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Recommended Citation
Bass C, Augello M. Guardians of the Skin: Preventing Pressure Injuries on a Stroke Unit. Quality Improvement poster presented at Transforming Practice: The Intersection of Technology and Nursing Excellence; Advocate Health Nursing Research and Professional Development Conference 2025; November 12, 2025; Virtual.
Presentation Notes
Quality Improvement poster presented at Transforming Practice: The Intersection of Technology and Nursing Excellence; Advocate Health Nursing Research and Professional Development Conference 2025; November 12, 2025; Virtual.
Abstract
Our nurses saw a rise in hospital-acquired pressure injuries in the stroke unit. NDNQI data showed we performed below the national mean in three out of four quarters. This project's aim was to identify gaps and create innovative solutions led by nurses, to reduce pressure injuries by 20%. Several factors contributed to the rise in pressure injuries, including length of stay, increase in acutely ill stroke patients due to bed designation, nutritional barriers, and mobility limitations. Post-covid, our unit experienced turnover, which resulted in new nurses being unaware of strategies used to prevent pressure injuries. Using the “5 Why” root cause analysis, we created a bundle for patients with a Braden score of 18 or less. This included a preventative foam dressing, a turn clock on the door for Q2 hour turns, a foam turning wedge, and a 2-person skin assessment each shift to prioritize integumentary assessment and accountability. The 2-person skin assessment was a new and innovative component for the team. We educated staff during huddles and monitored progress in the areas of turn compliance, 2-person skin assessment, and total pressure injuries. A daily compliance report was created to discuss successes and opportunities with the staff. Our turn compliance increased from a baseline of 30% to 54%, and our 2-person skin assessments increased from 0% to 49%. As a result, our pressure injuries decreased from 10 to 6 between 2023 and 2024, representing a 40% reduction. By comparing the annual costs of foam dressings and wedges to the expenses of treating pressure injuries, we achieved cost savings of $73,426 this year! This innovative approach to pressure injury reduction has shown impressive results, addressing turn effectiveness, visual management, accountability, and prioritization. As the project advances, stakeholders can extend the implementation of the bundle to additional units, ensuring widespread success.
Document Type
Poster
Publication Date
11-12-2025
Guardians of the Skin: Preventing Pressure Injuries on a Stroke Unit
Our nurses saw a rise in hospital-acquired pressure injuries in the stroke unit. NDNQI data showed we performed below the national mean in three out of four quarters. This project's aim was to identify gaps and create innovative solutions led by nurses, to reduce pressure injuries by 20%. Several factors contributed to the rise in pressure injuries, including length of stay, increase in acutely ill stroke patients due to bed designation, nutritional barriers, and mobility limitations. Post-covid, our unit experienced turnover, which resulted in new nurses being unaware of strategies used to prevent pressure injuries. Using the “5 Why” root cause analysis, we created a bundle for patients with a Braden score of 18 or less. This included a preventative foam dressing, a turn clock on the door for Q2 hour turns, a foam turning wedge, and a 2-person skin assessment each shift to prioritize integumentary assessment and accountability. The 2-person skin assessment was a new and innovative component for the team. We educated staff during huddles and monitored progress in the areas of turn compliance, 2-person skin assessment, and total pressure injuries. A daily compliance report was created to discuss successes and opportunities with the staff. Our turn compliance increased from a baseline of 30% to 54%, and our 2-person skin assessments increased from 0% to 49%. As a result, our pressure injuries decreased from 10 to 6 between 2023 and 2024, representing a 40% reduction. By comparing the annual costs of foam dressings and wedges to the expenses of treating pressure injuries, we achieved cost savings of $73,426 this year! This innovative approach to pressure injury reduction has shown impressive results, addressing turn effectiveness, visual management, accountability, and prioritization. As the project advances, stakeholders can extend the implementation of the bundle to additional units, ensuring widespread success.
Affiliations
Atrium Health - Carolinas Medical Center