients during the same timeframe,” she wrote. “Another concern was that proning required five to seven caregivers and significant PPE that was in limited supply worldwide. Proning is often a life-saving treatment, yet it takes considerable resources and time for an already stretched critical care workforce. To further complicate this problem, patients with high BMI have a higher risk of hospitalization and mortality from COVID-19. This makes all of the aforementioned risks of proning higher. We want to ensure we can offer this life-saving treatment to patients with high BMI while protecting and sustaining our workforce.”
SCL saw the use of proning grow quickly, but it involved health risks for staff, McGann wrote.
“With the onset of COVID-19, the use of proning increased exponentially. Prone positioning is an evidence-based clinical practice used to improve oxygenation in patients who require mechanical ventilation for the management of ARDS. In a pivotal clinical trial, Guerin et. al. (2013) provided strong evidence that oxygenation improves when patients are in the prone position for at least 16 consecutive hours. Mortality at 28 and 90 days was shown to be lower among the patients who were in the prone position compared to the control (supine) group (p<0.001),” she wrote. “Best practice from literature is proning 16 hours/day with swimming position changes every two hours (Bamford et al., 2019; Drahnak & Custer, 2015; Mitchel & Seckel, 2018). A recent study implied that there is an increased risk of skin injury and caregiver injury risk from the lateral transfers needed for proning unless lifts or air-assisted devices are used (Wiggerman et. al. 2019). Literature and internal data showed that 27%-50% of patient handling injuries occur from repositioning in bed (AON, 2018, SCL Health Internal Patient Handling Data).”
In May 2021, SCL performed an extensive literature search to explore proning techniques and determine if there was information already existing about how to prevent HAPI in this patient population. It returned 24 articles, primarily discussing manual proning techniques with no mention of skin injury.
“We had experienced success in proning using ceiling lifts in our healthcare system at one hospital but noted a large variation in proning methods at our eight hospitals. This variation included proning with bed sheets, friction reducing devices (FRD) and ceiling lifts. We needed to determine how to provide this treatment in a manner that is safe and efficient for both our patients and our workforce,” wrote McGann. “It was clear that the traditional manual way of proning required significant time and resources and carried an increased risk of pressure injury to our patients and overexertion injury to our caregivers. Therefore, we applied for an internal safety grant to improve the proning process.”
To resolve the challenge, SCL reached out to colleagues across the country to learn from their experiences, including those from New York City with the highest volumes of COVID-19 patients at that time. McGann wrote that this did not yield solutions for these problems, but they received an internal SCL Health Safety Grant.
“We pulled together an interdisciplinary team that treated the vast majority of COVID-19 patients requiring mechanical ventilation in the spring surge in Colorado. The team included, critical care nurses, wound care nurses, respiratory therapists, Safe Patient Handling & Mobility Leads, performance improvement specialists, nurse researchers, nurse practice leaders, and supply chain professionals,” wrote McGann. “We met virtually and for an in-person half-day facilitated meeting in June of 2020. All barriers, current practices and potential solutions were identified by clinicians through brainstorming sessions. We then created action items for all team members to perform over the summer. The clinicians worked with supply chain staff to identify all possible solutions to the known barriers and risks to the physical movement of proning and swimming patients, and how to best position them once prone. Several items came from OR spine procedures where proning had been performed for years.
After trialing and researching all summer, the team met in late August for an eight-hour simulation session with all of the proning and positioning equipment identified, McGann wrote.
“Three simulation rooms were used at Saint Joseph Hospital (SJH). One used a mobile lift, one had a ceiling lift and one used a variety of FRD systems. Each room had access to all of the additional positioning needs,” she wrote. “Each participant needed to be both a patient and a caregiver for every technique. We then immediately met to reach a consensus on the best method to prone since each site was using different equipment and processes and felt confident they had developed the most ideal process. Surprisingly, consensus was extremely easy to reach. The caregivers were especially surprised how much better they felt as the patient using both the ceiling or mobile lift and a FRD to prone. The vote was 100% for this method with other defined tools for positioning and securing the endotracheal tube.”
McGann wrote that the team developed a toolkit that included a three-tiered flow diagram so sites without ceiling lifts in their ICU had other options and supply chain ensured all items were available systemwide. Positioning equipment included wedges, fluidizers, foams, tape, aerated mats, and OR prone positioners. The toolkit also included videos, job aids, and a proning checklist that was then disseminated systemwide in September 2020 prior to the second surge in Colorado.
“SJH with 100% ceiling lift coverage completely adopted the change to a ceiling lift method by the fall-winter surge. In the spring surge, they used a FRD proning system,” McGann wrote. “Good Samaritan (GSMC) added in the FRD after only using ceiling lifts in the spring surge. A DNP student at SJH extracted several data points from Epic to compare outcomes before and after the significant proning practice change.”
Total HAPI reduction at SJH was 46% after the initial practice change from spring 2020 to fall-winter 2020 and was 70% in sustainment (January-June 2021). Facial HAPI was reduced 80% in sustainment. Time between pressure relief turns decreased 47 minutes from 3 hours and 8 minutes in the spring to 2 hours and 20 minutes in the fall-winter, and then to 2 hours and 9 minutes during January-June of 2021. This improvement was realized despite increased length of stay; 337 hours, 365 hours, 383 hours respectively and higher acuity measured by mortality; 27%, 52% and 31% respectively.
Time and staff savings:
Time study performed at GSMC showed an 83% decrease in the time needed to prone. The number of staff to prone was reduced from six to three, and minutes to prone from sixty to 20 contributing to the 83% overall reduction.
No patient handling overexertion injuries were reported proning patients when ceiling or mobile lifts were used.
“Moving to this three-tiered proning strategy allowed us to improve the safety and efficiency of proning regardless of ceiling lift coverage by using mobile lifts. This significantly reduced pressure injury and allowed us to prone pregnant patients and patients that were 400+ pounds with BMI in the 60s,” McGann wrote. “This life-saving technique may not have been physically possible without this approach. Sites with ceiling lift coverage in their ICUs reduced the time to prone by 83% per patient. This process has been fully adopted at both SJH and GSMC even with the passing of time, stress, turnover, and travel nurses. The time savings for this alone allows our staff to be able to perform other vital patient needs while keeping them healthy and at work. The patient and workforce safety benefits of this enhanced method of proning demonstrates that the patient lifts initially purchased to prevent workforce injury, also prevents patient injury and improves both the safety and efficiency of care delivery. This body of work also led to the recommendation to cohort ICUs during COVID-19 surges in areas with ceiling lifts when possible.
SCL has shared this work nationally on several occasions. It won a best poster award in March 2021 at the Association of Safe Patient Handling Professionals Conference and was presented via webinar in September 2021. It was again presented as a poster at a Rocky Mountain Evidence-Based Practice Conference in October 2021 and then presented to over 500 attendees on December 15, 2021, for an American Hospital Association (AHA) webinar. This information can also be seen on demand by registering for the free AHA webinar.
AON, (2018). Health Care Workers Compensation Barometer. https://www.aon.com/getmedia/4748a551-9c85-4ae4-b916-2badba48298c/Health-Care-Workers-Comp-Barometer-2018-Executive-Summary.aspx
Bamford, P., Denmade, C., Newmarch, C., Shirley, P., Singer, B., Webb, S., & Whitmore, Dl. (2019). Guidance for: Prone positioning in adult critical care. Intensive Care Society. https://www.ficm.ac.uk/sites/default/files/prone_position_in_adult_critical_care_2019.pdf
Drahnak, D., & Custer, N. (2015). Prone Positioning of Patients With Acute Respiratory Distress Syndrome. Critical Care Nurse, 35(6):29-37. https://doi: 10.4037/ccn2015753
Guerin, C., Reignier, J., Richard, J-C., Beuret, P., Gacouin, A., Boulain, T., … Ayzac, L. (2013). Prone positioning in severe acute respiratory distress syndrome. The New England Journal of Medicine, 368(23), pp. 2159-2168. https://doi.org/10.1056/NEJMoa1214103
Mitchel, D., & Seckel, M. (2018). Acute respiratory distress syndrome and prone positioning. AACN Advanced Critical Care, 29(4), pp. 415-425. https://doi.org/10.4037/aacnacc2018161
Wiggerman, N., Zhou, J., Hillrom, & McGann, N. (2020). Effect of repositioning aids and patient weight on biomechanical stresses when repositioning patients in bed. Human Factors: The Journal of the Human Factors and Ergonomics Society. Advance online publication. https://doi.org/10.1177/0018720819895850
The following submissions were selected as honorable mentions:
Guam Memorial Hospital Authority, Tamuning, Guam
Dealing with a staffing shortage during the height of the COVID-19 pandemic, the Guam Memorial Hospital Authority created a telemedicine program to connect physicians who were off-site with patients in the intensive care unit. With limited resources on an isolated island in the Pacific, GMHA was able to improve the quality of healthcare for its patients and reduce burnout for the physicians on site.
The Johns Hopkins Health System, Baltimore
Johns Hopkins Health System found that its electronic voluntary event reporting system was lacking and developed a new system called Hero that reimagines processes and workflows. The mobile-friendly application allows easier reporting with a single, simplified submission form and robust interfaces. It includes a chat function to allow reviewers and reporters to communicate about risks identified within the event report and mitigation strategies being implemented.
Creedmoor Psychiatric Center, Queens Village, New York
Creedmoor Psychiatric Center began a systemwide effort to reduce violence and improve safety. Using evidence-based review, leadership led the initiative to reduce patient aggression and staff injuries from patient assault by brainstorm causes of violence and soliciting improvement suggestions from staff. Progress was slow when the changes began in July 2018, but by mid-2021, staff injuries have decreased dramatically and patient aggression is trending downward.
NYC Health + Hospitals, New York City
NYC Health + Hospitals—a system with 11 hospitals, five post-acute facilities, and more than 70 outpatient centers—developed a High Value Care initiative designed to eliminate unnecessary testing and treatment that result in patient harm. NYC Health + Hospitals implemented interventions that included the utilization of behavioral nudges that helped establish a norm of appropriate testing and treatment and discouraged overuse that could cause harm. More than 120 projects were initiated over a 2.5-year period from July 2019 to December 2021, saving an estimated $19 million per year (based on a combination of publicly reported charge costs and an analysis of prevented adverse events and downstream services).