The implementation of a standardized prevention protocol helps to reduce BIPAP devicerelated pressure ulcers in HKSH

By Chan Suk Chu Gillian RN BN MSc (MHC) FHKAN (Surgical)


The purpose of the project was to introduce a new Bilevel Positive Airway Pressure (BIPAP) Skin Protection Protocol to prevent BIPAP device-related pressure ulcers and to evaluate the effectiveness of protocol implementation in preventing skin injury.


Medical Device Related Pressure Ulcers (MDRPUs) are pressure injuries associated with the use of devices applied for diagnostic or therapeutic purposes wherein the pressure ulcer (PU) that develops has the same configuration as the device. MDRPUs are reported as 25-29% of Hospital Acquired Pressure Ulcers (HAPUs). Many institutions have reported decreasing incidence in sacral or heel PU incidence, but MDRPUs persist. Hong Kong Sanatorium and Hospital strove to prevent HAPUs but found that MDRPUs increased in incidence while other high risk areas improved. The highest risk devices reported for MDRPU are respiratory device-related pressure ulcers. Therefore, this project focused on BIPAP-related Pressure Ulcer prevention using an evidence-based practice approach.


The intervention included education regarding MDRPUs prevention to ICU and Assisted Ventilation ward staff and a new poster of BIPAP skin protection protocol to guide practice. The sample included patients requiring BIPAP to assist ventilation under care in ICU and Assisted Ventilation Ward from May to October 2016 (total 24 weeks). Audits were completed after initiating the new skin protection bundle to evaluate the practice change.


A total of 67 patients from ICU and Ventilation Ward were audited after the intervention of using the BIPAP skin protection protocol. Two BIPAP-related PUs were reported with a prevalence rate of 2.98% (2/67), decreased from the pre-intervention rate of 7.81% (5/64), with an overall 64% reduction in MDRPUs with the intervention.


Adherence to the BIPAP skin protection protocol decreases the likelihood of PU development. The protocol can facilitate early detection and prevention of MDRPUs. Hospital Acquired Pressure Ulcer is considered a quality indicator among healthcare systems. Therefore, an evidence-based standardized prevention protocol becomes an essential component of overall pressure ulcer prevention strategies. This BIPAP-related PU prevention project reduced the incidence by 60%, increasing staff awareness and alertness in early recognition and prevention of skin injury. However continuous education, training, and compliance audit in following the protocol and documentation are crucial to sustain the improvement, Wound Care Link Nurses will take the lead to maintain a current guideline, collect feedback and monitor to promote skin integrity.