Implementing a Pressure Injury Prevention Bundle to Decrease Hospital-Acquired Pressure Injuries in an Adult Critical Care Unit: An Evidence-Based, Pilot Initiative

Preventing hospital-acquired pressure injuries (HAPIs) is a major concern in health care. HAPIs negatively impact patient outcomes. Pressure injuries are associated with increased morbidity and mortality rates. According to a Leaf Healthcare White Paper,¹ patients living with pressure ulcers suffer from pain and decreased quality of life. Approximately 60,000 patients die each year as a direct result of pressure ulcers.²  HAPIs result in increased length of stay and health care costs. Bauer et al³  reported that the median length of stay for patients with at least 1 pressure ulcer was 7 days (mean 11.1 ± 15), compared to a median of 3 days (mean 4.6 ± 6.8) for patients without a pressure ulcer. The Centers for Medicare & Medicaid Services⁴ considers any stage 3 and 4 pressure injury that develops after admission to a health care facility  to be a “never event” and do not reimburse for care associated with such occurrences. 

Patients in critical care units (CCUs) are at risk of HAPI development due to comorbidities.⁴ Patient acuity, clinical instability, and acute skin failure (ASF) combine to increase the patient’s risk of pressure injury development. Concomitant risk factors of pressure injury development include immobility, sedation, vasopressors, mechanical ventilation, hemodynamic instability, nutritional status, and comorbidities.^2,5–7 It is essential to differentiate skin injury related to ASF versus HAPI. Failure of body organs and the integumentary system due to hypoperfusion can leave the skin susceptible to the forces of pressure and shear. Life-saving interventions combined with ASF factors may result in ischemia and irreversible tissue damage, and also can culminate in an extensive deep tissue injury or subsequent full-thickness wound on the sacral/coccyx area that is presumed to be a pressure injury.⁸ According to Langemo and Brown,⁹ even with consistent skin assessments and the implementation of evidence-based pressure ulcer prevention strategies, pressure ulcer development in the ICU may be unavoidable because of hypoperfusion and subsequent sequelae, along with the need for vasopressors to shunt perfusion to other vital organs. Cox¹⁰ conducted a literature review and reported that patients who received norepinephrine for 60% of the ICU admission were 8 times more likely to have a pressure ulcer develop compared with patients who received norepinephrine for shorter durations or did not receive norepinephrine during the ICU admission (OR = 8.11; 95% CI, 3.64-18.0; P < .001). Cox¹⁰ also reported that the mean hours of norepinephrine infusions in patients with a stage II or higher (stage III, stage IV, unstageable, or suspected deep tissue injury) pressure ulcer were significantly higher (55 hours) compared with patients who remained pressure ulcer free (4 hours) (t = -4.00; P ≤ 0.01). 

The Institute for Healthcare Improvement’s 5 Million Lives Campaign¹¹ encourages the use of science-based guidelines to improve patient care and prevent pressure ulcers. Research supports the use of pressure injury prevention (PIP) bundles to standardize interventions and reduce HAPIs.^2,5,7  PIP bundles provide specific interventions to mitigate the risk of HAPI development. 

The European Pressure Ulcer Advisory Panel, National Pressure Injury Advisory Panel, and Pan Pacific Pressure Injury Alliance¹² recommend selecting a seat cushion for pressure redistribution, use of a prophylactic dressing beneath a medical device to reduce the risk of medical device-related pressure injuries (MDRPIs), and regularly rotating or repositioning medical devices to redistribute pressure at the skin–device interface. 

A previous initiative implemented at the primary author’s instititution to standardize prevention of tracheostomy-associated MDRPIs resulted in a decrease from 8 during the 1-year pre-intervention period to 3 during the 1-year post-intervention period. This represented a 63% decrease in MDRPIs associated with tracheostomies. The interventions to reduce the risk of developing tracheostomy-associated MDRPIs were included in the PIP bundle in the current initiative. Additionally, existing nasal cannulas were replaced with a soft polyvinyl chloride nasal cannula to reduce the risk of developing MDRPIs associated with nasal cannulas. 

The lack of a uniform process for preventing HAPIs in the primary author’s institution resulted in inconsistencies in PIP. The purpose of this evidence-based practice (EBP) initiative was to implement a PIP bundle to decrease HAPIs in an adult patient CCU. An increase in HAPIs was seen in the adult cardiac CCU during the 12-month period preceding the PIP initiative. The pre-intervention pressure injuries consisted of 3 stage 2 pressure injuries, 5 deep tissue pressure injuries (DTPIs), and 1 unstageable pressure injury. Prior to implementation of the bundle, there was no standardized protocol in place for PIP; each CCU developed individual plans. The use of positioning systems, skin protectants, and silicone foam dressings for PIP was based on the nurses’ clinical judgement and unit-based decisions. Root cause analysis conducted by wound, ostomy, and continence (WOC) nurses revealed variability in PIP strategies. The WOC nurses noted that during rounds and wound care consults, evidence-based recommendations were not always implemented. 

The Institute for Healthcare Improvement (IHI)¹³ defines a bundle as standardizing processes of care in order to improve patient outcomes. 

Anderson et al¹⁴ conducted a quasi-experimental, pre- and post-intervention design study to examine the effectiveness of a universal pressure ulcer prevention bundle (UPUPB) applied to patients in the ICU combined with proactive, semi-weekly WOC nurse rounds. Participants in that study included 181 pre- and 146 post-intervention patients who met the inclusion criteria and were admitted to ICU for more than 24 hours. The pre-intervention phase (June 2012 to October 2012) involved different patients from the post-intervention phase (January 2013 to June 2013). Patients in the pre-intervention phase received the standard care to prevent HAPUs based on risk determination, including referring patients at high risk to WOC nurses. The post-intervention phase involved use of the UPUPB with semi-weekly WOC nurse rounds. Prior to the intervention, pressure ulcers developed in 28 patients; multiple pressure ulcers developed in 7 of those patients (2 to 5 ulcers per subject). During phase 2, 3 subjects developed a single pressure ulcer. HAPUs decreased from 15.5% to 2.1%. Multivariate logistic regression modeling showed a substantial reduction in HAPUs (P < . 001). 

Coyer et al¹⁵ tested the effectiveness of an evidence-based skin integrity care bundle among adult ICU patients using a before-and-after design. A total of 207 patients were enrolled, 105 in the intervention group and 102 in the control group. Most patients were men, and the mean age was 55 years. The groups were similar in major demographic variables (age, Sequential Organ Failure Assessment [SOFA] scores, and ICU stay). The results showed a decrease in the cumulative incidence of pressure injuries in the intervention group (18.1%) compared with the control group (30.4%) (P =. 04). 

Krupp and Monfre⁵ conducted a literature review to identify recent advancements in pressure ulcer prevention and treatment in ICU patients. Several of the advancements included risk assessment, education, turning schedules, providing staff with feedback from audits, lift teams, review of linen, a consensus statement regarding unavoidable pressure ulcers, treatment modalities, and an assessment of provider knowledge regarding pressure ulcer prevention and treatment. The literature review also noted that multidisciplinary prevention teams, including clinical experts in wound care, significantly affected pressure ulcer prevention. Additionally, leadership support was essential for pressure ulcer prevention teams to be effective. The recommended leadership members included senior nurse executives, quality management directors, and senior physicians. 

Hommel et al¹⁶ conducted a qualitative study to explore successful factors for pressure ulcer prevention in hospital settings. Thirty-nine (39) participants (managers, physicians, and nurses) were interviewed. The authors identified the following 3 major factors: creating a good organization, maintaining persistent awareness, and understanding the benefits for patients. Examples of these successful factors included prioritizing pressure ulcer prevention at all levels in the organization, nurse managers’ attitudes and engagement, as well as staff education on a regular basis. The Agency for Healthcare Research and Quality² identified staff involvement as a key element to successful outcomes of a PIP bundle. 

Tayyib and Coyer⁶ conducted a review of 25 studies and a meta-analysis to identify the best evidence regarding the effectiveness of interventions to reduce HAPUs in ICUs. Three (3) studies reported that prophylactic application of a silicone foam dressing decreased the incidence of sacral HAPUs. A meta-analysis of the review revealed the effectiveness of applying a silicone foam dressing for preventing sacral HAPUs in the ICU setting. The overall effect size across the studies was 0.12 (95% CI, 0.05-0.29; P < .00001).

A non-randomized comparison cohort, quasi-experimental study conducted by Park¹⁷ examined the effect of a silicone foam border dressing on the development of pressure ulcers among 102 patients older than 40 years of age with a Braden scale score of 16 or less who were admitted to 2 ICUs. Fifty-two (52) patients received standard pressure ulcer prevention care plus application of a silicone border foam dressing, and 50 received standard pressure ulcer prevention measures (control). Patients in the intervention group managed by a silicone foam border dressing showed significantly less pressure ulcer development compared with the patients in the control group (6% vs. 46%; Χ² = 21.722; P < .001). The European Pressure Ulcer Advisory Panel, National Pressure Injury Advisory Panel, and Pan Pacific Pressure Injury Alliance¹² recommend repositioning and the use of offloading devices as PIP strategies. 

Swafford et al¹⁸ conducted a quality improvement study to assess the effectiveness of a formal, year-long HAPU prevention program in an adult ICU. The incidence of HAPUs in the unit was reduced by 69% (3% of patients in 2013 [n = 17] vs. 10% of patients [n = 45] in 2011), despite a 22% increase in patient load. Richardson et al¹⁹ performed a quality improvement project with the goal of reducing HAPUs in CCUs. They chose to incorporate pressure ulcer prevention strategies in a bundled approach including valid pressure ulcer assessments, turning, sitting regimens, mattresses, skin care, and incontinence management. Pressure ulcer rates decreased from 8.08/100 patient admissions to 2.97/100 patient admissions, reflecting a relative rate reduction of 63% over 4 years. 

The purpose of initiating an EBP PIP bundle was 2-fold. The first purpose was to standardize HAPI prevention strategies in the adult CCU. The second purpose was to reduce HAPIs on the unit. The bundle would be used by the interdisciplinary team composed of nursing managers, nurses, respiratory therapists, and patient care associates (PCAs). 

The decision to select the unit to pilot the bundle was based on its incidence of HAPIs. There were 9 HAPIs on the pilot unit during the 14-month pre-intervention period (January 2017 to February 2018); this represented a HAPI rate of 3.4. The 14-month pre-intervention period rate was determined using the calculation (pressure injuries / patient care days) × 1000.²⁰

The unit chosen for PIP bundle implementation had a high incidence of HAPIs during the pre-intervention period. Pre-intervention data were obtained from WOC nurse consults and quarterly prevalence surveys. The unit was an 11-bed adult CCU in a 652-bed, tertiary, acute care hospital in New York City. Most patients are acutely ill with cardiac disease but medical and surgical intensive care overflow patients are also admitted. The delivery of care model was primary nursing, with a registered nurse (RN) to patient ratio of 1:2, and a patient care associate (PCA)/nursing assistant to patient ratio of 1:11. The average daily patient census was 9 and fluctuated throughout the day, with an average length of stay of 5 to 6 days.

During the PIP bundle initiative, the WOC nurses collaborated with nursing management and staff to obtain feedback regarding ease of use of, and adherence to, the bundle. Staff provided valuable feedback, which resulted in multiple revisions of the bundle. Audits were also conducted to assess adherence.

An interdisciplinary team was established to address HAPIs. The team consisted of 2 WOC nurses, 1 nurse manager, assistant nurse managers, RNs, respiratory therapists, and PCAs. 

A Population Intervention Comparison and Outcome (PICO) question was used to outline the clinical question and consisted of: 

(P) Patients in an adult CCU at risk 

       for HAPIs

(I) Implementation of a PIP bundle 

(C) Lack of standardized practice

(O) Decrease HAPIs

A review of the literature was conducted to identify EBPs to reduce HAPIs. PIP bundles have been associated with a reduction in HAPIs.^2,5,7,15 A bundle provides structure and standardization of evidence-based interventions to promote positive patient outcomes. Information garnered from the literature review as well as plans to develop and pilot the PIP bundle to reduce HAPIs were shared with key stakeholders, which included senior nursing leadership, the unit nurse manager, assistant nurse managers, RNs, respiratory therapists, and PCAs. Providing evidence to support the use of the bundle fostered commitment and adherence. Insight and input from stakeholders were vital to the development of the multidisciplinary PIP bundle. Staff involvement in the development and implementation of initiatives fostered engagement and success of the initiative. 

The implemented PIP bundle included use of the Braden scale. Bergstrom et al²¹ developed the Braden scale to promote early identification of the risk of pressure injury development. The Braden scores for patients who had HAPIs in the unit chosen for the initiative ranged from 8 to 14 (average, 12). The standard bed on the CCU allowed for continuous lateral rotation of the patient. A repositioning system was also used for patients with Braden scores of 18 or less. The bundle consisted of 2 sections (Figure 1). The WOC nurses divided the PIP bundle into 2 categories to easily identify the standard interventions from the high-risk interventions. Section 1 outlined standard interventions for patients with a Braden score of 19 or greater. Interventions in section 1 included a 2-RN skin assessment conducted together on all patients upon admission, transfer to the unit, and PIP strategies to reduce the risk of MDRPI development. Section 2 delineated the PIP interventions for patients with a Braden score of 18 or less. Components of section 2 included applying prophylactic dressings for prevention of pressure injuries, turning, positioning devices, and repositioning every 2 hours. Additional interventions included nutrition consultations, adjusting the head of the bed to 30 degrees or less (unless contraindicated), early mobility, a WOC nurse consultation for all HAPIs, and tips on documentation. 

An audit tool (Figure 2) was developed to assess adherence to the PIP bundle. Audits were initially performed by the resource nurse daily and then weekly. The WOC nurses collected the data and disseminated the results to the nursing leadership and during quality council meetings. The WOC nurses provided additional teaching when needed. Adherence to the bundle was reinforced by the WOC nurses, nurse manager, assistant nurse managers, and resource nurses.

Pre-intervention period. Prior to bundle implementation, meetings were held with the unit nurse manager, assistant nurse managers, staff nurses, PCAs, and respiratory therapists to discuss development of the PIP bundle. These meetings encouraged staff involvement in the planning and development processes. The PIP bundle was shared with senior nursing leadership to engage them in the process. Research has shown that nurse leadership engagement is vital to successful implementation of and adherence to a bundle.^5,14,16,19 Additionally, the WOC nurses met with quality improvement specialists as well as the quality and education councils. The meetings served to disseminate information regarding the PIP bundle and the pilot. 

Quality improvement staff assisted in the development of the audit tool. Two (2) staff nurses volunteered to be resource nurses.

Intervention period. Throughout the month of February 2018, in-service programs were held by the WOC nurses during morning briefs to educate staff on the elements of the PIP bundle. Education included potential patient complications arising from a single pressure injury to foster commitment to use of the bundle. Morning briefs provided an opportunity to meet with morning and night staff working 12-hour shifts. The WOC nurses also met with the evening PCAs, because their work schedule is composed of 8-hour shifts. While in-service programs were held, the WOC nurses conducted daily and then weekly rounds to foster understanding and use of the PIP bundle. Rounds were also conducted by the nurse managers and assistant nurse managers. The bundle was incorporated into change-of-shift briefs as a reminder to implement the appropriate strategies. To further support the bundle, the resource nurses completed the audits and encouraged adoption of the bundle. Results of the audit tools were reviewed by the WOC nurses and disseminated to nursing leadership, nurse managers, and nursing executive leadership. Laminated copies of the PIP bundle and turn clocks were posted in all rooms for ease of reference and accessibility. 

WOC nurses conveyed to staff the importance of their involvement and the value of their feedback. Staff was receptive and committed to reducing HAPIs on the unit. Staff and the resource nurses provided constructive feedback regarding the bundle. Feedback included concerns regarding perceived additional time required to implement the bundle. Assistant nurse managers supported staff at the bedside when needed to ensure that the bundle was being used when appropriate. 

HAPI incidence was reported on a daily basis by the resource nurse or the bedside nurse through a WOC nurse consult. Pressure injury consults were also generated by physicians or physician’s assistants. HAPIs may have been identified during skin care rounds with WOC nurses or during quarterly prevalence surveys. 

Data management/analysis. The HAPI data were collected daily and reported monthly. The WOC nurses recorded monthly pressure injury data electronically in a pressure injury database, which was developed internally by the WOC nurses with assistance from a data analyst. The HAPI index was determined using the calculation (pressure injuries / patient care days) × 1000.²⁰  The pressure injury database is a repository for pressure injuries at the author’s facility and generates a pressure injury index. The monthly pressure injury index is then reported to the hospital health care system.  

The pre-intervention HAPI index was 3.4. This included all stages of HAPIs on the unit over a period of 13 months. The post-intervention HAPI index decreased to 0.48 over a period of 10 months.

The PIP bundle audit tool provided valuable information regarding adherence to the bundle and knowledge gaps regarding pressure injury prevention and documentation in the electronic medical record (EMR). Since the bundle was not a part of the EMR, the WOC nurses would reinforce its use during rounds and wound consults. Audits revealed that the PIP bundle interventions were documented in different areas of the EMR, making it time-consuming to find the documentation. Information gleaned from the audits was shared with staff. Feedback from staff identified gaps in knowledge regarding PIP prevention documentation in the EMR. Staff requested re-training on documentation related to pressure injury prevention and treatment.  The WOC nurses provided  re-training as requested. Additonally, the WOC nurses instructed and reviewed documentation with staff during daily briefs, rounds, and WOC consultations. Use of the bundle was reinforced by the WOC nurses, resource nurse, nurse manager, and assistant nurse managers during daily briefs and PIP rounds.

Results of the audits provided valuable information regarding gaps in knowledge associated with documentation in the EMR and adherence to the bundle. These gaps in knowledge were critically important to address due to the litigious environment associated with pressure injuries. The WOC nurses ensured staff was educated regarding documentation associated with PIP and treatment. The WOC nurses, nurse manager, assistant nurse managers, and resource nurses supported the staff to foster adherence to the bundle. As a result of the success of the PIP bundle in the adult CCU, the bundle was implemented in all critical care, step-down, and medical-surgical units in the hospital. The challenge, as with many initiatives, is sustaining the positive outcomes. 

Implementation of the PIP bundle resulted in a considerable decrease in HAPIs on the adult CCU. The pre-intervention HAPI index was 3.4. This included all stages of HAPIs on the unit over a period of 13 months. The post-intervention HAPI index decreased to 0.48 over a period of 10 months. The pre-intervention pressure injuries consisted of 3 stage 2 pressure injuries, 5 DTPIs, and 1 unstageable pressure injury. Pre-intervention HAPI locations were 1 on the ear, 5 on the sacrum, 1 on the ischial tuberosity, 1 on the upper thigh, and 1 on the heel. The post-intervention HAPI was a stage 2 on the sacrum. 

The implementation experiences were consistent with what are noted in the literature. The implementation of the PIP bundle and reduction of HAPIs required a comprehensive approach. In the current study, involvement and support of key stakeholders promoted engagement, a sense of ownership in the process, and pride in the successful outcomes. Support from staff and leadership were key elements to promote the adoption, adherence, and sustainability of the bundle. Routine auditing identified areas for improvement. 

Anderson et al¹⁴ described the use of the pressure ulcer prevention bundle with WOC nurse support in 3 ICUs. The unit-acquired pressure injury incidence rates decreased from 15.5% pre intervention to 2.1 % post intervention. Coyer et al¹⁵ reported on the effectiveness of a bundle in an adult ICU that resulted in 18.1% HAPUs in the intervention group compared with 30.4% in the control group (P = .4).

Educating staff about the complications arising from a single pressure injury helped foster commitment to the use of the bundle. Use of the bundle was determined by audits of the EMR, pressure injury prevention rounds, and wound consults. In addition to the resource nurses, skin champions were selected for both day and night shifts, and charge nurses were tasked to take the lead in assisting with adherence to the bundle. Positive results contributed to continued use of the bundle on the unit

A key limitation of these results is that patient and environmental variables that may have affected HAPI rates before and after implementation of the bundle were not assessed. An additional limitation is the follow-up time of only 10 months. Additional follow-up time would determine sustainability of its use. Future follow-up will incorporate potential variables that may have affected HAPI rates and longer post-intervention follow-up time. As with most initiatives, the ongoing challenge is to maintain staff commitment and engagement. Sustainability of the bundle and a continued decrease in HAPIs are dependent on all stakeholders remaining vigilant and focused on prevention. 

The purpose of this EBP initiative was to implement a PIP bundle and decrease HAPIs in an adult CCU. The WOC nurses spearheaded the initiative and developed, organized, and collaborated closely with all key stakeholders. Staff commitment to the initiative and their feedback propelled the initiative forward. Senior nursing leadership, the unit nurse manager, and assistant nurse managers conveyed the importance of decreasing HAPIs. The resource nurses provided invaluable insight from the bedside. 

Implementation of the bundle over a period of 10 months resulted in a decrease in the unit-acquired HAPI rate from 3.4 pre-intervention to 0.48 post-intervention. As a result, the bundle was implemented in the critical care, step-down, and medical-surgical units in the hospital.

Health care workers share the common goal of providing high-quality patient care. Preventing HAPIs is an essential part of that goal. Decreasing HAPIs and sustaining that momentum is an ongoing challenge. Further research such as randomized control trials are needed to increase the evidence level of PIP bundle implementation

The authors thank and acknowledge all members of the adult cardiac CCU for their professionalism, commitment, and support throughout the pilot program. Additionally, we extend our gratitude to senior nursing leadership for championing the bundle. Success and sustainability of the bundle would not have been possible without the efforts of all those involved. 

Ms. Rivera and Ms. Donohoe are wound, ostomy, and continence nurse educators, Department of Nursing Education and Professional Development, Lenox Hill Hospital, New York, NY. Ms. Deady-Rooney is  director of nursing, Intensive Care, Medical-Surgical, Rehabilitation, NYC Health and Hospitals, Metropolitan, New York, NY. Ms. Douglas is an assistant nurse manager, Cardiac Critical Care Unit, Lenox Hill Hospital, New York, NY. Ms. Samaniego is a nurse manager, Catheterization Lab, Lenox Hill Hospital, New York, NY. Address all correspondence to: Julie Rivera, MSN, RN, NPD-BC, CWOCN, Department of Nursing Education and Professional Development, 100 E 77th St, New York, NY 10075; email: jrivera31@northwell.edu.

None disclosed