Date of Doctor of Nursing Practice Project Completion

Fall 12-31-2027

Faculty Advisor

Dr. Shannon Warren

Abstract

PURPOSE

The purpose of this project was to evaluate the effectiveness of implementing an ICU-specific pressure injury prevention bundle (SKIN SAFE) Sto reduce hospital-acquired pressure injuries (HAPIs) in an adult Surgical ICU.

BACKGROUND

HAPIs remain a major safety concern in critically ill patients. Standardized prevention bundles improve adherence and reduce incidence.

METHODOLOGY

This QI project in a 20-bed Surgical ICU used the PDSA framework to implement the eight-component SKINSAFE bundle. Strategies included staff education, champions, and weekly audits. Data were collected through EMR review, monthly PIP audits for HAPI incidence, and weekly compliance audits.

RESULTS

Pre-intervention data showed two HAPIs in April 2025, one in August, and four in September. Post-implementation, zero HAPIs were reported in October and one in November. Three additional injuries occurred in December, all in a single critically ill patient with significant instability and multiple risk factors. Staff compliance improved from 65% to 80%, exceeding the 75% target.

IMPLICATIONS

Implementation of the SKINSAFE pressure injury prevention bundle improved adherence to evidence-based practices and was associated with a reduction in hospital-acquired pressure injuries in the Surgical ICU. These findings support the use of standardized prevention bundles to promote consistent, high-quality care in high-acuity settings.

Long-term sustainability will require ongoing education for newly hired staff, continuous compliance monitoring, and real-time feedback to reinforce adherence and support improved patient safety outcomes.

Keywords

hospital-acquired pressure injuries, pressure injury prevention bundle, critical care, surgical intensive care unit, quality improvement

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