Implementing Rivera’s Pressure Injury Prevention Bundle Dissertation

Introduction

Hospital-acquired pressure injuries (HAPI) are a significant burden for healthcare organizations worldwide that negatively impact the quality of life of patients and their caregivers. The global prevalence of HAPI is almost 13%, while the incidence rate is above 5 per 10,000 patient days (Li et al., 2020). Most cases of HAPI are preventable; however, highly cachectic patients may develop pressure injuries despite the use of cushions for pressure distribution (Ricci et al., 2017). In addition to being a stressful event for patients, HAPI is also a formidable financial burden because most pressure ulcers develop as a secondary condition, requiring additional expenses (Mansfield et al., 2019). According to national estimates, the overall expenditure for treating patients with HAPIs is close to $11 billion (Padula&Delarmente, 2019). The HAPI prevalence in the 13-bed medical intensive care unit (MICU) in urban New York was reported to be 14%, which is higher than the national average. Therefore, this quality improvement project aims to determine how implementing evidence-based practices, specifically Rivera’s pressure injury prevention (PIP) bundle, can reduce the HAPI incidence in the 13-bed MICU.

Although many evidence-based methods were developed to address pressure ulcer development in hospitalized patients, HAPI’s national prevalence and treatment costs remain high. Approximately 2.5 million American patients in intensive care units annually develop pressure injuries that result in 60,000 deaths (Padula&Delarmente, 2019). The incidence rate of HAPIs in intensive care units varies from 14% to 42% (Anderson, 2018). Moreover, according to Padula and Delarmente (2019), the treatment cost for one pressure injury ranges from $500 to $70,000 because HAPIs lead to more extended hospital stays. The length of stay of patients with HAPI can increase by 14 days, thereby disrupting patients’ physical and emotional well-being (Ricci et al., 2017). Therefore, finding an effective intervention is critical for resolving multiple issues associated with HAPIs. Indeed, the exploration of this topic started in the nineteenth century, and the first intervention to prevent HAPIs was developed by Browning (Mansfield et al., 2019). Still, the approach that would eliminate a high HAPI prevalence problem has not been described yet.

Since various risk factors contribute to the development of HAPIs, introducing Rivera’s PIP bundle can address several issues simultaneously. The risk factors associated with the formation of pressure ulcers include older age, reduced mobility, poor nutrition, dehydration, reduced tissue perfusion, oxygenation, and medical devices placement (Romanelli et al., 2018). The primary function of Rivera’s PIP bundle is to recognize risk and prevent HAPI with appropriate interventions for high-risk patients. It was developed by Rivera et al. (2020), whose methodology was based on assigning intervention depending on the severity of tissue damage. Specifically, patients with superficial HAPIs could receive a standard treatment plan, while those with deep pressure ulcers needed high-risk interventions (Rivera et al., 2020). The effectiveness of this approach was tested in an 11-bed critical care unit in one of the hospitals in New York City (Rivera et al., 2020). The results of the study demonstrated a seven-fold decrease in HAPI incidence in this department.

Chapter 1 presents background information regarding the problem of HAPIs in the literature and compares the information to the project site data. The problem at the project site is fully described along with the project’s purpose, clinical question, and explanation of how the work advances scientific knowledge. The chapter will also present data regarding the project significance, the rationale for choosing a specific methodology and a project design, definitions of terms, key assumptions, limitations, delimitations, and the summary.

Background of the Project

Pressure injuries have been a recurrent problem for the healthcare industry and, therefore, present historical data for consideration. The Joint Commission (2016) defines a pressure injury as localized skin and tissue damage caused by exposure to a medical device. Ricci et al. (2017) stipulate that the pressure ulcer prevalence was slightly lower than 15% in 1999; the 2009 International Pressure Ulcer Prevalence Survey reveals similar results. Li et al. (2020) also state that HAPI prevalence is approximately 12.8%, while its incidence rate is 5.4 per 10,000 patientdays (p. 2). According to the World Health Organization [WHO] (2008), their prevalence rates are relatively similar across various nations, including 10% in the USA, 11% in Germany, 12% in Sweden, and 13% in Israel (p. 45). These statistical data reveal that HAPIs are a significant threat to quality health care that affect over 2.5 million individuals resulting in 60,000 deaths (Padula et al., 2019, p. 132). Rivera et al. (2020) also tested the effectiveness of their PIP bundle for reducing HAPIs in a New York critical care facility, thus, showcasing how hospital-related injuries are as much a local problem as they are a global issue. The HAPI prevalence rate in the urban New York project site’s medical intensive care unit was 14% in 2020, which was higher than the national rate. Consequently, this quality improvement project aims to investigate the scourge and determine if Rivera’s PIP bundle presents a feasible solution for HAPI prevention in the project facility.

Problem Statement

It was not known if or to what degree the implementation of Rivera’s PIP bundle would impact HAPIs prevalence rate when compared to current practice among patients in critical care unit. HAPIs negatively impact the quality of life of patients and their caregivers. Their high prevalence rates imply that they also incur huge financial costs for the health care sector. The prevalence rates of HAPIs in the critical care unit at the project site was 14% in 2020 and a month prior to implementation of the project were at 13%.

There were major financial impact on this organization due to high HAPI prevalence rates. The estimated attributable costs of HAPIs at theproject site was about $70,000 per year. This critical care unit solely was responsible for cost of $7,000 month prior to the implementation of the project due to HAPIs. Centres for Medicare and Medicaid (CMS) does not also provide reimbursements for HAPIs, thereby eliminating payments to hospitals for their care (Padula et al., 2020). Besides financial costs, they also incur physical and psychological trauma associated with hospital-acquired injuries.

HAPIs mainly affect patients in critical care settings where they interact with numerous intrusive medical devices. According to Anderson (2018), their incidence rate in ICUs range from 14% to 42%; the rate at the project facility is 14%. Therefore, Rivera et al. (2020) sought to decrease its incidence in a New York City critical care hospital unit by implementing a PIP bundle. This DPI project seeks to measure the impact of their PIP bundle in the project facility’s medical intensive care unit. Thus, the problem is that it is not known if or to what degree the implementation of Rivera’s PIP bundle would impact HAPI incidence when compared to current practice among critical care patients in urban New York.

Purpose of the Project

The purpose of this quantitative, quasi-experimental project was to determine if or what degree implementation of Rivera’s Pressure Injury Prevention (PIP) bundle would impact HAPIs prevalence rate as compare to current practice among critical care patients in the Urban New York acute care hospital over four weeks. The independent variable, Rivera’s PIP Bundle, is an evidence-based assessment and intervention tool for mitigating HAPIs in patients. It delineates assessment, prevention, and mitigation strategies for both standard and high-risk patients. The bundle outlines varied interventions for the pressure ulcers depending on the level of risk the patient faces. The high-risk component includes more interventions such as dressing, turning, and positioning. Thus, it is a tool to help health care professionals standardize prevention of HAPIs and reduce their incidence.

The dependent variable, a HAPI incidence rate, was measured by the number of patients who developed pressure injuries due to medical devices during their hospital stays. Nurses are well-positioned to identify the condition and regularly updated their patient electronic health records (EHRs) about patients who developed them. Thus, the project site collected data about patients who developed HAPIs from the hospital’s EHR. HAPI incidence rate was useful for the indicating the impact of the quality improvement project. Lower incidence rates indicate an improvement in quality of care offered at the units and reduced costs of care.

Clinical Question

Last year (2020), project site has a very high prevalence rates of HAPIs (14%) in critical care units along with associated health care costs necessitated a clinical intervention for reducing HAPI occurrence at the project site. First seven month of this year 2021, HAPI prevalence rate were remain 14% and the month prior to implementation of this quality improvement project, site was at 13% prevelance rate. Rivera’s PIP bundle, was effective for reducing HAPIs incidence rates in one of the site’s critical care units. The preventive interventions in Rivera’s PIP bundle were effective in reducing the prevalence rates observed current in the facility. The clinical question guiding the project is: To what degree does the implementation of Rivera’s PIP bundle impact the HAPI incidence compared to current practice among critical care patients in a critical care unit in urban New York? The question sought to identify whether using Rivera’s PIP bundle is sufficient to reduce the HAPI incidence.

Advancing Scientific Knowledge

Scientific evidence indicates that HAPIs are a significant problem for health care. Ricci et al. (2017) and the 2009 International Pressure Ulcer Prevalence Survey revealed that that the pressure ulcer prevalence was slightly lower than 15% in 1999. Even though pressure injuries and their associated care costs have created immense problems for the entire healthcare industry, no improvement attempts have generated the required outcomes. Li et al. (2020) state that the HAPI prevalence is 12.8%, and the incidence rate is 5.4 for every 10,000 patientdays (p. 2). These statistical data reveal a challenging situation in health care. Padula et al. (2019) support the claim stating that pressure injuries cause approximately 60,000 deaths among an affected population of over 2.5 million individuals (p. 132). The high prevalence, incidence, and mortality rates of HAPIs reveal a gap in care. There is insufficient literature that provides significant interventions for the prevention and treatment of HAPI.

This quality improvement project utilizes Lewin’s theory of change and Watson’s theory of human caring. The three stages in Lewin’s theory of change, unfreezing, moving, and freezing will be used to implement the Rivera’s PIP bundle by providing a methodical approach towards the intervention. The framework of Lewin’s theory of change implies that patients change their behavior under the influence of driving or positive forces that affect individuals from outside (Lewin, 1951). During the unfreezing stage the unit needs to be prepared to accept the change. Implementation of Rivera’s PIP bundle is identified as moving stage. This stage requires leaders to provide staff with external support to ensure that they can overcome some challenges. The final stage of refreezing. Finally, after being evaluated as effective, the change is established as solution to the identified problem.This stage is refered as Lewin’s stage of refreezing. Lewin’s change theory is important to the project as it delineates processes for instigating Rivera’s PIP bundle in acute care settings where they have not been implemented before.

To identify how utilization of PIP bundle can be associated with reduced HAPI incidence. Jean Watson’s (1979) theoretical framework, Human caring theory, prescibes how to provide positive outcomes during human-to-human caring moments. She stipulates patients cannot be separated from the healthcare workforce, implying that a change occurs through nurses. This quality improvement project will demonstrate This project’s aim is to improve the care and quality of patients by implementing Rivera’s PIP bundle. Within this project nurses will provide individualized care to the patients, and will develop a transpersonal caring relationship with their patients. This information demonstrates that the theory will drive the intervention because it denotes healthcare workers should use interventions related to reduce HAPIs. The project can advance this theory by demonstrating whether its application leads to positive outcomes when applied to PIP bundle and the HAPI incidence. If positive results are found, it will be possible to state that it is reasonable to rely on this theoretical framework to combat the issue of pressure ulcers.

Significance of the Project

High healthcare costs present a significant problem for the United States (Padula&Delarmente, 2019). Prolonged hospital stays due to the development of pressure injuries in intensive care unit patients exponentially increase such costs. Treatment of superficial pressure ulcers costs about $500, while the price of more advanced HAPIs can rise to $70,000 (Padula&Delarmente, 2019). Every tenth patient in MICU in one urban New York hospital requires secondary interventions that increase the cost of primary care, thereby necessitating preventive measures that minimize these expenses (Rivera et al., 2020). In addition to economic benefit, patient outcomes and satisfaction will increase because the quality of life will be improved, allowing them to have shorter hospitalizations and return to their families early. Many clinical trials achieved a significant reduction in the HAPI incidence rate. A quasi-experimental clinical study by Anderson (2018) reached a seven-fold drop in the prevalence of pressure injuries. This project aims to utilize the quasi-experimental study design to determine how effective the selected scheme of the PIP bundle will be in the 13-bed MICU.

The problem of pressure injuries is widespread in the medical industry (WHO, 2008). Padula et al. (2019) argue that this health condition affects more than 2.5 million people. Padula and Pronovost (2018) also admit that HAPIs result in 60,000 deaths in the USA annually, and their costs are estimated at $9-$11 billion. Simultaneously, Li et al. (2020) argued that the HAPI prevalence is 12.8%, while the incidence rate is 5.4 for every 10,000 patient days (p. 2). The WHO (2008) states that HAPI prevalence is similar in different nations, including 10% in the USA, 11% in Germany, 12% in Sweden, and 13% in Israel (p. 45). These data indicate that a significant part of the US population is subject to this health condition. Simultaneously, the project site reports that it suffers from an 11% prevalence that refers to the incidence of 10 HAPIs per 100 patients. Thus, it is necessary to find a practical solution to minimize the incidence of HAPI and protect individual health.

The present quality improvement project’s purpose is to help critical care units with the highest numbers of HAPIs incidences to manage the situation. The project particularly targets our thirteen-bed hospital located in New York. A major focus concerning the study is to provide a reliable evidence-based way of reducing HAPIs cases by proving or disapproving the effectiveness of Rivera’s PIP bundle. As such, the point that healthcare facilities, including ours, cannot bill the treatments related to HAPIs subjects hospitals to immeasurable cost burdens. The project site spent about $60,000 to $75,000 every year towards the cost of HAPIs. The month prior to implementation of the Rivera’s PIP bundle, the estimated cost of HAPIs was &7,000. The issue of wrong branding as a result of the high HAPIs cases in the entity is also targated by the present study. The successful completion of the work thus stands to help our hospital, together with the other quality conscious heathcare facilities, to find solutions to one of the most probing issues in the care delivery line. The study’s timing appears appropriate based on the current situation where lots critical care facilties exeirnce congestion due to the COVID-19 pandemic. Arguably, the study, together with several others that concern HAPIs and the possible interventions, are what the healthcare realm has been waiting to realize real transformation.

Rationale for Methodology

This quality improvement projectused quantitative methodology to focus on measuring the impact of Rivera’s PIP bundle implementation on HAPI incidence rates. A quantitative methodology is useful for addressing clinical problems and answering clinical questions and relies on numerical data. Creswell and Creswell (2018) explain that the main benefit of the methodology is that it allows for an experiment to collect and analyze data and lead to conclusive results. Rutberg and Bouikidis (2018) stipulate that a quantitative method is appropriate when answering a clinical question that aims to achieve quality improvement.

This methodology was sufficient and effective for guiding how this quality improvement project was conducted. This project’s dependent variable is the incidence of HAPI, a quantity measured and reported in numeric values, thus proving suitable for a quantitative methodology. HAPI’s prevalence and mortality rates are also numerical values that are the focus of the project’s problem statement, thereby further justifying the use of a quantitative methodology. It is also suitable for addressing the project’s clinical question as it is suitable for making definite comparisons, such as the impact of Rivera’s PIP bundle compared to current practice. Therefore, the clinical question attempts to identify a measure of improvement, and the selected methodology frames the use of Rivera’s PIP bundle and statistical tests to find its answer and address the problem of HAPI among patients at the project site.

Nature of the Project Design

The quasi-experimental approach offers the best model to utilize in the present study. The approach follows the same steps like empirical design, but for the fact that it lacks the random assignment aspect. As such, the quasi experiment design answers questions by studying specific targeted population with the features or elements that the researcher is interested in (Harley, 2018). The quasi-experimental model stands out as one of the most reliable approaches for establishing causal effect(s) of an intervention on a particulalr target population. The assignment, however, occurs without the random assignment elements present in normal experimental designs (Harley, 2018).

A quasi-experimental approach is effective in handling a clinical problem and retorting a clinical inquiry. The point that the method utilizes numerical data makes the approach vital in identifying the specific incidence of given phenomena. Quasi-experiments are like normal experimentation tactics, only that they are suitable for spepfic cases, like the one targeted by the present study (Harley, 2018). The methodology applies essential tests, like the t-test, which upsurges the dependability of the acquired upshots. Creswell and Creswell (2018) further note that one of the primary benefits of the this statistical methodology is it’s ability to allow the steering of a trial to gather and evaluate the acquired data. Moreover, Creswell and Creswell (2018) specify that a quasi-experimental method is suitable when responding to a clinical problem to attain quality upgrading. As such, the incidence of HAPI cases constitute the dependent variable in this project, and is the quantity measured and stated in numeric figures. That way, the use of quasi-experimental design fully responds to the project’s clinical question, as well as addresses the problem statement effectively. Also, the present study’s clinical inquiry endeavors to isolate a degree of progress, while the designated approach runs arithmetical tests to deliver such an answer.

The sample population for this project includes all adult patients admitted into the critical care unit. Patients on this unit are critically ill with diagnosis of medical cardiac problems such as congestive failure or myocardial infarction, endocrine and renal problems, gastrointestinal and pulmonary ailments. A correlational design was also inappropriate since it does not imply using a comparison group that is necessary for measuring the impact of the clinical intervention on the HAPI incidence rates. Furthermore, the quasi-experimental design allows for the application of the quantitative methodology, which provides quantitative data for analysis and discussion, thus leading to conclusive results on the effectiveness of the clinical intervention.

Definition of Terms

The following terms are operationally defined in lay words and in the context in which they appear in the paper.

Pressure Injury Prevention Bundle.

This approach allows clinicians to have guidance for the assessment and monitoring of intensive care unit patients. This term refers to the plan of care that was developed to prevent the development of pressure injuries in patients at risk (Romanelli et al., 2018). The prevention bundle elements may vary between authors, but the overall goal of all methods is to prevent further complications of HAPI. The critical components of this bundle include comprehensive skin assessment, turning & repositioining, standardized risk assessment, wound care nurse consultation, and medical device-related interventions.

Pressure Ulcers (HAPIs).

This term denotes “areas of localized injury to the skin and underlying tissue, usually over a bony prominence, as a result of pressure, or pressure in combination with shear” (Li et al., 2020, p. 2).

Turning.

The process is when individuals move or change their position while sitting or lying. Immobilized patients in MICU on vents with paralytics and sedation require help with turning.

Assumptions, Limitations, Delimitations

The following assumptions are present in this quality improvement project:

1. It is assumed that the project participants do not create any treatment barriers and diligently follow the PIP bundle offered to them. This idea is necessary since it implies that changes in the HAPI incidence, if any, are directly related to the intervention, not external processes.
2. Another assumption denotes that the project will identify the positive connection between providing a PIP bundle and the decreased HAPI incidence. This statement implies that the project aims at arriving at the conclusion that utilizing the PIP bundle is an effective pressure injury prevention intervention.
3. One more assumption is that the healthcare facility correctly enters the data on patients’ pressure injuries in their EHRs. This condition is necessary because the project relies on EHRs to identify the HAPI incidence.

The following limitations are found in the project:

1. Time constraints can be considered an essential limitation of the project. Since the project covers four weeks, it fails to assess the long-term effect of the proposed intervention.
2. Another limitation is a small sample size because the project focuses on patients from a single medical facility in urban New York. It can be difficult to generalize the obtained results and determine whether the proposed intervention can be effective for the larger population.
3. One more limitation is that the project depends on how accurately and diligently the facility approaches its reporting system. It relates to the fact that if the healthcare unit fails to mention in its EHRs that some patients experience pressure ulcers, the project’s results will suffer.

The following delimitations are found in the project:

1. The project is delimited to a 13-bed critical care unit in urban New York. This delimitation is necessary because critical care patients are more subjected to pressure injuries due to poor tissue perfusion or hemodynamic instability.
2. Another delimitation is that the project chooses a nursing theory by Jean Watson (2018) to ensure that the project has some theoretical support.

Summary

Chapter 1 presents all the basic elements concerning the present study. The section starts by offering a description of the major issue concerning HAPIs and the need to resolve them. The section also provides adequate background for the study and the clinical question to be answered, as well as the project’s endeavor to advance clinical knowledge. Other areas covered by the chapter include the rational for the study, nature of the project design, assumptions, and definition of terms.

Padula et al. (2019) explain that HAPIs are a significant problem in the healthcare industry, meaning that a practical intervention is necessary to address the issue. Chapter 1 has also formulated the problem statement, the purpose of the project, and the clinical question. Evidence from scholarly sources demonstrates that the project can advance scientific knowledge because the existing literature offers conflicting results of using the PIP bundle (Rivera et al., 2020). Thus, the project is significant since it aims at addressing this gap and providing multiple stakeholders, including patients, healthcare professionals, and the whole medical facilities, with essential benefits.

Chapter 1 also comments on the methodological aspect of the project. The intervention for reducing HAPI prevalence was presented in this chapter. Specifically, the background knowledge about the PIP bundle developed by Rivera et al. (2020) and some other variations of this approach are discussed in chapter 1. Creswell and Creswell (2018) justify using a quantitative approach, while Rutberg and Bouikidis (2018) explain that it is reasonable to use a quasi-experimental design. Then, the key terms are defined to ensure that anyone reading them accurately understand the concepts under discussion. The project assumptions, limitations, and delimitations have also been discussed in detail, while specific comments are offered on how to overcome these limitations in a future project. Chapter 2 presents an overview of the current literature on the PIP bundle and whether this intervention effectively prevents pressure injuries.

Literature Review

The purpose of this quantitative, quasi-experimental project was to determine if or what degree implementation of Rivera’s Pressure Injury Prevention (PIP) bundle would impact HAPIs prevalence rate as compare to current practice among critical care patients in the Urban New York acute care hospital over four weeks. HAPIs are a major cause of concern for everyone involved in care delivery, especially those serving in the critical care department. The U.S., for example, loses billions of dollars every year to HAPIs-related complicaions. About sixty thousand patients also lose their lives die to HAPIs-founded complication. The life of an individual is very expensive and precious. That is why the present project purposes to investigate the matter with HAPIs and the possible solution through the application of Rivera’s PIP bundle. The present literature review section thus addresses some of the critical scholarly information that addresses the same clinical problem, together with the targeted intervention.

The project aims to measure the effectiveness of Rivera’s PIP bundle in reducing health-acquired pressure injuries (HAPIs) in a 13-bed critical care unit in urban New York over 4 weeks. HAPIs are preventable conditions that often occur in the intensive care unit. They involve pressure injuries that cause localized skin and tissue damage due to intense and continuous pressure. This review aims to uncover the importance of implementing a PIP bundle in reducing the prevalence of pressure ulcers in critical care units.This chapter reviews literature concerning the risk factors for HAPIs, various strategies for preventing HAPIs, and the usefulness of the PIP bundle as an intervention for HAPIs. thorough literature review was performed to identify the existing information, beginning with professional databases to find credible and timely literature on the topic. The literature search was conducted using the following databases: EBSCO, Cumulative Index to Allied Health Literature (CINAHL), Ovid, PubMed, and Google Scholar. The following keywords and their various combinations were used to identify the required sources of information: pressure injuries, pressure injury prevention bundle, interventions related to pressure injuries, risk factors, and incidence related to pressure injuries. The search results are limited to the studies that were published not earlier than 2017 to ensure that the project deals with the most recent literature. The identified articles are included in the project based on their abstracts. The articles are included if they are available in full text and peer-reviewed. As a result, 90 studies were retrieved, while a set of 50 credible and reliable studies were selected for this literature review.

It is vital to reduce incidences of HAPI at the project site particularly in thecritical care unit since it presents many problems. The project site was at 14% of HAPIs prevelance rate in 2020, higher than the national average (13%). Hospital-acquired pressure injuries (HAPIs) adversely affect patient care and are associated with deleterious consequences for the healthcare system especially when it comes to health care costs and patient (Padula&Delarmente, 2019.It has a major financial implication, with its cost extending beyond $2,000 per pressure injury (PI). The involved cost and associated human suffering explain the dire need to establish effective preventive strategies (Gaspar et al., 2019). High incidences can influence the affected organizations and lead to financial challenges. The National Quality Forum (NQF) considers most of the HAPIs preventable.

Theoretical Foundations

Jean Watson’s human caring theory (1979) identifies how to improve positive outcomes during human-to-human caring moments. The theory relies on practice, research, and theory-based education to ensure that any proposed intervention is suitable and can help patients achieve better health outcomes. They conducted a content analysis study to examine the opinions of interprofessional team members concerning a human caring model based on Watson’s theory. The study revealed the nursing theory enriches interhuman relations, establishes a holistic caring environment, and promotes patient care. Watson’s theory of caring helps create an excellent environment around the patients and staff to promote healing. Energetic authentic caring presence occurs when the nurse and patient come together to create a caring moment. Pressure injuries occur mostly in immobile and elderly patients and PIP bundle interventions, performed by the nurse or the healthcare team, such as repositioning an immobile patient can prevent pressure injuries, meet the basic needs of patient, and help sustain human dignity.

Jean Watson’s human caring philosophy covers the role of a nursing professional in the healing process. The model encourages nursing to engage their patients in positions that make self-healing possible. The nursing principle maintains that the nurse’s main role covers the aspects of health promotion, illness prevention, caring for the sick, and health restoration. Such implies the nurse’s central responsibility in promoting health and diseases’ treatment. As per Watson, caring is fundamental to nursing practice and encourages health better than a mere medical cure. Watson believes that that an all-inclusive attitude to health care is principal to the exercise of caring in the nursing profession.

Watson’s human caring theory informs the present project significantly. The work purposes to boost nurses’ knowledge concerning HAPIs management. The problem, HAPIs is a major concern in the present-day care provision realm. HAPIs makes the process of healing difficult. The point that they account for about sixty thousand deaths a year also imply their adverse effects to the general nursing profession. As such, Watson maintains that the primary purpose of a nurse is to restore health and promote healing (Watson, 2018). Undertaking this study thus complies with Watson’s carative factor of applying scientific problem solving approaches for caring decision making.

The project focuses on a specific change theory. It refers to Kurt Lewin’s (1951) change management theory that is typically used for numerous quality improvement projects. This framework implies that patients change their behavior under the influence of driving or positive forces that affect individuals from outside (Lewin, 1951). This information suggests that it is necessary to provide patients with external support to ensure that they can overcome some challenges. The Lewin change model implies that the project will rely on specific steps to measure the variables. First, it is necessary to improve patients’ knowledge about the problem and its possible solutions, Lewin’s stage of unfreezing (Burnes, 2020). The next step involves implementing the change, which involves establishing the solutions within the organization, Lewin’s stage of changing. Finally, after being evaluated as effective, the change is established as the industry standard concerning solutions to the problem; Lewin’s stage of refreezing. Lewin’s change theory is important to the project as it delineates processes for instigating Rivera’s PIP bundle in acute care settings where they have not been implemented before. As a result, the change will encounter obstacles and resistance that necessitate the change model for effective transition.

Review of the Literature

The literature review assessed evidence-based practices to explain existing challenges in prevention of HAP The literature identified gaps in the existing research and suggested areas for further study. The literature review built an argument on the development of the clinical question while explaining the current models, topics, and theories. It will enable the reader to understand the importance and relevance of the project. The literature review process revealed evidence organized into the following themes: Hospital acquired pressure injuries, Risk factors and Pressure injury prevention bundle.

Hospital-Acquired Pressure Injury

Hospital-acquired pressure injury (HAPI) affects patient care; it is associated with deleterious consequences for the healthcare system and patient (Padula&Delarmente, 2019). It is vital to reduce incidences of HAPI, particularly in the ICU since it presents many problems. It has a major financial implication, with its cost extending beyond $2,000 per pressure injury (PI). The involved cost and associated human suffering explaining the dire need to establish effective preventive strategies (Gaspar et al., 2019). Moreover, the scope of the problem is high and involves multiple levels. Rivera et al. (2020) revealed that at least one million people develop PI annually in the U.S. The study also indicated that 2.3 million patients in acute care facilities develop the condition where more than 60,000 lose their life due to related complications (Gaspar et al., 2019). High incidences can influence the affected organizations and lead to financial challenges. The National Quality Forum (NQF) considers most of the HAPIs preventable. Additionally, CMS does not provide reimbursements for HAPIs thereby eliminating payments to hospitals for their care (Padula et al., 2020).

• Incidence Rates. Chaboyer et al. (2018) conducted a systematic review and meta-analysis that examined the problem of pressure ulcers that emerge as a result of clinical treatment in terms of scale and scope. The conclusions are made based on the in-depth analysis of twenty-two studies that were reviewed and synthesized in alignment with the research questions. Chaboyer et al. (2018) report the cumulative incidence of HAPIs to be within the range of 10-26%. These numbers indicate that the matter at hand represents an issue of a serious magnitude. As for the location of the HAPIs, the systematic review indicates that most of them emerge on the patient’s sacrum, followed by the buttocks, heel, hips, ears, and shoulders (Chaboyer et al., 2018). Accordingly, pressure ulcers affect a considerable number of patients, causing moderate-to-severe discomfort in the fallout of prolonged care. Li et al. (2020) explored the issue from a global perspective, utilizing the international experience to address their clinical question. More specifically, they aim to quantify the prevalence and incidence of pressure injuries and the hospital-acquired pressure injuries rate in hospitalized adult patients (Li et al., 2020, para. 2). In order to address the research purpose, the authors rely on the formats of systematic review and meta-analysis. The research sample comprises cross-sectional, observational, and longitudinal studies that report HAPIs among hospitalized adults. Based on the examination of forty-two relevant studies and a total sample of 2,579,049 patients, Li et al. (2020) report an incidence rate of 5.4 per 1,000 patient days. Most of the HAPI cases represent stages I and II of the condition (71,5% in total). From a geographical perspective, the analysis revealed a considerable level of heterogeneity, implying certain territorial correlations that are to be explored in subsequent examinations. This study highlights that the prevalence of HAPIs is a global healthcare concern, but its exact magnitude may vary across different settings. According to Anderson (2018), HAPIs have high significance for patients in critical care. He defines them as pressure injuries that cause localized skin and tissue damage due to intense and continuous pressure. He also reports on their incidence rates in intensive care units varying from 14% to 42%. During a quasi-experimental clinical study for addressing HAPIs, Anderson (2018) reached a seven-fold drop in the prevalence of pressure injuries. As a result, he recommended that hospitals place readily available resources for nurses to utilize when monitoring and intervening on the pressure injuries.
• HAPI Impact on the Healthcare System. The elevated incidence rates of HAPIs are concerning for all parties involved in the delivery of medical services. In this regard, healthcare organizations equally sustain considerable damage, primarily in the financial domain. Padula and Delarmente (2019) extend this discussion even further, attempting to evaluate the national burden of hospital-acquired pressure injuries in the United States. To address the research question, the authors of the research rely on a Markov simulation. Through this method, they estimate the costs of staged HAPI’s that emerge during hospitalization from a medical organization’s point of view. As per the simulation’s results, the annual HAPI costs for the U.S. healthcare system exceed $26.8 billion, which is a colossal amount. Moreover, the distribution of the costs is not proportionate, as nearly 60% of the amount is a condition by the less frequent Stage III and Stage IV cases of pressure injuries. Therefore, the prevalence of HAPI’s undermines the financial aspect of the system, impeding the quality development of hospital units. In this context, significant progress can be made through the prevention of advanced-stage pressure injuries, alleviating the economic burden on organizations.

The immense economic impact of hospital-acquired pressure ulcers remains a matter of increased concern for the system’s management. Lim and Ang (2017) investigate this aspect of the problem within their research. The clinical report is based on the experience of a tertiary hospital in Singapore, thus contributing to the international dimension of the discussion. The clinical questions are presented from the managerial perspective, aiming at reducing the operational costs of healthcare organizations. The authors rely on the famous assumption, stating that the prevention of a problem is widely recognized as more effective than its treatment. In this regard, healthcare organizations are encouraged to pursue new avenues of reducing the incidence rates of HAPI’s like a phenomenon. These ideas align with the ongoing trends within the academic community, as researchers investigate the root causes of pressure injuries in order to develop stronger interventions. The examination by Lim and Ang (2017) reveals that HAPIs are a major stressor for hospitals, depleting their finite resources through prolonged stays, patient dissatisfaction, and corresponding expenses. Therefore, the impact of HAPIs on healthcare organizations is concerning, thus justifying the need for effective interventions.

The problem of HAPIs is global in nature, making it necessary to synthesize and implement the world’s best practices into intervention projects. Han et al. (2019) follow the data obtained through practical observations and analyses in a South Korean hospital with increased HAPI incidence rates. The clinical question was whether these conditions affected the key parameters of a healthcare organization’s performance. More specifically, the authors of the study associate HAPI’s with a strong negative impact on the patient’s health. The sample of 1,000 patients was compared with a 4,000-person control group. The results indicate that advanced HAPIs are associated with increased mortality rates, putting additional pressure on patients and medical units. In addition, the average duration of stay for the patients who develop this condition is longer, leading to higher healthcare costs and financial burdens. Finally, the emergence of HAPIs is a serious predictor of readmission, which, in turn, equally undermines the performance of a medical organization. Therefore, all parties involved in the clinical procedure will benefit from effective interventions aimed at the prevention of hospital-acquired pressure injuries.

The information presented in this section confirms the multi-faceted adverse impact of HAPIs on the functioning of medical organizations. In today’s environment, hospital units work with limited resources. In fact, the efficient distribution of these resources is an essential enabler of better healthcare outcomes that improve the patients’ well-being, promote public health, and sustain the system’s development. The presented findings indicate a major degree of negative influence by the HAPIs, undermining the system’s capacity to fulfill its obligations for the community. Increased healthcare costs are an overarching theme of these discussions, meaning that HAPIs become a serious financial burden for organizations. However, in addition to this, the repercussions of unaddressed HAPIs extend beyond these ideas, contributing to the increase of mortality and readmission rates in hospitals. When all these factors act combined, the prevalence of pressure injuries translates into major healthcare issues that encompass the primary aspects of the system, in general.

• Patients with Specific Health Conditions. There are a number of underlying conditions can aggravate the development of HAPIs. Typically, this health issue is the most acute for individuals who spend much time in prone or sitting positions. However, other factors can facilitate the emergence of pressure injuries, prompting scholars to seek specialized methods for such particular cases. Thus, it is reasonable to identify research pieces that would make it clear whether PIP bundle is helpful for people with particular health conditions.

In addition, cardiovascular conditions may entail serious complications in stressful environments. Chitambira and Evans (2018) assessed the effect of repositioning for stroke patients with pusher syndrome and using a quality improvement initiative with 140 adults. The researchers draw attention to 2-hourly repositioning and placing of pillows. This article supports the claim that repositioning becomes more effective when it is used together with an additional intervention. Since the study focuses on a short intervention period, the authors highlight the necessity to organize further research on this topic. A retrospective descriptive article by Cox, Roche, and Murphy (2018) argues that immobility and septic shock are among the most common pressure ulcer risk factors. Pittman, Beeson, Dillon, Yang, and Cuddigan (2019) offer another descriptive retrospective study highlighting that HAPIs can be preventable and unpreventable. The unavoidable HAPI occurs among patients with bowel management devices (Pittman et al., 2019).

As pressure injuries affect the skin tissue, corresponding health issues may also aggravate the development of this condition. Gray and Giuliano (2018) reveal that there is a robust correlation between pressure injuries and incontinence-associated dermatitis (IAD). A descriptive and correlational analysis of 5,342 adults demonstrates that an increased HAPU prevalence is found when it comes to focusing on IAD patients. The authors highlight that traditional prevention measures, are not sufficient to protect the population from the given health condition. Thus, another argument in favor of a combined approach is made. Razmus and Bergquist-Beringer (2017) state that pediatric patients are subject to the issue, while Hultin, Karlsson, Öhrvall, and Gunningberg (2019), Latimer et al. (2019), and others explain that older patients are at risk.

However, the range of underlying conditions is not limited to oncology, skin diseases, or cardiovascular issues. Mussa et al. (2018) focus on pressure injuries among patients with an endotracheal tube (ETT). A retrospective, pre-post intervention study indicates that a more frequent repositioning leads to some improvements, but they are not statistically significant. The authors prove it by analyzing data of 61 members from the pre-intervention group and 81 individuals from the post-intervention group. This finding demonstrates that it is not possible to rely on only one preventive intervention repositioning and turning exclusively to protect patients with ETTs from HAPUs.

The damage to a patient’s spine is a serious matter per se, limiting the mobility of a person. Eren, DeLuca, and Kirshblum (2020) consider what results preventive interventions offer to patients with spinal cord injury. The authors do not implement any interventions but interview such individuals regarding whether they rely on the intervention. The findings demonstrate that almost half of the 86 respondents fail to turn regularly, irrespective of the fact that they are aware of this action. That is why it is not surprising that patients with spinal cord injury are subject to HAPUs.

Risk Factors

Risk factors contributing to the development of HAPI ‘s in the clinical setting revolve around identifying and categorizing the primary predictors of pressure injuries that occur during a patient’s prolonged stay at a facility (Dreyfus et al., 2017). HAPIs are a major societal burden that can be addressed effectively and prevented if major underlying causes are correctly determined. Some of the risk factors identified by Kayser et al. (2019) during a longitudinal study include older age, male gender, unable to self-ambulate, all types of incontinence, additional linen layers, longer durations of stay, and being in an intensive care unit (p. 46).

• Malnutrition. According to Greenwood and McGinnis (2016), malnutrition is one of the root causes for increased incidence rates of HAPIs in acute care. However, analysis suggests that patient pressure injuries rarely appear from a single cause; instead, they arise from a combination of factors. The authors of the study refer to HAPI emergence as a sequence of events that leads to adverse consequences in terms of patients’ well-being. Greenwood and McGinnis (2016) place malnutrition among the most important causes of HAPIs. They used data analysis methods to process the findings obtained by the root cause analysis process implemented in the U.K. since 2010. The practical purpose of such research was for identifying the key themes and learning points that can help develop meaningful solutions to the clinical issue in question. The research sample comprised thirty-two HAPI RCA’s that provided insight into the root causes of the pressure ulcers. Predictors and determinants of HAPIs form an area of intense interest for researchers across the globe. Kayser et al. (2019) conduct their study to explore the differences between risk factors associated with a superficial and severe case of HAPIs. They analyzed 216,626 complete patient datasets from acute care hospitals in the United States. Having generated the annual linear trendlines, Kayser et al. (2019) performed two logistic regressions to examine the risk factors. The accumulated risk factor list comprised increased age, male gender, unable to self-ambulate, all types of incontinence, additional linen layers, longer durations of stay, and being in an intensive care unit (Kayser et al., 2019, p. 46). In addition, a U-shaped relationship between HAPI risks and body mass index was observed. In this context, both extremely low and high BMIs were associated with increased pressure injury risks. The study showed nutrition is a significant risk factor for HAPIs with deficiencies and obesity in nutrition causing increased risk for HAPIs.
• Immobility. Kennerly and Yap (2018) conducted a review that included adverse effects of immobility. They investigated the impact of manual turning for improving the health outcomes of patients in critical care. They demonstrated that manual turning helps patients avoid adverse musculoskeletal and cardiovascular effects of immobility. They attributed the effect of immobility to gravitational equilibrium which makes it more difficult to ascribe to positional changes. As patients grow resistant to position changes, they become immobile. The effect of immobility is reduction in plasma volume, change in bone mass, and change in muscle mass. These effects expand the adverse effects of medical devices on the patients’ skin leading to pressure ulcers. Additionally, they make patients more prone post-operative fever and pneumonia that increase their ICU days and degrade their health outcomes. A retrospective descriptive article by Cox et al. (2018) argues that immobility and septic shock are among the most common pressure ulcer risk factors.Patients in ICU are usually inactive and exposed to the risk of developing HAPIs. Cox et al. (2018) conducted a study to analyze and describe the risk factors for pressure ulcers in MICUs. The study used a sample of 57 patients all of whom experienced pressure ulcers while they were highly immobile in acute care. The injuries generally developed after 7 days and were mostly deep tissue pressure injuries around the sacrum. The study demonstrated immobility to be a significant risk factor for pressure injury development among acute care patients. Damage to a patient’s spine may limit their mobility. Eren et al. (2020) examined preventive interventions offered to patients with spinal cord injury with a descriptive, non-experimental study. The study did not implement any interventions; instead, the study team interviewed individuals with spine injuries regarding whether they reposition themselves. The findings revealed that almost half of the 86 respondents failed to turn regularly, irrespective of the fact that they are aware of this action; thus, it is not surprising that patients with spinal cord injury are subject to HAPUs.
• Poor Circulation. Risk factors for HAPI development include hemodynamic instability and vasopressors (Cox et al., 2018). Cox et al. (2018) conducted a descriptive analysis study to determine the risk factors for pressure injuries among patients in critical care. Among the sample of 57 patients who participated in the study, 50 identified with sedation as a risk factor for developing pressure injuries, 53 identified with head-of-bed elevation angle being greater than 30, and 37 identified with vasopressor use. These risk factors are highly associated with hemodynamic instability as they alter blood pressure by constricting blood vessels (vasopressors), decreasing the patient’s pulse rate (sedation), and introducing body positions that restrict optimal blood flow (head-of-bed elevation greater than 30) (Cox et al., 2018). Therefore, the risk factors show poor circulation to be a significant causative agent for pressure injuries among patients in critical care units. Cardiovascular conditions may entail serious complications in stressful environments. Chitambira and Evans (2018) assessed the effect of repositioning for stroke patients with pusher syndrome and using a quality improvement initiative with 140 adults. The researchers draw attention to 2-hourly repositioning and placing of pillows. This article supports the claim that repositioning becomes more effective when it is used together with an additional intervention. Since the study focuses on a short intervention period, the authors highlight the necessity to organize further research on this topic. Dreyfus et al. (2017) explored the risk factors contributing to the development of HAPIs in the clinical setting. They utilized U.S.-based data to address their clinical question. It revolved around identifying and categorizing the primary predictors of pressure injuries that occur during a patient’s prolonged stay at a facility. The authors refer to HAPI s as a major societal burden that can be addressed effectively and prevented if major underlying causes are correctly determined. They investigated 47,365 HAPI cases among 16,967,687 patients with a cumulative incidence of 0.28% including patients with health problems commonly associated with or resulting in poor circulation: history of diabetic foot ulcers and prior incidence of pressure. As per the findings, the prior incidence of pressure injuries is the most important predictor of future cases, along with a history of diabetic foot ulcers. Thus, they showed that hypertension and diabetes are high risk factors for HAPIs as they dysregulate blood flow in the patients. individuals with altered skin status are considered to have a high risk of new ulcer development. Shi et al. (2018) argued that there is insufficient evidence to support the potentially prognostic relationship. The study attempted to review the existing evidence systematically to understand the relationship between the development of pressure ulcer risks and skin status. A comprehensive electronic database search was performed in February 2017 to explore longitudinal studies that used skin status to support the prediction of pressure ulcers. It considered multivariable analysis studies where two reviewers independently selected studies. Data was collected on skin status, participants, as well as the characteristics of studies. This helped gather data on multivariable analyses of pressure-ulcer and the associated skin status. The article covered 41 studies involving 162,299 participants, out of which 7382 had new ulcers. It concluded that there exists low-certainty evidence that individuals suffering from non-blanchable erythema are at an increased risk of developing new pressure ulcers compared to those free from the condition. Further, low certainty evidence was noted for the prognostic effects of different skin descriptors, particularly the pressure ulcer history. These findings imply that there is a need for the adoption of improved preventive measures and skin assessment for patients with non-blanchable erythema.

The above subthemes provide detailed descriptions of the risk factors for HAPIs according to the literature. They present the major risk factors as poor circulation, immobility, and malnutrition. Understanding risk factors is essential to effective prevention of illnesses. Therefore, the next section proceeds to some ways pressure injuries can be mitigated

Pressure Injury Prevention

Preventive strategies can help decrease the incidence and impact of HAPI on the healthcare system and patients. Preventing pressure ulcers (PU) protects patient safety and comfort, and is a more cost-effective approach than treating HAPI when they develop. The three prevention components in this theme are positioning, skin assessment, medical device-related interventions, and PIP Bundles. The content presented includes the Rivera PIP bundle selected for implementation as the project intervention to address the problem and clinical question (Rivera et al., 2020).

• Positioning. Turning patients is one of the interventions that is widely applied to relieve pressure from prone areas. Kennerly and Yap (2018) conducted a review that included adverse effects of immobility. They investigated the impact of manual turning for improving the health outcomes of patients in critical care. They demonstrated that manual turning helps patients avoid adverse musculoskeletal and cardiovascular effects of immobility. They attributed the effect of immobility to gravitational equilibrium which makes it more difficult to ascribe to positional changes. As patients grow resistant to position changes, they become immobile. The effect of immobility is reduction in plasma volume, change in bone mass, and change in muscle mass. These effects expand the adverse effects of medical devices on the patients’ skin leading to pressure ulcers. Additionally, they make patients more prone post-operative fever and pneumonia that increase their ICU days and degrade their health outcomes. As a result, proper positioning instigated by manual turning led to better health outcomes and reduced ICU days.

Aljezawi and Tubaishat (2018) attempt to determine whether turning and repositioning, offloading and application of preventive dressings are effective for cancer patients. A multicenter, cross-sectional prevalence study of 110 patients used a quantitative methodology to analyze the impact of 2-hourly repositioning on protecting such individuals from the health issue under analysis. The scholars conclude that irrespective of short frequency, this intervention does not guarantee that pressure injuries will not develop in some patients, such as those with cancer.

A cross-sectional prevalence study by Courvoisier et al. (2018) focuses on 2,671 patients to identify and compare the effectiveness of various intervals. These intervals are considered independent variables, while HAPU incidence represents a dependent one. Thus, the scholars have determined that 2- and 3-hourly intervals are more effective than 4-hourly ones. It demonstrates that a higher intervention frequency leads to improved health outcomes for patients suffering from HAPUs.

• Skin Assessment. Comprehensive skin assessment involves the examination of the entire skin of an individual for abnormalities. It entails touching and looking at the skin while paying attention to the bony prominences. The examination is meant to detect present pressure ulcers and offer assistance in the risk stratification. This is done because patients with underlying pressure ulcers are at increased risk of developing more (Rivera et al., 2020). The assessment determines the presence of skin-related factors linked to the development of pressure ulcers, including moisture-associated skin damage (MASD) or excessively dry skin. It also enables the identification of other skin conditions and provides data required for the calculation of prevalence and incidences.

The type of intervention in patients varies depending on the Braden score. According to the bundle designed by Rivera et al. (2020), patients with a Braden score above 19 should receive the standard intervention. In contrast, patients with points equal to or below 18 will get high-risk intervention (Rivera et al., 2020). Implementation of this bundle resulted in a significant reduction in the occurrence of pressure ulcers (Rivera et al., 2020). Specifically, the index of healthcare-associated pressure injuries, which is the proportion of patients with pressure ulcers to the days spent in the hospital, dropped from 3.4 to 0.48 over the ten months (Rivera et al., 2020). The authors developed the bundling scheme with time intervals, but they do not discuss the intervention components in detail.

Effective skin assessment can support early detection and influence the implementation of an appropriate intervention. Bates-Jensen Wound Assessment Tool (BWAT) can be applied in clinical practice to assess wound healing. Bates‐Jensen et al. (2019) evaluated the application of the BWAT to assess home residents with a pressure injury. The study reported pressure injury characteristics including natural history, anatomic, and stage location among racially and ethnically diverse residents. The prospective 16 weeks study covered 142 participants with 305 pressure injuries representing a prevalence of 34%. Subepidermal moisture and visual assessment were attained from heel, ischial, buttock, and sacrum ulcers every week. The study revealed that BWAT is an effective assessment tool because it offers objective and reliable data to support the detection of the progress of pressure injury healing.

Early detection and identification of pressure damage risk need to be prioritized. Kim et al. (2018) evaluated the association between the application of sub epidermal moisture measurement and visual assessment of early pressure ulceration. The study employed a descriptive prospective observational design where data was obtained from at-risk patients in Ireland within an acute care facility. Obtained data included researcher-led sub-epidermal moisture measurements and the patient’s skin condition. With a sample of 47 patients who had a mean age of 74.7 years, 19 patients suffered stage 1 pressure ulcers and elevated sub-epidermal moisture (SEM) levels. Results showed 83% specificity, where the majority of false positives lacked adequate follow-up time. The study noted a medium correlation between SEM findings and nurses’ visual skin assessment.

The SEM measurement tool required 1.5 days to detect damage, while nurses took an average of 5.5 days. This implies that SEM measurement can detect early damage about days ahead of the nurse assessment. Early detection of the pressure ulcers damage is beneficial because it develops within the deeper tissues. This can enable the adoption of effective prevention strategies before worsening the condition. Moreover, early detection can limit the associated mortality and morbidity, reduce the length of hospital stay and improve patients’ experience.

Yafi et al. (2017) presented preliminary case studies showing the feasibility of spatial frequency domain imaging (SFDI) to promote assessing skin status in pre-existing wounds and high-risk populations. The technology involves the use of wide-field non-contact optical imaging with structured light to examining tissue constituents and optical properties. A near-infrared SFDI system was used to image patients at an increased risk for pressure ulcers. The study concluded that SFDI is a feasible optical technology that can be applied to assess blood volume status and tissue oxygen saturation quantitatively. It can offer an effective approach for pressure ulcer healing, risk stratification, and staging.

• Medical Device-Related Interventions. Pressure-reducing devices have proven effective in the prevention of HAPI in critical care settings. Static devices are appropriate when supporting patients who can independently change positions. An air-fluidized or low-air-loss bed is effective for patients with non-healing or multiple large ulcers. Accumulated risk factors for the HAPI include the inability to self-ambulate, male gender, old age, extended hospital stay, additional linen layers, hospitalized in an intensive care unit, and incontinence. Extremely low and high BMIs are linked to a high risk of developing pressure injuries (Rivera et al., 2020). Prior cases of hospital-acquired pressure injuries increase the chances of developing new instances. Spending much time in a sitting or prone setting is another factor that increases the risk. Therefore, pressure-reducing devices prevent HAPI by mitigating the effects of poor circulation, immobility, and malnutrition that lead to pressure injuries.

Prevention devices, such as pressure-relieving mattresses, special cushions, and heel-elevating boots may benefit patients in acute care, as well as nursing home residents. These devices operate by lessening pressure created on the skin and enhancing the patient’s comfort. Some devices alternate periodically to move pressure points to lower extensive pressure on one body part through a mechanical system that deflates or inflates air cells in the mattress to attain the required comfort. Moreover, special pads can be applied to soften the surface or lower pressure and avoid the development of ulcers. Kamikawa et al. (2018) explained that a special pressure-relieving mattress could be used to hinder the development of ulcers among patients with a high risk. Long-term facilities and hospitals should consider installing these mattresses when handling immobile, comatose as well as elderly residents and patients.

The application of preventive dressing on intact skin can significantly reduce shear forces and tension between the support surfaces and the skin. This helps lower shear forces within the underlying soft tissues and the skin. Hahnel et al. (2020) investigated whether the preventive dressing is effective when handling patients in the high-risk intensive care units. The study evaluated the effectiveness of preventive multilayered soft silicone foam dressing when applied with standard prevention approaches. The objective was to determine whether it could lower deep tissue injury (DTI) and cumulative PU incidence for categories II, III, and IV. Eligible patients were aged at least 18 years who were expected to remain in the ICU for more than 3 days. The risk assessment was based on the care dependency and mobility of patients. The study concluded that the use of preventive dressing and standard care could help prevent PUs among high-risk patients in the ICU. Unlike other interventions such as repositioning, special support surfaces, mobilization, and floating heels, the application of preventive dressing presents an easy-to-apply approach.

The use of prophylactic dressings can offer an effective strategy to support the prevention of pressure ulcers by enhancing the distribution of external pressure. They prevent friction and shear damage by hindering pressure in high-risk patients. Cornish (2017) confirmed that the application of a prophylactic dressing presents many benefits when considered in the holistic pressure ulcer prevention strategy. The dressing is examined from time to time without causing trauma or pain to patients making it an effective option. However, the article recommends nurses consider promoting hygiene and good nursing care to achieve the best outcome. The additional components of temperature, humidity, friction, and shear should motivate clinicians to establish a holistic approach to support high-risk patients. Prophylactic dressings can retain sufficient moisture to promote elasticity in the skin while reducing skin stripping, excoriation, and maceration. It also can retain the heat necessary for the healing process.

• Rivera Pressure Injury Prevention Bundle. Pressure ulcer prevention is a significantly compounded process. There are various items that ought to be deliberated and accomplished in the approach. Inaugurating superlative practices is also a perplexing task that necessitate the implementation of a ‘care bundle’ to aid the integration of such best observations. The bundle approach involves the advancement of the best practices and systematic application of the same. Definite care practices are valuable in assisting the achievement of the anticipated results (Rivera et al., 2020). The bundle needs to include numerous critical mechanisms, including all-inclusive skin assessment, identical risk assessment, care planning, wound care nurse consultation, as well as medical device-related mediations.

Bundle’s evidence-based approach demonstrated its effectiveness in various quality-improvement clinical trials. Standardized intervention methods are essential assets in preventing pressure injuries. For example, several evidence-based interventions, known as a bundle, are more efficient when introduced in combination (Frank et al., 2017). The classical prevention bundle consists of five items: skin assessment, surface support, mobility and repositioning, incontinence, and nutrition (Romanelli et al., 2018). Frank et al. (2017) presented the results from 33 pediatric hospitals that implemented the prevention bundle and found a twofold decrease in the incidence of stage 3 and 4 pressure injuries (Frank et al., 2017). The authors concluded that introducing the bundle approach can ensure the early detection of pressure injuries and reduce the prevalence of late-stage ulcers.

Critical components of the Rivera PIP bundle include comprehensive skin assessment, care planning, standardized risk assessment, wound care nurse consultation, and medical device-related interventions (Rivera et al., 2020). Standard risk interventions should consider different aspects of care and improve the existing practices. It can be tailored to a specific setting and supported with additional steps to ensure successful implementation. Key practices need to be achieved regularly to overcome the challenge of improving care.Rivera’s PIP bundle is described in two major categories: Standard and high risk interventions. Patietns with Braden score of 19 or more receive standartd interventions, which includes: skin assessment by two nurses upon admission and transfer, preventive dressings, early mobility and wound care nurse consult. Patients with Braden score of 18 or less receive all standard as well as high risk interventions, which include: turning and repositioning every two hours, preventive dressing on sacrum, offloading and nutritional consult. It ensures that every component of the bundle is performed consistently through the creation of a clinical pathway.

Similar to the Rivera PIP bundle, Gupta et al., (2020) used multidisciplinary clinical and risk assessment teams to test various changes as well as implementing an effective program including skin inspection, the surface, nutrition, incontinence, and keep moving bundle. Strategies to engage staff included PI incidence calendars, turning clocks, and signs as reminders in the unit. The IHI collaborative model was utilized in this stud. A multidicippilanary team performaed a pareto analysis and identified gaps related to skin assessment and other preventive measures. The study revealed an 83.5% reduction in HAPI incidences and a 9.7% drop in prevalence. It was concluded that the PIP bundle is an effective tool for the reduction of pressure injuries.

Other quality-improvement clinical studies also evaluated the effectiveness of the bundle approach. A systematic review by Lin et al. (2020) demonstrated a significant reduction in the prevalence of pressure ulcers in US hospitals after introducing the bundle approach of various components. The components of Rivera bundle include: comprehensive skin assessment, care planning, standardized risk assessment, wound care nurse consultation, and medical device-related interventions. However, most of the evaluated trials did not report the significance of their studies (Lin et al., 2020); further, the authors admit that there was no link between the number of components in bundles and the outcome. The retrospective study by Singh et al. (2018) examined data from 99 pediatric hospitals that implemented prevention bundle methods. The authors showed a mean drop of pressure injury incidence by 57% across hospitals (Singh et al., 2018). Still, the scholars are not sure about the reliability of the information because they could not control the data collection process.

Summary

In summary, hospital-acquired pressure injuries are an ongoing problem across the world (WHO, 2008), the nation, and in local healthcare facilities. Although there is growing evidence supporting the prevention of pressure injury, there exists a gap in the implementation of effective preventative strategies. Thus, HAPI continue to occur, causing detrimental impacts on hospitals and long-term care facilities, and on the lives of patients and their loved ones.

The use of the PIP bundle can support the standardization of PIP strategies, protect at-risk patients, and influence a reduction in pressure ulcers (Rivera et al., 2020). An evidence-based PIP bundle initiative needs support from the leadership and involved staff. The impact on the patient outcome negatively hinders nurse satisfaction. They are associated with the increased cost of medication, prolonged hospital stays, poor patient experience, and a high rate of mortality. Risk factors for HAPIs development include sedation, immobility, hemodynamic instability, and vasopressors.

The reduction of HAPIs and the implementation of PIP bundle necessitates a comprehensive approach while establishing a sense of ownership among nurses, involvement, engagement, and support of every stakeholder. The PIP bundle initiative is enhanced when health care workers show commitment to the provision of quality care to patients (Wei & Watson, 2019). Reducing HAPIs as well as maintaining the momentum is a major challenge affecting many critical care units. Implementing the integrated approach is an expensive process making it difficult for many hospitals to adopt despite its benefits. Moreover, there exists a gap in the literature, and further research is needed to improve the level of bundle evidence for the PIP implementation.

Chapter 3 presents the project methodology, beginning with the problem, purpose and clinical question. The selected methodology and design include the population and sample for the project, sources of data and the process to collect it, as well as aspects of data anlysis including statistical testing. Chapter 3 also present factors involved in the integrity of the project: validity, reliability, potential bias, ethical considerations, and limitations.

Methodology

The purpose of this quantitative quasi-experimental project is to determine the impact of Rivera’s PIP Bundle on the HAPI incidence when compared to current practice among critical care patients in a 13-bed unit in urban New York. The focus of this quality improvement project is to determine how implementing evidence-based practices, specifically Rivera’s pressure injury prevention (PIP) bundle, can reduce the HAPI incidence in the 13-bed MICU. HAPI has become a major global health issue with a prevalence rate of almost 13%, while the incidence rate is above 5 per 10,000 patient days (Li et al., 2020). However, HAPI is preventable if effective measures are implemented.

Hospital-acquired Pressure Injuries (HAPIs) present a significant issue for critical care units in hospitals. They increase the healthcare costs and decrease quality of care by instigating longer hospital stays for patients. The DPI project seeks to ameliorate the issue by introducing Rivera’s PIP bundle into a New York 13-bed critical care facility.

The present chapter considers the problem, clinical question, appropriate methodology, design, population, and sample to present the details of how the project was conducted. It comments on the instruments and sources used to obtain the data for the project and their validity and reliability. It also describes the data collection and analysis procedures and the project’s potential bias and mitigation efforts.

Statement of the Problem

It was not known if or to what degree the implementation of Rivera’s PIP bundle would impact the HAPI incidence when compared to current practice among the critical care patient population among a critical care unit in urban New York. HAPIs present a significant problem to health care as they affect more than 2.5 million individuals in the United States and cause up to 60,000 deaths (Padula et al., 2019). Moreover, there is insufficient literature addressing the problem concerning its prevention and treatment. Therefore, the present DPI project aims to address its prevention and treatment through Rivera’s PIP bundle in a critical care unit that reports HAPI incidence rate of 14%, which is higher than the national average.This unit had 250 HAPIs in 2020. There were 132 HAPIs identified in this year till July. The four weeks prior to implementation, this unit had 21 HAPIs.

Clinical Question

The following clinical question guides this quantitative project:

Q1: To what degree does the implementation of Rivera’s PIP bundle impact the HAPI incidence compared to current practice among critical care patients in a 13-bed unit in urban New York over four weeks? The question sought to identify whether using Rivera’s PIP bundle (independent variable) is sufficient to reduce the HAPIs’ incidence (dependent variable).

In an attempt to answer the clinical question, a between-groups approach to collecting data was utilized. The participants in the intervention and comparison groups were different. The intervention (after) group only includes individuals who received the proposed intervention. Thus, wound care nurses and head nurses of the unit collect aggregate data on the sample size to identify how many pressure injuries occur, and this process involves working with the patients’ EHRs.

Project Methodology

The project utilized a quantitative methodology, which is appropriate as it relies on numerical data and is necessary for identifying the incidence of the pressure injuries. Creswell and Creswell (2018) state that the main benefit of the quantitative approach is that it provides statistical means for collecting and analyzing data. Bell et al. (2018) also admit that it applies different statistical tests, including t-test, which increase the reliability of the obtained results. Rutberg and Bouikidis (2018) stipulate that a quantitative method is appropriate for answering a clinical question that aims to achieve quality improvement. Since the project’s clinical question focuses on HAPI incidence, which represents a quality improvement project with numerical significance, the quantitative methodology is the most optimal option.

While a quantitative method focuses on identifying numerical representations of an issue, a qualitative approach is typically used for exploring and establishing new knowledge regarding a phenomenon (Creswell & Creswell, 2018). As a result, the qualitative approach is unsuitable for the project, which has already determined HAPIs to be a significant health care problem and seeks to measure whether Rivera’s PIP bundle will decrease its incidence rates. Furthermore, qualitative methodologies are typically more resource and time consuming. The quantitative methodology is the best approach since it focuses on the credible measurement of numerical data and manages to answer the clinical question.

The present project focuses on reducing incidence rates of HAPIs in a critical care facility. As a result, a quantitative methodology is most appropriate for the study as incidence rates are numerical data. Therefore, the quantitative methodology best aligns with the numerical data collection and analysis techniques utilized when comparing incidence rates before and after implementation of the project’s intervention. Additionally, a quantitative methodology increases the simplicity of the project’s implementation, which then does not focus on complicated textual data analysis. Simple statistical analysis techniques, such as t-test, provide sufficient means for evaluating the project’s outcomes.

Project Design

This quality improvement project utilizes the quasi-experimental design is it carries the advantages of an experimental design, involving measurement of causality between an intervention and an outcome without applying randomization that is time- and resource-intensive. Thus, the quasi-experimental approach is time- and resource-efficient for identifying correlation between the project’s dependent and independent variables (Rutberg&Bouikidis, 2018). Rutberg and Bouikidis (2018) state that the design allows assessment of an intervention’s effectiveness for experimental and control groups. Siedlecki (2020) also admits that case studies, descriptive, and correlational designs are not appropriate for causality measurement since they are less practical and involve less measurements. Thus, the quasi-experimental design is ideally aligned with the quantitative methodology.

The present project focuses on applying Rivera’s PIP bundle intervention and identifying whether it leads to improved outcomes (reduced HAPI incidence). The independent variable that is the intervention is the use of PIP bundle. HAPI incidences are measured before the intervention’s implementation for the comparison chart review group and after its implementation for the intervention group. The PIP bundle components used in this project are based on standard- and high-risk interventions. According to the bundle designed by Rivera et al. (2020), patients with a Braden score above 19 should receive the standard intervention. In contrast, patients with points equal to or below 18 will get high-risk intervention (Rivera et al., 2020). These interventions include skin assessment, medical device-related interventions, wound care nurse consult, application of preventive dressings, turning, offloading and nutrition consult. Head nurse and wound care nurses were responsible for ensuring that the nurses followed the intervention. The dependent variable was the HAPI incidence rate that was measured by focusing on the number of patients who developed pressure injuries during their hospital stay. The data for the dependent variable was collected by analyzing electronic health records after the end of the intervention process. Wound care nurses accessed the records to stipulate how many pressure ulcers developed.

First step of the project was to collect the comparative data. The nursing staff was provided with education on the PIP bundle. Staff education of all elements of PIP bundle was very critical to preventing HAPIs. The education was continuous to provide necessary support to the staff. Head Nurse and Wound Care Nurses provided the necessary training in all shifts. Nurses then implemented the PIP interventions for patients according to their assessed risk: standard-risk versus high-risk. The following data were collected for the intervention population four weeks after the education had been completed and the PIP bundle interventions had begun: age, gender, and number of new HAPIs.

Population and Sample Selection

This project targeted a New York based hospital that has recorded a high incidence rate if HAPI. In this community, the risk of HAPI is high; hence this project targets establishing the effectiveness of the PIP bundle in addressing the issue. Despite their differences in age, gender, socioeconomic status, education, religion, or political affiliation, all community members have a right to access quality care in any hospital they choose to attend. The whole population targeted is a 13-bed unit in urban New York. This hospital received many patients each day for different treatments. Some of those hospitalized develop pressure ulcers and HAPIs. The project targets this specific hospital to help address the challenges of HAPIs and ensure the quality of care offered satisfies all patients.

The project sample consists of patients admitted to the Intensive Care Unit (ICU). Most patients in ICU have a high risk of developing HAPI, especially if they have a prolonged stay. HAPI reduces the quality of life and could lead to an extended stay in the ICU, increasing healthcare costs. This project aims to establish if PIP bundles can prevent HAPI incidents among ICU patients in this hospital. The population selected from this hospital consisted of adult patients admitted to critical care for various ailments and medical conditions. Patients admitted to critical care formed the subset of the population that comprised the project sample as they were at increased risk for developing HAPIs. The project focused on HAPIs incidence whose risk factors included older age, reduced mobility, poor nutrition, dehydration, reduced tissue perfusion, oxygenation, and medical devices placement (Romanelli et al., 2018). The sample population was at higher risk for contracting HAPIs. This sample was identified as the best for collecting the evidence required based on the research information.

Instrumentation or Sources of Data

This project will involve the implementation of the Pressure Injury Prevention (PIP) Bundle developed by Rivera. The bundle has eight elements that should be implemented to achieve the required reduction in hospital-acquired pressure injuries (HAPI). The first item is skin assessment. Rivera recommends that two registered nurses should assess the skin and pressure injury during admission and transfer. This information on skin integrity and skin assessment is then documented in a flow sheet.

The second intervention or component of the assessment bundle is prevention. Nurses have to prevent HAPIs using face masks, tracheostomy, proper positioning of the endotracheal tube and tube holders. Other interventions include using the recommended guidelines to facilitate early mobility, placing the head of bed at 30 degrees or less, and continence, wound, or ostomy nurses should consult for HAPIs.

The next interventions or components of the bundle are classified as high-risk interventions. They include prevention dressing, turn and position, and position system/offloading. Nurses are required to use Scrum by writing letter P for prevention on the dressing. They should also turn and position patients after every 2 hours. They should also use a turn and position system, seat cushion, positioning pillow, and heel protectors.

The HAPI incidence data is collected daily using the EMR by the bedside nurses. The HAPI incidence data was collected by the wound care nurses at the NYC critical care unit. For each patient in the project, the nurses assessed skin condition and attached medical devices to check for pressure injuries caused by the devices and record them as HAPI incidence. The HAPI incidents and risk factors were documented in the EMR. Wound care nurses can identify HAPI incidents when conducting skin care rounds or during their quarterly prevalence surveys. The PIP interventions and HAPI incidents are documented in different parts of the EMR. Wound care nurses collect HAPI data daily from the EMR. The information documented also included staff feedback and gaps in knowledge. The project’s dependent variable is HAPI incidence rate. It represents the main data collected before and after the implementation of Rivera’s PIP bundle.

Validity

Validity is a scientific studies’ aspect that tests the accuracy of a method in measuring the specific character that it is intended to measure. High validity studies produce outcomes that match real characteristics, properties, as well as variations in the physical world. Consequently, validity provides information about how accurately a method measures something. As such, if a scientific technique measures what it purports to measure, and provides results that closely correspond to the real-world values, then it is considered valid. There are four main types of validity, including face, content, criterion, and discriminant validities. The present study’s purpose is to investigate HAPIs incidence in critical care units and how they are affected by the implementation of Rivera’s PIP bundle intervention.

HAPIs constitute the facet under investigation; thus, the study purposes to identify this statistical measure by finding the number of pressure injury occurrences among the identified sample size. The site’s HAPI data is further stored in the identified hospital’s EHR system and constitutes the main source for data collection during the study. The point that the study measures the intended aspect thus makes the method and the research valid. Better still, relying on EHR for research data also makes the method valid. Hernandez-Boussard et al. (2019) provide EHR’s data validity to be above ninety-five percent, thus giving the project noteworthy criterion validity. Moreover, the aspect implies that the project deals with decent external validity since it ensures that the instrument focuses on the issue. Similarly, Rivera et al. (2020) maintain that the application of the PIP bundle intervention in hospitals reduces HAPIs’ incidence by over ten percent. The availability of parallel studies agreeing with the findings of the present study also makes the method highly valid. Additionally, the fact that the study measures the number of pressure injury occurrences among the study population, which is more stable relative to the general body aches, provides substantial discriminant validity to the research work.

Reliability

Reliability refers to how consistently a method can measure something. A method is considered reliable if the same result can be consistently realized by using the same methods under the same circumstances. Reliability shows a project’s replication capacity for the production of analogous results. There are at least three kinds of reliability; such include the test-retest, interrater, and internal consistency reliabilities. The test-retest reliability exists if repeating the same tests over time provides similar results. Similarly, interrater reliability refers to the consistency of a measure across observers or rater, while internal consistency reliability seeks regularity from the measurement of distinct parts of the whole. As for the present research work, the capacity to realize similar conclusions is limited because the utilized facility deals with a constantly changing population, thus affecting the test-retest reliability substantially.

The utilization of wound care nurses with standard certification and data management skills gives the present study noteworthy interrater reliability. Moreover, Hyun et al. (2019) identify the HAPI incidence of 5.81% in an academic medical center, which differs significantly from the 14% incidence at the utilized facility. Such a statistical measure can be used to assess the project’s findings reliability. As such, Barakat-Johnson et al. (2018) report that a Cohen’s Kappa of.88 is present when wound nurse consultants assess the presence of HAPIs using an electronic database, an aspect that also promotes the interrater reliability of the present project. The nurses handling HAPIs’ data at the project facility have the national certification of Wound Ostomy Continence Nurse, a certification that requires experience, training, and successful completion of a test, thus their expertise is reliable.

Data Collection Procedures

The permission was obtained from the project site in urban New York for conducting the project within its setting and to receive the data from wound care nurses. The project also required approval from the Institutional review board at the facility and Grand Canyon University for permission for this project. Data collection did not begin until the investigator received all required approvals. Pre-intervention data for the project consisted of HAPIs incidence rates within the selected critical care unit during the four weeks immediately prior to the implementation of Rivera’s PIP bundle. The data was available in the hospital’s EHR and the hospital’s wound care nurse provided the investigator deidentified data on the patients who developed HAPIs in that designated timeframe.

Before the intervention’s implementation, the nurses were educated on how to use Rivera’s PIP bundle to assess pressure injuries among critical care patients in their unit and to implement necessary prevention and treatment strategies. Their education included elements of PIP bundle and proper EHR documentation. The data included the patients’ demographic data and whether they contracted HAPIs during their stays. The nurses also received education on appropriate privacy and security measures because they were in contact with the patient data. Numbers were assigned to the participants as the coding system to ensure confidentiality. If a participant had experienced a pressure ulcer, 1 was placed while 0 denoted that no HAPI had occurred. As part of the security measures, the notes were not made available as automated reports and were not uploaded to web clouds to avoid a digital information leak. Instead, they were stored in a locked cabinet within the critical care unit that was only accessible by the chief investigator. The data files are kept for three months after intervention as reference points after which they are to be physically destroyed to prevent any misuse of this information.

The project’s focus was the intervention data that was useful for measuring the intervention’s effectiveness in reducing HAPI incidence (the project’s dependent variable). It was the HAPI surveillance details that the wound care nurses and head nurses gathered after the intervention was implemented. They included the number of patients who contracted HAPIs during their hospital stay after the attending nurses had implemented Rivera’s PIP bundle for HAPI prevention and treatment. The data also included the patients’ demographic information and their medical status information. The nurses recorded the data during the four weeks after the start of the PIP bundle implementation in paper charts which they stored in a locked cabinet within the critical care unit. After the four weeks elapsed, they provided the deidentified data to the EHR team for digital storage and analysis. The project’s focus was the aggregate and not the individual patients’ data. The following section comments on how the obtained results can be analyzed to arrive at appropriate conclusions.

Data Analysis Procedures

Upon completion of the project, deidentified data from the IT team and loaded the coded data into excel to prepare the data for analysis using “Statistical Package for the Social Science (SPSS). The latest version of SPSS software (1.0.0.1406) was used to perform various statistical tests, including t-tests, that compared the intervention data to the comparative data to measure the intervention’s effectiveness. Finally, the materials were stored for three ; when the period was over, their hard copies were physically destroyed using a paper shredding machine. Unauthorized people were not allowed to access the room containing hardcopies before they were destroyed. All computers were password enabled to allow only one individual to access the data.

Potential Bias and Mitigation

Scientific studies are subject to numerous biases that adversely affect the quality of work, and quantitative articles often face threats that undermine their internal validity. Internal validity refers to the degree to which the results are accurate and that permits causal inferences to be made regarding the association between the independent and dependent variable (Flannelly et al., 2018). There can be intentional and unintentional bias, and it is the investigator’s moral responsibility to address all the possible issues that can invalidate the project’s results. Consequently, the given section comments on what biases may be in the project and how they can be mitigated.

Sampling bias can occur because the project deals with non-probability convenience sampling, especially when some outcomes are favored over others (Fowler & Lapp, 2019). Convenience sampling can produce inferences that are not as trustworthy as if a random sampling technique is used. However, this bias is mitigated because the sample selection procedure did not have many inclusion and exclusion criteria. Patients are included in the project because they are currently available to the investigator. Consequently, this approach is also advantageous because it ensures that samples are sufficiently diverse (Jager et al., 2017). Therefore, potential bias from convenience sampling was mitigated.

Bias may adversely affect the data collection process (Fowler & Lapp, 2019). The selection bias implies that the project’s results can be impacted because some patient groups are underrepresented while others are over-represented. It can occur because people can be more or less likely to participate in the project. The project utilizes a convenience sampling technique that focuses on a single criterion to overcome this potential issue. If patients are available to the investigator, they are offered to participate in the project.

Manipulation or misinterpretation of the data may cause or contribute to data analysis bias (Fowler & Lapp, 2019). The investigator ensured that the data analysis procedure was transparent, described in detail, and strictly followed. The project collected, analyzed, and reported aggregate data, and appropriate statistical test was used to determine statistical significance of the intervention in relation to the project’s dependent variable.

The project focuses on ensuring that no bias affects the data interpretation step. Since a between-group design is employed, the t-test for independent groups is used because this parametric statistical test measures the difference between two independent groups (Creswell & Creswell, 2018). Furthermore, the project is not only focused on a single side of the problem. For example, even if the proposed intervention does not show statistically significant improvement in reducing the HAPI’s incidence, the project demonstrates whether the process results in other clinically significant improvements.

Ethical Considerations

The project adheres to the principles of the Belmont Report, as stipulated by the US Department of Health and Human Services (1979): respect, justice, and beneficence (Adashi et al., 2018). The principle of justice is present in the sample recruiting process since no bias is applied to representatives of a certain age, gender, or ethnic group. All participants were given an equal opportunity to participate. The research also ensured that the participant and investigator benefited equally from the research findings.

Also, the principle of beneficence is found in the project design and the theoretical framework. It refers to the fact that human subjects’ well-being is addressed because members of the two groups receive adequate care. The rules used to achieve the principle of beneficence were reduce possible harms, do not harm and increase possible benefits. The research therefore ensured each subject benefitted more at zero chances of becoming harmed.

In addition to that, the principle of beneficence is present in the project because no individuals involved in the scientific process are subjected to harm. The project respects its participants and beneficiaries by considering their inputs. The participants are only allowed to be the project’s sample population after signing the informed consent. The project also focuses on submitting valid and reliable results that are useful for nursing practice improvement to address the beneficiaries. Thus, the project wholly addresses components of the Belmont Report to adhere to appropriate ethical considerations.

Limitations

The project is subject to a few limitations; for instance, the sample size is small since only a few individuals from a single 13-bed critical care unit were included. Even though such a sample size is unavoidable when dealing with the narrow critical care setting, it is difficult to generalize the obtained results. Thus, the findings cannot be applied to representatives of other population groups. However, this limitation should not affect the findings negatively because the power analysis revealed that the sample size was sufficient. Furthermore, the focus on patients of a single facility allows for assessing the intervention’s effectiveness in the given context. This information can help identify an efficient way to prevent pressure ulcers among critical care patients.

The project’s results are also limited by its design and short timeframe. The quasi-experimental project lacks randomization and does not focus on long-term effects. This QI project uses convenience sampling, not random sampling, so concessions are implied and accepted with this type of sampling. This fact also demonstrates that it is impossible to generalize the findings. However, this weakness is delimited because the statistical test is used to assess specific outcomes in the short run. Additionally, this limitation is not negative since it brings some advantages. For example, the absence of randomization denotes that the project does not require many financial resources and much time. Focusing on a limited time frame can also be advantageous since it assesses the short-term effectiveness of the chosen intervention to reduce the incidence of pressure injuries.

A significant limitation exists because the project’s results depend on how accurately the EHRs are created. This weakness is unavoidable in the given design because healthcare professionals are responsible for making these records. In particular, nationally certified wound care nurses and head nurses of the unit will collect the aggregate data on HAPI incidence and insert it in the EHRs. However, this limitation should not generate many negative results because the project assumes that the healthcare professionals will perform these functions diligently and attentively.

The project has delimitations set out by the investigator. The project facility is chosen explicitly because its nursing staff welcomes the use of evidence-based practice. The facility has an existing culture that promotes the implementation of quality improvement initiatives; the selected site has a rich history of dealing with multiple health issues. Thus, the decision to focus on the 13-bed unit is a significant delimitation of the given project. This information justifies the assumption that the facility staff will actively and diligently participate in the project.

The focus on the specific population is also a delimitation because it ensures that the project will produce specialized findings. Luo, et al., (2019) explain that people of 60 years old and higher are more subjected to pressure ulcers. This information denotes that it will be possible to use the project findings as a guide to prevent HAPIs among hospitalized patients and improve the population’s health. Third, the use of a nursing theory by Jean Watson (2018) is another delimitation. This step ensures that the project has solid theoretical support as well as a caring perspective of patients.

Summary

HAPIs present a significant problem to health care as they affect more than 2.5 million individuals in the United States and cause up to 60,000 deaths (Padula et al., 2019). Therefore, the present DPI project aims to address its prevention and treatment. The project’s clinical question was: To what degree does the implementation of Rivera’s PIP bundle impact the HAPI incidence when compared to current practice among hospitalized critical care patients in a 13-bed unit in urban New York over four weeks?

The project utilizes a quantitative methodology, which is appropriate as it relies on numerical data and is necessary for identifying the incidence of the pressure injuries. It utilizes the quasi-experimental design is it carries the advantages of an experimental design, involving measurement of causality between an intervention and an outcome without applying randomization that is time- and resource-intensive. The project focuses on applying Rivera’s PIP bundle intervention and identifying whether it leads to improved outcomes (reduced HAPI incidence). The independent variable that is the intervention is the use of PIP bundle. HAPI incidences are measured before the intervention’s implementation for the comparison chart review group and after its implementation for the intervention group. The population consisted of adult patients who presented to the selected urban New York hospital and were admitted to critical care for various ailments and medical conditions. Patients admitted to critical care formed the subset of the population that comprised the project sample as they were at increased risk for developing HAPIs.

The project’s dependent variable is HAPI incidence rate. It represents the main data collected before and after the implementation of Rivera’s PIP bundle by the wound care nurses at the NYC critical care unit. The investigator collected the project’s deidentified data from the wound care nurse. This data was retrieved from EHR by the wound care nurse, which represents the project’s primary source of data. Rivera’s PIP bundle’s validity is evident in its ability to reduce incidence rates of HAPIs when implemented among adults in a critical care facility. Rivera et al. (2020) tested the bundle’s effectiveness in an 11-bed critical care unit in one of the hospitals in New York City and demonstrated a seven-fold decrease in HAPI incidence. They also demonstrated their PIP bundle’s reliability by testing its results for the same sample population over time. Implementation of the bundle resulted in a drop of the index of HAPIs, which is the proportion of patients with pressure ulcers to the days spent in the hospital, from 3.4 to 0.48 over ten months.

Data collection did not begin until the investigator received all required approvals from the selected critical care facility in urban New York and the Institutional review board at Grand Canyon University. Comparative data for the project consisted of HAPIs incidence rates within the selected critical care unit during the four weeks immediately prior to the implementation of Rivera’s PIP bundle. Before the intervention’s implementation, the investigator educated the nurses on how to use Rivera’s PIP bundle to assess pressure injuries among critical care patients in their unit and to implement necessary prevention and treatment strategies. As part of the security measures, the notes were stored in a locked cabinet within the critical care unit that was only accessible by the chief investigator. The project’s main focus was the post-intervention data that was useful for measuring the intervention’s effectiveness in reducing HAPI incidence (the project’s dependent variable). The primary investigator collected the deidentified data from the wound care nurse and loaded the coded data into excel sheets for analysis. The primary investigator utilized the Excel software and SPSS software to perform various statistical tests, including t-tests, which compared the post-intervention data to the comparative data to measure the intervention’s effectiveness.

The project is subject to numerous biases that adversely affect the quality of work and undermine its internal validity.Sampling bias could have occurred because the project dealt with non-probability convenience sampling where some outcomes could have been favored over others. However, the bias was mitigated because the sample selection procedure did not have many inclusion and exclusion criteria. The project was also liable to selection bias due to some patient groups being underrepresented while others are over-represented. It utilized a convenience sampling technique that focused on a single criterion to overcome this potential issue. Finally, manipulation or misinterpretation of the data may have contributed to data analysis bias but the investigator ensured that the data analysis procedure was transparent, described in detail, and strictly followed.The project adhered to the principles of the Belmont Report: respect, justice, and beneficence. It adhered to the principle of justice by mitigating bias in the participant selection phase, the principle of beneficence by not subjecting the participants to harm, and respect by considering the inputs of participants and beneficiaries. However, it was limited by a small sample size, short timeframe and accuracy during EHR creation.

The analysis and results of the project comprise the remainder of the project report. Chapters 4 and 5 follow the implementation of the PIP bundle intervention. Data description, variable data analysis procedures and results appear in Chapter 4. The project summary, findings, and conclusions, as well as theoretical, practical, and future implications and recommendations for future progress and practice are in Chapter 5.

Data Analysis and Results

The project considers the development of pressure ulcers among patients in the critical care units. It explains how the problem affects the quality of health care among hospitalized patients. The problem statement attempts to evaluate the impact of HAPI incidences upon the implementation of the PIP bundle when compared to current practice among the critical care patient population in a 13-bed unit in urban New York. Specifically, with an average age of 64, this unit reports the prevalence of pressure ulcers of 14%. Furthermore, 55% of all pressure injuries in the hospital are found in this unit. Older patients often experience mobility problems, and their skins are damaged through dehydration. Certain medical conditions can hinder the effective flow of blood, influence movement problems, and make skin more fragile.

The project utilized numerical data to determine the prevalence of pressure ulcers and enhance collection and analyzes of data. The reliability of the results will be improved by the use of statistical test. A quantitative approach was adopted because it is marked with increased clinical relevance and facilitates answering of the clinical question. The study involves a quantitative and quasi-experimental design to determine whether the implementation of a PIP bundle can reduce the prevalence of HAPIs among patients in critical care units.

Jean Watson’s human caring nursing theory is effective in examining the effectiveness of the bundle. The theoretical framework of Kurt Lewin’s (1951) change management theory supported the analysis of forces and subsequent balancing of the change plan. The theory offered an effective framework for the preventive bundle. Lewin’s Change Theory entailed a three-step change model, and it is effective in supporting the implementation of interventions to enhance the achievement of desirable changes in nursing. The purpose of the project is to measure the HAPI incidence rate during the patients’ hospital stay upon the implementation of the PIP bundle. For this purpose, the wound care team accessed EHR to identify whether a patient experiences a pressure ulcer.

Clinical question attempts to evaluate the degree of the PIP bundle implementations impacting the HAPI incidences among patients in critical care units within four weeks. This compares the effectiveness of the PIP bundle with that of the current practice. The clinical question determined whether implementation of PIP bundle has a greater impact of reducing HAPI incidences than current practice in a 13-bed unit in urban New York over four weeks. The clinical question helps suggests the intervention approach as well as the study settings.

The PIP bundle offered a beneficial audit tool to support the provision of valuable information concerning adherence and knowledge gaps. It focused on improving documentation in the EHR and reduction of pressure injuries among patients in the critical care units (Hahnel et al., 2020). The WOC nurses were encouraged to influence and reinforce the use of the PIP bundle during wound consults and rounds since it was not part of the EMR. The training was provided on specific areas to improve their ability to treat patients and implement the bundle effectively. WOC nurses also reviewed and instructed documentation during consultations and daily briefs. Reinforcement was ensured by every health provider during PIP rounds and daily briefs.

Audit results offered beneficial information concerning adherence to the bundle and existing gaps in documentation. The litigious environment linked to pressure ulcers shows that gaps in knowledge are of critical importance. The project team had to ensure that nurses are well educated on key issues such as documentation and the treatment process. All professionals, including the nurse manager, resource nurses, and physicians, encouraged the staff to ensure adherence (Hahnel et al., 2020). The bundle was implemented in the critical care unit, and measures were established to ensure its sustainability. Stakeholders were encouraged to remain vigilant and determined in the prevention of HAPI.

Descriptive Data

Table 1present the demographic data of the patients included in the analysis of this project. The sample population (N=128) for both the, comparative group (n=64) and post-implementation group (n=64) included males, (n=40, 62.5%) and females (n=24, 37.5) females. Their ages ranged from 28 to 86 and the median age was 66.

Table 1. Results For Comparative group and Intervention group Data

Table 2 presents the description of primary diagnoses recorded for both the comparartive group and intervention groups included medical cardiac problems such as congestive failure or myocardial infarction (n=20), endocrine (n=6) and renal problems(n=10), gastrointestinal (n=16) and pulmonary ailments (n=12). Data on HAPI incidence among the sample population was collected before and after receiving Rivera’s PIP bundle treatment to hinder the development of pressure ulcers.

Table 2. Primary Diagnoses Among Sample Population

Data Analysis Procedures

Data was extracted from the unit’s electronic record by the wound care nurses and later was analyzed using t-test statistical methods. Wound care nurses provided de-identified data to the primary investigator. The investigator obtained the required data before and after the implementation of the PIP bundle.

The comparative data collection engaged nurses with the standard practices for pressure injury prevention. Education and training were done before the bundle implementation. The appropriate nurse-to-patient ratio was maintained to ensure the satisfaction of all bundle requirements. The unit nurses were held responsible for implementing all interventions based upon the PIP bundle. Data collection was done by analyzing the implementation compliance differences before and after the PIP bundle intervention. The prevalence of pressure ulcers was measured before and after the bundle intervention.

The raw data consisted of demographic information and HAPI incidence among the sample population. The investigator collected the identified data from the wound care nurse and loaded the coded data into excel sheets for analysis. The team utilized the Excel software and SPSS software to perform various statistical tests, including t-tests, that compared the intervention group data to the comparative data to measure the intervention’s effectiveness. The clinical questions sought to identify to what degree does the implementation of Rivera’s PIP bundle impact the HAPI incidence compared to current practice among critical care patients in a 13-bed unit in urban New York over four weeks?. The data collected was for patients in critical care suffering from myocardial infarction, endocrine problems, renal problemss, gastrintestinal ailments and pulmonary ailments. The data was organizaed stating the existing ailment and how they responded to the intervention. Data was organizaed such that there statistics for presence of HAPIs without intervnetion using PIP Riveras bundle treatment and the presence of HAPIs after the use of the Riveras PIP bundle

Results

Results of the study answered the clinical question by confirming that the implementation of the PIP bundle reduced the incidences of pressure ulcers. The comparative group data collection engaged nurses with the standard practices for pressure injury prevention. Education and training were done before the bundle implementation. The appropriate nurse-to-patient ratio was maintained to ensure the satisfaction of all bundle requirements. The unit nurses were held responsible for implementing all interventions based upon the PIP bundle. Data collection was done by analyzing the implementation compliance differences before and after the PIP bundle intervention. The prevalence of pressure ulcers was measured before and after the bundle intervention.

Table 3.Reduced Incidences of Pressure Ulcers

The project also revealed that training of comparative group improved nurse’s confidence and familiarity, and subsequent compliance. Feedback and review of clinical manifestations facilitated the successful implementation of the PIP bundle and supported the development of professional behavior (Gaspar et al., 2019). High compliance was ensured by the development of an audit behavior checklist. The approach is an effective strategy to satisfy the individual needs of patients.

An audit tool was utilized to facilitate compliance, and it contained a series of yes or no questions. Table 3 below illustrates the checklist to analyze the achieved level of adherence. Table 3 answers whether the patient had this assignment or not. The PIP bundle was recorded upon satisfaction of the audit tool contents. In case a single requirement was not meet, results were recorded as unimplemented. The creation of awareness and training of nurses influenced a high level of adherence to the bundle implementation resulting in the achievement of a desirable outcome.

Summary

The PIP bundle has proven effective in the reduction of PIs among adult patients in critical care settings. Implementation of the bundle significantly reduced incidences and promoted patients safety (Rivera et al., 2020). The project used an intervention group who received care with the PIP bundle. The comparative group did not receive the PIP bundle and their retrospective data was collected prior to the implementation of the intervention with the intervention group. The provided data and subsequent analysis were relevant to the clinical question since they explained the process and impact of the PIP bundle implementation.

The data also helped determine beneficial preliminary measures that need to be considered to influence the success of the integrated approach. These include training and educating nurses to build their confidence and familiarity. Another important factor is the engagement of all stakeholders and encouraging everyone to play a role in ensuring that success is realized (Rivera et al., 2020). The development of an effective culture can support the implementation of the bundle because since it can support coordination, hard work, and desire to achieve the best outcome. The outcome of the study encouraged the implementation of the PIP bundle in a diverse setting to lower the chances of developing PIPs among patients with an extended hospital stay.

Chapter five will summarize the project and explain the importance of the topic, its contribution to the body of knowledge while providing recommendations. It will highlight important points in the study to help the audience attain a brief understanding of the entire project. It will offer a comprehensive recap of the applied procedures, obtained results while explaining its importance in the nursing field. By offering a summary of the results, it will provide details of the achieved outcome.

Summary, Conclusions, and Recommendations

The clinical question guiding the project was: To what degree does the implementation of Rivera’s PIP bundle impact the HAPI incidence compared to current practice among critical care patients in a 13-bed unit in urban New York over four weeks? The question sought to identify whether using Rivera’s PIP bundle would be sufficient to reduce the HAPI incidence within the critical care unit. The project utilized a quasi-experimental approach to answer the clinical question. The wound, ostomy, and continence nurses (WOC nurses) collaborated with stakeholders to organize and develop the implementation plan. The bundle implementation over four weeks influenced a massive reduction from the comparative phase to the intervention phase.

The following chapter provides a summary of the entire project. It covers the project’s purpose, design, setting, data collection and analysis techniques, and the results. It then presents a summary of the discussion regarding the results and the consequent conclusion. It discusses implications of the study’s design, results, and conclusions. These include the theoretical, practical, and future implications of the quality improvement project. The chapter then ends with recommendations for future projects and practice.

Summary of the Project

The project’s clinical question was: To what degree does the implementation of Rivera’s PIP bundle impact the HAPI incidence compared to current practice among critical care patients in a 13-bed unit in urban New York over four weeks? It aims to identify patients at an increased risk for the development of HAPIs and implement Rivera’s PIP bundle to reduce the HAPIs incidence rates within the critical care unit with 371 beds. The project considered patients in critical care units because they are at an increased risk for the development of HAPIs because of prolonged confinement in beds, hemodynamic instability, mechanical ventilation, sedation, immobility, as well as vasopressors (Kazemi et al., 2018). HAPIs tend to extend a negative impact to the patient/family experience, patient outcomes, cost of treatment, and nurse satisfaction. They result in an extended hospital stay that creates many other issues in the treatment process. The unit and the WOC nurses were encouraged to implement the PIP bundle to address the rising incidences of HAPIs in the adult critical care unit. Inconsistencies were noted during the root cause analysis in the PIP strategies.

Summary of Findings and Conclusion

To what degree does the implementation of Rivera’s PIP bundle impact the HAPI incidence compared to current practice among critical care patients in a 13-bed unit in urban New York over four weeks?Implementing the bundle influenced a decline in HAPIs for patients in the critical care unit. A 33% HAPI reduction was noted in the intervention stage upon implementation of the pressure injury intervention bundle over the four weeks. Comparative group’s injuries included unstageable pressure and stage 2 pressure injuries. HAPI locations were the sacrum, ear, upper thigh, heel, ischia tuberosity, as well as on the heel. During the intervention period, a stage two injury was noted on the sacrum. Table 3 shows that the intervention facilitated a significant reduction of HAPI and promoted the safety of patients in critical control units. There was reduction in stage I and stage II HAPIs as expected since this project was aimed only for four weeks. The reduction influenced beneficial impact to nurses and improved their job satisfaction and patient outcome. The bundle was implemented in the critical care unit, and measures were established to ensure its sustainability. Stakeholders were encouraged to remain vigilant and determined in the prevention of HAPI.

Implications

The results of the project are likely to encourage the adoption of a PIP bundle in critical care settings to hinder HAPIs and hospitals need implement the bundle to promote patient outcomes and offer better healthcare services.The DPI project results show that nursing theories are beneficial in guiding education and research, influencing better patient care, improving communication between nurses, and better professional status. Practically, it implies that the PIP bundle can be applied to a critical care unit setting to limit the chances of the development of HAPIs. It shows that better nursing outcomes would be achieved in the future due to improved research and implementation of EBP initiatives.

Guidelines for clinical practice can offer a starting point for the implementation of the PIP bundle. The study findings show that nurses knew beneficial preventive interventions. They were expected to apply basic interventions based on the provided guidelines to facilitate the effective implementation of the PIP bundle.

The need for explicit documentation is another practice implication noted from this EBP initiative. It is necessary to assess the skin status during the admission process and ensure that it is monitored closely. It is important to consistently document interventions for both the treatment and prevention of HAPIs. Documentation is necessary for legal and economic perspectives since PIP interventions are sometimes costly. Poor documentation can influence denial or reduction of reimbursement implying that it is important to ensure it is properly done. Insufficient documentation has influenced many medical liability allegations to go to trials and eventually face charges. Daily flow sheets and admission assessment forms can help staff nurses to promote documentation.

Theoretical Implications

The project involved practice improvement which aligns with various nursing theories concerning evidence-based nursing practice. Jean Watson’s human caring theory (2018) identifies how to improve positive outcomes during human-to-human caring moments. Wei and Watson (2019) indicate that the theory relies on practice, research, and theory-based education to ensure that any proposed intervention is suitable and can help patients achieve better health outcomes. Watson’s theory of caring helps create an excellent environment around the patients and staff to promote healing. Energetic authentic caring presence occurs when the nurse and patient come together to create a caring moment. Pressure injuries occur mostly in immobile and elderly patients and PIP bundle interventions, performed by the nurse or the healthcare team, such as repositioning an immobile patient can prevent pressure injuries, meet the basic needs of patient, and help sustain human dignity. The human caring nursing theory promotes healing and encourages the provision of a favorable healing environment. The theory encourages nurses to put their patients in the best environment to support their healing process.

Active engagement in the caring process through intentionality and authentic presence enabled nurses to promote the ability of patients to recover. It improved the ability of nurses to maintain caring attitudes and emotional sensitivity, particularly when working in a demanding and over-stressed workplace. It potentiates capabilities and regenerates life energies to motivate nurses to offer the best service in critical care units. During the implementation of PIP bundles, the theory promoted self-actualization both personally and professionally. It motivated nurses to implement the PIP bundle to reduce incidences of HAPIs among adults in CCU. The theory was applied to improve patient satisfaction and encourage nurses to develop a positive attitude towards their patients and the environment. It promoted quality caring and influenced the implementation of the PIP bundle while enhancing patients’ experiences.

Practical Implications

Practice improvement can improve job satisfaction, patient experience and promote the nursing outcome. It can play a role in the reduction of the cost of treatment and lower the hospital stay. It can motivate nurses to work harder and remain focused on the achievement of their expectations. This can help solve the problem of a poor attitude towards the job and ensure that everyone is focused on the improvement of patients’ safety. Further research in the PIP bundle is likely to influence the better outcome and facilitate the achievement of the nursing objectives.

Nurses caring for patients particularly those in high-risk settings need to understand risk factors associated with the development of HAPIs and interventions necessary to enhance control. They need to be educated on key areas such as risk factors, prevalence and incidence, documentation, preventative interventions, patient education strategies, risk assessment scales, prevalence, and incidences.

Clinicians need to make an effort to identify patients who are at an increased risk of developing pressure. They need to consider risk factors such as cognitive impairment, lower body weight, Hispanic ethnicity, older age, and physical impairments. Patients with other comorbid conditions affecting the healing process and the integrity of the soft tissues such as impaired microcirculation, edema, diabetes, malnutrition, hypoalbuminemia, and fecal incontinence are exposed to the risk of developing pressure ulcers. Individualized decisions are necessary to determine whether to use a multicomponent or single intervention to hinder the development of pressure ulcers.

Future Implications

The project revealed that the PIP bundle can offer a solution to the problem of HAPIs among adult patients in the critical care unit. This means that implementation of the PIP bundle is likely to transform the delivery of health services to patients in critical units. Reduction in the prevalence of pressure ulcers would promote patients ‘experience, reduce the cost of treatment and enhance job satisfaction among nurses. Future DPI projects are likely to focus on improved interventions meant to boost the implementation of the PIP bundle and enhance its relevance in critical care settings. They are likely to consider measures to boost the motivation of nurses and improve their ability to collaborate with other practitioners. The other implication is that the DPI project would be implemented in critical care units and not in other units. This is because it was conducted in a unit where adult patients were confined in the hospital beds for a prolonged period.

Recommendations

Recommendations for Future Projects

The findings of the present research work provide direction for both registered nurses involved in critical care and the professional nurses intending to further investigations regarding the issue of HAPIs. As such, future scientific projects should evaluate the outcomes of the Rivera PIP bundle implementation while paying attention to factors such as quality of care, cost, and motivation for nurses. A possible way to undertake future studies on this topic include the utilization of more quasi-experimental designs to test, describe, and explain the relationship between outcomes, interventions, and risks of associated with the new intervention. Quasi-experimental studies exibit the potential to support the development of better interventions to assist more patients in critical care units.

Future projects also need to analyze the cost-benefit in the preventative intervention to justify its application in critical care units. This should include the analysis of the cost, benefits, and challenges associated with the PIP implementation. It is necessary to determine the actual cost and consider the obtained benefits to justify the implementation of the PIP bundle. Benefits analyses need to be conducted on ulcer development and preventive interventions. This can help offer evidence of potential benefits against the associated costs with the bundle implementation. Evaluated benefits should include savings on the treatment process, quality of care, patients’ satisfaction, and employee morale. The research would support the effective making of decisions when caring for patients in critical care units.

Further research is necessary to determine the comparative efficacy of different pressure ulcer risk assessment tools as well as compare it with clinical judgment. Limited studies exist on the efficacy of interventions warranting more researches. This can improve the ability of nurses and others health practitioners to make informed decisions regarding the best interventions to apply based on the patient’s condition. This can play a role in the reduction of the cost of treatment and promote the quality of care to patients. It would boost the knowledge of health providers and improve their understanding of issues affecting their patients.

Future DPI projects need to evaluate the impact of the PIP bundle implementation on the educational and skills needs of nurses. Since the EBP initiative incorporates diverse disciplines and encourages the application of diverse interventions, it is necessary to determine whether higher education would be necessary. The research needs to provide an answer to whether critical skills would be necessary to meet the new requirements. This will also determine whether the skills of nurses in the current practice are sufficient to support the bundle implementation.

More research is also necessary to determine whether the bundle can be implemented in other setting apart from critical care units. The research needs to determine changes that can be done in the bundle to fit and remain effective in different places. This is important to increase the number of patients benefiting from the DPI project. The research needs to determine measures that can be taken to motivate nurses and enhance their commitment.

Recommendations for Practice

This project recommends further documentation of HAPIs in critical care units to understand changing needs of the population. Documentation is important for improved clinical communication ensuring that information is shared appropriately. Further documentation of HAPIs would offer an accurate reflection of patient safety, explain the need for nursing assessments, and improve the ability of the multidisciplinary team to offer quality care. Accurate documentation would offer evidence of care, legal requirements and support effective decisions. It would ensure consistent communication enabling every nurse to offer the best quality service.

The development of a PIP checklist can help promote adherence to the provided guidelines. The checklist can support the documentation of the number and types of the implemented preventive interventions. It can offer guidance to nurses during their practice and improve the patients’ experience. It would standardize the process enabling the consideration of all actions and elements. The predictability and structure of the checklist would support systematic and careful delivery of care to enhance performance while lowering variability. It would support the delivery of quality, safe, and evidence-based best practices by ensuring that every patient receives evidence-based care and democratizing knowledge. The checklist would support the implementation of a formalized process, eliminate inconsistent procedures, and reduce chances of errors. It would support the adoption of effective interventions to influence the achievement of a better outcome. To ensure success of the PIP bundle intervention, it is essential to adhere to the established guidelines and ensure that every detail is followed.

The other recommendation is to train new staff in the large-scale PIP Bundle implementation and ensure that they have the right skills. Training would ensure that nurses develop the right skills required to support the successful implementation of the bundle. This can play a role in the motivation of nurses and other health practitioners to offer the best services to their patients and enhance adherence to the bundle. Providing them with the right knowledge would ensure that everyone understands the need of implementing the PIP bundle and remain committed to the delivery of quality care.

References

Adashi, E. Y., Walters, L. B., &Menikoff, J. A. (2018). The Belmont Report of 40: Reckoning with time. American Journal of Public Health, 108(10), 1345-1348. doi:10.2105/AJPH.2018.304580

Aljezawi, M., &Tubaishat, A. (2018). Pressure injuries among hospitalized patients with cancer. Journal of Wound, Ostomy, and Continence Nursing, 45(3), 227-232(6). doi:10.1097/WON.0000000000000429

Anderson, M. (2018). Universal Pressure Ulcer Prevention Bundle with WOC Nurse Support: A Pressure Injury Prevention Journey. In Pressure Injury, Diabetes and Negative Pressure Wound Therapy (pp. 31-41). Springer, Cham.

Barakat-Johnson, M., Lai, M., Barnett, C., Wand, T., Lidia Wolak, D., Chan, C., Leong, T., & White, K. (2018). Hospital-acquired pressure injuries: Are they accurately reported? A prospective descriptive study in a large tertiary hospital in Australia. Journal of Tissue Viability, 27(4), 203-210.

Bates‐Jensen, B. M., McCreath, H. E., Harputlu, D., &Patlan, A. (2019). Reliability of the Bates‐Jensen wound assessment tool for pressure injury assessment: The pressure ulcer detection study.Wound Repair and Regeneration, 27(4), 386-395.

Bell, E., Bryman, A., & Harley, B. (2018). Business research methods. London, UK: Oxford University Press.

Burnes, B. (2020). The origins of Lewin’s three-step model of change. The Journal of Applied Behavioral Science, 56(1),32-59.

Chaboyer, W. P., Thalib, L., Harbeck, E., Coyer, F. M., Blot, S., Bull, C., Nogueira, P. C., & Lin, F. F. (2018). Incidence and prevalence of pressure injuries in adult intensive care patients: A systematic review and meta-analysis. Critical Care Medicine, 46(11), 1074-1081. doi:10.1097/CCM.0000000000003366

Chitambira, B., & Evans, S. (2018). Repositioning stroke patients with pusher syndrome to reduce incidence of pressure ulcers. British Journal of Neuroscience Nursing, 14(1), 16-21. doi:10.12968/bjnn.2018.14.1.16

Cornish, L. (2017). The use of prophylactic dressings in the prevention of pressure ulcers: a literature review. British journal of community nursing, 22(Sup6), S26–S32.

Courvoisier, D. S., Righi, L., Béné, N., Rae, A.-C., &Chopard, P. (2018). Variation in pressure ulcer prevalence and prevention in nursing homes: A multicenter study. Applied Nursing Research, 42, 45-50. doi:10.1016/j.apnr.2018.06.001

Cox, J., Roche, S., & Murphy, V. (2018). Pressure injury risk factors in critical care patients: A descriptive analysis. Advances in Skin & Wound Care, 31(7), 328-334. doi:10.1097/01.ASW.0000534699.50162.4e

Creswell, J. W., & Creswell, J. D. (2018).Research design: Qualitative, quantitative, and mixed methods approaches(5^th ed.).Thousand Oaks: CA. Sage Publications.

Dreyfus, J., Gayle, J., Trueman, P., Delhoughe, G., & Siddiqi, A. (2017). Assessment of risk factors associated with hospital-acquired pressure injuries and impact on health care utilization and cost outcomes in US hospitals. American Journal of Medical Quality, 33(4), 348-358. doi:10.1177/1062860617746741

Eren, F., DeLuca, R., &Kirshblum, S. (2020). Frequency of turning in bed at home in persons with chronic spinal cord injury. The Journal of Spinal Cord Medicine. doi:10.1080/10790268.2020.1800965

Flannelly, K. J., Flannelly, L. T., & Jankowski, K. R. B. (2018). Threats to the internal validity of experimental and quasi-experimental research in healthcare. Journal of Health Care Chaplaincy, 24(3), 107-130. doi:10.1080/08854726.2017.1421019

Fowler, S. B., & Lapp, V. (2019). Sample size in quantitative research: Sample size will affect the significance of your research. American Nurse Today, 14(5), 61-63.

Frank, G., Walsh, K. E., Wooton, S., Bost, J., Dong, W., Keller, L., Miller, M., Zieker, K., &Brilli, R. J. (2017). Impact of a pressure injury prevention bundle in the solutions for patient safety network.Pediatric Quality & Safety, 2(2), 1-8.

Gaspar, S., Peralta, M., Marques, A., Budri, A., & de Matos, M. G. (2019). Effectiveness on hospital-acquired pressure ulcers prevention: A systematic review. International Wound Journal, 16(5), 1087-1102. doi:10.1111/iwj.13147

Gray, M., & Giuliano, K. K. (2018). Incontinence-associated dermatitis, characteristics, and relationship to pressure injury. Journal of Wound, Ostomy, and Continence Nursing, 45(1), 63-67.

Greenwood, C., & McGinnis, E. (2016). A retrospective analysis of the findings of pressure ulcer investigations in an acute trust in the UK. Journal of Tissue Viability, 25(2), 91-97. doi:10.1016/j.jtv.2016.02.008

Gupta, P., Shiju, S., Chacko, G., Thomas, M., Abas, A., Savarimuthu, I., Omari, E., Al-Balushi, S., Jessymo, P., Mathew, S., Quinto, M., McDonald, I., & Andrews, W. (2020). A quality improvement programme to reduce hospital-acquired pressure injuries. BMJ Open Quality, 9(3), e000905.

Hahnel, E., El Genedy, M., Tomova-Simitchieva, T., Hauß, A., Stroux, A., Lechner, A., Richter, C., Akdeniz, M., Blume-Peytavi, U., Löber, N., &Kottner, J. (2020). The effectiveness of two silicone dressings for sacral and heel pressure ulcer prevention compared with no dressings in high-risk intensive care unit patients: a randomized controlled parallel-group trial.The British journal of dermatology, 183(2), 256–264.

Han, Y., Jin, Y., Jin, T., Lee, S. M., & Lee, J. Y. (2019). Impact of pressure injuries on patient outcomes in a Korean hospital: A case-control study. Journal of Wound, Ostomy and Continence Nursing, 46(3), 194-200. doi: 10.1097/WON.0000000000000528

Hernandez-Boussard, T., Monda, K. L., Crespo, B. C., & Riskin, D. (2019). Real word evidence in cardiovascular medicine: Ensuring data validity in electronic health record-based studies. Journal of the American Medical Informatics Association, 26(11), 1189-1194. doi:10.1093/jamia/ocz119

Hultin, L., Karlsson, A.-C., Öhrvall, M., &Gunningberg, L. (2019). Information and communication technology can increase patient participation in pressure injury prevention: A qualitative study in older orthopedic patients. Journal of Wound, Ostomy, and Continence Nursing, 46(5), 383-389. doi:10.1097/WON.0000000000000568

Hyun, S., Moffatt-Bruce, S., Cooper, C., Hixon, B., & Kaewprag, P. (2019). Prediction model for hospital-acquired pressure ulcer development: Retrospective cohort study. JMIR Medical Informatics, 7(3), e13785. doi:10.2196/13785

Jager, J., Putnick, D. L., & Bornstein, M. H. (2017). More than just convenient: The scientific merits of homogenous convenience samples. Monographs of the Society

Joint Commission. (2016). Preventing pressure injuries [PDF document]. Web.

Kamikawa, N., Hamada, H., Sekikawa, K., Yamamoto, H., Fujika, Y., Kajiwara, T., Aizawa, F., &Otoyama, I. (2018). Posture and firmness changes in a pressure-relieving air mattress affect cough strength in elderly people with dysphagia. PLOS ONE, 13(12), e0208895.

Kayser, S. A., VanGilder, C. A., &Lachenbruch, C. (2019). Predictors of superficial and severe hospital-acquired pressure injuries: A cross-sectional study using the International Pressure Ulcer Prevalence™ survey. International Journal of Nursing Studies, 89, 46-52.

Kazemi, A., Carnaggio, K., Clark, M., Shephard, C., &Okoye, G. A. (2018). Optimal wound care management in hidradenitis suppurativa. Journal of Dermatological Treatment, 29(2), 165-167.

Kennerly, S. M., & Yap, T. L. (2018). The role of manual patient turning in preventing hospital acquired conditions. California: Leaf Health Care.

Kim, C. G., Park, S., Ko, J. W., & Jo, S. (2018). The relationship of subepidermal moisture and early stage pressure injury by visual skin assessment. Journal of Tissue Viability, 27(3), 130-134.

Latimer, S., Chaboyer, W., Thalib, L., McInnes, E., Bucknall, T., & Gillespie, B. M. (2019). Pressure injury prevalence and predictors among older adults in the first 36 hours of hospitalisation. Journal of Clinical Nursing, 28(21-22), 4119-4127. Web.

Lewin, K. C. (1951). Field theory in social science. New York, NY: Harper & Row.

Li, Z., Lin, F., Thalib, L., &Chaboyer, W. (2020). Global prevalence and incidence of pressure injuries in hospitalized adult patients: A systematic review and meta-analysis. International Journal of Nursing Studies, 105(103546), 1-13. doi:10.1016/j.ijnurstu.2020.103546

Lim, M. L., &Ang, S. Y. (2017). Impact of hospital-acquired pressure injuries on hospital costs – experience of a tertiary hospital in Singapore. Wound Practice & Research: Journal of the Australian Wound Management Association, 25(1), 42-47.

Lin, F., Wu, Z., Song, B., Coyer, F., &Chaboyer, W. (2020). The effectiveness of multicomponent pressure injury prevention programs in adult intensive care patients: A systematic review. International Journal of Nursing Studies, 102. doi:10.1016/j.ijnurstu.2019.103483

Luo, M., Long, X.-H., Wu, J.-I., Huang, S.-Z., & Zeng, Y. (2019). Incidence and risk factors of pressure injuries in surgical spinal patients: A retrospective study. Journal of Wound, Ostomy, and Continence Nursing, 46(5), 397-400. doi:10.1097/WON.0000000000000570

Mansfield, S., Obraczka, K., & Roy, S. (2019). Pressure injury prevention: A survey. IEEE reviews in biomedical engineering, 13, 352-368.

Padula, W. V., &Delarmente, B. A. (2019). The national cost of hospital-acquired pressure injuries in the United States. International Wound Journal, 16(3), 634-640.

Padula, W. V., &Pronovost, P. J. (2018). Addressing the multisectoral impact of pressure injuries int the USA, UK, and abroad. BMJ Quality & Safety, 27(3), 171-173. doi:10.1136/bmjqs-2017-007021

Padula, W. V., Black, J. M., Davidson, P. M., Kang, S. Y., &Pronovost, P. J. (2020). Adverse effects of the Medicare PSI-90 hospital penalty system on revenue-neutral hospital-acquired conditions. Journal of patient safety, 16(2), e97-e102. doi: 10.1097/PTS.0000000000000517

Padula, W. V., Pronovost, P. J., Makic, M. B. F., Wald, H. L., Moran, D., Mishra, M. K., & Meltzer, D. O. (2019). Value of hospital resources for effective pressure injury prevention: A cost-effectiveness analysis. BMJ Quality & Safety, 28(2), 132-141. doi:10.1136/bmjqs-2017-007505

Razmus, I., & Bergquist-Beringer, S. (2017). Pressure injury prevalence and the rate of hospital-acquired pressure injury among pediatric patients in acute care. Journal of Wound, Ostomy, and Continence Nursing, 44(2), 110-117. doi: 10.1097/WON.0000000000000306

Ricci, J. A., Bayer, L. R., &Orgill, D. P. (2017). Evidence-based medicine: The evaluation and treatment of pressure injuries. Plastic and Reconstructive Surgery, 139(1), 275e-286e. doi:10.1097/PRS.0000000000002850

Rivera, J., Donohoe, E., Deady-Rooney, M., Douglas, M., &Samaniego, N. (2020). Implementing a Pressure Injury Prevention Bundle to Decrease Hospital-Acquired Pressure Injuries in an Adult Critical Care Unit: An Evidence-Based, Pilot Initiative.Wound Management & Prevention, 66(10), 20-28.

Romanelli, M., Clark, M., Gefen, A., &Ciprandi, G. (Eds.). (2018). Science and practice of pressure ulcer management (2^nded.). Springer Nature.

Rutberg, S., &Bouikidis, C. D. (2018). Focusing on the fundamentals: A simplistic differentiation between qualitative and quantitative research. Nephrology Nursing Journal, 45(2), 209-212.

Shi, C., Dumville, J. C., & Cullum, N. (2018). Skin status for predicting pressure ulcer development: a systematic review and meta-analyses.International Journal of Nursing Studies, 87, 14-25.

Siedlecki, S. L. (2020). Quasi-experimental research designs. Clinical Nurse Specialist, 34(5), 198-202. doi:10.1097/NUR.0000000000000540

Singh, C. D., Anderson, C., White, E., &Shoqirat, N. (2018). The impact of pediatric pressure injury prevention bundle on pediatric pressure injury rates. Journal of Wound, Ostomy and Continence Nursing, 45(3), 209-212.

US Department of Health & Human Services. (1979). The Belmont report.

Watson, J. (1979). Nursing: The philosophy and science of caring. Boston: Little, Brown.

Watson, J. (2018). Unitary caring science: The philosophy and praxis of nursing. Louisville, CO: University Press of Colorado.

Wei, H., & Watson, J. (2019). Healthcare interprofessional team members’ perspectives on human caring: A directed content analysis study. International Journal of Nursing Sciences, 6(1), 17-23. doi:10.1016/j.ijnss.2018.12.001

World Health Organization. (2008). Summary of the evidence on patient safety: implications for research. Geneva, Switzerland: WHO Press.

Yafi, A., Muakkassa, F. K., Pasupneti, T., Fulton, J., Cuccia, D. J., Mazhar, A., Blasiole, K. N., &Mostow, E. N. (2017). Quantitative skin assessment using spatial frequency domain imaging (SFDI) in patients with or at high risk for pressure ulcers: QUANTITATIVE SKIN ASSESSMENT USING SPATIAL FREQUENCY.Lasers in Surgery and Medicine, 49(9), 827-834.