Hospital Acquired Pressure Ulcer

Prevention
Ashlyn Barnes
Walden University
NURS: 4100 Quality and Safety Through
Evidence-Based Practice
August 17, 2016

THE QUESTION
Does nurse to nurse bedside-handoff
report at the change of each shift
decrease the incidence of hospitalacquired pressure ulcers in patients
with reduced mobility?

Hospital Acquired Pressure

Ulcers
P Hospitalized patients with decreased mobility
I - Mandatory Skin Assessment between two nurses at
each shift bedside handoff
C Comparison of incidence of HAPUs not assessed each
change of shift at bedside report
O Educating nurses on importance of skin checks at
beside
handoff to decrease incidence of HAPUs

Hospital-acquired pressure ulcers are a growing never event in our

hospitalized patients with decreased mobility.

More often than not when a patient is admitted to the hospital, they
experience some form of decreased mobility.

Nurses are ultimately responsible for preventing never events and HAPU in
the health care setting.

Evidence-based pressure ulcer prevention is fundamental to patient

safety (Sving, Gunningberg, Hogman & Mamhidir, 2012).

Research Shows
HAPUs are among one of the most severe safety concerns for
patients in a hospitalized setting (Choi & Kim, 2013).

Research and studies have consistently shown that bedside handoff

shows evidence of a decrease in patient safety incidents such as
hospital acquired pressure ulcers (Sand-Jecklin & Sherman, 2014).

Pressure Ulcers Can Be Prevented

SKIN CHECKS ARE CRITICAL

As we continually advance in our health care and nursing practices
of nursing, we find bedside-handoff to be a valuable tool in
assessing the patient.
For patients admitted to the hospital with decreased mobility, a
skin assessment is critical at the beginning and end of every shift
during bedside-hand off report.

Nurses must be more proactive in implementing a bedside handoff report

Bedside handoff is not being used to its full potential in patient care and
assessments

Hospital Acquired Pressure Ulcers are increasing in hospitals nation wide

Nurses need to take accountability for their patients safety and their skin

Nurses MUST take the practice of bedside handoff more seriously

According to research in one hospital, taking accountability at the patient

bedside can decrease the frequency of HAPU by 50 percent (Winnie, Yau &
Telebrico, 2015).

Change In Practice
Bedside-handoff at each change of shift is a critical time for passing
essential and crucial information on (Lindsay, 2015).
Bedside-handoff is a time for both nurses to take accountability for their
patient; this is the time for adequately assessing the patients skin.
For nurses to make a change and begin using their critical skills in the
manner that evidence-based practice suggests, they need to be more
proactive in implementing a bedside handoff report.
As hospitals implement this practice to improve patient quality of care and
safety, nurses must embrace it and take the opportunity to know about
everything going on with their patients from the start of their shift.

IN CONSLUSION

Studies have proven more than not to have positive results in quality
patient care and safety outcomes where HAPUs are involved (Mardis,
Davis, Benningfield, Elliott, Youngstorm, Nelson, Justice & Riesenberg,
2015)

More effort should be focused on implementing bedside handoff into

nursing practice to aid in the prevention of HAPUs.

Based on all the evidence, skin assessments should be a mandatory

nursing practice at each shift change bedside handoff to aid in the
prevention of hospital-acquired pressure ulcers in patients with
decreased mobility.

References:

Choi, J., Kim, J. (2013). Developing a Computer Interpretable Guideline with Nursing
Knowledge: A Pilot Study of a Pressure Ulcer Risk Assessment and Prevention.
Online Journal of Nursing Informatics (OJNI), vol. 17(1), Retrieved from
http://ojni.org/issues/? P=2393.

Mardis, M., Davis, J., Benningfield, B., Elliott, C., Youngstrom, M., Nelson, B., Justice,
E.M., Riesenberg, L.A. (2015). Shift-to-shift Handoff Effects on Patient Safety and
Outcomes: A systematic Review. American Journal of Medical Quality. Retrieved
from http://web.a.ebscohost.com.ezp.waldenulibrary.org/ehost/pdfviewer/

Sand-Jecklin, K., Sherman, J. (2014). Journal of clinical nursing: A quantitative

assessment of patient and nurse outcomes of bedside nursing report
implementation. Retrieved from
http://web.a.ebscohost.com.ezp.waldenulibrary.org/ehost/pdfviewer/

Sving, E., Gunningberg, M.H., Mamhidir, G.A., (2012). Journal of Clinical Nursing:
Registered Nurses attention to and perceptions of pressure ulcer prevention in
hospital settings. Retrieved from
http://web.a.ebscohost.com.ezp.waldenulibrary.org/ehost/pdfviewer/

Winnie, K., Yau, Hau., Telebrico, N. (2015). A Unit Based Quality Investigation Team:
Analysis and Accountability at Bedside. American Association of Critical Care Nurse:
2015 National Teaching Institute Evidence-Based Solutions and Chapter Best
Practices Abstracts. Retrieved from
http://ccn.aacnjournals.org/content/35/2/e18.full