Reducing the Pressure: Improving the Safety of Adult Inpatients at an Urban Hospital by Reducing Pressure Injury...

Background: Approximately 2.5 million hospital visits in the United States are due to pressure injuries (PIs), costing $11 billion and resulting in 60,000 deaths annually. Objective: The objective of the study is to decrease the incidence of PIs in a hospital setting using Situation, Background, Assessment, Recommendations, Wounds (SBARW) report sheets, turn clocks, and team engagement in a nurse-led quality improvement initiative. Methods: Four rapid Plan-Do-Study-Act cycles were implemented over 8 weeks. Aggregate data, run charts, staff feedback, and field notes were studied and guided new tests of change for each cycle. Results: The incidence of PIs decreased from a baseline of 40% to 17% over the 8-week period, which exceeded the goal of 20%. The average mean prevention score reached 74%, from a baseline of 45%. Skin assessment documentation increased from a baseline of 35% to 95%. Conclusions: The project was successful; the aim was exceeded through utilizing the best practice guidelines and toolkits, implementation of tools, and team participation. The project improved safety and communication while maintaining cost-effectiveness. Implications for Nursing: The SBARW and care audit tools can support the best practices to reduce PI incidence and show promise for improving quality nursing care.