NUR 684 Module 3 Milestone One Example

Milestone One: A Clinical Nurse Leader Project to Prevent Heel Pressure Injuries After Hip Fracture Surgery

[Student Name]

Southern New Hampshire University

NUR 684: Clinical Nurse Leader Capstone

Module Three Milestone One

[Instructor Name]

[Date]

Milestone One: A Clinical Nurse Leader Project to Prevent Heel Pressure Injuries After Hip Fracture Surgery

The microsystem assessment of the orthopedic and surgical unit at Clearwater General pointed in one direction: older patients admitted with hip fractures are developing pressure injuries on their heels, and the processes meant to prevent them are unreliable. This milestone proposes a clinical nurse leader project to close that gap. It summarizes the problem and its causes, explains why it matters, outlines the evidence on what works, states a PICOT question and aims and describes the scope and the CNL's role.

The Problem

Across four quarterly prevalence surveys, seven of 112 patients had a hospital-acquired pressure injury of stage 2 or worse. Five were on heels and six occurred in patients admitted with hip fractures, a group that makes up about a fifth of admissions but carries most of the harm. Three in four hip fracture patients score 18 or below on the Braden scale at admission, meaning they are at risk before they reach the unit.

The assessment identified likely causes along the patient's path. Before a bed opens upstairs, hip fracture patients typically spend around six hours lying on thin emergency stretchers, often with heels resting on the mattress and no skin check documented at transfer. On the unit, heel offloading devices were in place for only three of eleven at-risk patients on an audit day, repositioning was documented every two hours for 61% of at-risk patients and dietitian referrals took an average of three days. The wound nurse covers four units, and the unit's skin champion role has been empty for eight months.

Why It Matters

Lyder et al. (2012) examined a national sample of Medicare inpatients and found that roughly 4.5% acquired a new pressure injury during their admission. Compared with similar patients who did not, those with injuries were more likely to die in the hospital and within a month of discharge, stayed longer and were more often readmitted. For a hip fracture patient, a painful heel wound can also delay walking, the single most important goal after surgery, and may lengthen rehabilitation.

Prevention is also a sound investment. Padula et al. (2011) modeled the costs and outcomes of hospital pressure injury prevention programs and concluded that such programs were cost-effective and, in most scenarios, saved money compared with standard care, because the cost of treating injuries outweighs the cost of preventing them. Hospital-acquired stage 3 and 4 injuries are also reportable and are no longer reimbursed by Medicare at the higher rate, which places their cost on the hospital.

For nursing, pressure injuries are among the clearest indicators of the quality of basic care. A unit that prevents them shows that its processes, not just its intentions, are reliable.

What the Evidence Suggests

Sullivan and Schoelles (2013) systematically reviewed multicomponent programs to prevent pressure injuries in hospitals and long-term care. They found moderate evidence that such programs reduce injury rates and identified components that successful programs tended to share: simplifying and standardizing prevention practices and documentation, involving multidisciplinary teams and leaders, designating skin champions, providing ongoing education and auditing performance with regular feedback to staff.

Those components map directly onto the gaps in the assessment. The proposed bundle for hip fracture patients will include a heel check and offloading on arrival in the emergency department, heel offloading boots applied on the unit for all hip fracture patients and anyone scoring 18 or below, a visual repositioning cue at the bedside, a dietitian referral within 24 hours for low nutrition scores, weekly skin rounds led by the CNL with the wound nurse and a restored skin champion on each shift, with monthly audit and feedback.

PICOT Question

In patients aged 65 and older admitted with hip fracture to an orthopedic and surgical unit (P), does a heel-focused prevention bundle beginning in the emergency department and coordinated by a clinical nurse leader (I), compared with current practice (C), reduce stage 2 and deeper heel injuries acquired in the hospital (O) over sixteen weeks (T)?

Aims and Scope

The project has three aims. Within sixteen weeks, heel offloading will be in place for at least 90% of eligible patients on spot audits. Documented repositioning every two hours for at-risk patients will reach 85%. And hospital-acquired heel injuries of stage 2 or worse among hip fracture patients will fall toward zero on monthly incidence tracking, with no increase in device-related skin injuries as a balancing measure.

The scope is one microsystem and its immediate upstream partner, the emergency department's orthopedic bays. The project does not change staffing or purchasing policy, although it will request a stock of heel boots from existing supply budgets. Immersion hours will be used for skin rounds, audits and team meetings, and all project data will be collected without patient identifiers.

The CNL's Role

The CNL will not supervise anyone. The role in this project is lateral: assembling a small team of a night nurse, a nursing assistant, a physical therapist, the dietitian and an emergency department nurse; translating the evidence into a simple bundle; coordinating the handoff from the emergency department; leading weekly skin rounds; and tracking and feeding back the data. The nurse manager and the orthopedic hospitalists have agreed to sponsor the work.

Feasibility and Risks

The project is feasible within the immersion because most components use existing staff, equipment and routines. Heel boots are already on the supply formulary, the dietitian has agreed to prioritize referrals from the bundle and the emergency department's orthopedic bays have a nurse educator willing to champion the arrival heel check. The main risks are practical. Night nurses may see repositioning cues as extra work, boots can cause their own device-related injuries if straps are too tight and the emergency department may not sustain the arrival check on busy nights. Each risk has a response: night nurses will help design the cue, boot checks will be added to skin rounds and the emergency department will receive a monthly count of heel checks completed.

Conclusion

The unit's most common preventable harm has a clear pattern, identifiable causes and an evidence-based remedy. The next milestone will examine the evidence on the bundle's individual components in more depth.

References

Lyder, C. H., Wang, Y., Metersky, M., Curry, M., Kliman, R., Verzier, N. R., & Hunt, D. R. (2012). Hospital-acquired pressure ulcers: Results from the national Medicare Patient Safety Monitoring System study. Journal of the American Geriatrics Society, 60(9), 1603-1608. https://doi.org/10.1111/j.1532-5415.2012.04106.x

Padula, W. V., Mishra, M. K., Makic, M. B. F., & Sullivan, P. W. (2011). Improving the quality of pressure ulcer care with prevention: A cost-effectiveness analysis. Medical Care, 49(4), 385-392. https://doi.org/10.1097/MLR.0b013e31820292b3

Sullivan, N., & Schoelles, K. M. (2013). Preventing in-facility pressure ulcers as a patient safety strategy: A systematic review. Annals of Internal Medicine, 158(5 Pt 2), 410-416. https://doi.org/10.7326/0003-4819-158-5-201303051-00008