DNP Scholarly Projects


Each year in the U.S., pressure injuries, or PIs, are responsible for more than 60,000 patient deaths and billions of dollars’ worth of treatment costs. Research shows that roughly 95% of all PIs are preventable by following evidence-based practice guidelines which include early identification of patients at risk, frequent skin assessments, and implementation of prevention strategies. However, the ED environment creates unique risks for PI development due to the routine use of hard surfaces (i.e., stretchers, backboards, exam tables) and frequent hospital overcrowding. Although nurses play a pivotal role in PI prevention, frequent staffing shortages, high patient acuity levels, and competing patient care needs make protocol implementation difficult to prioritize. The purpose of this project was to analyze nursing workflow and healthcare technology utilization to identify opportunities to improve PI prevention protocol implementation. Additionally, this project explored how certain patient-level risk factors, when compounded by risk factors that are unique to the ED environment, create unrecognized risks for PI development. The Donabedian quality of care framework was used to guide the quality improvement project by assessing the relationship between system structures, clinical processes, and patient outcomes. Analysis of data from a retrospective chart review of 30 charts found patients were more likely to have an initial HAPI diagnosis that is at a more severe stage if they were female, younger than 65, had two or more comorbidities, or had a foley and/or ostomy. Regarding protocol compliance, the first two steps of the PI prevention protocol were met 80-90% of the time; however, the third step was met 6.67% of the time with an average of 15 days before a wound care consult was ordered after a patient was first identified as “at risk” for developing a PI. Additionally, on average, patients spent over 10 hours in the hospital before receiving a skin assessment indicating that the current 8-hour guidelines may not accurately assess the risks for PI development in patients admitted through the ED. Lastly, the results showed high variability between the processes of care indicating that PI protocol implementation lacks standardization and consistency. Developing an ED-specific PI risk assessment tool that includes an automated communication pathway between ED nursing and wound care can mend the gap caused by human error and also improve the early identification of patients at risk, timely implementation of PI prevention, and, overall, improve patient outcomes. The findings of this project confirm the need for a more standardized, streamlined clinical process regarding PI monitoring, surveillance, and prevention implementation that begins at the point of hospital entry in the ED.


Spring 4-13-2023

First Advisor

Elizabeth Morse, DNP, MPH

Second Advisor

David Phillippi, PhD

Scholarly Project Team Member

Lisa Mullaley

Scholarly Project Team Member

Amaka Otiono


Nursing, School of


Health Sciences & Nursing, Gordon E. Inman College of

Document Type

Scholarly Project


Doctorate of Nursing Practice (DNP)

Degree Level


Degree Grantor

Belmont University


pressure injury, hospital-acquired pressure injury, emergency department, risk, skin assessment, prevention