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Recommended Citation
Clontz S, Thompson L. Pressure Injury Prevention Enhanced Critical Care Bundle Quality Improvement Pilot 2024 Atrium Health Union and Atrium Health Union West. 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
Background: Critical care areas experience a higher incidence rate of hospital acquired pressure injuries due to the vulnerability of critically ill patients. These safety events negatively impact patient outcomes by increasing mortality, non-reimbursable hospital costs, and length of stay. Hospital acquired pressure injuries often lead to an increased length of stay and more complex interdisciplinary care.
Local Problem: Our nursing teams identified the need for an enhanced pressure injury prevention protocol that was standardized for critical care units due to increased incidence rates and associated patient outcomes. The previous year saw 18 critical care unit acquired pressure injuries, highlighting the urgent need for enhanced prevention strategies.
Method: A six-month pilot was developed and approved by Advocate Health’s Institutional Review Board. Nurses and respiratory therapists received training on prevention strategies, followed by a 16-question assessment bundle tool each shift to evaluate risk factors. Peer review tools validated prevention measures, and continuous feedback was collected via QR codes. Stakeholder involvement was ensured through educational sessions and shared decision-making.
Results/Conclusions: The pilot resulted in a 70.7% projected decrease in unit-acquired pressure injuries, reducing the projected number of events from 18 to 5.28. This significant reduction demonstrated the efficacy of the enhanced prevention bundle. Additionally, the pilot achieved estimated cost savings of $177,672.96 due to fewer pressure injuries. The structured approach improved nurses' ability to identify at-risk patients and take preventive actions, leading to better patient safety and outcomes.
Implications for Practice: The findings underscore the importance of consistent risk evaluation and focused education on pressure injury prevention. The successful strategies from this pilot can be implemented in other hospitals to enhance patient safety and outcomes. Ongoing quality improvement efforts, including monthly prevalence studies and continuous staff education, are essential to sustain the improvements achieved.
Document Type
Poster
Publication Date
11-12-2025
Pressure Injury Prevention Enhanced Critical Care Bundle Quality Improvement Pilot 2024 Atrium Health Union and Atrium Health Union West
Background: Critical care areas experience a higher incidence rate of hospital acquired pressure injuries due to the vulnerability of critically ill patients. These safety events negatively impact patient outcomes by increasing mortality, non-reimbursable hospital costs, and length of stay. Hospital acquired pressure injuries often lead to an increased length of stay and more complex interdisciplinary care.
Local Problem: Our nursing teams identified the need for an enhanced pressure injury prevention protocol that was standardized for critical care units due to increased incidence rates and associated patient outcomes. The previous year saw 18 critical care unit acquired pressure injuries, highlighting the urgent need for enhanced prevention strategies.
Method: A six-month pilot was developed and approved by Advocate Health’s Institutional Review Board. Nurses and respiratory therapists received training on prevention strategies, followed by a 16-question assessment bundle tool each shift to evaluate risk factors. Peer review tools validated prevention measures, and continuous feedback was collected via QR codes. Stakeholder involvement was ensured through educational sessions and shared decision-making.
Results/Conclusions: The pilot resulted in a 70.7% projected decrease in unit-acquired pressure injuries, reducing the projected number of events from 18 to 5.28. This significant reduction demonstrated the efficacy of the enhanced prevention bundle. Additionally, the pilot achieved estimated cost savings of $177,672.96 due to fewer pressure injuries. The structured approach improved nurses' ability to identify at-risk patients and take preventive actions, leading to better patient safety and outcomes.
Implications for Practice: The findings underscore the importance of consistent risk evaluation and focused education on pressure injury prevention. The successful strategies from this pilot can be implemented in other hospitals to enhance patient safety and outcomes. Ongoing quality improvement efforts, including monthly prevalence studies and continuous staff education, are essential to sustain the improvements achieved.
Affiliations
Atrium Health Union and Union West