Document Type


Publication Date


Date of Final Presentation


Committee Chair

Teresa Serratt, RN, PhD

Committee Member

Cara Gallegos, PhD, RN

Coordinator/ Chair of DNP Program

Pamela Gehrke, EdD, RN

Abstract/ Executive Summary

Background: For many health care organizations, pressure injury (PI) prevention strategies have become a priority focus to improve patient outcomes and associated costs.

Problem: A rural community hospital located in the Eastern U.S. experienced an increase in hospital acquired pressure injuries (HAPIs), predominantly in the intensive care unit (ICU). In 2018, 17.4% of HAPIs occurred in the ICU.

Approach: Implementation of a Quality Improvement project in an adult ICU, providing education and on-going learning activities to nursing staff, and applying a standardized plan of care “bundle” for prevention interventions.

Outcomes: The approach resulted in improved documentation of flotation of heels, incontinence pads, and moisturizer to skin. During the project period of 3 months, zero HAPI events occurred.

Conclusions: The implementation of a PIP program may contribute to the decrease in HAPI rates in the ICU setting. On-going monitoring is needed to evaluate sustainability of the program.

Available for download on Friday, April 08, 2022