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  1. Zubkoff, Lisa PhD
  2. Neily, Julia RN, MS, MPH
  3. McCoy-Jones, Shantia PhD, MSN, RN, CRNP, CWCN
  4. Soncrant, Christina MPH
  5. Young-Xu, Yinong PhD
  6. Boar, Shoshana MS
  7. Mills, Peter PhD, MS


Background: Pressure injury prevention is a persistent concern in nursing. The Veterans Health Administration implemented a creative approach with successful outcomes across the United States.


Problem: Pressure injury prevention is a measure of nursing quality of care and a high priority in the Veterans Health Administration.


Methods: A 12-month Virtual Breakthrough Series Collaborative utilizing coaching and group calls was conducted to assist long-term and acute care teams with preventing pressure injuries.


Interventions: Interventions from the Veterans Health Administration Skin Bundle were implemented, including pressure-relieving surfaces, novel turning techniques, specialized dressings, and emollients to prevent skin breakdown.


Results: The aggregated pressure injury rate for all teams decreased from Prework to the Action phase from 1.0 to 0.8 per 1000 bed days of care (P = .01). The aggregated pressure injury rates for long-term care units decreased from Prework to Continuous Improvement from 0.8 to 0.4 per 1000 bed days of care (P = .021).


Conclusion: The Virtual Breakthrough Series helped reduce pressure injuries.