Abstract
Background
Hospital-acquired pressure injuries (HAPIs) result in patient harm, discomfort, and even death, with an estimated 2.5 million HAPIs occurring annually in the United States. These pressure injuries from prolonged pressure on the skin and deeper tissues cause reduced blood flow and the breakdown of skin and tissues, resulting in wounds. Additionally, these injuries contribute to longer hospital stays and increased health care costs. Hospitals have programs aimed at reducing HAPIs as well as ongoing surveillance to identify new trends early on. This ongoing monitoring revealed a trend early at our institution that HAPIs were 66% higher than the national HAPI rate of 3.5% of observed patients. In rapid response, a multidisciplinary team was formed to address and improve the HAPI rate via a quality improvement project.
Methods
To achieve the goal of decreased pressure injuries or ulcers, a team of nurses, patient care technicians, nutritionists, infectious disease specialists, radiologists, surgeons, vascular technicians, supply chain administrators, case management and social workers, hyperbaric medicine specialists, and wound care experts was created. The team completed a gap analysis and discovered inconsistencies in documentation and care practices that led to HAPI rates above the national average. The team then standardized a policy, standardized documentation of wounds, and provided staff education. Measures were implemented to proactively prevent pressure injuries.
Results
There was a 4.2 percentage point decrease in HAPIs from the beginning of the project (5.76%) to the last survey (1.59%). However, this difference was not statistically significant (P = .07). Overall, there were 6 fewer patients (8 vs 2 patients) with hospital-onset observed injury. Additionally, the length of stay decreased by 46%. Documentation of skin assessments within 24 hours of admission improved to 100%.
Conclusion
We implemented a quality improvement program across 10 service lines, monitoring pressure injuries, HAPI incidence, and length of stay in 480 patients over 2 years. Although the reduction in HAPI was not statistically significant (P = .07), our program positively impacted the hospital’s response to pressure injuries and warrants further replication.
Keywords: HAPI, pressure injury, wound care, patient safety, prevention, quality improvement
Introduction
Each year in the United States (US), there are an estimated 2.5 million hospital-acquired pressure injuries (HAPIs).1 In the acute-care hospital setting, HAPIs pose a significant concern, and with good reason; not only do these injuries cause patients harm, discomfort, or, even death, but also, nationally, pressure injuries are associated with a 57% longer length of stay and a 22% higher rate of 30-day readmissions.2 Pressure injuries typically occur when sustained pressure is applied to the skin and deeper tissues, causing reduced blood flow (ischemia) and the breakdown of skin and tissues, resulting in wounds. Other contributing factors include friction, bony prominences, devices, and poor nutritional status. Sedentary or inadequately mobilized patients who are bedridden, have limited movement, or display an unhealthy weight face a higher risk of developing HAPIs. 3–5 Factors such as advanced age, vascular diseases, diabetes, male gender (though the difference is minor), anemia, and hypertension further heighten the risk of developing pressure injuries.4 In addition to regular movement or turning of the immobile patient, reduction of the number of layers (ie, bandages, grown, pads, mattress sheets, mattress pads, etc) under the patient to 3 layers or less and maintaining dry skin can reduce risk of developing pressure injuries.
In addition, mortality rates are estimated to be 5% higher for patients with HAPIs compared to those without such injuries.6 The hospital-level financial burden associated with pressure injuries is substantial, as well. On average in the US, the costs for a 100-bed hospital due to pressure injuries can exceed $1.8 million,2 and the cost for a facility for a stage III, IV, or unstageable pressure injury range from $75 000 to $150 000 per patient.5
HAPIs can be divided into 4 stages, based on severity. Stage I and II HAPIs are the least severe based on the amount and depth of tissue involved. Conversely, larger ulcers or sores may be staged as III or IV, potentially reaching the muscle or bone.7,8 Stage III, IV, or deep tissue injuries (DTIs, which, by definition, are unstageable) can lead to serious infection, pain, amputation, need for surgery, or even death.9 Patients presenting to the hospital with stage III or IV pressure injuries are usually suffering from other acute or chronic illnesses. These patients are frequently elderly and suffering from an infection. The mortality rate for an elderly person with an infection, other clinical issues, and a stage IV pressure injury is nearly 50%.6
Because of these risks, vigilant use of preventative measures and treatment of HAPIs from the point of admission not only mitigates hospital costs but also reduces the risk of additional patient harm and discomfort associated with complications such as infection, sepsis, and mortality.1 While standardized health care interventions, such as increasing mobilization, ambulation, and repositioning, have been implemented, their effectiveness is hindered by several limitations.1 These interventions often require significant time and attention from nursing staff, which may not always be feasible due to nursing shortages, the complexity of patient illnesses, or the presence of inexperienced staff. 10,11 This underscores the critical need for ongoing education, training, and surveillance in pressure injury prevention and management.12 Implementation of a standardized approach to reducing the potential for pressure injury should start at the point of patient admission.1 Patients should have pressure injury risks assessed within 24 hours of admission and interventions should be implemented immediately. Otherwise, these pre-existing community-acquired injuries will be attributed to hospitalization. This is especially important for individuals who present to the hospital for surgeries. A systematic review showed that 86% of the studies examined found a multidisciplinary approach to be more effective in decreasing the prevalence of pressure injuries compared to a single intervention approach, highlighting the importance of utilizing a multidisciplinary team.13,14
The institution’s HAPI data is regularly collected and reviewed by the hospital’s quality department. Patients included in the data are adult patients who developed a hospital-acquired condition (HAC), as defined by the Centers for Medicare and Medicaid Services (CMS). A HAC is a medical condition or complication that a patient develops during a hospital stay, which was not present at admission.15 CMS lists 16 different conditions included as HACs, including stages III and IV pressure injuries.16 HACs are based on coded data retrieved from the patient’s medical record. This diagnosis is based on physician documentation of the patient’s conditions. Upon review of HAC PI data, it was noted that there were ongoing instances of HAPIs, specifically Stage III and Stage IV.
The purpose of this single-center quality improvement (QI) project was to evaluate a multidisciplinary team approach to manage and reduce HAPIs, particularly stages III and IV. Since 2019, there has been a hospital goal of 0 HAPIs. In 2021, the HAC report revealed 5 stage III or IV HAPIs per HAC at our institution (Figure 1). The hospital chief nursing officer and patient safety director worked with the vice president of quality to initiate a QI project with an aim for 0 HAPIs in the future years. This project was undertaken as a QI project determined exempt by the institutional review board.
Figure 1.
Number of stage III and IV HAPI events based on HAC-reported data, shows the trend per quarter from 2021 to 2024.
Methods
Design, Sample, Setting
In order to have a real-time, evidence-based method of determining compliance with the care of the patients and actual point-in-time HAPIs, the hospital elected to participate in a nationally-recognized point prevalence study starting March 2022. The Hill-Rom® International Pressure Ulcer/Injury Prevalence Survey IPUP/IPIP™ is a program that has over 100 000 hospitalized patients surveyed by staff to determine if pressure injuries/ulcers exist, and the findings are compared to medical record documentation.17 The 24-hour survey, which can occur annually or biannually (our institution did not participate in the September 2022 survey), offers health care facilities an online or paper data collection process and interactive reporting and aids in establishing baseline prevalence and measuring the outcomes of interventions. IPUP/IPIP™ also furnishes customized facility reports and comparisons to national benchmarks. 7,8,17
The institution selected a specific day in advance to perform the IPUP/IPIP™ survey. On this day, 2 nurses consisting of the wound care staff and clinical staff rounded to every admitted patient who met the inclusion criteria. During rounding, a skin assessment was completed, documentation was reviewed in the medical record, and the findings were compared to the findings noted. The staff completed the internal questionnaire for every individual patient. This survey included questions about nutrition, surgical history, mobility, positioning, linens, skin assessment, restraints, and pressure injuries.17 After all of the qualified patients in the hospital were surveyed, the wound care director and his designees entered all data into the online IPUP/IPIP™ database.
Inclusion criteria for the IPUP/IPIP™ survey included any admitted patient from an inpatient unit or emergency department border patients. Patients were consented to participate; those who opted out were excluded from the study. Per IPUP/IPIP™ survey standards and benchmark for acute-care hospitals, the expected rate of stage II, III, IV, or deep tissue pressure injuries was 3.5% of patients surveyed.17 The March 2022 survey revealed a Stage II–IV HAPI rate of 5.8% of patients surveyed (n = 139), while HAC reports also revealed ongoing stage III and IV HAPIs. To address the HAPI rate, a QI project was initiated. In October 2022, a new director of wound care was hired, the institution’s outpatient wound care clinic opened, and the inpatient wound care staff was reorganized.
The patient safety director, the director of wound care, and the wound care coordinator were informed by literature studies, which showed that 86% of studies examined in a systematic review found a multidisciplinary approach was effective for decreasing the prevalence of pressure injuries compared to a single-invention approach.13,14 From this literature, we adopted the components that reported the best results, which were: (1) teamwork, (2) education of health care staff, (3) use of evidence-based risk assessment tools, (4) patient and family involvement, and (5) nurse rounds.14
The director of wound care then assembled a multi-disciplinary team called the Skin Care Champion Committee, which was formed in Quarter 4 of 2022 and included representation from more than 10 service lines, including nursing, nutrition, infectious disease, radiology, surgery, vascular technician, supply chain, case management and social work, hyperbaric medicine, and wound care. The key elements of the team were frontline nursing staff and patient-care technicians.
In Quarter 2 of 2023, nursing leaders were asked to identify 1 or 2 nurses from their respective clinical units to be part of the Skin Care Champion Committee as a reference point. The team felt it was critical to have these clinicians in place from the beginning in order to have buy-in and success across the hospital. All committee members were educated on HAPI prevention tactics and accurate wound assessment by the director and coordinator of wound care. In addition, the director of wound care reviewed previous data and provided education on new procedures for conducting the prevalence study to committee members to ensure a clear understanding of the project’s objectives. The provided education instructed (1) documentation within 24 hours of admission, (2) proper offloading (including associated equipment and devices), and (3) how to complete monthly auditing forms.
The team took a 3-phase approach to the reduction of HAPIs, including analysis, process improvement/implementation, data review/ sustainment, and ongoing education, as described below.
Phase 1: Identifying Potential Contributors to HAPIs, Quarter 4 2022-Quarter 1 2023
During the analysis phase of the facility-wide HAPI reduction project, the Skin Care Champion Committee conducted audits on clinical units, including skin care practices, off-loading techniques, clinical assessment of wounds, and clinical documentation to identify potential problem areas contributing to HAPIs. Four key findings emerged. 1) We found inconsistent documentation showing whether pressure injuries were present upon admission, suggesting a lack of uniformity not only in the timely performance of standardized skin assessments but also in the timely documentation of said assessments. (2) During the IPUP/IPIP™ study, we identified that the number of layers between patients’ skin and the surface they lay on often exceeded the national standard of less than 3 layers of bedding under the patient. (3) A review of nursing care practices by the wound care coordinator and unit-based Wound Care Champions revealed that there was confusion regarding evidence-based off-loading techniques and available resources for nurses, such as off-loading devices and basic education on the appropriate use of devices. (4) Initially, there was an inconsistency in having designated front line nursing staff serving as a reference point in their units.
To address the inconsistency in designated nursing staff, we introduced the “Skin Care Champion Initiative,” reemphasizing the necessity of 1 designated Skin Care Champion nurse per unit per shift. Expectations were clarified for these nurses, including the requirement that each designated skincare champion nurse must attend monthly Skin Care Champion Committee meetings and disseminate resulting educational insights to their assigned departments through staff meetings, lunch-and-learns, or poster presentations.
Phase 2: Improving Outcomes and Hardwiring Process, Quarter 2 2023-Quarter 3 2023
After identifying problem areas contributing to HAPIs and outcomes from the IPUP/IPIP™ survey, a plan was devised to enhance our practice and hard-wire the new process. To begin, comprehensive education was performed across the hospital by the wound care coordinator and nurses within the wound care department to all clinical staff on the basics of HAPI prevention, including: (1) identifying at-risk patients and ensuring effective assessment within 24 hours of admission and documentation to determine any present injury, (2) evaluating the use of evidence-based off-loading techniques to prevent skin injury, (3) re-teaching the importance of ensuring 3 or fewer layers under the patient, and (4) emphasizing the importance of accurate documentation.
To ensure compliance and maintain educational efforts, monthly skin care audits were initiated. As a part of the audits, Skin Care Champions reviewed skin care documentation from 30 patients per department, or 100% if fewer than 30 patients were present, for all inpatient departments monthly. Skin care audits focused on verifying documentation that standardized skin assessment was present in the medical record within 24 hours following admission and that proper utilization of offloading devices along with evaluation of the number of layers between patients’ skin and the surface they lay on were all present.
To strengthen adherence to the process, the participation of designated skin care champion nurses in all departments was monitored by nursing leadership. As noted above, these nurses were responsible for regular attendance at monthly Skin Care Champion meetings, as well as for creating and presenting trifold posters highlighting 3 key performance indicators: documentation of skin assessment, off-loading techniques, and adherence to the layers initiative to be presented to their department.
The Skin Care Champion Committee also amended the hospital Skin Assessment Policy. After approvals were obtained, staff education was conducted by the members of the Skin Care Champion Committee and nursing leaders. The policy elements were disseminated across the hospital and to physicians. It was important to have the buy-in of all clinicians to help achieve the goal. Members of the hospital wound care team were involved every step of the way and continued to help provide consultation and real-time education on the nursing units.
During phase 2, there was a 66.07% decrease (3.7 points) in HAPIs from March 2023 to September 2023 (Figure 2). This period saw an increase in rounding and leadership engagement from nursing managers/directors and the infection prevention team, which raised awareness among all hospital staff and reinforced wound care practices on campus. Monthly auditing increased 497% from Quarter 2 2022 (64 audits per quarter) to Quarter 3 2023 (382 audits per quarter; Figure 3). The previously listed interventions were heavily enforced during this phase, resulting in increased compliance and potentially contributing to the decreased rate of HAPIs.
Figure 2.
The timeline of quarterly changes in the percentage of patients with a HAPI are shown relative to the implementation of different phases of the prevention initiative from 2022–2024.
* New department organization: New Wound Care Director was hired, outpatient clinic opens, and inpatient wound care staff reorganized.
Phase 1: We found: (1) HAPI(s) were not always being documented as present upon admission (POA); (2) No consistency with Braden skin assessment(s) across units; (3) The number of layers between a patient’s skin and the surface they were laying on were often > 4 (> 3 layers is the national standard/goal); (4) Confusion on evidence-based offloading techniques and available resources; (5) Skin champions appeared not engaged from hospital departments and/or not assigned.
Phase 2: We implemented (1) Monthly audits (30 patients per department or if less than 30 pts, 100% of patients). Audits included (A) documentation of Braden Skin Assessment within 24 hours of admission, (B) offloading devices used, (C) number of layers present. (2) Mandatory skin champions assignment to all departments. Skin champions were required to (A) attend monthly Skin Champion Meeting(s), (B) create and teach to trifold posters outlining three key performance indicators (KPIs) off documentation of skin assessment, offloading techniques, and layers initiative, (C) monthly education to a poster, (D) monthly activity log.
Phase 3: Continued education with (1) monthly Skin Champion meeting, (2) quarterly educational pieces, (3) trauma Grand Round/oncology, etc, (4) huddle topics, (5) Braden Skin Assessment policy updates.
Figure 3.
Monthly auditing compliance trends of clinical units, including skin care practices, off-loading techniques, clinical assessment of wounds, and clinical documentation are shown to identify potential problem areas contributing to HAPIs.
Phase 3: Sustaining the Initiative and Ongoing Education, Quarter 4 2023-Current
To ensure the sustainability of our progress, several measures were implemented. The monthly Skin Care Champion meetings were supplemented with biannual education sessions by members of the wound care team. Some of the skin care topics included: Introduction to Hyperbaric chambers, Essentials of wound care in Trauma, Wound descriptions, Mechanisms of injury, Principles of wound management, Pressure Injury Prevention, Wound Care Services that are offered, and an Introduction to the IPUP/IPIP™ survey were covered during trauma grand rounds or team meetings. Additionally, huddle education topics were distributed to nursing units, which included updates to the Skin Assessment Policy or other skin care techniques. The huddle topics were disseminated to the departments to be reviewed at their departmental safety huddles.
The hospital agreed to continue to participate in the IPUP/IPIP™ survey at least annually. The survey results were disseminated across all departments, noting our rates and compliance with skin care audits and documentation. The Skin Care Champion Committee determined if further staff education was needed based on the results of the surveys as well as reported HAPI events. The Skin Care Champion Committee and wound care nurses continued surveillance of patients during daily rounds and monthly audits of intervention and documentation compliance.
Data Analysis
Descriptive statistics were conducted on prevalence survey data on HAPI rates for further insight into hospital trends summarized in Table 1. A Fisher’s exact test was performed to compare pre- and post-test HAPI rates as it met all assumptions required for the analysis, including nominal data and independence. The test was performed with a 95% confidence interval. All statistical analyses were executed using Python and Excel. No power analysis was conducted as this was a retrospective study.
Table 1.
Differences in Pressure Injuries (PIs) and Hospital-Acquired Pressure Injuries (HAPIs) Number and Frequency Before and After Implementation of Facility-Wide HAPI Reduction Program
Survey 1 (March 2022) | Survey 2 (March 2023) | Survey 3 (September 2023) | Survey 4 (March 2024) | Totals | |
---|---|---|---|---|---|
Pre-HAPI intervention | Post-HAPI intervention | ||||
Total number of patients surveyed for pressure injuries during survey | 139 | 107 | 108 | 126 | 480 |
Total number of PIs identified (any stage) | 16 | 12 | 2 | 3 | 33 |
Total PIs identified as HAPIs | 8 | 6 | 2 | 2 | 18 |
Stage 1 | 1 | 5 | 1 | 0 | |
Stage 2 | 5 | 1 | 0 | 0 | |
Stage 3 | 1 | 3 | 0 | 0 | |
Stage 4 | 2 | 2 | 0 | 1 | |
Unstageable | 4 | 0 | 1 | 1 | |
Percentage of total patients with HAPIs (can be multiple per patient) | 5.76% | 5.61% | 1.85% | 1.59% | |
Percentage of patients with documentation within 24 hours | 87.50% | 83.30% | 100% | 100% | |
Average overall length of stay in days | 26 | 12 | 10 | 14 |
Results
Impact of HAPI Reduction Program on HAPI Rates
Facility-wide HAPI rates before and after the implementation of the multi-step HAPI reduction program are summarized in Figure 4 and Table 1. Across 4 surveys performed, a total of 480 patients were assessed. Following the implementation of the program, HAPI rates in surveyed patients during prevalence studies fell from a rate of 5.8% in Survey 1 (March 2022) to 1.6% by Survey 4 (March 2024), as seen in Figures 2 and 4. Fisher’s exact test was performed to compare pre-intervention HAPI occurrences (n = 8) to post-intervention HAPI occurrences (n = 2; P = .0703).
Figure 4.
Hospital HAPI rate trends compared to IPUP/IPIP™ moving benchmarked data are shown for each IPUP/IPIP™ survey from 2022–2024.
Impact of HAPI Reduction Program on HAPI Severity
Differences in the percentage of stage I–IV HAPIs across the 4 surveys are summarized in Figure 4 and Table 1. The distribution of reduction of 6 HAPIs in all patients was observed. The majority of HAPIs identified throughout the program were stage I injuries (n = 7), stage II (n = 6), stage III (n = 4), stage IV (n = 5), and unstageable injuries or DTIs (n = 6). Skin assessment documentation within 24 hours of admission improved to 100% by the third survey (September 2023) and remained at 100% throughout the fourth survey see Figure 2 for a timeline.
Impact of HAPI Reduction Program on HAC reported Stage III or IV HAPI
Prior to the initiation of the Skin Care Committee and Initiative there were a total of 5 stage III or IV events in 2021. This was important because the 2021 data served as the impetus for this project, demonstrating to nursing leadership that improvements were necessary. After the first IPUP/IPIP™ survey and the rollout of staff education on prevention measures, accurate assessment, and documentation, there were no stage III or IV events for the September 2023 survey and 1 stage III or IV event for the March 2024 survey. One patient developed a stage III HAPI for the March 2023 survey due to a severe, multi-system illness. No other stage III or IV HAPIs were reported.
Impact of HAPI Reduction Program on Length of Stay and HAPI-Related Costs. Overall, the total hospital length of stay for HAPI patients was reduced by 46% (reduced by 12 days on average) (range: 10 to 26) from Survey 1 (March 2022), the average overall length of stay for all wounds was 26 days while Survey 4 (March 2024), and the average overall length of stay for all wounds was 14 days (Table 1). According to the National Pressure Injury Prevention Panel, stage III and IV injuries, or DTIs can be very costly at as much as $75 000 to $150 000 per HAPI.3 With the reduction of HAPI events from 6 to 1, there may have been savings of up to $375 000 to $750 000 per year.
Discussion
While the overall number of HAPI per HAC data was reduced, it was not statistically significant. The resulting P value (.0703), was likely not significant due to the limited sample size. Therefore, while these preliminary findings are encouraging, larger studies are needed to validate the effectiveness of the intervention. Despite the lack of statistical significance for the HAPI difference, we had an improvement in the HAPI rate from 5.8% to 1.6% during the study, a lower length of stay, and a substantial reduction in projected costs. Thus, we believe that our quality improvement study had a clinical impact.
However, the reduction in injury was previously reported to be tied to nursing staff and patient care technician buy-in.12 The engagement of the Skin Care Champion Committee and Skin Care Champion nurses augmented the overall initiative. The Skin Care Champions were empowered to provide real-time guidance and education to staff on the nursing units, conducted monthly skin care audits, and were part of conducting the IPUP/IPIP™ surveys. Having Skin Care Champions available on the nursing units gave staff easy access to resources and to answer questions. Additionally, the hospital’s wound care nurses were available daily for assistance with assessments and treatment. The reduction of risk for developing a HAPI in the acute care setting starts at the point of patient admission with standardized assessment of the patient’s skin and medical condition and assigned level of risk.7,8,12 Several studies recommend that interventions should be implemented immediately for patients with moderate or high risk.4,8,12,13 Nursing staff must be educated on adequate wound assessment and documentation as well as understanding appropriate interventions, such as off-loading the patient’s heels, use of positioning assist devices, limiting the number of layers under the patient, and mobilization of the patient when appropriate.7,8 Implementation of these evidence-based interventions has reduced the negative impact of pressure injuries on patients and limited costs to the hospital.
At the time of writing, a SPUP survey conducted in September 2024 reported a pressure injury rate of 0.9% among patients, reflecting a continued downward trend consistent with our findings.
Conclusion
We implemented a QI program that integrated the efforts of 10 service lines and monitored documentation of pressure injuries, HAPI incidence, and length of stay in a total of 480 patients over 2 years. The changes implemented for the QI project continue to the present day. The overall change in HAPI, while close to meeting our goal was not significant (P = .07), but this was associated with a change in documentation from 87% to 100% by Survey 3, which was sustained for Survey 4, and a shorter length of stay for HAPI patients, from 26 days at Survey 1 to 14 days at Survey 4. Therefore while we believe that our findings merit replication, it appears that our QI program to reduce HAPI had a positive impact on the hospital response to such injuries.
Funding Statement
This research was supported (in whole or in part) by HCA Healthcare and/or an HCA Healthcare affiliated entity.
Footnotes
Conflicts of Interest: The authors declare they have no conflicts of interest.
The authors are employees of St. Mark’s Hospital, a hospital affiliated with the journal’s publisher.
This research was supported (in whole or in part) by HCA Healthcare and/or an HCA Healthcare affiliated entity. The views expressed in this publication represent those of the author(s) and do not necessarily represent the official views of HCA Healthcare or any of its affiliated entities.
References
- 1.Haesler E. Prevention and Treatment of Pressure Ulcers/Injuries: Quick Reference Guide. 3rd ed. EPUAP/NPIAP/PPPIA; 2019. [Google Scholar]
- 2.How to detect and prevent pressure injuries. Hillrom; Feb 4, 2020. [Accessed May 9, 2024]. https://www.hillrom.com/en/knowledge/article/how-to-detect-and-prevent-pressure-injuries/ [Google Scholar]
- 3.Chen F, Wang X, Pan Y, Ni B, Wu J. The paradox of obesity in pressure ulcers of critically ill patients. Int Wound J. 2023;20(7):2753–2763. doi: 10.1111/iwj.14152. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 4.Aloweni F, Ang SY, Fook-Chong S, et al. A prediction tool for hospital-acquired pressure ulcers among surgical patients: Surgical pressure ulcer risk score. Int Wound J. 2019;16(1):164–175. doi: 10.1111/iwj.13007. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 5.National Pressure Injury Advisory Panel. [Accessed May 9, 2024]. www.npiap.com .
- 6.Kirman CN. Pressure injuries (pressure ulcers) and wound care: practice essentials, background, anatomy. eMedicine. Jan 5, 2023. [Accessed May 9, 2024]. https://emedicine.medscape.com/article/190115-overview?form=fpf .
- 7.Edsberg LE, Black JM, Goldberg M, McNichol L, Moore L, Sieggreen M. Revised national pressure ulcer advisory panel pressure injury staging system: revised pressure injury staging system. J Wound Ostomy Continence Nurs. 2016;43(6):585–597. doi: 10.1097/WON.0000000000000281. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 8.Edsberg LE, Cox J, Koloms K, VanGilder-Freese CA. Implementation of pressure injury prevention strategies in acute care: results from the 2018–2019 international pressure injury prevalence survey. J Wound Ostomy Continence Nurs. 2022;49(3):211–219. doi: 10.1097/WON.0000000000000878. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 9.Castlight Health, The Leapfrog Group. Hospital acquired conditions. [Accessed May 9, 2024]. https://www.leapfroggroup.org/sites/default/files/Files/Castlight-Hospital-Acquired_Conditions_Report%202017_round4%5B3%5D.pdf .
- 10.Haddad LM, Annamaraju P, Toney-Butler TJ. StatPearls. Treasure Island (FL): StatPearls Publishing; 2024. [Accessed May 9, 2024]. Nursing shortage. https://www.ncbi.nlm.nih.gov/books/NBK493175/ [PubMed] [Google Scholar]
- 11.Hezaveh MS, Rafii F, Seyedfatemi N. Novice nurses’ experiences of unpreparedness at the beginning of the work. Glob J Health Sci. 2013;6(1):215–222. doi: 10.5539/gjhs.v6n1p215. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 12.Singh C, Shoqirat N, Thorpe L, Villaneuva S. Sustainable pressure injury prevention. BMJ Open Qual. 2023;12(2):e002248. doi: 10.1136/bmjoq-2022-002248. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 13.Anderson M, Finch Guthrie P, Kraft W, Reicks P, Skay C, Beal AL. Universal pressure ulcer prevention bundle with WOC nurse support. J Wound Ostomy Continence Nurs. 2015;42(3):217–225. doi: 10.1097/WON.0000000000000109. [DOI] [PubMed] [Google Scholar]
- 14.Gaspar S, Peralta M, Marques A, Budri A, Gaspar de Matos M. Effectiveness on hospital-acquired pressure ulcers prevention: a systematic review. Int Wound J. 2019;16(5):1087–1102. doi: 10.1111/iwj.13147. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 15.Centers for Medicare & Medicaid Services. Hospital-acquired pressure injuries. 2024. [Accessed May 9, 2024]. https://www.cms.gov/medicare/payment/fee-for-service-providers/hospital-aquired-conditions-hac .
- 16.Centers for Medicare & Medicaid Services. Deficit Reduction Act (DRA) Hospital-Acquired Condition (HAC) reporting: frequently asked questions. 2019. [Accessed May 9, 2024]. https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/HospitalAcqCond/Downloads/FAQ-DRA-HAC-PSI.pdf .
- 17.International Pressure Ulcer/Injury Prevalence (IPUP) Survey Hillrom. [Accessed May 9, 2024]. https://www.hillrom.com/en/knowledge/international-pressure-ulcer-prevalence-ipup-survey/