Incidence Of Hospital-acquired Pressure Injuries Research Articles

Customized Silicone Foam Dressing Under Noninvasive Ventilation and Skincare Bundle to Reduce Hospital-Acquired Pressure Injuries in Neonates.

In a sixty-eight-bed level-IV NICU, an increased incidence of hospital-acquired pressure injuries (HAPIs) from noninvasive ventilation (NIV) devices was identified. The aim of this quality improvement project was to decrease HAPIs from NIV by 10%. A literature review and the Plan-Do-Study-Act were implemented. The intervention included a customized silicone foam dressing under NIV, an NIV skincare bundle, and multidisciplinary support. Hospital-acquired pressure injury rates were tracked over 3 years postinterventions. The incidence of HAPIs declined by 20% from 0.2 per 1,000 patient days to 0.05 per 1,000 patient days. Relative risk was 4.6 times greater prior to intervention (p = .04). Continuous positive airway pressure (CPAP) failure was not noted and measured by the percentage of patients on ventilators pre- and postintervention. Customized silicone foam dressings under NIV, NIV skincare bundle, and multidisciplinary team support may decrease HAPIs in neonates without CPAP failure.

Incidence of hospital-acquired pressure injuries and predictors of severity in a paediatric hospital.

Hospital-acquired pressure injuries (HAPIs) pose significant challenges in healthcare and cause increased patient suffering, longer hospital stays, and higher healthcare costs. Paediatric patients face unique risks, but evidence remains scarce. This study aimed to identify and describe HAPI admission incidence and severity predictors in a large Australian children's hospital. This retrospective cohort study investigated all paediatric patients between January 2020 and December 2021 using a census approach. Demographic and clinical data including HAPI-related data were accessed from the incident monitoring and hospital administration databases. The incidence rate (per 1000 patient admissions) was calculated based on all admissions. Predictors of HAPI severity were identified using multivariable multinomial logistic regression. The study adhered to the STROBE guidelines for retrospective cohort studies. The HAPI incidence rate was 6.96 per 1000 patient admissions. Of the age groups, neonates had the highest HAPI incidence (15.5 per 1000 admissions). Critically ill children had the highest rate for admission location (12.8 per 1000 patient admissions). Most reported cases were stage I (64.2%). Age was associated with injury severity, with older paediatric patients more likely to develop higher-stage HAPIs. Additionally, Aboriginal and/or Torres Strait Islander patients had a higher HAPI severity risk. HAPI injuries in paediatric patients are unacceptably high. Prevention should be prioritized, and the quality of care improved in Australia and beyond. Further research is needed to develop targeted prevention strategies for these vulnerable populations. This research emphasizes the need for standardized reporting, culturally sensitive care and tailored prevention strategies. The research has the potential to influence healthcare policies and practices, ultimately enhancing the quality of patient care. STROBE guidelines. There was no patient or public contribution to the conduct of this study.

Evaluating Natural Language Processing Packages for Predicting Hospital-Acquired Pressure Injuries From Clinical Notes.

Incidence of hospital-acquired pressure injury, a key indicator of nursing quality, is directly proportional to adverse outcomes, increased hospital stays, and economic burdens on patients, caregivers, and society. Thus, predicting hospital-acquired pressure injury is important. Prediction models use structured data more often than unstructured notes, although the latter often contain useful patient information. We hypothesize that unstructured notes, such as nursing notes, can predict hospital-acquired pressure injury. We evaluate the impact of using various natural language processing packages to identify salient patient information from unstructured text. We use named entity recognition to identify keywords, which comprise the feature space of our classifier for hospital-acquired pressure injury prediction. We compare scispaCy and Stanza, two different named entity recognition models, using unstructured notes in Medical Information Mart for Intensive Care III, a publicly available ICU data set. To assess the impact of vocabulary size reduction, we compare the use of all clinical notes with only nursing notes. Our results suggest that named entity recognition extraction using nursing notes can yield accurate models. Moreover, the extracted keywords play a significant role in the prediction of hospital-acquired pressure injury.

Driving Hospital-Acquired Pressure Injuries to Zero: A Quality Improvement Project.

To implement a collaborative, interdisciplinary team approach to reducing hospital-acquired pressure injuries (HAPIs) through nurse empowerment and engagement. This quality improvement project was conducted at a 288-bed community hospital. The Donabedian model was used to design this intervention. The authors used a collaborative, interdisciplinary team approach for pressure injury prevention and management, utilizing nurse empowerment and engagement as driving forces to reduce HAPI rates. The incidence of HAPI decreased from a peak of 5.30% in April 2019 down to 0% from August 2019 to December 2020. Pressure injuries are key quality indicators for patient safety and avoidance of patient harm. Through nurse empowerment and engagement, HAPIs were avoided, resulting in improved quality care outcomes and maintenance of a safe patient environment.

Implementation of a Pressure Injury Prevention Protocol for Intensive Care Unit Patients Undergoing Prone Positioning.

Pressure injuries remain the most common hospital-acquired condition, according to the Agency for Healthcare Research and Quality. Patients hospitalized with COVID-19 are at especially high risk for pressure injuries, including those related to medical devices, because of their lower tissue tolerance, prolonged intubation, and common treatment with prone positioning. The COVID-19 pandemic brought an increased incidence of hospital-acquired pressure injury. A 350-bed hospital in St. Joseph, Missouri, recognized that an intervention to lower the risk of pressure injury for these patients was needed. A quality improvement project was initiated to reduce the incidence of pressure injuries in patients with COVID-19 in the intensive care unit. A protocol was implemented for patients with COVID-19 undergoing prone positioning that included the use of dressing packets. The incidence of hospital-acquired pressure injury during the 1-year periods before and after implementation of the protocol were determined. Before implementation of the new protocol, 18 of 155 intensive care unit patients with COVID-19 who were placed in a prone position (11.6%) experienced a hospital-acquired pressure or medical device-related injury, compared with 3 of 111 patients (2.7%) after protocol implementation, a reduction of 76.7% (P = .008). The risk of hospital-acquired pressure injuries can be reduced with additional education and the use of appropriate products and protocols. All patients who undergo prone positioning, regardless of diagnosis, may benefit from implementation of a pressure injury prevention protocol that includes the use of dressing packets.

Reducing lower extremity hospital-acquired pressure injuries: a multidisciplinary clinical team approach

Objective: Optimal methods of reducing incidence of hospital-acquired pressure injuries (HAPIs) remain to be determined. We assessed changes in yearly incidence of lower extremity HAPIs before and after an intervention aimed at reducing these wounds. Method: In 2012, we implemented a three-pronged intervention to reduce the incidence of HAPIs. The intervention included: a multidisciplinary surgical team; enhanced nursing education; and improved quality data reporting. Yearly incidence of lower extremity HAPIs was tracked. Results: Pre-intervention, incidence of HAPIs was 0.746%, 0.751% and 0.742% in 2009, 2010 and 2011, respectively. Post-intervention, incidence of HAPIs was 0.002%, 0.051%, 0.038%, 0.000% and 0.006% in 2013, 2014, 2015, 2016 and 2017, respectively. Mean incidence of HAPIs was reduced from 0.746% before the intervention to 0.022% after the intervention (p<0.001). Conclusion: An intervention by a multidisciplinary surgical team enhanced nursing education, and improved quality data reporting reduced the incidence of lower extremity HAPIs.

The incidence and prevalence of medical device-related pressure injuries in pediatric patients: Systematic review and meta-analysis

ProblemTo determine the pooled incidence and prevalence rate of medical device-related pressure injuries(MDRPIs) using the Braden QD scale, medical devices that frequently cause MDRPIs, and anatomical locations that are vulnerable to them. Eligibility criteriaUsing the Braden QD scale, being published in English between 01/01/2018-and 01/03/2023. MethodsThis study was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analysis recommendations and registered in the International Prospective Register of Systematic Reviews database (No: CRD42021276501). SampleA total of 7 studies with 25,742 pediatric patients were included. ResultsThe pooled prevalence and cumulative incidence of hospital-acquired pressure injuries(HAPIs) were 7.8% (95% CI: 5.2–11.4%) and 3.9% (95% CI: 0.5–24.6%) respectively, and the incidence rate was 8.2/1000 person-days (95% CI: 2.4–14.2/1000 person-days). The pooled prevalence and cumulative incidence of MDRPIs were 7% (95% CI: 5.5–8.8%) and 5% (95% CI: 3.2–7.8%) respectively, and the incidence rate was 6.7/1000 person-days (95% CI, 0.11–13.4/1000 person-days). The most affected anatomical locations were the face (29.1%), ankle/foot (20.1%), and head (15.7%). Medical devices that frequently caused MDRPIs were external monitoring devices (24.5%), respiratory devices (22.8%), and supportive/securing devices (14.9%). ConclusionsAccording to the current systematic review and meta-analyses, the incidence and prevalence of HAPIs and MDRPIs are moderate to high. ImplicationsThe findings suggested that healthcare providers should pay more attention to reducing HAPIs and MDRPIs and future studies should be conducted to understand their characteristics and risk factors.

Incidence of hospital acquired pressure injury in critically ill patients with COVID-19 in prone position admitted to the intensive care unit.

Critical patients have conditions that may favor the occurrence of hospital-acquired pressure injury (HAPI). The objective of this study was to identify the incidence and factors associated with the occurrence of HAPI in patients with coronavirus disease 2019 admitted to the intensive care unit (ICU) who used the prone position. Retrospective cohort study carried out in an ICU of a tertiary university hospital. Two hundred four patients with positive real-time polymerase chain reactions were evaluated, of which 84 were placed in the prone position. All patients were sedated and submitted to invasive mechanical ventilation. Of the prone patients, 52 (62%) developed some type of HAPI during hospitalization. The main place of occurrence of HAPI was the sacral region, followed by the gluteus and thorax. Of the patients who developed HAPI, 26 (50%) had this event in places possibly associated with the prone position. The factors associated with the occurrence of HAPI in patients prone to coronavirus disease 2019 were the Braden Scale and the length of stay in the ICU. The incidence of HAPI in prone patients was extremely high (62%), which denotes the need to implement protocols in order to prevent the occurrence of these events.

Hospital-Acquired Pressure Injuries in Adults With Prone Positioning Using Manual Method Versus Specialty Bed: A Retrospective Comparison Cohort Study.

The purpose of this study was to compare the incidence of hospital-acquired pressure injuries (HAPIs) in patients with acute respiratory distress syndrome (ARDS) and placed in a prone position manually or using a specialty bed designed to facilitate prone positioning. A secondary aim was to compare mortality rates between these groups. Retrospective review of electronic medical records. The sample comprised 160 patients with ARDS managed by prone positioning. Their mean age was 61.08 years (SD = 12.73); 58% (n = 96) were male. The study setting was a 355-bed community hospital in the Western United States (Stockton, California). Data were collected from July 2019 to January 2021. Data from electronic medical records were retrospectively searched for the development of pressure injuries, mortality, hospital length of stay, oxygenation status when placed in a prone position, and the presence of a COVID-19 infection. A majority of patients with ARDS were manually placed in a prone position (n = 106; 64.2%), and 54 of these patients (50.1%) were placed using a specialty care bed. Slightly more than half (n = 81; 50.1%) developed HAPIs. Chi-square analyses showed no association with the incidence of HAPIs using manual prone positioning versus the specialty bed (P = .9567). Analysis found no difference in HAPI occurrences between those with COVID-19 and patients without a coronavirus infection (P = .8462). Deep-tissue pressure injuries were the most common type of pressure injury. More patients (n = 85; 80.19%) who were manually placed in a prone position died compared to 58.18% of patients (n = 32) positioned using the specialty bed (P = .003). No differences in HAPI rates were found when placing patients manually in a prone position versus positioning using a specialty bed designed for this purpose.

Improving Skin Care Protocol Use in the Intensive Care Unit to Reduce Hospital-Acquired Pressure Injuries

Patients in the intensive care unit have the highest rate of hospital-acquired pressure injuries (HAPIs). In the United States, treatment of HAPIs costs an estimated $9.1 to $11.6 billion annually, with each occurrence adding an average of $10 708 to a patient's total hospital cost. In addition to their financial impact, pressure injuries negatively affect patients physically, socially, and psychologically and are associated with increased morbidity and mortality. An intensive care unit had 42 HAPIs during a single fiscal year, with 45% of them related to lack of adherence to the institution's established evidence-based skin care protocol. This project was conducted to increase adherence to the protocol and thus reduce the incidence of HAPIs in the unit. This quality improvement initiative featured an evidence-based multifaceted intervention to increase adherence to the skin care protocol. A review of medical records was used to determine general skin care protocol adherence and to measure the monthly incidence of HAPIs in the unit. The number of HAPIs in the unit decreased from 33 in the preintervention period to 11 in the postintervention period, a reduction of 67%. The rate of general skin care protocol adherence improved to as high as 76% by the end of the postintervention period. Use of an evidence-based multifaceted intervention can improve adherence to a skin care protocol in the intensive care unit, resulting in a reduced incidence of HAPIs and improved patient outcomes.

Incidence of Hospital-Acquired Pressure Injury among Adult Inpatients at Kakamega County General Hospital, Kenya

A hospital-acquired pressure injury is a largely preventable adverse health event, which has remained high volume and high cost globally hence a significant concern in healthcare. This study used a prospective cohort model between April and July 2021 to determine the incidence of these injuries among adults at the Kakamega County General Hospital in Kenya, thus informing the need for scaled-up intervention strategies to eliminate these preventable harms on patients receiving care in line with international patients’ safety goal. Eighty participants above 18 years of age, systematically drawn from the male and female medical, surgical, and orthopaedic hospitalisation units, were followed up through their hospital stay for the development of pressure injury. Sociodemographic characteristics, units of hospitalisation, diagnosis and clinical variables were studied and outcomes were recorded, coded, and analysed on the statistical package for social sciences version 26. This study found an overall incidence rate of 15%, with men at 17.5% against women at 12.5%. The most affected site was the sacrum region accounting for 35.7% of all cases, with a mean day of occurrence at 5.58 days post-hospitalisation. This high incidence signifies pressure injury as a threat to healthcare quality, equity, and cost in Kakamega and Kenya. The Ministry of Heath should therefore adopt, customise, and implement the international guidelines on pressure injury to curb this menace. A multidisciplinary approach should be used, prioritising patients at increased risk and providing suitable prevention and treatment from the earliest opportunity

Evidence-Based Approach to Decrease Incidence of Hospital-Acquired Pressure Injuries.

Hospital-acquired pressure injuries (HAPIs) are a painful and unwanted experience for the patient and cause unwanted additional costs to hospitals. Because HAPIs are a preventable occurrence, they are a nurse-sensitive indictor for national benchmarking when looking at quality and safety. Controlling the occurrence of HAPI in the hospital setting can be challenging for any nurse, but the difficulty is enhanced in the intensive care unit. This article discusses how a group of nurses from various areas of the hospital came together to heighten awareness of skin care and provided frontline education to peers. Through the use of structured programs using both a nationally known Wound Associate treatment program and Lean methodology, the nurses were able to work through processes and barriers and successfully decrease the incidence of HAPI in this academic medical center.

Evaluation of Vasopressor Dose and the Incidence of Pressure Injuries in Critically Ill Patients.

To evaluate risk factors associated with vasopressor use and development of hospital-acquired pressure injuries (HAPIs). The researchers conducted a retrospective chart review in a 12-bed medical ICU at a community hospital. A total of 123 patients who received a minimum of 24 hours of continuous vasopressor administration between January 2017 and January 2019 were included. The primary outcomes assessed were vasopressor dose and HAPI incidence, with a subgroup analysis based on type. Secondary outcomes included quantity of vasopressors, duration, mean arterial pressure, mechanical ventilation, time to injury, severity, and location. The overall incidence of HAPIs was 20.3%, with 17% incidence in the low-dose cohort and 22.4% in the high-dose cohort ( P = .317). There were no differences in the subgroup analysis based on vasopressor type. The most common locations for injuries were the sacrum and coccyx, with the majority being stage 1 or 2 based on the National Pressure Injury Advisory Panel severity staging. No correlations were found between HAPI incidence and factors such as multiple vasopressors use, mechanical ventilation, mean arterial pressure, or duration of vasopressor administration. The documentation of time to injury was significantly shorter in the high-dose cohort compared with the low-dose cohort (157.58 vs 330.86 hours, P < .05). The incidence of HAPIs did not differ between the low- and high-dose vasopressor cohorts. However, patients who received higher doses of vasopressors had documented pressure injuries sooner than the low-dose cohort, emphasizing the importance of close monitoring for HAPIs in patients receiving vasopressors.

Reducing Hospital-Acquired Pressure Injuries During the COVID-19 Pandemic.

Reducing Hospital-Acquired Pressure Injuries During the COVID-19 Pandemic.

Effects of alternating pressure air mattresses on pressure injury prevention: A systematic review of randomized controlled trials.

Pressure injury (PI) is a significant health problem among inpatients that affects their health, quality of life, and expenses. This systematic review aimed to compare effects of alternating pressure air mattresses (APMs) with other types of supporting surfaces as a tool for PI prevention. The literature published between 2009 and 2020 was searched using the databases PubMed, EMBASE, CINAHL, and Cochrane. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses process was followed, including independent study selection and data extraction. Quality appraisal was conducted using the Cochrane Risk of Bias Tool (RoB 2.0). A total of six randomized controlled trials (RCTs) were analyzed. The incidence of hospital-acquired PIs at stage 1 or higher was reported in the APM group from 0.3% to 25%. In one study, APMs were found to be less effective than static air mattresses (SAMs); in contrast, two studies found no difference. In one study, the APM was reported to be more effective than the viscoelastic foam mattress (VFM). On the contrary, in a more recent study, the APM was reported to be less effective than the VFM, and there was no difference compared with high-specification foam mattresses in another study. Using the RoB 2.0 tool, one study was evaluated at "low risk of bias," another as "some concern," and four as "high risk." There is insufficient evidence to suggest that APM is more effective in preventing PIs than other supporting surfaces. Evidence to date suggests that APM can be used in patients at risk for PIs. It is important to change position regardless of the type of support surface used. Highly controlled RCTs with low risk of bias are needed to provide strong evidence for identifying the most effective PI prevention support surfaces.

Reducing Hospital-Acquired Pressure Injuries through Measure-vention.

Evidence has shown that Braden subscale scores are independent predictors of the development of pressure injuries. However, current practice is to implement preventive measures for pressure injuries based on the total Braden Scale score. Applying evidence from the literature on Braden subscales and using "Measure-vention," a quality improvement project using Braden subscales, was implemented in a 30-bed ICU in a Northern California level II trauma acute care hospital. The pilot study's purpose was to test whether tailoring interventions specific to the patient's subscale risk would decrease the incidence of hospital-acquired pressure injuries (HAPIs). A 6-month pilot was launched for all patients in the ICU, regardless of Braden total score. Frontline staff collected data in real time, measuring adherence to the "Interventions by Braden Subscale" protocol, and event reports were aggregated to measure the incidence of HAPIs before and after the pilot. At the end of the pilot, the ICU noted a decrease in HAPIs by 63.5%. The results demonstrated the efficacy of using the Braden subscales to guide preventive HAPI care, preventing both HAPIs and the overutilization of resources.

Pressure injury prevalence and incidence in acute inpatient care and related risk factors: A cross-sectional national study.

The aim of this national cross‐sectional study was to explore the prevalence of pressure injuries and incidence of hospital‐acquired pressure injuries, and the relating factors in somatic‐specialised inpatient care in Finland. The study was conducted in 16 (out of 21) Finnish health care organisations offering specialised health care services. Data were collected in 2018 and 2019 from adult patients (N = 5902) in inpatient, emergency follow‐up, and rehabilitation units. Pressure injury prevalence (all stages/categories) was 12.7%, and the incidence of hospital‐acquired pressure injuries was 10%. Of the participants, 2.6% had at least one pressure injury at admission. The risk of hospital‐acquired pressure injuries was increased for medical patients with a higher age, the inability to move independently, mode of arrival, being underweight, and the absence of a skin assessment or pressure injury risk assessment at admission. For surgical patients, the risk was associated with the inability to move independently, mode of arrival, and lack of skin assessment at admission, while being overweight protected the patients. Overall, medical patients were in greater risk of hospital‐acquired pressure injuries than the surgical patients. An assessment of the pressure injury risk and skin status should be carried out more systematically in Finnish acute care hospitals.

36 Using Pressure Mapping to Understand and Prevent Hospital-Acquired Pressure Injuries in the Burn ICU

Abstract Introduction Real-time pressure mapping devices may help prevent hospital-acquired pressure injury (HAPI) in Burn ICU (BICU) patients who are at a high baseline risk for HAPIs. While prior studies have demonstrated the utility of pressure monitoring devices in preventing pressure injuries, there has been little investigation into using pressure mapping data to better understand HAPI development, and to determine specific predictors of HAPIs. Such data could help risk stratify patients upon admission to the BICU and result in improved patient care as well as cost savings. This study retrospectively investigated the utility of pressure mapping data in predicting/preventing pressure injury among BICU patients, and estimated HAPI-related cost savings associated with the implementation of pressure monitoring. Methods This was a retrospective chart review of real-time pressure mapping in the BICU. Incidence of HAPIs and costs of HAPI-related care were determined through clinical record review, before and after implementation of pressure mapping. Multivariable-adjusted logistic regression was used to determine predictors of HAPIs, in the context of pressure mapping recordings. Results In total, 122 burn ICU patients met inclusion criteria during the study period, of whom 57 (47%) were studied prior to implementation of pressure mapping, and 65 (53%) were studied after implementation. The HAPI rate was 18% prior to implementation of pressure monitoring, which declined to 8% after implementation (chi square: p=0.10). HAPIs were more likely to be less severe in the post-implementation cohort (p&amp;lt; 0.0001). Upon multivariable-adjusted regression accounting for known predictors of HAPIs in burn patients (BMI, length of stay, co-morbidities, age, total body surface area burned, mobility), having had at least 12 hours of sustained pressure loading in one area significantly increased odds of developing a pressure injury in that area (odds ratio 1.3, 95%CI 1.0–1.5, p=0.04). When comparing patients who developed HAPIs to those who did not, pressure mapping demonstrated that patients who developed HAPIs were significantly more likely to have had unsuccessful repositioning efforts prior to HAPI development, defined as persistent high pressure in the at-risk area (60% versus 17%, respectively; p=0.02). Finally, implementation of pressure mapping resulted in significant cost savings ($2,063 prior to implementation, versus $1,082 after implementation, p=0.008). Conclusions The use of real-time pressure mapping decreased incidence of HAPIs in the burn ICU patients and resulted in significant cost savings.

Learning During Crisis: The Impact of COVID-19 on Hospital-Acquired Pressure Injury Incidence.

ABSTRACTThe impact of COVID-19, on the health and safety of patients, staff, and healthcare organizations, has yet to be fully uncovered. Patient adverse events, such as hospital-acquired pressure injuries (HAPIs), have been problematic for decades. The introduction of a pandemic to an environment that is potentially at-risk for adverse events may result in unintended patient safety and quality concerns. We use the learning health system framework to motivate our understanding of the impact of the COVID-19 pandemic on the incidence of HAPIs within our health system. Using a retrospective, observational design, we used descriptive statistics to evaluate trends in HAPI from March to July 2020. Hospital-acquired pressure injury numbers have fluctuated from a steady increase from March–May 2020, hitting a peak high of 90 cases in the month of May. However, the trend in the total all stage HAPIs began to decline in June 2020, with a low of 51 in July, the lowest number since March 2020. Patients evaluated in this study did not have a longitudinal increase in HAPIs from March–July 2020 during the COVID-19 pandemic, despite similarities in illness severity between the two time points. Our experience has demonstrated the ability of our organizational leaders to learn quickly during crisis.

The Effect of a Certified Wound Ostomy Nurse Educational Bundle on Hospital Acquired Pressure Injuries in the Intensive Care Unit: A Quality Improvement Project

<i>Purpose:</i> Patients in critical care units are considered high risk for pressure injury (PI) development with reported rates in the United States topping 40% in some cases. Multiple factors contribute to the risk of this population including a knowledge deficit among nurses which often leads to a lack of assessment and prevention measures needed to reduce pressure injuries. This project was launched after data collected by the Wound, Ostomy and Continence Nurse (WOCN) team showed an increase in hospital acquired pressure injuries (HAPI) in the intensive care unit (ICU) in the first quarter of 2016. The rate was 11.56 per 1000 patient days. This data was collected as part of our quarterly prevalence study reported to the National Database of Nursing Quality Indicators (NDNQI). Although this rate is lower than the national average, our patients deserve process improvement to achieve 0% incidence. <i>Participants and Setting:</i> The setting was a 16-bed ICU at a tertiary care hospital in the Southeastern United States. Monthly data was collected over the span of a year to evaluate incidence rates of hospital acquired pressure injuries (HAPI) from Q1 2016 to Q 4 2017. <i>Approach:</i> The cornerstone of this project was to focus on nursing education surrounding pressure injury prevention (PIP) intervention selections. The overall goal was to heighten the quality of patient care by implementing an innovative PIP bundle that was supported by Certified Wound, Ostomy Nurse (CWON) education and knowledge sharing throughout the ICU. The Plan, Do, Study, Act (PDSA) methodology was used to monitor interventions and outcomes. <i>Outcomes:</i> The measurable goal of this project was to decrease the quarterly rate of hospital acquired pressure injuries in the ICU by 50% by 4Q 2017, as compared to a rate of 11.54 per 1000 patient days 1Q 2016. Subsequent quarters demonstrated incremental decreased HAPI rates of 0.9, 1.8, 1.7, 5.2, 4.3, 0.9 and 0 by 4Q 2017. This was a total reduction rate greater than 50% which was our goal. The PIP bundle highlighted by WOC nurse education resulted in significant and clinically relevant reductions in incidence of HAPI in the ICU. Our future goal is to continue with an ongoing PIP bundle and WOC nurse rounding as part of our best practice within this hospital setting. In addition, we continue to share knowledge gained by this QI project with our extended WOCN team working at our surrounding facilities.