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Successful Reduction in Electrode-Related Pressure Ulcers During EEG Monitoring in Critically Ill Neonates

Mietzsch, Ulrike MD; Cooper, Kristin L. MBA; Harris, Mandy L. MD

Section Editor(s): Harris-Haman, Pamela A. DNP, CRNP, NNP-BC; ; Zukowsky, Ksenia PhD, APRN, NNP-BC;

doi: 10.1097/ANC.0000000000000641
Clinical Issues in Neonatal Care

Background: Neonates are at a high risk for pressure ulcers (PU) due to skin immaturity and exposure to various medical devices. The prevalence of PU in the neonatal intensive care unit is estimated to be 23%, with 80% of those being related to medical devices, including electroencephalographic (EEG) electrodes. Proposed mechanisms involve prolonged pressure to the electrodes and chemical reactions to conductive agents.

Purpose: The object of this quality improvement project was to reduce PU in neonates during continuous EEG (cEEG) monitoring by 50% within 12 months and 75% within 18 months. A secondary objective was to eliminate electrode-related infections by 12 months. Balancing measures included gestational age at the time of monitoring, integrity of the EEG setup, and cost effectiveness. The process measure was adherence to the skin-monitoring tool kit.

Methods: A multiple Plan-Do-Study-Act cycle method was used. All neonates monitored with cEEG were included. The monitoring tool kit was used to document the condition of scalp and EEG electrodes before, during, and after cEEG.

Results: In the preproject period, 8.5% (9/106) of monitored patients developed PU, and 22.2% (2/9) of those developed infections. During the project period, 3.5% (7/198) of monitored patients developed PU and no infections were observed. During monitoring, 21 patients showed skin irritation, and timely intervention resulted in resolution in more than 90% of the cases and prevented progression into PU. Silver/silver chloride–plated electrodes, when exposed to external heat sources, can cause burns, resembling PU.

Implications for Practice: Intervention at the electrode level together with skin inspection successfully reduces PU in neonates. Silver/silver chloride–plated electrodes should be avoided in neonates.

Implications for Research: Further research is needed to identify the optimal electrode for neonatal EEG.

Departments of Pediatrics/Division of Neonatology (Dr Mietzsch) and Neurology, Division of Child Neurology (Dr Harris), Indiana School of Medicine, Indianapolis; Department of Pediatrics, Division of Neonatology, University of Washington School of Medicine, Seattle (Dr Mietzsch); and Department of Neurophysiology, Indiana University Health, Neuroscience Center-Goodman Hall, Indianapolis (Ms Cooper).

Correspondence: Ulrike Mietzsch, MD, Department of Pediatrics, Division of Neonatology, University of Washington School of Medicine, Seattle Children's Hospital, 4800 Sand Point Way NE, M/S FA 2.113, Seattle, WA 98105 (

The authors have no conflict of interest.

© 2019 by The National Association of Neonatal Nurses