Authors: (including presenting author): :
Shit KYF (1)(2), Lam MY (2), Sze YMS (1), Lam SWT (1), Tong MH (1), Ngai MYL (1), Wong TW (1), Lau SM (1), Tsung PKP (1), Kwok MLA (3)
Affiliation: :
(1) NTEC Wound Management & Pressure Injury Prevention Workgroup, (2) NTEC Wound Services Team, Department of Surgery, PWH, (3) NTEC Central Nursing Division, PWH
Keyword 1: :
Pressure injury
Keyword 2: :
Contributing factor
Keyword 4: :
Staff awareness
Keyword 5: :
Multidisciplinary
Introduction: :
Pressure injury (PI) is a vital patient safety and quality indicator in the New Territories East Cluster (NTEC), requiring coordinated prevention efforts across various specialties. Previously, incident data was dispersed across different sources, limiting the PI Prevention Workgroup’s ability to identify contributing factors, and translate learning into prompt, cluster‑wide actions for PI reduction.
Objectives: :
To initiate standardized frontline PI contributing factors’ self-reporting system to increase multidisciplinary communication and situational awareness. To integrate PI contributing factors and data to Electronic PI Dashboard for each hospital for increase visibility and formulate improvement plan.
Methodology: :
A nurse‑led, multidisciplinary CQI project was launched in NTEC using a structured electronic dataset for all reported hospital‑acquired PI and medical device‑related PI (MDRPI) incidents. The dataset captured patient demographics, risk assessment scores, mobility and continence status, wound characteristics and different contributing factors (medical condition, age‑related, mobility, sensory loss, nutrition, moisture, friction/shear and medical devices) using a unified coding framework to support cluster‑level analysis. These data were converted into an interactive PI Dashboard showing temporal trends, ward and specialty distribution, PI staging and anatomical sites, together with patterns of contributing factors and device involvement to support frontline regular review and multi-disciplinary follow‑up actions.
Result & Outcome: :
Implementing a standardized PI incident dataset, contributing factor analysis, and Dashboard in NTEC to boost up staff awareness, enhance multidisciplinary clinical decision-making and ongoing quality improvement. This data-driven approach offers a scalable framework for cluster-wide learning that can be adapted to other patient safety indicators. PI contributing factors’ self-reporting system (adult & paediatric) was endorsed and implemented in NTEC from 1Q,2024. Concerned ward staff has to report all details of each PI incidence to local PI workgroup regularly. Concerned issues can be voiced out and problems will be solved by multidisciplinary discussion. Besides, individual Hospital PI Dashboard was established from 2Q, 2024. Clear performance metrics of each department were established for reviews and further improvement actions. Better resources utilization can be achieved with increased PI visibility. The intensive data analysis and rectification also greatly combated cluster PI incidence rate to recorded lowest of 0.1 (1Q, 2025), which is much lower than HA mean of 0.37; and 0.012 (MDRPI) lower than HA mean of 0.036. The Clause 1.9.1-Pressure Injury Prevention has obtained a “Highlight” achievement in Hospital Accreditation of PWH. Staff awareness has been raised and lead to PI reduction.
