Bundling for Change: Implementing Pressure Injury Prevention



Our critical care unit experienced a sharp increase in hospital acquired pressure injury (HAPI) incidence from 4.42 per 1000 patient days in fiscal year 2015 to 11.11 per 1000 patient days in Quarter (Q) 2 2016. This culminated in a total of 32 non-device related HAPI from Q1-Q3 2016, 24 of which were Deep Tissue Injuries (DTI). With 75% of our ICU HAPI being DTIs, and February 2016 reaching a peak HAPI incidence rate of 21.44 per 1000 patient days, the frontline staff began to search for a solution. (See Figure 1)


A 24 bed medical-surgical critical care unit in the Central South from June 2016 through March 2017


A multidisciplinary team was formed to initiate a quality improvement project (QIP) to reduce non-device related pressure injuries utilizing the Plan, Do, Study, Act cycle. (See Table 1) The hospital’s current pressure injury prevention protocol (PUP) was reviewed. (See Table 2) Compliance with the PUP, including turning every two hours, was confirmed through chart audit. It was noted, however, that the PUP lacked specific interventions to reduce friction and shear force.

Additionally, a review of literature identified unique risk factors in the critical care environment that were not addressed by the risk assessment tool in place. (See Table 2) Though evidence based validation is currently lacking, patients with frequent, non-purposeful movement were felt to be at high risk for shear induced hospital acquired pressure injury. As a result, a >/= +2 score on the Richmond Agitation and Sedation Scale1 (RASS) was included as a risk factor.

The PUP was continued on patients who were identified to be at-risk with the addition of a group of bundled interventions. Bundled interventions included a five layer soft silicone bordered foam sacral dressing, offloading fluidized positioning heel boots (fluidized heel boot) and a non-powered reactive support surface positioning system (NRSSPS) with fluidized positioner*. (See Figures 2-4)

Through the month of June 2016, a product trial of two similar sacral dressings was performed. The five layer soft silicone bordered foam sacral dressing was chosen after a review of supporting evidence and survey of nursing staff. The preventative dressing was left in place for up to seven days unless soiled.

To further reduce friction and shear, patients who scored a 1-2 on this Braden subscale were placed on the NRSSPS. The fluidized positioner component of the NRSSPS replaced positioning with a foam wedge and pillow. Because the positioning system made nursing assisted patient mobility significantly easier for staff, patients scoring a 1-2 on the Braden mobility subscale were also placed on the NRSSPS. Nurses were encouraged to place fluidized heel boots on these at-risk patients.

Staff were educated on all shifts. Each discipline evaluated the bundled interventions. Skin and risk assessments
every twelve hours continued throughout the project.


Since implementing the PUP plus bundled interventions, the unit has had three pressure injury free months. The HAPI incidence rate decreased from 11.11 per 1000 patient days in Q2 2016, during preproject analysis period, to 1.75 per 1000 patient days in Q2 2017. From Q1-Q2 2016, the PI incidence rate was 7.87 per 1000 patient days with a period high in Q2 of 11.11 per 1000 patient days. During implementation (Q3-Q4 2016) the rate decreased to 4.47 per 1000 patient days, and since full implementation (Q1-Q2 2017) the rate has decreased even further to 2.39 per 1000 patient days.

A survey of intensive care unit staff revealed that 92% found the NRSSPS with fluidized positioner to be more effective than the standard wedge for positioning, and 100% of respondents perceived less shear to the patient’s sacrum when using the NRSSPS.


The search for a solution began when the frontline team realized that compliance with our institution’s PUP failed to prevent shear, a major causative factor in the development of deep tissue injury. Continued patient repositioning increases shear forces on deep internal tissue adjacent to bony prominences.2 To reduce shear and friction forces during lifting, an NRSSPS made of low-friction material and a static low air pressure mat was placed under patients identified to be at-risk. The accompanying fluidized positioner was recognized by nursing staff to be a better alternative to foam wedges or pillows. It was felt to better maintain positioning because it did not compress or flatten and was able to be molded to hold the intended position.

Strong evidence, including three RCTs3-5, supports the effectiveness of five layer soft silicone bordered foam sacral dressings used for prevention of pressure injury in critically ill patients, but this intervention was new to our unit. The prophylactic dressing layers absorb shear force, and the dressing covers vulnerable skin and has a low friction backing6. Fluidized heel boots were available for use throughout the hospital before the start of our QIP, but were rarely used. Fluidized boots protect the heel by elevating the heel to offload pressure, and provide pressure redistribution over the Achilles7. Identification of high risk patients and bundling shear-reducing interventions brought attention to the product we already had available for use.


A significant reduction in ICU-acquired pressure injuries was achieved by using a bundled approach to reduce friction and shear. A five layer soft silicone bordered foam sacral dressing and nonpowered reactive support surface
positioning system with fluidized positioner, in combination with fluidized heel boots were added to the pressure injury prevention protocol. An additional benefit of this project was that ICU specific risk factors for PI development were identified.

While most of the pressure injuries on our unit were DTIs, the estimated cost of a DTI is variable and dependent on how the injury evolves. At minimum, the cost of treatment for a hospital acquired Stage 2 pressure injury is estimated at $10,0008. Stage 3 and 4 pressure injuries can total upwards of $70,000 per incidence9. The total cost of adding bundled interventions per patient including (2) heel boots, (1) positioning system and (1) sacral dressing was $242.18. The preventative cost using bundled interventions for forty-one ICU patients would be roughly equivalent to the cost of treating a single Stage 2 HAPI.


  1. Sessler C, Gosnell M, Grap MJ, et al. The Richmond agitation-sedation scale: validity and reliability in adult intensive care patients. American Journal of Respiratory and Cri6cal Care Medicine. 2002;166:1338-1344
  2. National Pressure Ulcer Advisory Panel, European Pressure Ulcer Advisory Panel and Pan Pacific Pressure Injury Alliance. Prevention and Treatment of Pressure Ulcers: Clinical Practice Guideline. Emily Haesler (Ed.). Cambridge Media: Osborne Park, Western Australia; 2014.
  3. Santamaria N, Gerdtz M, Sage S, et al. A randomised controlled trial of the effectiveness of soft silicone multi-layered foam dressings in the prevention of sacral and heel pressure ulcers in trauma and critically ill patients: the border trial. Int Wound J. 2015;12:3,302–308.
  4. Quili B and Qiongyu J. Observation on effect of Mepilex on the prevention and treatment of pressure sores. Chinese Journal of Medical Nursing, 2010.
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  6. Call E, Pedersen J, Bill B, et al. Enhancing pressure ulcer prevention using wound dressings: what are the modes of action? Int Wound J. ISSN 1742-4801.
  7. Molnlycke product information: Z-Flex™ Fluidized Heel Boot Brochure USMM 270496 09.16
  8. Spetz J, Brown D, Aydin C, Donaldson, N. The value of reducing hospital-acquired pressure ulcer prevalence: an illustrative analysis. Journal of Nursing Administra6on. 2013;42:235-241.
  9. Padula W, Mishra M, Makic MA, and Sullivan P. Improving the quality of pressure ulcer care with prevention: a cost-effectiveness analysis. MedCare 2011;49:385-392.

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