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

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's2 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).5Medical 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 study11 for various devices were as follows: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?The strategy included searching CINAHL and MEDLINE. Key words included hospital-acquired pressure injury, pressure ulcers, medical devices, and critical care patients. The search was limited to evidence in the past 10 years.Eight studies were retrieved (Table 1). One study was a case series, 2 observational, 1 quasi-experimental, 3 randomized controlled trials, and 1 expert opinion. Two of these studies were focused on all medical devices, 3 on tracheostomy protective dressings in children and adults, and 3 on protective dressings for noninvasive ventilation devices in neonates and adults. Time to development of skin complications was lower with the use of a HAPI bundle that incorporated care of medical devices15 as well as protective dressings for noninvasive ventilation devices.21The studies in this synthesis represent level B/C evidence (Table 2). Black et al9 found that MDRPIs were just as likely to occur in medical/surgical, progressive/step-down, and critical care units. Pressure injuries related to medical devices have also been shown to develop faster than non-MDRPIs across care settings.11 These findings reinforce the need for prevention in all settings. Infants, children, and adults with medical devices should be considered at risk for MDRPIs because no unique risk factors have been found that permit easy identification of higher risk patients.9 Risk factors for HAPIs and MDRPIs are similar (Table 3). If a medical device is used for a prolonged duration, it can create unrelieved pressure or edema, cause friction/shearing that may impair sensation, reduce circulation, and alter the microclimate (ie, heat and humidity at skin-device interface from moisture).5-8Medical devices should be selected on the basis of their ability to induce the least degree of damage from pressure and/or shear forces. Devices made from softer materials should be used whenever possible (eg, silicone oxygen tubing, padded cervical collars, soft feeding tubes). Medical devices need to be sized correctly to avoid excessive pressure and secured to prevent dislodgment without additional shear/pressure on adjacent skin. Tension on securement devices should be checked regularly and adjusted as required (eg, edematous tissue).5,26 Securement devices that splint tubes (eg, nasogastric tubes), allowing them to float, are preferable.6 Furthermore, medical devices that are potential sources of pressure should be removed as soon as clinically feasible.6,27The skin beneath and around medical devices—especially rigid parts—should be assessed at least every 12 hours for signs of pressure-related injury and moisture.6,7,27,28 More frequent skin assessment is warranted in patients vulnerable to fluid shifts or with localized/generalized edema.6 Devices should be lifted and repositioned at regular intervals to redistribute pressure and decrease shear force, or their positions should be rotated when possible (eg, pulse oximetry, endotracheal tubes) to prevent MDRPIs like the one featured in the Figure. Other devices such as graduated compression stockings or sequential compression devices should be removed with bathing and every 8 hours to relieve pressure and allow for skin inspection.5,28 After repositioning, the location of tubing (eg, urinary/fecal containment catheters) should be assessed to ensure that there is no direct contact with skin.5 Patients and caregivers should also be taught how to perform regular skin inspections and reposition medical devices.6Evidence from this synthesis supports the use of dressings (except for tight devices) to cushion medical devices, tubing, or fixators, thereby reducing shear friction, redistributing pressure, and absorbing moisture.10,26 With tracheostomies, MDRPIs were reduced with impermeable hydrocolloid barrier and absorbent silver-impregnated or foam dressings that manage moisture in the skin's microclimate.16-18 If tracheostomy sutures are used, it is important to ensure they provide enough room for dressings to be placed completely below the flange. With noninvasive ventilation devices, hydrocolloid, hyaluronic acid gauze or transparent dressings reduce MDRPIs.19-21 Opaque dressings should be avoided because they prevent visualization of underlying skin.6 The National Pressure Ulcer Advisory Panel6 recommended considering the following factors when selecting a dressing to prevent MDRPIs:Additional considerations are focused on assessing medical devices on hospital admission. Devices made of inexpensive material that is likely to harm skin should be changed. Using nasal cannulas as an example, lower cost versions made of hard tubing may enter facilities via emergency medical services providers or a patient's home durable medical equipment. Health care providers should be educated to assess all medical devices and replace those made from hard material with softer versions as soon as possible. Although medical devices with better material options may have a higher cost, that cost is offset by preventing the cost of harm to individual patients and populations of patients.Health care organizations need to collaborate with medical device companies to influence manufacturing decisions and encourage use of softer materials that reduce the risk of harm to skin. Health care providers can influence patient safety by advocating for harm prevention methods, such as selection of appropriate devices and protection/assessment of the skin surrounding the lifesaving medical devices used on our most vulnerable patients.