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

Designing the Innovation

From mid-to-late January 2017, the Magnet program coordinator guided the unit-level nursing workgroup in the design phase of their care innovation by selecting a few recently published findings with the strongest level of evidence. Through participation in the National Pressure Injury Advisory Panel (NPIAP), WOC nurses in the workgroup accessed and reviewed two best practices for preventing medical device pressure injuries on MST units and ICUs and incorporated evidence from a previously published institutional study endorsing a nurse-driven protocol for urinary catheters. During a series of discussions, consensus supported creating a two-part, four-item protocol. Using Watson's theory of caring, nurses named the protocol C.A.R.E to help increase translation efficiency and keep it top-of-mind. The C.A.R.E. framework outlines four key nursing and interdisciplinary actions when implementing preventive care for patients with a medical device:

  • Choose/verify size-appropriate devices and place on skin free from alterations in integrity

  • Assess skin under the medical device during focused rounds

  • Reposition and Reapply using protective padding

  • Empowered to evaluate daily discontinuation.

The workgroup presented a draft of the innovation to several organization-level councils and committees to solicit feedback from key stakeholders and finalize the protocol. The nurses introduced a preview of the protocol during a monthly Skin, Wound & Assessment Team (SWAT) Force meeting. SWAT Force is an organization-wide taskforce of 36 clinical nurses and interprofessional care providers who serve as unit-level resources for assessing and preventing pressure injuries. In addition to conducting quarterly prevalence studies, the taskforce reviews pressure injury data and provides guidance regarding care changes.

After review and discussion, SWAT Force members unanimously agreed to adopt the C.A.R.E. protocol and forwarded the proposal to the nursing leadership council for feedback. The council, which includes inpatient and ambulatory nurses, autonomously drives improvements and provides formal recognition in professional nursing practice based on strategic priorities.

Participants from the taskforce and the leadership council provided recommendations for simplifying and finalizing the two-part protocol. Part I promotes clinical autonomy and standardized implementation of the four C.A.R.E. actions based on each patient's total Braden Scale score. A score >18 triggers C.A.R.E. protocol implementation at least every 12 hours on MST units and every 4 hours in the ICU. A score ≤18 indicates implementation at least every 4 hours on MST units and every 2 hours in the ICU.

Part II, a 20-item list of high- and low-volume medical devices used across all MST units and ICUs, identifies the recommended minimum skin assessment frequency, protective barrier application, and documentation. (See Protection and assessment.)