C.A.R.E to Prevent Medical Device-Related Pressure Injuries

C. Preston Lewis, DNP, MSN, RN, CCRN-K; Kristene E. Colcord, MSN, RN, CWOCN; Ashley Peterson, BSN, RN, ONC; Charmaine Pfister, MSN, APRN, FNP-BC, CWOCN; Mary Ellen Robertson, MSN, RN; Aaron Slyh, BSN, RN, CWOCN; Brittany Smoot, MSN, RN; Kathy Tussey, MSN, RN, NEA-BC; Heather Whalen, MSN, APRN, FNP-BC, CWOCN, CFCN


Am Nurs Journal. 2021;16(6) 

In This Article

Establishing a Data-based Patient Safety Problem

Baptist Health Lexington, a 434-licensed bed community hospital in central Kentucky, has achieved Magnet designation four times. The organization's culture of nursing demonstrates EPP by its commitment to autonomous practice and sustained excellence in reported outcomes facilitated by the professional practice model (PPM). Since 2004, the two-tier shared governance empowerment model has been cultivating nurse engagement at all levels to address daily practice and patient- and family-centered care issues.

In early 2017, nurses from the wound, ostomy and continence (WOC) department and a doctorally prepared Magnet program coordinator and the nurse leader for the pressure injury program unveiled an opportunity to improve care related to medical devices. When reviewing the hospital-acquired pressure injury data for October–December 2016, the program coordinator identified an unusual escalation in the monthly incidence across all medical-surgical/telemetry (MST) units and intensive care units (ICU) among adult patients. During daily unit rounds, the coordinator presented the data and collaborated with four WOC nurses to review and categorize injuries by type and care setting. Data analysis revealed nearly 50% of all reported injuries involved a medical device.

Alarmed by the analysis, the coordinator and one of the WOC nurses conducted a critical literature review to explore the national incidence and availability of prevention measures. Findings from the review inspired an innovative proposal to improve the care delivery system using a high-level shared governance approach through the PPM.