The Neonatal Skin Risk Assessment Scale, first published in 1997, was developed by Huffines and Logsdon35 specifically for the neonatal population (gestational age 26–40 weeks) at risk of injury and is based off of the Braden scale. It has six subscales: general physical condition, mental status, mobility, activity, nutrition, and moisture. Interrater reliability for the subscales general physical condition, activity, and nutrition was 97%.35 The three subscales that were not included for the pilot study because of low reliability coefficients were mental status, mobility, and moisture. Evidence for predictive validity was present using a cutoff score of 5 with a sensitivity of 83% and specificity of 81%. However, despite the low reliability of the three subscales Huffines and Lodgson35 suggested using all six subscales of the instrument because all are considered important in determining neonate risk.
The Braden Q scale was adapted from the adult Braden Risk Assessment scale in 1996. In 2003, Curley and colleagues71 published their reexamination of the scale’s predictive validity and critical cutoff point for classifying risk. The Braden Q scale has the same six subscales as the Braden scale, with an added seventh subscale: tissue perfusion and oxygenation. The seventh subscale was added to reflect unique pediatric developmental characteristics and optimize the benefits of data that are commonly available in PICUs.72 The Braden Q scale is intended for use on pediatric patients from 21 days to 8 years old. Curley and colleagues71 reported a sensitivity of 88% and specificity of 58%; with an at-risk score of 16, high-risk patients will not be missed, nor will preventive therapies be applied on those who do not develop PIs.
The Glamorgan scale73 was the first widely used risk assessment scale to include devices. Willock and colleagues73 published their examination of the scale in 2009. They found that at a risk score of 10, sensitivity was 100% and specificity was 50.2%; at a risk score of 15, sensitivity was 98.4% and specificity was 67.4%; and at a risk score of 20, sensitivity was 93.4% and specificity was 71.5%.73
In 2015, Sterken and colleagues74 published their Pediatric Pressure Ulcer Prediction & Evaluation Tool (PPUPET). On admission, the PPUPET, which also has a subscale for external devices, was found to have a sensitivity of 74.58% and a specificity of 57.94%, retrospectively. On discharge, the PPUPET had a sensitivity of 76.27% and a specificity of 75.70%. However, sensitivity could not be calculated prospectively because of lack of patients with PIs; further, the specificity was very low. The authors believe the latter may be caused by the PPUPET’s definition of risk.74
The electronic Skin Injury Risk Assessment + Prevention instrument was published in 2017 by Foster and colleagues75 and also includes external devices. The authors used the Braden and Braden Q as a framework, but modified the eight subscales to have two responses that were “scored” either at risk or not at risk. The foundational concept of this instrument is that if a patient is at risk for any subscale, then the patient is at risk for all subscales. When “at risk” is selected, a list of evidence-based interventions is provided. The authors have compared the reliability and validity to the Braden and Braden Q; the Skin Injury Risk Assessment + Prevention has a correlative reliability of 0.556 and correlative validity range of −0.778 to −0.634.
The newest of these instruments, the Braden QD, was introduced by Curley and colleagues2 in their 2018 publication and was founded on the Braden Q scale. Intended for those patients born preterm to 21 years, the Braden QD scale examines the five subscales of the Braden Q with the addition of two others: number of medical devices and repositionability/skin protection. A total score of 13 or higher indicates that the patient is at risk, with a sensitivity of 0.86 and a specificity of 0.59.
Performing a PI risk assessment is still a valuable method for PI prevention. The 2014 NPUAP, EPUAP, PPPIA International Guideline5 recommended that a structured risk assessment be conducted as soon as possible upon admission (up to a maximum of 8 hours after admission), as often as required by the patient’s acuity, and with any significant change to the patient’s condition. The admission assessment should include both a risk assessment (to evaluate risk for developing a PI) and a skin assessment (to detect existing PIs). These two assessments should be thought of as a single process step: a PI admission assessment.76
Risk Assessment Instrument Factors and Subscales
The authors’ review of literature identified 18 skin and PI risk assessment instruments, some of which have undergone psychometric testing. In these 18 instruments, 58 different factors were identified. This variation and the sheer number of factors support the historic practice of each facility and/or nurse using clinical judgment to prevent pressure or skin injuries at a point in time. Although this may have served many patients successfully, it does leave a potential gap in practice. Any tenured nurse has a wealth of knowledge that cannot be immediately conveyed to newly graduated nurses during preceptorship. However, a risk assessment instrument has the sole purpose of presenting evidence-based practice in an algorithm that results in PI prevention through subscale intervention.
The most common factors in each instrument were the same as items normally found in adult risk assessment tools (Table 4). Nutrition was assessed in 12 (67%) of the 18 instruments, and weight was assessed in 6 (33%). These are important factors in PI prevention, but not all instruments assessed either or both of these factors. Tissue perfusion and skin moisture were each assessed in eight instruments (44%). One would expect that all 18 instruments would have looked at these important subscale factors. More surprisingly, only seven instruments (39%) assessed sensory perception, medical device/cast/splints, or friction/shear factors. However, as expected, mobility/activity was included in 14 (78%) of the 18 instruments. Again, with an effective and comprehensive risk assessment instrument, factors leading to pediatric PI are better understood and identified so that interventions can be put in place for prevention.
In addition, some instruments60,71,74,77 have subscales that measure the concept of shear, which can be an underlying causal factor in PI development. However, this concept has many definitions; risk assessment instruments that claim to measure the concept of shear may in fact be measuring friction, shear force, shear strain, shear stress, or other indirect factors that may not specifically measure all or any components of shear.78 A dedicated exploration of the complex concept of shear is beyond the scope of this article. The authors suggest that the evolution of science regarding shear should be taken into account in the development of future risk assessment scales, and researchers should clearly identify which aspect applies to a given risk assessment score. The forthcoming 2019 NPUAP, EPUAP, PPPIA International Guideline will discuss shear and tissue deformation in detail.
Clinical knowledge and practice have advanced since the first risk assessment instrument was developed. It is imperative that instruments be regularly reviewed against the current science of PI development and validated by reporting reliability, sensitivity, specificity, and predictive values. These instruments are a means for common communication and practice among direct care providers to protect pediatric patients. Initiating PI prevention strategies for at-risk patients, rather than all patients, will optimize the appropriate use of resources.72
VULNERABILITY TO PRESSURE INJURIES: CHALLENGES AND OPPORTUNITIES
Given the complexity of pediatric medicine, there are noted challenges in preventing PIs in this population. Most pediatric prevention protocols have been extrapolated from adult practice because the empiric data on which to base clinical practice guidelines are scarce, particularly for infants.79 Providers should not treat children simply as scaled-down adults;80 as previously discussed, pediatric PIs can be inherently different in etiology. Despite the many challenges, there are many opportunities to implement evidence-based recommendations.
Prevention Strategies for Optimal Skin Health
As previously discussed, maintaining skin integrity, especially in younger pediatric populations, is important in preventing PIs. Avoiding excess moisture is critical, because skin is susceptible to injury not only from moisture, but also the chemicals found in moisture sources such as stool, urine, respiratory devices, and caustic gastrointestinal effluent (eg, tube leakage). The fragility of the skin and the increased PI risk when the skin is damaged require products that can prevent, absorb, and/or diminish further damage. Routine use of petroleum-based products or products with zinc oxide is recommended for dermatitis, as well as “crusting” techniques using stoma powder in combination with a skin ointment barrier. Caustic effluent from a percutaneous endoscopic gastrostomy tube may require the use of a foam dressing for protection and absorption. The most common dressings in pediatric PI management include hydrocolloids, hydrogels (available as amorphous gel and sheets), polyurethane foams, and transparent films.81 Exercise caution with dressings that can trap moisture and cause epidermal stripping, such as hydrocolloids and transparent films. Gentle dressings or adhesives (eg, tapes) with silicone are generally recommended.
Preventing Medical Device-Related Pressure Injuries
With the recent acknowledgement of increasing medical device-related PIs (MDRPIs) among pediatric patients,82,83 more attention has been paid to ill-fitting medical devices or equipment that were not designed for pediatric patients, especially respiratory devices such as tracheostomies, endotracheal tubing, and continuous positive airway pressure (CPAP) machines.25,30,35,36,46,83–85 Interestingly, it appears that various terms other than PI, including “injuries,” “necrosis,” breakdown,” or “trauma,” have been used over the years to describe the damage created by respiratory devices that may now be called MDRPI.
For example, Robertson and colleagues86 reported nasal deformities along with “snubbing,” “flaring,” and columella nasi necrosis from CPAP prongs. Buettiker et al82 performed a randomized study among three different CPAP systems: one nasopharyngeal tube and two types of prong systems. They found that the prong systems caused more “nasal injuries.” Yong and colleagues87 randomized different CPAP systems on 89 VLBW infants. One system was a nasal CPAP (N-CPAP) mask, and the other was a nasal prong device. A higher incidence of nasal “trauma” was seen in the nasal prong group. The most common “traumatized” sites were at the nasal septum/philtrum junction for the mask group and the nasal septum walls in the prong group. Further, an integrative review of skin “breakdown” in preterm infants performed by Newnam and colleagues64 identified factors associated with “skin injury” during N-CPAP. A total of 46 studies were selected for data extraction on frequency of occurrence, severity, location, and type of “skin injuries” associated with nasal device interface.64
Because devices are a risk factor for pediatric PI, prevention strategies should aim to mitigate their effect.34 The 2014 NPUAP, EPUAP, PPPIA International Guideline5 made recommendations for reducing MDRPIs in conjunction with clinical judgment based on the patient’s clinical situation and goals of care. While there are 19 recommendations for avoiding MDPRIs, the essence of these recommendations is to select and properly fit the medical device; assess the area around and under the device at least twice daily or as needed; and rotate, remove, relieve, or replace the device as necessary. The 2014 NPUAP, EPUAP, PPPIA International Guideline5 recommendations have been upheld as the national standard and adopted by facilities and governing organizations. Adaptation of these recommendations can be seen in the literature; for example, using a moisture- and pressure-redistribution dressing such as a foam dressing83 at the device interface81 to reduce tracheostomy-related PIs. The forthcoming 2019 NPUAP, EPUAP, PPPIA International Guideline will incorporate new evidence regarding the prevention of MDPRI for all populations including children.
Based on the patient’s identified risk, it is important that prevention strategies such as turning and repositioning are implemented. To augment prevention strategies, support surfaces may be employed to alleviate poor tissue tolerance and shear, improve microclimate, and/or address pain but should not take the place of turning and repositioning.5 Choosing support surfaces for the pediatric population requires critical thinking and understanding of the anatomy and physiology. Pediatric muscle and fat tissue structures are softer than those of adults, making newborns and young children more susceptible to deformation-related injuries.79 A surface needs to envelop the patient to redistribute the pressure, provide a low-friction interface to reduce shear, accommodate the patient’s mobility status, and be appropriate for the developmental age of the patient.5,88 Providers should take into consideration the frequent movements and growth requirements of pediatric patients. Further, a support surface should conform to the misplacement of tubes and lines and decrease PI susceptibility.
Computer simulations indicate that air cell mattresses provide superior protection against increased soft tissue deformation around a misplaced tube in NICU and PICU populations, compared with foam mattresses.79,88 Other manufacturers produce low air-loss options such as mattress replacements, overlays, or pads. Unfortunately, the most common products for pressure redistribution, and the research behind them, are geared toward the adult population. The 2014 NPUAP, EPUAP, PPPIA International Guideline5 not only provided general recommendations for selecting a support surface based on mobility level; controlling microclimate; shear reduction; risk of developing PIs; and the number, severity, and location of existing PIs for the adult population, but also recommendations for pediatric patients (under Special Populations: Pediatrics) when selecting support surfaces and repositioning while on a surface.
Prevention by Age Range
Extant literature15 recommends that PI prevention in the pediatric population be conceptualized according to age. Some research has tried to demonstrate the effectiveness of interventions specifically based on age. There appears to be a natural division for care pathways and overall approach to care when guided by a framework based on selection of some defined age range according to characteristics such as integumentary development.
One such example is the neonate’s skin immaturity and propensity to PIs and other skin injuries. Based on their findings of extremely low birth weight as a risk factor for nasal trauma, Chen and colleagues89 advocated for guideline development around gestational age and birth weight because of physiologic differences. A multisite prospective study in Japan on PIs in a neonatal population (N = 211) demonstrated that skin texture was a predictor of PI risk.26 Early work by Harpin and Rutter46 demonstrated differences in the effectiveness of skin barrier properties explained by physiologic development of skin structure according to age. Infants who were 32 gestational weeks or less had marked drug absorption and water loss until 2 weeks of age compared with infants born at 37 or more gestational weeks. Newnam and colleagues64 found that neonates of smaller birth weights and younger gestational ages were at risk during N-CPAP use and recommended prevention strategies including frequent skin assessments, focused examinations, correct prong size, adequate humidification, strategies for positioning, and the use of skin barriers to protect them from direct pressure. The authors noted that many of the “injuries” were preventable but that a lack of standardization made prevention difficult, especially in preterm infants.64
In their retrospective study, Schlüer and colleagues15 identified factors associated with the development of occipital PIs in pediatric populations. They concluded that their data support early prediction and intervention to prevent PIs according to age.15 In Switzerland, Schlüer and colleagues16 conducted a descriptive, multicenter point prevalence study on 412 patients from birth to 17 years. They found that the age and the department/unit were the two single characteristics that influenced PI occurrence, stages 2 to 4. Patients with PI stages 2, 3, and 4 were older than 8 years and had chronic conditions or surgical procedures, especially orthopedics. One case-control study (N = 59) in a 30-bed PICU found that the majority of PIs developed in infants younger than 3 years.90 Distribution of PIs in patients younger than 1 year was 36%, whereas patients between 1 and 3 years had 30% of the PIs.
Based on literature like this, it seems evident that age-appropriate ranges are one way to categorize prevention strategies. However, part of the problem in addressing PI prevention by age may be that extant prevalence data may not include all pediatric-age groups or individuals, and thus epidemiologic data may not be reflective of pediatric populations at large. Further, to date, the literature demonstrates differences among pediatric populations regarding risk factors and PI locations.91 More research is required to identify whether these differences truly lead to an increase in PIs and thus require prevention strategies according to age group. Regardless, an argument may be made for the allocation of intervention bundles according to specific age ranges to allow for individualized care.
Prevention Bundles and Programs
Empiric evidence has shown that multicomponent interventions may be more effective than individual actions in the prevention of PIs.92 Pre- and postintervention studies, framed as quality improvement, describe interprofessional and multifaceted intervention bundles that have successfully decreased PI prevalence and incidence in specific populations.20
Solutions for Patient Safety, an initiative designed to reduce occurrences of harm in pediatric hospitals, examined active participation in a collaborative to implement PI prevention bundles of nursing interventions and found that PI occurrence decreased by 57%.93 Implemented from 2009 to 2016, the bundles included five risk factors: medical devices, moisture, immobility, skin integrity, and support surface selection. No particular risk factor exerted a greater effect on PI occurrence, supporting the need for intervention bundles.
Frank and colleagues1 also studied the pediatric population in 33 hospitals that were members of the Solutions for Patient Safety initiative. Their objectives were twofold: to increase the detection of PIs through active surveillance and to reduce the number of serious PIs (stage 3, stage 4, unstageable, deep tissue PI). This project used a three-pronged approach consisting of active surveillance, a prevention bundle, and the deployment of a wound ostomy continence nurse. After the implementation of the bundle, they found a decrease in PIs: 0.06 to 0.03 per 1,000 patient-days in participating institutions. They also found that hospitals reporting greater than 80% bundle adherence reported fewer PIs. Using a patient/day formula, Visscher and colleagues20 found that PICU PIs decreased from 14.3 to 3.7/1000 patient-days after implementing a quality improvement bundle. In the NICU, however, they found that PIs did not significantly change after bundle implementation.
In a children’s hospital, Boesch and colleagues94 noted a high number of tracheostomy-related PIs in their ventilator unit and implemented a bundled intervention model that included reducing moisture and pressure at the device interface. They implemented the model over a 30-month period and found a decrease in the number of patients who developed a tracheostomy-related PI, from 8.1% to 2.6%. With the intent to improve quality of care and decrease incidence of nasal trauma, Chen and colleagues89 initiated a standardized process and protocol with prepackaged kits. The kits and standardized nursing protocol decreased the incidence of nasal trauma from 42.2% to 19.6%, except for infants with extremely low birth weight (less than 1,000 g). The authors concluded that preventing nasal trauma by implementation of standard nursing protocol during N-CPAP is potentially one of the greatest opportunities for preventing of skin injury in this patient population.
In a PICU of a large tertiary care center, a prospective, quasi-experimental study was conducted to determine if a PI prevention program reduced PI development.21 The program included a skin care bundle that incorporated five components: appropriate support surface, frequent turning and repositioning, moisture and incontinence management, appropriate nutrition, and nursing staff education. The staff in the control group received education, and the patients received standard care. The intervention group also received education and standard care, but incorporated skin care champions (staff nurses) who helped to facilitate adherence to the bundle and unit-based advanced practice nurses who performed root-cause analyses. A χ2 analysis revealed that PI development in the control group was significantly higher than in the experimental group. This study demonstrates the importance of a systems approach to bundled interventions, along with dedicated skin care champions who reinforce and implement change into daily practice.
Prevention Through Industry Partnerships
Taking into consideration pediatric vulnerability to PIs and the current standard of care, several implications become apparent for the future of informed clinical practice. For example, given the high occurrence of MDRPIs, collaboration with industry partners to develop innovative solutions is one way to attack the root cause of PIs. The recommendations of Robertson and colleagues86 on pediatric CPAP use included providing rest time and ensuring an appropriate fit, but more importantly, they reported working with the manufacturer to address design flaws. The study led to a collaborative effort with the manufacturer to develop a new curved design with tapering nasal prongs that would help to eliminate the issues. In addition, the manufacturer worked with staff on modifications and learning activities that would support care until the new design was available. This is an example of a positive and productive resolution arising from a collaborative effort between clinicians and a manufacturer.
In their integrative literature review, Newnam and colleagues64 found that researchers had recommended device design changes that would ultimately reduce tissue injury. A retrospective chart analysis of occipital PI incidence found that the majority of patients younger than 1 year were critically ill and using multiple medical devices,59 including endotracheal tubes, mechanical ventilation, extracorporeal membrane oxygenation, central venous catheters, nasogastric tubes, saturation probes, and electroencephalography leads. This finding demonstrates the imperative to collaborate with industry partners to minimize the risks associated with these medical devices.
In their secondary analysis of the National Database of Nursing Quality Indicators, Razmus and Bergquist-Beringer95 found that pressure redistribution support surface use as an intervention in the pediatric population was lower than in a previously reported adult population. Based on this finding, they recommended further investigation to better understand the effectiveness of support surface use in decreasing pediatric HAPIs. What was not clear to them was whether the pressure redistribution support surfaces were designed for pediatric or adult patients.
Clearly, end users of a product are in a position to offer recommendations and suggestions for innovative designs based on daily clinical experience. All clinical disciplines offer value when consulting with industry members involved in the research and design of equipment and devices that address the unique aspects and needs of a special population, such as anatomical or care needs.
There are various opportunities to partner with industry and manufacturers to improve the design, safety, and efficacy of devices, especially in the pediatric population.96 Clinicians can partake in these opportunities through product evaluation committees in their own institutions or participate for advisory boards that engage clinicians and researchers for new product development; in fact, the American Nurses Association works to promote nurses who serve on various types of advisory boards through their Nurses on Boards Coalition.97 The NPUAP, which is composed of medical, nursing, physical therapy, nutrition, and industry stakeholders, forms a cohesive partnership with a mission to serve as the authoritative voice for improved patient outcomes in PI prevention and treatment through public policy, education, and research.98 This includes the Support Surface Standards Initiative (overseen by the NPUAP Research Committee), which is an interprofessional mix of industry, researchers, academics, and practicing clinicians who work together to standardize support surface performance evaluations.99
To be clinically relevant and meet the needs of the pediatric population, collaboration is required between professional caregivers and those involved in the design and development of equipment and medical devices. Developing devices and equipment that achieve highly reliable and quality care through the partnership of industry, researchers, academics, and providers should be the norm. Such interprofessional teams achieve the synergy required to enhance products and ultimately care.
Opportunities for PI Treatment
Unfortunately, like prevention strategies, pediatric PI treatment protocols are extrapolated from adult practice because of the paucity of relevant empiric data on which to base guidelines for clinical practice, particularly in infants.79 Pediatric wound management lacks consensus because research is geared toward adults, which can pose risks to the neonatal and pediatric populations. Baharestani and Ratliff30 stated that the rapid, uncomplicated wound healing of pediatric patients gives rise to a limited need for intervention, making it the “normative expectation” in this population. Some providers believe that healing occurs more expeditiously in younger patients, which is one of several factors that have resulted in\ the lack of consideration for wound care protocols with these populations.30
Wound care practices are currently based on a combination of provider experience and preference as well as a small number of published clinical guidelines based on expert opinion. This includes the choice of specific dressings or other wound care products for pediatric populations as evidenced by the following examples. Transparent films and hydrocolloids were favored at one point, especially in the younger pediatric populations. However, their increased propensity to cause skin stripping and/or moisture-associated skin damage has caused them to fall out of favor.44,48,55,81,100 Medical-grade honey has been used more recently because it is seen as a “natural” product and parents and children respond positively to natural and gentle dressings that are effective and easy to use.81,101 There is also documentation regarding its efficacy in healing wounds in pediatric populations, particularly oncology patients.81,101–103
However, rigorous evidence-based criteria and clinical guidelines for wound management for these populations are limited at best.81 Unfortunately, because of the lack of clear-cut treatment guidance, several problems arise. Importantly, clinicians may have to balance manufacturer-recommended products (which may not have been created with the pediatric patient in mind) with clinical concerns such as skin immaturity and absorption issues.30 Given these issues, clinicians often find it difficult to determine the appropriate treatment.
The future of wound management for neonates and other pediatric populations will depend on continued research and guidelines created to assist clinicians in treating PIs. Currently, there are only a limited number of published clinical guidelines for the evaluation and management of wounds in neonatal and pediatric populations. None of these have undergone the rigorous assessment required for the generation of evidence-based guidelines.81
This white paper reviewed the history of and continued journey to pediatric PI prevention to reveal the scope of the problem, how pediatric anatomy and physiology can lead to PI formation, and the current recommendations for pediatric PI prevention and treatment. More recent published literature and trends show that clinicians are paying attention to the specific issues that make this population vulnerable to PI formation. This population requires special consideration, protocols, and approaches compared with adult or other specific populations. The slow but steady realization of this fact has significantly advanced provider thought processes, approaches, and care provisions particularly when addressing PI prevention and treatment. The wound care discipline must construct standardized approaches that involve targeted risk assessment, evidence-based guidelines, prevention strategies, medical equipment and device design, and wound treatments specific to this special and vulnerable population. This can only be accomplished by working in interprofessional teams that integrate all stakeholders, including industry partners.
- Pediatric patients, especially neonates and infants, are vulnerable to PI formation.
- Pediatric patients should have a risk assessment using a validated risk assessment instrument for successful PI prevention.
- The known PI prevention principles are appropriate for the pediatric population, but the implementation is slightly different for each developmental age.
- There are limited evidence-based guidelines for treatment and management of pediatric PI.
- Providers must work in interprofessional teams that integrate all stakeholders, including industry partners, to effectively prevent and treat pediatric PI.
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Keywords:Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.
medical device-related pressure injury; pediatrics; pediatric risk assessment; pressure injuries; pressure injury prevention; pressure ulcers; white paper