Tools of Change in Critical Care: Impacting Hospital-acquired Pressure Injury Outcomes With A Skin Bundle, An Effective Positioning System, Education, Empowering Nurses, and the WTA Program

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In 2014, a 19 bed intensive care unit in a 250 bed regional level 2 trauma hospital had higher than acceptable hospital-acquired pressure injuries (HAPI). We suspected that our rates were even higher than calculated due to lack of staff knowledge and awareness of pressure injuries’ eticology.

In reviewing possible causes of HAPI in our unit we focused on staff competency in pressure injury prevention, and interventions to reduce both pressure and shear.


Over the next 3 years, successive iniKaKves were implemented beginning with education of selected staff through the Wound Treatment Associate ( WTA) cerKfication program in order to increase staff pressure injury prevention competence. See Figures 1 and 3. This poster focuses specifically on our efforts to address sacral and coccygeal pressure and shear, first by optimizing safe turning and positioning of patients and secondly through use of prophylactic sacral dressings. Our every 2 hour repositioning schedule was augmented by use of a non-powered reactive support surface positioning system (NRSSPS) and fluidized positioners effective at maintaining the therapeutic off-loaded patient position. Additionally, we implemented use of the evidence-based 5 layer soft silicone prophylactic sacral dressings applied to high risk ICU patients, and surgical patients prior to prolonged procedures.


Turning System and HAPI Reduction
Repositioning the patient redistributes pressure but in busy hospital units, repositioning is not always done often enough to prevent pressure injury or is not done correctly.1 Without proper technique or equipment, staff may drag the patient to reposition which causes shear and deformation in deep Kssue resulting in the more serious stage 3,4, DTI and unstageable pressure injuries.2 Other at-risk situations for shear include multiple lateral transfers, often necessary for critically-ill parents who need multiple interdepartmental interventions.2

We implemented a non-powered reactive support surface positioning system (NRSSPS), an in-bed assistive device. The system is designed to facilitate easy repositioning while diminishing shear forces and minimizing the physical effort required for turning or repositioning by caregivers, thus reducing the risk of injury to the patient and caregiver. The NRSSPS system remains under the parent so it is always available eliminating our search for positioning equipment. It is a static air displacement system so pressure redistribution is continual in supine position for the sacrum and in lateral position for the trochanter. We found that the ‘tail’ feature reduces sliding down in bed and the need for frequent boosting. See Table 1. and Images 1 and 2.

Fluidized Positioners and HAPI Reduction

To reduce the risk of pressure injury, it is important that the patient's bony prominences are in the offloaded position and weight not returned to the at-risk area.2 Patient pain, agitation or a feeling of instability or discomfort prompts frequent shifting and increases risk of shear injury.3

Pillows and foam wedges are standard positioning aids but they don’t always stay in place and can compress over time, then fail to redistribute pressure.2 A large fluidized positioner is a standard part of the NRSSPS system. Fluidized positioners are conformable and moldable so they adapt to the unique patient shape providing a greater surface area and improving pressure redistribution.4 They maintain their shape without compressing so they provide on-going support and stability to keep the patient off the at-risk area.4 They may help reduce patient shifting, thus reducing shear forces.

Fluidized positioners are also reported to have been important in reducing HAPI incidence rates in recent clinical literature. In a peer-reviewed journal article by Brennan, use of fluidized positioners reduced pressure ulcer incidence by 45%.4 We found several references articles that show pressure injury reduction with in-bed assistive technologies. 4-7

Sacral Prophylactic Dressing and HAPI Reduction

Considerable evidence exists regarding the effectiveness of the evidence-based 5 layer soft silicone bordered foam sacral dressing that we implemented for pressure injury prevention including 2 meta-analyses, 4 RCTs and many cohort studies.2,8,9 Prophylactic dressings redistribute some pressure and layers move independently on the horizontal plane to absorb shear. A single middle layer is vertically stable providing protection from vertical shear forces (sliding in a Fowler’s position). Moisture is absorbed and wicked away from the skin, then a breathable backing layer allows moisture to evaporate to prevent accumulation and damage from perspiration. A low resistance backing reduces friction.


Over the first 18 months following implementation of the WTA Program, in 2015 and 2016, the enhanced knowledge and assessment skill of the nursing staff resulted in an increased pressure injury incidence rate. However, comparing 2014 to 2017, there has been a 63% reduction in stage 2 and above sacral and coccygeal pressure injury incidence. See Figure 2. Of the 3 pressure injuries events in 2017, 1 was an unstageable ulcer that met the criteria for an unavoidable pressure injury.


Both the evidence-based soft silicone bordered foam prophylactic sacral dressings and nonpowered reactive support surface positioning systems (NRSSPS) function to reduce pressure and shear injury. Implementing these 2 interventions as part of our full Pressure Injury Prevention Program in March of 2015 may have contributed to a 63% reduction in stage 2 and above sacral and coccygeal pressure injuries over the 2014 incidence rates.

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