IMPLEMENTATION OF AN EBP AQUIRED PRESSURE INJURY STRATEGY 1

Implementation of an Evidence-based Hospital Acquired Pressure Injury Strategy in the

Intensive Care Unit

Implementation of an Evidence-based Hospital Acquired Pressure Injury Strategy in the

Intensive Care Unit

In the ever-changing arena of healthcare, our constant focus is on improving patient

outcomes, enhancing care quality, and implementing economically viable healthcare practices
IMPLEMENTATION OF AN EBP AQUIRED PRESSURE INJURY STRATEGY 2

(needs a citation). At its essence, EBP unifies three vital elements: the strongest and most up-to-

date scientific evidence, the priceless wisdom of clinical professionals, and the distinct

preferences and values of each patient. This trinity of knowledge, expertise, and patient-focus

constitutes the bedrock for making healthcare decisions (missing JHN citation). According to the

Li et al. (2019) the adherence to EBP stems from an unyielding dedication to optimizing patient

care and safety. It propels healthcare providers to persistently seek out and incorporate cutting-

edge research findings, clinical understanding, and patient viewpoints into their decision-making.

Thus, EBP not only improves care quality but also encourages patients to play an active role in

their health choices.

Li et al. (2019) states, a time where healthcare excellence is tantamount to EBP adoption,

the transformative capability of this method cannot be overstated. It directs practitioners toward

delivering care that is informed by top-notch evidence while also respecting each patient's unique

needs and desires. As healthcare continues to progress, EBP's principles stand unshaken,

guaranteeing that the quest for exemplary patient outcomes stays at the heart of medical practice.

The objective of this Doctor of Nursing Practice (DNP) project proposal is to tackle a

vital issue in clinical practice: preventing hospital-acquired pressure injuries (HAPI) among adult

patients in the intensive care unit (ICU). Be sure to make corrections each week so they will not

snowball on you.

Significance of the Practice Problem

Hospital-induced pressure wounds (HAPI) pose a significant concern in healthcare

environments. These wounds cause considerable pain and distress for patients, heavily impacting

their overall well-being during hospital stays. Apart from the discomfort, HAPIs often trigger a

domino effect of complications, such as infections that prolong hospitalization and increase
IMPLEMENTATION OF AN EBP AQUIRED PRESSURE INJURY STRATEGY 3

medical expenses. Preventing HAPIs is especially challenging for at risk groups like adult ICU

patients (Edsberg et al., 2016). Due to the severity of these patients’ health issues, immobility

becomes necessary, causing extended pressure on certain body parts and heightening the

likelihood of HAPI formation (Duquesne University, 2020). According to Saghaleini et al.,

(2018) pressure ulcers can diminish global life quality, contribute to rapid mortality in some

patients and pose a significant cost to healthcare organizations. Coexisting conditions like

diabetes or malnutrition can weaken skin resilience, making it more prone to pressure injuries.

The critical ailments facing these patients might demand invasive procedures, further

intensifying the risk.

Given the severe repercussions of HAPIs and the associated difficulties in prevention, de-

cisive measures are crucial. According to the Miller et al., (2019) Hospital-acquired pressure in-

juries (HAPI) increase patient mortality and length of stay. Thwarting these injuries not only

lessens patient suffering but also adheres to the core tenets of healthcare: delivering safe, effec-

tive, and patient-focused care. As HAPI occurrences continue to affect individuals, healthcare in-

stitutions, and society, tackling this problem has transformed into both an ethical obligation and

an integral aspect of providing top-tier healthcare services.

According to the Goodman et al. (2018) the imperative nature of halting HAPI at a

population-wide scale is truly inexpressible. Within the realm of adult ICU patients, the

emergence of HAPI can extend hospital stays, elevate healthcare expenses, and diminish their

overall quality of living. Individuals’ unfortunate enough to encounter HAPI are met with

protracted recuperation periods and find themselves more susceptible to infections and

subsequent complications. This, in turn, results in heightened morbidity and mortality rates.
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In the realm of healthcare facilities, reducing HAPI remains important in providing top-

notch patient care while controlling any associated expenses. According to Rondinelli et al.

(2018) addressing HAPI demands expert guidance in wound treatment, longer hospitalization,

and an increased burden on nursing personnel. Institutions that adeptly avert HAPI can distribute

their assets more effectively, resulting in improved care standards for their patients.

Efforts to prevent HAPI result in financial strain associated with HAPI treatment, which

can be considerable. Padula & Delarmente, (2019) suggested that by mitigating HAPI, we not

only decrease healthcare spending but also enhance overall quality. This approach aligns with

some broader objectives of healthcare improvement, prioritizing value-driven care, and patient-

focused care.

At our local medical center, the growing prevalence of HAPI has become a pressing

concern that demands attention. The occurrence of HAPI within local healthcare often reflects

wider-ranging patterns on a regional, national, and worldwide scale. Across the United States,

HAPI poses a substantial healthcare obstacle, impacting around 2.5 million individuals each

year. Rondinelli et al. (2018) suggested that tackling the frequency and widespread nature of

HAPI is crucial not just for our community's healthcare organization but also corresponds with

overall national and global healthcare goals. The monetary implications, risk of severe outcomes,

and moral obligation to stop HAPI render it an issue of utmost importance that demands

evidence-based solutions.

PICOT Question

In adult ICU patients (P), does the implementation of daily chlorhexidine gluconate

(CHG) baths with post bath barrier cream combined with intentional turning every 2 hours (I)
IMPLEMENTATION OF AN EBP AQUIRED PRESSURE INJURY STRATEGY 5

compared to standard skin care practices and nonintentional turning (C) reduce the incidence of

hospital-acquired pressure injuries (HAPI) (O) within a 30-day timeframe (T)?

Population (P): This refers to the specific group of patients for whom the intervention is

intended. In this case, the population comprises adult patients admitted to the ICU.

Intervention (I): This is the treatment or intervention I am interested in studying. In this context,

it's the daily administration of chlorhexidine gluconate (CHG) baths with barrier application post

bath and intentional turning every 2 hours as a preventive measure against HAPI (Lewis et al.,

2018).

Comparison Intervention (C): This is the alternative or standard treatment or intervention

which compare the intervention of interest. In this case, it's the standard skin care and turning

practices that are currently in place in the ICU.

Outcome (O): The focus of investigation is to gauge a particular consequence or impact. In the

context of project research, the desired outcome revolves around the decline in hospital-acquired

pressure sores (HAPI) prevalence amidst ICU patients (Rondinelli, 2018).

Timing (T): The time horizon for gauging the results of the study is a crucial aspect to consider.

In this research endeavor, by evaluating the findings within a span of 30 days, ensuring a

comprehensive interpretation of the outcomes.

The primary focus of this PICOT inquiry lies in evaluating the efficacy of introducing

daily CHG bathing with post bath barrier cream and intention turning every two hours among

adult patients in the ICU as a way to proactively reduce HAPI cases, as opposed to sticking with

prevailing skin care and turning methodologies (Duquesne University, 2020). This query

delineates the targeted populace, the proposed intervention, the reference group, desired
IMPLEMENTATION OF AN EBP AQUIRED PRESSURE INJURY STRATEGY 6

outcomes, and evaluation period. Serving as the bedrock for my DNP Scholarly Project, this

paramount question will steer literature examination and investigative endeavors.

Evidence-Based Practice Framework & Change Theory

Johns Hopkins Evidence-Based Practice (JHEBP) is a framework for systematically

identifying process problems. It is based on evidence appraisal and implementation of the same

evidence in actual practice and value generation. JHEBP helps practitioners integrate the best

evidence into their routine, boosting the quality of clinical expertise and patient outcomes

through informed decision-making strategies.

The proposed project will benefit from the JHEBP framework in that it will become a

blueprint for developing the application of evidence from research. This will ensure that the

process for applying evidence-based practice is systematic and that I can identify a problem in

practice and use the available research evidence to develop and implement a solution.

This paper will make use of the Rogers Diffusion of Innovation theory to analyze and

manage change. In this theory, the theorist posits that for change to take place, the process must

incorporate achievement of knowledge, persuasion, decision, implementation and lastly

confirmation. Thus, the approach will first focus on informing the stakeholders in the change

process in order for them to acquire the necessary information. It is based on this information

that the stakeholders will be in a position to get persuaded and make the right practice change

decisions. The decisions will then be implemented in order to attain a new level of performance

related to the intended change.

This theory will help me assess my project regarding the stakeholders, proposed changes,

and readiness requirements in terms of information and resources. The approach will enable the

development of interventions tailored to individuals at different stages of their readiness. This

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helps promote a smoother implementation of the change process, avoiding resistance to change

and, hence, better outcomes.

Evidence Search Strategy

A thorough search for significant research publications was necessary in the quest of

implementing an evidence-based Hospital Acquired Pressure Injury (HAPI) prevention approach

in the Intensive Care Unit (ICU). The goal was to find studies that were directly related to the

PICOT question, which looked at how well daily chlorhexidine gluconate (CHG) baths worked

in conjunction with barrier cream application and intentional turning every two hours to lower

the incidence of HAPI in adult ICU patients over the course of a 30-day period (Tripp, 2022).

In addition to PubMed/MEDLINE, CINAHL, the Cochrane Library, Embase, and Web of

Science were all included in the search. MeSH headings and extensive search phrases were used

to cover all facets of evidence-based management, ICU patients, CHG baths, and HAPI

prophylaxis.

In order to assure current relevance, inclusion criteria concentrated on research studies

that directly addressed the PICOT topic, were published in English, and were undertaken within

the last ten years (2013–2023). Studies that did not fit the PICOT question, were not in English,

were older than 2013, did not include adult ICU patients, or had poor methodological quality

were all excluded.

Only full-text papers were included in the search filters, ensuring that only complete

research investigations were taken into account for analysis.

180 research papers were found in the pool of results from the initial search in the chosen

databases. The removal of duplicates and further application of inclusion and exclusion criteria

led to a more selective selection of 15 research publications for additional evaluation.

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The Johns Hopkins Evidence-Based Practice (JHEBP) methodology was used to evaluate

the quality of the evidence. The articles that were chosen covered a wide range of study designs,

with a focus mostly on systematic reviews and randomized controlled trials, which suggests a

high level of evidence. The studies' quality varied, with some displaying more thorough research

design and methods.

The foundation for developing practice recommendations and an implementation plan

was laid by this evidence search technique. The chosen research will form the basis of an

evidence based HAPI prevention strategy in the ICU that aims to enhance patient outcomes and

care quality while lowering costs (Pittman et al., 2021).

Evidence Search Results

Research evidence quality depends on study design, sample size, and technique.

Goodman et al.'s (2018) Level II study scored an A- for excellence. The study had 348

participants, including ICU and non-ICU patients. The Plan-Do-Study-Act (PDSA) system

improved treatment, equipment, documentation, and education to reduce HAPIs. The Health

Belief Model was utilized to measure HAPI decrease. Hospitalized individuals saw a 16% HAPI

prevalence drop to < 10%. This study emphasizes the significance of focused PDSA in treating

patients and reducing pressure injuries.

In 2020, Gupta et al.'s study received an A- for Level II evidence quality—all patients

who attended specified hospitals throughout the two-year study. Multidisciplinary risk

assessment, treatment, and documentation for HAPI was based on the Institute for Healthcare

Improvement (IHI) collaborative paradigm. This study assessed HAPI reduction (Gupta et al.,

2020). The incidence of HAPI dropped 83.5% from 6.1/1000 patient days to 1.1/1000. This

shows how the institution's interdisciplinary approach reduces HAPI.

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Miller et al.'s (2019) B-quality Level IV study is good but not primary research. This

study did not intervene or compare hospital pressure injury prevention efforts. Instead of proving

any intervention works, this study highlights the multidisciplinary Pressure Injury Prevention

(PIP) team's findings (Miller et al., 2019). The committee's study found that full-thickness

HAPIs were reduced by 89% after the multidisciplinary team was established. Secondary

research cannot match primary research in dependability. However, this study shows that a

multidisciplinary approach may minimize HAPI.

Padula & Delarmente's (2019) B-rated, Level V evidence-based study was excellent. In

this study, researchers simulated US HAPI treatment costs. Researchers employed the Markov

Economic simulation model to estimate HAPI's financial effect. HAPI's monetary cost defined

the outcome. The study suggests that HAPIs may cost more than $26.8 billion in the US,

emphasizing the need to reduce their dangers and occurrence in healthcare institutions. This

study does not include treatment or outcome data, but it does illuminate HAPI's financial effects,

which may inform policymakers and resource allocation.

A study by Pittman et al. (2021) received an A-—level II study. Adults from cardiac

ICUs and operating rooms were examined. Alternating pressure (AP) overlays reduced HAPI.

Pressure injury prevention was the study's focus. The AP overlay cut operating room HAPIs

from 11% to 0%, saving $323,048. This research reveals that the AP overlay avoids pressure

injuries and is useful in various healthcare situations.

Rondinelli et al. (2018) did a B-level III study. This retrospective research covers all

hospitalizations. This research employed the Braden Scale for Predicting Pressure Ulcer Risk

with comorbidity and disease severity assessments. For HAPI prevalence, risk variables, and

risk-adjusted hospital variation, the Cox proportional hazards model was used. Age and severity
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of disease were risk factors for HAPI, which occurred 0.57 per 1,000 patient days. HAPI's

prevalence and causes are revealed in this research, aiding preventative efforts.

According to Saghaleini et al. (2018), this was B-quality Level V research. There was no

set number of participants. The study included reviews of literature and expert judgments. A

study explored diet's influence on HAPI prevention. Diets rich in minerals, water, and trace

elements may help avoid skin disease. This article reviews diet and HAPI avoidance studies and

expert comments. Level III study earned Takada et al. (2022) an A. This research scrutinized

Japanese annual medical insurance privileges. A Cox proportional-hazards model evaluated

complications. The preparation, action, and maintenance phases had fewer issues than pre-

contemplation. Chronic diseases need early identification and treatment.

In conclusion, research quality differs greatly. Goodman and Gupta's Level II research

shows that several medications lower HAPI prevalence and incidence with robust evidence and

good grades. However, Miller et al.'s Degree IV and Padula & Delarmente's Level V study give

valuable insights but little empirical data. When these data are integrated, we can better

understand HAPI prevention and treatment. Research quality also varies widely. Pittman and

Takada's Level II and Level III research were praised for their rigorous methods and reliable

results. This research offered useful data on therapy and prevention effectiveness. Although not

primary research, Rondinelli et al. (Level III) and Saghaleini et al. (Level V) provided useful

information. These studies helped us understand HAPI risk factors and diet's role in prevention.

This research gives a wealth of data that may inform HAPI therapy and prevention.

Themes with Practice Recommendations

Effectiveness of Daily CHG Baths and Barrier CreamPatienys Safety and Quality Health

care
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Prioritizing patient safety and delivering exceptional care are essential objectives in the field of

healthcare. Preventing hospital-acquired pressure injuries (HAPIs) greatly enhances patient

safety and the overall quality of treatment. The evidence from multiple research emphasizes the

crucial significance of HAPI prevention in attaining these objectives. Ensuring patient safety is

of utmost importance in healthcare environments, and Hospital-Acquired Pressure Injuries

(HAPIs) present a direct risk to the well-being of patients (Hannawa et al., 2022). Implementing

effective HAPI preventive techniques results in a significant decrease in the occurrence of these

incidents, therefore improving patient safety. The implementation of multidisciplinary

approaches and targeted interventions in these studies resulted in a reduction in the occurrence of

Hospital-Acquired Pressure Injuries (HAPI). This eventually guarantees the protection of

patients from the discomfort and problems that are commonly associated with pressure injuries.

Patient safety is intricately linked to the quality of care. Comprehensive care includes not just

clinical efficacy, but also patient-centeredness, promptness, and efficiency. Preventing

Healthcare-Associated Infections (HAPIs) is in accordance with these aspects of care quality.

One of the central themes that emerged from the evidence is the effectiveness of daily

chlorhexidine gluconate (CHG) baths with post-bath barrier cream in reducing the incidence of

hospital-acquired pressure injuries (HAPI) among adult ICU patients. The study quality

improvement project conducted by Goodman et al. (2018) presented convincing data on this

matter. Their study implemented a Plan-Do-Study-Act (PDSA) framework that integrated CHG

baths with barrier cream application into the regular care protocols. The study projct by

Goodman et al. revealed a noteworthy decrease in Hospital-Acquired Pressure Injuries (HAPI)

prevalence when daily Chlorhexidine Gluconate (CHG) baths and barrier cream are incorporated

into the intervention. The study successfully demonstrated a significant 16% decrease in the
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occurrence of Hospital-Acquired Pressure Injuries (HAPI), highlighting the considerable

effectiveness of this method in reducing pressure injuries. Implementing CHG baths and barrier

cream served as a preventive intervention for patients in the ICU, mitigating the likelihood of

HAPI production. The results of this study highlight the efficacy of daily CHG baths and barrier

cream as a preventive measure against HAPI in the ICU environment. This technique enhances

patient outcomes and overall quality of care by preserving the integrity of the skin and

minimizing the risk of infection.

Emphasizing the prevention of Hospital-Acquired Pressure Injuries (HAPI) is crucial in

healthcare organizations to prioritize patient safety activities. Highlight that the prevention of

Healthcare-Associated Infections (HAPIs) is not solely a clinical goal, but also a crucial ethical

duty. Establish and execute thorough HAPI preventive strategies that include evaluating risks,

implementing interventions based on evidence, and consistently monitoring to maintain patient

safety without compromise. Additionally, it is imperative for them to create and execute

customized quality enhancement initiatives aimed at preventing HAPI. These initiatives must to

incorporate precise metrics, such as periodic skin evaluations and interdisciplinary cooperation,

as well as evidence-based practices. Consistently appraise and analyze the influence of these

initiatives on patient safety and the overall standard of care

Emphasizing the prevention of Hospital-Acquired Pressure Injuries (HAPI) is crucial in

healthcare organizations to prioritize patient safety activities. Highlight that the prevention of

Healthcare-Associated Infections (HAPIs) is not solely a clinical goal, but also a crucial ethical

duty. Establish and execute thorough HAPI preventive strategies that include evaluating risks,
IMPLEMENTATION OF AN EBP AQUIRED PRESSURE INJURY STRATEGY

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implementing interventions based on evidence, and consistently monitoring to maintain patient

safety without compromise. Additionally, it is imperative for them to create and execute

customized quality enhancement initiatives aimed at preventing HAPI. These initiatives must to

incorporate precise metrics, such as periodic skin evaluations and interdisciplinary cooperation,

as well as evidence-based practices. Consistently appraise and analyze the influence of these

initiatives on patient safety and the overall standard of care.

According to the compelling evidence shown by Goodman et al. (2018), it is recommended that

healthcare facilities in the ICU setting use daily CHG baths with post-bath barrier cream as a

crucial part of their approach to avoid HAPI. This empirically supported strategy has

demonstrated a substantial decrease in Hospital-Acquired Pressure Injuries (HAPI), enhancing

the overall welfare of adult patients in the Intensive Care Unit (ICU). To proactively safeguard

patients from the debilitating repercussions of pressure injuries, healthcare practitioners can

integrate regular CHG baths and barrier creams into their standard treatment practices. The

approach promotes the implementation of a well-supported intervention that can improve patient

care and safety.

Pressure Injury Prevention Over Treatment

The theme underscores the importance of emphasizing pressure injury prevention above

their treatment. The subject of this theme is based on the research project conducted by Miller et

al. (2019), which highlighted the crucial function of a multidisciplinary team specializing in

Pressure Injury Prevention (PIP) in decreasing the occurrence of pressure injuries acquired in

hospitals (HAPI) among adult patients in the Intensive Care Unit (ICU). The study elucidated

emphasized the efficacy of a proactive, preventive approach in healthcare (Walker et al., 2020).

The development of the PIP team and their emphasis on preventive measures resulted in a
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remarkable 89% decrease in full-thickness hospital-acquired pressure injuries (HAPIs). This

result emphasizes that allocating resources toward preventative interventions can yield greater

effectiveness and economic efficiency than merely focusing on treating pressure

injuries. Healthcare facilities can mitigate exorbitant expenses, prolonged hospitalizations, and

patient distress by proactively preventing Hospital-Acquired Pressure Injuries (HAPI).

To align with the theme of "Pressure Injury Prevention Over Treatment," healthcare

facilities should consider implementing two key recommendations. First, they should establish

dedicated Pressure Injury Prevention (PIP) teams, similar to the approach highlighted in Miller et

al.'s study. These multidisciplinary teams should consist of specialists who focus on preventing

pressure injuries and educating staff on best practices. These teams can regularly assess high-risk

patients, develop individualized prevention plans, and ensure the implementation of evidence-

based preventive measures, such as repositioning, pressure-relieving surfaces, and skin care

protocols. Second, healthcare facilities should prioritize comprehensive staff training and

education on pressure injury prevention. Staff at all levels, from nurses to physicians, should

receive ongoing training to enhance their understanding of the importance of prevention and the

latest prevention strategies. This proactive approach not only reduces the incidence of pressure

injuries but also leads to cost savings by avoiding the need for prolonged and expensive

treatments.

According to the findings of Miller et al. (2019), it is recommended that healthcare

facilities prioritize preventing pressure injuries by creating interdisciplinary teams dedicated

explicitly to Pressure Injury Prevention (PIP). These teams should prioritize proactive

preventative efforts, such as conducting regular evaluations, providing information, and

implementing interventions to decrease the frequency of HAPI (Hospital-Acquired Pressure

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Injuries). By prioritizing prevention rather than treatment, healthcare institutions can effectively

diminish the impact of pressure injuries on patients and the healthcare system, eventually

enhancing patient outcomes and reducing expenses. This recommendation highlights the need for

a proactive approach to tackle the crucial problem of Hospital-Acquired Pressure Injuries (HAPI)

in the Intensive Care Unit (ICU) environment.

Interdisciplinary Collaboration

Financial Implications of HAPI Prevention

Preventing Hospital-Acquired Pressure Injuries (HAPI) is crucial for the well-being of

patients and the financial stability of healthcare organizations. The research by Padula &

Delarmente (2019) provides insight into the significant economic impact of Hospital-Acquired

Pressure Injuries (HAPIs). Based on Level V evidence, their study utilized an economic

simulation model to calculate the financial consequences of Hospital-Acquired Pressure Injuries

(HAPIs) in the United States. The study's findings demonstrate that Hospital-Acquired Pressure

Injuries (HAPIs) might incur a substantial financial burden, exceeding $26.8 billion in the United

States. This significant financial burden includes the costs of treating Hospital-Acquired Pressure

Injuries (HAPIs), such as wound management, specialized equipment, prolonged hospital stays,

and extra healthcare resources. Moreover, HAPIs might result in extended hospital stays and

heightened medical costs, impacting both patients and healthcare facilities. The financial

ramifications of preventing HAPI go beyond the acute expenses associated with therapy.

Proactively avoiding Healthcare-Associated Infections (HAPIs) can lead to substantial financial

savings for healthcare institutions.

By reducing the incidence of Hospital-Acquired Pressure Injuries (HAPIs), institutions

can optimize the allocation of their resources, resulting in enhanced care standards for their
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patients. In addition, HAPI prevention aligns with broader healthcare improvement goals,

stressing the provision of value-based and patient-centered care. Given the significant financial

consequences, healthcare organizations are advised to prioritize efforts to prevent Healthcare-

Associated Pressure Injuries (HAPIs). Adopting a proactive strategy to avoid Hospital-Acquired

Pressure Injuries (HAPIs) not only enhances patient outcomes and the quality of treatment

provided but also leads to cost savings and efficient utilization of resources. Recognizing the

financial consequences of preventing Hospital-Acquired Pressure Injuries (HAPI) highlights the

significance of employing evidence-based approaches and dedicating resources to reduce the

frequency of HAPI. The subject of interdisciplinary teamwork is crucial in the context of

reducing HAPI. The evidence highlights the crucial involvement of healthcare experts from

diverse fields collaborating to create and execute successful strategies for preventing HAPI.

Practically, it is essential to adopt an interdisciplinary team approach. These teams should

frequently gather to deliberate on HAPI prevention, exchange knowledge, and synchronize care

plans. Establishing transparent channels of communication and promoting the exchange of

information among team members enables a comprehensive strategy to preventing HAPI (Schot

et al., 2020). Interdisciplinary collaboration can greatly benefit from team meetings, case

reviews, and the establishment of shared protocols. Moreover, efficient multidisciplinary

cooperation not only improves the effectiveness of HAPI prevention but also conforms to

healthcare's optimal methodologies. It upholds the tenets of patient-centered care, evidence-

based decision-making, and a comprehensive approach to ensuring patient safety.

Healthcare facilities must to establish multidisciplinary teams comprising professionals

from many disciplines, such as nurses, physicians, physical therapists, wound care specialists,
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and dietitians. These teams should cooperate on HAPI prevention activities, with a focus on

consistent communication and sharing of information. By engaging in team meetings,

conducting case reviews, and implementing agreed protocols, team members can cultivate a

thorough comprehension of patient requirements and subsequently customize prevention tactics.

Healthcare facilities should additionally establish and execute collaborative protocols and

recommendations for the prevention of HAPI, incorporating contributions from all pertinent

disciplines. These procedures should clearly define the duties and responsibilities of each team

member, promoting a collective sense of ownership in the prevention of HAPIs. Furthermore,

they should offer multidisciplinary instruction and training on HAPI prevention to guarantee that

all team members are knowledgeable and prepared to contribute successfully to the collaborative

endeavor.

Recommendations

What are your recommendations for which of the above included strategies could resolve

the issue? The practice recommendations are… Based on the evidence … should answer the

PICOT question…That would be your last statement in the themes

Setting, Stakeholders, and Systems Change

1-2 pages. This section includes a description of the setting of the DNP scholarly project.

Include the type of setting, description of a typical participant, and the organizational structure

and culture (as applicable). Do not name the organization. Describe how organizational need was

established. Identify the stakeholders. Describe how organizational support was confirmed and

include plans for sustainability. Describe interprofessional collaboration required. Briefly discuss
IMPLEMENTATION OF AN EBP AQUIRED PRESSURE INJURY STRATEGY

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the SWOT analysis and include it as an appendix. Identify the level of systems change that the

project will create (micro, meso, macro) and describe the systems change succinctly. Amidst this

dynamic setting, evidence-based practice (EBP) has surfaced as a monumental shift in healthcare

delivery, guiding professionals towards safer, highly effective, and patient-centric care.

Implementation Plan with Timeline and Budget

2-3 pages. This section includes the project objectives, which state what will be achieved

in clear and measurable terms using the SMART format (specific, measurable, attainable,

realistic, and timed). Provide 3-5 objectives that will guide the implementation and evaluation of

the project. Identify how the objectives will be met.

Clearly reflect how the EBP and change models are used to guide the recommended

practice change. Describe interprofessional collaboration required during implementation. List

the steps of the project with detail. Specifically, and operationally define what must be done.

Address the timeframe for the change process and the evaluation knowing that implementation

and data collection must occur after obtaining all required approvals in NUR7802 (generally by

the end of week six) and prior to the end of week four in NUR7803. Implementation and

evaluation should take between 8-12 weeks and under no circumstances more than 12 weeks.

Taking longer will delay your graduation. Nothing should be left to decide later. Include

resources required for implementation of the project including the timeline and a budget as

appendices. Discuss the role of the project manager during implementation and the leadership

qualities and skills required for successful completion of the project.

All documents or information that will be used during implementation must be fully

developed, referenced in this section, and included in an appendix. This includes any

presentations, tools, signage, communication plans, instructions, etc.

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Evaluation Plan

1-2 pages. This section must include the detailed evaluation plan for the project.

Remember that the plan must evaluate the outcome(s) identified in the PICOT question. Discuss

recruitment and selection of participants including inclusion and exclusion criteria, if any.

Remember to only use EBP terminology! An EBP project does not use a sample group, but

instead a group of participants.

Describe the data that will be collected to determine how effectively the intervention

impacted the practice problem driving this project. Describe the data that will be collected,

including how and when it will be collected. Identify those who will collect, analyze, and store

the data and address the integrity of the process. Explain the integrity of the data sources (e.g.,

EMR, online survey, or an internally created tool?). Address how HIPAA concerns will be

addressed if they are relevant to the project. Describe the plan to handle missing data and where

and how data will be stored.

Discuss the evaluation design, including comparison data. Describe any included

categories of measures such as outcome, process, and sustainability. Clearly identify the

benchmarks for each measure, using a table or logic model. Describe and include any tool(s) that

are to be used in the project evaluation as appendices and discuss the reliability and validity of

the tool(s). This includes data collection tools. Address permission to use tools. Identify the type

of data (i.e., nominal, ordinal, interval, or continuous) produced by the evaluation tool(s).

Discuss planned analysis of the evaluation data. A table is the preferred method to

identify which basic, statistical test will be applied to each measure. Remember the goal is to not

prove or disprove the effectiveness of the intervention, which has already been proven effective

in previous research. This is not a research project, but an EBP project that is implementing
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existing research findings. Statistics are used to measure the level of change from pre-

intervention to post-intervention, but emphasis should be concentrated on the clinical

significance as opposed to the statistical significance of findings. Define what criteria will

determine a statistically significant change and what will determine a clinically significant

change. Briefly discuss why clinical significance is most important in EBP projects. Include a

statement about the approval processes required at USAHS as well as the facility.

All evaluation tools must be included in an appropriate appendix. Existing tools that have

been tested for validity and reliability should be used. Students should not develop evaluation

tools but may develop data collection tools (spreadsheets to collect data during the project). If

evaluation tools (surveys) are developed, they must document a minimum of face validity.

Copies of necessary permissions to use existing evaluation tools must be included in an

appendix.

Dissemination Plan

½-1 page. This section includes the plan for sharing results of the project within the

facility and within the professional community. Discuss who will be invited to the presentation

of results at the facility and the plan for how to present the information. In what form would the

organization prefer to have the findings disseminated? Also, discuss plans for presentation at

regional or national meetings and publication. Identify at least one professional journal to submit

the manuscript to and discuss why it is an appropriate choice. Address plans for peer review

prior to submitting abstracts, presentations, and manuscripts. Writing should be professional and

maintain an academic tone. Do not use first person.

Conclusion
IMPLEMENTATION OF AN EBP AQUIRED PRESSURE INJURY STRATEGY

21

1-2 paragraphs. The conclusion begins with a statement regarding the intention of the

project and the achievement of that intention. Also, briefly summarize the major points made

throughout the paper. The conclusion should contain a high-level summary of the entire project.
IMPLEMENTATION OF AN EBP AQUIRED PRESSURE INJURY STRATEGY

22

References

Duquesne University. (2020, September 26). Formulating a PICOT question | duquesne univer-

sity. Duquesne University School of Nursing.

https://onlinenursing.duq.edu/blog/formulating-a-picot-question/#:~:text=The%20word

%20PICOT%20is%20a

Edsberg, L. E., Black, J. M., Goldberg, M., McNichol, L., Moore, L., & Sieggreen, M. (2016).

Revised National Pressure Ulcer Advisory Panel Pressure Injury Staging System:

Revised Pressure Injury Staging System. Journal of wound, ostomy, and continence

nursing: official publication of The Wound, Ostomy and Continence Nurses

Society, 43(6), 585–597. https://doi.org/10.1097/WON.0000000000000281

Goodman, L., Khemani, E., Cacao, F., Yoon, J., Burkoski, V., Jarrett, S., Collins, B., & Hall, T.

N. T. (2018). A comparison of hospital-acquired pressure injuries in intensive care and

non-intensive care units: a multifaceted quality improvement initiative. BMJ open

quality, 7(4), e000425. https://doi.org/10.1136/bmjoq-2018-000425

Gupta, P., Shiju, S., Chacko, G., Thomas, M., Abas, A., Savarimuthu, I., Omari, E., Al-Balushi,

S., Jessymol, P., Mathew, S., Quinto, M., McDonald, I., & Andrews, W. (2020). A

quality improvement program to reduce hospital-acquired pressure injuries. BMJ open

quality, 9(3), e000905. https://doi.org/10.1136/bmjoq-2019-000905

Hannawa, A. F., Wu, A. W., Kolyada, A., Potemkina, A., & Donaldson, L. J. (2022). The aspects

of healthcare quality that are important to health professionals and patients: A qualitative

study. Patient Education and Counseling, 105(6), 1561–1570.

https://doi.org/10.1016/j.pec.2021.10.016
IMPLEMENTATION OF AN EBP AQUIRED PRESSURE INJURY STRATEGY

23

Lewis, S. R., Schofield-Robinson, O. J., Rhodes, S., & Smith, A. F. (2019). Chlorhexidine

bathing of the critically ill for the prevention of hospital-acquired infection. The

Cochrane database of systematic reviews, 8(8), CD012248.

https://doi.org/10.1002/14651858.CD012248.pub2

Li, L., Hou, K., Yuan, M., Zhang, Y., & Zhang, Y. (2022). Change lifestyle modification plan/

transtheoretical model in non-alcoholic simple fatty liver disease: a pilot randomized

study. BMC gastroenterology, 22(1), 483. https://doi.org/10.1186/s12876-022-02506-4

Li, S., Cao, M., & Zhu, X. (2019). Evidence-based practice: Knowledge, attitudes, implementa-

tion, facilitators, and barriers among community nurses-systematic review. Medicine,

98(39), e17209. https://doi.org/10.1097/MD.0000000000017209

Miller, M. W., Emeny, R. T., & Freed, G. L. (2019). Reduction of Hospital-acquired Pressure In-

juries Using a Multidisciplinary Team Approach: A Descriptive Study. Wounds: a com-

pendium of clinical research and practice, 31(4), 108–113.

Padula, W. V., & Delarmente, B. A. (2019). The national cost of hospital-acquired pressure in-

juries in the United States. International wound journal, 16(3), 634–640.

https://doi.org/10.1111/iwj.13071

Pittman, J., Horvath, D., Beeson, T., Bailey, K., Mills, A., Kaiser, L., ... & Sweeney, J. (2021).

Pressure injury prevention for complex cardiovascular patients in the operating room and

intensive care unit: a quality improvement project. Journal of Wound, Ostomy, and

Continence Nursing, 48(6), 510.

Rondinelli, J., Zuniga, S., Kipnis, P., Kawar, L. N., Liu, V., & Escobar, G. J. (2018). Hospital-

Acquired Pressure Injury: Risk-Adjusted Comparisons in an Integrated Healthcare Deliv-

IMPLEMENTATION OF AN EBP AQUIRED PRESSURE INJURY STRATEGY

24

ery System. Nursing research, 67(1), 16–25.

https://doi.org/10.1097/NNR.0000000000000258

Saghaleini, S. H., Dehghan, K., Shadvar, K., Sanaie, S., Mahmoodpoor, A., & Ostadi, Z. (2018).

Pressure Ulcer and Nutrition. Indian journal of critical care medicine: peer-reviewed, of-

ficial publication of Indian Society of Critical Care Medicine, 22(4), 283–289.

https://doi.org/10.4103/ijccm.IJCCM_277_17

Schot, E., Tummers, L., & Noordegraaf, M. (2020). Working on working together. A systematic

review on how healthcare professionals contribute to interprofessional collaboration.

Journal of Interprofessional Care, 34(3), 332–342.

https://doi.org/10.1080/13561820.2019.1636007

Takada, D., Kunisawa, S., Kikuno, A., Iritani, T., & Imanaka, Y. (2022). Stages of a Transtheo-

retical Model as Predictors of the Decline in Estimated Glomerular Filtration Rate: A

Retrospective Cohort Study. Journal of epidemiology, 32(7), 323–329.

https://doi.org/10.2188/jea.JE20200422

Tripp, J. (2022). Implementation of an Evidence-Based Bundle to Reduce Hospital Acquired

Pressure Injury Harm Rates in The Intensive Care Unit: A Quality Improvement Project.

Walker, R. M., Gillespie, B. M., McInnes, E., Moore, Z., Eskes, A. M., Patton, D., Harbeck, E.

L., White, C., Scott, I. A., & Chaboyer, W. (2020). Prevention and treatment of pressure

injuries: A meta-synthesis of Cochrane Reviews. Journal of Tissue Viability, 29(4), 227–

243. https://doi.org/10.1016/j.jtv.2020.05.004

Duquesne University. (2020, September 26). Formulating a PICOT question | duquesne univer-

sity. Duquesne University School of Nursing.

IMPLEMENTATION OF AN EBP AQUIRED PRESSURE INJURY STRATEGY

25

https://onlinenursing.duq.edu/blog/formulating-a-picot-question/#:~:text=The%20word

%20PICOT%20is%20a

Edsberg, L. E., Black, J. M., Goldberg, M., McNichol, L., Moore, L., & Sieggreen, M. (2016).

Revised National Pressure Ulcer Advisory Panel Pressure Injury Staging System:

Revised Pressure Injury Staging System. Journal of wound, ostomy, and continence

nursing: official publication of The Wound, Ostomy and Continence Nurses

Society, 43(6), 585–597. https://doi.org/10.1097/WON.0000000000000281

Goodman, L., Khemani, E., Cacao, F., Yoon, J., Burkoski, V., Jarrett, S., Collins, B., & Hall, T.

N. T. (2018). A comparison of hospital-acquired pressure injuries in intensive care and

non-intensive care units: a multifaceted quality improvement initiative. BMJ open

quality, 7(4), e000425. https://doi.org/10.1136/bmjoq-2018-000425

Gupta, P., Shiju, S., Chacko, G., Thomas, M., Abas, A., Savarimuthu, I., Omari, E., Al-Balushi,

S., Jessymol, P., Mathew, S., Quinto, M., McDonald, I., & Andrews, W. (2020). A

quality improvement program to reduce hospital-acquired pressure injuries. BMJ open

quality, 9(3), e000905. https://doi.org/10.1136/bmjoq-2019-000905

Lewis, S. R., Schofield-Robinson, O. J., Rhodes, S., & Smith, A. F. (2019). Chlorhexidine

bathing of the critically ill for the prevention of hospital-acquired infection. The

Cochrane database of systematic reviews, 8(8), CD012248.

https://doi.org/10.1002/14651858.CD012248.pub2

Li, L., Hou, K., Yuan, M., Zhang, Y., & Zhang, Y. (2022). Change lifestyle modification plan/

transtheoretical model in non-alcoholic simple fatty liver disease: a pilot randomized

study. BMC gastroenterology, 22(1), 483. https://doi.org/10.1186/s12876-022-02506-4

IMPLEMENTATION OF AN EBP AQUIRED PRESSURE INJURY STRATEGY

26

Li, S., Cao, M., & Zhu, X. (2019). Evidence-based practice: Knowledge, attitudes, implementa-

tion, facilitators, and barriers among community nurses-systematic review. Medicine,

98(39), e17209. https://doi.org/10.1097/MD.0000000000017209

Miller, M. W., Emeny, R. T., & Freed, G. L. (2019). Reduction of Hospital-acquired Pressure In-

juries Using a Multidisciplinary Team Approach: A Descriptive Study. Wounds: a com-

pendium of clinical research and practice, 31(4), 108–113.

Padula, W. V., & Delarmente, B. A. (2019). The national cost of hospital-acquired pressure in-

juries in the United States. International wound journal, 16(3), 634–640.

https://doi.org/10.1111/iwj.13071

Pittman, J., Horvath, D., Beeson, T., Bailey, K., Mills, A., Kaiser, L., ... & Sweeney, J. (2021).

Pressure injury prevention for complex cardiovascular patients in the operating room and

intensive care unit: a quality improvement project. Journal of Wound, Ostomy, and

Continence Nursing, 48(6), 510.

Rondinelli, J., Zuniga, S., Kipnis, P., Kawar, L. N., Liu, V., & Escobar, G. J. (2018). Hospital-

Acquired Pressure Injury: Risk-Adjusted Comparisons in an Integrated Healthcare Deliv-

ery System. Nursing research, 67(1), 16–25.

https://doi.org/10.1097/NNR.0000000000000258

Saghaleini, S. H., Dehghan, K., Shadvar, K., Sanaie, S., Mahmoodpoor, A., & Ostadi, Z. (2018).

Pressure Ulcer and Nutrition. Indian journal of critical care medicine: peer-reviewed, of-

ficial publication of Indian Society of Critical Care Medicine, 22(4), 283–289.

https://doi.org/10.4103/ijccm.IJCCM_277_17

Takada, D., Kunisawa, S., Kikuno, A., Iritani, T., & Imanaka, Y. (2022). Stages of a Transtheo-

retical Model as Predictors of the Decline in Estimated Glomerular Filtration Rate: A

IMPLEMENTATION OF AN EBP AQUIRED PRESSURE INJURY STRATEGY

27

Retrospective Cohort Study. Journal of epidemiology, 32(7), 323–329.

https://doi.org/10.2188/jea.JE20200422

Tripp, J. (2022). Implementation of an Evidence-Based Bundle to Reduce Hospital Acquired

Pressure Injury Harm Rates in The Intensive Care Unit: A Quality Improvement Project.
IMPLEMENTATION OF AN EBP AQUIRED PRESSURE INJURY STRATEGY

28

Table 1 [this is an example, yours may look different, include if specifically relevant to your

project.]

Implementation EBP Project Budget

Expenses Revenue
Indirect- Included in regular est. $ Billing $unknown
operating costs
Salary and benefits x 1 $/hr x ~n Supplies/ patient $unknown
hour for training, staff
variable staff.
Supplies x 1 patient/ day, $ x ~n Grants 0
variable patient count patients/ day
Overhead $0
Supplies – office $<100
Estimate Total Expenses $ Estimate Total Revenue 0
Net Balance $NA

Note: All budget entries are estimates. Expenses are based on means. Revenue estimates do not

include potential cost avoidance due to realized outcomes. All costs associated to salary and

benefits, patient care supplies, and overhead are fixed indirect expenses not associated with this

project. Project costs are nominal for printing and laminating, under $100.
IMPLEMENTATION OF AN EBP AQUIRED PRESSURE INJURY STRATEGY 29

Appendix A

Citation Design, Level Sample Intervention Theoretical Foun- Outcome Defi- Usefulness
dation nition Results
Quality Sample size Comparison Key Findings
Grade (Definitions should
include any specific
research tools used
along with reliabil-
ity & validity)
(Goodman et Level II ICU and Non- Plan-Do-Study-Act Health Belief Reduction in The prevalence of HAPI reduced from 16%
al., 2018) Grade: A- ICU patients. (PDSA) method to Model. HAPI preva- to less than 10% in the hospitals. The imple-
High Quality n= 348 improve quality of lence. mentation of focused PDSA technique in
care, equipment, management of patients helped reduce the
documentation and prevalence of pressure injuries in the hospi-
education in order to tals.
reduce HAPI.
(Gupta et al., Level II All patients Multidisciplinary Institute for Reduction in HAPI incidence reduced from 6.1/1000 pa-
2020) Quality attending the approach to risk as- Healthcare Im- HAPI incidence tient-days to 1.1/1000 patient-days, an
Grade: A- selected hos- sessment, care and provement (IHI) 83.5% reduction. This indicated that the in-
High Quality pitals in 2 documentation for collaborative stitutional multidisciplinary approach helped
years. HAPI. model reduce the risk for HAPI.
(Miller et al., Level IV Not primary Hospital Units de- None Reduction of Committee report indicated that there was a
2019) B Good qual- research scription of efforts full-thickness 89% reduction in incidences of full-thick-
ity: to reduce PI in their HAPIs ness HAPIs after the formation of a multi-
units. disciplinary PIP team.
(Padula & Level V Report Simulation of the Markov Economic Estimated eco- US HAPI costs could exceed $26.8 billion.
Delarmente, Quality cost of HAPI in the simulation model nomic burden of Thus, there is need to focus attention on re-
2019) Grade: B USA. HAPI duction if risks and prevalence of HAPI in
Good quality the healthcare setting.
(Pittman et Level II Adult patients Application of alter- None Reduction in the Using the alternating pressure (AP) overlay
al., 2021) Quality in 8 cardio- nating pressure (AP) incidence and for the patients helped reduce OR-related re-
Grade: A- vascular OR overlay on patients risk of pressure lated HAPIs from 8/71 (11%) to 0/147 (0%);
High Quality suites and 1 to reduce HAPI injury among translating to a cost avoidance of $323,048
surgical CICU patients in ICU and positive staff satisfaction. This means
in a large In- and cardiac op- that the AP overlay helped to reduce pres-
diana hospital erating rooms sure injury and can be implemented in dif-
ferent settings.
IMPLEMENTATION OF AN EBP AQUIRED PRESSURE INJURY STRATEGY 30

(Rondinelli et Level III Retrospective Longitudinal comor- Cox proportional Evaluation of HAPI incidence was 0.57 per 1,000 patient
al., 2018) Quality study of all bidity burden (Co- hazards model HAPI incidence, days. A multivariate Cox proportional haz-
Grade: B patients ad- morbidity Point risk factors, and ards model showed significant (p <.001)
Good quality mitted in the Score, Version 2 risk-Adjusted hazard ratios (HRs) for the change from the
hospital. [COPS2]), a sever- hospital varia- 25th to the 75th percentile for age. This indi-
ity-of-illness score tion cated that HAPI incidence and risks in-
(Laboratory-Based creased with age, severity of the condition.
Acute Physiology
Score, Version 2
[LAPS2]), and the
Braden Scale for
Predicting Pressure
Ulcer Risk.
(Saghaleini et Level V No samples Empirical literature None Evaluation of lit- Proper nutrition, including minerals, water
al., 2018) Quality indicated: review erature evidence and trace elements help in skin health and
Grade: B Peer-reviewed in relation to the hence boost the other efforts in prevention of
Good quality literature re- role of nutrition pressure injury.
view and ex- in prevention of
pert opinions. HAPIs
(Takada et al., Level III Annual health Analysis of Sec- Cox proportional- Reduction in Compared with the pre-contemplation stage
2022) Quality and insurance ondary data hazards model complication (stage 1), the preparation, action and mainte-
Grade: A claims data of risks. nance stages (stages 3, 4, and 5), were asso-
High quality the Japan ciated with a lower risk of complications.
Health Insur- Early screening of risks therefore helps to re-
ance Associa- duce complications among patients with
tion in Kyoto chronic illnesses
April 2012
and March
2016.

Legend:
IMPLEMENTATION OF AN EBP AQUIRED PRESSURE INJURY STRATEGY 31

Appendix B

Summary of Systematic Reviews (SR) (this table may be single space)

Citation Quality Question Search Strategy Inclusion/ Data Extraction Key Findings Usefulness/Recommendation/
Grade Exclusion Criteria and Analysis Implications

Legend:
IMPLEMENTATION OF AN EBP AQUIRED PRESSURE INJURY STRATEGY

32

Appendix C

Data Collection Tool for Evaluation (Use the name of the tool here). Be sure that permission to

use an existing tool are included in a separate appendix. If the tool was student created, be sure

that at least face validity was conducted and is explained in the narrative of the manuscript.