Implementing Pressure Injury Prevention Bundle to Reduce Pressure Injuries in Critical Care

Abstract

Hospital acquired Pressure Injuries (HAPIs) are not a new issue in the healthcare industry, meaning that they can be viewed historically. HAPIs are costly to the healthcare system and mostly preventable, yet incidence rates remain high. Recommendations for improved care and prevention of pressure injuries from the Joint Commission revolve around continuous monitoring of prevention protocols and prompts for the care team. The purpose of this quantitative, quasi-experimental project was to determine if or to what degree the implementation of Pressure Injury Prevention (PIP) Bundle impacts the HAPIs prevalence rate among critical care patients in acute care hospital over four-weeks. Jean Watson’s Human caring nursing theory is used in this DPI project to identify how PIP bundle can be associated with reduced HAPI incidence. The sample population for this project will be minimum 60 adult patients. The HAPI incidence is the project’s dependent variable, and it is necessary to compare this value for two independent groups. The collected data will be analyzed by utilizing the t-test, since this inferential statistical test measures the difference between the means of two groups. The specific level of the statistical significance (p =.05) is chosen to ensure that the obtained results are statistically significant and minimize the effect of chance. This requirement is also necessary because it justifies that the findings are scientifically valuable. It is anticipated that utilization of PIP bundle can reduce the pressure injuries among adult critical care patients.

Introduction to the Project

Hospital-acquired pressure injuries (HAPI) are a significant burden for healthcare organizations worldwide that negatively impacts the quality of life of patients and their caregivers. The global prevalence of HAPI is almost 13%, while the incidence rate is above 5 per 10,000 patient days (Li et al., 2020). Most cases of HAPI are preventable; however, highly cachectic patients may develop pressure injuries despite the use of cushions for pressure distribution (Ricci et al., 2017). In addition to being a stressful event for patients, HAPI is also a formidable financial burden because most pressure ulcers develop as a secondary condition, requiring additional expenses (Mansfield et al., 2019). For example, according to national estimates, the overall spending for treating patients with HAPIs is close to $11 billion (Padula & Delarmente, 2019). The HAPI prevalence in the 13-bed medical intensive care unit (MICU) in urban New York was reported to be 14%, which is higher than the national average. Therefore, this quality improvement project aims to determine how implementing evidence-based practices, specifically the pressure injury prevention (PIP) bundle, can reduce the HAPI incidence in the 13-bed MICU.

Although many evidence-based methods were developed to address pressure ulcer development in hospitalized patients, HAPI’s national prevalence and treatment costs remain high. For example, approximately 2.5 million American patients in intensive care units annually develop pressure injuries that result in 60,000 deaths (Padula & Delarmente, 2019). The incidence rate of HAPIs in intensive care units varies from 14% to 42% (Anderson, 2020). Moreover, according to Padula and Delarmente (2019), the treatment cost for one pressure injury ranges from $500 to $70,000 because HAPIs lead to more extended hospital stays. For instance, the length of stay of patients with HAPI can increase to 14 days that causes a tremendous disturbance to patients’ physical and emotional well-being (Ricci et al., 2017). Therefore, finding an effective intervention is critical for resolving multiple issues associated with HAPI. Indeed, the exploration of this topic started in the nineteenth century, and the first intervention to prevent HAPIs was developed by Browning (Mansfield et al., 2019). Still, research in this field was started a long time ago, but the approach that would eliminate a high HAPI prevalence problem has not been described yet.

Since various risk factors contribute to the development of HAPIs, introducing the PIP bundle can address several issues simultaneously. The risk factors associated with the formation of pressure ulcers include older age, reduced mobility, poor nutrition, dehydration, reduced tissue perfusion, oxygenation, and medical devices placement (Romanelli et al., 2018). It appears that many intensive care unit patients have an increased likelihood of the development of HAPIs. Therefore, implementing the prevention bundle, a combined scheme of standardized methods that target different aspects of the pressure ulcers issue, can minimize risks, and reduce the HAPI incidence rate (Rivera et al., 2020). The elements of this method may vary between authors; however, numerous US-based quality-improvement clinical studies demonstrated the effectiveness of this approach regardless of the number of components in the bundle (Lin et al., 2020). Therefore, this evidence-based practice will be presented and utilized in this project to attain lower HAPI prevalence in the intervention site.

The primary function of the PIP bundle is to recognize pressure ulcers in high-risk patients and introduce appropriate measures to prevent further progression of the damage. For example, the SAFER bundle, which stands for skin emollients, head-to-toe assessment, float heels, early pressure identification, and repositioning, allowed North Memorial Nursing Service to reach the drop of HAPI prevalence from 15% to 2% (Anderson, 2020). Other types of the bundle include skin assessment, surface support, incontinence, nutrition, and mobility (Romanelli et al., 2018). The bundle approach that will be used in this project was developed by Rivera et al. (2020), whose methodology is based on assigning intervention depending on the severity of tissue damage. Specifically, patients with superficial HAPIs can receive a standard treatment plan, while those with deep pressure ulcers should get high-risk intervention (Rivera et al., 2020). The effectiveness of this approach was tested in an 11-bed critical care unit in one of the hospitals in New York City (Rivera et al., 2020). The results of the study demonstrated a seven-fold decrease in HAPI incidence in this department.

The PIP bundle is divided into two categories: Standard interventions and High-risk interventions. According to the bundle designed by Rivera et al. (2020), patients with a Braden score above 19 should receive the standard intervention. In contrast, patients with points equal to or below 18 will get high-risk intervention (Rivera et al., 2020). According to Rivera et al. (2020), this intervention includes skin assessment, changing endotracheal tube holder every four days, foam dressing to patients with facemasks, and silicone dressing in tracheostomy every three days. The higher stages of pressure injuries require standard intervention combined with high-risk methods. Rivera et al. (2020) suggest changing prevention dressing on the sacrum once in three days, alter the patient’s position every two hours, use seat cushions and heel protectors, and nutritional consult. Importantly, inadequate nutrition is the risk factor for pressure injury formation and an impediment to faster healing. Therefore, a nutritional consult is vital for maintaining an adequate supply of proteins, fats, carbohydrates, vitamins, and minerals to facilitate wound repair (Romanelli et al., 2018)

Since the project focuses on an actual problem, it should follow a specific structure to ensure that it offers a scientific meaning. Thus, Chapter 1 presents general details, including background information, problems statement, the project’s purpose, clinical question, and explanation of how the work advances scientific knowledge. Chapter 1 also presents data regarding the project significance, the rationale for choosing a specific methodology and a project design, definitions of terms, key assumptions, limitations, delimitations, and the summary. Simultaneously, Chapter 2 presents the literature review on the topic. This chapter also offers detailed information regarding the topic’s background and comments on the theoretical foundations of the project, focusing on nursing and change theories. In turn, Chapter 3 focuses on the project’s methodology, considering population, instrumentation, validity, reliability, data collection, data analysis, and other relevant issues. Chapter 4 will present the graphic and written description of the results. Chapter 5 outlines the assessment of the findings and discusses them.

Background of the Project

Pressure injuries are not a new issue in the healthcare industry, which denotes that they can be considered from a historical perspective. According to the World Health Organization (WHO) (2008), this issue’s prevalence is similar in different nations, including 10% in the USA, 11% in Germany, 12% in Sweden, and 13% in Israel (p. 45). The Joint Commission (2016) defines pressure injury as localized skin and tissue damage related to exposure to a medical device. Ricci et al. (2017) stipulate that the pressure ulcer prevalence was slightly lower than 15% in 1999, while the 2009 International Pressure Ulcer Prevalence Survey revealed similar results. Li et al. (2020) argue that the HAPI prevalence is 12.8%, while the incidence rate is “5.4 per 10,000 patient-day” (p. 2). These statistical data reveal a challenging situation in health care and Padula et al. (2019) state that pressure injuries “affect over 2.5 million individuals resulting in 60,000 deaths” (p. 132). This information demonstrates that pressure injuries continue to be a problem in the healthcare industry.

The issue is represented differently in the community under investigation. According to the New York State Department of Health (2017), the community has overall an effective response to the problem because the state average HAPI prevalence is 0.1% (para. 4). However, there exist individual facilities where the incidence is 5%, 6%, and even 30% (New York State Department of Health, 2017, para. 5). As for the project site, it has a rate of 14%. This information demonstrates that the local data are slightly different from global data, but it highlights the necessity to address the problem. Problem Statement

This project will focus on the 13-bed MICU in urban New York, where the number of patients with HAPIs was higher than the national average. Specifically, this unit reports the prevalence of pressure ulcers of 14%, which means that every tenth patient in MICU will develop HAPI. Furthermore, MICU is the primary facility that admits HAPI cases; thus, 55% of all pressure injuries in the hospital are found in this unit. The average age of MICU patients is 68, which is a significant risk factor for HAPI. Moreover, most patients in the department are critically ill, placing them in a high-risk group for pressure injuries development. It appears that addressing this problem is vital to improving patient outcomes in MICU. However, it is unknown if or to what degree the implementation of a Pressure Injury Prevention bundle would impact the HAPI incidence compared to current practice among the critical care unit population in a 13-bed unit in urban New York. Even though this problem statement focuses on a single medical establishment, it does not mean that the project’s need is limited to this facility. Therefore, it is essential to determine whether utilizing the PIP Bundle can lead to better health outcomes.

Wang et al. (2020) acknowledge that the HAPI risk depends on age and the length of hospital stay. It denotes that the risk of suffering from a pressure injury is higher for adults and positively connected to a person’s age. Simultaneously, the studies by Hultin et al. (2019), Latimer et al. (2019), Mäki-Turja-Rostedt and associates (2019), and many others also focus on HAPIs among older patients. This information indicates that the DPI project focuses on older hospitalized individuals from a single healthcare unit since they represent the broad population significantly affected by the problem. The rationale behind this claim is that these people are under the influence of specific HAPI risk factors.

This quality improvement project can contribute to solving the problem because it offers to find a practical solution of how to protect the identified population from HAPIs. Since this study field provides mixed findings regarding the PIP Bundle, it is reasonable to conduct a quality improvement project that can offer precise results. If the project reveals that the PIP bundle leads to significantly better outcomes, the healthcare industry can obtain a practical guideline to reduce the HAPI incidence. If the intervention does not lead to improvement, it will be necessary to look for other quality improvement measures. In this case, it can be reasonable to utilize a different methodological approach to studying the issue.

Purpose of the Project

The purpose of this quantitative quasi-experimental project is to determine if or to what degree the implementation of the PIP Bundle would impact the HAPI incidence when compared to current practice among critical care patients in a 13-bed unit in urban New York. The independent variable, PIP Bundle, will be defined as the standard and high-risk PIP bundles. The dependent variable, a HAPI incidence rate, will be measured by the number of patients who develop this condition during a hospital stay. The project site collects data about pressure injuries in its electronic health records (EHRs) that can be used for this project, and the facility indicates that HAPIs are a problem. It denotes that the given healthcare unit frequently deals with pressure ulcers among its patients, meaning that it will benefit from quality improvement.

For this purpose, the wound care team will access these EHRs to identify whether a patient experiences a pressure ulcer. It is expected that the implementation of the independent variable can result in the reduced incidence of the dependent one among the population under investigation. The project’s purpose aligns with and builds on the problem statement above because the two focus on the same issues. This requirement is necessary to ensure that the project is consistent.

It is possible to mention that the project will offer an essential contribution to the field. The rationale behind this statement is that multiple scholarly articles admit that the older population significantly suffers from HAPIs. They typically have deteriorated health conditions that make them experience pressure ulcers when they are hospitalized. Extended periods of hospital stay denote that patients spend much time in a sitting or lying position. Consequently, their skin is subject to constant pressure that, in turn, results in the occurrence of HAPIs. This situation describes that the project will address an essential issue that creates some challenges for a specific population. This statement is based on the issue that a few healthcare facilities in New York suffer from increased HAPI incidence (New York State Department of Health, 2017). This project tries to address this adverse state of affairs, which can provide the whole healthcare industry with noticeable improvement.

Clinical Question

It is challenging to predict what bundle methodology should be introduced in MICU and what outcomes will be achieved. Although the prevention bundle was proven to diminish the HAPI incidence rate in many clinical studies, the statistical significance of their results could not be obtained in some cases (Lin et al., 2020). Therefore, it is unknown if the issue of high HAPI prevalence in MICU will be resolved with the chosen approach.

The question guiding this project is: To what degree does the implementation of the PIP bundle impact the HAPI incidence compared to current practice among critical care patients in a 13-bed unit in urban New York over four weeks? The question also reveals that the project seeks to identify whether the use PIP bundle, the independent variable, is sufficient to reduce the HAPI incidence, the dependent variable. Thus, this project will conduct a specific quasi-experimental project to answer this question.

This discussion demonstrates that the project tries to identify the effectiveness of the PIP bundle. The clinical question reveals that it is possible to cope with this task if the project deals with specific variables. Potential reduction in the HAPI incidence will be measured according to the medical establishment’s EHRs. However, it is necessary to state that the project should focus on a specific sample size to limit its scope. Furthermore, only adult critical care patients will be included in this study. The rationale behind this selection is that critical care patients are more prone to multiple risk factors that contribute to the spread of pressure ulcers (Mervis & Phillips, 2019). As a result it is essential to determine whether the PIP bundle leads to the expected positive outcomes among critical care patients.

Advancing Scientific Knowledge

Scientific evidence demonstrates that the problem under consideration is consistent. Ricci et al. (2017) stipulate that the pressure ulcer prevalence was slightly lower than 15% in 1999, while the 2009 International Pressure Ulcer Prevalence Survey revealed approximately the same results. Even though the issue created fundamental problems for the whole medical industry, no improvement attempts could generate the required outcomes. As for the current state of affairs, Li et al. (2020) argue that the HAPI prevalence is 12.8%, while the incidence rate is “5.4 per 10,000 patient-day” (p. 2). These statistical data reveal a challenging situation in health care, and Padula et al. (2019) support this claim stating that pressure injuries “affect over 2.5 million individuals resulting in 60,000 deaths” (p. 132). This information demonstrates that pressure injuries continue to be a problem in the healthcare industry. Consequently, there is a gap in care because the current practice is insufficient to reduce HAPI incidence and prevalence.

This quality improvement project will advance scientific knowledge in the sphere of addressing pressure injuries among hospitalized patients because evidence-based practice addresses the gap. A systematic review by Lin et al. (2020) demonstrated a significant reduction in the prevalence of pressure ulcers in US hospitals after introducing the bundle approach of various components. According to the bundle designed by Rivera et al. (2020), patients with a Braden score above 19 should receive the standard intervention. In contrast, patients with points equal to or below 18 will get high-risk intervention (Rivera et al., 2020).

Implementation of this bundle resulted in a significant reduction in the occurrence of pressure ulcers (Rivera et al., 2020). Standardized intervention methods are essential assets in preventing pressure injuries. For example, several evidence-based interventions, known as a bundle, are more efficient when introduced in combination (Frank et al., 2017). The classical prevention bundle consists of five items: skin assessment, surface support, mobility and repositioning, incontinence, and nutrition (Romanelli et al., 2018). High risk interventions are essential for patients with deep tissue pressure injuries and those with such risk factors as old age, immobility, malnutrition, or a condition that causes delayed healing. The cornerstone of this intervention is using seat cushions, heel protectors, and providing proper nutrition. Indeed, a dehydrated and malnourished organism needs more time and care to regenerate pressure ulcers. Rivera et al. (2020) suggest changing prevention dressing on the sacrum once in three days, alter the patient’s position every two hours, use seat cushions and heel protectors, and nutritional consult. Importantly, inadequate nutrition is the risk factor for pressure injury formation and an impediment to faster healing.

Human caring nursing theory (Watson, 2018) is used in this to identify how utilization of PIP bundle can be associated with reduced HAPI incidence. Jean Watson (2018) proposed this theoretical framework by highlighting how to improve positive outcomes during human-to-human caring moments. She stipulates that patients cannot be separated from the healthcare workforce, implying that a change occurs through nurses. This information demonstrates that the theory will drive the intervention because it denotes healthcare workers should use interventions related to reduce HAPIs. The study by Kennerly and Yap (2018) demonstrates that the theory can be applied in evidence-based practice projects. The project can advance this theory by demonstrating whether its application leads to positive outcomes when applied to PIP bundle and the HAPI incidence. If positive results are found, it will be possible to state that it is reasonable to rely on this theoretical framework to combat the issue of pressure ulcers. The project also adds to explaining what role healthcare professionals play in combatting pressure injuries.

Significance of the Project

High healthcare costs are a significant problem in the United States. Prolonged hospital stays due to the development of pressure injuries in intensive care unit patients complicate this issue further. For example, treatment of superficial pressure ulcers may cost about $500, while the price of more advanced HAPIs can rise to $70,000 (Padula & Delarmente, 2019). The fact that every tenth patient in MICU in one urban New York hospital requires secondary intervention that increases cost overthe primary treatment demands ng preventive measures to minimize these expenses. In addition to economic benefit, patient outcomes and satisfaction will increase because quality of life will be improved, allowing them to have shorter hospitalizations and return to their families early. Many clinical trials achieved a significant reduction in the HAPI incidence rate. For example, a quasi-experimental clinical study by Anderson (2020) reached a seven-fold drop in the prevalence of pressure injuries. Similarly, this project aims to utilize this study design to determine how effective the selected scheme of PIP bundle will be in the 13-bed MICU.

The problem of pressure injuries is widespread in the medical industry. Padula et al. (2019) argue that this health condition affects more than 2.5 million people. Padula and Pronovost (2018) also admit that HAPIs result in 60,000 deaths in the USA annually, and their costs are estimated at $9-$11 billion. Simultaneously, Li et al. (2020) argue that the HAPI prevalence is 12.8%, while the incidence rate is “5.4 per 10,000 patient-day” (p. 2). The WHO (2008) states that this issue’s prevalence is similar in different nations, including 10% in the USA, 11% in Germany, 12% in Sweden, and 13% in Israel (p. 45). These data indicate that a significant part of the US population is subject to this health condition. Simultaneously, the project site reports that it suffers from an 11% prevalence that refers to the incidence of 10 HAPIs per 100 patients. Thus, it is necessary to find a practical solution to minimize the incidence of the HAPI and protect individual health.

The retrospective study by Singh et al. (2018) examined data from 99 pediatric hospitals that implemented prevention bundle methods. The authors showed a mean drop of pressure injury incidence by 57% across hospitals (Singh et al., 2018). Still, the scholars are not sure about the reliability of the information because they could not control the data collection process.

These studies represent an evidence-based practice approach to the problem. Still, there is a gap in the literature because multiple articles offer mixed findings regarding the effectiveness of the proposed intervention. Since the current literature comments on the possible efficacy of PIP bundle approaches, the project aims at enriching knowledge. Since multiple studies offer conflicting findings regarding the proposed intervention’s effectiveness, this paper is an attempt to identify the actual effect of PIP bundle. Consequently, this quality improvemennt project is significant since it addresses a sensitive topic in the healthcare industry and aims at generating unambiguous conclusions regarding the issue under investigation.

The project completion is also significant for numerous stakeholders. Firstly, clinicians, nurses, and other healthcare professionals can witness essential benefits since the project offers an opportunity to advance the quality of care relating to older patients (Hultin et al., 2019; Latimer et al., 2019). While these people typically suffer from deteriorated health conditions, it is reasonable to provide them with improved care, and the project tries to cope with it. It is expected that the results will improve the clinical site practice because the project can reveal efficient, practical applications. Secondly, there is an evident connection between the project and improved public health. The rationale behind this statement is that the project can develop specific guidelines for healthcare professionals to ensure that patients are less subject to pressure injuries. Finally, the project can be beneficial for the whole healthcare industry. The financial impact is the key, and Padula and Pronovost (2018) admit the financial burden of this issue, meaning that its prevention can make the medical system more cost-effective. It denotes that the DPI project can effectively protect older hospitalized populations from pressure injuries.

Rationale for Methodology

A quantitative methodology is effective in addressing a clinical problem and answering a clinical question. The rationale behind this statement is that it relies on numerical data, and this approach is necessary to identify the incidence of a particular phenomenon. For that purpose, various statistical tests should be used, and Bell, Bryman, and Harley (2018) admit that this methodology applies some of them, including t-test, which increases the reliability of the obtained results. Creswell and Creswell (2018) explain that the main benefit of this approach is that it allows for conducting an experiment to collect and analyze the data. Rutberg and Bouikidis (2018) stipulate that a quantitative method is appropriate when answering a clinical question to achieve quality improvement. More specifically, the dependent variable in this project is the incidence of HAPI, a quantity measured and reported in numeric values.

Thus, quantitative methodology answers the project’s clinical question and addresses the problem statement. The problem statement reveals that it is necessary to compare the effectiveness of two interventions, and the description above shows that a quantitative method is a suitable option to cope with the task. Simultaneously, the clinical question attempts to identify a measure of improvement, and the selected methodology runs statistical tests to find this answer.

Nature of the Project Design

This quality improvement project uses a quasi-experimental design to answer the clinical question. The reason for selecting this approach is the necessity of applying the intervention (PIP Bundle) and identifying whether it leads to improved outcomes (reduced HAPI incidence). Thus, the given design is relevant because Rutberg and Bouikidis (2018) state that it allows for assessing the intervention’s effectiveness for quasi-experimental and comparison groups.

Simultaneously, it is reasonable to contrast the design to the correlational and experimental ones. Siedlecki (2020) also admits that case studies, descriptive, and correlational designs are not appropriate since they are less practical than the selected approach. On the one hand, a correlational design is inappropriate since it does not imply using a controlled intervention. On the other hand, an experimental design is not suitable since it implies randomization, which would make the project more time and resourceconsuming. Thus, it is necessary to stipulate that the quasi-experimental design aligns with the quantitative methodology.

It is reasonable to provide a detailed explanation of the project design. Since the project is the implementation of evidence-based practice (EBP), it follows a before and after design. Consequently, the project sample should be divided into two groups. The before group includes those patients who receive the care based on current practice.The after group consists of those patients who are to receive PIP bundle. The project will collect and analyze the data regarding the number of pressure injuries that developed in the two groups. This approach will identify the HAPI incidence within each group and compare the obtained data to determine whether there is an improvement following the proposed intervention. An appropriate statistical test is necessary to identify whether the changes are statistically significant and directly connected to the intervention.

The discussion of the project design includes attention to data collection and analysis for the project variables. The independent variable that is the PIP bundle of evidence-based practices and actions to reduce HAPIs. Nurse managers and wound care nurses should ensure that the nurses are utilizing the PIP bundle. The dependent variable refers to a HAPI incidence rate measured by focusing on the number of patients who develop pressure injuries during their hospital stay. The data for the dependent variable will be collected by analyzing electronic health records after the end of the intervention process. Wound care nurses will access the records to stipulate how many pressure ulcers will develop.

These data may only be accessed after the facility under investigation issues corresponding permission. This discussion proves the statement by Rutberg and Bouikidis (2018) that the quasi-experimental design is suitable for this project. Thus, one can stipulate that the selected project design is appropriate to answer the clinical question.

Definition of Terms

The following terms are operationally defined in lay words and in the context in which they appear in the paper.

• Pressure Injury Prevention Bundle. This approach allows clinicians to have guidance for the assessment and monitoring of intensive care unit patients. This term refers to the plan of care that was developed to prevent the development of pressure injuries in patients at risk (Romanelli et al., 2018). The prevention bundle elements may vary between authors, but the overall goal of all methods is to prevent further complications of HAPI.
• Pressure Ulcers (HAPIs).This term denotes “areas of localized injury to the skin and underlying tissue, usually over a bony prominence, as a result of pressure, or pressure in combination with shear” (Li et al., 2020, p. 2). This health condition is widespread, affecting people’s psychological and physiological
• Turning (i.e., repositioning).Even though these are separate words, often they are used interchangeably in scholarly literature. Their meaning is the process when individuals move or change their position while sitting or lying. There exist two approaches to promoting turning and repositioning in the healthcare industry. On the one hand, Schutt and associates (2018) indicate that self-turns and rolls are an effective strategy for hospitalized patients to avoid pressure ulcers. On the other hand, Woodhouse et al. (2019) state that medical professionals can turn and reposition individuals. This term represents a component of the independent variable, the PIP bundle,

Assumptions, Limitations, Delimitations

The following assumptions are present in this quality improvement project:

1. It is assumed that the project participants do not create any treatment barriers and diligently follow the PIP bundle offered to them. This idea is necessary since it implies that changes in the HAPI incidence, if any, are directly related to the intervention, not external processes.
2. Another assumption denotes that the project will identify the positive connection between providing a PIP bundle and the decreased HAPI incidence. This statement implies that the project aims at arriving at the conclusion that utilizing the PIP bundle is an effective pressure injury prevention intervention.
3. One more assumption is that the healthcare facility correctly enters the data on patient’s pressure injuries in their EHRs. This condition is necessary because the project relies on EHRs to identify the HAPI incidence.

The following limitations are found in the project:

1. Time constraints can be considered an essential limitation of the project. Since the project covers four weeks, it fails to assess the long-term effect of the proposed intervention.
2. Another limitation is a small sample size because the project focuses on patients from a single medical facility in urban New York. It can be difficult to generalize the obtained results and determine whether the proposed intervention can be effective for the larger population.
3. One more limitation is that the project depends on how accurately and diligently the facility approaches its reporting system. It relates to the fact that if the healthcare unit fails to mention in its EHRs that some patients experience pressure ulcers, the project’s results will suffer.

The following delimitations are found in the project:

1. The project is delimited to a 13-bed critical care unit in urban New York. This delimitation is necessary because critical care patients are more subjected to pressure injuries due to poor tissue perfusion or hemodynamic instability.
2. Another delimitation is that the project chooses a nursing theory by Jean Watson (2018) to ensure that the project has some theoretical support.

It is reasonable to mention that the limitations above can be overcome in future projects. For future papers, it is necessary to conduct a more extensive project that will include more participants who will be under investigation for a more extended period. Simultaneously, it will be reasonable for investigators to have greater control over the future project by participating in reporting activities to minimize its dependence on a facility.

Summary and Organization of the Remainder of the Project

Chapter 1 has presented basic information regarding this project. Padula et al. (2019) explain that HAPIs are a significant problem in the healthcare industry, meaning that a practical intervention is necessary to address the issue. Chapter 1 has also formulated the problem statement, the purpose of the project, and the clinical question. Evidence from scholarly sources demonstrates that the project can advance scientific knowledge because the existing literature offers conflicting results of using PIP bundle (Rivera et al., 2020). Thus, the project is significant since it aims at addressing this gap and providing multiple stakeholders, including patients, healthcare professionals, and the whole medical facilities, with essential benefits.

Chapter 1 also comments on the methodological aspect of the project. The intervention for reducing HAPI prevalence was presented in this chapter. Specifically, the background knowledge about the PIP bundle developed by Rivera et al. (2020) and some other variations of this approach are discussed in chapter 1. Creswell and Creswell (2018) justify using a quantitative approach, while Rutberg and Bouikidis (2018) explain that it is reasonable to use a quasi-experimental design. Then, the key terms are defined to ensure that anyone reading the accurately understand the concepts under discussion. The project assumptions, limitations, and delimitations have also been discussed in detail, while specific comments are offered on how to overcome these limitations in a future project.

At this point, it is also appropriate to present the organization of the remainder of the project. Chapter 2 will overview the current literature on the PIP bundle and whether this intervention effectively prevents pressure injuries. Chapter 3 will present a detailed description of the project methods and procedures, commenting on the sample, data collection, data analysis, and other methodological affairs. Finally, Chapter 4 will introduce a graphic summary of the project results, while their discussion and interpretation will be offered in Chapter 5.

Literature Review

A hospital-acquired pressure injury is a preventable event that often happens in the intensive care unit. A pressure injury is localized skin and tissue damage caused by intense and continuous pressure (Anderson, 2020). The risk factors for developing healthcare-acquired pressure injuries are immobility, altered mental status, and advanced age (Frank et al., 2017). This review aims to uncover the importance of implementing a PIP bundle in reducing the prevalence of pressure ulcers in critical care units.

Pressure Injuries (PIs) refers to local injuries to the subcutaneous tissue or the skin, and they are usually are experienced over bonny prominences. They are caused by pressure, and it sometimes comes with shear forces. Hospital-acquired pressure injuries (HAPIs) usually increase the medical burden, workload of nurses, as well as length of hospital stay (Gaspar et al., 2019). It tends to lower patient’s health-related quality of life (HRQOL). They increase mortality and cause diverse medical disputes affecting patients’ experience. Many risks factors exist for PI, particularly for critical-care patients, including poor perfusion, older age, as well as change in mobility. Critical care patients are exposed to a greater risk of developing PIs, implying that it is important to establish effective measures to improve the safety of patients in intensive care units (ICUs). The bundle approach is a care standardizing process meant to promote patient outcomes. It argued that its success depends on various factors, including the involvement of key stakeholders, audits and feedback, and the motivation of the pressure injury prevention teams.

Patients in critical care units are exposed to a risk of developing HAPIs. This project will support the use of a PIP bundle to reduce incidences of HAPIs in an adult setting. It will focus on enhancing the identification of the best bundle implementation and PIP practices (Gaspar et al., 2019). This will influence the standardization of the HAPI prevention process and lower incidences of HAPI incidences. Implementation of the project will require leadership and staff involvement to hinder HAPIs. The literature review will be organized into various sections, namely introduction, theoretical foundation, review of the literature, and summary. The theoretical framework will discuss Kurt Lewin’s (1951) change management theory to support the analysis of forces and subsequent balancing of the change plan. The theory will offer an effective framework for the preventive bundle. Lewin’s Change Theory entails a three-step change model, and it is effective in supporting the implementation of interventions to enhance the achievement of desirable changes in nursing. The review of the literature will be supported by three main themes and several sub-themes. The main themes will be PIP bundle: high-risk interventions, PIP bundle: standard risk interventions, and hospital-acquired pressure injuries/ulcers (HAPIs/HAPUs).

The project implemented a thorough literature review to analyze the existing information, beginning with professional databases to find credible and timely literature on the topic.An extensive literature search was conducted for this project using the following databases: EBSCO, Cumulative Index to Allied Health Literature (CINAHL), Ovid, PubMed, and Google Scholar. The following keywords and their various combinations were used to identify the required sources of information: pressure injuries, pressure injury prevention bundle, interventions related to pressure injuries, risk factors, and incidence related to pressure injuries. The search results are limited to the studies that were published not earlier than in 2017 to ensure that the project deals with the most recent literature. The identified articles are included in the project based on their abstracts. The articles are included if they are available in full text and peer-reviewed. As a result, 90 studies were retrieved, while a set of 50 credible and reliable studies are selected for this literature review.

Pressure injuries affect multiple patients, and it is impossible to deny that some improvements are needed. Ricci et al., (2017) admit that “the overall pressure injury prevalence rate described in 1999 for acute care facilities was 14.8 percent” (p. 275e). Simultaneously, the 2009 International Pressure Ulcer Prevalence Survey revealed approximately the same results irrespective of some improvement measures (Ricci et al., 2017). Simultaneously, Li et al. (2020) indicate that the current HAPU prevalence is 12.8%, while the incidence rate is “5.4 per 10,000 patient-day” (p. 2). These findings demonstrate that a gap exists because no significant improvements have occurred over more than 20 years in the sphere of addressing pressure injuries.

Theoretical Foundations

Human caring nursing theory is used in this project to identify how PIP bundle can be associated with reduced HAPI incidence. Jean Watson (2018) proposed this theoretical framework by highlighting how to improve positive outcomes during human-to-human caring moments. Wei and Watson (2019) also indicate that the theory relies on practice, research, and theory-based education to ensure that any proposed intervention is suitable and can help patients achieve better health outcomes. This theory denotes thosesuccessful results can only be achieved if a medical practice is backed theoretically. Watson’s theory of caring helps in creating an excellent environment around the patients as well as staff to promote healing. Energetic authentic caring presence occurs when the nurse and patient come together to create a caring moment. Pressure injuries occur mostly in immobile and elderly patients and PIP bundle interventions like repositioning an immobile patient can prevent pressure injuries to meet the basic needs of patient and helps to sustain the human dignity.

In addition, the project focuses on a specific change theory. It refers to Kurt Lewin’s (1951) change management theory that is typically used for numerous quality improvement projects. This framework implies that patients change their behavior under the influence of driving or positive forces that affect individuals from outside (Lewin, 1951). This information suggests that it is necessary to provide patients with external support to ensure that they can overcome some challenges. The Lewin change model implies that the project will rely on specific steps to measure the variables. First, it is necessary to improve patients’ knowledge about the problem and its possible solutions, Lewin’s stage of unfreezing (Burnes, 2020). In this case, the findings from Ricci et al. (2017), Li et al. (2020), Courvoisier et al. (2018), and others are helpful. This information justifies the use of PIP bundle and HAPI incidence as the project variables. Second, it is reasonable to implement a change by subjecting patients to specific interventions of the standard-risk or the high-risk bundle components as denoted by Lewin’s change stage, also known as moving (Burnes, 2020). Subsequently, Lewin’s refreezing stage will incorporate and sustain the PIP into the unit’s standard practice; Lewin’s change theory helps change current practice to answer the identified clinical question (Burnes, 2020).

Review of the Literature

The literature review collects and analyzes findings from 50 credible and reliable sources. It is worth admitting that most of these sources were published within the last five years, which indicates that the project relies on timely data. Reliable sources will be consulted to ensure the provision of valid and relevant information. The objective will be to survey the available literature on PIP bundles and offer a synthesis of the information. It will offer a critical analysis by focusing on the identification of the existing gaps in the current knowledge. This will be done by evaluating the existing limitations of theories as well as consider different views of authors. The literature review will show that the research is valid and add beneficial information to the available knowledge. This implies that it will summarize and integrate known information regarding the implementation of PIP bundles in critical care. It will evaluate strategies adopted to reduce hospital-acquired pressure injuries and promote patient safety.

The purpose of the literature review is to enhance the standardization of HAPI prevention strategies in an adult setting. It encourages the establishment of an interdisciplinary team including nurses, managers, patient care associations, and respiratory therapists. It will support the development of a comprehensive approach and promote the engagement of stakeholders, sustainability, adherence, and adoption. Evaluating diverse studies will enhance the understanding of the development, implementation, evaluation, and monitoring of the PIP bundle (Gaspar et al., 2019). It will assess evidence-based practices to explain how existing challenges can be eliminated. Moreover, the literature will identify gaps in the existing research and suggest areas where further studies need to be conducted. The literature will build an argument entailing how the development of the research question while explaining the current models, topics, and theories. It will enable the reader to understand the importance and relevance of the project.

Hospital-Acquired Pressure Injuries/Ulcers (HAPIs/HAPUs)

Hospital-acquired pressure injury (HAPI) affects patient care since it is associated with deleterious consequences for the healthcare system and patient. It is vital to reduce incidences of HAPI, particularly in the ICU since it presents many problems. It has a major financial implication, with its cost extending beyond $2,000 per PI. The involved cost and associated human suffering explaining the dire need to establish effective preventive strategies (Gaspar et al., 2019). Moreover, the scope of the problem is high and involves multiple levels. Rivera et al. (2020) revealed that at least one million people develop PI annually in the U.S.The study also indicated that 2.3 million patients in acute care facilities develop the condition where more than 60,000 lose their life due to related complications (Gaspar et al., 2019). High incidences can influence the affected organization to lose reputation and eventually face financial challenges. The National Quality Forum (NQF) considers most of the HAPIs preventable.

The application of a care bundle can help hinder PIs even better than clinical guidelines. They entail a set of nursing interventions for a given individual or class of patient to promote healthcare outcomes. The approach is beneficial since it is based on the best evidence, and it is associated with many benefits to patients. There exists an association between the best evidence and bundle approach since it promotes positive clinical outcomes (Green et al., 2018). However, it is faced with challenges such as the severity of the patient’s illness and the complexity of the ICU environment. It is necessary to evaluate the implementation compliance when using the care bundle. It is difficult to realize the benefits of evidence-based practical intervention without considering intervention guidelines. This implies that it is not possible to maximize the benefits obtained from the evidence-based practical intervention in case teamwork and effective communication are ignored(Gaspar et al., 2019). Understanding the quality of the bundle as well as its implementation requires the determination of the effectiveness of the prevention approach, particularly its usefulness during clinical setting trials. Compliance with care bundles can improve interventions and help achieve the desired outcome.

Risk Factors and Incidence Rates

Patients in the critical setting are exposed to higher risks and incidence rates for the development of HAPIs/HAPUs. In this regard, it is crucial to establish a clear understanding of this phenomenon. Chaboyer et al. (2018) review this issue at length within the framework of a systematic review. The purpose of their research was to examine the problem of pressure ulcers that emerge as a result of clinical treatment in terms of scale and scope. The conclusions are made based on the in-depth analysis of twenty-two studies that were reviewed and synthesized in alignment with the research questions. Chaboyer et al. (2018) report the cumulative incidence of HAPIs to be within the range of 10-26%. These numbers indicate that the matter at hand represents an issue of a serious magnitude. As for the location of the HAPIs, the systematic review indicates that most of them emerge on the patient’s sacrum, followed by the buttocks, heel, hips, ears, and shoulders (Chaboyer et al., 2018). Accordingly, pressure ulcers affect a considerable number of patients, causing moderate-to-severe discomfort in the fallout of prolonged care.

The problem of HAPIs is not unique to the United States or any other country. Li et al. (2020) explored the issue from a global perspective, utilizing the international experience to address their clinical question. More specifically, they aim to “quantify the prevalence and incidence of pressure injuries and the hospital-acquired pressure injuries rate in hospitalized adult patients” (Li et al., 2020, para. 2). In order to address the research purpose, the authors rely on the formats of systematic review and meta-analysis. The research sample comprises cross-sectional, observational, and longitudinal studies that report HAPIs among hospitalized adults. Based on the examination of forty-two relevant studies and a total sample of 2,579,049 patients, Li et al. (2020) report an incidence rate of 5.4 per 1,000 patient days. Most of the HAPI cases represent stages I and II of the condition (71,5% in total). From a geographical perspective, the analysis revealed a considerable level of heterogeneity, implying certain territorial correlations that are to be explored in subsequent examinations. This study highlights that the prevalence of HAPIs is a global healthcare concern, but its exact magnitude may vary across different settings.

Evidently, exploring the prevalence of pressure ulcers in the clinical setting per setting will not yield substantial improvements. Accordingly, Greenwood and McGinnis (2016) venture into the territory of the root cause determination. Their article aims to outline the primary avenues of HAPI’s development in acute care environments. The authors apply data analysis methods to process the findings obtained by the root cause analysis process implemented in the U.K. since 2010. The practical purpose of such research consists of identifying the key themes and learning points that can help develop meaningful solutions to the clinical issue in question. The research sample comprised thirty-two HAPI RCA’s that provided insight into the origins of the problem. According to Greenwood and McGinnis (2016), malnutrition becomes the primary root from which increased incidence rates of HAPI s in acute care stem. However, analysis suggests that patient pressure injuries rarely appear in the fallout of a single cause, becoming a product of a combination of factors. More specifically, the authors of the study refer to HAPI emergence as a “sequence of events” that leads to adverse consequences in terms of patients’ well-being. Ultimately, the understanding of the problem’s roots in specific contexts is a major step toward the provision of meaningful solutions.

A similar perspective was taken by the authors of the next study, who explored the risk factors contributing to the development of HAPI ‘s in the clinical setting. Dreyfus et al. (2017) utilized U.S.-based data to address their clinical question. It revolved around identifying and categorizing the primary predictors of pressure injuries that occur during a patient’s prolonged stay at a facility. The authors refer to HAPI s as a major societal burden that can be addressed effectively and prevented if major underlying causes are correctly determined. Dreyfus et al. (2017) investigated 47,365 HAPI cases among 16,967,687 patients with a cumulative incidence of 0.28%. As per the findings, the prior incidence of pressure injuries is the most important predictor of future cases, along with a history of diabetic foot ulcers. In addition, the authors concur with the findings provided by Greenwood and McGinnis (2016), placing malnutrition among the most important causes of HAPI s. The impact of the condition is equally assessed, as authors report an increased duration of stay and elevated hospitalization costs in the case of pressure injuries.

As can be inferred from the current body of knowledge, predictors and determinants of HAPI ‘s form an area of intense interest for researchers across the globe. Kayser et al. (2019) conduct their study along similar lines, venturing into the underlying issue territory. In terms of the clinical question, the authors of this article explore the differences between risk factors associated with a superficial and severe case of HAPI ‘s. As per the study’s design, 216,626 complete patient datasets from acute care hospitals in the United States were analyzed. Having generated the annual linear trendlines, Kayser et al. (2019) performed two logistic regressions to examine the risk factors. The accumulated risk factor list comprised “increased age, male gender, unable to self-ambulate, all types of incontinence, additional linen layers, longer durations of stay, and being in an intensive care unit” (Kayser et al., 2019, p. 46). In addition, a U-shaped relationship between HAPI risks and body mass index was observed. In this context, both extremely low and high BMIs were associated with increased pressure injury risks. Thus, this study introduces physical parameters that represent specific risk groups to be addressed in further interventions.

Overall, hospital-acquired pressure injuries have a long history of a negative influence on the functioning of the healthcare system. This issue is global in nature, as institutions across the world face its adverse implications. However, as can be inferred from the current body of knowledge, the exact incidence rate of the HAPI s is inconsistent across various settings. In addition, the vast majority of cases represent Stages I and II of the condition, accounting for over 70% of all cases. As per the academic consensus, HAPI s originate from various factors that usually act in a combination. More specifically, prior cases of hospital-acquired pressure injuries make a patient subject to new instances of the condition in the future. In addition, aside from previous cases, malnutrition remains a prevalent predictor of HAPI s in the clinical environment. A considerable part of the contemporary research is aimed at the identification of key determinants that aggravate the issue. Through such studies, the system acquired a deeper understanding of these predictors and developed fitting solutions that address them effectively.

Patients with Specific Health Conditions

As can be inferred from the prior discussion, a number of underlying conditions can aggravate the development of HAPIs. Typically, this health issue is the most acute for individuals who spend much time in prone or sitting positions. However, other factors can facilitate the emergence of pressure injuries, prompting scholars to seek specialized methods for such particular cases. Thus, it is reasonable to identify research pieces that would make it clear whether PIP bundle is helpful for people with particular health conditions.

Cancer patients form one of the most vulnerable clinical groups in terms of both physical and moral aspects. Aljezawi and Tubaishat (2018) attempt to determine whether turning and repositioning, offloading and application of preventive dressings are effective for cancer patients. A multicenter, cross-sectional prevalence study of 110 patients used a quantitative methodology to analyze the impact of 2-hourly repositioning on protecting such individuals from the health issue under analysis. The scholars conclude that irrespective of short frequency, this intervention does not guarantee that pressure injuries will not develop in cancer patients.

In addition, cardiovascular conditions may entail serious complications in stressful environments. Chitambira and Evans (2018) assessed the effect of repositioning for stroke patients with pusher syndrome and using a quality improvement initiative with 140 adults. The researchers draw attention to 2-hourly repositioning and placing of pillows. This article supports the claim that repositioning becomes more effective when it is used together with an additional intervention. Since the study focuses on a short intervention period, the authors highlight the necessity to organize further research on this topic. A retrospective descriptive article by Cox, et al., (2018) argues that immobility and septic shock are among the most common pressure ulcer risk factors. Pittman, and associates,(2019), offer another descriptive retrospective study highlighting that HAPIs can be preventable and unpreventable. The unavoidable HAPI occurs among patients with bowel management devices (Pittman et al., 2019).

As pressure injuries affect the skin tissue, corresponding health issues may also aggravate the development of this condition. Gray and Giuliano (2018) reveal that there is a robust correlation between pressure injuries and incontinence-associated dermatitis (IAD). A descriptive and correlational analysis of 5,342 adults demonstrates that an increased HAPU prevalence is found when it comes to focusing on IAD patients. The authors highlight that traditional prevention measures, are not sufficient to protect the population from the given health condition. Thus, another argument in favor of a combined approach is made. Razmus and Bergquist-Beringer (2017) state that pediatric patients are subject to the issue, while Hultinet al. (2019), Latimer et al. (2019), and others explain that older patients are at risk.

However, the range of underlying conditions is not limited to oncology, skin diseases, or cardiovascular issues. Mussa et al. (2018) focus on pressure injuries among patients with an endotracheal tube (ETT). A retrospective, pre-post intervention study indicates that a more frequent repositioning leads to some improvements, but they are not statistically significant. The authors prove it by analyzing data of 61 members from the pre-intervention group and 81 individuals from the post-intervention group. This finding demonstrates that it is not possible to rely on only one preventive intervention repositioning and turning exclusively to protect patients with ETTs from HAPUs.

The damage to a patient’s spine is a serious matter per se, limiting the mobility of a person. Eren et al. (2020) consider results preventive interventions offer to patients with spinal cord injury. The authors do not implement any interventions but interview such individuals regarding whether they rely on the intervention. The findings demonstrate that almost half of the 86 respondents fail to turn regularly, irrespective of the fact that they are aware of this action; thus, it is not surprising that patients with spinal cord injury are subject to HAPUs.

This subtheme has a particular meaning for the entire project. Firstly, it proves that pressure injuries are a widespread problem that requires specific interventions. Secondly, the subtheme has revealed that individuals with particular health conditions are more subject to suffering from the given issue because they spend much time in sitting and prone positions. It indicates that only one preventive intervention can only be effective for patients who do not suffer from additional issues.

HAPIs Impact on the Healthcare System

The elevated incidence rates of HAPIs form an area of concern for all parties involved in the delivery of medical services. In this regard, healthcare organizations equally sustain considerable damage, primarily in the financial domain. Padula and Delarmente (2019) extend this discussion even further, attempting to evaluate the national burden of hospital-acquired pressure injuries in the United States. In order to address the research question, the authors of the research rely on a Markov simulation. Through this method, they estimate the costs of staged HAPI’s that emerge during hospitalization from a medical organization’s point of view. As per the simulation’s results, the annual HAPI costs for the U.S. healthcare system exceed $26.8 billion, which is a colossal amount. Moreover, the distribution of the costs is not proportionate, as nearly 60% of the amount is a condition by the less frequent Stage III and Stage IV cases of pressure injuries. Therefore, the prevalence of HAPI’s undermines the financial aspect of the system, impeding the quality development of hospital units. In this context, significant progress can be made through the prevention of advanced-stage pressure injuries, alleviating the economic burden on organizations.

The immense economic impact of hospital-acquired pressure ulcers remains a matter of increased concern for the system’s management. Lim and Ang (2017) investigate this aspect of the problem within their research. The clinical report is based on the experience of a tertiary hospital in Singapore, thus contributing to the international dimension of the discussion. The clinical questions are presented from the managerial perspective, aiming at reducing the operational costs of healthcare organizations. The authors rely on the famous assumption, stating that the prevention of a problem is widely recognized as more effective than its treatment. In this regard, healthcare organizations are encouraged to pursue new avenues of reducing the incidence rates of HAPI’s like a phenomenon. These ideas align with the ongoing trends within the academic community, as researchers investigate the root causes of pressure injuries in order to develop stronger interventions. The examination by Lim and Ang (2017) reveals that HAPIs are a major stressor for hospitals, depleting their finite resources through prolonged stays, patient dissatisfaction, and corresponding expenses. Therefore, the impact of HAPIs on healthcare organizations is concerning, thus justifying the need for effective interventions.

As a matter of fact, the utilization of the international experience in the discussed context appears relevant and necessary. The problem of HAPIs is global in nature, making it necessary to synthesize and implement the world’s best practices into intervention projects. Han et al. (2019) follow the data obtained through practical observations and analyses in a South Korean hospital with increased HAPI incidence rates. The clinical question was whether these conditions affected the key parameters of a healthcare organization’s performance. More specifically, the authors of the study associate HAPI’s with a strong negative impact on the patient’s health. The sample of 1,000 patients was compared with a 4,000-person control group. The results indicate that advanced HAPIs are associated with increased mortality rates, putting additional pressure on patients and medical units. In addition, the average duration of stay for the patients who develop this condition is longer, leading to higher healthcare costs and financial burdens. Finally, the emergence of HAPIs is a serious predictor of readmission, which, in turn, equally undermines the performance of a medical organization. Therefore, all parties involved in the clinical procedure will benefit from effective interventions aimed at the prevention of hospital-acquired pressure injuries.

Ultimately, the information presented in this section confirms the multi-faceted adverse impact of HAPIs on the functioning of medical organizations. In today’s environment, hospital units work with limited resources. In fact, the efficient distribution of these resources is an essential enabler of better healthcare outcomes that improve the patients’ well-being, promote public health, and sustain the system’s development. The presented findings indicate a major degree of negative influence by the HAPIs, undermining the system’s capacity to fulfill its obligations for the community. Increased healthcare costs are an overarching theme of these discussions, meaning that HAPIs become a serious financial burden for organizations. However, in addition to this, the repercussions of unaddressed HAPIs extend beyond these ideas, contributing to the increase of mortality and readmission rates in hospitals. When all these factors act combined, the prevalence of pressure injuries translates into major healthcare issues that encompass the primary aspects of the system, in general.

In summary, there are many incidences of HAPI/HAPUs in health care settings implying that effective measures need to be taken to prevent their occurrences. They are associated with an increased hospital stay, higher cost of treatment, and they affect the overall patients’ experience. These injuries present a global healthcare concern since their magnitude tends to differ with settings. The establishment of learning points and key themes can facilitate the development of an effective solution to the problem. Since malnutrition is a major cause of high incidence rates, it is necessary to identify and implement interventions to address the issue. Efforts need to be made to identify the major root causes of HAPI to facilitate the provision of meaningful solutions (Rivera et al., 2020). Correct determination of the underlying causes can help address the social burden. This can prevent prolonged hospitalization and the involved cost due to pressure injuries.

Accumulated risk factors for the HAPI include the inability to self-ambulate, male gender, old age, extended hospital stay. Additional linen layers, hospitalized in an intensive care unit, and incontinence. Extremely low and high BMIs are linked to a high risk of developing pressure injuries (Rivera et al., 2020). Prior cases of hospital-acquired pressure injuries increase the chances of developing new instances. Spending much time in a sitting or prone setting is another factor that increases the risk.

Healthcare organizations are also negatively affected by HAPIs in many ways since they hinder the ability to deliver quality medical services. Prolonged hospital stay increases the national economic burden and undermines the financial aspect of hospitals. It is necessary to establish effective avenues of addressing the problem and ensure that stronger interventions are put in place (Rivera et al., 2020). It is associated with many issues, including depleting finite resources, increasing cost, and influencing patient dissatisfaction.

Pressure Injury Prevention Bundle: Standard Risk Interventions

Pressure ulcer prevention presents a complex process since there are diverse items that need to be considered and completed. Establishing best practices is a challenging task necessitating the adoption of a care bundle to support the incorporation of the best practices. It entails the development of the best practices as well as systematically applying them. Specific care practices are beneficial in supporting the achievement of the desired outcomes. The bundle needs to incorporate various critical components, including comprehensive skin assessment, care planning, standardized risk assessment, would care nurse consult, and medical device-related interventions (Rivera et al., 2020). Standard risk interventions should consider different aspects of care and improve the existing practices. It can be tailored to a specific setting and supported with additional steps to ensure successful implementation. Key practices need to be achieved regularly to overcome the challenge of improving care. It ensures that every component of the bundle is performed consistently through the creation of a clinical pathway.

This evidence-based approach demonstrated its effectiveness in various quality-improvement clinical trials. Standardized intervention methods are essential assets in preventing pressure injuries. For example, several evidence-based interventions, known as a bundle, are more efficient when introduced in combination (Frank et al., 2017). The classical prevention bundle consists of five items: skin assessment, surface support, mobility and repositioning, incontinence, and nutrition (Romanelli et al., 2018). Frank et al. (2017) presented the results from 33 pediatric hospitals that implemented the prevention bundle. This study showed a twofold decrease in the incidence of stage 3 and 4 pressure injuries (Frank et al., 2017). The authors conclude that introducing the bundle approach can ensure the early detection of pressure injuries and reduce the prevalence of late-stage ulcers.

The type of intervention in patients varies depending on the Braden score. According to the bundle designed by Rivera et al. (2020), patients with a Braden score above 19 should receive the standard intervention. In contrast, patients with points equal to or below 18 will get high-risk intervention (Rivera et al., 2020). Implementation of this bundle resulted in a significant reduction in the occurrence of pressure ulcers (Rivera et al., 2020). Specifically, the index of healthcare-associated pressure injuries, which is the proportion of patients with pressure ulcers to the days spent in the hospital, dropped from 3.4 to 0.48 over the ten months (Rivera et al., 2020). The authors developed the bundling scheme with time intervals, but they do not discuss the intervention components in detail.

Other quality-improvement clinical studies also evaluated the effectiveness of the bundle approach. A systematic review by Lin et al. (2020) demonstrated a significant reduction in the prevalence of pressure ulcers in US hospitals after introducing the bundle approach of various components. However, most of the evaluated trials did not report the significance of their studies (Lin et al., 2020). The authors admit that there was no link between the number of components in bundles and the outcome. The retrospective study by Singh et al. (2018) examined data from 99 pediatric hospitals that implemented prevention bundle methods. The authors showed a mean drop of pressure injury incidence by 57% across hospitals (Singh et al., 2018). Still, the scholars are not sure about the reliability of the information because they could not control the data collection process.

Skin Assessment

Comprehensive skin assessment involves the examination of the entire skin of an individual for abnormalities. It entails touching and looking at the skin while paying attention to the bony prominences. The examination is meant to detect present pressure ulcers and offer assistance in the risk stratification. This is done because patients with underlying pressure ulcers are at increased risk of developing more (Rivera et al., 2020). The assessment determines the presence of skin-related factors linked to the development of pressure ulcers, including moisture-associated skin damage (MASD) or excessively dry skin. It also enables the identification of other skin conditions and provides data required for the calculation of prevalence and incidences.

Conventionally, individuals with altered skin status are considered to have a high risk of new ulcer development. Shi et al. (2018) argued that there lacks evidence to support the potentially prognostic relationship. The study attempted to review the existing evidence systematically to understand the relationship between the development of pressure ulcer risks and skin status. A comprehensive electronic database search was performed in February 2017 to explore longitudinal studies that used skin status to support the prediction of pressure ulcers. It considered multivariable analysis studies where two reviewers independently selected studies. Data was collected on skin status, participants, as well as the characteristics of studies. This helped gather data on multivariable analyses of pressure-ulcer and the associated skin status.

The article covered 41 studies involving 162,299 participants, out of which 7382 had new ulcers. It concluded that there exists low-certainty evidence that individuals suffering from non-blanchable erythema are at an increased risk of developing new pressure ulcers compared to those free from the condition. Low certainty evidence was noted for the prognostic effects of different ski descriptors, particularly the pressure ulcer history. This implies that there is a need for the adoption of improved preventive measures and skin assessment for patients with non-blanchable erythema.

Effective skin assessment can support early detection and influence the implementation of an appropriate intervention. Bates-Jensen Wound Assessment Tool (BWAT) can be applied in clinical practice to assess wound healing. Bates‐Jensen et al. (2019) evaluated the application of the BWAT to assess home residents with a pressure injury. The study reported pressure injury characteristics including natural history, anatomic, and stage location among racially and ethnically diverse residents. The prospective 16 weeks study covered 142 participants with 305 pressure injuries representing a prevalence of 34%. Subepidermal moisture and visual assessment were attained from heel, ischial, buttock, and sacrum ulcers every week. The study revealed that BWAT is an effective assessment tool because it offers objective and reliable data to support the detection of the progress of pressure injury healing.

Early detection and identification of pressure damage risk need to be prioritized. Kim et al. (2018) evaluated the association between the application of sub epidermal moisture measurement and visual assessment of early pressure ulceration. The study employed a descriptive prospective observational design where data was obtained from at-risk patients in Ireland within an acute care facility. Obtained data included researcher-led sub-epidermal moisture measurements and the patient’s skin condition. With a sample of 47 patients who had a mean age of 74.7 years, 19 patients suffered stage 1 pressure ulcers and elevated sub-epidermal moisture (SEM) levels. Results showed 83% specificity, where the majority of false positives lacked adequate follow-up time. The study noted a medium correlation between SEM findings and nurses’ visual skin assessment.

The SEM measurement tool required 1.5 days to detect damage, while nurses took an average of 5.5 days. This implies that SEM measurement can detect early damage about days ahead of the nurse assessment. Early detection of the pressure ulcers damage is beneficial because it develops within the deeper tissues. This can enable the adoption of effective prevention strategies before worsening the condition. Moreover, early detection can limit the associated mortality and morbidity, reduce the length of hospital stay and improve patients’ experience.

Pediatric pressure ulcers present a challenging problem in the healthcare services since it affects patients in many ways. Early detection is important to enable the establishment of effective corrective actions before the condition advances. The predictive power of Braden Q scale is controversial though it has been widely applied in the assessment of pediatric pressure ulcers. Liao et al. (2018) conducted a meta-analysis study to evaluate the scale’s predictive power for pressure ulcers among hospitalized children. Diverse databases were consulted, including CNKI, CINAHL, Cochrane Library, VIP, SinoMed, and Wangfang. Predictive value and demographic data were extracted. A MetaDiSc 1.4 was applied to calculate the pooled specificity, sensitivity as well as receiver operating characteristics (ROC). The study concluded that the Braden Q scale has a low specificity for pressure ulcers, medium sensitivity, and moderate predictive validity. This implies that the modification and development of the tool can promote the early detection of pressure ulcers among the pediatric population.

Medical Device-Related Interventions

Preventing pressure ulcers (PU) is better than treating them when they develop. Turning patients is one of the interventions that is widely applied to relieve pressure from prone areas. However, medical device-related interventions exist, and they can be applied to avoid bed sores. They can benefit nursing home residents, and hospital patients can take advantage of these prevention products, such as pressure-relieving mattresses, special cushions, and heel-elevating boots. Kamikawa et al. (2018) explained that a special pressure-relieving mattress could be used to hinder the development of ulcers among patients with a high risk. Long-term facilities and hospitals should consider installing these mattresses when handling immobile, comatose as well as elderly residents and patients. They operate by lessening pressure created on the skin and enhancing the patient’s comfort. They alternate periodically to move pressure points to lower extensive pressure on one body part. They can apply a mechanical system, including deflating or inflating air cells in the mattress to attain the required comfort. Moreover, special pads can be applied to soften the surface or lower pressure and avoid the development of ulcers.

PUs are major problems affecting the health system across the globe. Yafi et al. (2017) presented preliminary case studies showing the feasibility of spatial frequency domain imaging (SFDI) to promote assessing skin status in pre-existing wounds and high-risk populations. The technology involves the use of wide-field non-contact optical imaging with structured light that is capable of examining tissue constituents and optical properties. A near-infrared SFDI system was used to image patients at an increased risk for pressure ulcers. The study concluded that SFDI is a feasible optical technology that can be applied to assess blood volume status and tissue oxygen saturation quantitatively. It can offer an effective approach for pressure ulcer healing, risk stratification, and staging.

Most of the PIs present major health issues of concern around the globe that are preventable. However, effective guidelines, equipment, commitment, and education can help identify causes, examine issues as well as offer a solution to the problem. Gupta et al. (2020) used multidisciplinary clinical and risk assessment teams to test various changes as well as implementing an effective program. The study implemented skin inspection, the surface, nutrition, incontinence, and keep moving bundle. It used PI incidence calendars, turning clocks, and signs as reminders in the unit. Addressing device-related pressure injuries was achieved by paying attention to the endotracheal tube.

Attained changed were then determined using the Plan-Do-Study-Act approach. The study revealed an 83.5% reduction in HAPI incidences and a 9.7% drop in prevalence. It was concluded that the PIP bundle is an effective tool for the reduction of pressure injuries. This made it clear that the adoption of proper measures can help boost prevention and enable health organizations to reduce their cost of operation. The initiative presents a positive outcome to all the involved stakeholders, including patients, facility, and staff. Organizations realized cost reduction and achieve better utilization of staff resources due to fewer extended hospital stays. The reduction of the risk of PIs benefits patients since it promotes the quality of life and reduces the time spent in the hospital. Staff also benefits by achieving better job satisfaction and reduced workload. Nurses feel more satisfied with their work when they note progress among their patients. They also acquire beneficial quality improvement skills that can be applied to influence the success of other improvement projects.

Wound Care Nurse Consult

A wound care nurse consult is a healthcare professional who is experienced in wound care. The nurse is responsible for the evaluation of the effectiveness of the wound care program and offers advice to support the achievement of patients’ expectations. Working as a wound care center consultant requires one to attain the minimum educational requirements of a bachelor’s degree, several years of experience, and attain professional certification (Kazemi et al., 2018). These nurses must possess all the necessary skills, including effective communication and desire to offer quality services to patients. The ability to coordinate with other professionals, administrators, and staff is paramount in achieving the nursing objectives.

Patients with pressure ulcers depend on wound care nurses to support their treatment and avoid infections. They are involved in various critical services, including identification of the cause of wounds, development of treatment plans, mitigating infections, and caring for pressure injuries (Kazemi et al., 2018). They promote healing and show determination in the reduction of patient’s pain. They are expected to keep on improving their skills from time to time to remain relevant. This means that they need to enroll in specialized clinical training and continuing education courses. Wound care nurses consult are involved in the identification and implementation of the best care practices to hinder the development of pressure ulcers. They encourage the establishment of effective interventions to prevent the development of wounds among patients in post-acute and long-term care environments.

Education of healthcare providers, caregivers, families, and patients is important for the achievement of a proactive program of appropriate prevention interventions. Wound management requires the establishment of a comprehensive care plan to ensure that all the contributing factors are addressed. Since it is difficult to achieve a single solution to the issue, implementing a PIP bundle is necessary to support the provision of the best care to patients (Green et al., 2018). The best outcome can be achieved by the involvement of well-educated and dedicated personnel from diverse disciplines who are working together to achieve holistic patient care. A pressure ulcer is a significant problem because it is a major cause of high mortality and morbidity. They result in increased incidences long term care compromising the quality of healthcare and patient experience.

Hospital-acquired injuries are associated with poor quality of care in a facility and can affect its reputation (Green et al., 2018). These injuries can also influence lawsuits against staff and a health care facility. This implies that managing pressure ulcers is a challenging problem that requires the adoption of a holistic approach that considers diverse aspects. Wounds affect the patient care since it is associated with many issues, including regulatory, psychosocial, emotional, financial, as well as, medical-legal aspects. Téot et al. (2020) noted that improved knowledge of the pathophysiology of wounds could help address the complex factors. The article explained the evolving and current knowledge linked to pressure ulcers while considering the effective usage of negative pressure wound therapy. Green et al. (2018) explained that consultation is beneficial in disclosing issues affecting patients that are likely to cause pressure ulcers. Patients with chronic venous leg ulcers need quality care to manage their wounds and prevent deterioration of their condition.

Gaspar et al. (2019) explained that safe patient-handling techniques could lower the risk of pressure ulcers that occurs due to shearing and friction. Prophylactic application of materials such as soft silicone sacral dressing can limit the risk of sacral pressure injuries. Wound care nurse consults recommend continuing the preventive interventions and initiating the prevention bundle to improve the quality of care to patients in a critical care setting. They also recommend the assessment of education needs before the implementation of the bundle care to establish the baseline knowledge. Offering education can improve the ability of nurses to detect the presence of pressure ulcers and understand interventions measures to limit their development. Increased awareness needs to be emphasized on key areas, including pressure ulcer prevention, development, and specific details of the prevention bundle.

Dressings that are capable of maintaining a moist wound environment are beneficial because they promote healing and can also be applied for autolytic debridement. Synthetic dressing cause less discomfort, reduce caregiver time, and offer consistent moisture. Dressing includes hydrogels, transparent films, hydrocolloids, and foams. Transparent films are effective can be used alone or in combination with hydrocolloids or hydrogels. Foams and alginates can be applied for wounds with heavy exudate because they are highly absorbent. Wound nurse care consult recommends the use of wet-to-dry dressings for debridement while avoiding them for use as a substitute. Physicians need to be familiar with the available wound dressing options to offer the best care to patients.

Patients in critical care units are at a greater risk of acquiring HAPIs. Since addressing the problem requires integrated interventions, it is important to implement a PIP bundle to standardize strategies and lower incidences of PIs. An evidence-based PIP bundle initiative involving leadership support and staff involvement has proven effective in the reduction of HAPIs and subsequent improvement of patient experience, reduction in the cost of treatment, and length of hospital. Care bundles incorporate many interventions to hinder complications and enhance preventive measures. Bundle components include skin and pressure ulcers, use of pressure-relieving devices and surfaces, risk assessment, and regular repositioning. The institute of healthcare developed the concept to enhance the consistent application of preventive measures to eliminate and reduce the risk of certain complications. Facilities can implement the approach to lower the possibility of developing pressure ulcers and promote patients’ safety.

The existing gap is that there exist limited published research studies on HAPIs, making it difficult to access sufficient information. The literature recommends health providers improve risk assessment, avoidance of shear forces and friction, and pressure redistribution as important measures for the prevention of the HAPI initiative. Risk assessment covers a comprehensive skin assessment ranging from visual inspection to physical examination. It is necessary to adopt an effective skin assessment tool to ensure consistency in the delivery of healthcare to patients.

Medical device-related interventions encourage the provision of equipment to hinder the development of pressure injuries in hospitals. Pressure redistribution surfaces such as pressure-relieving mattresses act by reducing pressure on a particular part of the body by supporting extended spreading. However, hospitals need to inspect their mattresses regularly to eliminate those that are damaged or worn out since they would achieve the desired objective.

Pressure Injury Prevention Bundle: High-Risk Interventions

Pressure injuries present major economic and clinical issues extending a detrimental impact to the health care system and patients. Most of these are hospital-acquired, implying that they are preventable through the taking of the necessary precaution. Although there is growing evidence supporting the prevention of pressure injury, there exists a gap in the implementation of effective preventative strategies. This means that pressure injuries continue causing detrimental impacts in hospitals. The pressure injury prevention care bundle is an effective approach to protect at-risk patients. This theme will provide information on high-risk interventions and explore three subthemes, namely the application of preventive dressing, turning, reposition and offloading, and other interventions.

Application of Preventive Dressings

Implementation of PU preventive strategies can play a role in the reduction of injury occurrences in long-term and acute settings. These injuries result in a massive economic and social burden and considerable mortality and morbidity. These sub-themes will consult various published recommendations for the application of preventive dressing in the treatment of open wounds to hinder the development of PUs. Encompassing the best practices with preventive dressing can influence the achievement of the best outcome. The application of the care bundle offers standardized methods for preventing the development of PUs.

Hahnel et al. (2020) argued that the application of dressings with the integration of the standard prevention is an effective approach in the prevention of HAPIs on the sacrum and heels. It involved a controlled, randomized, two-arm, superiority pragmatic study where the heels and sacrum of the intervention group were dressed. The study screened 7575 patients for eligibility, where 475 were allocated and included. The control group had 210, while the intervention group was allocated, 212 patients. The study revealed that incidences of PU among high-risk patients remain high in ICU. It made it clear that dressing of heels and sacrum, when done with additional standard preventive measures, lower absolute and relative risks for PU development. This provided evidence that preventive dressing at the sacrum and heels is a feasible approach in the prevention of PUs.

The application of preventive dressing on intact skin can significantly reduce shear forces and tension between the support surfaces and the skin. This helps lower shear forces within the underlying soft tissues and the skin. Hahnel et al. (2020) investigated whether the preventive dressing is effective when handling patients in the high-risk intensive care units. The study evaluated the effectiveness of preventive multilayered soft silicone foam dressing when applied with standard prevention approaches. The objective was to determine whether it could lower deep tissue injury (DTI) and cumulative PU incidence for categories II, III, and IV. Eligible patients were aged at least 18 years who were expected to remain in the ICU for more than 3 days. The risk assessment was based on the care dependency and mobility of patients. The study concluded that the use of preventive dressing and standard care could help prevent PUs among high-risk patients in the ICU. Unlike other interventions such as repositioning, special support surfaces, mobilization, and floating heels, the application of preventive dressing presents an easy-to-apply approach.

The use of prophylactic dressings can offer an effective strategy to support the prevention of pressure ulcers by enhancing the distribution of external pressure. They prevent friction and shear damage by hindering pressure in high-risk patients. Cornish (2017) confirmed that the application of a prophylactic dressing presents many benefits when considered in the holistic pressure ulcer prevention strategy. The dressing is examined from time to time without causing trauma or pain to patients making it an effective option. However, the article recommends nurses consider promoting hygiene and good nursing care to achieve the best outcome. The additional components of temperature, humidity, friction, and shear should motivate clinicians to establish a holistic approach to support high-risk patients. Prophylactic dressings can retain sufficient moisture to promote elasticity in the skin while reducing skin stripping, excoriation, and maceration. It also can retain the heat necessary for the healing process.

El Genedy et al. (2020) considered the cost of applying a preventive dressing and noted that they are less cost-effective and more expensive when applied on heels due to low incidences. They can generate better outcomes when applied with other PU prevention strategies. The dressing should only be applied to patients at high risk because of the economic efficiency. The analysis was conducted in a hospital setting where 422 ICU patients were analyzed. The calculated cost was based on the total for both change and application labor and applied preventive dressing. The actual number of dressings on sacrum and heels were computed, and the figure was multiplied by the unit price. The time needed for change of dressings and application was multiplied by the labor costs and then by the hourly pay for the nurses. The study recommends the involvement of all parties in both social and financial terms to determine whether to apply the approach.

Avsar et al. (2020) argued that preventive dressing could help reduce frictional forces extended to the skin since the outer surface consist of a friction resistance material. It can redistribute and absorb shear forces since they have high adhesion to the skin. The study also noted that the lateral and high loft movement is important characteristics of preventive dressing in lowering shear forces. The padding and high loft/thickness propriety reduce pressure on the body tissues enabling cushioning of bony prominences. Another important characteristic is the reduction of humidity at the dressing and skin interface. This is because the dressing allows moisture to evaporate since it is absorbent. This implies that dressing can play a role in the reduction of PU incidences and improvement of patient’s safety in ICU.

Nutrition services

Nutrition services offer patients with counseling and education on the appropriate diet based on their health condition. It focuses on well-being and overall health, and it can sometimes be considered as part of the treatment process. They are provided by a registered nutritionist or dietitian who is specialized in the area of interest. Registered dietitians apply evidence-based practice and offer reliable information based on the expected outcome. Pérez‐Escamilla & Engmann (2019) argued that PIs could be linked to malnutrition and undernutrition, explaining the importance of involving a specialist to enhance their prevention. The risk of developing PIs tends to increase when patients in critical care units become undernourished and lose weight. The dietician can guide a patient on the most appropriate diet to reduce the risk of developing PIs. Moreover, the specialist can offer guidance to support those who have already developed PIs to realize faster recovery. Billah et al. (2017) explained that increased energy and protein intake play a role in the reduction in the improvement of the healing process. Guidelines for nutritional treatment and assessment entail conducting a nutritional screening for patients at a heightened risk of developing pressure ulcers and a comprehensive nutritional assessment for those at the risk of malnutrition. It also encourages the development of a customized care plan for an individual with PIs and are malnourished. Dieticians determine the quality of food and evaluate whether they are meeting the minimum requirements by estimating the patients’ needs in terms of protein and calories.

Consultant dietitians are skilled in the identification of the causes of undernutrition, including dentition issues, dysphagia, dentition issues, loss of appetite, and other issues. They use their knowledge to offer recommendations to support the best interventions. They also coordinate with other practitioners to achieve the best nutritional needs (Billah et al., 2017). These specialists apply diverse approaches depending on issues affecting the patient and the type of wound, characteristics, and severity. This facilitates the development of the most appropriate care plan for the patient. These specialists take part in the treatment of wounds as well as in the establishment of preventive measures. They offer education and recommendations that help reduce the risk of developing PUs and improve the patient’s experience. They are also involved in goal setting, counseling, and monitoring of nutritional needs to support patients, particularly those in the critical care units.

The risk of developing PUs is high among overweight and underweight patients who are not eating a balanced diet. Maintaining a healthy weight can limit the risk of developing PUs because the skin required an adequate supply of nutrients and fluid to ensure its circulation as well as keep it supple. Underweight patients have reduced padding on bony areas increasing chances of developing PUs on areas such as hips and bottom. Having excess weight increases the weight-bearing load while reducing mobility. This exposes them to a greater risk of developing PUs because of the created excessive pressure.

Nutrition is important for the healing of PUs once they have occurred and prevent their advancement. The body requires energy, proteins, minerals, and vitamin to function properly and attain faster healing. Dietitians ensure that patients take plenty of fluid to boost their healing process. Patients with PUs are advised to take more protein since it forms the building blocks necessary for their recovery. These foods include eggs, fish, meat, beans, nuts, milk, and pulses (Pérez‐Escamilla & Engmann, 2019). It is important to ensure that patients in critical care units have at least one source of protein in all their meals. Iron is also important for the healing process, and patients are encouraged to ensure that they attain the right intake. The mineral is necessary for the maintenance of sufficient blood hemoglobin levels. They should eat such as eggs, fish, meat, beans, green vegetables, and dried fruits to ensure the right intake of iron. The food of patients in the critical care units must contain sufficient vitamin C since it promotes the absorption of iron from the food. This promotes the healing process and improves the quality of care to patients. It is necessary to ensure that their meals contain sufficient sources of vitamin C, including vegetables and fruits (Pérez‐Escamilla & Engmann, 2019). Zinc is another important mineral for patients since it plays a role in the development of new tissues.

Turning, Repositioning, and Offloading

The following subtheme refers to the idea that various turning, repositioning, and offloading techniques; approaches to this intervention can lead to better patient outcomes. Repositioning and turning effectiveness is supposed to increase when medical professionals follow specific strategies to make decisions and take action. The articles of this subtheme try to address appropriate research questions as to how it is possible to maximize repositioning effectiveness.

Various positioning and turning types form an area of interest for modern scholars. The study by Krapfl et al. (2017) is a literature review that has searched three databases, including CINAHL, EMBASE, and PubMed, to identify relevant articles. As a result, the scientists have extracted five research pieces that focused on the effect of incremental positioning. The findings demonstrate that this approach leads to certain changes regarding gravitational equilibrium, but this fact does not result in a reduced number of pressure injuries.

Oomens et al. (2016) selected 14 volunteers and analyzed magnetic resonance imaging (MRI) of their sacral areas. It was necessary to determine how tilting would affect individuals’ skin. The participants in a supine position demonstrate the highest strains in the muscle and fat,resulting in the scholarly view that tilting at an angle between 20º and 30º is optimal since it protects individuals from pressure injuries in their sacral areas.

Next, the development of effective, evidence-based turning schedules is an important component of reducing the incidence rate and impact of HAPIs. Sving et al. (2016) conduct a quasi-experimental, pre-and post-test study of 506 patients. The scientists implemented different turning schedules and assessed their impact on participants’ health. The analyzed findings demonstrate that turning schedules are not effective when used in isolation. This information indicates that it is necessary to use repositioning and turning together with additional interventions to ensure that the HAPI incidence is addressed.

A laboratory study by Wiggermann, Zhou, and McGann (2021) assesses the effectiveness of three repositioning aids, including turn and position glide sheets, pair of friction-reducing sheets, and air-assisted transfer devices, for three participants. This research demonstrates that these aids are typically insufficient to mitigate the risk of traumas. Consequently, it is not rational to rely on the interventions above to protect individuals from pressure injuries.

The findings of the current subtheme support the overall tendency that has been identified throughout the theme exploration. It relates to the fact that there is controversial evidence regarding the effectiveness of repositioning and turning in preventing pressure ulcers. These four studies have demonstrated that the same is true for various repositioning techniques and approaches. Even though the findings are controversial, it is possible to extract one typical issue. Many articles demonstrate that managing pressure injuries is a complex task that requires a comprehensive approach.

Each of the presented articles implies some limitations that deserve attention. Relatively small sample size is a limitation for some articles (Avsar et al., 2020; Mäki-Turja-Rostedt et al., 2019; Lin et al., 2020; Jocelyn Chew et al., 2018; Mussa et al., 2018; Eren, et al., 2020; Krapfl et al., 2017; Oomens et al., 2016; Sharp et al., 2019; Wiggermann et al., 2021). The reliance on relatively outdated sources is a limitation of a different group of articles (Atkinson & Cullum, 2018; Latimer et al., 2017; Courvoisier et al., 2018; Pechlivanoglou et al., 2018; Lovegrove et al., 2020; Aljezawi & Tubaishat, 2018; Chitambira & Evans, 2018; Gray & Giuliano, 2018; Sving et al., 2016). The study by Gaspar et al. (2019) is limited since it does not imply coding to ensure an unbiased review of the articles. The studies’ strengths refer to the fact that the findings are consistent and reliable.

Since the articles above represent a single theme, it is not a surprise that they focus on similar variables. All of them focus on what effects turning, and repositioning can produce. The research pieces under analysis have provided some controversial findings. For example, Atkinson and Cullum (2018) and Latimer et al. (2017) admit the effectiveness of turning and repositioning, while Gaspar et al. (2019) and Mäki-Turja-Rostedt et al. (2019) state that their effect is limited. The same is found with repositioning intervals because Courvoisier et al. (2018) highlight the effectiveness of 2- and 3-hourly repositioning, while Jocelyn Chew et al. (2018) do not admit any statistically significant difference between them. This information reveals that it is reasonable to conduct a quantitative study to fill the gap regarding the effectiveness of 2-hourly repositioning. The following theme will comment on the use of turning and repositioning with other interventions to assess whether this approach is more effective.

Six studies are analyzed, including the works by Jiang et al. (2020), Powers (2016), Sauvage et al. (2017), Alshahrani, Sim, and Middleton (2021), Bai, Liu, Chou, and Hsu (2020), and Bambi, Yusuf, and Irwan (2020). These pieces of research try to answer research questions of whether mattresses and pillows increase turning and repositioning effectiveness in reducing the pressure ulcer incidence and mattresses of what type are better.

Jiang et al. (2020) have conducted a multicenter, open-label, and comparative study with 1,204 participants. This fact has allowed the researchers to compare the effectiveness of viscoelastic foam and air pressure redistribution mattresses. The researchers mention that the viscoelastic foam and air pressure redistribution mattresses are effective pressure injury prevention methods, but there is no significant difference between the two. According to the authors, further research is necessary to assess the mattresses’ effect for different repositioning intervals.

Powers (2016) has selected 59 participants and investigated whether the standard of care (SOC) using pillows is better than a patient positioning system (PPS) in a nonrandomized study. The scholar states that the use of pillows is not sufficient to reduce the pressure injury prevalence. It is reasonable to conduct a randomized study to investigate the given issue and identify what additional measures are necessary to solve the problem.

Simultaneously, a literature review by Bambi et al. (2020) deals with randomized controlled trials and prospective cohort studies. The scholars analyze four studies that fit their inclusion criteria. They insist that the use of 30º repositioning cushions reduces interface pressure, which, in turn, leads to a reduced incidence of pressure ulcers in healthcare facilities. It is possible to claim that these results are reliable and credible since the authors deal with a high level of evidence.

The article by Sauvage et al. (2017) is a randomized, controlled, superiority, parallel-group, open-label, multicenter study of 76 patients. The scientists have compared the effectiveness of alternating pressure air mattresses (APAM) and viscoelastic foam mattresses (VFM). The authors admit that the APAMs are more effective compared to the VFMs. It is reasonable to involve a larger sample size to test the reliability of these results and consider their generalizability.

Alshahrani et al. (2021) offer a systematic review of randomized controlled trials, quasi-experimental designs, case series, and cross-sectional studies. Analysis of 14 articles demonstrates positive outcomes of using specific surface support in addition to repositioning. This information allows for concluding that there is a robust connection between the reduced HAPI incidence and a multifaceted intervention. However, the authors assess the level of evidence as moderate or low, meaning that further research is necessary.

An observational prospective cohort study by Bai et al. (2020) compares the effectiveness of non-pressure redistributing foam mattresses and pressure redistributing ones. The sample size of 254 participants was divided into experimental and control groups with 127 members in each. The authors indicate that the use of pressure redistributing mattresses leads to a significantly reduced risk of pressure injury occurrence. These findings allow for concluding that the combination of this intervention with repositioning can lead to better outcomes.

The results of this subtheme are of significance for the major theme and overall project. The articles demonstrate that pillows, as well as viscoelastic foam and air pressure redistribution mattresses, can cope with the task. In addition to that, the subtheme indicates that APAMs are better at decreasing the incidence of pressure ulcers among older patients. It means that the research field agrees that regular repositioning can be more effective if patients use specific mattresses that reduce pressure on individuals’ skin and muscles.

Usage of Technology to Prevent Pressure Injuries

According to the information above, it is natural to discuss the use of interventions with other technologies to combat pressure injuries. This topic is requested in the research field as scholars continue to assess various additional measures’ effectiveness.This subtheme addresses the issue that using the PIP bundle and related interventions charges nurses with responsibility. It relates to the fact that many individuals forget to move to avoid pressure injuries because of various reasons. Thus, crucial tasks of nurses include remindingpatients of the necessity of moving, applying preventive dressings, or repositioningthem. In this case, medical professionals need assistance to cope with the assignment successfully, and CBPM systems and other electronic devices can be helpful in this case. There are various electronic devices, including automatic repositioning systems, wearable patient sensors, accelerometers, and others, can decrease the incidence of pressure injuries.

The work by Gunningberg, Sedin, Andersson, and Pingel (2017) is a pragmatic randomized controlled trial of 190 patients, including control and intervention groups. CBPM systems were applied to the intervention group to test whether the given intervention has the potential to protect older patients from pressure injuries. The authors conclude that the application of the CBPM systems does not lead to any significant improvement regarding pressure injury incidence. It means that further research is necessary to test whether the blinded intervention will have the same impact on patient health.

Gunningberg and Carli (2016) have conducted a prospective and quantitative study of 19 registered nurses and 33 assistant nurses, where the medical professionals assessed the effectiveness of CBPM. This approach allows the researchers to find that healthcare professionals highly appraise the instrument, stating that this intervention leads to optimized repositioning, which is helpful to reduce pressure ulcers. Further research is necessary to investigate the patients’ perception of CBPM systems.

Hultin et al. (2019) offer a qualitative, descriptive study of 31 orthopedic patients who are 65 years old and higher. They participated in semi-structured interviews, and their answers were subject to qualitative content analysis. This approach allows for identifying that the CBPM system increases adults’ awareness of pressure injuries and the necessity to prevent them. It denotes that this instrument is significant for patients to make them more engaged in HAPI prevention measures.

The given subtheme demonstrates that both medical professionals and patients positively assess the use of CBPM to prevent pressure injuries. This instrument implies some benefits because regular notifications of the necessity to change the patients’ position are convenient for all the stakeholders. Qualitative methodologies produce these results, while a randomized controlled trial by Gunningberg et al. (2017) does not identify reduced HAPI incidence. Further research implying a blind intervention is necessary to find the actual effect of CBPM systems. These findings reveal that this topic is considered using different methodologies, meaning that the given project is not interested in addressing this topic.

Edger (2017) conducts a prospective before-and-after study with 717 patients to test a repositioning device’s impact. The author also focuses on the cost-effectiveness of the given intervention. This repositioning device reduces the pressure injury incidence from 1.3% to 0%, while the return on investment accounts for more than $16,000 (Edger, 2017, p. 236). This information reveals that the tool under analysis maximizes the repositioning and turning advantages.

Knibbe, Zwaenepoel, Knibbe, and Beeckman (2018) assess the effect of an automatic repositioning system on 13 patients over four weeks to analyze how an automated repositioning system can influence their skin. The authors admit that an automatic repositioning system leads to recovery from pressure ulcers. This article is another research piece that supports the idea that the combination of turning and repositioning with additional technological tools is beneficial for patients.

Minteer et al. (2020) analyze two sensor devices that imply no contact with the patient skin to track ten individuals’ movements. The scholars organize a specific experiment to assess this tool’s effectiveness. The study reveals that the sensor devices accurately track patient movements. This finding allows for concluding that medical professionals can rely on these devices to monitor if patients engage in regular repositioning and address this situation if some inefficiencies exist.

The article by Gunningberg, Bååth, and Sving (2018) is a descriptive study of 50 medical professionals who participate in semi-structured interviews. The authors claim that nurses highly appreciate the use of pressure mapping systems to stimulate the repositioning and turning of patients. Hommel, Gunningberg, Idvall, and Bååth (2017) conduct qualitative semi-structured interviews of 39 participants. This article shows that nurses believe that regular turning is an effective intervention to reduce pressure injury prevalence.

The study by Pickham et al. (2018) is a randomized clinical trial that includes 1,312 participants divided into control and experimental groups to evaluate the use of a wearable patient sensor. The experiment demonstrates that the tool under analysis is helpful since it makes patients change their positions every two hours. This approach results in the fact that the article offers arguments to support the effectiveness of 2-hourly repositioning.

Richardson, Peart, Wright, and McCullagh. (2017) conduct a quality improvement program that took place in four adult critical care units with 88 beds in total to test the use of technical and non-technical interventions. The study reveals that wearable sensors lead to lower pressure ulcer rates. In particular, the authors claim that the HAPI incidence reduced by 63% over four years (Richardson et al., 2017, p. 433). Consequently, it is rational to rely on devices to address HAPIs.

Duvall, Karg, Brienza, and Pealrman (2019) assess the effectiveness of the E-scale monitoring system for preventing pressure injuries among ten participants. The study reveals that the tool under analysis is capable of identifying patient movements with an increased level of accuracy. It denotes that the E-scale system can be considered a helpful instrument for healthcare professionals to monitor bed movements and promote them among patients when required.

A study by Yap, Kennerly, and Ly (2019) follows a mixed-method, pre-and post-test design. The scholars focus on 44 residents and 38 staff participants to identify whether a patient monitoring system can increase repositioning compliance. The study results demonstrate that this approach can increase the effectiveness of 2-hourly repositioning among nursing home residents. Consequently, this electronic device implies essential advantages that make it a helpful tool in preventing HAPIs.

Stinson, Ferguson, and Porter-Armstrong (2018) analyze the findings of two recent articles with at-risk cohorts, including 21 participants in total. The study assesses the use and impact of accelerometers and interface pressure mapping systems. It is the only study that fails to highlight the positive effects of using electronic devices. The scholars admit that accelerometers and interface pressure mapping systems are not effective in preventing pressure injuries.

The studies of this subtheme demonstrate that the use of electronic devices can improve the effectiveness of repositioning in combating pressure ulcers. Even though some research pieces may not identify positive outcomes, most articles reveal that medical professionals and establishments should make an effort to choose the most suitable interventions. These findings show a consistent set of literature that proves the effectiveness of using electronic devices to manage HAPIs.

The articles from this theme have certain limitations that deserve attention. First, some studies are limited because they focus on small sample sizes (Hultin et al., 2019; Sauvage et al., 2017; Powers, 2016; Alshahrani et al., 2021; Bambi et al., 2020; Knible et al., 2018; Minteer et al., 2020; Stinson et al., 2018; Duvall et al., 2019; Yap et al., 2019). Secondy, other studies are narrow-focused, meaning that their results cannot be generalized (Gunningberg & Carli, 2016; Gunningberg et al., 2017; Jiang et al., 2020; Bai et al., 2020; Edger, 2017; Pickham et al., 2018; Richardson et al., 2017). Scholars make specific efforts to ensure that these limitations are addressed. Some of them rely on reputable review guidelines (Alshahrani et al., 2021; Bambi et al., 2020), while others invest in following scientific principles to increase the level of evidence.

These results support the findings of Theme 1 that turning and repositioning are effective when used with additional interventions. It denotes that there is no gap in this area, meaning that the scientific processes of the project should focus on turning and repositioning in isolation. Quantitative articles from Theme 2 demonstrate that this methodology can provide the required information to identify the effectiveness of quality improvement initiatives. The following section will determine how it is possible to affect HAPIs.

Summary of literature review

Patients in ICU are usually inactive, exposing them to the risk of developing HAPIs. The use of the PIP bundle can support the standardization of PIP strategies and influence a reduction in pressure ulcers. An evidence-based PIP bundle initiative needs support from the leadership and involved staff. The impact on the patient outcome negatively and hinders nurse satisfaction. They are associated with the increased cost of medication, prolonged hospital stay, poor patient experience, and a high rate of mortality. Risk factors for HAPIs development include sedation, immobility, hemodynamic instability, and vasopressors.

The management of PIP is an interdisciplinary approach, and its basic components include debriding necrotic tissue, relieving and reducing pressure on the skin, managing bacterial colonization and load, and identifying wound dressing. Pressure-reducing devices have proven effective in the prevention of HAPI in critical care settings. Static devices are appropriate when supporting patients who can independently change positions. An air-fluidized or low-air-loss bed is effective for patients with non-healing or multiple large ulcers. It is necessary to evaluate pain during debridement, dressing changes, and repositioning. Pain needs to be eliminated by adjusting pressure-reduction surfaces, covering the wound, and systematic analgesia.

The reduction of HAPIs and the implementation of PIP bundle necessitates a comprehensive approach while establishing a sense of ownership among nurses, involvement, engagement, and support of every stakeholder. The PIP bundle initiative is enhanced when health care workers show commitment to the provision of quality care to patients. Reducing HAPIs as well as maintaining the momentum is a major challenge affecting many critical care units. Implementing the integrated approach is an expensive process making it difficult for many hospitals to adopt despite its benefits. Moreover, there exists a gap in the literature, and further research is needed to improve the level of bundle evidence for the PIP implementation.

Limitations in the implementation of the PIP bundle care is the existence of environmental and patient variables that are likely to interfere with HAPI rates during the implementation process. This would affect the validity of the intervention because of the other influencing factors. Another limitation is that the PIP bundle required follow-up to ensure its sustainability. This calls for more commitment from nurses and facility administrators. Since the approach requires the integration of diverse care approaches, it requires the involvement of different disciplines and strong coordination. It necessitates improvement of communication to ensure that all the involved staff works together towards the achievement of desired objectives.

The project is important to be conducted because it encourages critical care units to implement PIP bundles to prevent patients from developing pressure ulcers. It is necessary to prevent the development of PUs because they are associated with poor functional recovery, and they increase chances of infections and pain, as well as extending the hospital stay. They can contribute to high mortality rates and are an indication of a poor overall prognosis. The project can enable health practitioners and critical care facilities to achieve their objectives of offering quality care to patients. PUs increases pressure on patients and compromises their ability to respond to treatment. This implies that health organizations should not hesitate to implement PIP to promote patients’ experience and reduce their stay in the hospital. The design of the project is applicable in diverse settings enabling its implementations in different facilities. Health providers should consider investing in the PIP bundle to boost their service to patients.

Methodology

The project addresses an essential healthcare issue that adversely affects population health. The purpose of this project is to identify whether implementation of PIP bundle contribute to reduced HAPI incidence. It means that the project aims at identifying whether usage of PIP bundle more effective than the current practice. For that purpose, it is reasonable to use appropriate methods.

Since the chapter’s focus is to explain the specifics of conducting the project, the aim is to mention specific details. In this chapter, the problem, clinical question, appropriate methodology, design, population, and sample are considered. Chapter 3 comments on the instruments and sources used to obtain the data for the project. Their validity and reliability are described, while the data collection and analysis procedures are also explained in detail. A sufficient narrative is also dedicated to potential bias and mitigation efforts. Thus, all this information is required to demonstrate how the project should be conducted so that replication by others is possible.

Statement of the Problem

The project focuses on a specific problem that negatively impacts the quality of health care that hospitalized patients receive. The problem statement is as follows: It is not known if or to what degree the implementation PIP bundle would impact the HAPI incidence when compared to current practice among the critical care patient population in a 13-bed unit in urban New York. This situation deserves attention because more than 2.5 million individuals suffer from the given issue (Padula et al., 2019) despite the efforts of healthcare professionals and organizations that devote their time and efforts to mitigate the problem. The project seems rational because the unit under analysis reports an HAPI rate of 14%, which is higher than the national average.

Clinical Question

The question guiding this project is: To what degree does the implementation of PIP bundle impact the HAPI incidence when compared to current practice among hospitalized critical care patients in a 13-bed unit in urban New York over four weeks? Any clinical question is necessary to narrow the focus of the project. It also reveals the basic information of how the project is going to be performed, including the proposed intervention, and chosen setting. It is possible to rephrase the clinical question into a shorter one that is presented below:

Q1: Is usage of PIP bundle more effective when compared to current practice?

The clinical question also introduces the matching of the project variables. PIP bundle represent an independent variable, and nurses have to use PIP bundle for every patient in critical care unit. A dependent variable is defined by the HAPI incidence that will be measured pre- and post-intervention to identify whether the implementation of the independent variable results in any quality improvement.

In an attempt to answer the clinical question, a between-groups approach to collecting data should be used. It implies that participants in the intervention and comparison groups are different. The intervention (after) group only includes individuals who received the proposed intervention. Thus, wound care nurses and head nurses of the unit collect aggregate data on the sample size to identify how many pressure injuries occur, and this process implies working with patients’ EHRs.

Project Methodology

A quantitative methodology is appropriate because it relies on numerical data, and this approach is necessary to identify the incidence of a particular phenomenon. Creswell and Creswell (2018) explain that the main benefit of this approach is that it allows for conducting an experiment to collect and analyze the data. Bell et al. (2018) admit that this methodology applies different statistical tests, including t-test, which increases the reliability of the obtained results. Simultaneously, Rutberg and Bouikidis (2018) stipulate that a quantitative method is appropriate when it is necessary to answer a clinical question to achieve quality improvement. Since the project’s clinical question focuses on HAPI incidence, it is not a surprise that the quantitative methodology is the most optimal option.

At this point, it is rational to compare quantitative and qualitative methodologies. While a quantitative method focuses on identifying numerical representations of an issue, a qualitative approach is typically used to identify new perspectives regarding a phenomenon under analysis (Creswell & Creswell, 2018). Furthermore, qualitative methodologies are typically more energy and time consuming, and it denotes that the given approach is not appropriate to the project.

The project is based on the existing knowledge about pressure injuries, meaning that this approach is not required. The quantitative methodology is the best approach since it is feasible for the project and contributes to an increased clinical relevance because it focuses on the credible measurement of numerical data and manage to answer the clinical question and meet the specific purpose.

Project Design

The reason for selecting a quasi-experimental design is to conduct an experiment that does not imply randomization. This approach is time and resource-efficient to identify a correlation between dependent and independent variables. Thus, the given design is relevant because Rutberg and Bouikidis (2018) state that it allows for assessing the intervention’s effectiveness for experimental and control groups. Siedlecki (2020) also admits that case studies, descriptive, and correlational designs are not appropriate since they are less practical compared to the selected approach. Thus, it is necessary to stipulate that the quasi-experimental design is ideally aligned with the quantitative methodology.

The reason for selecting this approach is the necessity of applying the intervention (PIP bundle) and identifying whether it leads to improved outcomes (reduced HAPI incidence). The independent variable that is the intervention is the use of PIP bundle.This term stands for several evidence-based interventions, known as a bundle, are more efficient when introduced in combination (Frank et al., 2017). The PIP bundle components used in this project are based on standard- and high-risk interventions. According to the bundle designed by Rivera et al. (2020), patients with a Braden score above 19 should receive the standard intervention. In contrast, patients with points equal to or below 18 will get high-risk intervention (Rivera et al., 2020). These interventions include skin assessment, medical device-related interventions, wound care nurse consult, application of preventive dressings, turning, offloading and nutrition consult.

Head nurse and wound care nurses should ensure that the nurses follow this intervention. The dependent variable refers to a HAPI incidence rate that is measured by focusing on the number of patients who develop pressure injuries during their hospital stay. The data for the dependent variable will be collected by analyzing electronic health records after the end of the intervention process. Wound care nurses will access the records to stipulate how many pressure ulcers will develop.

First step of this project is to collect the pre-intervention data, the nursing staff will be provided with education on the PIP bundle (independent variable). Staff education of all elements of PIP bundle is very critical to prevent HAPIs. Education will be ongoing to provide necessary support to the staff. Head Nurse and Wound Care Nurses will be providing training in all shifts.Nurses will implement the PIP interventions for patients according to their assessed risk: standard-risk versus high-risk. The following data will be collected for the intervention population four weeks after the education has been completed and the PIP bundle interventions have begun: age, gender, and number of new HAPIs.

Population and Sample Selection

The project focuses on the total population consisting of all people that come to the project facility for care. This definition refers to adults of different ages, sexes, and nationalities. This organization stipulates that it had 371 staffed beds in 2016. This number is considered a basis from which the project sample can be found. It is also reasonable to admit that the unit staff members are included in the project population.

The project sample includes hospitalized critical care patients admitted to adult medical intensive care unit. The rationale behind this choice is that these patients have higher HAPI risks, including instable vital signs and spending much time in lying or sitting positions. The project sample is found from a 13-bed unit of the selected facility. A non-probability convenience sampling technique is used for this project. It implies that the participants are included in the project because they are currently available to the investigator. Jager, Putnick, and Bornstein (2017) clarify that this approach is advantageous because it ensures that samples are sufficiently diverse. It occurs because no strict exclusion criteria are used in the project. Since the project uses a before and after design, it is necessary to have two groups of patients. The before (comparison) group includes the described patients on the unit four weeks before the project, while the members of the after (intervention) group will be subject to use of PIP bundle.

It is reasonable to state that all the available patients admitted to the unit will be subject to the intervention. The intervention protocol implies that the members of the after group will get PIP bundle related interventions, and head nurses will also ensure that these individuals receive PIP bundle. With this, all the participants’ data will be used in analysis to identify the HAPI incidence. It allows for supposing that the project sample size will equal the number of people who will be used in instruments. It is also necessary to admit that no informed consent is necessary for this quality improvement project. The sample size will consist of people who meet the following criteria: being admitted to critical care unit, and from urban New York. The project will ensure confidentiality because the investigators will define the HAPI incidence by working with wound care nurses. Investigator will be using a coding system without copying or reproducing information in any way.

Instrumentation or Sources of Data

The project focuses on EHR to collect data. Wound care nurses will collect data from EHR. Wound care nurses will provide the HAPI incidence numbers to investigator without providing the name of the patient and medical record number. This data refers to assessing the HAPI incidence that is possible when the investigators have access to the participants’ EHRs to identify who of them suffer from pressure injuries. It is reasonable to use this intervention measurement because evidence-based practice supports it (Hyun, Moffatt-Bruce, Cooper, Hixon, & Kaewprag, 2019; Wu, Lee, Lai, Huang, & Chang, 2019).

Electronic Health Records

This indicator can be assessed from the facility’s EHRs that should contain information on whether a person has a pressure ulcer. The selected facility uses a specific electronic database to store, manage, and work with patients’ data. It means that EHRs should include all the details that are directly related to individual health. The project site use Epic system for electronic documentation. At the facility, nurses are responsible for completing the documentation in Epic system.

In addition, wound care nurses retrieve this data from epic for reporting purposes. Epic is a reliable system that is used for documentation of new hospital acquired pressure injuries. The investigators should ensure that the patient information is protected by not copying or distributing the data. The investigator will get data from the wound care team. A Health Insurance Portability and Accountability Act (HIPAA) waiver of authorization is necessary to ensure that the medical facility may provide patient information to third parties. This instrumentwill be used to collect the data regarding the newly acquired pressure injuries.

Validity

Validity demonstrates whether the project accurately assesses the concept that it intends to analyze. Since the HAPI incidence is under investigation, the project aims at identifying this statistical measure by finding the number of pressure injury occurrences among the sample size. The site’s HAPI data are stored in the EHR and will be the source for data collection in the project;validity of the EHR as the source of data and of the PIP bundle intervention documentation are cornerstones of the project. According to Hernandez-Boussard, Monda, Crespo, and Riskin (2019), the validity of electronic health records is higher than 95% (p. 1189). Thus, the project deals with decent external validity since it ensures that the instrument focuses on the issue.

Reliability

Reliability refers to whether a project can be replicated to produce similar results. As for the given project, its ability to yield similar conclusions is limited because the facility deals with a constantly changing population. Hyun et al. (2019) identify the HAPI incidence of 5.81% in an academic medical center (para. 4). This statistical measure can be used to assess the project’s findings reliability. The wound care nurses who handle HAPI data at the project facility have the national certification of Wound Ostomy Continence Nurse, a certification that requires experience, training, and successful completion of a test, thus their expertise is reliable. Further, the reliability statistics can reported in a seminal work by Barakat-Johnson et al. (2018), report that a Cohen’s Kappa of.88 is present when wound nurse consultants assess the presence of HAPIs using an electronic database.

Data Collection Procedures

Following approval from the Institutional review board at Grand Canyon University, the investigator will contact the chosen facility in urban New York to obtain its permission to conduct the project within this setting and access patients’ EHRs. Simultaneously, the Institutional Review Board’s (IRB) approval is necessary prior to involve in any project activities. These two approvals are of significance since they justify the project and confirm that it aims at achieving positive outcomes.

The following step will be receiving the pre-intervention data. Currently, the assigned critical care unit has 14% HAPIs rate. In this project, it refers to HAPI surveillance data that the facility gathers. Wound care nurses and head nurses of the unit collect the required information and transmit it to EHRs. Consequently, the primary investigator accesses the unit’s aggregate data reports to identify how many patients suffer from HAPIs when receiving the standard of care over four weeks. This information demonstrates that the project does not include any direct contact with patients. Simultaneously, this narrative indicates that the project deals with aggregate data.

During this step, sufficient attention is drawn to security measures. To ensure the privacy of data, the investigator uses a coding system. Numbers from 1 to 64 (or others, depending on how many individuals will participate in the project) are assigned to the participants to ensure confidentiality. If a participant has experienced a pressure ulcer, 1 is placed, while 0 denotes that no HAPI has occurred. The investigator writes the notes by hand, and each of them has one figure representing the participant number (1-64) and another figure displacing the presence of absence of a HAPI (0 or 1). The notes are not available as part of an automated report and may not be uploaded to any web clouds to avoid a digital information leak. Instead of it, the notes should be stored in a locked cabinet that may only be accessed by the chief investigator. The data should be kept for three years after the project is completed. When this period is over, the materials will be physically destroyed to prevent any misuse of this information.

Prior to implementing the intervention, it is reasonable to provide education to the nurses who are responsible for using PIP bundle for critical care patients with the project guidance. It is rational to highlight to the healthcare professionals that the project results are dependent on their actions.

The following step deals with collecting the post-intervention data that refer to the project’s dependent variable. The after data is also HAPI surveillance details that the facility gathers after the intervention has been implemented. Thus, the wound care nurses and head nurses of the unit will also collect these data. The information is also transmitted to the facility’s EHRs where it is stored. This description denotes that no direct contact with patients is implied. Furthermore, it is worth admitting that aggregate, not individual, data are the project’s focus.

When the 4-week period is over, the investigator should access the facility’s EHRs to identify the aggregate data on how many participants have experienced pressure ulcers. An appropriate coding system is used to achieve privacy standards. The participants are assigned numbers 1-64 (or others, depending on how many individuals will participate in the project) to protect their personal data. Simultaneously, codes are used to track the dependent variable, HAPIs. Thus, 1 is given to patients with a pressure ulcer, while 0 implies that this condition does not affect the person. The investigator writes the notes by hand, and each of them has one figure representing the participant number (1-64) and another figure displacing the presence of absence of a HAPI (0 or 1). The notes are not available as part of an automated report and may not be uploaded to any web clouds to avoid a digital information leak. Furthermore, all these materials should be stored in a locked cabinet that may only be accessed by the investigator. The data should be kept for three years after the project is completed. When this period is over, the materials will be physically destroyed to prevent any misuse of this information.

It is worth admitting that Step 2 and Step 5 contribute to collecting the information that is required for the comparison of variables. It refers to the fact that these activities allow the investigator to collect the necessary details that can be used to identify whether the proposed intervention (PIP bundle) leads to statistically significant quality improvement. Consequently, the following section comments on how the obtained results can be analyzed to arrive at conclusions.

Data Analysis Procedures

The question guiding this project is: To what degree does the implementation of PIP bundle impact the HAPI incidence when compared to current practice among hospitalized critical care patients in a 13-bed unit in urban New York over four weeks? The independent variable, PIP bundle, is the project’s intervention and is absent in the comparison groups. The HAPI incidence is the project’s dependent variable, and it is necessary to compare this value for two independent groups. For that purpose, the independent t-test is suitable since this inferential statistical test measures the difference between the means of two groups. This parametric test is appropriate to the project since the latter follows a before and after design, meaning that two groups should reveal the effect of the intervention.

The first step of running the t-test is to prepare the raw data. The coding system, where 1 refers to a HAPI and 0 denotes its absence, produces categorical data. It is necessary to create two tables with numbers 1-64, and each line should contain either 1 or 0, depending on whether the participant has experienced a pressure ulcer. Since the t-test focuses on the means, the second step is to calculate this measure for the two samples. Once these values are obtained, it is possible to conduct the third step of running the t-test to identify whether the difference between the measures is statistically significant. The specific level of the statistical significance (p<.05) is chosen to ensure that the obtained results are statistically significant and minimize the effect of chance. This requirement is also necessary because it justifies that the findings are scientifically valuable.

Potential Bias and Mitigation

Any scientific study can be subject to numerous biases that can adversely affect the quality of work, and quantitative articles often face threats that can undermine their internal validity. This term is the degree to which the results are accurate and that “permits causal inferences to be made regarding the association between the independent and dependent variable” (Flannelly, Flannelly, & Jankowski, 2018). There can be intentional and unintentional bias, and it is the investigator’s moral responsibility to address all the possible issues that can invalidate the project’s results. Consequently, the given section comments on what biases may be in the project and how they can be mitigated.

Firstly, a sampling bias can occur because the project deals with non-probability convenience sampling. Sometimes, this sampling technique witnesses criticism because this approach can favor some outcomes over others. This statement denotes that convenience sampling can produce inferences that are not as trustworthy as if a random sampling technique is used. However, this bias is mitigated because the sample selection procedure did not have many inclusion and exclusion criteria. Patients are included in the project because they are currently available to the investigator. Consequently, this approach is also advantageous because it ensures that samples are sufficiently diverse (Jager et al., 2017). This narrative reveals that the potential bias from convenience sampling was mitigated.

Secondly, some bias can adversely affect the data collection process. The selection bias implies that the project’s results can be impacted because some patient groups are underrepresented while others are over-represented. It can occur because people can be more or less likely to participate in the project. The project utilizes a convenience sampling technique that focuses on a single criterion to overcome this potential issue. If patients are available to the investigator, they are offered to participate in the project.

Third, specific efforts are dedicated to ensuring that data analysis is free from bias. This outcome is possible because the data is fully reported, meaning that it is not manipulated or misrepresented. The investigator ensures that it is true because the data analysis procedure is transparently described in detail. The project collects and analyzes aggregate data, and an appropriate statistical test is used to identify whether statistically significant improvements are found regarding the project’s dependent variable.

Fourthly, the project draws sufficient attention to ensuring that no bias affects the data interpretation step. Since a between-group design is employed, the t-test for independent groups is used because this parametric statistical test measures the difference between two independent groups (Creswell & Creswell, 2018). Furthermore, the project is not only focused on a single side of the problem. For example, even if the proposed intervention does not show statistically significant improvement in reducing the HAPI’s incidence, the project demonstrates whether the process results in other clinically significant improvements.

Ethical Considerations

A significant ethical issue relates to the fact that the project deals with patients’ EHRs. The challenge is that these records contain protected health information according to the HIPAA; it is necessary to obtain permission from the chosen facility. In this case, the project demonstrates that all the ethical issues are addressed. Simultaneously, the investigator ensures that confidentiality, anonymity, and privacy are present. For that purpose, the coding system is applied to use numerals instead of participants’ personal details. This requirement is necessary to protect personal data from disclosure.

The IRB approval is necessary since it should claim that it is a quality improvement project rather than research. This approval demonstrates that the investigator can proceed to data collection. The IRB approval letter is included in Appendix A to indicate that the project meets the requirement. Since the project is deemed a quality improvement one that is generally applied to all patients, there is no necessity to obtain informed consent from the participants. Furthermore, it is reasonable to admit that informed consent is also not required because the project deals with aggregate, not individual data. The site authorization letter is found in Appendix B, and it demonstrates that the chosen facility permits the investigator to conduct the project in the selected setting. Conflict of interest is absent because the investigator is not biased in completing the project in a particular way to achieve specific results. Full transparency is present in the project to prove the statement above.

The project adheres to the principles of the Belmont Report,as stipulated by the US Department of Health and Human Services (1979):respect, justice, and beneficence (Adashi, Walters & Menikoff, 2018). The principle of respect is ensured because no individuals are coerced to be involved in the project against their will. Thus, respect is found in the projects’ sample selection procedure. The principle of justice is present in the sample recruiting process since no bias is applied to representatives of a certain age, gender, or ethnic group. Simultaneously, the principle of beneficence is found in the project design and the theoretical framework. It refers to the fact that human subjects’ well-being is addressed because members of the two groups receive adequate care. In addition to that, the principle of beneficence is present in the project because no individuals involved in the scientific process are subjected to harm.

Hard copies of the coded materials will be stored in a locked cabinet in a safe place. The project does not involve the creation of digital copies of these data. The project’s results will be published as a requirement of the investigator’s Doctor of Nursing Practice. Finally, the materials will be stored for three months; when this period is over, their hard copies will be physically destroyed using a paper shredding machine.

Limitations

A few limitations are inherent to the given project. First, it refers to a small sample size since the project focuses on few individuals from a single 13-bed critical care unit. Even though such a sample size is unavoidable when dealing with similar healthcare setting, it is worth admitting that it is impossible to generalize the obtained results. This fact denotes that the findings cannot be applied to representatives of other population groups. However, this limitation is not expected to affect the findings negatively because the power analysis revealed that the sample size is sufficient. Furthermore, the focus on patients of a single facility allows for assessing the intervention’s effectiveness in the given context. This information can help identify an efficient way to prevent pressure ulcers among hospitalized individuals.

Second, the project’s results can be limited by its design and short timeframe. It refers to the fact that this quasi-experimental project lacks randomization and does not focus on long-term effects. This QI project uses convenience sampling, not random sampling, so concessions are implied and accepted with this type of sampling. This fact also demonstrates that it is impossible to generalize the findings. However, this weakness is delimited because the statistical test is used to assess specific outcomes in the short run. In addition to that, this limitation is not negative since it brings some advantages. For example, the absence of randomization denotes that the project does not require many financial resources and much time. Focusing on a limited time frame can also be advantageous since it assesses the short-term effectiveness of the chosen intervention to reduce the incidence of pressure injuries.

Third, a significant limitation exists because the project’s results depend on how accurately the EHRs are created. This weakness is unavoidable in the given design because healthcare professionals are responsible for making these records. In particular, nationally certified wound care nurses and head nurses of the unit will collect the aggregate data on HAPI incidence and insert it in the EHRs. However, it is not expected that this fact will generate many negative results because it is assumed that the healthcare professionals perform these functions diligently and attentively.

The project has delimitations set out by the investigator. First, the project facility is chosen explicitly because its nursing staff welcomes the use of evidence-based practice. The facility has an existing culture that promotes the implementation of quality improvement initiatives; the selected site has a rich history of dealing with multiple health issues. Thus, the decision to focus on the 13-bed unit is a significant delimitation of the given project. This information justifies the assumption that the facility staff will actively and diligently participate in the project.

Second, the focus on the specific population is also a delimitation because it ensures that the project will produce specialized findings. Luo, Long, Wu, Huang, and Zeng (2019) explain that people of 60 years old and higher are more subjected to pressure ulcers. This information denotes that it will be possible to use the project findings as a guide to prevent HAPIs among hospitalized patients and improve the population’s health. Third, the use of a nursing theory by Jean Watson (2018) is another delimitation. This step ensures that the project has solid theoretical support as well as a caring perspective of patients.

Summary

Chapter 3 presents the main methodological details of the given project, and important consideration for possiblereproduction or replication of the intervention by other investigators addressing the same problem. The chapter includes tasks or process steps and their rationale.

The project focuses on an important healthcare problem that affects many individuals. More than 2.5 million people are subject to pressure ulcers, meaning that it is necessary to address the issue (Padula et al., 2019). This project aims at answering whether PIP bundle is more effective than current practice. Thus, PIP bundle is the independent variable, while the HAPI incidence among hospitalized patients is a dependent one.

Scientific evidence demonstrates that a quantitative methodology is optimal to answer the question above. The rationale is that this approach collects numerical data and applies statistical tests to identify whether the obtained results are statistically significant (Creswell & Creswell, 2018; Bell et al., 2018). Simultaneously, a quasi-experimental design is used to answer the clinical question. This design is appropriate because it assesses the effectiveness of an intervention for experimental and control groups(Rutberg & Bouikidis, 2018). This information demonstrates that the project follows a suitable approach to assess the intervention.

Chapter 3 also describes how the project finds and selects the sample. For that purpose, a 13-bed critical care unit of a medical facility is contacted to find individuals whose data can be used in the project. The inclusion criteria are being all patients admitted to medical intensive care, and from urban New York. A non-probability convenience sampling technique is used, and this approach is advantageous for scientific works (Jager et al., 2017). Furthermore, the project deals with specific instruments and sources of data. The project focuses on aggregate data, the investigator does not cooperate with patients directly to determine how many individuals are subject to pressure injuries. Sufficient details are mentioned that this approach is valid and reliable (Barakat-Johnson et al., 2018). This information demonstrates that there is a rationale behind following the proposed method.

The exhaustive discussion also addresses data collection and analysis procedures. First, Chapter 3 offers a step-by-step narrative regarding how the data should be accessed and collected. Five separate steps describe the data collection process addressing many aspects including confidentiality and others. Second, the discussion of the data analysis process comments on the preparation of raw data for analysis and stipulates that the t-test for independent groups is suitable for the project (Creswell & Creswell, 2018). Third, Chapter 3 also discusses many ethical issues that can address the project, including confidentiality, respect, justice, and others. Finally, the project enumerates possible biases and limitations and offers reliable arguments on how these weak points can be overcome.

The process and products of the project comprise the remainder of this project report. Chapters 4 and 5 follow the implementation of the PIP bundle intervention. Data descriptive data, depending variable data analysis procedures and results appear in Chapter 4. The project summary, findings, and conclusions, as well as theoretical, practical, and future implications and recommendations for future progress and practice are the components of Chapter 5.

Data Analysis and Results

The project considers the development of pressure ulcers among patients in the critical care units. It explains how the problem affects the quality of health care among hospitalized patients. The problem statement attempts to evaluate the impact of HAPI incidences upon the implementation of the PIP bundle when compared to current practice among the critical care patient population in a 13-bed unit in urban New York. Specifically, with an average age of 64, this unit reports the prevalence of pressure ulcers of 14%. Furthermore, 55% of all pressure injuries in the hospital are found in this unit. Older patients often experience mobility problems, and their skins are damaged through dehydration. Certain medical conditions can hinder the effective flow of blood, influence movement problems, and make skin more fragile.

The project utilized numerical data to determine the prevalence of pressure ulcers and enhance collection and analyzes of data. The reliability of the results will be improved by the use of statistical test. A quantitative approach was adopted because it is marked with increased clinical relevance and facilitates answering of the clinical question. The study involves a quantitative and quasi-experimental design to determine whether the implementation of a PIP bundle can reduce the prevalence of HAPIs among patients in critical care units. Jean Watson’s human caring nursing theory is effective in examining the effectiveness of the bundle. The theoretical framework of Kurt Lewin’s (1951) change management theory supported the analysis of forces and subsequent balancing of the change plan. The theory offered an effective framework for the preventive bundle. Lewin’s Change Theory entailed a three-step change model, and it is effective in supporting the implementation of interventions to enhance the achievement of desirable changes in nursing. The purpose of the project is to measure the HAPI incidence rate during the patients’ hospital stay upon the implementation of the PIP bundle. For this purpose, the wound care team accessed EHR to identify whether a patient experiences a pressure ulcer.

Clinical question attempts to evaluate the degree of the PIP bundle implementations impacting the HAPI incidences among patients in critical care units within four weeks. This compares the effectiveness of the PIP bundle with that of the current practice. The clinical question determined whether implementation of PIP bundle has a greater impact of reducing HAPI incidences than current practice in a 13-bed unit in urban New York over four weeks. The clinical question helps suggests the intervention approach as well as the study settings.

The PIP bundle offered a beneficial audit tool to support the provision of valuable information concerning adherence and knowledge gaps. It focused on improving documentation in the EHR and reduction of pressure injuries among patients in the critical care units (Hahnel et al., 2020). The WOC nurses were encouraged to influence and reinforce the use of the PIP bundle during wound consults and rounds since it was not part of the EMR. The training was provided on specific areas to improve their ability to treat patients and implement the bundle effectively. WOC nurses also reviewed and instructed documentation during consultations and daily briefs. Reinforcement was ensured by every health provider during PIP rounds and daily briefs.

Audit results offered beneficial information concerning adherence to the bundle and existing gaps in documentation. The litigious environment linked to pressure ulcers shows that gaps in knowledge are of critical importance. The project team had to ensure that nurses are well educated on key issues such as documentation and the treatment process. All professionals, including the nurse manager, resource nurses, and physicians, encouraged the staff to ensure adherence (Hahnel et al., 2020).

The bundle was implemented in the critical care unit, and measures were established to ensure its sustainability. Stakeholders were encouraged to remain vigilant and determined in the prevention of HAPI.

Descriptive Data

The project took a sample of patients from a 371 staffed-bed hospital in 2021. The sample covered patients admitted in the critical care unit since they had increased chances of developing HAPI (Chapter 2). A 13-bed unit was selected for analysis within the facility. The project screened the data over four weeks before the implementation phase in the adult critical care unit The sample consisted of total 64 patients, 40 (62.5%) males and 24 (37.5) females. As noted in the table 1 below, the ages of the samples ranged from 28 to 86. In post-implementation phase, total of 63 patients were involved in sample size, ages of the samples ranged from 29-83. The median age of the post-implementation group was 66 year old. The primary diagnoses included medical cardiac problems such as congestive failure or myocardial infarction. Others included endocrine and renal problems, gastrointestinal and pulmonary ailments. Demographic data for the sample included age, gender, and admission date (Table 1). Selected patients were placed in two groups, namely pre-intervention and post-intervention group, the post-intervention group received the PIP bundle treatment to hinder the development of pressure ulcers. Criteria for selection included adult patients from urban New York who were admitted to the selected critical care unit.

With a fairly wide variability of ages, mainly among elderly people, the duration of their stay in the hospital was, on average, slightly higher in the pre-intervention group than in the post-intervention group, but the boundary values ​​are wider in the first group. The calculated p-values ​​from the t-test results, equal to 0.9 and 0.8 for the first and second sample of correspondence, show weak statistical significance both in terms of age and duration of stay. In this regard, it is still impossible to deny the null hypothesis of the absence of statistically significant correlations.

	Pre-intervention				Post intervention
	M	SD	Min	Max	M	SD	Min	Max
Age	64.516	13.486	28	86	65.634	12.792	29	83
LOS	4.924	3.788	0.9	25.95	4.847	3.659	1.89	24.88

Data Analysis Procedures

Data was extracted from the unit’s electronic record by the wound care nurses and later was analyzed using t-test statistical methods. Wound care nurses provided de-identified data to the primary investigator. The investigator obtained the required data before and after the implementation of the PIP bundle.

The pre-intervention data collection engaged nurses with the standard practices for pressure injury prevention. Education and training were done before the bundle implementation. The appropriate nurse-to-patient ratio was maintained to ensure the satisfaction of all bundle requirements. The unit nurses were held responsible for implementing all interventions based upon the PIP bundle. Data collection was done by analyzing the implementation compliance differences before and after the PIP bundle intervention. The prevalence of pressure ulcers was measured before and after the bundle intervention.

Results

	Result
Age	-0.235
LOS	0.1169

The t-test results, which are 0.12 and -0.23 for LOS and age, respectively, can be interpreted as follows. First, the pre-intervention and post intervention groups are quite similar, as evidenced by the low value of the t criterion, which is less than one. A negative value does not affect the significance, as it is also not too large for the age attribute. Consequently, the difference from the null hypothesis has a very low probability in the t-distribution, which is also evidenced by a sufficiently high p-value.

Results of the study answered the clinical question by confirming that the implementation of the PIP bundle reduced the incidences of pressure ulcers. Support and involvement of stakeholders promoted a sense of ownership and engagement (Green et al., 2018). Leadership and staff support were essential elements in the improvement of sustainability, adherence, and adoption of the bundle. Identification of gaps during the implementation process and routine auditing facilitated the establishment of the necessary corrective measures to influence the success. Table 2 below illustrates that the implementation of PIP bundle reduced the number of reported cases of PIs and improve the quality of health care. Reduction of the incidences of pressure injuries is an indication that the PIP bundle was an effective approach.

	Pre-intervention group	Post intervention group
Incidences of pressure ulcers	21	14

Implementing the bundle influenced a massive decline in HAPIs (Chapter 2) for patients in the critical care unit. A 33% HAPI reduction was noted in the post-intervention stage upon implementation of the pressure injury intervention bundle over the four weeks. Pre-intervention injuries included unstageable pressure and stage 2 pressure injuries. HAPI locations were the sacrum, ear, upper thigh, heel, ischia tuberosity, as well as on the heel. During the post-intervention period, a stage two injury was noted on the sacrum. Table 4.3 shows that the intervention facilitated a significant reduction of HAPI and promoted the safety of patients in critical control units. There was reduction in stage I and stage II HAPIs, this was an expectation since this project was aimed only for four weeks.

The reduction influenced beneficial impact to nurses and improved their job satisfaction and patient outcome. The bundle was implemented in the critical care unit, and measures were established to ensure its sustainability. Stakeholders were encouraged to remain vigilant and determined in the prevention of HAPI. A poor nursing ratio can hinder the effective implementation of the bundle since it comes with more responsibilities to nurses. High workload due to shortage of nurses may influence infrequent repositioning for patients in critical care units. The study revealed that the PIP bundle lowers the severity of PIs, implying that there is a need to enhance the training of nurses.

The study also revealed that pre-intervention training improved nurse’s confidence and familiarity, and subsequent compliance. Feedback and review of clinical manifestations facilitated the successful implementation of the PIP bundle and supported the development of professional behavior (Gaspar et al., 2019). High compliance was ensured by the development of an audit behavior checklist. The approach is an effective strategy to satisfy the individual needs of patients.

An audit tool was utilized to facilitate compliance, and it contained a series of yes or no questions. Table 3 below illustrates the checklist to analyze the achieved level of adherence. Table 3 answers whether the patient had this assignment or not. The PIP bundle was recorded upon satisfaction of the audit tool contents. In case a single requirement was not meet, results were recorded as unimplemented. The creation of awareness and training of nurses influenced a high level of adherence to the bundle implementation resulting in the achievement of a desirable outcome.

Covered area	Intervention	Answer: yes or no
Patient repositioning	Patients completely turned every two hours	Yes
Skin assessment	Use of PI staging assessment tool as well as records to ensure complete skin assessment	Yes
Skincare	Effectively used neutral/ weak acid to clean the skin	Yes
	Used skin protectant to hinder skin lessons associated with moisture skin	Yes
	Maintained the skin clean and dry	Yes
Medical devices	Used pressure redistribution or decompression device for patients at risk	Yes
Nutrition	Regularly and closely monitored nutritional needs	Yes
	Offered individualized nutritional guidance	Yes

The PIP bundle was successful because it reduced the incidences of HAPIs and played a role in the improvement of patients’ safety. Extended hospital stay is a risk factor for the development of PIs or secondary skin failure and disease burden (Gaspar et al., 2019). This makes it difficult to completely prevent or eradicate the development of the condition.

The guiding clinical question was to what degree does the implementation of the PIP bundle impact the HAPI incidence compared to current practice among critical care patients in a 13-bed unit in urban New York over four weeks? The project answered the question by confirming that the implementation of the PIP bundle reduces the HAPIs incidence compared to pre-implementation practice among critical care patients in a 13-bed unit in urban New York over four weeks. It made it clear that the PIP bundle is a sufficient approach for the reduction of HAPI incidences (Green et al., 2018). This means that the PIP bundle is an effective solution to the problem, and it is necessary to support its implementation.

Summary

The PIP bundle has proven effective in the reduction of PIs among adult patients in critical care settings. Implementation of the bundle significantly reduced incidences and promoted patients safety (Rivera et al., 2020). The project used an intervention group who received care with the PIP bundle. The pre-intervention group did not receive the PIP bundle and their retrospective data was collected prior to the implementation of the intervention with the intervention group. The provided data and subsequent analysis were relevant to the clinical question since they explained the process and impact of the PIP bundle implementation.

The data also helped determine beneficial preliminary measures that need to be considered to influence the success of the integrated approach. These include training and educating nurses to build their confidence and familiarity. Another important factor is the engagement of all stakeholders and encouraging everyone to play a role in ensuring that success is realized (Rivera et al., 2020). The development of an effective culture can support the implementation of the bundle because since it can support coordination, hard work, and desire to achieve the best outcome. The outcome of the study encouraged the implementation of the PIP bundle in a diverse setting to lower the chances of developing PIPs among patients with an extended hospital stay.

Chapter five will summarize the project and explain the importance of the topic, its contribution to the body of knowledge while providing recommendations. It will highlight important points in the study to help the audience attain a brief understanding of the entire project. It will offer a comprehensive recap of the applied procedures, obtained results while explaining its importance in the nursing field. By offering a summary of the results, it will provide details of the achieved outcome.

Summary, Conclusions, and Recommendations

This evidence-based practice (EBP) initiative project involved the implementation of a Pressure Injury Prevention (PIP) bundle to lower incidences of hospital-acquired pressure injuries (HAPIs) in an adult critical care setting. The wound, ostomy, and continence nurses (WOC nurses) collaborated with stakeholders to organize and develop the implementation plan. The nurse managers and senior leadership emphasized the importance of lowering HAPIs. Beneficial insight was provided from the bedside by the resource nurses. The bundle implementation over four weeks influenced a massive reduction from the pre-intervention to the post-intervention. Since it is an effective approach, the PIP bundle was implemented in the critical care unit. The health care workers were determined to provide quality health care to patients. Sustaining the momentum of HAPIs needs the involvement of all stakeholders and the support of every patient. The evidence of the bundle implementation level can be improved by conducting further research including randomized control trials.

Summary of the Project

The objective of the project was to identify patients at an increased risk for the development of HAPIs and implement a PIP bundle to reduce HAPIs in a critical care unit with 371 beds. With a sample size of 64 patients, the initiative described the PIP bundle implementation. The confirmed that the PIP bundle has the potential to reduce incidences of HAPIs and improve the quality of health care among critical care unit patients. It answered the clinical question by confirming that a bundle of interventions can reduce incidences of HAPIs and promote patients’ safety.

The study considered patients in critical care units because they are at an increased risk for the development of HAPIs because of prolonged confinement in beds, hemodynamic instability, mechanical ventilation, sedation, immobility, as well as vasopressors (Kazemi et al., 2018). It was noted that HAPIs tend to extend a negative impact to the patient/family experience, patient outcomes, cost of treatment, and nurse satisfaction. They result in an extended hospital stay that creates many other issues in the treatment process. The unit and the WOC nurses were encouraged to implement the PIP bundle to address the rising incidences of HAPIs in the adult critical care unit. Inconsistencies were noted during the root cause analysis in the PIP strategies.

The literature review offered an assessment and supported the evaluation of the current state of research on HAPI prevention, and evaluated initiatives taken in previous studies to reduce HAPIs. It provided a comprehensive definition of the bundle supporting the establishment of a standardized care process to enhance patient outcomes. Further, the literature review supported the identification of key questions regarding the implementation and selection of the PIP bundle to hinder the development of PIs. Apart from the provision of a knowledge foundation on HAPI prevention, the literature identified areas already covered in research to avoid duplication. Identified key factors that influence the successful implementation of a PIP bundle including feedback and audits, staff education, stakeholders’ involvement, and effective PIP teams.

Summary of Findings and Conclusion

The adult critical care unit selected had high incidences of HAPIs to support the evaluation of the impact of the implementation of the PIP bundle. There was high confinement in the hospital bed increasing the chances of developing PIs among patients. High incidences of HAPIs were recorded during the pre-intervention period and the team identified the best practice concerning the prevention of PIs. The adherence to the PIP bundle was assessed using an audit tool. This helped determine gaps in knowledge and understand areas that required improvement. Meetings with stakeholders helped engage and inform them about the process to be followed. The staff nurse was considered the skin champion to support the implementation of the process and following the provided guidelines. The overall efforts in the bundle implementation were meant to sustain the HAPI reduction. The sustainability of the bundle depends on the vigilance of the stakeholders implying that they must remain determined.

Implications

The results of the project are likely to encourage the adoption of a PIP bundle in critical care settings to hinder HAPIs. Many hospitals would implement the bundle to promote patient outcomes and offer better healthcare services. The DPI project results show that nursing theories are beneficial in guiding education and research, influencing better patient care, improving communication between nurses, and better professional status. Practically, it implies that the PIP bundle can be applied to a critical care unit setting to limit the chances of the development of HAPIs. It shows that better nursing outcomes would be achieved in the future due to improved research and implementation of EBP initiatives.

Guidelines for clinical practice can offer a starting point for the implementation of the PIP bundle. The study findings show that nurses knew beneficial preventive interventions. They were expected to apply basic interventions based on the provided guidelines to facilitate the effective implementation of the PIP bundle.

The need for explicit documentation is another practice implication noted from this EBP initiative. It is necessary to assess the skin status during the admission process and ensure that it is monitored closely. It is important to consistently document interventions for both the treatment and prevention of HAPIs. Documentation is necessary for legal and economic perspectives since PIP interventions are sometimes costly. Poor documentation can influence denial or reduction of reimbursement implying that it is important to ensure it is properly done. Insufficient documentation has influenced many medical liability allegations to go to trials and eventually face charges. Daily flow sheets and admission assessment forms can help staff nurses to promote documentation.

Theoretical Implications

The human caring nursing theory promotes healing and encourages the provision of a favorable healing environment. The theory encourages nurses to put their patients in the best environment to support their healing process. Active engagement in the caring process through intentionality and authentic presence enabled nurses to promote the ability of patients to recover. It improved the ability of nurses to maintain caring attitudes and emotional sensitivity, particularly when working in a demanding and over-stressed workplace. It potentiates capabilities and regenerates life energies to motivate nurses to offer the best service in critical care units. During the implementation of PIP bundles, the theory promoted self-actualization both personally and professionally. It motivated nurses to implement the PIP bundle to reduce incidences of HAPIs among adults in CCU. The theory was applied to improve patient satisfaction and encourage nurses to develop a positive attitude towards their patients and the environment. It promoted quality caring and influenced the implementation of the PIP bundle while enhancing patients’ experiences.

Practical Implications

Practice improvement can improve job satisfaction, patient experience and promote the nursing outcome. It can play a role in the reduction of the cost of treatment and lower the hospital stay. It can motivate nurses to work harder and remain focused on the achievement of their expectations. This can help solve the problem of a poor attitude towards the job and ensure that everyone is focused on the improvement of patients’ safety. Further research in the PIP bundle is likely to influence the better outcome and facilitate the achievement of the nursing objectives.

Nurses caring for patients particularly those in high-risk settings need to understand risk factors associated with the development of HAPIs and interventions necessary to enhance control. They need to be educated on key areas such as risk factors, prevalence and incidence, documentation, preventative interventions, patient education strategies, risk assessment scales, prevalence, and incidences.

Clinicians need to make an effort to identify patients who are at an increased risk of developing pressure. They need to consider risk factors such as cognitive impairment, lower body weight, Hispanic ethnicity, older age, and physical impairments. Patients with other comorbid conditions affecting the healing process and the integrity of the soft tissues such as impaired microcirculation, edema, diabetes, malnutrition, hypoalbuminemia, and fecal incontinence are exposed to the risk of developing pressure ulcers. Individualized decisions are necessary to determine whether to use a multicomponent or single intervention to hinder the development of pressure ulcers.

Future Implications

The project revealed that the PIP bundle can offer a solution to the problem of HAPIs among adult patients in the critical care unit. This means that implementation of the PIP bundle is likely to transform the delivery of health services to patients in critical units. Reduction in the prevalence of pressure ulcers would promote patients ‘experience, reduce the cost of treatment and enhance job satisfaction among nurses. Future DPI projects are likely to focus on improved interventions meant to boost the implementation of the PIP bundle and enhance its relevance in critical care settings. They are likely to consider measures to boost the motivation of nurses and improve their ability to collaborate with other practitioners. The other implication is that the DPI project would be implemented in critical care units and not in other units. This is because it was conducted in a unit where adult patients were confined in the hospital beds for a prolonged period.

Recommendations

Recommendations for Future Projects

Recommendations by experts should be tested empirically to ensure the most preventive interventions are adopted. More quasi-experimental studies are necessary to describe and test precisely and explain the relationship between outcomes, interventions, and risks. Based on the findings and results of the project, future DPI projects should evaluate the outcome of the bundle implementation while paying attention to factors such as quality of care, cost, and motivation for nurses. Quasi-experimental studies can support the development of better interventions to assist more patients in critical care units. They would also critically evaluate the involved risks offer guidance to improve patients’ safety. It is necessary to conduct further studies to evaluate the applied intentions and explain their relevance.

Future projects need to analyze the cost-benefit in the preventative intervention to justify its application in critical care units. This should include the analysis of the cost, benefits, and challenges associated with the PIP implementation. It is necessary to determine the actual cost and consider the obtained benefits to justify the implementation of the PIP bundle. Benefits analyses need to be conducted on ulcer development and preventive interventions. This can help offer evidence of potential benefits against the associated costs with the bundle implementation. Evaluated benefits should include savings on the treatment process, quality of care, patients’ satisfaction, and employee morale. The research would support the effective making of decisions when caring for patients in critical care units.

Further research is necessary to determine the comparative efficacy of different pressure ulcer risk assessment tools as well as compare it with clinical judgment. Limited studies exist on the efficacy of interventions warranting more researches. This can improve the ability of nurses and others health practitioners to make informed decisions regarding the best interventions to apply based on the patient’s condition. This can play a role in the reduction of the cost of treatment and promote the quality of care to patients. It would boost the knowledge of health providers and improve their understanding of issues affecting their patients.

Future DPI projects need to evaluate the impact of the PIP bundle implementation on the educational and skills needs of nurses. Since the EBP initiative incorporates diverse disciplines and encourages the application of diverse interventions, it is necessary to determine whether higher education would be necessary. The research needs to provide an answer to whether critical skills would be necessary to meet the new requirements. This will also determine whether the skills of nurses in the current practice are sufficient to support the bundle implementation.

More research is also necessary to determine whether the bundle can be implemented in other setting apart from critical care units. The research needs to determine changes that can be done in the bundle to fit and remain effective in different places. This is important to increase the number of patients benefiting from the DPI project. The research needs to determine measures that can be taken to motivate nurses and enhance their commitment.

Recommendations for Practice

This project recommends further documentation of HAPIs in critical care units to understand changing needs of the population. Documentation is important for improved clinical communication ensuring that information is shared appropriately. Further documentation of HAPIs would offer an accurate reflection of patient safety, explain the need for nursing assessments, and improve the ability of the multidisciplinary team to offer quality care. Accurate documentation would offer evidence of care, legal requirements and support effective decisions. It would ensure consistent communication enabling every nurse to offer the best quality service.

The development of a PIP checklist can help promote adherence to the provided guidelines and improve patient outcomes and nursing interventions. PIP checklist is the same as the intervention tool. The checklist can support the documentation of the number and types of the implemented preventive interventions. It can offer guidance to nurses during their practice and improve the patients’ experience. It would standardize the process enabling the consideration of all actions and elements. The predictability and structure of the checklist would support systematic and careful delivery of care to enhance performance while lowering variability. It would support the delivery of quality, safe, and evidence-based best practices by ensuring that every patient receives evidence-based care and democratizing knowledge. The checklist would support the implementation of a formalized process and eliminate inconsistent procedures and reduce chances of errors. It would support the adoption of effective interventions to influence the achievement of a better outcome. To avoid failure, it is recommendable to adhere to the established guidelines and ensure that every detail is followed.

The other recommendation is to train new staff in the large-scale PIP Bundle implementation and ensure that they have the right skills. Training would ensure that nurses develop the right skills required to support the successful implementation of the bundle. This can play a role in the motivation of nurses and other health practitioners to offer the best services to their patients and enhance adherence to the bundle. Providing them with the right knowledge would ensure that everyone understands the need of implementing the PIP bundle and remain committed to the delivery of quality care.

References

Adashi, E. Y., Walters, L. B., & Menikoff, J. A. (2018). The Belmont Report of 40: Reckoning with time. American Journal of Public Health, 108(10), 1345-1348. doi:10.2105/AJPH.2018.304580

Aljezawi, M., & Tubaishat, A. (2018). Pressure injuries among hospitalized patients with cancer. Journal of Wound, Ostomy, and Continence Nursing, 45(3), 227-232(6). doi:10.1097/WON.0000000000000429

Alshahrani, B., Sim, J., & Middleton, R. (2021). Nursing interventions for pressure injury prevention among critically ill patients: A systematic review. Journal of Clinical Nursing. doi:10.1111/jocn.15709

Anderson, M. (2020). Universal pressure ulcer prevention bundle with WOC nurse support: A pressure injury prevention journey. In M. A. Shiffman & M. Low (Eds.), Pressure Injury, Diabetes and Negative Pressure Wound Therapy (pp. 31–41). Springer International Publishing.

Atkinson, R. A., & Cullum, N. A. (2018). Interventions for pressure ulcers: A summary of evidence for prevention and treatment. Spinal Cord, 56, 186-198. doi:10.1038/s41393-017-0054-y

Avsar, P., Moore, Z., Patton, D., O’Connor, T., Budri, A. M. V., & Nugent, L. (2020). Repositioning for preventing pressure ulcers: A systematic review and meta-analysis. Journal of Wound Care, 29(9), 496-508. doi:10.12968/jowc.2020.29.9.496

Bai, D. L., Liu, T.-W., Chou, H.-L., & Hsu, Y.-L. (2020). Relationship between a pressure redistributing foam mattress and pressure injuries: An observational prospective cohort study. PLoS ONE, 15(11). doi:10.1371/journal.pone.0241276

Bambi, A., Yusuf, S., & Irwan, A. (2020). Use of pillow 30-degree in preventing the pressure in preventing pressure injury event. Jurnal Keperawatan, 12(3), 341-350. doi:10.32583/keperawatan.v12i3.742

Barakat-Johnson, M., Lai, M., Barnett, C., Wand, T., Lidia Wolak, D., Chan, C., Leong, T., & White, K. (2018). Hospital-acquired pressure injuries: Are they accurately reported? A prospective descriptive study in a large tertiary hospital in Australia. Journal of Tissue Viability, 27(4), 203-210.

Bates‐Jensen, B. M., McCreath, H. E., Harputlu, D., & Patlan, A. (2019). Reliability of the Bates‐Jensen wound assessment tool for pressure injury assessment: The pressure ulcer detection study. Wound Repair and Regeneration, 27(4), 386-395.

Bell, E., Bryman, A., & Harley, B. (2018). Business research methods. London, UK: Oxford University Press.

Billah, S. M., Saha, K. K., Khan, A. N. S., Chowdhury, A. H., Garnett, S. P., Arifeen, S. E., & Menon, P. (2017). Quality of nutrition services in primary health care facilities: Implications for integrating nutrition into the health system in Bangladesh. PloS one, 12(5), e0178121.

Burnes, B. (2020). The origins of Lewin’s three-step model of change. The Journal of Applied Behavioral Science, 56(1),32-59.

Chaboyer, W. P., Thalib, L., Harbeck, E., Coyer, F. M., Blot, S., Bull, C., Nogueira, P. C., & Lin, F. F. (2018). Incidence and prevalence of pressure injuries in adult intensive care patients: A systematic review and meta-analysis. Critical Care Medicine, 46(11), 1074-1081. doi:10.1097/CCM.0000000000003366

Chitambira, B., & Evans, S. (2018). Repositioning stroke patients with pusher syndrome to reduce incidence of pressure ulcers. British Journal of Neuroscience Nursing, 14(1), 16-21. doi:10.12968/bjnn.2018.14.1.16

Cornish, L. (2017). The use of prophylactic dressings in the prevention of pressure ulcers: a literature review. British journal of community nursing, 22(Sup6), S26–S32.

Courvoisier, D. S., Righi, L., Béné, N., Rae, A.-C., & Chopard, P. (2018). Variation in pressure ulcer prevalence and prevention in nursing homes: A multicenter study. Applied Nursing Research, 42, 45-50. doi:10.1016/j.apnr.2018.06.001

Cox, J., Roche, S., & Murphy, V. (2018). Pressure injury risk factors in critical care patients: A descriptive analysis. Advances in Skin & Wound Care, 31(7), 328-334. doi:10.1097/01.ASW.0000534699.50162.4e

Creswell, J. W., & Creswell, J. D. (2018).Research design: Qualitative, quantitative, and mixed methods approaches(5^th ed.).Thousand Oaks: CA. Sage Publications.

Dreyfus, J., Gayle, J., Trueman, P., Delhoughe, G., & Siddiqi, A. (2017). Assessment of risk factors associated with hospital-acquired pressure injuries and impact on health care utilization and cost outcomes in US hospitals. American Journal of Medical Quality, 33(4), 348-358. doi:10.1177/1062860617746741

Duvall, J., Karg, P., Brienza, D., & Pealrman, J. (2019). Detection and classification methodology for movements in the bed that supports continuous pressure injury risk assessment and repositioning compliance. Journal of Tissue Viability, 28(1), 7-13. doi:10.1016/j.jtv.2018.12.001

Edger, M. (2017). Effect of a patient-repositioning device in an intensive care unit on hospital-acquired pressure injury occurrences and cost: A before-after study. Journal of Wound, Ostomy, and Continence Nursing, 44(3), 236-240. doi:10.1097/WON.0000000000000328

El Genedy, M., Hahnel, E., Tomova‐Simitchieva, T., Padula, W. V., Hauß, A., Löber, N., Blume‐Peytavi, U., & Kottner, J. (2020). Cost-effectiveness of multi-layered silicone foam dressings for prevention of sacral and heel pressure ulcers in high-risk intensive care unit patients: An economic analysis of a randomised controlled trial. International Wound Journal, 17(5), 1291-1299.

Eren, F., DeLuca, R., & Kirshblum, S. (2020). Frequency of turning in bed at home in persons with chronic spinal cord injury. The Journal of Spinal Cord Medicine. doi:10.1080/10790268.2020.1800965

Flannelly, K. J., Flannelly, L. T., & Jankowski, K. R. B. (2018). Threats to the internal validity of experimental and quasi-experimental research in healthcare. Journal of Health Care Chaplaincy, 24(3), 107-130. doi:10.1080/08854726.2017.1421019

Frank, G., Walsh, K. E., Wooton, S., Bost, J., Dong, W., Keller, L., Miller, M., Zieker, K., & Brilli, R. J. (2017). Impact of a pressure injury prevention bundle in the solutions for patient safety network. Pediatric Quality & Safety, 2(2), 1-8.

Gaspar, S., Peralta, M., Marques, A., Budri, A., & de Matos, M. G. (2019). Effectiveness on hospital-acquired pressure ulcers prevention: A systematic review. International Wound Journal, 16(5), 1087-1102. doi:10.1111/iwj.13147

Gray, M., & Giuliano, K. K. (2018). Incontinence-associated dermatitis, characteristics, and relationship to pressure injury. Journal of Wound, Ostomy, and Continence Nursing, 45(1), 63-67. doi:10.1097/WON.0000000000000390

Green, J., Jester, R., McKinley, R., & Pooler, A. (2018). Chronic venous leg ulcer care: Putting the patient at the heart of leg ulcer care. Part 1: exploring the consultation. British Journal of Community Nursing, 23(Sup3), S30-S38.

Greenwood, C., & McGinnis, E. (2016). A retrospective analysis of the findings of pressure ulcer investigations in an acute trust in the UK. Journal of Tissue Viability, 25(2), 91-97. doi:10.1016/j.jtv.2016.02.008

Gunningberg, L., & Carli, C. (2016). Reduced pressure for fewer pressure ulcers: can real-time feedback of interface pressure optimise repositioning in bed?: Pressure ulcer prevention. International Wound Journal, 13(5), 774-779.

Gunningberg, L., Sedin, I.-M., Andersson, S., & Pingel, R. (2017). Pressure mapping to prevent pressure ulcers in a hospital setting: A pragmatic randomised controlled trial. International Journal of Nursing Studies, 72, 53-59.

Gunningberg, L., Bååth, C., & Sving, E. (2018). Staff’s perceptions of a pressure mapping system to prevent pressure injuries in a hospital ward: A qualitative study. Journal of Nursing Management, 26(2), 140-147.

Gupta, P., Shiju, S., Chacko, G., Thomas, M., Abas, A., Savarimuthu, I., Omari, E., Al-Balushi, S., Jessymo, P., Mathew, S., Quinto, M., McDonald, I., & Andrews, W. (2020). A quality improvement programme to reduce hospital-acquired pressure injuries. BMJ Open Quality, 9(3), e000905.

Hahnel, E., El Genedy, M., Tomova-Simitchieva, T., Hauß, A., Stroux, A., Lechner, A., Richter, C., Akdeniz, M., Blume-Peytavi, U., Löber, N., & Kottner, J. (2020). The effectiveness of two silicone dressings for sacral and heel pressure ulcer prevention compared with no dressings in high-risk intensive care unit patients: a randomized controlled parallel-group trial. The British journal of dermatology, 183(2), 256–264.

Han, Y., Jin, Y., Jin, T., Lee, S. M., & Lee, J. Y. (2019). Impact of pressure injuries on patient outcomes in a Korean hospital: A case-control study. Journal of Wound, Ostomy and Continence Nursing, 46(3), 194-200. doi: 10.1097/WON.0000000000000528

Hernandez-Boussard, T., Monda, K. L., Crespo, B. C., & Riskin, D. (2019). Real word evidence in cardiovascular medicine: Ensuring data validity in electronic health record-based studies. Journal of the American Medical Informatics Association, 26(11), 1189-1194. doi:10.1093/jamia/ocz119

Hommel, A., Gunningberg, L., Idvall, E., & Bååth, C. (2017). Successful factors to prevent pressure ulcers – An interview study. Journal of Clinical Nursing, 26(1-2), 182-189. doi:10.1111/jocn.13465

Hultin, L., Karlsson, A.-C., Öhrvall, M., & Gunningberg, L. (2019). Information and communication technology can increase patient participation in pressure injury prevention: A qualitative study in older orthopedic patients. Journal of Wound, Ostomy, and Continence Nursing, 46(5), 383-389. doi:10.1097/WON.0000000000000568

Hyun, S., Moffatt-Bruce, S., Cooper, C., Hixon, B., & Kaewprag, P. (2019). Prediction model for hospital-acquired pressure ulcer development: Retrospective cohort study. JMIR Medical Informatics, 7(3), e13785. doi:10.2196/13785

Jager, J., Putnick, D. L., & Bornstein, M. H. (2017). More than just convenient: The scientific merits of homogenous convenience samples. Monographs of the Society

Jiang, Q., Liu, Y., Yu, H., Song, S., Li, G., Liu, H., Zhou, Y., Zhu, Y., Jia, J., Huang, Y., & Wang, J. (2020). A Multicenter, Comparative Study of Two Pressure-Redistribution Mattresses with Repositioning Intervals for Critical Care Patients. Advances in skin & wound care, 33(3), 1–9.

Jocelyn Chew, H.-S., Thiara, E., Lopez, V., & Shorey, S. (2018). Turning frequency in adult bedridden patients to prevent hospital-acquired pressure ulcer: A scoping review. International Wound Journal, 15(2), 225-236. doi:10.1111/iwj.12855

Joint Commission. (2016). Preventing pressure injuries [PDF document]. Web.

Kayser, S. A., VanGilder, C. A., & Lachenbruch, C. (2019). Predictors of superficial and severe hospital-acquired pressure injuries: A cross-sectional study using the International Pressure Ulcer Prevalence™ survey. International Journal of Nursing Studies, 89, 46-52.

Kamikawa, N., Hamada, H., Sekikawa, K., Yamamoto, H., Fujika, Y., Kajiwara, T., Aizawa, F., & Otoyama, I. (2018). Posture and firmness changes in a pressure-relieving air mattress affect cough strength in elderly people with dysphagia. PLOS ONE, 13(12), e0208895.

Kazemi, A., Carnaggio, K., Clark, M., Shephard, C., & Okoye, G. A. (2018). Optimal wound care management in hidradenitis suppurativa. Journal of Dermatological Treatment, 29(2), 165-167.

Kennerly, S. M., & Yap, T. L. (2018). The role of manual patient turning in preventing hospital acquired conditions. California: Leaf Health Care.

Kim, C. G., Park, S., Ko, J. W., & Jo, S. (2018). The relationship of subepidermal moisture and early stage pressure injury by visual skin assessment. Journal of Tissue Viability, 27(3), 130-134.

Knibbe, N. E., Zwaenepoel, E., Knibbe, H. J., & Beeckman, D. (2018). An automatic repositioning system to prevent pressure ulcers: A case series. British Journal of Nursing, 27(6), S16-S22. doi:10.12968/bjon.2018.27.6.S16

Krapfl, L. A., Langin, J., Pike, C. A., & Pezzella, P. (2017). Does incremental positioning (weight shifts) reduce pressure injuries in critical care patients? Journal of Wound, Ostomy, and Continence Nursing, 44(4), 319-323. doi:10.1097/WON.0000000000000340

Latimer, S., Chaboyer, W., Thalib, L., McInnes, E., Bucknall, T., & Gillespie, B. M. (2019). Pressure injury prevalence and predictors among older adults in the first 36 hours of hospitalization. Journal of Clinical Nursing, 28(21-22), 4119-4127. doi:10.1111/jocn.14967

Latimer, S., Gillespie, B. M., & Chaboyer, W. (2017). Predictors of pressure injury prevention strategies in at-risk medical patients: An Australian multi-center study. Collegian, 24(2), 155-163. doi:10.1016/j.colegn.2015.11.005

Lewin, K. C. (1951). Field theory in social science. New York, NY: Harper & Row.

Li, Z., Lin, F., Thalib, L., & Chaboyer, W. (2020). Global prevalence and incidence of pressure injuries in hospitalized adult patients: A systematic review and meta-analysis. International Journal of Nursing Studies, 105(103546), 1-13. doi:10.1016/j.ijnurstu.2020.103546

Lim, M. L., &Ang, S. Y. (2017). Impact of hospital-acquired pressure injuries on hospital costs – experience of a tertiary hospital in Singapore. Wound Practice & Research: Journal of the Australian Wound Management Association, 25(1), 42-47.

Lin, F., Wu, Z., Song, B., Coyer, F., & Chaboyer, W. (2020). The effectiveness of multicomponent pressure injury prevention programs in adult intensive care patients: A systematic review. International Journal of Nursing Studies, 102. doi:10.1016/j.ijnurstu.2019.103483

Lovegrove, J., Fulbrook, P., & Miles, S. (2020). International consensus on pressure injury preventative interventions by risk level for critically ill patients: A modified Delphi study. International Wound Journal, 17(5), 1112-1127. doi:10.1111/iwj.13461

Luo, M., Long, X.-H., Wu, J.-I., Huang, S.-Z., & Zeng, Y. (2019). Incidence and risk factors of pressure injuries in surgical spinal patients: A retrospective study. Journal of Wound, Ostomy, and Continence Nursing, 46(5), 397-400. doi:10.1097/WON.0000000000000570

Mäki-Turja-Rostedt, S., Stolt, M., Leino-Kilpi, H., & Haavisto, E. (2019). Preventive interventions for pressure ulcers in long-term older people care facilities: A systematic review. Journal of Clinical Nursing, 28(13-14), 2420-2442. doi:10.1111/jocn.14767

Mansfield, S., Obraczka, K., & Roy, S. (2019). Pressure injury prevention: A survey. IEEE reviews in biomedical engineering, 13, 352-368.

Mervis, J. S., & Phillips, T. J. (2019). Pressure ulcers: Pathophysiology, epidemiology, risk factors, and presentation. Journal of the American Academy of Dermatology, 81(4), 881-890. doi:10.1016/j.jaad.2018.12.069

Minteer, D. M., Simon, P., Taylor, D. P., Jia, W., Li, Y., Sun, M., & Rubin, J. P. (2020). Pressure ulcer monitoring platform – A prospective, human subject clinical study to validate patient repositioning monitoring device to prevent pressure ulcers. Advances in Wound Care, 9(1), 28-33. doi:10.1089/wound.2018.0934

Mussa, C. C., Meksraityte, E., Li, J., Gulczynski, B., Liu, J., & Kuruc, A. (2018). Factors associated with endotracheal tube related pressure injury. SM Journal of Nursing, 4(1), 1-6.

New York State Department of Health. (2017). Pressure ulcer.

Oomens, C. W. J., Broek, M., Hemmes, B., & Bader, D. L. (2016). How does lateral tilting affect the internal strains in the sacral region of bed ridden patients? – A contribution to pressure ulcer prevention. Clinical Biomechanics, 35, 7-13. doi:10.1016/j.clinbiomech.2016.03.009

Padula, W. V., & Delarmente, B. A. (2019). The national cost of hospital-acquired pressure injuries in the United States. International Wound Journal, 16(3), 634-640.

Padula, W. V.,& Pronovost, P. J. (2018). Addressing the multisectoral impact of pressure injuries int the USA, UK, and abroad. BMJ Quality & Safety, 27(3), 171-173. doi:10.1136/bmjqs-2017-007021

Padula, W. V., Pronovost, P. J., Makic, M. B. F., Wald, H. L., Moran, D., Mishra, M. K., & Meltzer, D. O. (2019). Value of hospital resources for effective pressure injury prevention: A cost-effectiveness analysis. BMJ Quality & Safety, 28(2), 132-141. doi:10.1136/bmjqs-2017-007505

Pechlivanoglou, P., Paulden, M., Pham, B., Wong, J., Horn, S. D., & Krahn, M. (2018). Turning high-risk individuals: An economic evaluation of repositioning frequency in long-term care. Journal of the American Geriatrics Society, 66(7), 1409-1414. doi:10.1111/jgs.15387

Pérez‐Escamilla, R., & Engmann, C. (2019). Integrating nutrition services into health care systems platforms: Where are we and where do we go from here. Maternal & child nutrition, 15, e12743.

Pickham, D., Berte, N., Pihulic, M., Valdez, A., Mayer, B., & Desia, M. (2018). Effect of a wearable patient sensor on care delivery for preventing pressure injuries in acutely ill adults: A pragmatic randomized clinical trial (LS-HAPI study). International Journal of Nursing Studies, 80, 12-19. doi:10.1016/j.ijnurstu.2017.12.012

Pittman, J., Beeson, T., Dillon, J., Yang, Z., & Cuddigan, J. (2019). Hospital-acquired pressure injuries in critical and progressive care: Avoidable versus unavoidable. American Journal of Critical Care, 28(5), 338-350. doi:10.4037/ajcc2019264

Powers, J. (2016). Two methods for turning and positioning and the effect on pressure ulcer development: A comparison cohort study. Journal of Wound, Ostomy, and Continence Nursing, 43(1) 46-50. doi:10.1097/WON.0000000000000198

Razmus, I., &Bergquist-Beringer, S. (2017). Pressure injury prevalence and the rate of hospital-acquired pressure injury among pediatric patients in acute care. Journal of Wound, Ostomy, and Continence Nursing, 44(2), 110-117. doi:10.1097/WON.0000000000000306

Ricci, J. A., Bayer, L. R., & Orgill, D. P. (2017). Evidence-based medicine: The evaluation and treatment of pressure injuries. Plastic and Reconstructive Surgery, 139(1), 275e-286e. doi:10.1097/PRS.0000000000002850

Richardson, A., Peart, J., Wright, S. E., & McCullagh, I. J. (2017). Reducing the incidence of pressure ulcers in critical care units: A 4-year quality improvement. International Journal for Quality in Health Care, 29(3), 433-439. doi:10.1093/intqhc/mzx040

Rivera, J., Donohoe, E., Deady-Rooney, M., Douglas, M., & Samaniego, N. (2020). Implementing a Pressure Injury Prevention Bundle to Decrease Hospital-Acquired Pressure Injuries in an Adult Critical Care Unit: An Evidence-Based, Pilot Initiative. Wound Management & Prevention, 66(10), 20-28.

Romanelli, M., Clark, M., Gefen, A., & Ciprandi, G. (Eds.). (2018). Science and practice of pressure ulcer management (2^nd ed.). Springer Nature.

Rutberg, S., & Bouikidis, C. D. (2018). Focusing on the fundamentals: A simplistic differentiation between qualitative and quantitative research. Nephrology Nursing Journal, 45(2), 209-212.

Sauvage, P., Touflet, M., Pradere, C., Portalier, F., Michel, J. M., Charru, P., Passadori, Y., Fevrier, R., Hallet-Lezy, A. M., Beauchêne, F., & Scherrer, B. (2017). Pressure ulcers prevention efficacy of an alternating pressure air mattress in elderly patients: E²MAO a randomised study. Journal of wound care, 26(6), 304–312.

Schutt, S. C., Tarver, C., & Pezzani, M. (2018). Pilot study: Assessing the effect of continual position monitoring technology on compliance with patient turning protocols. Nursing Open, 5(1), 21-28.

Sharp, C. A., Moore, J. S. S., & McLaws, M.-L. (2019). Two-hourly repositioning for prevention of pressure ulcers in the elderly: Patient safety or elder abuse? Bioethical Inquiry, 16, 17-34. doi:10.1007/s11673-018-9892-3

Shi, C., Dumville, J. C., & Cullum, N. (2018). Skin status for predicting pressure ulcer development: a systematic review and meta-analyses. International Journal of Nursing Studies, 87, 14-25.

Siedlecki, S. L. (2020). Quasi-experimental research designs. Clinical Nurse Specialist, 34(5), 198-202. doi:10.1097/NUR.0000000000000540

Singh, C. D., Anderson, C., White, E., & Shoqirat, N. (2018). The impact of pediatric pressure injury prevention bundle on pediatric pressure injury rates. Journal of Wound, Ostomy and Continence Nursing, 45(3), 209-212.

Stinson, M., Ferguson, R., & Porter-Armstrong, A. (2018). Exploring repositioning movements in sitting with “at risk” groups using accelerometry and interface pressure mapping technologies. Journal of Tissue Viability, 27(1), 10-15. doi:10.1016/j.jtv.2017.11.001

Sving, E., Högman, M., Mamhidir, A.-G., & Gunningberg, L. (2016). Getting evidence-based pressure ulcer prevention into practice: A multi-faceted unit-tailored intervention in a hospital setting. International Wound Journal, 13(5), 645-654. doi:10.1111/iwj.12337

Téot, L., Geri, C., Lano, J., Cabrol, M., Linet, C., & Mercier, G. (2020). Complex wound healing outcomes for outpatients receiving care via telemedicine, home health, or wound clinic: a randomized controlled trial. The International Journal of Lower Extremity Wounds, 19(2), 197-204.

US Department of Health & Human Services. (1979). The Belmont report.

Wang, H.-R. N., Campbell, J., Doubrovsky, A., Singh, V., Collins, J., & Coyer, J. (2020). Pressure injury development in critically ill patients with a cervical collar in situ: A retrospective longitudinal study. International Wound Journal. doi:10.1111/iwj.13363

Watson, J. (2018). Unitary caring science: The philosophy and praxis of nursing. Louisville, CO: University Press of Colorado.

Wei, H., & Watson, J. (2019). Healthcare interprofessional team members’ perspectives on human caring: A directed content analysis study. International Journal of Nursing Sciences, 6(1), 17-23. doi:10.1016/j.ijnss.2018.12.001

Wiggermann, N., Zhou, J., & McGann, N. (2021). 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, 63(3), 565-577. doi:10.1177/0018720819895850

Woodhouse, M., Worsley, P. R., Voegeli, D., Schoonhoven, L., & Bader, D. L. (2019). How consistent and effective are current repositioning strategies for pressure ulcer prevention? Applied Nursing Research, 48, 58-62. doi:10.1016/j.apnr.2019.05.013

World Health Organization. (2008). Summary of the evidence on patient safety: implications for research. Geneva, Switzerland: WHO Press.

Wu, M.-W., Lee, T.-T., Lai, S.-M., Huang, C.-Y., & Chang, T.-H. (2019). Evaluation of electronic health records on the nursing process and patient outcomes regarding fall and pressure injuries. CIN: Computers, Informatics, Nursing, 37(11), 573-582. doi:10.1097/CIN.0000000000000548

Yafi, A., Muakkassa, F. K., Pasupneti, T., Fulton, J., Cuccia, D. J., Mazhar, A., Blasiole, K. N., & Mostow, E. N. (2017). Quantitative skin assessment using spatial frequency domain imaging (SFDI) in patients with or at high risk for pressure ulcers: QUANTITATIVE SKIN ASSESSMENT USING SPATIAL FREQUENCY. Lasers in Surgery and Medicine, 49(9), 827-834.

Yap, T. L., Kennerly, S. M., & Ly, K. (2019). Pressure injury prevention: Outcomes and challenges to use of resident monitoring technology in a nursing home. Journal of Wound, Ostomy, and Continence Nursing, 46(3), 207-213. doi:10.1097/WON.0000000000000523

Appendix A: The 10 Strategic Points

Broad Topic Area/Title of Project

Implementing Pressure Injury Prevention Bundle to Reduce Pressure Injuries in Critical Care.

Literature Review

• Background of the Problem/Gap:
  • The average age of MICU patients is 68, which is a significant risk factor for HAPI. Moreover, most patients in the department are critically ill, placing them in a high-risk group for pressure injuries development.
  • In the USA, pressure injuries or Hospital-Acquired Pressure Ulcers (HAPUs) “affect over 2.5 million individuals resulting in 60,000 deaths” (Padula et al., 2019, p. 132).
  • Pressure injuries are costly to the health care system and preventable.
  • An approach to using pressure injury prevention bundle can reduce the HAPIs among critical care patients.
• Theoretical Foundations (models and theories to be the foundation for the project):
  • Human caring nursing theory is used in this DPI project to identify how 2-hourly turning and repositioning can be associated with reduced HAPI incidence. Jean Watson (2018) proposed this theoretical framework by highlighting how to improve positive outcomes during human-to-human caring moments.
  • In addition to that, the DPI project focuses on a specific change theory. It refers to Kurt Lewin’s (1951) change management theory that is typically used for numerous quality improvement projects. This framework implies that patients change their behavior under the influence of driving or positive forces that affect individuals from outside (Lewin, 1951).
• Review of Literature with Key Organizing Themes and Sub-themes
  • Hospital-Acquired Pressure Injuries
    • HAPIs are preventable conditions, and their prevalence rates may vary from 3% to 33%, depending on external circumstances (Gray & Giuliano, 2018; Latimer et al., 2017; Lin et al., 2020).
    • Pressure injuries can affect individuals of various groups, including pediatric (Razmus & Bergquist-Beringer, 2017) and older patients (Hultin et al., 2019; Latimer et al., 2019).
    • Various factors contribute to the development of HAPUs, including diabetes mellitus (Cox, 2018), being 65 and more years old (Alvarez et al., 2016), and an increased length of hospital stay (Wang et al., 2020).
  • Risk Factors and Incidence Rates
    • Chaboyer et al. (2018) review this issue at length within the framework of a systematic review. The purpose of their research was to examine the problem of pressure ulcers that emerge as a result of clinical treatment in terms of scale and scope.
    • Greenwood and McGinnis (2016) venture into the territory of the root cause determination of HAPIs. Their article aims to outline the primary avenues of HAPU’s development in acute care environments.
    • Li et al. (2020) explore the issue from a global perspective, utilizing the international experience to address their clinical question. More specifically, they aim to “quantify the prevalence and incidence of pressure injuries and the hospital-acquired pressure injuries rate in hospitalized adult patients” (Li et al., 2020, para. 2). In order to address the research purpose, the authors rely on the formats of systematic review and meta-analysis.
  • Patients with Specific Health Conditions
    • Gray and Giuliano (2018) reveal that there is a robust correlation between pressure injuries and incontinence-associated dermatitis (IAD). A descriptive and correlational analysis of 5,342 adults demonstrates that an increased HAPU prevalence is found when it comes to focusing on IAD patients.
    • Mussa et al. (2018) focus on pressure injuries among patients with an endotracheal tube (ETT). A retrospective, pre-post intervention study indicates that a more frequent repositioning leads to some improvements, but they are not statistically significant.
    • Eren, DeLuca, and Kirshblum (2020) consider what results turning and repositioning offer to patients with spinal cord injury. The authors do not implement any interventions but interview such individuals regarding whether they rely on the intervention.
  • HAPIs Impact on the Healthcare System
    • Han et al. (2019) follow the data obtained through practical observations and analyses in a South Korean hospital with increased HAPU incidence rates.
    • Lim and Ang (2017) reveals that HAPUs are a major stressor for hospitals, depleting their finite resources through prolonged stays, patient dissatisfaction, and corresponding expenses. Therefore, the impact of HAPUs on healthcare organizations is concerning, thus justifying the need for effective interventions.
    • Padula and Delarmente (2019) extend HAPIs discussion even further, attempting to evaluate the national burden of hospital-acquired pressure injuries in the United States.
  • Pressure Injury Prevention Bundle: Standard Risk Interventions
    • Kim et al. (2018) evaluated the association between the application of sub epidermal moisture measurement and visual assessment of early pressure ulceration. The study employed a descriptive prospective observational design where data was obtained from at-risk patients in Ireland within an acute care facility.
    • Kamikawa et al. (2018) explained that a special pressure-relieving mattress could be used to hinder the development of ulcers among patients with a high risk.
    • Rivera et al. (2020) explained the bundle needs to incorporate various critical components , including comprehensive skin assessment, care planning, standardized risk assessment, would care nurse consult, and medical device-related interventions
    • Yafi et al. (2017) presented preliminary case studies showing the feasibility of spatial frequency domain imaging (SFDI) to promote assessing skin status in pre-existing wounds and high-risk populations.
  • Pressure Injury Prevention Bundle: High-Risk Interventions
    • Hahnel et al. (2020) argued that the application of dressings with the integration of the standard prevention is an effective approach in the prevention of pus at the sacrum and heels. The study evaluated the effectiveness of preventive multilayered soft silicone foam dressing when applied with standard prevention approaches.
    • Pérez‐Escamilla & Engmann (2019) argued that PIs could be linked to malnutrition and undernutrition, explaining the importance of involving a specialist to enhance their prevention. The risk of developing PIs tends to increase when patients in critical care units become undernourished and lose weight.
    • Sving et al. (2016) conduct a quasi-experimental, pre-and post-test study of 506 patients. The scientists implemented different turning schedules and assessed their impact on participants’ health.
• Summary
  • Gap/Problem: There is a need to implement a PIP bundle to decrease HAPIs in the critical care patients.
  • Prior studies: Prior studies have demonstrated that a PIP bundle has resulted in decreased HAPIs, and increased nurse satisfaction.
  • Quantitative application: Sources of data exist to collect numerical data on the number of HAPIs on critical care unit.
  • Significance: Implementing a PIP bundle will decrease the HAPIs, improve the health outcomes of the critical care patients.

Problem Statement

There is a need to identify to degree the implementation of PIP bundle impacted HAPIs when compared to the current practice.

Clinical/PICOT Questions

(P) Among critical care patients (I) PIP bundle, (C) compared to current practice, (O) reduce the HAPI incidence (T)over four weeks? To what degree does the implementation of PIP bundle patients impacts the HAPI prevalence rate when compared to current practice among critical care patients with in Coney Island Hospital over four weeks?

Sample (and Location):

• Location: Urban (Coney Island Hospital, Brooklyn).
• Population: critical care patients.
• Sample: 64 Patients
• Inclusion Criteria
  • All patients in critical care unit can participate. They can be of various genders, nationalities, and others. It is also possible to analyze participants with different health issues, including diabetes mellitus, hypertension, and other comorbidities.
• Exclusion Criteria
  • All non-critical care patients cannot participate Furthermore, pediatric patients are not included.

Define Variables and Level of Measurement

• Independent Variable (Intervention):
  • PIP bundle.
• Dependent Variable:
  • The HAPI incidence rate.

Methodology and Design

This project will use a quantitative methodology with a quasi-experimental design.

Purpose Statement

The purpose of this quantitative, quasi-experimental project was to determine if or to what degree the implementation PIP bundle impacts the HAPI prevalence rate when compared to current practice among critical care patients with in Coney Island Hospital over four-weeks.

Data Collection Approach

During this step, sufficient attention is drawn to security measures. To ensure the privacy of data, the investigator uses a coding system. Numbers from 1 to 64 (or others, depending on how many individuals will participate in the project) are assigned to the participants to ensure confidentiality. If a participant has experienced a pressure ulcer, 1 is placed, while 0 denotes that no HAPI has occurred. The investigator writes the notes by hand, and each of them has one figure representing the participant number (1-64) and another figure displacing the presence of absence of a HAPI (0 or 1). Currently, the assigned critical care unit has 14% HAPIs rate. In this project, it refers to HAPI surveillance data that the facility gathers. Wound care nurses and head nurses of the unit collect the required information and transmit it to EHRs. When the 4-week period is over, the investigator should receive the data from wound care nurses to identify the aggregate data on how many participants have experienced pressure ulcers.

Data Analysis Approach

The HAPI incidence is the project’s dependent variable, and it is necessary to compare this value for two independent groups. For that purpose, the t-test is suitable since this inferential statistical test measures the difference between the means of two groups. One can mention that this parametric test is appropriate to the project since the latter follows a before and after design, meaning that two groups should reveal the effect of the intervention.

The first step of running the t-test is to prepare the raw data. The coding system, where 1 refers to a HAPI and 0 denotes its absence, produces categorical data. It is necessary to create two tables with numbers 1-64, and each line should contain either 1 or 0, depending on whether the participant has experienced a pressure ulcer. Since the t-test focuses on the means, the second step is to calculate this measure for the two samples. Once these values are obtained, it is possible to conduct the third step of running the t-test to identify whether the difference between the measures is statistically significant. The specific level of the statistical significance (p<.05) is chosen to ensure that the obtained results are statistically significant and minimize the effect of chance. This requirement is also necessary because it justifies that the findings are scientifically valuable.

References

Alvarez, O. M., Brindle, C. T., Langemo, D., Kennedy-Evans, K. L., Krasner, D. L., Brennan, M. R., & Levine, J. M. (2016). The VCU pressure ulcer summit. Journal of Wound, Ostomy, and Continence Nursing, 43(5), 455-463. Web.

Chaboyer, W. P., Thalib, L., Harbeck, E., Coyer, F. M., Blot, S., Bull, C., Nogueira, P. C., & Lin, F. F. (2018). Incidence and prevalence of pressure injuries in adult intensive care patients: A systematic review and meta-analysis. Critical Care Medicine, 46(11), 1074-1081. doi: 10.1097/CCM.0000000000003366Cox, J., Roche.

S., & Murphy, V. (2018). Pressure injury risk factors in critical care patients: A descriptive analysis. Advances in Skin & Wound Care, 31(7), 328-334. doi:10.1097/01.ASW.0000534699.50162.4e.

Eren, F., DeLuca, R., & Kirshblum, S. (2020). Frequency of turning in bed at home in persons with chronic spinal cord injury. The Journal of Spinal Cord Medicine. doi:10.1080/10790268.2020.1800965.

Gray, M., & Giuliano, K. K. (2018). Incontinence-associated dermatitis, characteristics, and relationship to pressure injury. Journal of Wound, Ostomy, and Continence Nursing, 45(1), 63-67. Web.

Greenwood, C., & McGinnis, E. (2016). A retrospective analysis of the findings of pressure ulcer investigations in an acute trust in the UK. Journal of Tissue Viability, 25(2), 91-97. doi:10.1016/j.jtv.2016.02.008.

Han, Y., Jin, Y., Jin, T., Lee, S. M., & Lee, J. Y. (2019). Impact of pressure injuries on patient outcomes in a Korean hospital: A case-control study. Journal of Wound, Ostomy and Continence Nursing, 46(3), 194-200. doi: 10.1097/WON.0000000000000528.

Hultin, L., Karlsson, A.-C., Öhrvall, M., & Gunningberg, L. (2019). Information and communication technology can increase patient participation in pressure injury prevention: A qualitative study in older orthopedic patients. Journal of Wound, Ostomy, and Continence Nursing, 46(5), 383-389. doi:10.1097/WON.0000000000000568.

Kim, C. G., Park, S., Ko, J. W., & Jo, S. (2018). The relationship of subepidermal moisture and early stage pressure injury by visual skin assessment. Journal of Tissue Viability, 27(3), 130-134. Web.

Latimer, S., Chaboyer, W., Thalib, L., McInnes, E., Bucknall, T., & Gillespie, B. M. (2019). Pressure injury prevalence and predictors among older adults in the first 36 hours of hospitalisation. Journal of Clinical Nursing, 28(21-22), 4119-4127. Web.

Latimer, S., Gillespie, B. M., & Chaboyer, W. (2017). Predictors of pressure injury prevention strategies in at-risk medical patients: An Australian multi-center study. Collegian, 24(2), 155-163.

Lewin, K. C. (1951). Field theory in social science. New York, NY: Harper & Row.

Li, Z., Lin, F., Thalib, L., & Chaboyer, W. (2020). Global prevalence and incidence of pressure injuries in hospitalized adult patients: A systematic review and meta-analysis. International Journal of Nursing Studies, 105(103546), 1-13. doi:10.1016/j.ijnurstu.2020.103546.

Lim, M. L., & Ang, S. Y. (2017). Impact of hospital-acquired pressure injuries on hospital costs – experience of a tertiary hospital in Singapore. Wound Practice & Research: Journal of the Australian Wound Management Association, 25(1), 42-47.

Lin, F., Wu, Z., Song, B., Coyer, F., & Chaboyer, W. (2020). The effectiveness of multicomponent pressure injury prevention programs in adult intensive care patients: A systematic review. International Journal of Nursing Studies, 102. doi:10.1016/j.ijnurstu.2019.103483.

Padula, W. V., & Delaramente, B. A. (2019). The national cost of hospital-acquired pressure injuries in the United States. International Wound Journal, 16(3), 634-640. doi: 10.1111/iwj.13071.

Padula, W. V., Pronovost, P. J., Makic, M. B. F., Wald, H. L., Moran, D., Mishra, M. K., & Meltzer, D. O. (2019). Value of hospital resources for effective pressure injury prevention: A cost-effectiveness analysis. BMJ Quality & Safety, 28(2), 132-141.

Pérez-Escamilla, R., & Engmann, C. (2019). Integrating nutrition services into health care systems platforms: Where are we and where do we go from here. Maternal & child nutrition, 15 Suppl 1(Suppl 1), e12743. Web.

Razmus, I., & Bergquist-Beringer, S. (2017). Pressure injury prevalence and the rate of hospital-acquired pressure injury among pediatric patients in acute care. Journal of Wound, Ostomy, and Continence Nursing, 44(2), 110-117. doi: 10.1097/WON.0000000000000306.

Ricci, J. A., Bayer, L. R., & Orgill, D. P. (2017). Evidence-based medicine: The evaluation and treatment of pressure injuries. Plastic and Reconstructive Surgery, 139(1), 275e-286e. doi:10.1097/PRS.0000000000002850.

Rivera, J., Donohoe, E., Deady-Rooney, M., Douglas, M., & Samaniego, N. (2020). Implementing a Pressure Injury Prevention Bundle to Decrease Hospital-Acquired Pressure Injuries in an Adult Critical Care Unit: An Evidence-Based, Pilot Initiative. Wound Management & Prevention, 66(10), 20-28.

Sving, E., Högman, M., Mamhidir, A.-G., & Gunningberg, L. (2016). Getting evidence-based pressure ulcer prevention into practice: A multi-faceted unit-tailored intervention in a hospital setting. International Wound Journal, 13(5), 645-654. doi:10.1111/iwj.12337.

Wang, H.-R. N., Campbell, J., Doubrovsky, A., Singh, V., Collins, J., & Coyer, J. (2020). Pressure injury development in critically ill patients with a cervical collar in situ: A retrospective longitudinal study. International Wound Journal. doi:10.1111/iwj.13363.

Watson, J. (2018). Unitary caring science: The philosophy and praxis of nursing. Louisville, CO: University Press of Colorado.

Yafi, A., Muakkassa, F. K., Pasupneti, T., Fulton, J., Cuccia, D. J., Mazhar, A.,… & Mostow, E. N. (2017). Quantitative skin assessment using spatial frequency domain imaging (SFDI) in patients with or at high risk for pressure ulcers. Lasers in Surgery and Medicine, 49(9), 827-834. Web.

Appendix B: What is my DPI project design?