Improving Documentation to Prevent Hospital-Acquired Pressure Injuries

Andrea DiMartino, RN

Delaware Technical Community College

NUR 410: Nursing Informatics

Dr. Jackie Henaghan

November 29, 2020

For nurses working in an inpatient hospital environment, a large portion of time is spent

charting in the Electronic Health Record to document various tasks and assessments. In

successful urban hospital systems, the support of informatics in technology can aid the nurse in

accomplishing various tasks more efficiently, such as medication scanners and triggered alerts

Unfortunately, much time is spent documenting in the medical record, taking away time that

could be spent on patient care and focusing more closely on patient outcomes. One such

example of this is hourly rounding. The intention of hourly rounding and repositioning is to

protect the patient from Hospital-Acquired Pressure Injuries, also known as HAPI, and

protecting the skin integrity of patients at higher risk for skin breakdown. This is accomplished

through ensuring the patient is cleaned up quickly after incontinence episodes and ensuring the

patient is frequently repositioned to reduce sustained pressure on bony prominences.

In a perfect world, nurses would be able to devote their full attention to a single patient at

a time then immediately chart on the computer the patient repositioning and any care performed

directly after it was completed. Unfortunately, hospitals are far from a perfect world and often

nurses will have to go back to chart several hours' worth of tasks when they have time to sit

down and focus on data entry. Because of this shortcoming, several aspects of patient care may

not be accurately documented including timing of repositioning, the frequency of patient

voiding, or even the correct positioning of the patient during rounding. Additionally, since more

than just nursing is responsible for patient rounding, nurses may be documenting care that was

performed by other providers including patient care technicians. As a result of these shortcoming

in documentation, patients may go for extended periods without repositioning, or may be

positioned too frequently, impairing the sleep-wake cycle and increasing patient stress.
 The complications from hospital-acquired pressure injuries causes additional expense to

hospital systems and increase the mortality rates for patients impacted. As a result, more than

60,000 deaths annually have HAPI as a contributing factor. A study in the Annals of Internal

Medicine found that the key components to reducing the number of hospital-acquired pressure

injuries were the simplification and standardization of pressure injury specific interventions and

documentation. Process improvements in intervention and documentation were enacted along

with several other prevention-focused programs, particularly for individuals at higher risk of

HAPI (Sullivan & Schoelles, 2013).

Creating the Documentation

In healthcare, one of the most valuable tools in communication and effective care is the

Electronic Health Record, also known as the EHR. Though still a fairly new technology, the

EHR has proven to be a useful tool both in communicating between providers and maintaining

up-to-date patient information. its downfalls and challenges, some

of which are slippery slope issues that could impact the ways in which documentation will

change in the years to come. Among the challenges with new and emerging technologies, there

are ethical and legal considerations associated with EHRs that will need to be reviewed and

evaluated as new issues arise because it is not possible at this time to consider every potential

issue that could be brought to light in the future. Regardless of the issues though, the EHR is a

valuable and irreplaceable tool that has vast potential to improve patient care, both now and in

the future, but it needs to be extended to the bedside with new and emerging technologies and

informatics.
issues surrounding documentation within and access to Electronic Health Records. The first key

issue that is discussed is the implications of changes in technology such as the EHR which are

supposed to streamline the documentation process but require additional time without a systemic

increase in the time allotted for patient interaction and care. Because of this, many clinicians and

nurses will postpone documentation until later, when the information may not be as accurate or

complete due to relying on accurate recall, to spend more time cultivating a strong relationship

with the pat In

some cases, the EHR can be less efficient in documentation, especially when having to navigate

complicated software or using workarounds for inefficient documentation templates.

For any type of technology that documents directly to the Electronic Health Record is the

issue of information security and privacy within the guidelines of HIPAA and general

information technologies. The digital age has created a multitude of quality-of-life

improvements, but the issues of creating access, in particular for medical information, is a

multifaceted problem. Securing the information against hackers and others who have less than

good intentions is a constant and changing challenge. Not only does access need to be restricted

to the intended audiences only, there needs to be effective methods to ensure that the individuals

accessing the information are authorized to do so. Often in order to protect the EHR, series of

complicated login and password requirements are needed, but a backdoor is inevitable as patients

and healthcare providers must be given opportunities to regain access if they are unable to recall

a password or login (Harman, Flite, & Bond, 2012). Furthermore, information required to regain

access may be protected information which could be compromised in other ways but create a

weak link in protecting the EHR. The difficulty lies in protecting sensitive patient information

while also protecting patient autonomy in accessing their records (Phillips, 2015).

Support for Bedside Charting

who participated in the study prefer bedside documentation but recognize that there are barriers

to utilizing the EHR directly at bedside. The primary issues noted were the physical

environment and space constraints, as well as system barriers (Moody et al., 2004). As a result,

charting on the health record was done later, away from the bedside. This brings into question

other studies, such as one which evaluated the predicitive validity of the Braden Scale as an

indicator for risk of hospital-acquired pressure injuries, which rely purely on data pulled from

health records, because the charted data may not be accurate. The report did indicate that there

were additional characteristics that needed to be considered, such as the presence of additional

medical devices, the age of the patient, and the circulatory health of the patient (Hyun et al.,

2013).

To effectively improve patient outcomes regarding the timely and accurate

documentation of hourly rounds and patient repositioning in the Electronic Health Record, an

add-on application should be developed to coordinate with the handheld scanner devices

currently in use at several hospital systems, including ChristianaCare, which allows a simple

interface for nurses to document rounds and patient care at the bedside at the time the care is

provided. The purposes of this application would be a brief interface that would document

accurately on the EHR to reduce the time spent charting and also create alerts within the system

that would trigger for the nurse to do more focused assessments based on specific criteria.

There are several factors which put a patient at risk for pressure injuries, including but

not limited to advanced age, mobility, nutrition status, and moisture from incontinence.

Currently this is assessed as a Braden Score. Patients with a score of 18 or less are typically

considered to be at a higher risk for developing a pressure injury, while patients falling under 16

often require significant nursing intervention to maintain skin integrity. Sometimes, medical
interventions create additional risk to a patient when devices are present long-term, therefore

additional criteria should be considered when developing informatics to support nursing in

identifying patients at higher risk. Examples of additional criteria would be known causes for

hospital-acquired pressure injuries, such as presence of nasogastric tubes, nasal cannulas,

tracheostomy equipment, foley catheters, and heart monitors.

With these triggers loaded into the application, it could set reminders for nursing to do

additional interventions to ensure fewer HAPI have the opportunity to develop. Examples of

these reminders could be to reposition a nasogastric tube, confirming that heels are elevated

when patients have been supine or who have a history of circulatory insufficiencies, and

verification that preventative measures are taken for patients with oxygen tubing to prevent skin

breakdown behind the ears. In many units, the use of an adhesive foam pad over the pati

coxxyx helps to reduce the risk of injury, but those require replacement every 72 hours, or more

frequently in cases where a patient is frequently incontinent. The replacement of those items falls

on nursing to remember when the foam pad should be replaced, but a built-in option to document

replacement with a hard time limit would ensure that replacement is documented and that the

nurse is alerted as replacement is due.

The interface itself does not need to be complicated, and in fact should be kept as simple

as possible to promote adherence to using the program. Utilizing the scanners already used for

medication admi

categories for nursing to document. First, would be patient position, which would be head of bed

elevation followed by right, left, supine, or other. Under this section there would be additional

options for offloading devices such as pillows and heels-up devices. Next, safety interventions
would be accounted for, which include but are not limited to bed exit alarms, low bed, use of

side rails, patient access to call bell, and if the patient is wearing non-slip socks.

The second portion of the interface would be documentation of patient care. This would

allow a quick fill-in of common care tasks including toileting, documentation of bowel

movements and urine output, and bed baths or peri care. By utilizing this more timely

documentation of patient care, providers are more able to identify patterns, such as retention or

frequency, and nursing will be able to spend less time sitting at the computer, allowing more

time for direct patient care.

Finally, after completing those two input categories, the handheld would display any

triggered notification for the nurse. These triggered instances would include the suggested

reminders to check skin around medical devices but could be expanded to include other

interventions to improve patient safety. An example of a triggered reminder would be to suggest

a bladder scan if a patient had not voided after a set period of time, such as 6 hours, particularly

if there are orders to do so in the system. The program may remind a nurse to reposition a

nasogastric tube if it had been last completed 8 hours prior. And finally, it would remind nursing

to document foley output and perform foley care every 8 hours to ensure better documentation of

patient output if the EHR has a foley present.

All of these interventions and reminders together improve patient care by allowing more

time for nursing to be present. Creating more efficient and accurate documentation while saving

hours of nursing time that would otherwise be spent in front of a computer helps return the focus

to the patients. Because having to stay and complete charting is a frequent reason for staff to

stay beyond their scheduled hours, more efficient documentation reduces staffing costs by

lowering incidences of overtime caused by insufficient time for charting. And finally, small
reminders about nursing interventions improve timely intervention that reduce the risks to the

patients for hospital-acquired pressure injuries and other issues that can extend hospital stays and

cause undue harm to our patients.

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Appendix