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Hospital Acquired Pressure Injuries (HAPI) are a complex and important safety issue. They increase length of stay, readmission rates, costs , and mortality. Per NPIAP Pressure Injury (PI) Fact Sheet- 2019: Avg cost per patient for HAPIs: $29,000-$151,700; 2.5 million patients develop PI and 60,000 die annually. At HFH Detroit, HAPI rates from Jan to Aug 2022 peaked to 6.5% (NDNQI* mean 2021 Q1 benchmark is 2.9%). Increased HAPI rate, high staff turnover, and supply chain challenges made evaluating PI prevention strategy implementation crucial. HFH Detroit Wound Care Team sought to decrease HAPI rate to the goal of 4% in 12 months. Approach/Plan: Wound care team developed an audit tool to measure compliance of: Current PI Prevention Strategies, Skin Assessment, Documentation on turning/positioning, and Appropriate layering under patients to prevent moisture skin damage. Audit also identified prevention supplies stocked and available on each unit. Data from the audit was used to: Develop education tailored to each units needs; Address supply stocking issues; Identify contributing factors that may increase HAPI rates; From Aug 2022-Jan 2023, 16 units were audited. Same units were re-audited from Nov 2023-Jan 2024.

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Henry Ford Health


Detroit, Michigan


Quality Expo, posters, poster competition

Project #54: An Individualized Unit Based Approach to Utilizing Pressure Injury Prevention Strategies for Acute Care Nursing Staff



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