Prevention and Treatment of Device-Related Hospital-Acquired Pressure Injuries

Kim D. Cooper, MSN, RN, CPHQ, CMSRN; Kevin M. McQueen, MHA, RRT, RRT-ACCS, CPPS, CM; Margo A. Halm, PhD, RN, NEA-BC; Rochelle Flayter, MSN, RN, CCRN, TCRN


Am J Crit Care. 2020;29(2):150-154. 

In This Article

Abstract and Introduction


Twenty years ago, in To Err Is Human, the Institute of Medicine estimated that 44 000 to 98 000 people die in hospitals each year from preventable errors.[1] Fast forward to 2014 to 2017, the Agency for Healthcare Research and Quality's[2] national scorecard on hospital-acquired conditions revealed a dramatic decrease in avoidable patient harm that helped prevent 20 500 deaths. Every hospital-acquired condition had reductions—from adverse drug or obstetrical events; catheter-associated urinary tract, central catheter–associated bloodstream, or Clostridium difficile infections; falls; ventilator-associated pneumonia; to venous thromboembolism—except for hospital-acquired pressure injuries (HAPIs), which increased 6% during this time.

Nationally, the annual cost of treating HAPIs is $11 billion (with up to $70 000 for stage 4 HAPIs).[3] A costly preventable condition, HAPIs have gained more attention as a quality indicator of high-reliability organizations. The Centers for Medicare and Medicaid Services has financially incentivized hospitals to reduce hospital-acquired conditions by denying reimbursement for harms like stage 3 or 4 HAPIs, and they project increased penalties for HAPI incidence for fiscal year 2020.[4] These incentives have pushed health systems to advance improvement efforts to reduce HAPIs, but it has also brought to light the number of hospital-acquired medical device–related pressure injuries (MDRPIs).[5]

Medical devices are intertwined in daily patient care for physiological monitoring and treatment, particularly in critical care, increasing patients' vulnerability to hospital-acquired conditions.[6] Such devices are often made of rigid plastic material to maintain shape and functionality but at the cost of potentially causing undue pressure and/or friction on underlying soft tissues and/or mucosal tissues.[5,7,8] In a cross-sectional study of 2 years of point prevalence data, patients with medical devices were 2.4 times more likely to have a HAPI develop.[9] The definition of MDRPIs is "pressure injuries associated with the use of devices applied for diagnostic or therapeutic purposes wherein the pressure ulcer that develops has the same configuration as the device."[10] (p322)

In a large international survey of 117 988 patients in 1115 facilities across acute and long-term care settings, MDRPI incidence was reported as 10%.[11] Other estimates ranged from 3% (critically ill patients),[12] 13% (trauma population),[13] 35% (hospitalized patients),[9] and 80% to 90% (premature infants/neonates).[6,14] The prevalence of MDRPIs reported in the international study[11] for various devices were as follows:

  • 26%, nasal oxygen tubing (behind ears)

  • 9%, airway pressure masks (cheeks, chin, bridge of nose)

  • 7.7%, sequential compression devices

  • 7.5%, endotracheal tubes

  • 5.6%, nasal oxygen prongs (nostrils/nasal vestibule)

  • 5.5%, tracheostomy tubes (under flanges)

  • 5%, nasogastric tubes

  • 2.4%, cervical collars (under rim)

Although stage 1/2 MDRPIs are most common, some studies found unstageable and deep tissue injuries.[9,11,12,14] MDRPIs may not be identified until they are at stage 3, stage 4, or unstageable owing to the lack of standardized skin assessment practices.[11] Thus, the research question for this synthesis was, In hospitalized patients, what preventive and treatment strategies are effective in reducing MDRPIs?