Background: Governmental agencies have called upon healthcare organizations to take responsibility and accountability for those they serve. Almost 60,000 U.S. patients die from complications due to hospital-acquired pressure ulcers (HAPU). Healthcare costs increase when patients acquire a HAPU during hospitalization. Foreground: A rural Medical Center’s 42-bed Medical Unit acquired 12 HAPU in 2013. Negative patient outcomes resulted in lower patient satisfaction, increased healthcare costs, and loss of reimbursement monies for Medicare beneficiaries. Positive quality patient outcomes and the highly satisfied patient/family drive reimbursement monies for healthcare services. Frameworks: The Iowa Model of Evidence-based Practice (EBP), John Kotter’s Leading Change, and the Institute for Healthcare Improvement (IHI) Plan-Do-Study-Cycle models guided this DNP Capstone Change Project. Methods: The objective of this project was to provide an EBP Mentorship to decrease HAPU in 30 days by ensuring skin inspection was completed on every patient within 6 hours of admission, followed by timely re-inspection and, repositioning for all patients with a Braden Score of 14 or less. The outcome was to decrease HAPU using the Braden Scale as an evaluation tool. A sense of urgency permeated throughout the rural Medical Center to decrease HAPU. Findings/Results: The change project positively impacted the rural Medical Center by resulting in zero HAPU for the Medical Unit over 30 days. Conclusion/Recommendations: The impact of using an EBP Mentorship to prevent HAPU was remarkable. Recommendations from this project include measuring sustainable change over the next months and years.
