Benchmark – Evidence-Based Practice Proposal Final Paper

Benchmark – Evidence-Based Practice Proposal Final Paper

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HAPUs is an issue of significance to healthcare systems, policymakers, and patients in the US. Apart from causing patients severe pain, HAPUs increase the potential risks of severe infection, increase the hospital los, and account for significant healthcare-related costs. HAPU care bundles are an efficient and effective intervention to reduce los among elderly inpatients in acute care settings. HAPU bundles comprise the following elements: repositioning, skincare, patient and staff education, and risk assessment. The Iowa Model of Evidence-Based Practice will guide the implementation of this EBP since it emphasizes on multidisciplinary collaboration, change within an organization, and feedback obtained from the implementation team. A multidisciplinary team of nurses, physicians, physiotherapists, clinical nutritionists, and clinical nurse leaders of the med-surge unit will implement this EBP within 14 weeks. A pre and post assessment tool, patient satisfaction survey, and a HAPU audit tool will be used to collect pre and post-implementation data.  In nursing practice, this EBP recommends the use of HAPU bundles a practical and useful tool to decrease incidences of HAPUs and reduce hospital los among hospitalized patients. Further studies should examine strategies to improve staff compliance with HAPU bundles post-implementation.

Table of Contents

Abstract 2

Section A: Organizational Culture and Readiness Assessment 4

Barriers to Implementing EBP. 4

Facilitators to Implementing EBP. 4

Section B: Proposal/Problem Statement and Literature Review.. 5

PICOT Question. 5

Proposal/Problem Statement 5

Literature Review.. 6

Section C: Solution Description. 7

Proposed Solution. 7

Consistency of the Proposed Solution with the Organizational Culture. 8

Expected Outcomes. 9

Method to Achieve Outcomes. 9

Outcome Impact 10

Section D: Change Model 10

Iowa Model of Evidence-Based Practice and Its Relevance. 10

Stages of the Iowa Model 10

Applying Stages of Iowa Model To The Proposed Implementation. 11

Section E: Implementation Plan. 12

Setting. 12

Time. 12

Resources. 13

Methods and Instruments. 14

Data Collection Plan. 15

Addressing Potential Barriers. 15

Feasibility. 15

Maintenance Plan. 16

Section F: Evaluation of Process. 16

Rationale for Data Collection Methods. 16

How Outcome Measures Determine Achievement of Objectives. 16

Measurement and Evaluation of Outcomes-Based On Evidence. 17

Strategies If Outcomes Do Not Provide Positive Results. 17

Implications for Practice and Future Research. 17

References. 19

Appendices. 21

Appendix A: Conceptual Model 21

Appendix B: Staff Pre and Post Knowledge Assessment Form.. 21

Appendix C: Budget 23

Append D: Timeline. 24

Appendix E: Resource List 25

Appendix F: Patient Satisfaction Survey. 26

Appendix G: HAPU Audit tool 27

Appendix H: Approval Form.. 28

Benchmark – Evidence-Based Practice Proposal Final Paper

 Section A: Organizational Culture and Readiness Assessment

To assess the organization’s level of readiness for change and implementing EBP, the author used OCRSIEP (Organization Culture and Readiness for System-Wide Integration of EBP) survey tool (Melynyk & Fineout-Overholt, 2015). This survey tool comprises 25 items to measure the cultural factors that facilitate or hinder the system-wide adoption of EBP and the perceived readiness of Mayo Clinic.

Barriers to Implementing EBP

The most critical barriers to implementing EBP based on the findings of the survey tool are individual and organizational. Individual barriers include; lack of skills to conduct evidence-based research such as searching for research articles, conducting a critical appraisal, or synthesizing a research article. Therefore, rather than searching for information in peer-reviewed and journal articles or textbooks, most nurses obtain information from colleagues. A potential organizational barrier is an inadequate time to take part in EBP processes such as retrieving clinically relevant data since the organization serves a large population. Besides, although nurses who comprise the majority of the organization’s healthcare workforce know the importance of knowledge based on research, most of them consider it an overwhelming and time-consuming process.

Facilitators to Implementing EBP

The leadership of Mayo Clinic is dedicated to providing safe and quality healthcare services to patients. This objective reflects the organization’s mission, vision, and goals. According to Melynyk & Fineout-Overholt (2015), to implement new policies, programs, or practices in a healthcare organization, it is integral that the intended change remains consistent with the organizational culture and philosophy to support the proposed change.

The work environment of Mayo Clinic respects the authority, independence, and power that nurses possess in clinical practice. In the recent past, the organization’s leaders adopted the use of multidisciplinary teams to provide patient-centric culturally sensitive care to patients. The aforementioned aspects make it easy for nurses to implement a change in practice with the input, consent, and approval of other healthcare stakeholders. To address the tension that might arise through working with multidisciplinary teams, each member of the team should have well-defined roles and responsibilities.

To add on, healthcare staff unanimously acknowledge that there has been a gradual increase in incidences of HAPUs. HAPUs prolong the LOS of elderly patients hospitalized in the med-surge units. As a result, this has increased awareness of the urgent need for a change in practice and ownership of implementing the change by nurses, clinical nurse leaders, and clinicians.  

Section B: Proposal/Problem Statement and Literature Review

PICOT Question

 In elderly acute care in-patients (P) does the use of Hospital Acquired Pressure Ulcer (HAPU) prevention bundles (I) compared to no HAPU bundles (C) reduce the extent of hospital stay (O) over six months (T)?

Proposal/Problem Statement

HAPUs is an issue of significance to healthcare systems, policymakers, and patients in the US. Apart from causing patients severe pain, HAPUs increase the potential risks of severe infection, increase the hospital LOS, and account for significant healthcare-related costs (Chaboyer et al., 2016).To prevent the development of HAPU and reduce los, healthcare institutions are implementing care bundles that comprise of a set of more than three interventions. HAPU prevention bundle comprises of interventions directed towards skincare, patient, and healthcare provider education (Lavallée et al., 2019).

Literature Review

In a quality improvement project done in a 144-bed capacity hospital by implementing a Pressure Injury Prevention (PIP) bundle. Al-Otaibi, Al-Nowaiser & Rahman (2019) noted an 84% decline in the prevalence of PU (P- <0.0001, 95% CI) within 12 weeks. A limitation of this study is that the researchers used a quasi-experimental design and this limits the applicability of the outcomes to general populations.

In the cluster-RCT by Chaboyer et al., (2016), the researchers randomized participants (1600 patients, aged 18 years or older and at risk of pressure ulcers-immobility and long hospital stay) to standard care or a HAPU bundle care. The researchers found no harm or adverse events but found a new PU hazard ratio of 0.58 (P= 0.198, CI: 95%). This study’s limitation is that the researchers used small clusters resulting in a potentially low statistical power.

Cano et al., (2015) facilitated a QI project in the inpatient setting of a large hospital by implementing a HAPU prevention bundle. There was a reduction in the prevalence of stage II-IV HAPU (11.7%-2.1%). The rate rose again to 4.1% from 3.1%, dropped further to 2.76%, and remained at 1-2% ever since, after re-education and introduction of new skin products. The findings of this study are similar to that of Lavallée et al., (2019) where the researchers collected quantitative data on the behaviors and incidences of HAPU prevention before and after implementation of a HAPU bundle. The researchers noted no more PU and the recorded HAPU prevention behaviors were: inspection of the skin, re-positioning, and checking surfaces for support. Besides, patients reported that the HAPU bundle improved their care (Lavallée et al., 2019). A major limitation of this study is that of response bias since the researchers depended on self-reported behaviors and respondents were informed that the researchers were monitoring their HAPU prevention behaviors.

In the quantitative study by Padula et al., (2016), the researchers characterized the adoption of EBP interventions for quality improvement using IT, hospital leadership, improvement, staff, and performance. They later collected in patient characteristics and incidences of HAPU; analyzed using mixed-effects regression models. The researchers noted a modest decrease in the rates of HAPU (p=0.002) with a greater effect on the HAPU prevention non-payment policy (p<0.001). A great limitation of this study is that of response bias that limited responses in administered surveys during observations of the positive impact after the adoption of QI interventions.

Section C: Solution Description

Proposed Solution

HAPUs are underrated yet they have a high prevalence. Their incidence in acute care settings ranges between 0.4-12% and the prevalence ranges from 12-18%. In settings with chronic care patients, it ranges from 2.2-23.9% and 53.2% respectively (Padula et al., 2016). The prevalence of HAPUs I the US   is 13.3 million, accounting for approximately $2.2-3.6 billion every year. HAPUs also increase the workload of nurses and decrease their morale. Those with stage II to IV HAPUs have a low QoL, may experience moderate to very severe pain or secondary bacterial infections with high morbidity and mortality (Padula et al., 2016).

This EBP proposes the use of HAPU care bundles as the most efficient and effective intervention for reducing los of elderly inpatients in acute care settings. According to Lavallée et al. (2019), care bundles describe a set of EBP supported solutions meant for a particular population of patients and healthcare settings, whose collective adoption leads to improved outcomes in comparison to individual implementation. According to Barakat-Johnson et al., (2019), a HAPU bundle comprises of more than three independent interventions that require a multidisciplinary approach to implement. The proposed HAPU bundle comprises the following elements: repositioning, skincare, patient and staff education, and risk assessment. This intervention is realistic and appropriate for implementation in the healthcare organization since nurses who comprise the majority of the health workforce have some knowledge on how to conduct evidence-based research. However, they will require more training to improve their knowledge, understanding, and skills on the same.

Consistency of the Proposed Solution with the Organizational Culture

The healthcare organization is an urban medical clinic providing acute care services to more than 40,000 residents. The organization has embraced a patient safety and learning culture that is illustrated in its mission, vision, and goals. The organization’s philosophy is anchored on practices, processes, conventions, and values that encourage staff to develop competence and knowledge through continuous learning to influence each other.

The organization’s leadership embraces the transformational leadership style, which integrates other stakeholders in decision-making processes. This leadership style has prompted the implementation of other quality improvement projects to improve care outcomes. Padula et al. (2016) emphasize that the implementation of HAPU bundles requires a multidisciplinary approach to improve the chances for more successful outcomes. This healthcare organization embraced a culture of working in interprofessional teams, which improves the responsiveness of healthcare providers increases patient satisfaction rates and reduces patient-safety and quality-related issues. 

Expected Outcomes

After implementing the proposed solution (HAPU bundles), it is anticipated that patient los will reduce significantly. Patient los describes the duration of hospitalization and evidenced by hospital admission data. Los is an important aspect used to gauge the efficiency of a healthcare organization.

Method to Achieve Outcomes

There will be an initial training session to identify potential gaps in knowledge about the proposed intervention. Internal and external quality improvement experts will do the training. There will be a specific schedule for training based on the work schedules of all healthcare providers. A quality improvement committee will oversee the implementation of the proposed intervention. This committee will comprise of stakeholders from different healthcare professionals and a representative from the organization’s leadership with well-defined roles and responsibilities (Frank et al., 2017). In this case, the committee will comprise of a nurse, nutritionist, clinical nurse leader, a physiotherapist.

Nurses will reposition patients and ensure skincare. Nutritionists will ensure that patients receive adequate hydration and nutritional status and the physiotherapist will conduct mobility exercises. The role of the CNL will be to ensure that all members adhere to the HAPU intervention bundle and to ascertain that nurses document care appropriately as needed. This committee will also oversee the monitoring and evaluation process post-implementation to determine the attainment of the project goals and objectives and potential area for adjustments.  

Outcome Impact

After implementing the proposed intervention, patient los will decrease. This implies that there will be increased efficiency in the services offered in the med-surge units evidenced by a short duration of los and early discharge (Qaseem et al., 2015). Ultimately, the incidence, prevalence, and HAPUs healthcare-related costs will also decrease which will guarantee an improvement in the quality of patient care as well as patient safety.

Section D: Change Model

Iowa Model of Evidence-Based Practice and Its Relevance

The Iowa EBP model guides nurses on how to utilize the findings from research to promote care. The author selected this model since it emphasizes multidisciplinary collaboration, change within an organization, and feedback obtained from the implementation team (Buckwalter et al., 2017). Therefore, this change model reveals the essence of integrating the complete healthcare system in the decision-making process, which requires a multi-system commitment. In the context of this EBP, the Iowa model connects changes in practice within the organization through leading, performance, engagement, and supporting change (Nilsen, 2015). This approach is integral to determining how EBP influences healthcare systems and patient outcomes. Its integral implication is the mandatory inclusion of values, patient, family, and individual patient preferences.

Stages of the Iowa Model

Iowa model has seven stages namely; topic selection, team formation, retrieving evidence, and grading, EBP standard development, and implementation, and evaluation. In the first stage of topic selection, a researcher identifies a topic, which can be triggered by knowledge or a clinical problem. The second step of team formation consists of different stakeholders with clearly outlined roles and responsibilities to ensure interdisciplinary collaboration (Farrington, Laffoon & Kealey, 2015). The third step involves evidence retrieval where members of the implementation team collect and analyze evidence using the PICO framework. In the fourth step, members of the implementation team take time to critique, synthesize, and grade evidence. The fifth step involves developing an EBP standard after ascertaining that there is adequate evidence. In the sixth step, a researcher must run a pilot program using one or two units for evaluation. In the final step, a researcher must conduct ongoing evaluations to determine the feasibility and effectiveness of the proposed change before actual implementation.

Applying Stages of Iowa Model To The Proposed Implementation

The decision to implement a HAPU bundle in the authors’ organization was triggered by a clinical problem where the organization still records incidences of HAPU among patients hospitalized in the med-surge units. HAPU incidences had a negative impact on the organization’s financial performance, prolonged the length of hospital stay, and increased patient mortality and healthcare-related costs. To facilitate a successful implementation of the proposed plan, an implementation team comprising of clinical nurse leaders, nurses, dieticians, and physicians will be formed.

Collectively, the implementation team will retrieve, analyze, critique, and synthesize evidence to get the best and most current evidence that supports the implementation of HAPU bundles as the most effective intervention to reduce the length of hospital stay of elderly patients in acute care settings (Jones, 2019). After ascertaining that there is adequate evidence, the team will progress to conduct a pilot study and evaluate outcomes. If the outcomes will be clinically significant, the team will progress to conduct an actual implementation, which includes educating staff about HAPU bundles and documenting the HAPU bundled care a patient receives. The final step will be writing policies and guidelines that describe a HAPU bundle, its components, when and how to implement each of its items, and measurable outcomes.

Section E: Implementation Plan


The implementation of this evidence-based project will be in the med-surge unit of a metropolitan medical clinic that serves approximately 40,000 people. It will include a nurse sample of all RNs, clinical nurse leaders, physiotherapists, and clinical nutritionists who will consent to participation during the period of implementation. The approximated sample size will however be 60. The implementation of a HAPU bundle will purpose to reduce the length of hospital stay through different strategies such as; identifying patients at risk and initiating different strategies to either prevent or reduce HAPU (Barakat-Johnson et al., 2019).  

The author will obtain a Non-Human Research approval from the Institution’s Review Board (IRB) as well as the Nurse Research Council of the community medical clinic where this evidence-based project will be implemented. During the implementation of the HAPU bundle and data collection process, patients’ privacy and confidentiality will be of utmost significance. To maintain privacy, the author will exclude all patient identifiers. As suggested by Frank, et al. (2017), the HAPU bundle will include conducting skin assessments 12 hourly upon admission using a Skin Assessment tool, regular repositioning, nutrition assessment, glycemic control and use of redistribution surfaces


This evidence-based project will be implemented in 14 weeks. In week one will be the formation of a multidisciplinary team (MDT) and week two will include staff training. In week three, members of the MDT will gather relevant literature, critique, and synthesis it to determine if the available literature is adequate to support the proposed intervention.  In week five and si, the team will pilot the change in practice to help in prior identification of potential barriers to implementation. In week seven, the implementation team will assess potential barriers, facilitators, and adjustments to improve the effectiveness of the proposed intervention. From week eight to week twelve, the implementation team will conduct the actual implementation and focus on making potential modifications to the HAPU bundle and distributing reference staff badges that will act as reminders to comply with each component of the HAPU bundle. In weeks 13 and 14, the implementation team will assess staff compliance rates with the HAPU bundle using an audit tool. A clinical nurse leader will disseminate results to the nurse administrator.


The implementation of this evidence-based project will primarily require human resources. The organization will hire an external quality improvement trainer who will partner with the institution’s internal improvement team and the implementation team to train staff in the initial two weeks of implementation. As recommended by Lavallée et al. (2019), a multidisciplinary team comprising of nurses, clinical nurse leaders, clinical nutritionists, and physiotherapists will implement the proposed intervention. Each member will have well-defined roles and responsibilities as follows:

Nurses -conducting skin assessments and documenting care (Padula et al., 2016).

Physiotherapists-repositioning patients every 2 hours and maintain up-to-date documentation of the same.

Clinical nutritionists -conducting nutritional assessments and intervene as required to ensure that patients are adequately hydrated and have proposer nutritional status.

Clinical nurse leaders-supervising participants to ensure that they adhere to the components of the HAPU bundle as required, care is appropriately and Upto date documented.

Laboratory specialists- taking prealbumin measurements on admission and after every seven days, performing random blood glucose tests six-hourly, documenting, and maintaining up to date patient records of the same.

The author will use a skin assessment tool (Braden Scale) to conduct skin assessments and determine patients at high risk of developing HAPU and intervening appropriately while nursing notes will be used to document patients turning schedule/repositioning.

Methods and Instruments

To monitor the implementation of the proposed solution, the author will use a satisfaction survey and an audit tool. The satisfaction survey will be used to collect data from patients on the care given concerning HAPU prevention and collected data will be used to determine patient satisfaction rates.  The implementation team will use a HAPU audit tool to collect data on patient-specific interventions and outcomes. Interventions in this context refer to specific components of the HAPU bundle implemented by a caregiver, while outcomes will be in the context of an incidence of a new HAPU, duration of hospitalization, mobility days, and skin outcomes.

The HAPU audit tool will also be used to determine participants’ compliance with the proposed intervention. However, before implementation, all participants will undergo mandatory training. An internal and external quality improvement specialist will conduct the training, which will focus on how to conduct and document all the components of the HAPU bundle. All the participants (nurses, clinical nutritionists, physiotherapists, and clinical nurse leaders) will complete a pre and post-assessment and are expected to attain 80% or higher to demonstrate improved knowledge.

Data Collection Plan

The implementation tea will collect data in three stages, before implementation, the implementation team will administer a survey to assess the current practice. During implementation in week six and thirteen, members of the implementation team will conduct an audit to determine the compliance rates with components of the HAPU bundle. The audit will include comprehensive assessments of skin assessment tools for completed Braden scores, patient charts for documentation of regular repositioning, and the Electronic Health Records of each patient for completed glucose and prealbumin levels.

Addressing Potential Barriers

Since the proposed intervention will require prompt documentation of care as evidence to demonstrate that care was given,  the participants may have an attitude that the entire process is time-consuming and thus not a priority. The author will address this barrier through training to improve participants’ knowledge and understanding as to why it is crucial to document every care component (Qaseem et al., 2015). Besides, since the implementation of the proposed intervention requires a multidisciplinary approach, it will be important to ensure that the care plan is interdisciplinary rather than leaving it to nurses to develop and implement. The author will address this barrier by assigning every contributor to the HAPU bundle roles and responsibilities as essential team players in the process of planning for care.


The implementation of the proposed intervention is cost-friendly. Since the organization has computerized charting to guide care planning, there will be no costs to incur in documenting patient care. Major costs will be incurred in training staff when hiring an external trainer. However, the Agency for Healthcare Research Quality (AHRQ) website is a potential resource for information on HAPU prevention.

Maintenance Plan

If the outcomes from the HAPU audit support the expected outcomes of this evidence-based project the author, in collaboration with the implementation tea will proceed to develop and implement written policies and guidelines that will help to prevent HAPU in clinical practice. The implementation team will make adjustments through quarterly reviews when outcomes fail to meet the desired goals.

Section F: Evaluation of Process

Rationale for Data Collection Methods

The author will collect outcome data using a survey and a HAPU audit tool. Surveys are affordable, easy to develop and implement, and quick to obtain feedback especially in this context where the organization must obtain positive feedback from patients and healthcare staff. Besides, surveys enable data the collection of feedback from a large population sample in a short duration (Young, 2016). As the best method to obtain qualitative feedback, a researcher can easily compare data, make analyses, and develop themes. The author will use the HAPU audit tool to collect data on patient specific-HAPU intervention and outcomes such as hospital los, and HAPU incidences. The author will collect data before the implementation of the HAPU bundle, at 3 months and 6 months.

How Outcome Measures Determine Achievement of Objectives

The primary outcome measure being measured in this evidence-based project is a decrease in the hospital los after 6 months following the implementation of a HAPU bundle. The author will evaluate the attainment of objectives using quantitative measures. Quantitative measures will include the use of statistical tests to make correlations and comparisons between baseline data and outcome data. The correlations will particularly be between specific components of the HAPU bundle, hospital los.

Measurement and Evaluation of Outcomes-Based On Evidence

The author will determine the reliability and validity of the project’s outcomes using ANOVA. The variables being tested in this evidence-based project are incidences of HAPU, duration of hospital los. It is expected that there will be a 95% decrease in HAPU incidences and the length of hospital stay will reduce significantly at 3 and 6 months to 6 days and 4 days respectively. ANOVA was the most preferred statistical method since it is used to analyze differences that exist in group samples (Boisgontier & Cheval, 2016). Therefore, in this project, the author will use ANOVA to determine correlations and subsequently confirm the applicability, reliability, and validity of the outcomes.

Strategies If Outcomes Do Not Provide Positive Results

If the findings do not provide the desired outcomes, the author will identify areas where potential gaps exist, and carefully analyze the outcomes before making specific recommendations for improvement or further research. Thus, other researchers can re-do the project using a very distinct approach with consideration of the proposed recommendations.

Implications for Practice and Future Research

This EBP proposal reveals that a HAPU bundle is a practical and useful tool to decrease incidences of HAPUs and reduce hospital los among hospitalized patients. It further indicates that for success, organizations must use a multidisciplinary approach during the implementation of the HAPU bundle. Further studies should examine strategies to improve staff compliance with HAPU bundles post-implementation.





Al-Otaibi, Y. K., Al-Nowaiser, N., & Rahman, A. (2019). Reducing hospital-acquired pressure injuries. BMJ Open Qual8(1), e000464.

Barakat-Johnson, M., Lai, M., Wand, T., & White, K. (2019). A qualitative study of the thoughts and experiences of hospital nurses providing pressure injury prevention and management. Collegian26(1), 95-102.

Boisgontier, M. P., & Cheval, B. (2016). The ANOVA to mixed model transition. Neuroscience & Biobehavioral Reviews68, 1004-1005.

Buckwalter, K. C., Cullen, L., Hanrahan, K., Kleiber, C., McCarthy, A. M., & Authored on behalf of the Iowa Model Collaborative. (2017). Iowa model of evidence‐based practice: Revisions and validation. Worldviews on Evidence‐Based Nursing14(3), 175-182.

Cano, A., Anglade, D., Stamp, H., Joaquin, F., Lopez, J. A., Lupe, L., & Young, D. L. (2015, September). Improving outcomes by implementing a pressure ulcer prevention program (PUPP): going beyond the basics. In Healthcare (Vol. 3, No. 3, pp. 574-585). Multidisciplinary Digital Publishing Institute.

Chaboyer, W., Bucknall, T., Webster, J., McInnes, E., Gillespie, B. M., Banks, M., & Cullum, N. (2016). The effect of a patient-centered care bundle intervention on pressure ulcer incidence (INTACT): a cluster-randomized trial. International journal of nursing studies64, 63-71.

Frank, G., Walsh, K. E., Wooton, S., Bost, J., Dong, W., Keller, L., & Brilli, R. J. (2017). Impact of a PIP bundle in the solutions for patient safety network. Pediatric quality & safety2(2).

Jones, D. W. (2019). Hospital-Acquired Pressure Ulcer Prevention.

Lavallée, J. F., Gray, T. A., Dumville, J., & Cullum, N. (2019). Preventing pressure ulcers in nursing homes using a care bundle: A feasibility study. Health & social care in the community27(4), e417-e427.

Melynyk, B. & Fineout-Overholt, E. (2015). Evidence-based practice in nursing and healthcare. A guide to best practice (3rd ed.). China: Wolters Kluwer Health.

Michele Farrington, B. S. N., Laffoon, C. T., & Kealey, B. C. (2015). Iowa Model of Evidence-Based Practice to Promote Quality Care.

Nilsen, P. (2015). Making sense of implementation theories, models, and frameworks. Implementation Science10(1), 53.

Padula, W. V., Gibbons, R. D., Valuck, R. J., Makic, M. B. F., Mishra, M. K., Pronovost, P. J., & Meltzer, D. O. (2016). Are evidence-based practices associated with effective prevention of hospital-acquired pressure ulcers in US academic medical centers?. Medical care54(5), 512.

Qaseem, A., Mir, T. P., Starkey, M., & Denberg, T. D. (2015). Risk assessment and prevention of pressure ulcers: a clinical practice guideline from the American College of Physicians. Annals of internal medicine162(5), 359-369.

Young, T. J. (2016). 11 Questionnaires and Surveys. Research methods in intercultural communication: A practical guide, 165.



Appendix A: Conceptual Model

















Appendix B: Staff Pre and Post Knowledge Assessment Form

Question 1: Nurses must conduct ______   skin assessments using a Braden score  

1) Daily

2) 48 hourly

3) Weekly

4) 72 hourly

Question 2: Components of this HAPU bundle include:

1) Regular Repositioning

2) Daily Skin Assessments

3) Nutrition Assessments

4) Calorie intake and blood glucose monitoring and Control

5) Use of Redistribution Surfaces

Question 3: Nurses must post repositioning schedules in ______

1) Patients with Braden scores <16

2) Patients with Braden scores ≤ 16

3) Each patients’ room

4) Patients with Braden scores ≤ 18

Question 4: The Association of American Medical Colleges (AAMC) policy on Wound and Skin Assessment that discusses the Prevention and Management of HAPU recommends that patients can have sacral preventative dressings if they are unsoiled for ____ hours.

  • 72 hours
  • 12 hours
  • 48 hours
  • 24 hours

Question 5: Nurses should place patients with a Braden score of ______ on a C2 bed and get a sacral preventative dressing

  • < 18
  • <16
  • ≤ 18
  • ≤ 16



Appendix C: Budget



Human Resources


Medical Resources


Education and Training




Append D: Timeline



Week 1

Forming a multidisciplinary team

Week 2

Staff training

Week 3 & 4

Gathering literature, Critique, and synthesis

Week 5 & 6

Pilot proposed change

Week 7

Assess potential implementation barriers and facilitators and make proper adjustments

Week 8, 9, 10, 11 &12

Actual implementation

Week 13 &14

Assessment, monitoring, and evaluation




Appendix E: Resource List

Literature Resources

  1. Cochrane
  1. PubMed

Human Resources

  1. Nurses
  1. Physiotherapists
  1. Clinical nutritionists
  1. Clinical nurse leaders(CNL)



Appendix F: Patient Satisfaction Survey

Dear Patient: I would like to know how you feel about the care you received during your hospitalization. Kindly take one minute to complete this survey about your hospitalization. The responses provided are confidential.  Your responses are confidential. Thank you.

Please rate each of the following:

  1. I can rate the care received during my hospitalization as:
  • Excellent
  • Good
  • Fair
  • Poor
  1. Healthcare staff take a lot of interest in patients care
  • Strongly Agree
  • Agree
  • Not Sure
  • Disagree
  • Strongly Disagree
  1. The bedding and seats in the patient’s room are very comfortable
  • Strongly Agree
  • Agree
  • Not Sure
  • Disagree
  • Strongly Disagree
  1. I feel that  I will be in good care in case I visit the hospital again
  • Strongly Agree
  • Agree
  • Not Sure
  • Disagree
  • Strongly Disagree
  1. Areas that could be improved  in my care are:

Appendix G: HAPU Audit tool



Performed /Not Performed by


Outcome of

Skin Assessment



HAPU incidence


Patient Repositioning


HAPU incidence


Glucose Control


HAPU incidence


Calorie Intake Monitoring



HAPU incidence


Nutrition Assessment



HAPU incidence


Use of Redistribution surfaces



HAPU incidence





Appendix H: Approval Form

Student’s Name:  _____________________________   Date: _______________________

Proposed Topic / Title: ______________________________________________________________

Type of Project:          □ Poster Presentation □ Research Project                 □ Literature Review      

                                    □ Case Review                        □ Other:                                             

EBP Project Requires IRB approval:             □ Yes              □ No

Projected completion date: ___________________________

Faculty member signature: _______________________                 

Mentor’s Signature: ________________________________________________________       

EBP Project Approved           □ Yes              □ No

□ Reviewed and approved by research committee                 Draft due:                                           

IRB approval needed □ Application Submitted                    Date:                                         

□Approved      □ Not Approved                     

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