Strategies for HAPU prevention

[ThrivingSince2017]

I’m looking for any and all helpful recommendations for HAPU prevention in the inpatient setting, specifically for floors working with amputees.

Background: I work on the East coast at an academic hospital on an intermediate vascular surgical floor. Since my 2017 BSN graduation, I only have RN experience on this unit. We frequently work with lower-limb amputees, so most of our pts are at risk for HAPU (we chart a Braden score on every pt every shift). Our unit-based patient care team is madeup of the charge nurse (usually free-floating), RNs, and CNAs; RN-patient ratio is 1:3-5 and CNA-patient ratio is 1:5-7.

BUT we have no unit-wide strategy for achieving our q2hr turns, and I think we as a unit are hitting a breaking point. In the last 2 months we’ve had 4 HAPUs.

I’ve heard of units doing something where qshift the charge nurse checks in with each nurse to identify which patients are at risk and need to be turned q2hrs. I’ve heard of assigning certain nurses to be turning teams, where every 2hrs one team turns all those at risk and the next 2hr mark the other team turns the same pts. I’ve heard of identifying patients at risk with discreet magnets outside the door so all staff are aware of the need to turn this patient. I want to hear from YOU, AllNurses community, what strategies are both practical and work for HAPU prevention?

I want to share your recommendations with my team and discuss what we as a unit could implement. Thank you for everything you have to offer.

[hppygr8ful, ASN, RN, EMT-I]

I was once rounding with a wound care doc who told me that q2 turning does not prevent HAPUs from occurring. Wound development has a vey complex pathophysiology and he had never seen a wound caused directly by a lack of turning a patient. It certainly does not hurt but the doctor felt this huge emphasis on turning patients was window dressing to keep bean counters happy

Hppy

[mmc51264, BSN, MSN, RN]

we have a protocol in place with a different name. Our latest issue is heel. They need waffle boots or floatedon pillows. We have a lot of pts that come in with hip fx and are geriatric and need to be turned. We use a scale/assessment and according to the score, they are recommended for Q2H turns. Ortho floor.

We do fairly well. I have the avoidable ones like laying on a syringe cap or the filter of a nerve block.

I disagree with the premise that turning often doesn't help. It does. One of the issues is that it takes so long for some to appear. We are very proactive of assessing and documenting skin up on admission. Any area of concern is documented so if something comes up, it is documented.

[K+MgSO4, BSN]

I work geri ortho as well.

Turning doesn't help in itself, it is the skin assessment that should happen every time a patient is turned or moved in or out of bed that needs to happen.

I would suggest a multi disciplinary approach to this. Including dietitian for nutrition, OT to look at your equipment, pharmacy to look at meds that could increase risk, talk with a patient that has sustained a PU in the past to talk about their experience.

Consider your delirium rates, a delirious patient will be difficult to get food and fluid into as well as being able to assess skin integrity either from hyperactive or hypoactive type.

Consider volunteer programs such as pet therapy and volunteers who can interact with patients.

As much as it sickens me to use the buzz phrase "burning platform " you need to get a few nurses and CNAs to get passionate about this, you cannot do it all on your own.

Good luck!

["nursy", RN]

Turning patients absolutely helps, but you have to do it the right way. The last unit I worked on (ICU) the nurses were great about turning q2hours, but all they really did was stick a pillow under one side or the other. The patient was slightly tilted, but the pressure points remained the same. And of course, they got PUs. The very first ICU I worked in, we never saw a PU unless the patient came in with it from another facility. We totally put the patients on their side with however many pillows it took. Picture yourself sleeping on your side: one leg is over the other (not side by side); your upper arm crosses over your body. We did this with all our patients, intubated as well. It was rare that someone was so hemodynamically unstable that they couldn't tolerate it. Back in those days, our patients tended to stay in ICU forever, and we just never saw PUs. We took pride in the care, everyone worked together, and it was just something that we all did because we understood the importance. I think nowadays nurses are so overworked, and most on the edge of burn out, documentation takes preference over things like turning a patient.

[CoffeeRTC, BSN, RN]

LTC nurse's view....

I second the previous posters.

Look at the entire patient and get the entire team involved. Braden scores are helpful but only if completed accurately.

Repositioning is important but only if it is done correctly. What are your bed and chair surfaces like? Do you individualize your plan of care for each patient?

OT should be helpful with positioning devices. Where are you seeing the most pressure injuries? With each newly acquired PI we do a root cause analysis. maybe it isn't just the positioning but incontinence or poor nutrition? Do you offer supplements if po intake is poor at meals? What about moisture barriers? Heel ulcers can actually be related to some of the bunny boots that are used.