Wound Care

J Wound Ostomy Continence Nurs. 2017;44(3):1-5.

Published by Lippincott Williams & Wilkins

Effect of a Patient-Repositioning Device in an Intensive

Care Unit On Hospital-Acquired Pressure Injury
Occurances and Cost
A Before-After Study
Melinda Edger

ABSTRACT
PURPOSE: The principal aim of this study was to determine the hospital-acquired pressure injury (HAPI) rate before and after
introduction of a repositioning device, measure staff-perceived level of exertion with device use, and assess return on investment.
DESIGN: 1 group, before-and-after study.
SUBJECTS AND SETTING: The sample comprised 717 patients cared for in a 17-bed intensive care unit. The study setting
was the medical-surgical intensive care unit at Bon Secours Maryview Medical Center located in the mid-Atlantic United States
(Portsmouth, Virginia).
METHODS: A safe patient-handling intervention was implemented as part of a quality improvement initiative. The effect of this
system was measured using several outcome measures: (1) HAPI occurrences on the sacral area and buttocks, (2) perceived
effort of use by staff, and (3) cost analysis. We used the validated Borg Scale to measure perceived exertion that was ranked
on a scale from 6 to 20, where higher scores indicate greater exertion. Cost comparisons were completed before and after
introduction of the patient-repositioning system. Cost analysis was determined using internal dollar amounts calculated for each
stage of pressure injury. The return on investment was calculated by comparing the cost of HAPIs and the product after the
intervention with the costs of HAPIs before the intervention.
RESULTS: Analysis revealed a statistically significant reduction in HAPI occurrence from 1.3% to 0% (P = .004) when baseline
manual repositioning (standard of care) was compared with use of the repositioning system. Caregivers reported significantly
less exertion when using the repositioning device as compared with standard of care repositioning (P < .001). The return on
investment was estimated to be $16,911.
CONCLUSION: Use of a repositioning device resulted in significantly reduced HAPIs. Perceived exertion for repositioning the
patient with a repositioning device was significantly less than repositioning with standard of care. A cost analysis estimated a
return on investment as a result of the intervention on HAPI prevention.
KEY WORDS: Hospital-acquired pressure injury, Patient-repositioning device, Pressure injury, Pressure ulcer

INTRODUCTION implementing evidence-based prevention protocols.3 Because

HAPIs can be prevented in most cases, the Centers for Med-
Pressure injuries can lead to infection, scarring, discomfort,
icaid & Medicare Services has included HAPIs on the list of
along with increased length of hospital stay, and cost of care.1,2
hospital-acquired conditions for which additional reimburse-
Prevention of hospital-acquired pressure injuries (HAPIs) is
ment is not provided.4,5
a fundamental aspect of intensive care nursing. A growing
The 2009 International Pressure Ulcer Prevalence Survey
body of clinical evidence and widespread consensus among
found that HAPI prevalence rates were highest in the medical
clinical experts suggests that most HAPI can be prevented
intensive care unit (ICU) (12.1%).6 Critically ill patients are
by identifying patients at risk and promptly and consistently
at greater risk for HAPI because they typically have multiple
comorbid conditions, along with impaired sensory function
Melinda Edger, MSN, RN, FNP-BC, CWOCN, Bon Secours Maryview and mobility that negatively influences their ability to repo-
Medical Center, Portsmouth, Virginia.
sition themselves. In addition, critically ill patients are fre-
Sage Products LLC reimbursed the services of a medical communications quently treated with anesthetic and sedative drugs, impairing
company for statistical analysis, medical writing, medical editing, and graphics
development. The author maintained total editorial control of all content.
their ability to identify and respond to ischemic discomfort.
Evidence-based guidelines recommend initiation of HAPI
The author declares no conflicts of interest.
prevention protocols as soon as a patient is identified as being
Correspondence: Melinda Edger, MSN, RN, FNP-BC, CWOCN, 285 Guthrie
Drive, Troy, PA 16947 (edger_melinda@guthrie.org).
“at risk.”7
Prevention of HAPIs requires multiple interventions, in-
DOI: 10.1097/WON.0000000000000328 cluding regular turning and repositioning to offload pressure

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Copyright © 2017 Wound, Ostomy and Continence Nurses Society™. Unauthorized reproduction of this article is prohibited.
2 JWOCN ¿ May/June 2017
from areas such as the buttocks and sacrum where they develop
most frequently.8 Turning and repositioning also contribute to
comfort, hygiene, dignity, and functional ability.7 Given these
benefits, a global coalition that includes the National Pressure
Ulcer Advisory Panel suggests initiating a repositioning sched-
ule immediately for patients admitted to the ICU.7 However,
repositioning of critically ill patients is a challenge because of
the acuity of their illness, limited mobility, need for life-sus-
taining interventions, and vulnerability to hemodynamic
instability.9 As a result, it is not uncommon for health care
workers to experience strains or injuries when repositioning
patients. The Occupational Safety and Health Administration
has published safe patient-handling guidelines that discourage
health care workers from manually lifting patients.10
In the summer and fall of 2012, a point-prevalence survey
revealed a spike in buttocks and sacral HAPIs detected in the
ICU at Bon Secours Maryview Medical Center located in the
mid-Atlantic United States (Portsmouth, Virginia). A quality
improvement (QI) initiative was implemented to reduce but-
tock and sacral HAPIs and strain or injuries among health care
providers when repositioning critically ill patients. The prin-
cipal aim of this study was to determine HAPI occurrences
before and after introduction of a repositioning device, mea-
sure staff-perceived level of exertion with device use compared
with standard of care (SOC), and assess cost-effectiveness of
the intervention.
METHODS
We completed a single-group, prospective before-and-after
study. The clinical setting was a 17-bed ICU at Bon Secours
Maryview Medical Center located in Portsmouth, Virginia.
Inclusion criteria were body weight less than 350 lb (159 kg),
immobile and unable to assist with repositioning, Braden
Scale for Pressure Sore Risk cumulative score of 14 or less,
mobility subscore of 1, and moisture subscore 2 or less. Acute
agitation was an exclusion criterion. Data were collected from
June 2012 through September 2013.
Figure 1. Protocol for use of repositioning system.
Copyright © 2017 Wound, Ostomy and Continence Nurses Society™. Unauthorized reproduction of this article is prohibited.
www.jwocnonline.com
Intervention
The repositioning device (Prevalon Turn and Position System;
Sage Products LLC, Cary, Illinois) comprised two 30° body
wedges with an anchor strap, a low-friction glide sheet, and
full-length body pad designed for microclimate management.
The 2 body wedges and the glide sheet are single-patient use,
and the first layer against the patient's skin is a disposable mi-
croclimate pad.
An intervention algorithm, illustrated in Figure 1, was em-
ployed to ensure appropriate use of the patient-repositioning
device. The device was also used for patients with 1 or more
of the following conditions: sepsis, stroke, quadriparesis, co-
matose/unconscious, spinal or head injury, multisystem organ
failure, surgery that limits patient movement, and/or vasopres-
sor in use.
Instruments
Pressure injury risk was evaluated via the Braden Scale for
Pressure Sore Risk.11 This instrument generates a cumulative
score of 9 to 23, where scores of 19 to 23 indicate no risk
of HAPI development, scores of 15 to 18 indicate mild risk,
scores from 10 to 14 indicate high risk, and scores less than 9
signify very high risk.
Perceived exertion during turning and repositioning was
measured via the Borg Scale of Perceived Exertion.12 This vali-
dated instrument ranks exertion on a scale from 6 to 20, where
a score of 6 to 11 indicates light exertion, scores between 12
and 16 indicate moderate exertion, and scores of 17 to 20 in-
dicate hard exertion.
Cost-effectiveness was determined using internal dollar
amounts calculated by the facility for each stage of pressure
injury. Costs associated with HAPI during the before period
were calculated by reviewing the number of HAPIs and their
stages that had occurred over the prior 10 months (June 2012
to April 2013) and compiling costs associated with treatment.
An average cost per month was estimated. The return on in-
vestment was calculated by comparing the cost of HAPIs and
JWOCN ¿ Volume 44 ¿ Number 3 Edger 3

the product after the intervention with the costs before the
intervention.
Study Procedures
Prior to implementation of the intervention, staff were
trained by the principal investigator (ME) and 1 other
wound care nurse, who conducted hands-on training in the
ICU with the device 2 months and 2 weeks prior to study
initiation using a return demonstration approach. Follow-
ing initial training, twice weekly rounding was conducted by
certified wound care nurses, who reinforced appropriate use
of the positioning device according to the intervention algo-
rithm, and monthly rounding was conducted by the study
author to assist with troubleshooting and optimal use of the
repositioning device.
Perceived exertion using the Borg Scale was recorded at the
beginning of the intervention (April 2013) to capture day shift
and night shift nurses. Nurses were asked to rank perceived
level of exertion for patient repositioning with the reposition-
ing device compared with SOC.
All nurses working in the ICU were educated on use of the
algorithm to determine whether patients met the inclusion
criteria for the repositioning device on admission to the ICU
(Figure 1). Once a patient was placed on the repositioning
device, 2 staff members repositioned the patient every 2 hours.
Cleaning or replacement of the device was determined per
manufacturer guidelines. When soiled with urine, the reposi-
tioning device was wiped down with bath cloths and allowed
to dry. In the case of stool contamination, clinical judgment
was used to determine whether the repositioning device should
be discarded and replaced. After being placed on the reposi-
tioning device, the intervention was continued until change in
inclusion criteria, transfer, or discharge.
Over the course of the study, patients were monitored
for the presence or absence of HAPI, level of mobility, and
skin moisture before and after implementation of the new
patient-repositioning device. The electronic medical record
was reviewed on a daily basis using an internal report audit
feature run by the wound care nurses to determine whether
new wounds had developed since the prior report. When a
new wound was identified, the wound care nurses inspected
the patient to verify whether the wound was an HAPI of the
sacral or buttocks regions. In addition, a “turn-and-position”
documentation flow sheet was audited on a daily basis. Data
collection began when the patient was placed on the reposi-
tioning device until the device was discontinued due to change
in inclusion criteria, transfer, or discharge.
Data Analysis
Data were summarized via means, medians, standard devia-
tions, and ranges for continuous variables and percentages for
categorical variables. Although this was a before-after study,
the data were not matched or paired, and outcomes were
analyzed using parallel group rather than paired tests. Age and
Borg Scale scores were approximately normally distributed
and were analyzed with t tests, while Braden scores were ana-
lyzed with a Wilcoxon rank sum test. The remaining variables
were categorical and were analyzed with χ2 or Fisher exact test
if cells in the cross-tabulation had expected counts less than 5.
Results with P values less than or equal to an overall alpha level
of .05 were considered statistically significant. SAS statistical
software, version 9.4 (SAS Institute, Cary, North Carolina),
was used to summarize and analyze data.
RESULTS
Seven hundred seventeen patients were included in this
6-month before-after study. Demographic data of patients are
summarized in Table 1. Table 2 shows the comparison of the
pressure injury risk profile between before and after patient
samples, with mean Braden score in the before group 18.4 ±
5.15 and mean score in the after group 18.9 ± 4.80; no sta-
tistically differences were noted in cumulative Braden Scale
scores or subscale scores in the before and after groups.
HAPI Occurrences
At the beginning of the study, a point-prevalence survey doc-
umented 9 patients (1.3%) with HAPIs. At the end of the
6-month study, a record review revealed that no patients (0%)
developed HAPIs, representing a statistically significant reduc-
tion in pressure injury occurrences (P = .004; Fisher exact
test, Figure 2).
Perceived Level of Exertion Required for to Use Device
Health care providers rated perceived exertion according to
the Borg Scale using the repositioning device compared with
SOC. As shown in Figure 3, less effort was reported using the
repositioning device compared with SOC, the mean exertion

TABLE 1.
Demographic Data
Characteristics Statistic/Category Before After P Value
Age N 717 706 .27
Mean (standard deviation) 64.0 (15.64) 64.9 (16.21)
Range 20.0-98.0 18.0-95.0
Median 64.0 66.0
Gender Female 360 (50.2%) 338 (47.9%) .38
Male 357 (49.8%) 368 (52.1%)
Ethnicity Asian 1 (0.1%) 6 (0.8%) .35
Black or African American 283 (39.5%) 299 (42.4%)
Hispanic 2 (0.3%) 0 (0.0%)
Native American and Alaskan Native 1 (0.1%) 0 (0.0%)
Other 3 (0.4%) 4 (0.6%)
Patient refused 165 (23.0%) 88 (12.5%)
White or Caucasian 262 (36.5%) 309 (43.8%)

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TABLE 2.
Pressure Ulcer Risk Profile of Patients in Study
Characteristics Statistic/Category Before After P Value
Braden Score N 714 702 .010
Mean (standard deviation) 18.4 (5.15) 18.9 (4.80)
Range 6.0-23.0 6.0-23.0
Median 20.0 21.0
Moisture 1 0 (0.0%) 1 (0.1%) .56
2 0 (0.0%) 1 (0.1%)
3 35 (4.9%) 35 (5.0%)
4 679 (947%) 665 (94.2%)
Missing values 3 (0.4%) 4 (0.6%)
Mobility 1 23 (3.2%) 13 (1.8%) .11
2 42 (5.9%) 38 (5.4%)
3 225 (31.4%) 196 (27.8%)
4 424 (59.1%) 455 (64.4%)
Missing values 3 (0.4%) 4 (0.6%)

score, when manually repositioning patients was 88% great- DISCUSSION

er than the mean exertion using the repositioning device
Use of a repositioning device was associated with a statistically
(P < .001; t test).
significant reduction in HAPI occurrences over a 6-month pe-
riod. Device use was also associated with lower perceived staff
Cost Analysis
exertion than was manual repositioning, and the intervention
An internal review of 10 months of pressure injury data
was found to be cost-effective with an estimated return on in-
revealed 17 HAPIs (n = 10 stage 2; internal cost $2000
vestment of $16,911. My findings are consistent with those of
each; n = 1 stage 3; internal cost $43,180 each; n = 5 deep
Powers,13 who reported a significant reduction in HAPI occur-
tissue injuries; internal cost $5562 each; n = 1 unstageable;
rence with use of a patient-repositioning device.13
internal cost $5562). The total HAPI cost was $96,552 over
As a result of the QI project, Bon Secours Maryview
10 months (June 2012 to April 2013), an average of $9655
Medical Center decided to include HAPI occurrence in annual
per month. In the 6 months after launching the interven-
evaluations of all clinical staff, thereby reinforcing accountabil-
tion, no HAPI occurred and the total cost of product was
ity. If the unit percentile exceeds the year per unit benchmark,
$41,020. Return on investment was calculated by compar-
additional interventions were used to ensure staff met expec-
ing an average of $9655 per month for 6 months before
tations for turning and repositioning. With this QI initiative
the intervention with product cost after the intervention
in place, nurses and certified nursing assistants are challenged
($41,020), revealing an estimated return on investment of
to make HAPI prevention a key nursing quality indicator, as
$16,911.
reflected in performance reviews.

Limitations
Several limitations of the study may have influenced generaliz-
ability of findings. Data were collected at a single crucial care

Figure 2. Number of patients presenting with hospital-acquired

pressure injury before and after intervention. A significant change
in the occurrence of pressure injury before and after implementa- Figure 3. Mean scores and standard error of the mean on the
tion was observed (P = .004). Borg Scale for perceived exertion.

Copyright © 2017 Wound, Ostomy and Continence Nurses Society™. Unauthorized reproduction of this article is prohibited.
JWOCN ¿ Volume 44 ¿ Number 3
unit in a single facility. Subjects were not randomly allocated
to intervention. Group assignment was based on a before-after
design; subjects were not randomly allocated intervention
versus SOC group.
CONCLUSIONS
Use of a repositioning device in this before-after study result-
ed in significantly reduced HAPI development. Use of the
repositioning device also resulted in less perceived exertion
than manual repositioning. The repositioning system proved
cost-effective.
ACKNOWLEDGMENTS
The author would like to thank Certified Wound Ostomy and
Continence Nurse/Certified Foot Care Nurse, Sheryl Bailey,
RN, for her assistance in data collection. The author would
also like to thank Kersten Hammond and Rose Byrne for med-
ical writing services, Michelle Secic for statistical analysis, and
Lauren Baker for medical editing assistance throughout the
development of this article.
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