Quality Improvement Proposal
Hospital acquired pressure injury (HAPI) is a growing concern within the acute and
critical care settings of the hospital. The skin is the largest organ in the body and is just as
important as any other organ in the body. Unfortunately, when looking at older adults, patients
with multiple co-morbidities, and very sick patients, skin can be frail and fail just like any other
organ within the body (Gesensway, 2009). The Centers for Medicare and Medicaid Services
(CMS) have declared HAPI as one of 10 conditions or occurrences that should be “never events”
during a hospital stay. As defined by the National Quality Forum (NQF), a “never event” is an
“error in medical care that is clearly identifiable, preventable, and serious in their consequences
for patients, and that indicate a real problem in the safety and credibility of a health care facility
("Never Events," 2006, para. 2). HAPI is one of many “never events” that attribute to
compromised safety to the patient and increased hospital costs throughout the admission.
Because of the increase in costs incurred due to HAPIs and other “never events,” CMS has
developed a Hospital-Acquired Condition (HAC) Reduction Program that “encourages hospitals
to make patient safety better and reduce the number of hospital-acquired conditions” (CMS.gov
website, 2018, para. 1). For hospitals that are evaluated and listed as worst among other
hospitals for the number of hospital-acquired conditions, there is a reduction in reimbursement
and in many instances, the HAC costs become the burden of the facility (CMS.gov website,
2018).
Necessity for Quality Improvement Initiative
Pressure injury can have many adverse effects on a patient throughout their admission.
Pressure injury can: increase length of stay, increase costs, increase patient recovery time,
increase pain and discomfort for the patient, increase chances for infection, and increase their
QUALITY IMPROVEMENT PROPOSAL 3
morbidity and mortality rate (Salicki & Dion, 2016). There are times when HAPI cannot be
avoided. When a patient is highly compromised medically, it may be impossible to prevent a
HAPI from occurring. However, we must do all we can to document and show that everything
possible was done to try to prevent a HAPI from occurring. This includes documentation of skin
on admission, hydration, nutrition, turning frequencies, mobility, and proper bed surface for the
individual patient assessed. Nurses must also be vigilant to inform the physician when a pressure
injury is present on admission so that proper documentation can be provided by the physician to
prevent the pressure injury from being identified as a HAPI down the line (Gesensway, 2009).
HAPI within my facility has shown a significant increase over the last year. In 2018,
the total number of HAPI events was 8. From January through the end of May 2019, our facility
has identified 23 HAPI events. This is an alarming increase in HAPI in a short period. The need
to address the issue was immediately identified in order to provide quality and safe care to our
patients and to allow for optimal reimbursement from our insurance providers. Due to the
increase of identified HAPI, in March of 2019, our Wound & Ostomy nurses started to drill
down on the individual events and researched a plan of attack to decrease HAPI events.
Supporting Evidence for Quality Improvement Initiative
Multiple research studies have been conducted surrounding pressure injury prevention.
One such study centered on nursing knowledge about pressure injuries and nursing attitude
toward pressure injury prevention. The study was done to “determine if there was a relationship
between knowledge, attitude, and years of experience following an unexplained increase in
reported hospital-acquired pressure injuries” (Barakat-Johsnon, Barnett, Wand, & White, 2018,
p. 233). The findings demonstrated a strong knowledge base for pressure injury (PI)
identification and prevention, as well as a positive attitude toward prevention. However, the
QUALITY IMPROVEMENT PROPOSAL 4
findings were a contradiction to the increase in HAPI which was the initial reason for the study
(Barakat-Johsnon et al., 2018). This brought on the thought process that “successful transfer of
knowledge relies upon a process that considers the clinical context and methods needed to
change and sustain practice” (Barakat-Johsnon et al., 2018, p. 236). This means, knowledge and
attitude are not enough to