Reducing Hospital-Acquired Pressure Injuries via a Quality Improvement Initiative: Results and Insights Gained

Hospital-acquired pressure injuries (HAPIs) remain a largely preventable cause of patient injury and are often utilized as nursing-sensitive quality metrics. At a tertiary military hospital in XXXXXX, rising HAPI rates necessitated implementing a comprehensive quality improvement program in accordance with the National Database of Nursing Quality Indicators (NDNQI) guidelines. On the basis of Donabedian's Structure-Process-Outcome model, we hypothesized that the implementation of a standardized, evidence-based pressure injury prevention bundle, accompanied by structured staff education (structure), will enhance adherence to prevention practices (process) and markedly decrease HAPI incidence and prevalence (outcomes) among hospitalized adult inpatients.

To assess the effect of introducing a standardized, evidence-based pressure injury prevention bundle and corresponding staff education on HAPI incidence and prevalence.

We implemented a comprehensive hospital-wide quality improvement project utilizing a pre-post methodology underpinned by Plan-Do-Study-Act (PDSA) cycles, statistical process control monitoring, and the FOCUS-PDSA framework. The strategy established a standardized preventive package for high-risk patients; it included routine risk and skin assessments, scheduled repositioning, pressure redistribution support surfaces, nutrition optimization with dietitian input, and moisture control. The primary outcomes were monthly HAPI incidence (per 1,000 patient-days), measured using wound care census and unit reporting, and quarterly HAPI prevalence, evaluated using NDNQI surveys by trained NDNQI link nurses, with >90% interrater reliability for staging.

In the initial deployment phase (July-December 2023), the HAPI incidence rate was 2.32 per 1,000 patient-days (267 cases/115,314 patient-days). The incidence declined to 1.44 per 1,000 patient-days (330 cases/229,647 patient-days) in 2024 (38% reduction from the baseline) and to 0.88 per 1,000 patient-days (98 cases/111,589 patient-days) by June 2025, (62% reduction from the baseline). The prevalence decreased from 5.12% in Q3 2023 to 1.38% in Q3 2024 and remained low at 1.43% in Q2 2025.

Implementation of a standardized prevention bundle, supported by systematic staff education, interdisciplinary collaboration, and periodic incidence and prevalence surveillance was associated with sustained reductions in HAPI incidence and prevalence over 2 years. These findings support a bundle-based approach to prevention, combined with real-time feedback and competency-driven teaching, as a scalable means of enhancing patient safety.

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