Table 1.

Summary of gap analysis

	Gap analysis findings	Response
People	No certified wound ostomy continence nurse on staff. General lack of knowledge in maintaining skin integrity. No one to lead pressure injury prevention initiative. Lack of knowledge on use of bordered foam dressing.	Hired certified wound ostomy nurse. Three nurses participated in an accredited WOCNEP and sat for boards. Training material developed for maintaining skin integrity. Certified wound care nurses lead pressure injury prevention. Collaboration with certified wound care nurses working in industry to provide nursing education.
Products	No evidence-based products available. No effective way to offload heel pressure. No pressure offloading turn and position system. No effective way to manage and wick moisture and urine.	Collaboration with material and supply chain directors to stock pressure offloading products on the units. Added turn and position system, offloading boots. Heel bordered foam dressings. Moisture wicking fabric and adult briefs.
Process	Complicated unclear process for initiating higher level support surface. Policy not consistent with current evidence-based practice. No clear time frame for initiating pressure injury prevention. Relying on a person process for identifying patients with pressure injuries.	Standardised support surface for the ICU. Standardised use of overlay across the organisation. Updated the policy. Clear messaging pressure injury prevention is implemented on admission. Created an automated process to identify patients with pressure injuries or at risk for pressure injuries.

ICU, intensive care unit; WOCNEP, Wound Ostomy Continence Nursing Education Programme.