Other Titles
Device Manager: Implementation of a Bundle to Prevent Medical Device-Related Pressure Injuries [Poster Title]
Other Titles
Rising Star Poster/Presentation - Rapid Presentation Round
Abstract
Background: Pressure injuries (PIs) are a continuing global problem in healthcare and worse for critically ill patients, costing up to $30 billion annually in the United States and are not reimbursable. Medical devices provide life support and healing in hospitalized patients but can also cause harm. Approximately 30-60% of PIs come from medical devices, causing pain, discomfort, and patient dissatisfaction while worsening patient outcomes.
Problem: The practicum site saw increased MDRPIs over two years, over the hospital average, due to a lack of standardization and knowledge for preventing MDRPIs. This led to extended lengths of stay, increased healthcare costs, and poor patient outcomes.
Methods: A quality improvement project, guided by the Knowledge-To-Action framework, implemented an MDRPI prevention bundle over ten weeks in critically ill adults. Healthcare professionals were educated on the bundle for integration into clinical practice. An electronic audit tool collected observational data and electronic health record reviews to measure the incidence of MDRPIs. Descriptive and inferential statistics were used to compare pre-post rates.
Intervention: The literature supports using a bundle of evidence-based interventions endorsed by leading international organizations to prevent MDRPIs. An MDRPI prevention bundle aimed to prevent and reduce the rate of MDRPIs was proven reliable and valid in improving care processes and patient outcomes.
Results: Descriptive studies and Fisher’s exact test were performed. The incidence decreased from 1.17% to 0%. Although the pre-and post-intervention MDRPI rates decreased, computing a p-value for the post-intervention rate of 0 MDRPI was not meaningful or statistically significant. However, clinical significance proved meaningful.
Conclusions: The project revealed a reduction in MDRPIs with no statistical significance. Preventing PIs remains a high priority for healthcare organizations. Implementing an evidence-based bundle can prevent MDRPIs, reduce the rate of MDRPIs, standardize nursing care, and improve patient outcomes. The project led to bundle uptake across all critical care units in the healthcare system. Further research on the impact and value of nursing care is recommended.
Notes
References:
Gefen, A., Alves, P., Ciprandi, G., Coyer, F., Milne, C. T., Ousey, K., Ohura, N., Waters, N., Worsley, P., Black, J., Barakat-Johnson, M., Beeckman, D., Fletcher, J., Kirkland-Kyhn, H., Lahmann, N. A., Moore, Z., Payan, Y., & Schlüer, A. B. (2022). Device-related pressure ulcers: SECURE prevention. Second edition. Journal of Wound Care, 31(Sup3a), S1–S72. https://doi.org/10.12968/jowc.2022.31.Sup3a.S1
Jackson, D., Sarki, A. M., Betteridge, R., & Brooke, J. (2019). Medical device-related pressure ulcers: A systematic review and meta-analysis. International Journal of Nursing Studies, 92, 109–120. https://doi.org/10.1016/j.ijnurstu.2019.02.006
Monarca, M., Marteka, P. & Breda, K. (2018). Decreasing incidence of medical device– related pressure injuries in a small community hospital. Journal of Wound, Ostomy and Continence Nursing, 45(2), 137-140. https://doi.org/10.1097/WON.0000000000000419
Pittman, J., & Gillespie, C. (2020). Medical device-related pressure injuries. Critical Care Nursing Clinics of North America, 32(4), 533-542. https://doi.org/10.1016/j.cnc.2020.08.004
Tayyib, N., Asiri, M. Y., Danic, S., Sahi, S. L., Lasafin, J., Generale, L. F., Malubay, A., Viloria, P., Palmere, M. G., Parbo, A. R., Aguilar, K. E., Licuanan, P. M., & Reyes, M. (2021). The effectiveness of the SKINCARE bundle in preventing medical-device related pressure injuries in critical care units: A clinical trial. Advances in Skin & Wound Care, 34(2), 75–80. https://doi.org/10.1097/01.ASW.0000725184.13678.80
The Joint Commission. (2018). Managing medical device-related pressure injuries. (Quick Safety, 43). https://www.jointcommission.org/-/media/tjc/newsletters/qs-43-med-dev-pressure-injuries-7-17-18-final3.pdf
Siotos, C., Bonett, A. M., Damoulakis, G., Becerra, A. Z., Kokosis, G., Hood, K., Dorafshar, A. H., & Shenaq, D. S. (2022). Burden of pressure injuries: Findings from the Global Burden of Disease Study. Eplasty, 22, e19. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9275412/
Sigma Membership
Non-member
Type
Poster
Format Type
Text-based Document
Study Design/Type
Quality Improvement
Research Approach
Other
Keywords:
Pressure Ulcer Prevention, Pressure Ulcer -- Risk Factors, Critically Ill Patients
Recommended Citation
Holloway, Sierra, "Device Manager: Bundle Implementation for Reducing Device-Related Pressure Injuries" (2026). Creating Healthy Work Environments (CHWE). 3.
https://www.sigmarepository.org/chwe/2024/posters_2024/3
Conference Name
Creating Healthy Work Environments
Conference Host
Sigma Theta Tau International
Conference Location
Washington, DC, USA
Conference Year
2024
Rights Holder
All rights reserved by the author(s) and/or publisher(s) listed in this item record unless relinquished in whole or part by a rights notation or a Creative Commons License present in this item record. All permission requests should be directed accordingly and not to the Sigma Repository. All submitting authors or publishers have affirmed that when using material in their work where they do not own copyright, they have obtained permission of the copyright holder prior to submission and the rights holder has been acknowledged as necessary.
Review Type
Abstract Review Only: Reviewed by Event Host
Acquisition
Proxy-submission
Date of Issue
2026-02-16
Device Manager: Bundle Implementation for Reducing Device-Related Pressure Injuries
Washington, DC, USA
Background: Pressure injuries (PIs) are a continuing global problem in healthcare and worse for critically ill patients, costing up to $30 billion annually in the United States and are not reimbursable. Medical devices provide life support and healing in hospitalized patients but can also cause harm. Approximately 30-60% of PIs come from medical devices, causing pain, discomfort, and patient dissatisfaction while worsening patient outcomes.
Problem: The practicum site saw increased MDRPIs over two years, over the hospital average, due to a lack of standardization and knowledge for preventing MDRPIs. This led to extended lengths of stay, increased healthcare costs, and poor patient outcomes.
Methods: A quality improvement project, guided by the Knowledge-To-Action framework, implemented an MDRPI prevention bundle over ten weeks in critically ill adults. Healthcare professionals were educated on the bundle for integration into clinical practice. An electronic audit tool collected observational data and electronic health record reviews to measure the incidence of MDRPIs. Descriptive and inferential statistics were used to compare pre-post rates.
Intervention: The literature supports using a bundle of evidence-based interventions endorsed by leading international organizations to prevent MDRPIs. An MDRPI prevention bundle aimed to prevent and reduce the rate of MDRPIs was proven reliable and valid in improving care processes and patient outcomes.
Results: Descriptive studies and Fisher’s exact test were performed. The incidence decreased from 1.17% to 0%. Although the pre-and post-intervention MDRPI rates decreased, computing a p-value for the post-intervention rate of 0 MDRPI was not meaningful or statistically significant. However, clinical significance proved meaningful.
Conclusions: The project revealed a reduction in MDRPIs with no statistical significance. Preventing PIs remains a high priority for healthcare organizations. Implementing an evidence-based bundle can prevent MDRPIs, reduce the rate of MDRPIs, standardize nursing care, and improve patient outcomes. The project led to bundle uptake across all critical care units in the healthcare system. Further research on the impact and value of nursing care is recommended.
Description
Pressure injuries are a pervasive problem in healthcare and up to 60% are caused by medical devices. Bundles are proven reliable to reduce medical device-related pressure injuries (MDRPIs). The purpose of this activity is to inform clinicians on the use of a bundle to reduce MDRPIs and improve patient safety.