Phillip December 11, 2025 No Comments

D221 Final Paper: Practice Improvement Plan for Pressure Injury Prevention

Name

Western Governors University

D221 Organizational Systems and Healthcare Transformation

Prof. Name

Date

D221 Practice Improvement Plan Proposal

Situation (S)

What is the healthcare-related situation?

Implementing systematic, evidence-based turning protocols for immobile hospitalized patients is essential in nursing care to ensure patient safety. Without proper repositioning and vigilant monitoring, patients are at a heightened risk of developing pressure injuries. These injuries can cause significant pain, lead to infections, and result in prolonged hospital stays. Such complications not only delay recovery but also complicate discharge planning and increase the chances of hospital readmissions. Ultimately, the lack of effective pressure injury management negatively affects patient outcomes, increases strain on healthcare resources, and hampers the operational efficiency of hospital units.

Background (B)

What data highlight the issue of hospital-acquired pressure injuries?

Hospital-acquired pressure injuries (HAPIs) serve as a crucial quality indicator across healthcare facilities in the United States, reflecting nursing care standards and patient safety levels (Tervo-Heikkinen et al., 2023). Annually, over 2.5 million Americans suffer from pressure ulcers, which cause considerable pain, elevate infection risks, and add substantial healthcare costs. To combat this, the Agency for Healthcare Research and Quality (AHRQ) introduced the Pressure Injury Prevention Toolkit in 2012. This toolkit advocates for multidisciplinary collaboration, routine skin assessments, adherence to patient repositioning schedules, and comprehensive staff education on risk management. Through these concerted efforts, healthcare professionals can enhance patient safety, reduce complications, and support more effective healing processes.

What are the patient safety standards related to pressure injury prevention?

The Joint Commission’s National Patient Safety Goal (NPSG.14.01.01) emphasizes the importance of preventing pressure injuries as a core safety initiative. Compliance with these clinical standards allows for early detection and timely intervention for patients at risk. Healthcare providers employ validated tools like the Braden Scale to systematically assess skin integrity and risk levels. Preventive measures encompass keeping the skin clean and dry, reducing friction and shear forces, and strictly following repositioning schedules. These practices collectively improve tissue resilience, minimize injury risks, and align with the highest nursing standards to ensure quality care.

Assess (A)

What is the impact of pressure injuries on healthcare systems?

Pressure injuries impose a substantial financial and operational burden on healthcare organizations. Hospitals face rising expenses related to specialized wound care products, advanced support surfaces, longer nursing hours, and the use of antibiotics to manage infections. Beyond financial implications, these injuries can diminish patient satisfaction scores and negatively affect care quality metrics. The increased demand for pressure injury management contributes to nurse fatigue, stress, and burnout, which in turn can reduce overall organizational productivity and effectiveness.

What is the value of preventing pressure injuries?

Preventive strategies offer clear benefits to both patients and healthcare teams. Patients benefit from quicker recoveries, decreased pain levels, and enhanced comfort. For clinical staff, prevention decreases the time spent on documentation, frees up valuable clinical hours, and improves workflow efficiency. Moreover, pressure injury prevention reflects a commitment to patient-centered care, fulfilling ethical duties and professional nursing responsibilities.

Evidence-Based Practice Change

How does integrating pressure injury prevention protocols support organizational goals?

Adopting a structured pressure injury prevention protocol aligns with the pursuit of becoming a High-Reliability Organization (HRO). HROs prioritize consistent practices, accountability, and proactive risk management to reduce patient harm (Khan & Jonusas, 2019). By standardizing repositioning intervals and employing validated risk assessment tools across care units, hospitals can ensure equitable and evidence-based care for all patients. Research consistently shows that repositioning immobile patients every two hours significantly lowers the risk of pressure injuries. Compliance with guidelines from AHRQ and The Joint Commission fosters a culture of safety and strengthens organizational resilience.

What are the common barriers to implementing turning protocols?

Two major challenges hinder the adoption of turning schedules:

Barrier	Description
Scheduling Conflicts	High patient-to-nurse ratios and unpredictable unit activities disrupt regular repositioning.
Patient Non-Compliance	Patients may refuse repositioning due to discomfort, fatigue, or lack of understanding.

What interventions can overcome these barriers?

Targeted strategies can effectively address these challenges:

Barrier	Intervention
Scheduling Conflicts	Assign dedicated “turn teams” or staff members to focus exclusively on repositioning duties.
Patient Non-Compliance	Involve patients in planning their repositioning schedules and educate them using visual aids and bedside communication tools.

Why is shared decision-making important in pressure injury prevention?

Successful implementation depends on collaborative decision-making among nurses, physicians, and wound care specialists. Establishing common goals regarding skin integrity promotes accountability and enhances communication. A team-based nursing model fosters shared responsibility, reducing confusion about roles and responsibilities. This cooperative approach leads to consistent and coordinated care, improving patient outcomes.

What outcome measures are useful to evaluate the intervention?

Effectiveness should be measured using specific outcome indicators, including:

Tracking the incidence rate of new pressure injuries pre- and post-protocol implementation.
Using audit tools and electronic health record (EHR) documentation to assess compliance with repositioning schedules.
Gathering qualitative feedback from nursing staff about operational challenges and workflow barriers to guide continuous improvements.

How does the care delivery model influence pressure injury prevention?

Transitioning from a task-focused to a team-based care model provides a more sustainable framework for pressure injury prevention. Within this model:

Role	Responsibilities
Nurse Managers	Oversee adherence to protocols and documentation accuracy.
Charge Nurses	Coordinate staff schedules and monitor workflow efficiency.
Nursing Staff	Carry out repositioning tasks and provide feedback on care processes.

This structured approach promotes interprofessional collaboration, accountability, and enhanced communication, which collectively improve patient outcomes, increase staff engagement, and elevate overall hospital performance.

Summary Table: Barriers and Interventions for Turning Schedule Implementation

Barrier	Intervention
Scheduling Conflicts	Assign and train designated staff specifically responsible for patient repositioning.
Patient Refusal to Comply	Engage patients in care planning and provide educational support to encourage cooperation.

References

Agency for Healthcare Research and Quality. (2017). Pressure injury prevention in hospitals training program. https://www.ahrq.gov/patient-safety/settings/hospital/resource/pressureinjury/index.html