J Wound Ostomy Continence Nurs. 2015;42(2)151-154.Published.docx

J Wound Ostomy Continence Nurs. 2015;42(2):151-154.
Published by Lippincott Williams & Wilkins
WOUND CARE
Copyright © 2015 by the Wound, Ostomy and Continence
Nurses Society™ J WOCN ■ March/April 2015 151
Patient safety and prevention of harm are foundational
principles of healthcare, and nursing in particular, yet pa-
tients continue to develop pressure ulcers while under our
care. Hospital-acquired pressure ulcers (HAPUs) cause pain,
loss of function, and infection, extend hospital stays, and
increase costs. The cost of treating these wounds is approx-
imately $11 billion a year. In spite of progress in wound
care products, support surfaces, and prevention methods,
occurrences of pressure ulcers persist. 1 Medical device-re-
lated HAPUs are common in both adults and children in
the acute care setting.
Medical Device–Related Hospital-
Acquired Pressure Ulcers
Development of an Evidence-Based Position Statement
Joyce Pittman � Terrie Beeson � Jessica
Kitterman � Shelley Lancaster � Anita Shelly
■ ABSTRACT
Hospital-acquired pressure ulcers (HAPUs) are a problem
in the acute care setting causing pain, loss of function,
infection, extended hospital stay, and increased costs. In

spite of best practice strategies, occurrences of pressure
ulcers continue. Many of these HAPUs are related to
a medical device. Correct assessment and reporting of
device-related HAPUs were identifi ed as an important
issue in our organization. Following the Iowa Model
for Evidence-Based Practice to Promote Quality Care,
a task force was created, a thorough review of current
evidence and clinical practice recommendations was
performed, and a defi nition for medical device-related
HAPU and an evidence-based position statement were
developed. Content of the statement was reviewed by
experts and appropriate revisions were made. This posi-
tion statement provides guidance and structure to accu-
rately identify and report device-related HAPU across our
18 healthcare facilities. Through the intentional focus on
pressure ulcer prevention and evidence-based practice in
our organization and the use of this position statement,
identifi cation and reporting of device-related HAPUs
have improved with a decrease in overall HAPU rates
of 33% from 2011 and 2012. This article describes the
development and implementation of this device-related
HAPU position statement within our organization.
KEY WORDS: Evidence-based , Iowa Model , Medical
device-
related pressure ulcers , Position statement
A pressure ulcer can occur wherever external pressure
impairs circulation to the skin. Pressure ulcers have been
defi ned by the National Pressure Ulcer Advisory Panel
(NPUAP) as “a localized injury to the skin and/or underly-
ing tissue usually over a bony prominence, as a result of
pressure, or pressure in combination with shear.” 2 (p6) This
defi nition is helpful but many pressure ulcers occur as a
result of external pressure from medical devices that do not
completely fi t this defi nition. The NPUAP addressed device-
related HAPUs, which develop on mucosal membranes by

issuing a statement describing the inappropriate use of stag-
ing/category classifi cation due to anatomical differences
between mucosal membrane with skin structures. The
National Database of Nursing Quality Indicators recom-
mends using the term “indeterminate” when classifying
HAPUs over mucosal membranes when reporting HAPU. 3 , 4
However, neither of these recommendations provides a
clear and concise defi nition for all device-related HAPUs.
Hospital-acquired pressure ulcer development is con-
sidered a quality indicator across healthcare systems. 5
Healthcare facilities are required to track and report HAPU
rates. In our large academic healthcare system, prevention
and accurate identifi cation and classifi cation of HAPUs are
a high priority. Monthly skin audits within our facility
found that a high percentage, often more than 50%, of
HAPUs are device related. In addition, the identifi cation,
� Joyce Pittman, PhD, ANP-BC, FNP-BC, CWOCN, Indiana
University
Health–Methodist, Indiana University School of Nursing,
Indianapolis.
� Terrie Beeson, MSN, RN, CCRN, ACNS-BC , Indiana
University
Health- University Hospital, Indianapolis.
� Jessica Kitterman, BSN, CWOCN , Indiana University
Health- Ball
Hospital, Muncie.
� Shelley Lancaster, MSN, CNS, CWOCN , Indiana
University Health-
West Hospital, Indianapolis.
� Anita Shelly, MSN, CNS, CWOCN , Indiana University
Health- Riley
Hospital, Indianapolis.
The authors declare no confl icts of interest.
Correspondence: Joyce Pittman, PhD, ANP-BC, FNP-BC,

CWOCN,
Indiana University Health–Methodist, Indiana University School
of
Nursing, 1701 Senate Blvd, Room B651, Indianapolis, IN 46202
( [email protected] ).
DOI: 10.1097/WON.0000000000000113
Copyright © 2015 Wound, Ostomy and Continence Nurses
Society™. Unauthorized reproduction of this article is
prohibited.
JWOCN-D-14-00006_LR 151JWOCN-D-14-00006_LR 151
21/02/15 2:01 PM21/02/15 2:01 PM
152 Pittman et al J WOCN ■ March/April 2015
defi nition, and reporting of these types of HAPU are in-
consistent with high variation across this organization’s
acute care facilities. Therefore, a task force was created and
given the directive to explore this issue. The purpose of
this article is to describe the process this task force used to
address this important issue.
■ Development of the Project
When examining a practice issue or problem, it is helpful to
use a model that provides a guide to identify areas of clinical
inquiry through synthesis and application of research fi nd-
ings. 6 One such model is the Iowa Model of Evidence-based
Practice to Promote Quality Care (Figure 1). It provides guid-
ance for nurses to use research fi ndings for improvement of
patient care. Using this model, we fi rst created a task force
that included members of our Pressure Ulcer Prevention sys-

temwide committee. Task force members represented 4 of
our adult acute care facilities and our childrens’ hospital.
Four of the task force members were certifi ed WOC nurses,
3 were also masters prepared and/or a clinical nurse special-
ist, and 1 member was doctorally prepared. Using the Iowa
Model of Evidence-based Practice to Promote Quality Care,
the task force identifi ed medical device-related pressure ul-
cers as a problem-focused trigger, a clinical problem, and a
priority of the healthcare organization. This was an impor-
tant fi rst step because a topic that is aligned with the strate-
gic goals of the organization and embraced by staff has a
high likelihood of being adopted by those providing care. 6
In addition, connecting the knowledge gained from research
to an organizational initiative that has relevance to both the
organization and the WOC nurse creates an opportunity
and environment for support that might not be available if
the topic were chosen to fulfi ll local interests alone. 7
Developing a well-formulated purpose statement is
benefi cial once the topic or problem is identifi ed. The
purpose statement directs the evidence search, helps focus
reading, and defi nes the boundaries and limits around the
work to be accomplished. Finally, we advocate formulat-
ing a clear and concise purpose statement to assist with
developing an appropriate implementation and evalua-
tion plan. The task force was charged with developing a
standardized, evidence-based defi nition for device-related
HAPU, which would support appropriate identifi cation
and reporting of these pressure ulcers.
The next step in the Iowa Model is to appraise the evi-
dence related to the question or purpose statement. In
order to fi nd the most current new knowledge related to
device-related pressure ulcers, a search was conducted of
the current relevant literature. We searched the MEDLINE
electronic database. Key search strategies were: (1) time

frame: 1996 to September 2012; (2) exp *“Equipment and
Supplies”/ (312834); (3) exp *Pressure Ulcer/ep, et
[Epidemiology, Etiology] (851); (4) 1 and 2 (84); (5) limit 3
to (English language and humans) (78); and (6) from 4
keep 2–4, 6, 13, 16–17, 20, 23–24, 26–31, 35–39, 53–54, 64,
69–71, 76–78 (30). This search identifi ed 30 references,
which were reviewed by our team.
The task force identifi ed the defi nition of medical de-
vices by the Food Drug & Cosmetic Act as integral to de-
veloping a defi nition of device-related HAPUs. The US
Food and Drug Administration defi nes a medical device as
“…an instrument, apparatus, implement, machine, con-
trivance, implant, in vitro reagent, or other similar or re-
lated article, including a component part, or accessory
which is: recognized in the offi cial National Formulary, or
the United States Pharmacopoeia, or any supplement to
them, intended for use in the diagnosis of disease or other
conditions, or in the cure, mitigation, treatment, or pre-
vention of disease, in man or other animals, or intended
to affect the structure or any function of the body of man
or other animals, and which does not achieve any of its
primary intended purposes through chemical action
within or on the body of man or other animals and which
is not dependent upon being metabolized for the achieve-
ment of any of its primary intended purposes.” 8 (p1)
Another important piece of evidence was that of the
NPUAP and its work surrounding pressure ulcers. The
NPUAP hosted a consensus conference in 2010 and again in
2014 to discuss the complexities of avoidable versus un-
avoidable HAPUs. As a result of this work, NPUAP has led
efforts of the wound and pressure ulcer expert community
in identifying key components related to pressure ulcer de-
velopment and the complexities surrounding these wounds.

This work is in its initial stages, but a state of the science
article was published recently describing unavoidable pres-
sure ulcer incidence and the key risk factors that infl uence
them. 9 One of these key risk factors identifi ed is that of med-
ical devices. Medical device-related pressure ulcers are diffi -
cult to prevent as they are necessary for treatment. They are
also challenging to assess due to the inability to remove
them in certain instances, and they may produce compro-
mise of underlying tissue due to moisture or edema.
Many states are recognizing the importance of HAPUs
and are requiring the reporting of prevalence of HAPUs as
a quality measure. Minnesota used data collected through
mandatory statewide adverse health events reporting sys-
tem to identify trends in causative factors for device-re-
lated pressure ulcers. An interdisciplinary team convened
to develop best practices for prevention of pressure ulcers
related to the use of medical devices. 10 Although the fi nd-
ings from this report are helpful, no defi nitive defi nition
for device-related HAPUs was described.
■ Implementation of the Project
Using the US Food and Drug Administration defi nition for
medical devices, evidence-based guidelines, and position
statements from various organizations, and results of an ex-
pert review, the task force defi ned device-related skin injury
to those devices that were medical and external. The task
force identifi ed 2 critical elements to be included in the
prohibited.
21/02/15 2:01 PM21/02/15 2:01 PM

J WOCN ■ Volume 42/Number 2 Pittman et al 153
Assemble Relevant Research & Related Literature
Critique & Synthesize Research for Use in Practice
NoYes
Yes
Is Change
Appropriate for
Adoption in
Practice?
Yes
Institute the Change in Practice
No
Continue to Evaluate Quality
of Care and New Knowledge
No
Disseminate Results
Problem Focused Triggers
1. Risk Management Data
2. Process Improvement Data
3. Internal/External Benchmarking Data

4. Financial Data
5. Identification of Clinical Problem
Knowledge Focused Triggers
2. National Agencies or Organizational
Standards & Guidelines
3. Philosophies of Care
4. Questions from Institutional Standards Committee
1. New Research or Other Literature
Consider
Other
Triggers
Is this Topic
a Priority
For the
Organization?
Form a Team
Is There
a Sufficient
Research
Base?
Pilot the Change in Practice
1. Select Outcomes to be Achieved
2. Collect Baseline Data
3. Design Evidence-Based
Practice (EBP) Guideline(s)

4. Implement EBP on Pilot Units
5. Evaluate Process & Outcomes
6. Modify the Practice Guideline
Base Practice on Other
Types of Evidence:
1. Case Reports
2. Expert Opinion
3. Scientific Principles
4. Theory
Conduct
Research
Monitor and Analyze Structure,
Process, and Outcome Data
• Environment
• Staff
• Cost
• Patient and Family
The Iowa Model of Evidence-Based
Practice to Promote Quality Care
DO NOT REPRODUCE WITHOUT PERMISSION Revised
April 1998 © UIHC
= a decision point Titler, M.G., Kleiber, C., Steelman, V.J.,
Rakel., B. A., Budreau, G., Everett, L.Q.,
Buckwalter, K.C., Tripp-Reimer, T., & Goode C. (2001). The
Iowa Model Of Evidence-
Based Practice to Promote Quality Care. Critical Care Nursing
Clinics of North America,
13(4), 497-509.
REQUESTS TO:

Department of Nursing
University of Iowa Hospitals and Clinics
Iowa City, IA 52242-1009
FIGURE 1. The Iowa Model of Evidence-Based Practice to
Promote Quality Care. Reprinted with permission from the
University
of Iowa Hospitals and Clinics and Marita G. Titler, PhD, RN,
FAAN, Copyright 1998. For permission to use or reproduce the
model,
please contact the University of Iowa Hospitals and Clinics at
319-384-9098 or [email protected]
prohibited.
21/02/15 2:01 PM21/02/15 2:01 PM
154 Pittman et al J WOCN ■ March/April 2015
defi nition of device-related HAPUs: (1) NPUAP defi nition of
pressure ulcers provides the basis of the defi nition and (2)
device-related HAPUs will be limited to external medical de-
vices. After a thorough review of the evidence and using
clinical practice expertise, an evidence-based device-related
HAPU defi nition for adults and pediatrics was developed. A
device-related HAPU is defi ned as a localized injury to the
skin and/or underlying tissue including mucous membranes,
as a result of pressure, with a history of an external medical
device at the location of the ulcer, and mirrors the shape of
the device. This defi nition provides needed guidance, struc-
ture, and process to assist with prevention, identifi cation,

reporting, and treatment of medical device-related HAPU.
The task force used this evidence-based defi nition to de-
velop the Medical Device-Related Pressure Ulcer Position
Statement. Following the format example of the Wound,
Ostomy and Continence Nursing Society and other organi-
zations, a position statement was developed. In order to
improve the content validity of the position statement, ex-
perts in wound management and pressure ulcers were asked
to review the content. Based on their recommendations,
appropriate revisions were incorporated into the document.
The next step in the Iowa Model is to move the evi-
dence into practice. Effective dissemination of evidence
includes mindful communication among opinion leaders,
change champions, core groups of infl uence, and aca-
demic detailing. Opinion leaders were defi ned as those col-
leagues who are viewed as important and respected sources
of infl uence among their peers. Change champions
embrace and demonstrate the persistence necessary to pro-
mote the adoption of evidence.
The task force disseminated the position statement by
informing various systemwide leadership groups involved
in patient quality/safety, systemwide pressure ulcer pre-
vention committee, facility-specifi c WOC nurse experts,
and facility-specifi c direct-care nurse wound teams.
Dissemination continues as the use of the Medical Device-
Related Pressure Ulcer Position Statement is integrated
into the process of conducting our monthly facility-wide
pressure ulcer prevalence surveys.
■ Conclusion
A pressure ulcer may occur wherever external pressure im-
pairs circulation to the skin. Pressure ulcers cause pain, loss

of function, and infection, extend hospital stays, and in-
crease cost. In addition, pressure ulcer development is con-
sidered a quality indicator across healthcare systems. 5
Increased scrutiny and reduced payment or nonpayment
for HAPU by the Centers for Medicare & Medicaid Services
has made the prevention and early detection of pressure
ulcers a prominent quality improvement initiative of
healthcare systems across the country. A key component in
prevention and detection of pressure-related injury is an
accurate skin assessment. In order to perform an accurate
skin assessment, an evidence-based defi nition for device-
related pressure ulcers is crucial. Our Device-Related
Pressure Ulcer Position Statement guides practice, educa-
tion, and research within this healthcare organization. This
defi nition is used when identifying, reporting, treating, and
developing prevention strategies for device-related HAPU.
It has proven useful for distinguishing between pressure
ulcers resulting from an external medical device versus
nonmedical device. Through the intentional focus on pres-
sure ulcer prevention and evidence-based practice in our
organization and the use of this position statement, identi-
fi cation and reporting of medical device-related HAPUs
have improved with a decrease in overall HAPU rates of
33% from 2011 and 2012. This concise and evidence-based
position statement supports appropriate and consistent
identifi cation and reporting of medical device–related pres-
sure ulcers. Staging of these ulcers continues to follow the
staging recommendations of NPUAP and National Database
for Nursing Quality Indicators reporting instructions.
■ References
1. Ayello E , Lyder C . Protecting patients from
harm: preventing
pressure ulcers . Nursing 2007 ; 37 : 36-40 .

2. EPUAP/NPUAP . European Pressure Ulcer Advisory
Panel and
National Pressure Ulcer Advisory Panel. Treatment of Pressure
Ulcers: Quick Reference Guide . Washington, DC : National
Pressure Ulcer Advisory Panel ; 2009 .
3. Berquist-Beringer S , Davidson J . NDNQI:
Pressure Ulcer Training .
2013 . Accessed December 18, 2014 . at
https://members.nursing
quality.org/NDNQIPressureUlcerTraining/
4. NPUAP. Mucosal Pressure Ulcers: An NPUAP
Position Statement
2012. Accessed December 18, 2014 at http://www.npuap.org/
wp-content/uploads/2012/03/Mucosal_Pressure_Ulcer_
Position_Statement_fi nal.pdf
5. Centers for Medicare & Medicaid Services. Hospital-
Acquired
Conditions and Present on Admission Indicator Reporting
Provision. Accessed December 18, 2014 at http://www.cms
.gov/Outreach-and-Education/Medicare-Learning-Network-
MLN/MLNProducts/Downloads/wPOAFactSheet.pdf
6. Titler M , Kleiber C , Steelman V , et al.
The Iowa model of
evidence-based practice to promote quality care . Crit Care
Nurs
Clin North Am. 2001 ; 13 ( 4 ): 497-509 .
7. Stanley T , Sitterding M , Broome M ,
McCaskey M . Engaging and
developing research leaders in practice: Creating a foundation
for a culture of clinical inquiry . J Pediatr Nurs. 2011 ; 26 :

480-488 .
8. Food and Drug Administration . Is the product a
medical de-
vice ? http://www.fda.gov/MedicalDevices/DeviceRegulation
andGuidance/Overview/ClassifyYourDevice/ucm051512.htm .
Published 2013. Accessed December 16, 2013.
9. Edsberg LE , Langemo D , Baharestani
MM , Posthauer ME ,
Goldberg M . Unavoidable pressure injury: state of the
science
and consensus outcomes . J Wound Ostomy Continence Nurs .
2014 ; 41 ( 4 ): 313-334 .
10. Apold J , Rydrych D . Preventing device-
related pressure ulcers:
using data to guide statewide change . J Nurs Care Qual .
2012 ; 27 ( 1 ): 28-34 .
The CE test for this article is available online only at the
journal website, jwocnonline.com, and
the test must be taken online at NursingCenter.com/CE/JWOCN.
prohibited.
21/02/15 2:01 PM21/02/15 2:01 PM
Running head: NURSING RESEARCH UTILIZATION
PROJECT PROPOSAL
1

NURSING RESEARCH UTILIZATION PROJECT PROPOSAL:
7
title page
Methods for monitoring solution implementation using the Iowa
Model
The success of the solution implementation project relies
heavily on the monitoring and evaluating of the project. The
Iowa Model of Evidence Based Practice will be used to guide
the project which relies on feedback loops which make the
continued monitoring and evaluating of structures, processes,
and outcome data a crucial part in its success. One of the first
steps in the model requires that the practice question be aligned
with the goals of the organization. This project has been
requested of management and fits perfectly with the goal of
improved patient care and improved outcomes. The continued
monitoring of this alignment will be necessary with
management and stakeholders and the ongoing results will be
reviewed with them on an ongoing regular basis. The Iowa
Model also stipulates the development and use of a team to
gather, analyze, and critique the literature and its utilization in
clinical practice. The team has already been assembled and
includes member from various disciplines. This group will meet
on a regular basis to refine the project and to move the project
forward and to analyze and evaluate the results. A method to
monitor deadlines and interim goals will be established and
followed.
Methods to Evaluate

During the pilot, staff compliance will be monitored to ensure
the process is utilized correctly and that accurate data is being
collected. Spot checks will be completed by at least two team
members on a weekly basis and reported back to the committee.
If the change works, it will become permanent and continued
monitoring will be conducted to ensure workflow efficiency and
continued SSI improvements. The overall success of the
protocol will be measured by using the baseline measurement of
SSIs from the entire OR suite within the last 12 months. After
implementation, the team will collect SSI on a weekly basis
from the entire OR suite and compare those results from that of
the previous 12 month period.
Outcome Measure
Measurements are extremely important in quality management
but in order to be effective, Smith (2014), insisted they be
precise, useful, simple, and consistently reported. The outcome
measure that will support the success of this project’s objective
will be a reduction in SSI rates of at least three percent within
12 months of implementing the new protocol. This measure will
be reported on a line graph (see Appendix for example) which
will show a month-by-month comparison of SSI rates from the
previous year. Line graphs are extremely useful when
conducting an analysis of metrics as they provide practitioners a
method to easily identify trends and improvement opportunities.
Validity and Appropriateness
The St. Mary’s Quality Improvement Department collects the
data on SSI’s. This is the only data that is appropriate to ensure
the outcome is achieved. The Quality Improvement Department
has been doing this for many years as they do all infection rates
within the facility. They will use the same method after the
implementation of this protocol as they have for the past several
years so the data and the process for collecting the data, has not
changed and will not change for the duration of this project
which increases the validity of this data.
Resources and Methods
Patient records are a useful data collection tool as they can

provide an overall view and details of a patient visit. St.
Mary’s records are electronic and so any infections reported
back from the lab will be flagged and sent directly to the OR
manager and the Quality Improvement Department. This
happens in real time and then monthly reports are automatically
generated and distributed to the appropriate management team.
In this case, reports will also be sent in real time to the new
implementation team. No additional resources will be needed
except for the time the team members need to meet.
Feasibility
The evaluation plan for the solution implementation is feasible
and is actually being requested from OR management and
surgeons. The problem was identified in 2013, yet it has yet to
be addressed by the appropriate staff. The team has already
been assembled and providing them with the details of an
evidence-based solution along with an implementation and
evaluation plan, makes this an easy potential solution. The
Iowa Model of Evidence Based Practice will be used to guide
the project which incorporates natural feedback loops as part of
the process making the evaluation part of the normal everyday
process. The evaluation plan requires very few resources with
virtually no added cost to the departmental budget.

Appendix
References
SSI Rates 2014 vs 2015
2014 4.3 5.4 3.8 4.4000000000000004 3.8 5.3 6
5.4 4.4000000000000004 3.7 5.7 6.2 2015 2.4
2.2000000000000002 0 2.2999999999999998
1.9 2.5 2 1.3 0 2.1 1.1000000000000001
1.8
SSI Rate %

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