NUR 684 Module 9 Final Project Example

Preventing Heel Pressure Injuries in Older Adults After Hip Fracture: A Clinical Nurse Leader Microsystem Project

[Student Name]

Southern New Hampshire University

NUR 684: Clinical Nurse Leader Capstone

Module Nine Final Project

[Instructor Name]

[Date]

Preventing Heel Pressure Injuries in Older Adults After Hip Fracture: A Clinical Nurse Leader Microsystem Project

Abstract

Heel pressure injuries are a common and preventable harm in older adults after hip fracture. On a composite 32-bed orthopedic and surgical unit, four prevalence surveys found hospital-acquired injuries in about 6% of patients, five of seven on heels and six in hip fracture patients. A microsystem assessment traced the problem to long emergency department waits, unreliable heel offloading, inconsistent repositioning, slow nutrition referral and a vacant champion role. This clinical nurse leader project introduces a heel-focused bundle from emergency department arrival to discharge, coordinated through interdisciplinary skin rounds and SBAR, rolled out in stages and evaluated with all-or-none bundle completion, heel injuries per 100 hip fracture admissions and balancing measures including falls. A business case shows break-even at four avoided injuries a year.

Introduction

Clinical nurse leaders work at the level of the clinical microsystem, the front-line unit where patients, families and clinicians meet. Bender (2014) describes the role as a master's-prepared clinician who stays close to care and improves outcomes for a population of patients by integrating care across disciplines, translating evidence and managing outcomes with data. This project applies that role to one persistent harm on Clearwater General's orthopedic floor: heel pressure injuries in older patients admitted with hip fracture.

Microsystem Assessment

Nelson et al. (2002) studied high-performing front-line units and described the features they shared, including interdependent teams, attention to patients, use of data and continuous process improvement. Their work gave rise to an assessment organized around a unit's purpose, patients, professionals, processes and patterns. Applied to the orthopedic floor, it showed a unit dedicated to restoring mobility after surgery, a population whose hip fracture patients were typically in their early eighties, with three in four scored 18 or below on the Braden scale on admission, a thin wound nursing resource and many inexperienced night nurses.

Audits compared policy with practice. Braden scores were documented promptly for most patients, but heel offloading devices were on three of eleven at-risk patients observed, turning every two hours appeared in the record for about three in five at-risk patients and dietitians saw flagged patients only after roughly three days. Hip fracture patients spent roughly six hours on emergency department stretchers with no documented heel check at handoff. The pattern of injuries, concentrated on the heels of these same patients, pointed to a single focus.

Evidence Base

The bundle's design draws on three strands of research. First, Moore and Patton (2019) found it uncertain whether structured risk tools reduce injuries compared with clinical judgment, which means a Braden score protects no one unless it triggers prevention. Because the scale does not fully capture the risks of hip fracture, the bundle treats every hip fracture patient as at risk from arrival. Second, Sullivan and Schoelles (2013) found moderate evidence that multicomponent programs reduce pressure injuries and identified components successful programs share, including standardized practice, champions, education, leadership involvement and audit with feedback. Third, Chaboyer et al. (2016) randomized whole hospitals to a bundle built around patient participation and saw fewer injuries without statistical certainty, alongside incomplete delivery, which makes fidelity a central concern.

Evidence on repositioning intervals is also uncertain, so the bundle individualizes turning and always pairs it with direct heel offloading, which addresses the mechanism of heel injury more directly than turning alone.

The Bundle

The bundle has six elements, each with an owner. Emergency department nurses in the orthopedic bays check both heels at arrival, float the heels on a pillow and state heel condition at handoff. Unit nurses and assistants fit heel boots on all hip fracture admissions and on other patients with a Braden total of 18 or lower and follow an individualized repositioning plan. Physical therapists replace boots after each session. The dietitian sees patients with low nutrition scores within 24 hours. The CNL and wound nurse lead skin rounds twice a week. Hospitalists respond to early skin changes reported through a short SBAR script. All elements appear in a single checklist in the electronic record.

Lateral Integration

The CNL supervises no one, so integration depends on shared routines, language and data. Twice-weekly skin rounds bring nursing, therapy, nutrition and wound care to each high-risk bedside. An SBAR script for heel concerns gives every nurse a clear way to raise a change with a hospitalist. An ownership table, agreed before launch, shows each group its piece. When therapists and nurses disagreed about boots during mobility, the CNL framed the shared goal of early walking and asked a nurse and a therapist to design the fix, which produced a lighter boot for transfers and a rule to replace boots after each session.

Implementation and Outcomes Management

The bundle is introduced over sixteen weeks: two weeks of preparation, a two-week pilot on eight beds, a review and spread to the full unit and the emergency department bays. The primary process measure is all-or-none bundle completion for hip fracture patients, audited weekly. Implementation outcomes include staff acceptability, adoption and sustainability three months after the immersion. The primary outcome is heel injuries of stage 2 or deeper per 100 hip fracture admissions, with admissions between injuries charted because events are rare. Balancing measures are falls while wearing boots, strap-related skin injuries and therapy delays. Written triggers link data to action, such as a meeting with the owning group when completion falls below 70% for two weeks.

Table 1. Key Measures

Note. Full measure definitions appear in the implementation plan.

Business Case

Padula et al. (2011) found hospital prevention programs to be cost-effective and frequently cost-saving compared with standard care. Locally, the bundle costs about $32,000 a year, mostly boots and champion time. Using the finance office's illustrative estimate of $8,000 in added cost per stage 2 injury, it breaks even at four avoided injuries a year, and a sensitivity analysis shows the case holds under moderately less favorable assumptions if the bundle is delivered faithfully.

Sustainability and Limitations

Sustainability rests on filled champion roles, the electronic checklist, orientation for new staff, monthly feedback and skin rounds that continue after the immersion under the wound nurse and a unit CNL. The project's limitations are real: a single-unit design without concurrent controls, small numbers of injuries, bundled components whose separate effects cannot be separated and reliance on skin rounds that could miss injuries between visits. Results will be interpreted with those limits in mind.

Conclusion

This project shows the clinical nurse leader role at work: assessing a microsystem with data, choosing a focus the data selected, translating uncertain evidence into clear practice, leading across disciplines without authority, managing outcomes with measures and triggers and making a sound business case. Heel injuries in older hip fracture patients are a problem that falls between disciplines, which is precisely why a CNL is placed to solve it.

References

Bender, M. (2014). The current evidence base for the clinical nurse leader: A narrative review of the literature. Journal of Professional Nursing, 30(2), 110-123. https://doi.org/10.1016/j.profnurs.2013.08.006

Chaboyer, W., Bucknall, T., Webster, J., McInnes, E., Gillespie, B. M., Banks, M., Whitty, J. A., Thalib, L., Roberts, S., Tallott, M., Cullum, N., & Wallis, M. (2016). The effect of a patient centred care bundle intervention on pressure ulcer incidence (INTACT): A cluster randomised trial. International Journal of Nursing Studies, 64, 63-71. https://doi.org/10.1016/j.ijnurstu.2016.09.015

Moore, Z. E., & Patton, D. (2019). Risk assessment tools for the prevention of pressure ulcers. Cochrane Database of Systematic Reviews, 2019(1), Article CD006471. https://doi.org/10.1002/14651858.CD006471.pub4

Nelson, E. C., Batalden, P. B., Huber, T. P., Mohr, J. J., Godfrey, M. M., Headrick, L. A., & Wasson, J. H. (2002). Microsystems in health care: Part 1. Learning from high-performing front-line clinical units. The Joint Commission Journal on Quality Improvement, 28(9), 472-493. https://doi.org/10.1016/S1070-3241(02)28051-7

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