Enhancing Hospital-Acquired Pressure Injuries Prevention and Reduction

Subject: Nursing
Pages: 6
Words: 1675
Reading time:
8 min


Hospital-acquired pressure injuries (HAPIs) is a sizeable healthcare problem impacting hospitals in the United Arab Emirates as well as around the globe. It is estimated that the issue affects one in twenty hospitalized patients, accentuating the need to act (1). The problem is caused principally by a patient’s lack of mobility and its implications (1). Consequently, an array of solutions and interventions were designed to compensate for the deficiency and take care of the affected areas, but staff’s non-compliance and ignorance regarding the issue prompt high prevalence and incidence of HAPIs.

The Problem Statement

Despite extensive efforts and multiple prevention programs developed worldwide, pressure injuries continue to remain a problem with which patients with limited mobility struggle in hospitals in developed as well as developing countries. The persistence of the problem, particularly in ICUs, provoked the thought that some HAPIs might be unavoidable (2). Yet scientific evidence shows that appropriate documentation and evidence-based preventive measures are critical in dealing with the problem, as the predominant portion of HAPIs can be avoided (2). The relevancy of the question of whether all bedsores can be prevented is diminished by such a gap in nursing practice as insufficient nurses’ knowledge. For instance, a study conducted by De Meyer et al. shows a deficit in HAPI prevention knowledge among nurses and nursing assistants (3). The study’s results underscore the need to enhance education to improve nursing practice.

Furthermore, the strain that HAPIs pose on the country’s healthcare system is augmented by the lack of structured SSKIN care bundle in ICUs. This intervention bundle is a powerful instrument consisting of regular skin inspection, use of effective skincare products, systematic repositioning, managing incontinence, preventing moisture, and heightened attention to hydration and diet (4). Many of these elements seem to be incorporated and maintained in healthcare facilities; still, the bundle’s effectiveness lies in the unified and multifaceted approach to the problem’s prevention. The use of a separate SSKIN care bundle elements does not yield the needed efficiency but is commonly practiced. For instance, a patient at risk of developing a bedsore is regularly repositioned, and moisture is prevented, but the diet and skincare are neglected. As a result, this unstructured partial prevention strategy does not contribute to the problem’s resolution.

The expertise and knowledge about the Braden Scale’s use is another significant problem that was observed through meeting with the staff and in scholarly literature. Thus, a survey effectuated by Feng et al. demonstrated that “nursing staff had little knowledge of the Braden Scale” (p. 31, 5). The survey included approximately three hundred nurses, which makes the results statistically significant for the institution. Moreover, another study performed by Pandhare and Dhudum established that a strong necessity to improve nursing staff’s knowledge regarding the assessment tool in question existed (6). Such a gap in expertise prevents medical professionals from timely recognizing patients at higher risk of developing a pressure injury and, consequently, providing appropriate care (6). Not being able to incorporate the Scale into their pressure injury prevention clinical practice in-depth, nurses frequently do not know what scores correspond to what interventions.

Standard Interventions and Solutions

Firstly, nurse education and training are crucial in decreasing the hospital’s high-pressure injury prevalence and incidence rates. Staff education and training campaigns revolving around standardizing the management of HAPIs would help in alleviating the issue. Nursing staff of all levels, but notably in ICU, needs to participate in pressure injury training, providing them with information regarding causes, risk factors, assessment tools, prevention strategies, interventions, treatment, and ultimate developments. The most considerable section of such a campaign will be acquainting the nursing staff with international guidelines for the prevention and treatment of pressure injuries, which provide evidence-based reliable recommendations on HAPIs (7). A comprehensive test incorporating various aspects of HAPI prevention and treatment will finalize the staff education and training campaign. It should be noted that although staff education is indispensable in prevention, without the proper resources and materials that the SSKIN bundle requires, it potentially cannot yield maximum results.

Secondly, implementing the SSKIN care bundle is fundamental for decreasing HAPI incidence in the healthcare facility under consideration. Academic literature supports the effectiveness of the resource pack. For instance, Smith et al. declare SSKIN care bundle one of the most popular for preventing pressure ulcers (8). This prevention and reduction method locates and unites the most effective practices by targeting the primary causes of HAPIs: limited movement, pressure, moisture, shear, and friction. An additional advantage of the SSKIN care bundle is that it emphasizes preventive measures instead of treatment (8). Yet, implementing this care bundle has a considerable disadvantage: revising the diet of patients at higher risk of developing a pressure injury entails substantial financial expenditures for the hospital. Still, to be the most effective, all elements of the resource pack need to be incorporated into clinical practice.

Lastly, successful HAPIs prevention necessitates that nursing staff masters the assessment tools, notably the Braden Scale. Although it is widely-recognized and employed globally, this assessment tool has a major drawback: the patient status descriptions that it uses are rather vague and leave nurses space for interpretation (9). Therefore, besides general training on proper assessment using the Braden Scale, it is proposed to use visualization so that the subjectivity of descriptions could be avoided (9). Another visualization element would be assigning various color markers to the Braden Scale risk categories, identifying the patients needing urgent attention. These cost-efficient measures serve to increase the HAPI prevention training’s effectiveness.

Goals and Measurable Outcomes

The general goal is to reduce the incidence of HAPIs in the facility optimally by ten percent. In order to narrow down the established gaps, several major goals should be reached, including increasing the staff’s awareness regarding HAPIs, implementing evidence-based interventions such as the SSKIN care bundle, and refining the use of the Braden Scale in the facility. Therefore, three major goals are defined and should be achieved by the end of this project. The approximate duration of the improvement project is two and a half years – this period should suffice to localize and mobilize the resources, develop an educational campaign, and observe the interventions’ results.

The first goal presupposes testing nurses’ HAPI prevention and reduction awareness before and after an educational campaign, as a result of which it should increase by at least 20%. The second and third goals will be founded on the first one. Thus, the SSKIN care bundle will be explained and demonstrated to the nurses and nursing assistants by chief nurses, who will supervise how well it is implemented into practice. The medical staff will undergo visualized lessons on the Braden Scale, and they will be acquitted with the new color-coding system, signaling a patient’s risk of developing a pressure ulcer.

Overall, by the end of the project, its effectiveness will be judged by whether the next criteria are obtained:

  • the staff’s test results on HAPI awareness and prevention knowledge is increased by 20%;
  • the Braden Scale is used regularly applied to all patients with limited mobility, and their status showed through a color-coding system;
  • the SSKIN care bundle is extensively practiced in the hospital’s ICU;
  • in the result, the incidence of HAPIs in the facility is reduced by ten percent.

Literature Review

HAPIs, as an impactful public health problem, gathered a sizeable body of research literature dedicated to the subject. Generally, pressure injuries can be characterized as adverse effects of hospitals with poor quality of provided care. From the academic perspective, a pressure injury can be defined as a “localised injury to the skin and underlying tissue, usually over a bony prominence, as a result of pressure, or pressure in combination with shear” (10, p. 2). It appears to be commonly accepted that the problem has a global scope, and its financial implications for healthcare systems are tangible (11, 12). The United Arab Emirates is also not invulnerable to this public health issue.

Given the impact that HAPIs cause on the global healthcare situation, numerous solutions have been elaborated. Thus, nurse education and training are academically supported interventions. Gupta et al. emphasize the role that the use and education about the Braden Scale played in their quality improvement program: the researchers reeducated their nursing staff on the proper usage of this assessment instrument (13). Among other interventions, this training contributed to a 73.4% decline in HAPI prevalence (13). One more essential element in resolving the problem is a systematic approach to HAPI prevention embodied in the SSKIN bundle. Mitchell positions the SSKIN bundle as one of the most prominent prevention strategies (14). Campbell similarly encourages the use of this strategy, stating that it yields “sustained pressure ulcer reductions, which should be embraced” (4, p. 19). Additionally, the Braden scale color-coding seems to be more and more adopted. McNeil et al. implemented an electronic visual tool that displayed a patient’s status according to the Braden Scale (15). The system increased early detection and intervention, reducing the mortality rate (15). Although the visual tool will be manual in the proposed project, this difference is not supposed to significantly reduce its effectiveness.

Overall, the selected interventions were chosen among numerous others due to their high effectiveness evidenced in scholarly research sources. The SSKIN care bundle has been repeatedly demonstrated as one of the most productive reduction and prevention strategies. The Braden Scale, if used correctly, helps identify at-risk patients early, entailing timely intervention. Nursing staff education and training are supposed to prepare the ground for the implementation of the proposed solutions.


Such gaps in clinical practice as lack of HAPI awareness, ineffective assessment, and unstructured prevention strategies contributed to the current high prevalence of pressure injuries in the hospital. The presented interventions serve to resolve the challenge that HAPIs pose in the facility under consideration. Staff education and training, a structured multifaceted approach (the SSKIN care bundle), and efficient early detection (the Braden Scale) target the prevalence of pressure ulcers, particularly among ICU patients. The interventions are extensively tested, and their efficiency is corroborated by research studies conducted in various parts of the world.


  1. Renganathan B, Preejith S, Nagaiyan S, Joseph J, Sivaprakasam M. A novel system to tackle hospital acquired pressure ulcers. 2016 38th Annual International Conference of the IEEE Engineering in Medicine and Biology Society (EMBC). 2016: 4780-4784.
  2. Pittman J, Beeson T, Dillon J, Yang Z, Cuddigan J. Hospital-acquired pressure injuries in critical and progressive care: Avoidable versus unavoidable. American Journal of Critical Care. 2019; 28(5): 338-350.
  3. De Meyer D, Van Damme N, Van den Bussche K, Van Hecke A, Verhaeghe S, Beeckman D. PROTECT – trial: A multicentre prospective pragmatic RCT and health economic analysis of the effect of tailored repositioning to prevent pressure ulcers – study protocol. Journal of Advanced Nursing. 2016;73(2): 495-503.
  4. Campbell N. Electronic SSKIN pathway: Reducing device-related pressure ulcers. British Journal of Nursing. 2016;25(15): 14-26.
  5. Feng H, Li G, Xu C, Ju C. Educational campaign to increase knowledge of pressure ulcers. British Journal of Nursing. 2016;25(12): 30-35.
  6. Pandhare S, Dhudum B. Effectiveness of PTP regarding use of Braden Scale for pressure sore on knowledge and practices among staff nurses working in selected hospitals. International Journal of Nursing Education. 2018; 10(4): 139.
  7. European Pressure Ulcer Advisory Panel, National Pressure Injury Advisory Panel, and Pan Pacific Pressure Injury Alliance. Prevention and Treatment of Pressure Ulcers/Injuries: Clinical Practice Guideline. The International Guideline. Emily Haesler (Ed.). EPUAP/NPIAP/PPPIA: 2019.
  8. Smith H, Moore Z, Tan M. Cohort study to determine the risk of pressure ulcers and developing a care bundle within a paediatric intensive care unit setting. Intensive and Critical Care Nursing. 2019;53: 68-72.
  9. Kayma N. Pressure injury prevention in an urban surgical intensive care unit. Walden University Press. 2020; 1-62.
  10. Li Z, Lin F, Thalib L, Chaboyer W. Global prevalence and incidence of pressure injuries in hospitalised adult patients: A systematic review and meta-analysis. International Journal of Nursing Studies. 2020;105: 1-13.
  11. Mallah Z, Nassar N, Kurdahi Badr L. The effectiveness of a pressure ulcer intervention program on the prevalence of hospital-acquired pressure ulcers: Controlled before and after study. Applied Nursing Research. 2015;28(2): 106-113.
  12. Cano A, Anglade D, Stamp H, Joaquin F, Lopez J, Lupe L et al. Improving outcomes by implementing a pressure ulcer prevention program (PUPP): Going beyond the Basics. Healthcare. 2015;3(3): 574-585.
  13. Gupta P, Shiju S, Chacko G, Thomas M, Abas A, Savarimuthu I et al. A quality improvement programme to reduce hospital-acquired pressure injuries. BMJ Open Quality. 2020;9(3): 1-9.
  14. Mitchell A. Adult pressure area care: preventing pressure ulcers. British Journal of Nursing. 2018;27(18):1050-1052.
  15. McNeil D, O’Driscoll J, Patel J, Decker M, McGovern J. Utilization of an innovative tool to improve oncology patient outcomes. Journal of Clinical Oncology. 2016;34(7) :231-231.