QUALITY IMPROVEMENT Article Review Briefly summarize the article and its findings. Critique and review the writing style of the article. Specifically, c

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  1. Briefly summarize the article and its findings.
  2. Critique and review the writing style of the article. Specifically, consider the following aspects:
    1. What did you notice about the “voice” or “tone” of the article?
    2. What techniques or structure did the author(s) use in their writing? 
    3. Is the information clear? (if so, how does the author’s writing style create clarity? if no, discuss what areas or parts are unclear and why is it not clear to you as the reader.)
    4. Introduction/Background/Significance: Does the article provide adequate justification and convey the importance of the problem that they are focusing on? What elements of the Introduction/Background support this? If you believe that there is insufficient information, what would enhance the section to make it more compelling to you?
    5. Methods: Does the article provide a clear overview of what intervention(s) were implemented?
    6. Conclusion/Implication: Does the article provide appropriate conclusions? Does it relate back to the original introduction?




6 American Nurse Journal Volume 16, Number 7 MyAmericanNurse.com

THE Centers for Medicare and Medicaid Serv-
ices report that pressure injuries (PIs) affect
millions of patients each year, with incidence
rates ranging from 2.2% to 23.9% in long-term
care organizations. PIs occur as a result of in-
tense or prolonged pressure in combination
with shear and are affected by excessive heat
and moisture, poor nutrition and blood circu-
lation, chronic illness, and soft-tissue condi-
tions (for example, an abrasion or sprain).

For 3 years, PI prevalence increased at a
Texas long-term continuing care retirement com-
munity that provides independent living, assisted
living, memory care, and skilled nursing. The or-
ganization faced several challenges, including
the lack of a nurse educator and inconsistent
continuing education for nursing staff.

To address these challenges, a PI quality
improvement team, consisting of the director
of nurses, an assistant director of nurses, an
RN, a licensed practical nurse (LPN) and a
certified nurse assistant (CNA), was created to
develop an evidence-based practice (EBP)
project of educational interventions and
strategies for consistent PI prevention. The
project was part of the author’s doctor of
nursing practice (DNP) program.

First steps
The QI team started the project by using the
PICOT (Patient, population, problem; Inter-
vention; Comparison, control; Outcome, ob-
jective; Timeframe) mnemonic to develop
this question:
P: In LPNs caring for older adult residents in
nursing homes,
I: how will the implementation of a formal PI
prevention program

Pressure injury
prevention in

long-term care
Follow the

evidence to


By Melissa De Los Santos, DNP, RN


1. Describe strategies for preventing pressure injuries (PIs) in long-term care (LTC).

2. Discuss how to implement a project designed to prevent PIs in LTC.

The author and planners of this CNE activity have disclosed no relevant financial relationships
with any commercial companies pertaining to this activity. See the last page of the article to
learn how to earn CNE credit.

Expiration: 7/1/24


1.6 contact

MyAmericanNurse.com July 2021 American Nurse Journal 7

C: compared to no formal program
O: affect PI incidence
T: over a 5-month period?

A systematic literature search was then
completed across three databases (PubMed,
CINAHL, and Cochrane Library). The search
initially yielded more than 65,000 articles, but
applying subject headings when possible and
reviewing journal titles and abstracts nar-
rowed the results to 51 articles. The inclusion
criteria for those articles consisted of partici-
pants 18 years of age and older, articles pub-
lished within 10 years, and those written or
translated in English. Exclusion criteria includ-
ed treatment options such as redistribution de-
vices, wound care products, non-English items,
and articles published before 2008. Applying
these criteria and removing duplicate articles
reduced the number to 20 studies: four Level
I studies, four Level IV studies, two Level V
studies, seven Level VI studies, and three Lev-
el VII studies from around the world. (See Hi-
erarchy of evidence.)

On the basis of a study analysis, the team
found a body of evidence indicating that for-
mal PI programs with consistent PI preven-
tion education, interdisciplinary techniques,
standardized PI risk assessments, increased
communication, consistent documentation,
and ongoing monitoring can help decrease PI

Building the project
Building the formal PI program required de-
termining the stakeholders and establishing a

Project stakeholders were the facility residents
and their families, CNAs, staff RNs and LPNs,
nursing administrators, and the organization’s
leaders. The EBP project included all residents
who were at risk for PIs, and all received pre-
vention strategies.

Preliminary discussions began in the fall of 2018
and concluded in the spring of 2019, when the
project received approval by the university, the
DNP program, and the long-term care organiza-
tion (the project didn’t require institutional re-
view board approval). By the end of 2019, QI
team meetings were planned and support and
resources were finalized.

A timeline with evidence-based interventions
and outcomes organized, captured, and docu-
mented three project implementation phases:
educational intervention, implementation, and
sustainment and dissemination. Health informa-
tion collected as part of the project was de-

I used a logic model as the framework for
my project. (See Logic model in action.)

Launching the project
The EBP project launched on July 1, 2019, with
self-paced online PI education, risk assess-
ments (weekly and Braden Scale assessments),
interdisciplinary teamwork strategies, PI pre-
vention strategy communication, and docu-
mentation using PI identification communica-
tion tools and repositioning charts to increase
reporting and encourage ongoing monitoring.

I led four staff development sessions on all
shifts to introduce the EBP project to nursing
staff. Participants completed a pretest (to
gauge current PI knowledge) before the on-
line education program and a post-test after.

Phase 1: Educational intervention
Phase one consisted of implementing three
online, self-paced PI education modules from
an outside vendor and developing the quality
improvement team. The team’s responsibilities
included increasing PI prevention communica-
tion, promoting an effective multidisciplinary
team, discussing goals in staff meetings, mon-
itoring progress, assisting with accurate docu-
mentation of PI prevention strategies, and pro-
moting sustainability.

The 20-week nursing staff educational pro-
gram focused on consistent use of PI risk assess-
ment methods, effective interdisciplinary strate-
gies, increased communication, and accurate
documentation of PI prevention strategies. Inte-
grated checklists served as reminders to consis-

Hierarchy of evidence

Different types of studies provide different levels of evidence.

• Level I—Systematic review or meta-analysis of all relevant random-
ized controlled trials (RCTs)

• Level II—Well-designed RCTs
• Level III—Well-designed controlled trials without randomization
• Level IV—Well-designed case control and cohort studies
• Level V—Systematic reviews of descriptive and qualitative studies
• Level VI—Single descriptive or qualitative study
• Level VII—Opinions of authorities, reports of expert committees

Source Mazurek Melnyk B, Fineout-Overholt E. Evidence-based Practice in Nursing & Health-
care: A Guide to Best Practice. 4th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2018.

8 American Nurse Journal Volume 16, Number 7 MyAmericanNurse.com

tently implement the change based on current
protocols. For example, RNs completed monthly
comprehensive skin assessments; LPNs complet-
ed quarterly and as-needed Braden Scale assess-
ments; RNs and LPNs completed weekly skin as-
sessments; and CNAs, restorative aids, and
medication aids completed daily skin assess-
ments during routine care.

Flyers posted in the breakroom, next to the
time clock, and behind both nurses’ stations
outlined the importance of implementing and
documenting PI prevention. (See Promoting
PI prevention.)

Phase 2: Implementation
Phase two focused on PI prevention strategies,
consistent use of the Braden Scale, and weekly
skin assessments. Two project implementation

forms (a PI identification communication tool
and a repositioning chart) previously used
within the organization were resurrected for
this project. Daily skin checks were document-
ed on the PI identification communication
tool, and PI prevention strategies, such as turn-
ing residents on a schedule, were documented
on repositioning charts.

Phase 3: Sustainment
Phase three consisted of sustaining the pre-
vention strategies, conducting team meetings,
developing a skin algorithm, and incorporat-
ing project implementation forms into the
electronic health record.

Analyzing outcomes
Outcome analysis included educational inter-

Logic model in action
A logic model is a graphic tool for planning, describing, managing, communicating, and evaluating a program or intervention. It
consists of two main sections: process (inputs, activities, and outputs) and outcomes (short-, medium-, and long-term goals). Fre-
quently, assumptions and contextual or external factors also are included.
The author used the body of evidence and recommendations in the literature to create the model for the project described in the
article. The process section helped guide implementation, and project outcomes were planned, outlined, and appraised through-
out. External factors included the time it would take to complete training, and underlying assumptions included awareness of pre-
vention strategies that will decrease PI risk.

CNAs = certified nursing assistants, ID = identification, LPNs = licensed practical nurse, MAs = medication aids, PI = pressure injury, PIP = pressure injury prevention, RAs = restorative aids

Learn more about logic models at cdc.gov/dhdsp/docs/logic_model.pdf.

• Staff members
(RNs, LPNs,
CNAs, MAs,

• PIP online edu-
cation on Braden
Scale, PI ID
tion Tool, and

• Access to resi-
dent electronic
charts and
meeting rooms


• By month 5,
there will be
a reduction
of PI rates
and costs
with treat-
ment in resi-


• Conduct training
sessions for accurate
implementation and
documentation of
Braden Scale


• Inservices or work-
shops for staff lead-
ing to better docu-
mentation and
increased reporting
of skin alterations
and PIs will occur

• PIP education will be
completed during
the first month of
implementation and
available online for
reinforcement for
future use


• By the first
month after
there will be
an increase of
knowledge of
PI risk factors
as evidenced
by consistent
use of Braden
Scale, PI ID
tion Tool, and

• By month 3, there
will be an increased
proportion of staff
strategies to de-
crease the risk of
PIs as evidenced
by consistent use
of Braden Scale,
PI ID Communica-
tion Tool, and
Chart and de-
creased incidence
of PIs in residents

Long-term goalShort-term goal Medium-term goal

• Time to complete

• Paid or unpaid train-

• Other protocols cur-
rently being imple-

External factors

• Improve health
outcomes by
eliminating PIs


• Awareness of PIP strategies will decrease risk of PIs.
• Consistent and accurate use of PIP risk assessments will decrease risk of PIs.
• Increased understanding of PIP will decrease costs and improve health

• Empowering staff will influence behaviors to improve health outcomes.


MyAmericanNurse.com July 2021 American Nurse Journal 9

vention, PI prevention strategies, PI rates, and
cost savings.

Educational intervention
The educational intervention yielded a 57% nurs-
ing staff completion rate. Knowledge change
was calculated by analyzing staff pretest and
post-test scores. In the pretest, 61.5% of nursing
staff scored 80 on the PI assessments and 42%
scored 100. In the post-test, 13% of staff scored
80 and 87% scored 100 (a more than 50% in-
crease in 100 scores).

PI prevention strategies
In two-thirds of cases where CNAs had docu-
mented abnormal skin concerns on the PI
identification communication tool, RNs and
LPNs responded by completing multiple Braden
Scale assessments, even though there was no
formal protocol requiring them to do so. The
results confirmed the value of the tool.

Results also indicated the benefits of im-
plementing multicomponent PI prevention
initiatives, such as turning, repositioning, and
mobilizing frequently, along with other inter-
ventions (such as completing the Braden
Scale, skin assessments, special mattresses,
topical products, heel protectors, pillows, nu-
tritional assessments and interventions, hy-
dration, PI reporting, and communication).
Analysis of Braden Scale score averages and
repositioning frequency percentages showed
that patients with a high-risk Braden Scale
score (between 10 and 12) had a 71% reposi-
tioning average; moderate risk (13 to 14) had
a 59% repositioning average; at risk (15 to 18)
had a 66% repositioning average. Inconsistent
documentation affected the results, but repo-
sitioning averages were at or above 59% con-

PI rates
For 3 years, PI incidence rates at the organiza-
tion had been rising steadly, from 0.67% in
2016 to 2.3% in 2017 and 5.3% in 2018. The
national average was 7.2% to 7.3%. The EBP
project achieved anticipated decreased PI
rates. Between July and December 2019, four
Stage II PIs were reported during the interven-
tion (4% PI incidence rate in 2019), resulting
in a 25% decrease in PI rates. Based on analy-
sis, more consistent use of the PI identifiction
communication tool with appropriate follow-
up may have prevented more PIs.

Cost savings
According to the Agency for Healthcare Re-
search and Quality, PIs in the United States
cost between $9.1 and $11.6 billion per year.
Costs associated with legal action resulting
from facility-acquired PIs add to the econom-
ic burden. Based on the evidence, the EBP

Promoting PI prevention
As part of the quality improvement team’s efforts to educate nursing staff
about pressure injury (PI) prevention, they created a flyer to post through-
out the organization. The flyer promoted staff empowerment through edu-
cation and encouraged the use of a repositioning/skin inspection chart and
a PI identification communication tool. At the end of each shift, completed
charts and tools are submitted to the assistant director of nursing, who
promptly reviews them to identify any new skin issues.

Repositioning/skin inspection chart
When developing the care plan, consider comorbid conditions, such as
frailty and dementia.

• Change the patient’s position at least every 2 hours.
• Reposition patients sitting in chairs every hour.
• Inspect skin during activities of daily living.
• Document the patient’s position and skin inspection every shift.
(View a repositioning chart at myamericannurse.com/?p=258423.)

PI identification communication tool
• Complete on all residents daily during routine care every shift.
• If the skin inspection reveals an area of concern, note it on the tool below.

PI identification communication tool

Date: Check all that apply:

Resident’s name:
n No skin problem noted

Reporter’s name:
n Bruise n Skin tear

n Reddened area

Place an “X” on the area of the body where you see a concern.

Reporter’s signature ______________________________________________

Nurse’s signature (if reporter is not a nurse) __________________________

10 American Nurse Journal Volume 16, Number 7 MyAmericanNurse.com

project was expected to reduce PI prevalence
by at least 62%. This long-term care organiza-
tion’s financial policies prohibited the discov-
ery of direct costs, but because PI prevalence
decreased by 25% between July and Decem-
ber of 2019, it’s safe to assume some savings
occurred. In addition, it’s reasonable to con-
clude that decreased PI prevalence rates are
viewed as desirable by potential residents,
which could increase revenue from patient

Sustaining the intervention
To support sustainability and continued use of
evidence for data-driven changes, the QI team
developed a skin integrity algorithm. (See
Skin integrity algorithm.) The team also rec-
ommended to nursing leadership that the or-
ganization continue to use Braden Scale and
weekly skin assessments. The EBP project

prompted a culture change within the organi-
zation, enhancing PI awareness and contin-
ued use of the implementation forms by nurs-
ing staff after the EBP project ended.

Closing the gap
This EBP project used evidence to close the
gap between knowledge and action. Contin-
ued efforts include integrating implementation
forms and the skin integrity algorithm into
electronic formats for permanent use. Other
recommendations are incorporating increased
EBP into long-term care facilities for better
outcomes and to increase the quality of care
for all residents. AN

Access references at myamericannurse.com/?p=258423.

Melissa De Los Santos is a professor in the vocational nursing
program at Austin Community College, Eastview Campus in
Austin, Texas.

Skin integrity algorithm
To ensure the pressure injury (PI) prevention evidence-based practice was sustained, the quality improvement team developed a skin
integrity algorithm.

Weekly skin assessment

Abnormal findingNo abnormal finding

Continue Braden Scale assessments per protocol Nurse follow-up assessment and complete a Braden Scale assessment

Braden Scale risk scores*

Mild-risk scores (15 to 18)
Encourage mobilization, turning, and repositioning; document on
repositioning chart every shift.
Assist with peri-care and ADLs as needed.
Maintain hydration and nutrition.

Assist with mobilization, turning, and repositioning; document on
repositioning chart every shift.
Assist with peri-care and ADLs every shift.
Implement consultations with physician, wound team, and
dietician as needed.

Assist with mobilization, turning, and repositioning; document on
repositioning chart every shift.
Assist with peri-care and ADLs every shift.
Consult with physician, wound team, and dietician for additional

Inspect, report, and document skin concerns on PI identification
communication tool every shift.

Inspect, report, and document skin concerns on PI identification
communication tool every shift.
Assist with hydration and nutrition every shift.

Inspect, report, and document skin concerns on PI identification
communication tool every shift.
Assist with hydration, nutrition, and offer supplements every shift.

Moderate-risk scores (13 to 14)

High-risk scores (12 or below)

ADLs = activities of daily living, PI = pressure injury
*For this project, the Braden Scale Score for very high risk (9 or below) was incorporated into the high-risk score.

MyAmericanNurse.com July 2021 American Nurse Journal 11

Please mark the correct answer

1. Harold*, your 88-year-old patient,
enjoys sitting in his chair for the en-
tire morning. How often should you
reposition him?

a. Every 30 minutes

b. Every 45 minutes

c. Every 60 minutes

d. Every 90 minutes

2. You should document your inspec-
tion of Harold’s skin every

a. hour.

b. shift.

c. day.

d. week.

3. Joan, a 78-year-old resident in a
long-term care (LTC) facility, has a
Braden Scale score of 16. You know
that all of the following actions are
appropriate except:

a. assisting with mobilization, turn-
ing, and repositioning.

b. assisting with peri-care every

c. assisting with activities of daily
living every shift.

d. requesting a consultation with the
wound care team and dietician.

4. Which of the following statements
about PICOT is incorrect?

a. P = patient, population, problem

b. I = intervention

c. C = contrast, contractual

d. O = outcome, objective

5. You’re asked to spearhead a team
to reduce PIs in the LTC setting where
you work. The team is analyzing the
results of a literature search, and
some team members aren’t familiar
with the levels of evidence used to
guide the analysis. You explain that al-
though the precise levels can vary,
Level I typically includes

a. case control and cohort studies.

b. systematic review or meta-analy-
sis of all relevant randomized
controlled trials.

c. opinions of authorities and re-
ports of expert committees.

d. a single descriptive or qualitative

6. Level VII typically includes

a. case control and cohort studies.

b. systematic review or meta-analy-
sis of all relevant randomized
controlled trials.

c. opinions of authorities and re-
ports of expert committees.

d. a single descriptive or qualitative

7. Which of the following statements
about logic models is correct?

a. It’s a graphic tool for planning,
describing, managing, communi-
cating, and evaluating a program
or intervention.

b. It’s a written tool for planning,
describing, managing, communi-
cating, and researching a pro-
gram or intervention.

c. It includes outcomes in the form
of long-term goals.

d. The process section includes
medium-term goals.

8. You’re assembling a team for a
project to reduce PIs in your LTC set-
ting. Whom would you include on the




9. What would you anticipate the
team would identify as activities that
would help reduce PIs?




10. What would be reasonable short-,
medium-, and long-term goals for this




*Names are fictitious.

POST-TEST • Pressure injury prevention in long-term care
Earn contact hour credit online at myamericannurse.com/pressure-injury-prevention

Provider accreditation
The American Nurses Association is accredited as a provider
of nursing continuing professional development by the
American Nurses Credentialing Center’s Commission on

Contact hours: 1.6

ANA is approved by the California Board of Registered Nurs-
ing, Provider Number CEP17219.
Post-test passing score is 80%.
Expiration: 7/1/24

CNE: 1.6 contact hours


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