Date of Graduation

Summer 8-3-2025

Document Access

Project/Capstone - Global access

Degree Name

Master of Science in Nursing (MSN)

College/School

School of Nursing and Health Professions

Program

Kaiser cohort MSN capstone

Abstract

Problem: Hospital-acquired pressure injuries (HAPIs) are a significant source of preventable harm. Often associated with increased patient morbidity, reduced quality of life, and substantial financial costs. In 2023, a Northern California level II trauma center reported 44 HAPI cases, with 25% occurring in the telemetry units. Despite a hospital-wide reduction in HAPIs in 2024, telemetry units accounted for 33% of the cases in the first quarter of 2025, highlighting a need for targeted intervention.

Context: The project was conducted in four adult inpatient telemetry units of a 241-bed level two trauma center. The units faced challenges with inconsistent adherence to pressure injury prevention practices, including appropriate bed surface selection, two-RN skin assessments with baseline posterior photos on admission/transfer, and patient repositioning every two hours.

Interventions: The SOS (Save Our Skin) program was launched to address these gaps using a multi-pronged approach. Key interventions included the implementation of a simplified bed surface selection algorithm, standardization of skin assessment documentation, deployment of wall-mounted monitors to improve repositioning compliance, and enhanced leadership oversight with real-time data monitoring.

Measures: The primary outcome measure was the quarterly incidence of HAPIs, with a goal of reducing telemetry unit cases from two to one or fewer by June 30, 2025. Process measures included compliance with every-two-hour repositioning, completion rates of two-RN skin assessments within eight hours of admission or transfer, and documentation of baseline sacrococcygeal photos. Balancing measures included monitoring staff injuries related to patient mobility.

Result: Early implementation of the SOS program resulted in increased awareness, improved documentation practices, and stronger interdisciplinary collaboration. Process compliance rates showed upward trends during the first Plan-Do-Study-Act (PDSA) cycle. Initial cost analysis projected potential first-year savings exceeding $100,000 by preventing HAPI cases and reducing related treatment expenses.

Conclusions: The structured, evidence-based SOS initiative demonstrated promising early results in reducing HAPI incidence and improving nursing practices. This project illustrates how transformational leadership, frontline staff engagement, and standardized workflows can align to enhance patient safety and organizational outcomes. Continued evaluation and sustainability planning will be essential to long-term success and potential hospital-wide expansion.

Keywords: Hospital acquired pressure injuries, skin bundles, repositioning, and pressure injury prevention

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