MSN support page for evaluating a hospital-acquired pressure injury prevention QI initiative using benchmarks, outcome measures, and interprofessional perspectives.
This assessment asks the learner to evaluate an existing quality improvement initiative and determine whether it improves patient safety, quality of care, cost, efficiency, and related outcomes.
Evaluation of the Hospital-Acquired Pressure Injury Prevention Quality Improvement Initiative
Evaluation of the Hospital-Acquired Pressure Injury Prevention Quality Improvement Initiative
Hospital-acquired pressure injuries (HAPIs) are among the most common and expensive preventable complications in the acute care setting resulting in patient suffering, longer hospital stays, and unnecessary deaths. In January 2022, a large academic medical center in the Midwest was aware of persistently high HAPI rates identified through routine data surveillance, and initiated a comprehensive Quality Improvement (QI) process to address HAPI prevention on all inpatient units. As a nurse on the medical-surgical unit where this program was implemented, I was asked to assess the implementation of this program and share my results with interprofessional and nursing colleagues. In developing this analysis, I spoke with four main members of the interprofessional team (IPT); the staff of a certified wound ostomy continence nurse (WOCN), a registered dietitian, a physical therapist, and a hospitalist physician – whose views are reflected throughout this report. This evaluation provides a review of the initiative's genesis, identifies issues that occurred and were not addressed, compares the results to known standards, includes interprofessional feedback, and suggests other indicators and protocols to enhance the impact of the initiative.
The QI initiative was motivated by internal performance data which indicated that the facility's HAPI rate had risen to 2.8 per 1,000 patient days in 2021, well above the National Database of Nursing Quality Indicators (NDNQI) facility key indicator mean of approximately 0.4–2 per 1,000 patient days for similar facilities (Terhi Lemetti et al., 2025). The data were exposed as part of routine nursing quality surveillance data and brought to the attention of hospital leadership after two successive quarters of no measurable improvement. The four major contributing factors that emerged from a formal root cause analysis are as follows: inconsistent Braden Scale risk assessments when patients are admitted, poor implementation of repositioning protocols, poor coordination of care surrounding special surface support, and poor communication between the nursing, dietetic and therapy staff. The financial burden of the Centers for Medicare and Medicaid Services (CMS) non-reimbursable policy for hospital-acquired Stage 3, Stage 4, and unstageable pressure ulcers also put tremendous institutional pressure. Leadership initiated an interprofessional Wound Care Committee to plan and execute a structured, evidence-based approach to prevent wounds. The five components of the initiative were mandatory Braden Scale assessment at admission and every 24 hours, repositioning protocol for high-risk patients implemented in 2 hours of identification, automatic mattress change to pressure-redistributing mattresses within four hours of identification, a nutritional screen that prompted referral to a dietitian and a facility-wide education program on wound care for all nursing staff.
The project had a good design, but faced many major issues once implemented and some issues were not addressed during the design stage. The biggest challenge, however, was ensuring the consistent repositioning adherence, especially during high census times and night shifts. At six months, only 61% of the turning documentation was compliant with the targets, against 90%. The need for more staff to be available to care for more patients, namely, nurse-to-patient staffing ratios, was the issue consistently mentioned by nursing staff as a key barrier to the implementation of this initiative (Crotty et al., 2023). The second issue identified was with the documentation burden in the electronic health record (EHR), with three different sections of the EHR containing Braden scores, repositioning logs, and skin assessment findings, which made it difficult to ensure the accuracy of findings and completeness of the information. Third, there was no patient and family education component, which is a key component of HAPI prevention that is well-documented (Cesca et al., 2024). Last, the effort failed to break down outcome information by race/ethnicity or insurance status to determine if there was an equitable distribution of prevention efforts across patient populations.
The initiative was assessed through performance indicators that matched national quality standards. The primary outcome measure was the facility-wide HAPI rate per 1,000 patient days, which was compared to the percentile ranking in the NDNQI for academic medical centers. Secondary process measures were Braden Scale assessment compliance (at admission), turning documentation rates, pressure redistributing surface utilization (for high-risk patients), and dietitian consultation completion rates, all of which were related to structural and process standards set forth by The Joint Commission (TJC) and were required to submit with the NDNQI to maintain Magnet Recognition Program status (American Nurses Credentialing Center [ANCC], 2023). The HAPI rate decreased to the NDNQI 50th percentile in 2022, down 50% from December 2021 in the lowest quartile to just above the 50th percentile. The percentage of patients that were admitted while compliant with the Braden Scale did not change, moving from 91% to 91%. The percentage of surface utilization of high-risk patients did improve, from 87% to 87%, and dietitian consultation was completed at 78%, up from 77%. The most successful component – which met the compliance objective – in the first quarter was the standardized risk assessment workflow. The other key barrier to repositioning adherence was the overall staffing and workload issues, and this was the weakest performing element over the years.
The results of the initiative had important institutional implications. In FY 2023, the facility is estimated to have saved $1.2 million, due to lower wound care costs and fewer CMS non-reimbursable cases of HAPI. There was reduced exposure to legal liability since there were previously frequent adverse events resulting in patient grievances and litigation, related to HAPI. Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) scores were enhanced by the improvements in HAPI metrics for nursing responsiveness and overall care quality domains. There was a positive change in staff confidence in using evidence-based skin care protocols on post-initiative surveys, and the initiative put the facility in a good position to be redesignated as a Magnet (ANCC, 2023).
To ensure a thorough evaluation, I have included the feedback from four interprofessional colleagues, whose feedback guided this analysis. The WOCN who co-chaired the Wound Care Committee shared that this had been a successful project to normalize HAPI prevention as a shared clinical priority, but sometimes low-level wounds were not treated as soon as they should have been because floor nurses did not know when to seek a consult. The registered dietitian said that the referral rate for a patient's nutrition screening was increased from 40% to 78% by placing the nutrition screening in the nursing admission order set, but noted that patients referred late in the admission process benefitted less from the nutrition screening, underscoring the importance of not only accurate, but also early screenings for nutrition. The physical therapist stressed that the two-hour schedule of repositioning was not sufficient for the patients with a neurologic impairment, such as stroke patients, who needed an individualized plan of positioning in collaboration with the therapy staff. The hospitalist physician commented that although the use of vasopressor medications has negative effects on tissue perfusion, and increases the risk of HAPI, the status of HAPI was seldom discussed in the medical rounding. These views together validated the positive impact of the initiative and also highlighted limitations in functionality that would not have been able to be quantified (Cesca et al., 2024).
There are several evidence-based additions recommended to strengthen and expand the initiative. A patient and family education module that is structured and delivered at admission (with teach-back reinforcement) and reinforced at discharge would engage patients as active prevention partners, a gap well-supported by the literature (Crotty et al., 2023). A formal WOCN escalation pathway should outline when the nurse should consult with a WOCN versus when the nurse is able to manage the wound themselves and minimise variation in early wound response. HAPI risk should be a part of the daily multidisciplinary rounds on high acuity units, and it should include the medical team's feedback on the effects of any medication that alters perfusion and the course of the disease. In terms of technology, the gap of staffing can be overcome by the automatic alert of nurses through continuous bed-sensor or wearable patient-monitoring systems to remind patients to position themselves, as these systems can address the adherence issue (Crotty et al., 2023). Having Braden assessments, log repositioning, and skin documentation all in one module within the EHR would decrease charting load and increase data completeness. Three outcome measures should be added: a health equity indicator that will report on the incidence of HAPIs by race/ethnicity and insurance status to identify disparities, a 30-day post-discharge HAPI-related readmission rate to capture outcomes beyond the hospital in alignment with CMS value-based purchasing goals, and an annual staff education competency metric to document successful completion of HAPI training by all clinical disciplines to ensure interprofessional accountability.
Over the first year of implementation, the HAPI prevention QI resulted in significant and measurable improvements in patient safety and institutional performance, with HAPI incidence rates falling by 50% and meaningful progress towards compliance with key process indicators. Its success has shown the strength of evidence-based protocols when carried out with good interprofessional commitment. Concurrently, there are key gaps that emerge in this evaluation, including difficulties with repositioning adherence, lack of patient education, suboptimal EHR patient workflows, and lack of equity and post-discharge outcome measures. The interprofessional perspectives generated by the WOCN, dietitian, physical therapist and physician added to this analysis that could not have been gathered by data alone and identified functional deficits that must be addressed with specific solutions. This recommended protocol additions, technologies, and new outcome indicators give a clear, actionable path to further deepen the reach and sustainability of the program. Ensuring that nurse participation in assessing and improving QI efforts continues to be a professional obligation to provide safe, equitable, quality health care services to all patients.
American Nurses Credentialing Center. (2023). Magnet Recognition Program. American Nurses Credentialing Center. https://www.nursingworld.org/organizational-programs/magnet/program-tools/
Cesca, N., Szczepanski, A., Malik, W., Cheema, M., Allen, B., Dutta, T., ... & Gabison, S. (2024). Facilitators and barriers to pressure injury prevention, management and education: Perspectives from healthcare professionals—A qualitative study. International Wound Journal, 21(1), e14371. https://onlinelibrary.wiley.com/doi/pdf/10.1111/iwj.14371
Crotty, A., Killian, J. M., Miller, A., Chilson, S., & Wright, R. (2023). Using wearable technology to prevent pressure injuries: An integrative review. Worldviews on Evidence‐Based Nursing, 20(4), 351-360. https://sigmapubs.onlinelibrary.wiley.com/doi/pdf/10.1111/wvn.12638
Terhi Lemetti, Anniina Heikkilä, Asta Heikkilä, Kristiina Junttila, Marja Kaunonen, Tiina Kortteisto, Anu Nurmeksela, Salmela, S., Pia-Maria Tanttu and Tarja Tervo-Heikkinen (2025). Inpatient Falls and Pressure Ulcers as Nursing Quality Indicators in National Benchmarking-A Retrospective Observational Registry Study. PubMed. [online] doi:https://doi.org/10.1093/intqhc/mzaf055
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