NUR 684 Module 5 Milestone Two Example

Milestone Two: What Makes Pressure Injury Prevention Bundles Work? A Synthesis for a Heel-Focused Project

[Student Name]

Southern New Hampshire University

NUR 684: Clinical Nurse Leader Capstone

Module Five Milestone Two

[Instructor Name]

[Date]

Milestone Two: What Makes Pressure Injury Prevention Bundles Work? A Synthesis for a Heel-Focused Project

Prevention bundles group several practices so that they are delivered together. The heel pressure injury project proposed for Clearwater General's orthopedic floor is a bundle: an arrival heel check in the emergency department, heel offloading, individualized repositioning, early nutrition referral and weekly skin rounds with a skin champion and monthly feedback. This synthesis asks whether bundles of this kind reduce injuries, which components seem to matter most, whether involving patients adds benefit and where the evidence is thin. Sources were identified through CINAHL, PubMed and the Cochrane Library and were limited to hospital studies in adults.

Do Bundles Reduce Injuries?

Soban et al. (2011) systematically reviewed quality improvement programs in hospitals that relied mainly on nurses to prevent pressure injuries. Nearly all combined several strategies, such as staff education, risk assessment protocols, prevention guidelines and audits, and most reported lower injury rates after implementation. The authors noted that study designs were generally weak, mostly before-and-after comparisons, and that programs were described in too little detail to know exactly what was done.

Sullivan and Schoelles (2013) reached a similar conclusion across hospital and long-term care settings, finding moderate strength of evidence that multicomponent initiatives reduce the incidence of pressure injuries. Both reviews point in the same direction: bundles are associated with fewer injuries, although the size of the benefit and the certainty behind it vary.

Which Components Matter?

Because nearly every program combined several elements, no study isolated the effect of one component. Sullivan and Schoelles instead looked for components common to programs that succeeded. Five stood out: simplifying and standardizing prevention practices and their documentation; involving a multidisciplinary team and visible leadership; designating champions on the unit; providing education that continued beyond the launch; and auditing performance regularly and feeding results back to staff. Soban and colleagues similarly found that audit and feedback appeared in many of the programs that reported improvement.

These components overlap with what the unit lacks. Its skin champion role is vacant, feedback on pressure injuries reaches staff only after quarterly surveys and documentation of prevention is spread across several screens in the electronic record.

Does Involving Patients Help?

Chaboyer et al. (2016) tested a patient-centered bundle in a cluster randomized trial across hospitals in Australia. Patients at risk were taught three simple messages about keeping moving, caring for their skin and eating well, and nurses were asked to partner with them in prevention. Injury rates came out lower in the intervention hospitals, yet the gap fell short of statistical significance, and process evaluation showed that the bundle was not delivered to all patients as intended.

The trial is the most rigorous study in this synthesis, and its result is instructive. A bundle that is sensible on paper may produce only a modest, uncertain effect if staff deliver it inconsistently. For the heel project, the finding supports including patients and families, since many hip fracture patients are too confused or frail to participate alone, while making clear that fidelity must be monitored.

Synthesis

Across the sources, three conclusions emerge. First, prevention bundles are associated with fewer pressure injuries, with moderate but not strong certainty. Second, successful programs share a recognizable set of components, especially champions, standardization and audit with feedback. Third, the benefit depends heavily on whether the bundle is actually delivered, which means fidelity is as important to measure as outcomes. Table 1 summarizes the evidence.

Table 1. Summary of Bundle Evidence

Note. Designs are described as reported by the authors.

Gaps

None of the sources focused on heels, the site of most injuries on the unit, or on hip fracture patients specifically. None addressed the hours patients spend in the emergency department before admission, which is where heel damage may begin. And most studies followed units for a year or less. These gaps mean the project will add a heel-specific component, extend the bundle upstream into the emergency department and track results beyond the immersion.

Extending the Bundle Upstream

Because the reviewed programs worked inside inpatient units, the project must reason from first principles about the emergency department. Hip fracture patients on the unit spend around six hours on stretchers before admission, often with heels pressed into thin mattresses while they wait for imaging, pain control and a bed. Tissue damage that appears as a blister on day four may well have started during that wait. Extending the bundle upstream therefore means three small steps in the emergency department's orthopedic bays: a heel check documented at arrival, a pillow or boot placed under the calves to float the heels and a line in the handoff report stating heel condition. These steps borrow the logic of the reviewed bundles, standardized practice with a named owner and feedback, and apply it where the unit's own data suggest harm begins. The emergency department's nurse educator will act as champion there, and the CNL will send monthly counts of completed heel checks.

Design Decisions

The synthesis leads to five decisions. The skin champion role will be filled on every shift, with the CNL coaching champions weekly. Prevention documentation will be consolidated into a single bundle checklist in the electronic record. Unit results will be posted monthly rather than quarterly, including process measures that change quickly. Families of confused patients will be shown how to check that heel boots are on. And fidelity will be tracked by auditing each bundle element, so that a disappointing outcome can be traced to a delivery problem rather than blamed on the bundle itself.

Conclusion

Evidence supports a multicomponent bundle with champions, standardization and feedback, delivered faithfully and extended to where heel injuries start. The next milestone describes how the CNL will lead the team that delivers it.

References

Chaboyer, W., Bucknall, T., Webster, J., McInnes, E., Gillespie, B. M., Banks, M., Whitty, J. A., Thalib, L., Roberts, S., Tallott, M., Cullum, N., & Wallis, M. (2016). The effect of a patient centred care bundle intervention on pressure ulcer incidence (INTACT): A cluster randomised trial. International Journal of Nursing Studies, 64, 63-71. https://doi.org/10.1016/j.ijnurstu.2016.09.015

Soban, L. M., Hempel, S., Munjas, B. A., Miles, J., & Rubenstein, L. V. (2011). Preventing pressure ulcers in hospitals: A systematic review of nurse-focused quality improvement interventions. The Joint Commission Journal on Quality and Patient Safety, 37(6), 245-252. https://doi.org/10.1016/S1553-7250(11)37032-8

Sullivan, N., & Schoelles, K. M. (2013). Preventing in-facility pressure ulcers as a patient safety strategy: A systematic review. Annals of Internal Medicine, 158(5 Pt 2), 410-416. https://doi.org/10.7326/0003-4819-158-5-201303051-00008