Introduction: Pressure injuries occur more frequently in ICUs than in non-critical care areas. A 2018 global study found that 59.2% of 3, 997 pressure injuries developed during ICU admission. To address risks associated with essential medical devices and acute physiological conditions, an enhanced prevention bundle was developed incorporating both evidence-based physical protective devices and targeted process improvements. Methods: An enhanced PIP bundle was developed targeting the needs of ICU patients including new physical protective devices and process changes. Stakeholders buy in was achieved by including care teams in development, education, and process changes. Over four weeks, nurses attended 30-minute education sessions, provided feedback, and helped shape the bundle. Frontline nurses submitted twenty-one weekly anonymous peer audits via QR code to collect compliance data on enhanced provisions and staff feedback. Unit leaders and pilot champions participated in monthly prevalence studies to collect data, assess opportunities, and provide real time feedback. Literature reviews highlight inconsistencies with repositioning and accountability as key contributors to hospital acquired pressure injuries. In response, a visual turn tool was introduced mid-study, placed on each ICU door, and updated collaboratively to ensure turn equality and promote a team approach. Results: In 2023, the units recorded eighteen ICU-acquired pressure injuries. During the six-month study, only three occurred-projecting a 66.6% decrease over a rolling twelve months. Since the implementation of the initiative in February 2024, ICU acquired pressure injuries across both intensive care units have decreased to seven, representing a 61% overall reduction. Conclusions: This nurse-driven initiative has demonstrated significant clinical impact, yielding measurable improvements in patient care, safety, and quality outcomes. The initiative fostered a culture of shared accountability and collective effort. Interdisciplinary collaboration served as a cornerstone for achieving and sustaining evidence-based prevention outcomes for critically ill patients.
Thompson et al. (Sun,) studied this question.