Date of Graduation

Winter 12-12-2025

Document Access

Project/Capstone - Global access

Degree Name

Master of Science in Nursing (MSN)

College/School

School of Nursing and Health Professions

Program

MSN project

First Advisor

Josephine Juan, MSN, RN, CCRN

Abstract

Objective: With the increasing prevalence of hospital-acquired pressure injuries (HAPIs) among trauma patients at Highland Hospital, a quality improvement initiative was developed as a call to action. The overarching goal of this project was to design and implement a Quality Assurance and Performance Improvement (QAPI) intervention that was both feasible and cost-effective to address existing gaps and disparities during hospitalization at Highland Hospital, part of Alameda Health System in the Bay Area. Aim: The project aimed to evaluate whether a bedside visual cueing system could strengthen nursing compliance with pressure-injury prevention protocols and improve the consistency of communication among interdisciplinary care teams. Methods: Key quality metrics were measured to support Highland Hospital in developing the QAPI intervention. Baseline data, staff perspectives, and unit-level barriers were assessed to identify opportunities for improvement. These findings were used to guide the development of a feasible visual cue that aligned with workflow needs and unit practices. Time constraints and limited implementation periods were identified as major limitations. Intervention: A modified bedside visual cueing system was introduced, showcasing each patient’s Braden Score and a turning clock for two-hour repositioning. The cueing tool was used for a two-week period to evaluate feasibility, clarity, and alignment with clinical workflow. Staff were surveyed to provide feedback and share ideas, which guided refinements to the final visual cue. Results: Quality metrics suggested both improvements and remaining limitations in reducing HAPI prevalence and enhancing communication among care teams. Staff expressed support for ongoing interdisciplinary collaboration and recognized the potential value of standardized visual reminders. Although promising, the short implementation window limits the ability to fully evaluate long-term adoption and impact. Conclusion: This initiative highlights the potential for bedside visual cueing systems to strengthen nursing compliance, reinforce patient safety, and promote a sustainable culture of prevention. Continued QAPI efforts and interdisciplinary engagement will be essential in ensuring long-term success and reducing HAPI burden within the trauma population.

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