Implementing a Quality Improvement Project to Reduce Incidents of Hospital-Acquired Pressure Injury.
Saqer Al Mualla, Noura Salim, Salma Saeed and 2 others
PMID 40833507WHAT IT FOUND
Hospital-acquired pressure injuries fell from 3.4 to 1.7 per 1000 patient days after a bundle including assessment, repositioning, surfaces, nutrition and incontinence care, then to 0.8 by 2023.
Key findings
01The average hospital-acquired pressure injury rate fell from 3.4 to 1.7 per 1000 patient days by the end of December 2021.
02The average rate was 0.9 per 1000 patient days in 2022 and 0.8 per 1000 patient days in 2023.
03Braden Scale assessment compliance averaged 96% in the first 18 months.
STILL TO COME
How it was doneWhat they foundWhat it means for RNs
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What it does not show
It was a single-hospital quality improvement project without a control group, so other changes could have contributed to the fall in pressure injuries. The bundle contained several simultaneous changes, so the effect of any one element cannot be isolated. Initial staff resistance and shortages of pressure-relieving mattresses meant the full bundle may not have been delivered consistently. Stage 1 pressure injuries were not counted, so the project may not capture the earliest skin damage.
The easy way to misread this
Do not read the fall in pressure injuries as proof that any single part of the bundle caused it. The project had no control group and changed assessment, repositioning, surfaces, nutrition and incontinence care at the same time.