Decreasing Pressure Injuries on an Adult Inpatient Unit through Implementation of a Nutrition Assessment and Management Process : Advances in Skin & Wound Care

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Decreasing Pressure Injuries on an Adult Inpatient Unit through Implementation of a Nutrition Assessment and Management Process

Hamidi, Lida DNP, BSN, RN, PCCN

Author Information
Advances in Skin & Wound Care 36(8):p 1-5, August 2023. | DOI: 10.1097/ASW.0000000000000004



To lower the rate of hospital-acquired pressure injuries (HAPIs) by identifying at-risk patients based on the Braden Scale score, evaluating nutrition using a Mini Nutrition Assessment (MNA) tool, and implementing nutrition improvement measures.


There were three steps in this intervention. First, patients with a Braden Scale score of 18 or lower were identified as being at risk for HAPI. Next, the MNA screening tool was implemented to identify nutrition deficiencies. The MNA screening tool can predict malnutrition, HAPI development, and/or additional complications. It is validated, cost-effective, and easy to administer to patients who are hospitalized with HAPI complications. In the final step, the author implemented a multicomponent nutrition intervention to improve the nutrition status of patients at risk for developing HAPI.


Included patients (N = 205) were hospitalized in the intermediate ICU, had a Braden Scale score of 18 or lower, and had poor nutrition status. There was a 74% decrease in HAPI rate following the MNA nutrition screening and management, with HAPI incidence decreasing from 1.9% preintervention to 0.5% postintervention.


Categorizing patients who are at risk for developing HAPI, assessing for nutrition deficiency, and then implementing a multicomponent nutrition intervention considerably reduced the rate of HAPIs per number of patients admitted to the unit.


A common complication for hospitalized patients is hospital-acquired pressure injury (HAPI), which can cause delayed wound healing, scarring, sepsis, prolonged hospitalization, and even death.1 An estimated 1 to 3 million people in the US develop HAPI each year, and it is the third most expensive diagnosis following cancer and cardiovascular disease,2 costing more than $26.8 billion a year. In addition, HAPIs have a considerable negative impact on the quality of life of hospitalized patients.3 Preventing HAPIs is important not only to protect patients from infection but also to reduce the cost of care. Although HAPI prevention is not a new topic in critical care, it is considered a significant indicator of care quality.

Unfortunately, patients admitted to ICUs are at higher risk for HAPI development.4 At the project site for the present study, an intermediate ICU (IICU), HAPIs continue to be a significant burden among hospitalized patients. The HAPI rate was 5.29% for the fiscal year 2021, which was greater than the 2.5% hospital benchmark. A retrospective chart review revealed the rate of HAPIs remained at 3.45% in the third quarter of 2021.

To identify and quantify HAPI risk at the project site, the Braden Scale was used because it is a universal tool that consists of six subscale scores: nutrition status, sensory perception, skin moisture, friction and shear, activity, and mobility.5 The lower the Braden Scale score number, the higher the risk for developing a HAPI. Nutrition is one of the main components of the Braden Scale, and it has a critical role in skin and tissue protection, wound healing, and patients’ overall health status. Adequate nutrition including vitamins, proteins, and hydration is particularly important for patients at risk for HAPI in hospital settings. Inadequate dietary intake and nutrition deprivation are the main risk factors for HAPI development and delayed wound healing.6 Unfortunately, malnutrition is a major problem affecting more than half of hospitalized patients in the US and has been linked to HAPI development.7 Poor nutrition status is a significant contributor to the low Braden Scale scores in the project setting and is associated with HAPI development. Nutrition deficiencies in the project setting are linked to delayed and inconsistent assessment of nutrition status.

Although several initiatives have been implemented to prevent HAPIs at the project site, a root-cause analysis determined that a lack of nutrition screening was a major contributing factor to the high HAPI rates. The current nutrition screening at the project site is the administration of a one-time admission nutrition screen that includes only four questions (Supplemental Table, This assessment is limited and does not account for patients with multiple medical conditions that may cause a rapid decline in their appetite and increase their nutrition needs. A systematic nutrition screening followed by nutrition care is essential, particularly in the ICU setting, to preserve skin and tissue viability. Early and continuous nutrition interventions can lead to more positive nutrition outcomes and contribute to pressure injury (PI) prevention.7 Therefore, adopting a different enhanced method for frequent nutrition evaluation was required at the project site.

The specific aim of this project was to implement a clinical workflow nutrition assessment using the Mini Nutrition Assessment (MNA) tool to regularly monitor nutrition status. The MNA is the most well-validated nutrition screening tool for hospitalized patients.8 The original validation study on the full MNA demonstrated that the MNA had a sensitivity of 96%, specificity of 98%, and a positive predictive value of 97% compared with clinical status.8 To improve nutrition issues in the project setting, assessing and reassessing nutrition status frequently and regularly with a validated and accurate scale were essential. Therefore, the MNA was determined to be the most appropriate tool for predicting complications, long length of hospital stay, and mortality.8

The overall purpose of this project was to reduce the incidence of HAPIs at the project site by screening with a validated nutrition assessment tool followed by a multicomponent intervention to improve nutrition. This project adopted a quality improvement (QI) intervention to support the effective implementation of evidence-based practices to achieve desired outcomes, such as HAPI prevention. The Knowledge to Action model served as the translational framework for the implementation of this project. This framework has both a knowledge generation and an action cycle, and it is this action cycle that focuses on implementation issues.9 This study focuses on the seven steps within the action cycle of the Knowledge to Action framework using a qualitative research method.



The main objective of this QI project was to lower HAPI incidence by identifying patients at risk based on the Braden Scale score, followed by nutrition reassessment using the MNA tool and implementation of nutrition-improvement measures.

Setting and Population

This QI project was completed in an IICU at a 508-bed medical complex hospital. The IICU has a 36-bed capacity providing highly skilled critical care for adult and older adult patients who require critical care services. The nursing staffing matrix in the IICU is one RN per three or four patients, depending on patient acuity. The IICU includes three nursing stations with 12 beds and one nursing assistant at each station. The nursing assistants help nurses with patient needs, such as personal care and other nonlicensed responsibilities.

The management team for this unit has a proactive approach to patient outcomes. A group of physicians and members of other clinical disciplines make rounds daily. Dietitians and the HAPI team work closely with nurses and physicians; one dietitian and a wound nurse are available in the unit anytime a consult is requested. Nutrition services provide food and nutrition to patients three times a day, from 7 am to 7 pm, but the unit has two nutrition rooms that provide drinks and snacks for patients.

The patients included in the postintervention period of this study were hospitalized patients admitted to the IICU between February 1, 2022, and June 31, 2022. Patients were included in this project if they had a Braden Scale score of 18 or lower and no HAPIs upon admission. Patients with existing HAPIs were excluded unless they developed a new HAPI after their admission to this unit. Patients admitted to this unit are often at high risk for developing HAPIs due to poor nutrition and complex health status that limits autonomous mobility.


Preintervention data were collected from September 2021 to January 2022. The intervention phase of this project consisted of three components: (a) identifying the patients with a Braden Scale score of 18 or lower, (b) administering nutrition screening using the MNA screen tool, and (c) conducting a nutrition intervention and HAPI prevention bundle.

The Mini Nutritional Assessment (MNA) screening tool aided in updating the patient’s nutrition and hydration status. The MNA is a validated and highly sensitive screening tool for identifying malnutrition in older adults. It is the most widespread tool for nutrition screening and assessment because of its ease of use and feasibility in any clinical care setting.10 The short form of the tool (MNA-SF; Supplemental Figure 1,; Supplemental Figure 2, was used in this intervention. It consists of six questions related to food intake, weight loss, mobility, psychological stress or acute disease, neuropsychological problems, and body mass index. After discussions with the nursing staff, it was agreed that the MNA was quick and easy to use, with minimal risk to the individual being screened. Further, it was an effective and appropriate tool for the population at high risk for developing HAPIs and other clinical complications in the project site. The MNA screening tool did not replace the current admission nutrition screening in the project site; rather, it was an additional tool to measure nourishment. It was administered every 3 to 4 days for some patients who experienced longer stays and rapid medical changes.

The nurse determined the need for administration of the MNA based on the following criteria: Braden Scale score of 18 or lower, poor nutrition status, severity of acute illness, and history of HAPIs. These measures were chosen because Braden Scale score and a history of PI are independent risk factors for HAPI at this IICU unit. Although serum albumin levels are routinely measured in this unit for severely ill or malnourished patients, it was not the criterion for MNA administration. In general, MNA can detect the risk for imbalanced nutrition in patients, even if serum albumin level, total protein, and weight are still within the reference range.11

Following MNA screening, a score of 12 or higher revealed the person was well-nourished, and no further intervention was required. A score of 8 to 11 confirmed the person was at risk for undernourishment, and a score of 7 or lower identified the patient as lacking essential nutrients and food. A dietitian reconsult and the development of an individualized nutrition care plan were performed for patients with an MNA score of 11 or lower. For individuals who were malnourished, it was very important to identify the cause of poor nutrition intake and address it through the project intervention.

A multidisciplinary team was involved with the intervention to ensure individual nutrition care plans were improving and the implementation of the project was successful. The team consisted of doctor of nursing practice (DNP) students, IICU nurses and assistive personnel, charge nurses, a unit manager, physicians, dietitians, and a HAPI team. Prior to and during project implementation, multiple staff education meetings were held to introduce the MNA tool and the individualized nutrition care plan. Bimonthly staff check-in and follow-up support were provided by a DNP student during project implementation. One-on-one, in-person meetings with nurses and nurse assistants were held to discuss barriers to implementation and potential resolutions. Concurrently, individual meetings conducted by the DNP student allowed time for staff to express concerns and receive support with feedback. Prior to implementation of the intervention, the author provided a PowerPoint (Microsoft Inc) presentation regarding the project description, MNA nutrition screening tool, and HAPI preventive strategies to the key stakeholders, nurses, and nurse assistants in a virtual format. The PowerPoint was distributed to the team by email and the facility’s education system.

The dietitian consults and collaboration were very effective for addressing the tube feeding and other causes of malnutrition in patients with MNA scores lower than 11. The facility’s available nutrition supplements provide more calories, vitamins, and minerals to the patients at risk for nutrition deficiencies. Nurses and staff adopted different types of strategies in nutrition intervention including menu selection assistance, meal setup, and feeding assistance for patients who needed it. There was no additional follow-up on nutrition corrections during the short study period except for tracking HAPI incidence, which was the goal of this project.

Data Collection and Outcome Measures

To calculate the HAPI incidence rate, the total number of patients who developed a new PI (of any stage) after being admitted to the IICU was divided by the total number of patients admitted per month. Every month, these data were collected from the HAPI team and the electronic health record (EHR), respectively, and compared with the facility’s benchmark of 2.5%. Data at baseline in the fiscal year of 2021 were compared with data collected postimplementation through June 2022.

During the project implementation period, the author extracted demographic data from the EHR, including age, sex, and clinical indicators. The clinical indicators included the MNA and Braden Scale score at each screening, as well as severity of illness. In this study, a chart review on nutrition intervention, dietitian consult, percentage of meal intake, and HAPI incidence was performed on all patients who received MNA screening. Approximately one-third of the patients admitted to the IICU received MNA screening intervention.

Ethical Considerations

The final version of this project was submitted to the university institutional review board prior to project implementation and deemed to be a QI project with minimal risk to patients during data collection with respect to the vulnerable status of patients served at the project site. To prevent disclosure of identifying patient information, random chart reviews were completed at the project site, and unique patient identifiers were removed before the data were entered into Excel (Microsoft Corp). The Excel spreadsheet was password protected, and project information was shared only through the facility’s secure email system.

Statistical Analysis

The author used Excel to analyze the data. Descriptive statistics were used to analyze and compare the preintervention and postintervention HAPI rates.


This study included 211 adult patients (107 women, 104 men) admitted to the IICU who ranged in age from 19 to 95 (mean, 68 [SD, 15]; median, 70) years. The primary IICU admission diagnoses were respiratory insufficiency or failure, cardiac arrhythmia, conduction disorders, neurologic conditions, sepsis, renal failure, gastrointestinal hemorrhage, and diabetes with complications or comorbidity. Acute and chronic respiratory illnesses, including COVID-19, were the most common diagnoses.

Postintervention almost one-third of IICU patients scored 18 or lower on the Braden Scale and were eligible to be assessed with the MNA screening tool (n = 211; Figure 1). Of these, 85% of patients (n = 180) scored 11 or lower on the MNA tool because of severe acute illness, thus warranting further nutrition improvement. The patients with an MNA score greater than 11 (ie, good nutrition status) and comfort care status did not receive nutrition intervention.

Although albumin and protein levels were not required to receive MNA screening, more than 95% of patients who received MNA screening (n = 211) were those with low albumin levels (eg, <3.4 g/dL) and low total protein (eg, <7 g/dL).

Scores on the MNA screening tool can range from 0 to 14 points, with scores of 0 to 7 indicating malnourishment, 8 to 11 indicating risk for malnutrition, and 12 to 14 indicating normal nutrition status. In this study, MNA scores in the IICU population ranged from 6 to 12, with scores of 8 to 11 being most common and requiring intervention. Common causes of malnutrition at the project site included loss of appetite, digestive problems, chewing and swallowing difficulty, need for assistance in eating, impaired mobility, poor positioning, medications, respiratory distress, COVID-19, neuropsychological problems such as dementia, psychosocial stress, acute illness, and factors such as isolation and depression.

Following initiation of the MNA screening tool, the HAPI rate per number of patients admitted to the IICU substantially decreased. Only 4 of the 211 patients in this study developed a HAPI within 5 months of MNA screening intervention (measured February 2022 to June 2022). Figure 2 shows monthly HAPIs from September 2021 through June 2022. A decrease in the HAPI rate prior to the intervention correlated with a reduction in patients with COVID-19. The COVID-19 pandemic significantly increased the HAPI rate in the first and second quarters of 2021 at the project site. Figure 1 shows the HAPI rate of 3.5% in the second quarter of 2021, which is greater than the hospital benchmark. During the preintervention period in the third quarter of 2021, decreasing the number of patients with COVID-19 reduced the HAPI rate from 3.5% to 1.9%.

Figure 1.:
Figure 2.:

In addition, following the initiation of the MNA screening tool and nutrition intervention, certain variation is noted with a positive downward shift in the HAPI rate from the second month of 2022 through the fifth month of 2022. There was a 74% drop in the monthly HAPI rate from a mean of two HAPIs per number of patients (measured from September 2021 through June 2022) to one HAPI per number of patients admitted to IICU. Following the MNA nutrition screening and management, HAPI rate decreased from a mean of 1.9% in the preintervention period to 0.5% postintervention.


The purpose of this study was to reduce IICU HAPI rates by implementing a nutrition intervention. Results demonstrated that the use of a validated nutrition assessment tool, the MNA along with the nutrition improvement intervention, reduced HAPI rates by 74%. Prior to this QI project, all patients admitted to the IICU were screened only one time for nutrition deficiencies, upon admission. However, some hospitalized patients are at much higher risk than others and need repeat screening. The evidence demonstrated that use of the MNA screening tool and a tailored nutrition improvement intervention could reduce HAPI rates.

Because this QI project needed to focus on a small percentage of the patient population, the author relied on Braden Scale scores of 18 or lower to identify patients who were at risk. Thus, only 33% of the patient population admitted to the IICU qualified to receive the MNA screening tool. Those patients who scored less than 11 on the MNA received nutrition intervention, which included a dietitian consult, nutrition supplements, and making sure that the patient received three timed meals a day as well as snacks and drinks as required. There were no reported patient complaints or concerns about the MNA screening tool. The project was well-received by nursing staff and administrative staff.

Challenges, Strengths, and Limitations

One of the challenges in this QI project was the nurses’ workload. They are responsible for all aspects of patient care, making them very busy during their shifts. Because nutrition is a lower priority than respiration, circulation, infection, and many other complications, nurses forgot to complete the MNA screening tool on some of their patients. The DNP student reminded and helped nurses to fill out the forms. Regular education was necessary about the importance of nutrition status, Braden Scale score, and PI prevention. This QI project was designed to increase nurses’ awareness about the essential role of nutrition to protect skin and prevent PI. Although this study highlighted nutrition improvement, it strongly emphasized the use of a HAPI prevention bundle. By alerting nursing staff ahead of time with the Braden Scale score, followed by the MNA score, the nursing staff were better aware of patients’ HAPI risk and implemented the nutrition improvement bundle along with standardized preventive measures to decrease PI incidence.

A strength of this project was the use of the MNA screening tool because it has high sensitivity, specificity, and positive predictive value and is also low cost and simple to use. However, the findings of this QI project should be viewed considering certain limitations. First, the author selected the Braden Scale because it was already built into the EHR and was available to use. Although the Braden Scale is a valid tool to assess patients’ PI risk and includes nutrition assessment, it has a moderate predictive validity for PI risk assessment and effective impact on clinical outcome.12 In addition, this study was conducted in only one unit of the hospital for a short period, from February to June 2022. Only one-third of the patient population admitted to this floor qualified for this project. Future studies could expand this QI project to all patients in different sections of the hospital.


This QI project found that the MNA tool, paired with a nutrition improvement intervention for eligible patients, can reduce HAPI rates in an adult inpatient unit. It is critical to consider and test the implementation of this intervention in other settings to prevent HAPIs and improve health outcomes. Nutrition improvement should be a major component of HAPI prevention and assigned priority in hospitals. Individual health professionals need to enhance their focus on the importance of nutrition in the management of patients with HAPIs.


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Braden Scale score; hospital-acquired pressure injury; Mini Nutrition Assessment tool; MNA screening; nutrition; nutrition intervention; pressure injury; pressure injury prevention

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