Date of Award

Spring 5-5-2022

Scholarly Projects

Projects: Open Access

Degree Name

Doctor of Nursing Practice (DNP)



Faculty Chair

Lorie Wild

Faculty Reader

Erla Champ-Gibson

Executive Summary

Executive Summary

Introduction: Pressure injuries (PI) are wounds caused by pressure, friction, or sheer on the skin and the underlying structures, resulting in cell death (Berlowitz et al., 2014). When hospital-acquired pressure injuries (HAPI) occur, they severely affect a patient's quality of life. It is estimated HAPI is the cause of death in 41 out of every 1000 patients (AHRQ, 2017). Annual costs related to HAPI in the United States are estimated at $26.8 billion (Padula & Delarmente, 2019). HAPI prevention is a priority in the hospital setting as it is a quality indicator. There is emerging evidence that foam dressings over the sacrum, as an addition to the standard of care, may further reduce the incidence of HAPI.

Problems and Purpose Statement: Currently, nurses use foam dressings as PI prevention as an independent practice decision at the project hospital. The purpose of this project was to determine whether the application of sacral foam dressings over intact skin by hospital staff RNs as PI prevention would reduce the incidence of HAPI in high-risk adult patients. Eligibility criteria included a) <24 hours admission to the unit; b) Braden score ≤18; c) Braden sub-category moisture >2; d) no tape allergy; e) intact sacral skin, no history of sacral PI, or sacral scar; f) continent or contained urine/stool; g) no diarrhea even if continent. After implementation, additional exclusion criteria included patients who became incontinent, those with a history of noncompliance with care, and patients who refused skin assessment. Specific aims included a reduction in the incidence of HAPI, and successful adoption of the intervention by nursing staff on the project unit. Though evidence supports the use of foam dressings as HAPI prevention, the overall goal of this study was to incorporate the intervention into hospital policy to help standardize the practice and improve patient safety.

Methods: The project was implemented in one inpatient unit at the project hospital. Lewin's Change Theory (Lewin, 1947) and the Plan-Do-Study-Act (PDSA) framework guided the project (IHI, 2020). Patients and nurses were considered participants. All nurses and a convenience sample of all eligible high-risk patients from May through June 2021 were eligible to participate. Nurses charted skin assessment, dressing application, and interventions using an existing wound tracking flowsheet in the EHR. Additional chart data was collected regarding interventions reflecting the standard of care for PI prevention. The RN Unit Post Satisfaction Survey was used to assess whether the project protocol was acceptable and feasible to the nursing staff on the unit as a measure to promote sustainability.

Results/Outcomes: Of the 243 patients admitted to the unit during the project, 23 met eligibility criteria, with 6 enrolled in the project. Most of those eligible were excluded. The sample included 3 males and 3 females, ages 53 to >90 years, with Braden scores ranging from 16-18.

No patients developed a pressure injury during the project. Though low enrollment, the foam dressing showed promise in mitigating pressure injury, which is in line with the research.

Anecdotally, 2 of the 6 patients exhibited improved skin under the dressing when compared to the surrounding skin.

Whether the standard of care for pressure injury had been met was poorly understood by staff and the project lead. While there were aspects of nurse charting which were measurable, time-sensitive, and could be quantified (e.g., assessments and hourly rounding) due to the complexity and the intradisciplinary nature of PI interventions, the measure of standard of care was unknown to nursing staff.

The RN Unit Post Satisfaction Survey included 5 questions with 5-point Likert type survey response sets, plus space for comments. The survey was available for two weeks post-intervention, was anonymous, and open to every RN regardless of experience with a patient in protocol. With 64 nurses assigned during the project period, 30 responses were returned (47%). Participant responses showed variability, which may be an indicator of thoughtful responses rather than socially desired answers. Results considered favorable were those marked as either agree or strongly agree. Unfavorable results were marked disagree or strongly disagree. There was also a neutral option.

The items related to the protocol intervention were favorable: a) understanding the inclusion criteria (97%); b) availability of dressings (83%); c) low impact on time management (82.7%), and d) understanding the charting protocol (76%). When asked if nurses were more aware of PI prevention because of the project, 83% responded favorably as well.

Sustainability: Though the project had the support of nurses, there were barriers to sustainability that would need to be addressed in future projects. The inclusion/exclusion criteria should be simplified. Though nurses endorsed the necessity of a tracking tool for the prevention dressing, using the existing EHR wounds flowsheet was cumbersome and complex. Time was also a factor noted in the survey. With chronic short-staffing related to Covid-19 as a global concern, adding a new process would be challenging as even the best ideas need front-line support.

Understanding whether the standard of care for PI interventions had been met remained poorly understood. Though nurses and CNAs were actively engaged in PI prevention, the measure at the staff level remained unclear. Additional education on how to pair Braden scores with specific interventions may bring clarity.

Limitations: Limitations included implementing a QI project during the Covid-19 global pandemic, which had already placed unprecedented stress on healthcare systems, including critical staffing shortages. Though the survey results supported the project, the project lead was aware from 1:1 conversations that staff were burdened by the extra work the project was generating. In response, the project lead took on more responsibility which impacted sustainability.

Implications: Implications for practice suggest creating a new protocol during the stressors related to the ongoing Covid-19 pandemic may be poor timing. However, despite pandemic-related complications, the study results showed the nursing staff were able to successfully adopt the intervention, though some aspects were confusing at times.

Despite promising results both for patients and adoption by nurses, challenges remain in integrating the protocol steps into a usable model. However, nurses who are well versed in evidence-based practice may be more willing to use a simple to implement protocol where the benefits are easily understood.

Finally, these results show there is value in doing a unit-based QI project as participation can elevate knowledge of this practice or others. Here, 83% of nurses agreed they had increased knowledge of pressure injury prevention because of exposure to the project. Even those nurses who were not directly involved with patients in protocol received the secondary benefit of deeper understanding regarding HAPI prevention practices. Future endeavors might consider this secondary benefit when planning evidence-based practice projects and find ways to engage staff even during times of extreme challenges in the healthcare setting.


Agency for Healthcare Research and Quality [AHRQ]. (2017). Partnership for patients.

Agency for Healthcare Research and Quality[AHRQ]. (n.d.). 5. How do we measure our pressure ulcer rates and practices? safety/settings/hospital/resource/pressureulcer/tool/put5.html

Berlowitz, D., VanDeusen, C., Niederhauser, A., Silver, J., Logan, C., Ayello, E., & Zulkowski, K. (2014, October). Preventing pressure ulcers in hospitals: A toolkit for improving quality of care. Agency for Healthcare Research and Quality.

Institute for Healthcare Improvement [IHI]. (2020). Plan-Do-Study-Act (PDSA) worksheet: IHI.

Lewin, K. (1947). Frontiers in group dynamics: Concept, method and reality in social science; social equilibria and social change. Sage Journals - Human Relations.

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.

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