Date of Graduation

Summer 7-24-2025

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

First Advisor

Dr. Sara Horton-Deutsch

Second Advisor

Dave Ainsworth, DNP, RN, CNL

Abstract

Background:
This quality improvement project was implemented in the Transitional Cardiac Unit (TCU), a 32-bed telemetry unit primarily serving older adults recovering from cardiac procedures. A microsystem assessment revealed a hospital-acquired pressure injury (HAPI) rate of 1.49 per 1,000 patient days, exceeding the regional target of 0.82. Key barriers included limited skin assessment frequency, inconsistent documentation, and gaps in staff training.

Problem:
From June to December 2024, six HAPIs occurred in the TCU. Despite existing protocols requiring two-RN skin assessments at admission, transfer, and discharge, early detection of skin breakdown remained insufficient. Contributing factors included inconsistent surveillance, varied assessment skills, and missed follow-up on early signs of skin compromise. The project aimed to reduce HAPIs to no more than two cases in six months by implementing weekly two-RN skin assessments.

Intervention:
Guided by the Johns Hopkins Nursing Evidence-Based Practice model and Plan-Do-Study-Act (PDSA) cycles, a standardized weekly two-RN skin assessment protocol was implemented for high-risk patients (Braden score ≤18 or length of stay ≥7 days) from January to July 2025. The initiative included targeted staff education, visual checklists, CNL oversight, wound care specialist input, and collaboration with the Unit Council and Daily Integrated Safety Huddle (DISH).

Results:
The project led to improved assessment consistency, early identification of at-risk skin, and enhanced accountability. Only three HAPIs were reported—a 50% reduction. Estimated cost avoidance was $210,000.

Conclusion:
Weekly two-RN skin assessments effectively reduced HAPI incidence. Ongoing refinement aims to achieve zero HAPIs by end of 2025, supporting organizational safety goals.

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