Pressure Ulcer Interventions: Implementing Evidence-Based Practices for HAPIs

Hospital-acquired pressure injuries (HAPIs), also known as pressure ulcers, pressure injuries, or bedsores, are one of the the most persistent healthcare challenges that patients and practitioners face. Approximately 2.5 million HAPIs occur every year in the United States alone, and these injuries contribute to longer hospital stays, increased 30-day readmissions, and a total economic burden exceeding $26.8 billion. Despite ongoing quality improvement efforts, the global number of HAPI cases more than doubled between 1990 and 2021 — an alarming trend considering how far technology and medical practices have evolved in that time.

There are a number of reasons for the rise of HAPIs and lack of success in implementing pressure ulcer intervention protocols. Factors include overlapping guidelines, varying local protocols, and fragmented ownership across nursing, therapy, and support services. To make real strides towards pressure ulcer prevention, hospitals must create collaborative, evidence-based protocols and ensure that all teams have access to the knowledge and training needed to implement them.

Key takeaways:

• Hospital-acquired pressure injuries (HAPIs), also known as pressure ulcers, are one of the most prevalent patient challenges in healthcare settings.
• While certain patients are more vulnerable than others, HAPIs are generally caused by long periods of immobility.
• There are four stages of pressure ulcers, but the best way to treat them is to prevent them entirely.
• Prevention requires a collaborative, evidence-based set of protocols that can be easily accessed by all members of the care team.
• In order to effectively roll out a pressure ulcer intervention system, healthcare teams need a robust implementation platform that streamlines protocol access and activates guidance in clinical workflows.
  
  

Understanding hospital-acquired pressure injuries

Why are HAPIs so prevalent and expensive? Answering that question requires a thorough understanding of the pressure ulcer risk factors and the stages of pressure ulcers. The Mayo Clinic defines bedsores as “injuries to the skin and the tissue below the skin that are due to pressure on the skin for a long time,” and they’re particularly common on “skin that covers bony areas of the body, such as the heels, ankles, hips, and tailbone.” Patients with pressure ulcers experience symptoms like changes in skin color and texture, swelling, draining, and soreness.

Not all HAPIs are equal in severity. The pressure ulcer scale has four stages; at the first stage, pressure ulcers might be red or pink, but they don’t turn into a shallow wound until stage two. This progression is often accompanied by skin loss, abrasions, and blisters. By stage three, the ulcer goes deeper into the hypodermis. And at the final stage, “the wound penetrates all three layers of skin, exposing muscles, tendons, and bones in your musculoskeletal system.”

Patients with mobility issues are generally most at risk for HAPIs, including those who use wheelchairs, experience paralysis, wear casts or prosthetic devices, or are in a coma. However, a number of health issues can increase risk: cancer, cerebral palsy, diabetes, and malnutrition are just a few. The American Journal of Critical Care states that the length of hospital stays is also a factor, meaning pressure ulcer prevention is especially important in long-term patients.

By the time pressure ulcers reach the later stages, patients are at risk for life-threatening bacterial infections, as well as sepsis and amputation. These patients need timely skin assessments, repositioning, mobilization, nutrition support, and consistent handoffs across shifts and settings. That all adds up: The Agency for Healthcare Research and Quality estimates that pressure ulcers cost an average of $14,506 per patient on top of existing healthcare charges, which adds up to billions of dollars a year. Hospitals absorb most of these costs directly, impacting budgets and expenditure.

According to pressure injury experts, “Preventing pressure injuries remains the most effective way to reduce their burden.” In other words, the healthcare system needs consistent pressure ulcer intervention policies — so why are medical institutions struggling to implement them?

Addressing the hospital-acquired pressure injury compliance gap

As with many of the challenges healthcare organizations face, the lack of interventions for pressure ulcers has nothing to do with a lack of commitment or investment from providers. A 2025 C8 Health survey of 100 clinical quality leaders reveals a “knowledge chaos” problem throughout the industry. Nearly a third of those surveyed cited “fragmented systems and information storage” as their biggest barrier to implementing quality initiatives.

Here’s what that means in practice: Hospitals might have protocols and policies stored in a cloud platform. But perhaps training materials can only be found in an internal learning management system. Meanwhile, some updated guidelines live in unit-specific binders, or are posted as checklists on a wall. The shape of knowledge chaos varies, but every institution likely manages a patchwork of digital and paper systems that sit separate from operational platforms — like the scheduling system, EHR, and contact directory. More challenging, still, is the issue of keeping resources aligned with evolving regulatory and society standards.

As a result, a hospital's best practices are typically difficult to access in the flow of care. This dynamic produces cognitive friction for staff, while impacting outcomes and patient satisfaction. Downstream, quality and operational leaders struggle to implement new initiatives — data only illuminates the shape of the problem, not the path to success.

This disconnect is especially dangerous with pressure ulcer prevention because it’s a multidisciplinary practice. It requires the cooperation of nurses, physicians, dieticians, and physical therapists. Perioperative and inpatient care teams must work together to relieve the causes of HAPIs, so a single function can’t be tasked with prevention. It requires a coordinated, around-the-clock plan to minimize time spent in one position, optimize tissue tolerance, and remove barriers to movement as quickly as possible. If every department interprets pressure ulcer prevention differently, hospitals cannot establish a reliable practice at scale.

The first step in overcoming this compliance gap is acknowledging that it exists. From there, all teams can work together toward a collaborative, evidence-based, and easily repeatable solution that can be shared widely and put into practice.

Working together toward universal pressure ulcer intervention

The good news for healthcare providers is that institutional systems and cultures are already shifting to promote evidence-backed practices. Enhanced Recovery After Surgery (ERAS) programs, created by the ERAS Society to “develop perioperative care and to improve recovery through research, education, audit, and implementation of evidence-based practice,” have already been implemented in a number of healthcare facilities around the world. One of the key tenets of ERAS protocols emphasizes a collaborative model by combining early mobilization, optimized analgesia, early drain and catheter removal, and nutrition support to reduce complications, including HAPIs, through coordinated multidisciplinary pathways.

According to a study published by Houston Methodist Hospital in 2018, “Data suggests that these pathways have produced not only improvements in clinical outcome and quality of care but also significant cost savings. Large trials reveal an increase in five-year survival and a decrease in immediate complication rates when strict compliance is maintained with all pathway components.” A 2026 study further confirmed these findings, stating, “A relationship between compliance and clinical outcomes across multiple surgical types, as demonstrated in the present study, together with similar findings in surgery-specific studies highlight the importance of complying with ERAS guidelines.”

The early success of ERAS serves as a case study for collaborative, evidence-based treatment of hospital-acquired injuries like pressure ulcers. Putting these pathways into practice, however, is far more difficult in execution than it is on paper. First, healthcare institutions need to make siloed data a thing of the past. A governed, accessible, and centralized platform created specifically to implement best practices in healthcare environments should serve as a single source of truth for prevention protocols. This provides streamlined access to all approved knowledge and stronger cross-functional collaboration.

Pressure ulcer prevention protocols also need to be customized for each specific role. Care teams are made up of various positions, all of which interact with prevention guidance in different ways. Every team member needs to be able to find the information they need quickly, and training should address these differences rather than taking a one-size-fits-all approach.

Once a pressure ulcer intervention strategy is created, automated workflows can help ensure the systematic organization and completion of the new tasks needed to reduce HAPIs. Gentle reminders aligned with these workflows, such as repositioning schedules, further helps providers adhere to science-based practices and ensures universal execution.

Measuring operational efficiency by collecting and analyzing key data points will provide an indication of how well new protocols are performing. Are resources being managed intelligently? Is the staffing model effective? Do you have the right technology stack? Having the data to answer these questions leads to stronger cross-functional collaboration and greater accountability.

Figure 1

Reducing the incidences of hospital-acquired pressure injuries not only improves patient comfort and sleep quality, it also reduces costly errors and increases profitability. A nurse-led quality improvement initiative published in 2025 showed that switching to a safety framework designed for pressure ulcer intervention decreased their incidence by 64.4%. When Cleveland-based MetroHealth adopted C8 Health to address the anesthesia team’s “serious information overload,” the team increased ERAS compliance from 65% to 88% in just five months. If we calculate the impact of that compliance increase against 3,000 cases, it could save hospitals over one million dollars (see figure 1).

Pressure ulcer intervention starts with best practices, but you need a last-mile solution to translate this guidance into actual practice. C8 Health is an AI platform for implementing best practices in healthcare environments. Our solution aggregates hospital-approved knowledge and makes it actionable in context. That means standardized care, improved patient outcomes, and better financial performance. Seamless workflow integration, natural language querying with the C8 AI Assistant, and centralized knowledge access have made our implementation platform a vital tool for over 150 hospitals, health systems, and physical groups. Want to learn more? Contact us for a free demo.