Nurses and Teamwork Play Vital Role in Reducing Hospital-Acquired Pressure Injuries

During late 2021 and early 2022, Salinas Valley Health Intensive Care Unit (ICU) clinical nurse Francie Espino, BSN, RN, CCRN, CSC, noticed increases in both the rate (incidence) of new hospital-acquired pressure injuries (HAPIs) and their quarterly prevalence. By February 2022, the rate had jumped to 3.88%.

The jump was likely due to increased use of respiratory devices, prone positioning and isolating patients during the COVID-19 pandemic. Still, as co-chair of the Quality Council, Espino felt a need to act. She and Becky Rodriguez, MSN, RN, CEN, CPHQ, Clinical Excellence Specialist from the Magnet® Department, contacted Katrina Cross, BS, RN, CWOCN, the inpatient wound care clinical nurse who tracks HAPI incidence data and leads the quarterly prevalence studies. Together, they reviewed the data and the literature and then created an evidence-based HAPI prevention bundle tailored to the needs of ICU patients. By the end of the intervention period, they had led an effort that cut the HAPI rate essentially in half.

Literature Search Yields a Tailored Care Bundle

The work began with securing support from ICU Manager Kelly Flower, MSN/MHA, RN, CCRN-K, CNML, and Critical Care Director Carla Spencer, MSN, RN, NEA-BC. Espino, Rodriguez and Cross then searched the literature and professional guidelines for care bundles and other best practices for HAPI prevention. The goal was to address the fact that HAPI prevention for nurses had typically relied on individual nurses’ knowledge of prevention strategies or the use of an old checklist about which some nurses were unaware.

Espino, Rodriguez and Cross met regularly to synthesize the most promising HAPI prevention strategies, ultimately compiling their findings into a draft care bundle with a checklist and eight color-coded sections, called HAPI SKIN. They also worked with informatics to design a pop-up within the electronic health record, activated when a clinician documented a Braden score of 18 or less. The pop-up prompts the nurse to view HAPI SKIN and document that they evaluated and implemented all applicable components of the bundle.

After sharing the draft bundle with members of the Quality Council, Practice Council and inpatient Unit Practice Councils and gathering staff feedback, they created a final version. They then worked with the Marketing Department to create an easy-to-use infographic.

Spreading the Word and Educating the Nurses

In addition, Espino worked with ICU Educator Mark Stevens, MSN, RN, CCRN-KTM, to develop accompanying education for nurses. In September, Espino and Stevens shared the education and pop-up screen with ICU nurses via a mandatory e-learning module and a binder on the unit and during unit rounds. In addition, once HAPI SKIN went live in the ICU in October 2022, Cross helped spread the word by discussing it at unit huddles and staff meetings.


“The results are clear. For the final two months of 2022 and the first of 2023, HAPI incidents dropped significantly from a baseline of 3.88% to between 1% and 2.4%,” says Espino.

Infographic of reduced HAPI incidence rates

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