Hospital-Acquired Injuries: Device-Related Pressure Ulcers, Falls, and Restraints

  • Stefano Bambi


Among nurse-sensitive outcome indicators, there are “patient falls” and “pressure ulcers.” Some private institutions such as the National Quality Forum consider fundamental also the measure of “restraint prevalence.” So, pressure sores (and device-related pressure ulcers), patient falls, and resorting to physical restraints (with related injuries) can be all collected under an idea that overcomes the generic “iatrogenic complications” concept, to embrace the more appropriate definition of “nursing-induced complications,” originating a new terminology: “hospital-acquired injuries (HAInj).” The cross trajectories of device-related pressure ulcers, falls, and physical restraints should be traced, and their cause-effect relationships need to be explored and faced by the nursing staff in critical care settings. In fact, it’s intuitive to draw a bidirectional vicious circle involving patient’s agitation, physical restraints, device pressure ulcer, and falls from ICU beds. More research is needed to find effective measure in prevention of falls from bed and chairs, alternative intervention to physical restraints, and optimal management of medical device to reduce the risk of pressure ulcers induced by their application.


Iatrogenic disease Equipment and supplies Pressure ulcer Accidental falls Physical restraints Ethics 


  1. 1.
    Rhodes A, Moreno RP, Azoulay E, Capuzzo M, Chiche JD, Eddleston J, et al. Prospectively defined indicators to improve the safety and quality of care for critically ill patients: a report from the Task Force on Safety and Quality of the European Society of Intensive Care Medicine (ESICM). Intensive Care Med. 2012;38:598–605. Scholar
  2. 2.
    Critical Care Services Ontario. Critical care unit balanced scorecard toolkit. Critical Care Secretariat. 2012. Accessed 04 Mar 2016.
  3. 3.
    de Vos M, Graafmans W, Keesman E, Westert G, van der Voort PH. Quality measurement at intensive care units: which indicators should we use? J Crit Care. 2007;22:267–74.CrossRefGoogle Scholar
  4. 4.
    Tsang C, Palmer W, Aylin P.. Patient safety indicators: a systematic review of the literature. Centre for Patient Safety and Service Quality. London: Imperial College London. 2008. Accessed 03 Mar 2016.
  5. 5.
    Stalpers D, de Brouwer BJ, Kaljouw MJ, Schuurmans MJ. Associations between characteristics of the nurse work environment and five nurse-sensitive patient outcomes in hospitals: a systematic review of literature. Int J Nurs Stud. 2015;52:817–35. Scholar
  6. 6.
    Savitz LA, Jones CB, Bernard S. Quality indicators sensitive to nurse staffing in acute care settings. In: Henriksen K, Battles JB, Marks ES, et al., editors. Advances in patient safety: from research to implementation (volume 4: programs, tools, and products). Rockville: Agency for Healthcare Research and Quality (US); 2005. p. 375–85.Google Scholar
  7. 7.
    Cooper KL. Evidence-based prevention of pressure ulcers in the intensive care unit. Crit Care Nurse. 2013;33:57–66. Scholar
  8. 8.
    Coyer FM, Stotts NA, Blackman VS. A prospective window into medical device-related pressure ulcers in intensive care. Int Wound J. 2014;11:656–64. Scholar
  9. 9.
    ECRI Institute. Medical devices’ role in causing pressure ulcers. Published 8/1/2014. Accessed 01 Mar 2016.
  10. 10.
    Apold J, Rydrych D. Preventing device-related pressure ulcers: using data to guide statewide change. J Nurs Care Qual. 2012;27:28–34. Scholar
  11. 11.
    Ackland HM, Cooper DJ, Malham GM, Kossmann T. Factors predicting cervical collar-related decubitus ulceration in major trauma patients. Spine (Phila Pa 1976). 2007;32:423–8.CrossRefGoogle Scholar
  12. 12.
    Black J, Alves P, Brindle CT, Dealey C, Santamaria N, Call E, Clark M. Use of wound dressings to enhance prevention of pressure ulcers caused by medical devices. Int Wound J. 2015;12:322–7. Scholar
  13. 13.
    Sammon MA, Montague M, Frame F, Guzman D, Bena JF, Palascak A, et al. Randomized controlled study of the effects of 2 fecal management systems on incidence of anal erosion. J Wound Ostomy Continence Nurs. 2015;42:279–86. Scholar
  14. 14.
    Mulhall AM, Jindal SK. Massive gastrointestinal hemorrhage as a complication of the Flexi-Seal fecal management system. Am J Crit Care. 2013;22:537–43. Scholar
  15. 15.
    Carron M, Freo U, BaHammam AS, Dellweg D, Guarracino F, Cosentini R, et al. Complications of non-invasive ventilation techniques: a comprehensive qualitative review of randomized trials. Br J Anaesth. 2013;110:896–914. Scholar
  16. 16.
    Lucchini A, Valsecchi D, Elli S, Doni V, Corsaro P, Tundo P, et al. The comfort of patients ventilated with the Helmet Bundle. Assist Inferm Ric. 2010;29:174–83.PubMedGoogle Scholar
  17. 17.
    Wounds UK. Device related pressure ulcers made easy. 2012; 8. Accessed 29 Feb 2016.
  18. 18.
    Black JM, Cuddigan JE, Walko MA, Didier LA, Lander MJ, Kelpe MR. Medical device related pressure ulcers in hospitalized patients. Int Wound J. 2010;7:358–65. Scholar
  19. 19.
    Ham WH, Schoonhoven L, Schuurmans MJ, Leenen LP. Pressure ulcers in trauma patients with suspected spine injury: a prospective cohort study with emphasis on device-related pressure ulcers. Int Wound J. 2016;14:104–11. Scholar
  20. 20.
    Dyer A. Ten top tips: preventing device-related pressure ulcers. Wounds. Int J. 2015;6:9–13.Google Scholar
  21. 21.
    Makic MBF. Medical device-related pressure ulcers and intensive care patients. J Perianesth Nurs. 2015;30:336–7. Scholar
  22. 22.
    Cappell MS, Inglis B, Levy A. Two case reports of gastric ulcer from pressure necrosis related to a rigid and taut percutaneous endoscopic gastrostomy bumper. Gastroenterol Nurs. 2009;32:259–63. Scholar
  23. 23.
    Yamaguti WP, Moderno EV, Yamashita SY, Gomes TG, Maida AL, Kondo CS, et al. Treatment-related risk factors for development of skin breakdown in subjects with acute respiratory failure undergoing noninvasive ventilation or CPAP. Respir Care. 2014;59:1530–6. Scholar
  24. 24.
    Bambi S, Peris A, Esquinas AM. Pressure ulcers caused by masks during noninvasive ventilation. Am J Crit Care. 2016;25:6. Scholar
  25. 25.
    Dellweg D, Hochrainer D, Klauke M, Kerl J, Eiger G, Kohler D. Determinants of skin contact pressure formation during non-invasive ventilation. J Biomech. 2010;43:652–7. Scholar
  26. 26.
    Weng MH. The effect of protective treatment in reducing pressure ulcers for non-invasive ventilation patients. Intensive Crit Care Nurs. 2008;24:295–9. CrossRefPubMedGoogle Scholar
  27. 27.
    Ham HW, Schoonhoven LL, Galer AA, Shortridge-Baggett LL. Cervical collar-related pressure ulcers in trauma patients in intensive care unit. J Trauma Nurs. 2014;21:94–102. Scholar
  28. 28.
    Ham W, Schoonhoven L, Schuurmans MJ, Leenen LP. Pressure ulcers from spinal immobilization in trauma patients: a systematic review. J Trauma Acute Care Surg. 2014;76:1131–41. Scholar
  29. 29.
    National Pressure Ulcer Advisory Panel (NPUAP). Best practices for prevention of medical device-related pressure ulcers in critical care. 2013. Accessed 04 Mar 2016.
  30. 30.
    Coleman S, Smith IL, Nixon J, Wilson L, Brown S. Pressure ulcer and wounds reporting in NHS hospitals in England part 2: survey of monitoring systems. J Tissue Viability. 2016;25:16–25. Scholar
  31. 31.
    Glasgow D, Millen IS, Nzewi OC, Varadarajaran B. Device-related atypical pressure ulcer after cardiac surgery. J Wound Care. 2014;23:383-4–6-7. 10.12968/jowc.2014.23.8.383.CrossRefGoogle Scholar
  32. 32.
    Degelau J, Belz M, Bungum L, Flavin PL, Harper C, Leys K, et al. Institute for clinical systems improvement. Prevention of falls (acute care). Updated April 2012. Accessed 01 Mar 2016.
  33. 33.
    Cangany M, Back D, Hamilton-Kelly T, Altman M, Lacey S. Bedside nurses leading the way for falls prevention: an evidence-based approach. Crit Care Nurse. 2015;35:82–4. Scholar
  34. 34.
    Pearson KB, Coburn AF. Evidence-based falls prevention in critical access hospitals. Policy Brief #24. 2011. Accessed 01 Mar 2006.
  35. 35.
    Rush KL, Robey-Williams C, Patton LM, Chamberlain D, Bendyk H, Sparks T. Patient falls: acute care nurses' experiences. J Clin Nurs. 2009;18:357–65. Scholar
  36. 36.
    Falen T, Alexander J, Curtis D, UnRuh L. Developing a hospital-specific electronic inpatient fall surveillance program: phase 1. Health Care Manag (Frederick). 2013;32:359–69. Scholar
  37. 37.
    Lake ET, Shang J, Klaus S, Dunton NE. Patient falls: association with hospital magnet status and nursing unit staffing. Res Nurs Health. 2010;33:413–25. Scholar
  38. 38.
    Yilmaz Z, Goris S. Determination of the patient safety culture among nurses working at intensive care units. Pak J Med Sci. 2015;31:597–601. 10.12669/pjms.313.7059.CrossRefPubMedPubMedCentralGoogle Scholar
  39. 39.
    Warshawsky N, Rayens MK, Stefaniak K, Rahman R. The effect of nurse manager turnover on patient fall and pressure ulcer rates. J Nurs Manag. 2013;21:725–32. Scholar
  40. 40.
    Richardson A, Carter R. Falls in critical care: a local review to identify incidence and risk. Nurs Crit Care. 2015.
  41. 41.
    Taylor S, Sayre C, Nasenbeny K, Sisco K. A step toward decreasing falls and preventing injuries in critical care. Crit Care Nurse. 2008;28:e47.Google Scholar
  42. 42.
    Rochefort CM, Buckeridge DL, Abrahamowicz M. Improving patient safety by optimizing the use of nursing human resources. Implement Sci. 2015;10:89. Scholar
  43. 43.
    Callis N. Falls prevention: identification of predictive fall risk factors. Appl Nurs Res. 2016;29:53–8. Scholar
  44. 44.
    Flanders SA, Harrington L, Fowler RJ. Falls and patient mobility in critical care: keeping patients and staff safe. AACN Adv Crit Care. 2009;20:267–76. Scholar
  45. 45.
    Mullin SG, Chrostowski W, Waszynski C. Promoting safety in the cardiac intensive care unit: the role of the geriatric resource nurse in early identification of patient risk for falls and delirium. Dimens Crit Care Nurs. 2011;30:150–9. Scholar
  46. 46.
    McCarter-Bayer A, Bayer F, Hall K. Preventing falls in acute care: an innovative approach. J Gerontol Nurs. 2005;31:25–33.CrossRefPubMedGoogle Scholar
  47. 47.
    Pettit NR, Wood T, Lieber M, O'Mara MS. Intensive care unit design and mortality in trauma patients. J Surg Res. 2014;190:640–6. Scholar
  48. 48.
    Kozub E, Ravelo A, Gamboa M, Worthy K. Reducing patient falls in a surgical intensive care unit. Crit Care Nurse. 2015;35:e41–2.Google Scholar
  49. 49.
    Nydahl P, Ewers A, Brodda D. Complications related to early mobilization of mechanically ventilated patients on Intensive Care Units. Nurs Crit Care. 2014.
  50. 50.
    Bonuel N, Manjos A, Lockett L, Gray-Becknell T. Best practice fall prevention strategies. CATCH! Crit Care Nurs Q. 2011;34:154–8. Scholar
  51. 51.
    Freeman S, Hallett C, McHugh G. Physical restraint: experiences, attitudes and opinions of adult intensive care unit nurses. Nurs Crit Care. 2016;21:78–87. Scholar
  52. 52.
    Li X, Fawcett TN. Clinical decision making on the use of physical restraint in intensive care units. Int J Nurs Sci. 2014;1:446–50.Google Scholar
  53. 53.
    Mion LC, Minnick AF, Leipzig R, Catrambone CD, Johnson ME. Patient-initiated device removal in intensive care units: a national prevalence study. Crit Care Med. 2007;35:2714–20.PubMedGoogle Scholar
  54. 54.
    Möhler R, Meyer G. Attitudes of nurses towards the use of physical restraints in geriatric care: a systematic review of qualitative and quantitative studies. Int J Nurs Stud. 2014;51:274–88. Scholar
  55. 55.
    Nirmalan M, Dark PM, Nightingale P, Harris J. Editorial IV: physical and pharmacological restraint of critically ill patients: clinical facts and ethical considerations. Br J Anaesth. 2004;92:789–92.CrossRefPubMedGoogle Scholar
  56. 56.
    Benbenishty J, DeKeyser Ganz F, Adam S. Differences in European critical care nursing practice: a pilot study. Intensive Crit Care Nurs. 2005;21:172–8.CrossRefPubMedGoogle Scholar
  57. 57.
    Benbenbishty J, Adam S, Endacott R. Physical restraint use in intensive care units across Europe: the PRICE study. Intensive Crit Care Nurs. 2010;26:241. Scholar
  58. 58.
    Martin B, Mathisen L. Use of physical restraints in adult critical care: a bicultural study. Am J Crit Care. 2005;14:133–42.PubMedGoogle Scholar
  59. 59.
    Minnick AF, Mion LC, Johnson ME, Catrambone C, Leipzig R. Prevalence and variation of physical restraint use in acute care settings in the US. J Nurs Scholarsh. 2007;39:30–7.CrossRefPubMedGoogle Scholar
  60. 60.
    Fogel JF, Berkman CS, Merkel C, Cranston T, Leipzig RM. Efficient and accurate measurement of physical restraint use in acute care. Care Manag J. 2009;10:100–9.CrossRefPubMedGoogle Scholar
  61. 61.
    Langley G, Schmollgruber S, Egan A. Restraints in intensive care units--a mixed method study. Intensive Crit Care Nurs. 2011;27:67–75. Scholar
  62. 62.
    De Jonghe B, Constantin JM, Chanques G, Capdevila X, Lefrant JY, Outin H, et al. Physical restraint in mechanically ventilated ICU patients: a survey of French practice. Intensive Care Med. 2013;39:31–7. Scholar
  63. 63.
    Kandeel NA, Attia AK. Physical restraints practice in adult intensive care units in Egypt. Nurs Health Sci. 2013;15:79–85. Scholar
  64. 64.
    Krüger C, Mayer H, Haastert B, Meyer G. Use of physical restraints in acute hospitals in Germany: a multi-centre cross-sectional study. Int J Nurs Stud. 2013;50:1599–606. Scholar
  65. 65.
    Pagliuco Barbosa T, Artuzi Arantes de Oliveira G, Neves de Araujo Lopes M, Aparecida Poletti NA, Marinilza Beccaria LM. Care practices for patient safety in an intensive care unit. Acta Paul Enferm. 2014;27:243–8.CrossRefGoogle Scholar
  66. 66.
    van der Kooi AW, Peelen LM, Raijmakers RJ, Vroegop RL, Bakker DF, Tekatli H, et al. Use of physical restraints in Dutch intensive care units: a prospective multicenter study. Am J Crit Care. 2015;24:488–95. Scholar
  67. 67.
    Stinson KJ. Nurses' attitudes, clinical experience, and practice issues with use of physical restraints in critical care units. Am J Crit Care. 2016;25:21–6. Scholar
  68. 68.
    Choi E, Song M. Physical restraint use in a Korean ICU. J Clin Nurs. 2003;12:651–9.CrossRefPubMedGoogle Scholar
  69. 69.
    Micek ST, Anand NJ, Laible BR, Shannon WD, Kollef MH. Delirium as detected by the CAM-ICU predicts restraint use among mechanically ventilated medical patients. Crit Care Med. 2005;33:1260–5.CrossRefPubMedGoogle Scholar
  70. 70.
    Rose L, Burry L, Mallick R, Luk E, Cook D, Fergusson D, et al. Prevalence, risk factors, and outcomes associated with physical restraint use in mechanically ventilated adults. J Crit Care. 2016;31:31–5. Scholar
  71. 71.
    Burk RS, Grap MJ, Munro CL, Schubert CM, Sessler CN. Predictors of agitation in critically ill adults. Am J Crit Care. 2014;23:414–23. Scholar
  72. 72.
    Chang LY, Wang KW, Chao YF. Influence of physical restraint on unplanned extubation of adult intensive care patients: a case-control study. Am J Crit Care. 2008;17:408–15.PubMedGoogle Scholar
  73. 73.
    Perren A, Corbella D, Iapichino E, Di Bernardo V, Leonardi A, Di Nicolantonio R, et al. Physical restraint in the ICU: does it prevent device removal? Minerva Anestesiol. 2015;81:1086–95.PubMedGoogle Scholar
  74. 74.
    Hofsø K, Coyer FM. Part 2. Chemical and physical restraints in the management of mechanically ventilated patients in the ICU: a patient perspective. Intensive Crit Care Nurs. 2007;23:316–22.CrossRefPubMedGoogle Scholar
  75. 75.
    Laursen SB, Jensen TN, Bolwig T, Olsen NV. Deep venous thrombosis and pulmonary embolism following physical restraint. Acta Psychiatr Scand. 2005;111:324–7.CrossRefPubMedGoogle Scholar
  76. 76.
    Jones C, Bäckman C, Capuzzo M, Flaatten H, Rylander C, Griffiths RD. Precipitants of post-traumatic stress disorder following intensive care: a hypothesis generating study of diversity in care. Intensive Care Med. 2007;33:978–85.CrossRefPubMedGoogle Scholar
  77. 77.
    Antonelli MT. Restraint management: moving from outcome to process. J Nurs Care Qual. 2008;23:227–32. Scholar
  78. 78.
    Reigle J. The ethics of physical restraints in critical care. AACN Clin Issues. 1996;7:585–91.CrossRefPubMedGoogle Scholar
  79. 79.
    Martin B. Restraint use in acute and critical care settings: changing practice. AACN Clin Issues. 2002;13:294–306.CrossRefPubMedGoogle Scholar
  80. 80.
    Yönt GH, Korhan EA, Dizer B, Gümüş F, Koyuncu R. Examination of ethical dilemmas experienced by adult intensive care unit nurses in physical restraint practices. Holist Nurs Pract. 2014;28:85–90. Scholar
  81. 81.
    Bray K, Hill K, Robson W, Leaver G, Walker N, O'Leary M, et al. British Association of Critical Care Nurses position statement on the use of restraint in adult critical care units. Nurs Crit Care. 2004;9:199–212.CrossRefPubMedGoogle Scholar
  82. 82.
    Kapp MB. Physical restraint use in critical care: legal issues. AACN Clin Issues. 1996;7:579–84.CrossRefPubMedGoogle Scholar
  83. 83.
    Park M, Tang JH. Changing the practice of physical restraint use in acute care. J Gerontol Nurs. 2007;33:9–16.PubMedGoogle Scholar
  84. 84.
    Happ MB. Further considerations regarding the effects of physical restraint in the intensive care unit. Crit Care Med. 2004;32:1977.CrossRefPubMedGoogle Scholar
  85. 85.
    Johnson K, Curry V, Steubing A, Diana S, McCray A, McFarren A, et al. A non-pharmacologic approach to decrease restraint use. Intensive Crit Care Nurs. 2016;34:12–9. Scholar
  86. 86.
    Hurlock-Chorostecki C, Kielb C. Knot-So-Fast: a learning plan to minimize patient restraint in critical care. Dynamics. 2006;17:12–8.PubMedGoogle Scholar
  87. 87.
    Maccioli GA, Dorman T, Brown BR, Mazuski JE, McLean BA, Kuszaj JM, et al. Clinical practice guidelines for the maintenance of patient physical safety in the intensive care unit: use of restraining therapies-American College of Critical Care Medicine Task Force 2001-2002. Crit Care Med. 2003;31:2665–76.Google Scholar
  88. 88.
    Vance DL. Effect of a treatment interference protocol on clinical decision making for restraint use in the intensive care unit: a pilot study. AACN Clin Issues. 2003;14:82–91.CrossRefPubMedGoogle Scholar

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© Springer International Publishing AG, part of Springer Nature 2018

Authors and Affiliations

  • Stefano Bambi
    • 1
  1. 1.Emergency and Trauma ICU, University Hospital CareggiFlorenceItaly

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