Master’s Thesis

entitled

The Management and Prevention of

Hospital Acquired Pressure Injuries (HAPIs)

by

Denise Lauderbaugh

Thesis Submitted in Partial Fulfillment of the Requirements for the

Degree of Masters in Public Health

Independence University

December 2018
 Copyright  2018

Denise Lauderbaugh

This document is copyrighted material. Under copyright law, no parts of this document

may be reproduced without the expressed permission of the author.

ii
 Approval Page

INDEPENDENCE UNIVERSITY

As members of the Final Project Committee, we certify that we have read the

document prepared

by

Denise Lauderbaugh

The Management and Preventions of

Hospital Acquired Pressure Injuries (HAPIs)

and recommend that it be accepted as fulfilling the final project

Requirement for the Degree of

Master’s in Public Health

Dr. Doret Ledford Date: 12/19/2018

Dr. Doret Ledford, Course Instructor/AD/FPA

Date: 12/28/2018
Dr. Carmen Herbel Spears RN DHA MSN BSN Dean of the School of Healthcare

iii
 Abstract

Hospital acquired pressure injuries (HAPIs) remain a major cause of morbidity and mortality for

hospitalized patients. Most HAPIs are preventable, and HAPIs have been identified as a hospital

quality indicator by the National Quality Forum. Hospitalized patients are at higher risk of

developing pressure injuries, and prevention of pressure injuries in this population has been

identified by the Joint Commission as one of the most difficult challenges hospitals face.

Hospitals have been utilizing individual interventions, such as turning, to reduce pressure injuries

for many years. Some have added foam barriers between devices and the skin to offload

pressure on the skin, while others utilize silicone protection on bony prominences or other

interventions. Most hospitals do not utilize bundles to reduce pressure injury. The objective of

the study is to determine if a comprehensive bundle practice, based on the evidence, can lead to

reductions in HAPIs over individual interventions. A literature review was conducted to find

studies utilizing interventions and bundle practices to reduce pressure injuries in hospitalized

patients utilizing the key words pressure injury, pressure ulcer, decubitus, multidisciplinary, skin

barriers, and bundles. Results demonstrated that there was a decrease in the occurrence rate of

HAPIs after use of barriers, multidisciplinary care, and bundle practices were initiated.

Recommendations and implications for interdisciplinary bedside clinicians are discussed.

Keywords: Pressure Ulcer, Pressure Injury, Hospital Acquired Pressure Ulcer, Hospital

Acquired Pressure Injury, Bedsore, Decubitus, Hospital Acquired Condition, Multidisciplinary

Care, Bundles, Pressure Points

iv
 Acknowledgements

I would like to acknowledge and thank Dr. Doret Ledford for all of her help and guidance

through this process. I would also like to acknowledge God for his faithfulness, as well as Toni

Popien MA, RRT-NPS, RPFT, AE-C, Mary Fagan, PhD, RN, NEA-BC, and Kirsten Turner

MBA, RRT-NPS, CPFT for their unwavering belief in my abilities and support.

Acknowledgement would not be complete without mentioning Mary Ann Dilloway RN, BS,

CWOCN for her enthusiasm for preventing pressure injuries that inspired me, my husband for

his never ending support of my education, my family for their patience, and Erin Young MEd for

all her help and encouragement with this project.

v
 Table of Contents

Project Abstract...…………………………………………...…………………………….………iv

Acknowledgements……...………………………………………………………………………...v

Table of Contents……………………………………… …………………………………….vi

Chapter 1: Introduction …………………………………………….………………………......... 1

Introduction to the Study………………………………………………………………….1

Background of the Study………………………………………………………………….2

Statement of the Problem………………………………………………………………….3

Purpose of the Study………………………………………………………………………3

Objective of the Study…………………...………………………………………………..4

Research Question and Hypotheses……………………………………………………….5

Limitations of the Study…………………………………………….…………………….5

Assumptions of the Study………………………………………….……………………..5

Significance of the Study……………………………………...………………………….5

Definition of Terms……………………………………………………………………….5

Summary………………………………………………………………………………….7

Chapter 2: Literature Review…………………………………………...……………...………....8

Overview………………………………………………………………………………….8

Multidisciplinary Care…………………………………………………………………...10

Utilization of Pressure Barriers…………………………………………………………..10

Frequent Skin Monitoring to Prevent HAPIs…………………………………………….11

vi
 Alternating Pressure Points to Prevent HAPIs…………………………………………...12

Using Bundles to Prevent HAPIs………………………………………………………...13

Summary……………………………………………………………………………...….13

Chapter 3: Methods………………………………………………………………….….............14

Research Method………………………………………………………………………...14

Research Question and Hypotheses……………………………...………………………14

Design…………………………..………….…………………………………………….15

Target Audience……………………..………………….………………………………..15

Studies……………………………………………………………………………………15

Study One: Multidisciplinary care to prevent HAPIs 2014……………………...15

Study Two: Barrier to prevent HAPIs 2014……………………………………..16

Study Three: Bundles to prevent HAPIs 2015…………………………………...17

Chapter Summary…………………………………………..……………………………20

Chapter 4: Results..................................................................................................…...................22

Purpose of the Study…………………………………….……………………………….22

Descriptive Statistics……………………………………………………………………..24

Study One: Multidisciplinary Care to prevent HAPIs 2014……………………..24

Study Two: Barriers to prevent HAPIs 2014…………………………………….25

Study Three: Bundles to prevent HAPIs 2015…………………………………...26

Summary of Findings…………………………………………………………………….28

Chapter 5: Summary and Conclusions……………………...……………..……..........................30

Introduction………………………………………………………………………………30

Discussion………………………………………………………………………………..31

vii
 Interpretation of the Findings…………………………………………………………….31

Recommendations for Future Research………………………………………………….32

Implications for Practice…………………………………………………………………32

Limitations of the Study…………………………………………………………………32

Conclusion……………………………………………………………………………….33

References……………………………………………………………………………………......35

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 1

Chapter 1: Introduction

Introduction to the Study

The estimated prevalence rate of HAPIs in acute-care hospitals is between 0.4% and

38%. HAPIs contribute to higher cost, pain, increased infection rate, disfigurement, and

increased length of hospital stay. The annual expenditure on HAPIs in the United States alone is

around $11 billion (Qaseem, Mire, Starkey, and Denberg, 2016). In 2017 the Agency for

Healthcare Research and Quality did a review of the literature and discovered that based on 3

studies the mortality for patients who contracted HAPIs was estimated at 0.041 (95% CI: 0.013

to 0.093) per HAPI case (41 excess deaths per 1000 HAPIs) (Agency for Healthcare Research

and Quality, 2017). Due to the nature and extent of the damage, pain, costs, and mortality due to

HAPI, interventions must be utilized for prevention. Pressure injury prevention should begin

with an accurate bedside skin assessment that looks at moisture, incontinence management,

nutrition, and positioning (Levine, Sinno, Levin, & Saadeh 2013). This paper will discuss how

incorporating new pressure injury prevention techniques into a comprehensive bundle will

protect patients from harm over doing isolated interventions.

Prevention of patient injury is a vital part of patient care. Primum non nocere is the

classical Latin phrase that means “first, do no harm” (Medial-the free dictionary, 2013), and yet

in healthcare sometimes patients are injured despite this fundamental principle of bioethics.

Over the past few decades increased focus has been placed upon this principle with hospital

acquired conditions (HACs) having garnered significant attention but with little impact on

outcomes (Society for Healthcare Epidemiology of America, 2018). Preventing preventable

conditions, and thus doing no harm, has become the frontline of hospital quality and safety

committees (Chassin & Loeb, 2011).

 2

According to the Centers for Medicaid and Medicaid services, 2018 the following are the

most concerning preventable HACs; retained foreign bodies, air embolism, catheter-associated

urinary tract infection (CAUTI), catheter line associated bloodstream infection (CLABSI),

surgical site infection (SSI), deep venous thrombosis (DVT), pulmonary embolism (PE,

iatrogenic pneumothorax after venous catheterization, and hospital acquired pressure injuries

(HAPIs) (CMC, 2018). According to the National Pressure Ulcer Advisory Panel (NPUAP)

pressure injuries are defined as “localized damage to the skin and underlying soft tissue usually

over a bony prominence or related to a medical or other device (National Pressure Ulcer

Advisory Panel, 2016). HAPIs standout as one of the most preventable conditions amongst

HACs.

Background of the Study

HAPIs can lead to increased costs for care and length of hospitalization, as well as

disfigurement and pain for the patients (Jull, 2010). The risk for development of HAPIs include

“advanced age, immobility, incontinence, inadequate nutrition and hydration, neuro-sensory

deficiency, device-related skin pressure, multiple comorbidities, and circulatory abnormalities”

(Health Research and Educational Trust, 2017). Over one hundred intrinsic and extrinsic risk

factors for HAPIs have been identified in the literature. Risk factors associated with HAPIs in

adults include; diabetes mellitus, cerebral vascular accident, peripheral vascular disease, sepsis,

and hypotension (Lyder & Ayello, 2016). All of these are frequent factors in hospitalized

patients, placing them at high risk for HAPIs.

An increased focus on preventing HAPIs in the acute care settings has emerged with

goals to improve patient safety, reduce medical errors, and meet regulatory requirements. The
 3

focus on HAPIs is stimulated in part by state and federal mandated reporting and lack of

reimbursement for these preventable injuries (Zaratkiewica et al., 2010). The prevention of

HAPIs has earned increased attention by the hospital safety and quality council, and reduction of

HAPIs is one of the National Patient Safety goals. Identification of HAPI was designated as a

“Never Event” on the preventable hospital acquired conditions list (Centers for Medicaid and

Medicare Services, 2008). In 2010 the absence of HAPIs became an indicator of quality care for

Nursing (Jull, 2010), and in 2016 the Joint Commission has recognized the prevention of HAPIs

as one of the most challenging issues hospitals face in protecting patients (The Joint Commission

2016).

Statement of the Problem

Patients in the hospital, because of poor nutrition, lack of movement, excess moisture,

and poor perfusion are at high risk for getting HAPIs. Because patients in the acute care setting

are dependent on their caregivers for care and protection, the development of strategies to

prevent pressure injuries should be implemented and conducted within those settings to address

this major public health problem.

Purpose of the Study

Multiple studies have shown that it is possible to reduce the number of HAPIs through

multidisciplinary care, utilization of barriers, frequent skin monitoring, and alternating pressure

points. While several of these studies have implemented practices shown to reduce HAPIs, a

comprehensive bundle that includes common practices such as risk assessment scoring, frequent

skin assessment, and pressure point changes with newer evidence based interventions such as

multidisciplinary skin teams and skin barriers has not been adapted for prevention. The purpose
 4

of this paper is to combine proven practices that prevent HAPIs into one bundle for

comprehensive patient protection from pressure injury.

Objective of the Study

The objective of the study is to review the literature on HAPI prevention and make

recommendation for a comprehensive safe bundle practice, based on the evidence, which can

lead to reductions in HAPIs in an acute care setting. Does utilizing a multidisciplinary care team

to assess skin and intervene prevent HAPIs?

1. Does implementing a barrier between the skin and pressure prevent HAPIs?

2. If the answers to the first two questions prove to be yes, will combining interventions

that have been shown to prevent HAPIs into one comprehensive bundle reduce more

HAPIs than one bundle alone?

In addition to hospitalized patients, patients in sub acute, rehabilitation, convalescent, and home

care settings who are at risk for development of pressure injuries will benefit from the outcome

of this study.

Research Question and Hypotheses

Combining tested interventions to reduce pressure injuries is the research question that

will be investigated. All races will be included in this study, because pressure injuries do not

discriminate. The study will review secondary evidence within acute care settings for patients of

all ages. The hypotheses that are created by these questions are as follows;

H1a: Those utilizing multidisciplinary teams are less likely to acquire HAPIs.

H10: Those not utilizing multidisciplinary teams are less likely to acquire HAPIs.
 5

H2a: Those implementing a skin barrier to pressure are less likely to acquire HAPIs.

H20: Those not implementing a skin barrier to pressure are less likely to acquire HAPIs.

H3a: If the first two questions prove positive, the combination of the two is likely to

reduce the rate of HAPIs greater than one element alone.

H30: If the first two questions prove positive, the combination of the two is unlikely to

effectively reduce the rate of HAPIs over one element alone

Limitations of the Study

Limitations of this review deserve comment. Due to the nature of utilizing secondhand

evidence there is no way to review the actual outcomes. Due to the nature of this review, actual

Pressure Injury reduction will not be able to be collected.

Assumptions of the Study

Combing multiple HAPI interventions known to reduce pressure injuries into one bundle

will lead to a reduction in HAPI’s more than utilizing one intervention alone. The end result

should be a reduction in cost, suffering, morbidity and mortality.

Significance of the Study

The findings of this paper will be to the benefit of acute care hospitals, long term care

facilities, home care groups, and society due to the nature of pressure injury prevention. The

hospitals that apply the prevention bundle approach will be able to have a significant reduction in

HAPIs and subsequently less HACs. This approach may move into long-term settings with

implications for care there as well as in home care settings. For the researcher the research will

help uncover areas that have not previously been under consideration as part of the bundle. The
 6

outcomes will also allow doctors, nurses, and other healthcare professionals to work diligently to

help reduce these afflictions and prevent patients from getting HAPIs.

Definition of Terms

Hospital acquired Condition (HAC): “is an undesirable situation or condition that affects a

patient and that arose during a stay in a hospital or medical facility. It is a designation used by

Medicare/Medicaid in the US for determining MS-DRG reimbursement beginning with version

26 (October 1, 2008) (CMC, 2018)”.

Pressure Injury (PI): “A pressure injury is localized damage to the skin and underlying soft

tissue usually over a bony prominence (National Pressure Ulcer Advisory Panel, 2016)”.

Hospital Acquired Pressure Injury (HAPI): A pressure injury (sometimes referred to as a bedsore

pressure ulcer, or skin breakdown) that occurs during hospitalization as a result of pressure

caused by prolonged immobility or devices secured to skin (New England Baptist Hospital,

2013).

National Pressure Injury Advisory Panel (NPUAP): A panel of experts in pressure injuries

who serve “as the authoritative voice for improved patient outcomes in pressure injury

prevention and treatment through public policy, education and research” (National Pressure

Ulcer Advisory Panel, 2016).

NPUAP 2016 Staging Definitions (National Pressure Ulcer Advisory Panel, 2016):

Stage 1: Non-blanchable erythema of intact skin

Stage 2: Partial-thickness skin loss with exposed dermis

Stage 3: Full-thickness skin loss

Stage 4: Full-thickness skin and tissue loss

Unstageable: Obscured full-thickness skin and tissue loss

 7

Deep Tissue Injury (DTI): Persistent non-blanchable deep red, maroon or purple

discoloration

Summary

Utilizing individual interventions alone are just not enough to prevent Hospital Acquired

Pressure Injuries (HAPIs) in critically ill patients. Recently, some inpatient facilities have been

utilizing multiple interventions within a bundle to prevent HAPIs. The purpose of this research

was to identify if utilizing a bundle approach for HAPI prevention decreased HAPI incidence

over traditional interventions alone in the acute care setting. Next, the review of literature will

be presented.

Chapter Two: Literature Review

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Overview

Hospital Acquired Pressure Injuries (HAPIs), a new injury caused by pressure to the skin

during hospitalization, increased by 80% from the year 1995 to 2008, with every year 2.5 million

patients getting a HAPI (Agency for Healthcare Research and Quality, 2008). Pressure Injuries

usually develop on skin over bony prominences after unrelieved pressure over time (Ayello &

Lyder, 2007). At this time large organizations such as the Centers for Medicaid and Medicare

Services, National Pressure Ulcer Advisory Panel (NPUAP), Wound and Ostomy Care Nursing

Society (WOCN), Agency for Healthcare Research and Quality, as well as the Joint Commission

began focusing on this important health issue. Hospital reform in the United States to reduce

HAPIs in the acute care settings was sought for more than a decade, with increasing pressure

being placed by federally mandated reporting and lack of reimbursement (Zaratkiewica,

Whitney, Lowe, Taylor, O’Donnell, Minton-Foltz, 2010).

In addition to the detrimental cost to healthcare organization, pressure injuries cause

significant health and mental health costs to the affected patient (Spetz & Brown, 2013). The

deeper the pressure injury the more risk to the patients health and wellbeing. HAPIs can cause

infection, sepsis, need for surgery, potential disfigurement, pain, and an elevated risk of death for

the patients (Jull, 2010).

Although there has been increased focus on preventing HAPIs, and there have been

multiple studies looking at interventions to prevent them, they are still occurring at a high

prevalence rate 0.4% to 38% (Qaseem, Mire, Starkey, and Denberg, 2016). Qaseem 2016 shows

us that there is wide variance in care and interventions, allowing hospitals to operate at different

levels even though pressure injuries are measurably lower at some facilities. The gap in care

puts patients in danger of both morbidity and significant risk of mortality (Agency for Healthcare
 9

Research and Quality, 2017). This significant gap in quality of care exists not due to healthcare

provider inadequacy or actions, but rather is due to lack of healthcare organization to incorporate

known improvement processes into routine care (Mayberry, Nicewander, Qin, & Ballard, 2006).

Because pressure injuries occur due to a variety of reasons, a comprehensive bundle is

preemptive in preventing HAPIs ("Module 1: Preventing Pressure Injuries in Hospitals—

Understanding Why Change Is Needed | Agency for Healthcare Research & Quality," 2016).

The change in standards of practice can be a challenge for both nurses and bedside

caregivers across the United States, elevating the scale of operations bedside professionals must

fulfill. Nurses and Healthcare providers are required to have a vast knowledge base, some of it

outside their historical practice. This is driving a shift in the education of bedside clinicians to

promote higher levels of certification, additional training, and expand specialization roles

(Wilson, 2018). While these bedside providers continue to memorize facts and follow

algorithms, it is difficult to remember it all. Care bundles are designed to improve quality and

patient outcomes by consistent implementation of a group of proven interventions (Camporota &

Brett, 2011). Combining all proven interventions into one comprehensive bundle should make

their job easier to complete and reduce the number of HAPIs that occur in the acute care patient

population.

This chapter reviews the literature on interventions shown to reduce the number of

HAPIs acquired during hospitalization. The chapter will then further discuss the evidence for

utilization of a comprehensive bundle as a way to reduce HACs that include HAPIs. The first

theme includes multidisciplinary care. The second theme addresses the utilization of pressure

barriers for the preventions of HAPIs. The third and fourth themes are more commonly utilized

as pressure injury prevention strategies. The third theme gives examples of success with
 10

utilization of frequent skin monitoring. The fourth theme will discuss how combining

interventions has shown improvement in HAPIs over choosing individual interventions alone.

From these themes, it will be shown that putting tested interventions that have reduced HAPIs

into one comprehensive bundle with frequent skin checks and alternating pressure points will

create a greater reduction in HAPIs than one intervention alone.

Multidisciplinary Care

In 2016 the Agency for Healthcare Research and Quality stressed the importance of

multidisciplinary care as one of the tools in their toolkit to decrease HAPIs. Hospital based

multidisciplinary teams can include a wide variety of caregivers. According to the World Health

Organization in 2010 “Bringing together the skills of different individual will strengthen the

health care system and lead to improved outcomes”. It’s not the people in the team, but the

cohesiveness of the team approach that limits adverse events, improves patient outcomes, patient

safety and patient satisfaction (Epstein, 2014). In 2011 Peninsula Regional Medical Center

started a multidisciplinary care group including physicians, physical therapy, dietary, a clinical

nurse specialist, a clinical analyst, a CWOCN wound care nurse, and a coding specialist to

reduce HAPIs at their facility. Multidisciplinary groups provide the opportunity to design and

implement skin care reviews; assess more patients with greater frequency, as well as

documentation practices where a single wound care nurse does not. After implementation they

had a greater than 50% reduction in their HAPI rate, as well as an overall prevalence rate

reduction to 2.9%, reduced from 9.5% the year before (Sheets, 2011).

Utilization of Pressure Barriers

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The use of pressure barriers such as foam barriers or five-layer silicone bordered

dressings has recently been reviewed for application in the prevention of HAPIs. In 2014 an

international panel of wound care experts met to review the literature available on utilization of

pressure barriers for prevention of HAPIs. After review, they came to a consensus and are

recommending the use of five-layer silicone bordered dressings as a protective measure in bony

areas with high risk patients such as the intensive care unit or operating room. Another

systematic review in 2014 revealed a single high quality high-quality randomized control trial

(RCT) as well as some cohort studies and a weak RCT that all suggest utilization of a dressing

for prevention of HAPIs in patients with medical devices or high risk intensive care unit patients.

Frequent Skin Monitoring to prevent HAPIs

Frequent comprehensive skin assessments, audits, or monitoring, are an essential part of

pressure ulcer prevention. This process reviews the entire skin of each individual, with emphasis

on looking at or touching skin over bony prominences. By utilizing a comprehensive skin

review bedside clinicians can identify any pressure injuries early, prevent high stage injuries to

that area by implementing barriers, and calculating prevalence ("What are the best practices in

pressure ulcer prevention that we want to use? | Agency for Healthcare Research & Quality,"

2014). The Joint Commission on Healthcare wrote in 2016 that skin monitoring is important to

prevent early identified Stage 1 injuries from progressing to a higher stage. They recommend

inspecting the skin everywhere, but especially at pressure points and beneath medical devices

upon admission and at least daily for signs of HAPIs (The Joint Commission, 2016). In a

multicenter randomized control trial Demare et al. in 2014 found that “Even if preventative

measures are in place, continuous (skin) assessment is necessary in all patients at risk” for

pressure injuries.
 12

Alternating Pressure Points to Prevent HAPIs

Pressure Injuries can occur within the first hour of significant pressure, or between 4 and

6 hours of sustained pressure (Gefen, 2008). Alternating pressure points can be considered a part

of positioning and mobilization. In 1975 Norton & Mclaran found that alternating pressure points

every 2 to 3 hours in elderly patients reduced the number of pressure injuries in that group. A

randomized control trial in 2009 showed there was no difference in number of pressure injuries

when repositioning intensive care unit patients every 4 hours compared to every 2 hours

(Manzano, 2013). The Joint Commission states that immobility causes pressure on areas for a

prolonged time, so enabling early mobilization is important. If patients cannot be mobilized,

then care with these high risk patients should focus on scheduled turning and repositioning of

medical devices to different pressure points. They also discuss that avoiding pressure on the

pressure injury area is necessary after recognition (The Joint Commission, 2016).

Using Bundles to prevent HAPIs

In the year 2014 the Agency for Healthcare Research and Quality started a “toolkit”

bundle to reduce pressure injuries that they implemented at 11 acute care facilities. They noted

significant reductions in both HAPI from 27 to 16 as well as costs reduction related to HAPIs

from $1,165,860 to $690,880 just through implementation of a bundle of interventions to reduce

HAPIs. Of these HAPIs the number of stage 1 injuries was eliminated, stage 2, 3, and deep tissue

injuries were cut in half. The number of unstageable injuries did not have a significant change.

This toolkit approach optimized effectiveness of individual interventions by tailoring

interventions based on multidisciplinary care, assessing their effectiveness, and frequent skin

monitoring ("Module 1: Preventing Pressure Injuries in Hospitals—Understanding Why Change

 13

Is Needed | Agency for Healthcare Research & Quality," 2016). In 2105 Tayyib, Coyer, and

Lewis designed a randomized control trial to look at patients who were followed with a skin care

bundle versus standard intensive care unit skin care in their facility. The study showed

significant reductions in incidence, severity, and total number of pressure injuries recorded

(Tayyib, Coyer, & Lewis, 2015)

Summary

Using individual proven interventions has reduced the number of HAPIs, but utilization

of interventions is dependent upon hospital preferences, knowledge, and memorization of

bedside care staff. Caregivers need the best available interventions and methodologies

incorporated into one bundle to ensure consistent quality care that will in turn reduce HAPIs.

Utilization of bundle practices that include proven interventions have been shown to decrease

pressure injuries in acute care patients (Agency for Healthcare Research & Quality, 2016)

(Tayyib, Coyer, & Lewis, 2015).

Hospitals today are highly motivated to work toward quality outcomes due to the costs of

poor hospital consumer assessment of healthcare providers and systems (HCAHPS) scores, and

treatment for HAPIs. Combining proven interventions of multidisciplinary care, utilization of

pressure barriers, and frequent skin monitoring into one comprehensive bundle enables hospitals

to utilize evidence based practice that will improve HCAHPS while reducing HAPIs and costs.

Next, the study methodology will be presented.

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Chapter 3: Methods

Research Method

Pressure Injuries contribute to increased costs and harm to both patient and facility. Most

hospital acquired pressure injuries HAPIs are preventable, and preventing HAPIs is one of the

National Patient Safety Goals. The goal of this project was to create a bundle of interventions

that would prevent HAPIs. This paper utilized pre-existing studies and employed the mixed-

method in order to extrapolate quantitative information. In order to provide a strong framework

regarding the research in this area, three studies were included that have a direct relationship

with the three key research questions;

1. Does utilizing a multidisciplinary care team to assess skin and intervene prevent

HAPIs?

2. Does implementing a barrier between the skin and pressure prevent HAPIs?

3. If the answers to the first two questions prove to be yes, will combining

interventions that have been shown to prevent HAPIs into one comprehensive

bundle reduce more HAPIs than one bundle alone?

Research Questions and Hypotheses

The hypotheses that are created by these questions are as follows;

H1a: Those utilizing multidisciplinary teams are less likely to acquire HAPIs.

H10: Those not utilizing multidisciplinary teams are less likely to acquire HAPIs.

H2a: Those implementing a skin barrier to pressure are less likely to acquire HAPIs.

H20: Those not implementing a skin barrier to pressure are less likely to acquire HAPIs.
 15

H3a: If the first two questions prove positive, the combination of the two is likely to

reduce the rate of HAPIs greater than one element alone.

H30: If the first two questions prove positive, the combination of the two is unlikely to

effectively reduce the rate of HAPIs over one element alone.

Design

This project’s design outcome gives clinicians a bundle of elements that can be utilized

together as a comprehensive bundle to prevent HAPIs in the acute care setting. Each

intervention was designed to prevent HAPIs by itself, but including it as a bundle practice should

effectively eradicate all preventable HAPIs. The design of the program uses current research to

determine the most effective interventions to include in the bundle.

Target Audience

This project was specifically designed for bedside clinicians in an acute care setting. The

interventions were designed with the intention of this audience, but can be applied to clinicians

in the sub-acute, rehabilitation, convalescent, and home care arenas as well. The key

interventions were designed into a comprehensive bundle to standardize and ensure equal care

that will lead to a reduction in HAPIs.

Studies

Study One: Multidisciplinary Care to prevent HAPIs 2014

According to JACHO 2016 “Pressure injury prevention requires a multidisciplinary

approach to care. No individual clinician working alone, regardless of how talented, can prevent

all pressure injuries from developing”. In the Journal of Pediatric Nursing the Author Darlene

E. Acorda (2015) examined how HAPIs can be reduced through multidisciplinary care.
 16

Specifically the author was looking to reduce device related pressure injuries during

hospitalization. The Author used a quality improvement model with a pre and post quantitative

design to assess reduction in the number of device related pressure injuries after implementation

of a multidisciplinary skin care team that included wound, ostomy and continence (WOCN)

nurses, respiratory therapists, and nursing leadership. Materials used were new masks, a foam

dressing barrier, a template for better mask fit.

During the intervention phase the bedside nurses and respiratory therapists did every 4

hour skin assessments and notified WOCN nursing and leadership of any redness of the skin.

The goal of the study was to develop a collaborative team relationship between nursing and

respiratory teams with accountability and shared ownership for prevention of pressure injuries.

The pressure injury rate decreased from eleven in the first three quarters to only one in the fourth

quarter of fiscal year 2012, and the decrease in pressure injuries was sustained in fiscal year

2013. The authors concluded that “close collaboration between respiratory and nursing has been

the primary factor” in decreasing pressure injuries.

Study Two: Barriers to prevent HAPIs 2014

In the International Wound Journal the Authors Clark, Black, Albes, Brindle, Calls,

Dealey, and Santamaria 2013 examined whether using prophylactic barriers can lead to

reductions in the occurrence of low stage (Stage I & II) pressure injuries. For the purpose of their

systematic review of the literature, they used the following research questions:

1. What evidence was available to indicate that the use of dressings in pressure ulcer

prevention leads to reduced pressure ulcer incidence?

2. What evidence was available to indicate that different types of prophylactic dressing may

have a greater or lesser effect upon the prevention of superficial pressure ulcers?
 17

To identify studies their search strategy included Medline, Cochrane Library, CINAHL Plus,

and PubMed. Search was performed on July 25, 2013 for any studies in the English language

with the following key words; pressure ulcer, pressure sore, decubitus ulcer, bedsore, pressure

injury, prevention, TX dressing. The bibliographies of the included studies were reviewed for

any additional relevant studies. Additional searches were performed with Google on July 26,

2013 using key words wound dressing, pressure sore, pressure injury, bedsore, and decubitus

ulcer. Any reports describing product news, testimonials, laboratory based in vitro studies, and

studies with no primary data were excluded from the review. A single reviewer selected the

articles to be reviewed by their abstracts and titles, with independent review by the authors where

discrepancies were resolved through discussion. Data was abstracted by the single reviewer and

checked by the review authors. Data was collected based on design, participants, methods,

outcomes, and baseline characteristics of the studies. Studies were then assessed for internal and

external validity according to the criteria suggested by SIGN based on study type. The quality

was then assessed by a checklist and validated for all published case series with multiple subjects

to assess risk for bias. Analysis included relative risk of 95% and confidence intervals using

random effects model. All studies had a narrative synthesis. The sample included RCTs,

controlled trials, cohort studies, and case series.

The searches found 3026 titles, with 2819 titles after removal of duplicates. Of these 2777

were excluded by abstract and title because they discussed pressure ulcer healing and treatment

of other chronic or acute wounds, or where a prophylactic dressing was not used. The full text of

42 papers was reviewed, with 21 excluded and 21 included after review. Of the 21 reviewed, 9

compared the use of prophylactic dressings to no use of prophylactic dressings. 2 were RCT, 5

Cohort, one within subjects design, and one with no specified design. The nine studies were
 18

heterogeneous groups from different care settings, and reported on 4 specific body sites where

pressure injury might occur that were covered by prophylactic dressings. The four specific sites

reviewed were pressure injury at the nose, the quality of the studies ranged from low to

moderately high. Some failings of the study included no masking of outcomes, or not reporting

the number of patients approached to participate. The authors identified one single high-quality

RCT and a growing number of cohort or weak RCT that all suggest the introduction of a dressing

for pressure injury prevention may help reduce the incidence of pressure injuries associated with

medical devices and immobile ICU patients. There was no clear evidence identified that one

type of dressing is more effective than another.

Study Three: Bundles to Prevent HAPI 2015

In the Journal of Nursing Scholarship the Authors Tayyib, Coyer, and Lewis 2015 tested

the effectiveness of bundle practices to reduce pressure injuries. They utilized a two arm cluster

RCT to assess the effect of bundle practices in ICU patients. The two groups were intervention

group that received the Pressure Injury prevention bundle, and the control group that received

standard skin care per local ICU policy. The key aspects of the pressure injury prevention bundle

included risk assessment (q24h), skin monitoring (q8h), nutrition, pressure point changes (q3h),

support surfaces, education and training, and assessment of skin around medical devices (q12h).

There were no significant differences between groups based on demographics or clinical

characteristics, except age where the mean age of participants in the intervention group of 63

years was significantly higher than the mean age of the control group of 56 years (p=.02). Braden

Q scores showed the majority of patients in both groups were at high risk for pressure injury.

Patients were not individually randomized, but rather randomization of the two hospitals was

done by computer, with one hospital using the bundle intervention.

 19

Descriptive statistical and correlation statistical methods were performed. Pressure

Injury cumulative incidence rate was measured using the proportion of participants who

developed a new pressure injury within a specific time by the total number of participants who

were at risk for pressure injury development. Log-rank and Cox proportional hazard analysis

were used to compare the pressure injury events amongst the two groups to determine a hazard

ration. Then Poisson regression model was used to compare the incidence ratio differences

between groups with 95% confidence interval.

Data collected included: demographics, Braden Q score, use of mechanical ventilation,

severity of organ function score, pressure injury presence, and pressure injury staging. Data was

collected every two days from admission to discharge or death up to a maximum of 28 days.

Data was analyzed using descriptive correlation statistics, Kaplan-Meier survival analysis, and

Poisson regression. Data was collected from October 2013- February 2014 in two Intensive Care

Units in Saudi Arabia. Sample size needed to assess efficacy was 48 persons. Total number of

participants recruited was 140, with 70 in each control and intervention groups. Pressure Injury

incidence was significantly lower in the intervention group at 7.14% incidence versus 32.68%

incidence in the control group. Poisson regression revealed that the likelihood of developing a

pressure injury in the interventions group was 70% less than the control group. The intervention

group also had a significantly lower low stage pressure injury development over the control

group.

The authors conclude that significant improvements were observed in the number of

pressure injuries in the intervention group and that utilizing a bundle approach and standardized

language has the potential to reduce HAPIs in critically ill patients.

 20

Summary

Hospital acquired pressure injuries continue to be a significant hospital acquired

condition here in the United States, where acute care hospitals treat approximately 2.5 million

pressure injuries (Landro, 2007).The implications of a bundle for reducing HAPI will affect not

only acute care hospitalized patients, but those in rehabilitation, convalescence, and home care

prompts research to continue to search for preventative measures that might eradicate this issue.

The number of HAPIs has decreased over time with findings of interventions that help reduce

them, but there is still significant room for preventative measures, especially ensuring that each

team is utilizing prevention bundles.

Are there evidence based interventions for preventing HAPIs? Research studies have

been conducted in the hopes of answering this very question. Studies such as those that have

been included as study 1 and study 2 here provide information regarding how evidenced based

interventions can reduce HAPI and are recommended by subject experts. An additional study,

study 3, demonstrated potentially valuable information on how bundling interventions into one

comprehensive bundle could prevent HAPIs over using individual interventions alone.

If the answers to the three prior questions both prove to be positive, will the combination

of the three interventions be enough to eliminate HAPIs? The theory of combination has long

been an integral part of fighting hospital acquired conditions. For example, combining

interventions to effectively eliminate HAPIs has been studied. For the first time, researchers can

now effectively reduce HAPIs in the clinical setting. The discoveries discussed above are

individually relevant in their own right. However, when we combine interventions through

different groups of researchers and scientists are we able to see progress towards eradicating

HAPIs? Next, the Results will be discussed.

 Chapter 4: Results

Purpose of the Study

Because most hospital acquired pressure injuries are preventable, reducing these

preventable pressure injuries will reduce costs and harm to both patient and facility. The goal of

this project was to create a bundle of interventions that would prevent HAPIs over interventions

alone. This mixed-method, quantitative study was conducted in order to assess if implementing a

bundle of interventions designed to reduce HAPIs is more effective at reducing HAPI prevalence

over individual interventions alone. More specifically this study investigated; (A) if utilizing a

multidisciplinary care team to assess skin can prevent HAPIs and (B) if implementing a barrier

between the skin and pressure can prevent HAPIs. Further, if both (A) and (B) are positive then

will (C) combining interventions into one comprehensive bundle reduce the incidence of HAPIs?

Three studies were reviewed for the purpose of answering these three questions. Many different

studies have reviewed HAPI prevention over the last three decades in the fight to prevent

preventable harm to patients. However, only the most current research that investigated recent

interventions and bundles to prevent HAPIs were included as they represent the most current

approach to the prevention of HAPIs.

Study one examined the utilization of a collaborative multidisciplinary approach to skin

injury prevention. This study illustrated that a multidisciplinary team is much more effective at

reducing HAPI due to accountability and shared ownership for the prevention of pressure

injuries. As a result of the collaborative team approach to pressure injuries in combination with

frequent skin checks and utilization of foam barriers and templates there was a significant

decrease in the number of HAPIs.

 22

Study two researchers focused on the utilization of barriers to prevent HAPIs. This

study’s focus was on using prophylactic barriers to lead to reductions in the occurrence of low

stage pressure injuries (Stage I & II). The researchers were successful in identifying one

randomized control trial (RCT) and a number of cohort or weaker RCT that supported the

introduction of a dressing for pressure injury prevention.

In the third study researchers concentrated on an even more progressive approach to

HAPI prevention that included bundling historical interventions of pressure point changes and

nutrition with new interventions of risk assessment, standardizing language regarding HAPIs,

and frequent skin monitoring. The researchers successfully utilized this bundle practice to

reduce the number of pressure injuries in the intervention group over the control group.

The research questions asked were;

4. Does utilizing a multidisciplinary care team to assess skin and intervene prevent

HAPIs?

5. Does implementing a barrier between the skin and pressure prevent HAPIs?

6. If the answers to the first two questions prove to be yes, will combining

interventions that have been shown to prevent HAPIs into one comprehensive

bundle reduce more HAPIs than one bundle alone?

From these questions the following hypotheses are created;

The hypotheses that are created by these questions are as follows;

H1a: Those utilizing multidisciplinary teams are less likely to acquire HAPIs.

H10: Those not utilizing multidisciplinary teams are less likely to acquire HAPIs.
 23

H2a: Those implementing a skin barrier to pressure are less likely to acquire HAPIs.

H20: Those not implementing a skin barrier to pressure are less likely to acquire HAPIs.

H3a: If the first three questions prove positive, the combination of the three is likely to

reduce the rate of HAPIs greater than one element alone.

H30: If the first three questions prove positive, the combination of the three is unlikely to

effectively reduce the rate of HAPIs over one element alone.

This chapter provides a thorough review of the data of each of the studies utilized in this

secondary study. Following the written descriptive statistics there will be graphs, and tables to

provide additional clarity of study findings. This chapter concludes with an overview of the data

presented in the Summary of Findings.

Descriptive Statistics

Study One: Multidisciplinary Care to prevent HAPIs 2014

In this interventional quality study Acorda (2015) utilized the Plan Do Study Act quality

model. For planning they reviewed mask types, pressure barriers and at the lack of skin

documentation. Nurse and respiratory therapists were asked why they did not document skin.

Nurses were worried to remove the mask causing a loss of needed pressure while respiratory did

not have a place to document skin. A literature review was then done on the subject. After

problem identification and literature review, a cohesive multidisciplinary team was formed. One

of the prime areas of focus was the utilization of a cohesive multidisciplinary care team to

collaborate, share accountability, and share ownership for the prevention of hospital acquired

pressure injuries (HAPIs).

 24

During the intervention phase the bedside nurses and respiratory therapists did every 4

hour skin assessments and notified WOCN nursing and leadership of any redness of the skin.

The goal of the project was to prevent HAPIs by developing a collaborative team relationship

between nursing and respiratory therapy with accountability and shared ownership. The HAPI

rate decreased from eleven in the first three quarters to only one in the fourth quarter of fiscal

year 2012, and the decrease in HAPIs was sustained in fiscal year 2013 (Graph 1).

Graph 1

Graph 1: Number of HAPIs after Multidisciplinary Intervention

4
3
2 # of PI/mo
1
0
12

12

12

12

13

13

13

13

14

14

14

14
20

20

20

20

20

20

20

20

20

20

20

20
Q2

Q3

Q1

Q2

Q3

Q2
Q1

Q4

Q4

Q1

Q3

Q4

Study Two: Barriers to prevent HAPIs 2014

The researchers Clark, Black, Albes, Brindle, Calls, Dealey, and Santamaria (2013) in this

study examined whether the use of prophylactic barriers can lead to reductions in the occurrence

of low stage (Stage I & II) hospital acquired pressure injuries (HAPIs). For the purpose of their

study they completed a systematic review of the literature using the following research

questions: “What evidence was available to indicate that the use of dressings in pressure ulcer

prevention leads to reduced pressure ulcer incidence?”

3. “What evidence was available to indicate that different types of prophylactic dressing

may have a greater or lesser effect upon the prevention of superficial pressure ulcers?”
 25

The researchers found one single high quality randomized control trial and nine weak cohort and

RCT trials supporting the introduction of a dressing as a preventative measure for reducing the

incidence of pressure injury formation (Table 1).

Table 1 shows a summary of ten studies with comparisons between the incidence of pressure

injury with (a) a prophylactic dressing to protect the skin and no dressing and (b) where the

effect of different dressings upon pressure injury incidence was compared.

 26

Table 1
 27

Study Three: Bundles to Prevent HAPI 2015

Researchers Tayyib, Coyer, and Lewis (2015) tested the effectiveness of bundle practices

to reduce pressure injuries in a two arm cluster randomized control trial (RCT), comparing a

single intervention (bundle) against a control (no bundle). The aim of the study was to test the

effectiveness of a pressure injury prevention bundle in reducing incidence of pressure injuries in

critically ill patients in intensive care units.

70 subjects were enrolled in each arm of the study. Incidence of HAPI was significantly

lower in the bundle group (7.14% or 5 PI in 70 subjects) versus the no bundle group (32.68% or

23 PI in 70 subjects) with (p=<.001). The likelihood of developing a pressure injury in the no

bundle group was 70% more than the bundle group. The bundle group had less Stage I and Stage

II pressure injuries (p=.002) than the no bundle arm. The analyses revealed that the

implementation of the pressure injury prevention bundle significantly reduced the severity of the

HAPIs (2/5) versus the no bundle arm (7/23) as well (Table 2).
 28

Table 2: Demographic and Clinical Characteristics of Patients with Pressure Injuries

Summary of Findings

The objective of this study was to determine whether or not a bundle of interventions

would prevent more HAPIs than single interventions alone? The results of this study were very

illuminating, showing there are new interventions that should be included in bundle practices to

prevent HAPIs. This study indicated that bundle practices to prevent HAPIs which incorporate

multidisciplinary skin teams and prophylactic barriers will have the most effect on the reduction

of HAPIs. However, the study also indicated there are some HAPIs that will still occur despite

our best efforts at reduction.

Chapter five discusses the interpretations of the research findings, implications for the

research/medical communities, and what these findings could mean in the fight to reduce HAPIs.
 29

Conclusions and recommendations for future studies and research are included at the end of

chapter five.

Chapter 5: Discussion, Conclusion, and Recommendation

 30

Introduction

Hospital acquired pressure injuries (HAPIs) persist as a problem in acute care hospitals

and continue to be a major cause of morbidity and mortality (Salcido & Popescu, 2009) despite

increased efforts to reduce HAPIs in the inpatient setting. Efforts to decrease HAPIs have

increased due to Centers for Medicaid value-based purchasing plans which force the hospital to

absorb the cost of care for preventable eleven hospital acquired conditions, including HAPIs.

The occurrence of HAPIs was named a nurse-sensitive quality indicator and most are considered

preventable (Spetz & Brown, 2013).

HAPIs in acute care hospitals continue to occur at an estimated prevalence rate of 0.4%-

38%. A review of data was conduction in 2017 by the Agency for Healthcare Research and

Quality who discovered that the mortality for patients who contracted HAPIs was estimated at

0.041 (95% CI: 0.013 to 0.093) per HAPI case (41 excess deaths per 1000 HAPIs) (Agency for

Healthcare Research and Quality, 2017). Several other studies noted mortality rates as high as 60

percent for older persons with pressure ulcers within 1 year of hospital discharge (Allman, 1995)

(Thomas, Goode, Tarquine, & Allman, 1996). The expenditure to treat HAPIs in the United

States is approximately $11 billion to treat the 2.5 million preventable pressure injuries that

occur during hospitalization (Health Research and Educational Trust, 2017). In addition to the

cost for the hospital, there is significant cost to the patient as well which include higher

hospitalization costs, pain, infection, disfigurement, longer hospital stays (Spetz & Brown,

2013), and risk of death (AHRQ, 2017). HealthGrades Patient Safety in American Hospitals

fourth annual study found pressure ulcers had one of the highest hospital error occurrence rates

(Washington Post, 2007).

 31

Preventing HAPIs is a major focus of quality in the Healthy People 2020 objectives

(USDHHS, 2018). Despite the increased focus on these objectives, the incidence range is still

elevated at 7%-9% (Kelleher, Moorer, and Makic, 2012). Factors that play into HAPI formation

include immobility, incontinence, poor nutrition, neurological disease, shearing forces, friction,

and moisture (Berlowitz, 2010). The highest risk for HAPIs occurs in the intensive care unit in

patients with mechanical ventilation, trapped moisture, shearing force with repositioning,

vasopressors, hemodynamic instability, and multisystem organ failure put them at much higher

risk (Chaiken, 2012).

Discussion

My personal experience as a respiratory therapist in an acute care facility for the last

twenty-three years helped me realize that pressure injuries are a significant problem for our

patients, and that not interventions are being utilized to prevent HAPIs. For me this was due in

part to a lack of knowledge about pressure injury prevention as a bedside clinician. Concern for

my patients prompted this study in order to investigate the impact of utilizing bundle practices to

reduce HAPIs. Traditionally, attempts to prevent HAPIs have included routine repositioning,

and incontinence management (Levine, Sinno, Levine, & Saadeh, 2013). Risk Assessment

Scoring, skin audits, mattress overlays, specialty beds, waffle cushions were then added to the

mix. Most recently multidisciplinary skin teams, increasing frequency of skin audits, and

utilizing barriers were incorporated to reduce HAPIs. Bedside clinicians need to be aware of all

these prevention techniques so that they can help prevent HAPIs. These preventions used

individually are not enough to prevent HAPIs, particularly in high risk acute care patients.

Recently, studies have been done that show a significant benefit of incorporating multiple

interventions into a single cohesive bundle.

 32

Interpretation of the Findings

The purpose of this study was to determine if incorporating new pressure injury

prevention techniques into a comprehensive bundle will protect patients from harm over doing

isolated interventions. To do this a literature review on HAPI prevention was conducted looking

at the following research question:

1. Will combining interventions that have been shown to prevent HAPIs into one

comprehensive bundle reduce more HAPIs than one bundle alone?

The hypothesis that is created from this question is:

H1a. Putting tested interventions that have reduced HAPIs into one comprehensive

bundle will create a greater reduction in pressure injuries than one intervention alone.

H1o. Putting tested interventions that have reduced HAPIs into one comprehensive

bundle will not create a greater reduction in pressure injuries than intervention alone

In the Journal of Pediatric Nursing the author Darlene E. Acorda (2015) examined how

HAPIs can be reduced through multidisciplinary care. After implementation of a

multidisciplinary skin care team that included wound, ostomy and continence (WOCN) nurses,

respiratory therapists, and nursing leadership the pressure injury rate decreased from eleven in

the first three quarters to only one in the fourth quarter of fiscal year 2012, and the decrease in

pressure injuries was sustained in fiscal year 2013. The authors concluded that “close

collaboration between respiratory and nursing has been the primary factor” in decreasing

pressure injuries.
 33

In the International Wound Journal the authors Black, Clark, Albes, Brindle, Calls,

Dealey, and Santamaria (2014) performed a systematic review of the literature to assess whether

using prophylactic barriers can lead to reductions in the occurrence of low stage (Stage I & II)

pressure injuries. The authors identified one single high-quality RCT and a growing number of

cohort or weak RCT which led them to the conclusion that the introduction of a dressing for

pressure injury prevention may help reduce the incidence of pressure injuries associated with

medical devices and immobile ICU patients.

In the Journal of Nursing Scholarship the authors Tayyib, Coyer, and Lewis (2015) tested

the effectiveness of bundle practices to reduce pressure injuries in a two arm randomized control

trial. They found that amongst similar demographic groups, with both groups equally at risk for

pressure injuries, HAPI incidence was significantly lower in the bundle intervention group at

7.14% incidence versus 32.68% incidence in the control group. The control group was 70% more

likely to acquire a pressure injury than the bundle intervention group. The intervention group

also had a significantly lower low stage pressure injury development over the control group. The

authors conclude that the use of a bundle can reduce total number of HAPI, HAPI incidence, and

severity of pressure injuries. They also note that there is a high likelihood that increased staff

awareness and training oo HAPI prevention and interventions may contribute to decreased HAPI

occurrence.

Limitation of the Study

While the findings from this study will be effective in reducing preventable HAPIs, there

were limitations to the study that deserve mention. Due to the nature of utilizing secondhand

evidence there is no way to control variable that may have impacted outcomes. Due to the nature
 34

of this review, actual Pressure Injury reduction overall data will not be able to be collected. A

major limitation of this study was the exclusion of non-English language publications. The

search strategy including non-English publications revealed two further clinical studies.

Recommendations for Future Research

More randomized control trials (RCTs) need to be performed to ensure high quality

evidence regarding hospital acquired pressure injuries (HAPIs). In additions, very little research

has been performed on device related HAPIs. Future research should focus on RCT and device

related pressure injuries.

Implications for Practice

Prevention of patient injury is a vital part of patient care. As care providers we are

supposed to do no harm, and yet in healthcare sometimes patients are injured despite this

fundamental principle of healthcare. When the injuries are preventable, then it is the

responsibility of the hospital quality department and bedside clinicians to prevent them. Because

of this responsibility, reducing hospital acquired pressure injuries is a leading focus of acute care

hospitals quality metrics and as a nursing quality indicator. Hospital acquired conditions,

including HAPIs are costly to acute care facilities, and patient alike. In addition to monetary

costs, HAPIs can be devastating mentally and physically to both patients and their families.

Financial benefits aside, it is the ethically necessary to strive for best patient outcomes.

All members of the health care team are responsible for patient outcomes, promoting

wellness, and preventing preventable conditions. The bedside nurse, advanced practice nurse,

physical therapist, occupational therapist, nutritionist, physician, respiratory therapist, and other
 35

key members of the healthcare team all have important roles to play in the patients plan of care,

skin assessments, multidisciplinary rounding, and prevention of hospital acquired conditions.

Hospital leaders, advanced practice nurses, wound and ostomy nurses, Nursing and

Respiratory educators should be actively involved in developing best practices and prevention

guidelines. They should be involved in evidence based practice, research, building order sets,

and bundle practices related to prevention of HAPIs. The scope of practice for bedside providers

should not be limited to their area of expertise, but rather should be expanded beyond treating

illness to treating the whole person. This can be accomplished best by providing evidence based

safe care, while ensuring cost-effectiveness of care, as a multidisciplinary team of caregiver.

Establishing a health care team that promotes best practice, health, illness prevention, and equal

responsibility for patient outcomes is paramount to success.

Conclusion

Hospital acquired pressure injury (HAPI) is both a hospital quality and safety goal.

Multidisciplinary teams play a vital role in the prevention and management of HAPIs. This study

provides a clearer understanding of the significant role a bundle can play in the reduction of

number of and level of pressure injuries. Utilizing individual interventions alone has been

confirmed by this study to not be effective enough to prevent harm to patients. The researcher

Acorda (2015) concluded that “close collaboration between respiratory and nursing has been a

primary factor” in decreasing HAPIs during the study. The authors Black, Clark, Albes, Brindle,

Calls, Dealey, and Santamaria (2014) found that the introduction of a dressing for the prevention

of pressure injuries may help reduce the incidence of HAPIs associated with medical devices and

immobile patients. The authors Tayyib, Coyer, and Lewis (2015) discovered there were
 36

significant improvement in the number of pressure injuries and a decrease in the number of high

level pressure injuries when using a bundle of interventions for HAPI prevention.

It is quite possible that the information gained from this study could be applied to other

areas such as sub-acute care, convalescence, and home care. Because patients in acute care are

at higher risk of pressure injury and bundle interventions is effective at reducing the number of

pressure injuries in this population, it is reasonable to expect a similar reduction in patients who

are at lower risk. Most importantly, bedside clinicians should be better educated to act as a

multidisciplinary team with strong knowledge of evidence based interventions to prevent

hospital acquired pressure injuries.

 37

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