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Practice Problem: Pressure injuries (PIs) are a significant healthcare problem globally. Adult patients in the intensive care setting are especially vulnerable to the development of PIs given the acuity of their diagnoses requiring extensive treatments, procedures and the use of multiple medical devices. PICOT: The PICOT question that guided this project was, “In adult intensive care unit (ICU) patients, how does the effect of implementing a pressure injury prevention bundle compare in patients who received the bundle, and patients receiving standard pressure injury prevention in reducing the incidence of pressure injuries after two months?” Evidence: Evidence exist that bundle implementation significantly reduced incidence of PIs in adult ICU patients. Intervention: A pressure injury preventive bundle consisting of six evidence-based interventions were consistently and collectively implemented to reduce incidence of PIs in adult ICU patients at a tertiary hospital in South Texas. Further, a multidisciplinary approach, monitoring, auditing, and providing constructive feedback to staff were employed to ensure appropriate implementation and increase likelihood of achieving positive outcomes. Outcome: Findings revealed a 7.37% reduction in incidence after two months of bundle implementation. Also, findings showed more than 90% compliance with five out of the six components of the bundle. Conclusion: The reduction in the incidence of PIs with the implementation of a pressure injury preventive bundle in adult ICU patients was not statistically significant. However, the reduction indicated a clinically meaningful improvement in pressure injury outcomes two months after implementing the bundle. REDUCING INCIDENCE OF PRESSURE INJURIES 3 Reducing the Incidence of Pressure Injuries in Adult ICU Patients with the Implementation of a Pressure Injury Prevention Bundle: A Quality Improvement Project Pressure injuries (PIs) ae localized injuries to the skin and or its surrounding tissues that often occur over bony prominences or related to a medical or other device (European Pressure Ulcer Advisory Panel [EPUAP] and National Pressure Ulcer Advisory Panel [NPUAP], 2009). The injury can present as intact skin or an open ulcer and may be painful. The injury occurs as a result of intense and/or prolonged pressure or pressure in combination with shear (National Pressure Ulcer Advisory Panel, 2009). Most PIs are preventable (Australian Wound Management Association, 2012). However, the prevalence and incidence of PIs are usually higher in the intensive care unit (ICU) compared to general care areas (Cuddigan, 2012). Critical patients admitted in the ICU have greater risks for the development of PIs as they are more likely to have severe illness requiring extensive treatments and multiple medical devices, on mechanical ventilator, sedated, immobile, hemodynamically unstable requiring multiple pharmacological therapies, incontinent, and have poor nutrition (Amr,Yousef, Amirah, & Alkurdi, 2017; Anderson et al., 2015; Coyer et al., 2015; Richardson, Peart, Wright, & MCcullaugh, 2017; Tayyib & Coyer, 2017; Tayyib, Coyer, & Lewis, 2015). Moreover, the environmental factors and complicated care in the ICU inevitably increase the risks for PIs (Tayyib, Coyer, & Lewis, 2016). This paper aimed to evaluate the effect of pressure injury preventive bundle implementation after two months in reducing the incidence of pressure injuries in adult ICU patients in a tertiary hospital in South Texas.. Included in the paper are a discussion on the significance of the practice problem, PICOT question, theoretical framework, a synthesis of reviewed literature, practice recommendations, and project setting. Additionally, the paper REDUCING INCIDENCE OF PRESSURE INJURIES 4 outlined the project’s mission, vision, and objectives, project plan, project evaluation, discussion and implications, dissemination along with a conclusion. Significance of the Practice Problem Pressure injuries (PIs) are a significant global healthcare problem (Coyer et al., 2015; Tayyib, Coyer, & Lewis, 2015). PIs cause substantial harm to patients by causing pain and severe infections; deterring recovery; lengthening hospital stays; and increasing healthcare costs, thus creating financial strain on patients and their families (Grealy & Chaboyer, 2012). PIs are indicators of the quality of care patients receive while admitted to the hospital (Coyer et al., 2015). Therefore, PIs are a priority for patient safety and risk management concerns (Soban, Hempel, Munjas, Miles, & Rubenstein, 2011). According to Lyder et al. (2012), acute care hospitals treat approximately 2.5 million PIs every year with an estimated treatment costs of $11 billion annually in the United States. PIs are associated with about 60,000 deaths per year (Lyder et al., 2012). The Center for Medicare and Medicaid Services (CMS) mandated a non-payment for the treatment of hospital-acquired PIs and caused tremendous financial burden on healthcare organizations (Ober & Craven, 2008). The prevalence of PIs is higher in the intensive care setting (Berlowitz, 2014; Cuddigan, 2012). According to Berlowitz (2014), the worldwide prevalence rate of PIs varies from 3% to 50% in the ICU. The incidence rate in the ICU was as high as 39.3% in a Saudi Arabian study (Tayyib, et al., L2015) and up to 50% in Australia (Coyer et al., 2015). According to the EPUAP and NPUAP (2009), PIs are highly preventable. The prevention of PIs requires significant amounts of limited resources in nursing care and finances (Zuo & Meng, 2015). However, the cost of treating pressure injury per patient per day is considerably higher than the cost of preventing PIs (Demarre et al., 2015). Therefore, prevention must be a REDUCING INCIDENCE OF PRESSURE INJURIES 5 crucial component of patient care to meaningfully improve care and reduce the costs associated with treatment in the ICU (Zuo & Meng, 2015). In February of 2019, the ICU at a South Texas hospital had a 20.68% pressure injury incidence rate (Hillrom, 2019). This incidence rate is an indication for a need to carefully examine the current ICU care practices for patients who are at high risk for developing PIs. The high incidence of PIs requires the implementation of an evidence-based intervention to effectively reduce the incidence of PIs in adult ICU patients and improve pressure injury outcomes. Framework of the Problem The Virginia Henderson Need Theory views the patient as an individual requiring assistance in achieving independence and wholeness of mind and body (Henderson, 1960). Henderson’s theory outlined self-directed nursing functions, goals of interdependence for the patient, and self-help concepts (Pokorny, 2014). Henderson (1960) advocated the utilization of the nursing process and contended that the nursing practice is independent of the physician's practice. The nurse interacts with the patient and acts as a substitute, a collaborator, and a partner to form a meaningful nurse-patient relationship (Harmer & Henderson, 1995). Further, Henderson (1960) stresses that the nurses' role is to effectively assist the individual, sick or well, to decisively perform activities that contribute to health and recovery that he would independently perform if he had the needed strength, will, or knowledge, and accomplishing it as promptly as possible. Additionally, the nurse, according to Henderson, must be a scientific problem solver and should be educated in both arts and science of nursing to effectively practice (Harmer & Henderson, 1995). REDUCING INCIDENCE OF PRESSURE INJURIES 6 Virginia Henderson's Need theory has a three-fold application to this project. First, her theory offers a framework to accurately identify the patient's needs and methodically address them through the nursing process (George, 2011). Second, the theory centers on the nurses' knowledge, skills, and competence to carry out independent nursing interventions that support a patient’s health and wellbeing. The nursing staff has the expertise to assist patients back to health, prevent PIs, and promote early recovery (Coyer et al., 2015). Third, the theory advocates for recognizing and attending to the nursing staff's need for education, training, and support to prepare them adequately for the bundle implementation (Tayyib & Coyer, 2016). Scholarly Question The PICOT question for the change project is: In adult ICU patients, how does the effect of implementing a pressure injury prevention bundle compare in patients who received the bundle, and patients receiving standard pressure injury prevention in reducing the incidence of pressure injuries after two months? Adult patients age 18 years and older admitted in the ICU served as the target population of the study. Patients who obtained a Braden risk score of 16 and below who did not have pressure injuries upon admission to the ICU were included as participants in the study. Pediatric patients were excluded. The implementation of a pressure injury prevention bundle is the intervention. Six individual evidence-based pressure injury preventive interventions are collectively and consistently implemented to produce the desired positive outcomes (Horner & Bellamy, 2012; Tayyib & Coyer, 2016). The components of the bundle consist of using the Braden scale; turning the patient every two hours; obtaining a nutritional consult; application of protective dressings to the sacral area, bilateral heels, and on body parts where medical devices are in use; use of air vented mattresses on top of regular mattresses; and education and training to the staff. Patients REDUCING INCIDENCE OF PRESSURE INJURIES 7 who received the intervention were compared to patients who received standard pressure injury prevention after two months. Standard pressure injury prevention refers to the individual components of the pressure injury prevention bundle with the exclusion of the education and training. Literature Sear

Reducing the Incidence of Pressure Injuries in Adult ICU Patients at McAllen Medical Center with the Implementation of a Pressure Injury Preventive Bundle: A Quality Improvement Project