• Megan W Miller, Rebecca T Emeny, and Gary L Freed.
• Department of Wound Care Services, Dartmouth Hitchcock Medical Center, Lebanon, NH.
• Wounds. 2019 Apr 1; 31 (4): 108-113.

IntroductionHospital-acquired pressure injuries (HAPIs) increase patient mortality and length of stay (LOS). Twenty-eight full-thickness HAPIs occurred in fiscal year 2015 (FY15), and that trend continued into FY16 with 14 injuries on multiple units throughout a tertiary acute care center with 400 beds. To address this trend, a multidisciplinary Pressure Injury Prevention (PIP) team was created.ObjectiveThis report is a description of ongoing, hospital-wide efforts to understand the common factors of HAPI causality and to establish corrective action plans institutionally to prevent similar events in the future.MethodsThe team goals were to document the occurrence of HAPIs across all hospital units, reduce preventable full-thickness PIs to zero, and recommend institution-wide changes as those opportunities were recognized.ResultsSince the committee's inception in July 2015, an 89% reduction of full-thickness HAPIs, with only 2 full-thickness HAPIs in FY17 and 3 in FY18, has been seen. This effort has been hospital wide with involvement of all inpatient units and perioperative areas (including the operating rooms). Opportunities remain for improvement around the prevention of deep tissue and partial-thickness HAPIs.ConclusionsThe data demonstrate that the formation of a multidisciplinary PIP team of engaged clinicians can reduce the number of preventable full-thickness HAPIs.

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