Of the 99 children's hospitals included in the study, 77 submitted complete data on the implementation of nursing interventions addressing the risk factors included in the PPIPB. Descriptive analysis of the nursing interventions addressing the 5 risk factors indicated that support surface selection, patient positioning, and skin integrity assessment interventions were implemented 95%, 96%, and 97% (n = 76) of the time, respectively. Moisture management and medical device rotation were implemented 89% and 85% (n = 76) of the time, respectively. Overall, 96% (n = 76) of the pediatric hospitals implemented nursing interventions addressing 4 or 5 of the risk factors addressed by the PPIPB. However, further exploration revealed that in 44% of medical records reviewed no nursing interventions were documented that addressed identified PI risk factors. None of the 5 risk factors addressed by the PPIPB—presence of medical devices, moisture, immobility, skin integrity, or support surface—had a stronger correlation with PI rates (P = .28).
Data analysis identified a positive relationship between implementation of the PPIPB and reduction of PI occurrences. At the end of the data collection period, aggregated PI incidence decreased by 57%, with 100% compliance in documentation of PPIPB interventions. However, further review of data revealed that 44% of the charts identified no nursing interventions implemented to address 1 or more of the 5 risk factors for PI development. This apparent paradox in outcomes is confusing and promising. It is unclear whether the continuous quality improvement process or the nursing interventions have a greater impact on PI rates or whether they are equally weighted. Other study findings demonstrated decreased PI occurrences after implementation of a continuous quality improvement program despite the absence of a mechanism for reporting compliance to specific interventions.18–20 Further research is needed to understand the role of continuous quality improvement in pediatric hospitals and PI incidence.
Our review of the literature also supports active nursing engagement as a factor in reducing PI rates, and we found that nurses' active engagement in this study exerted a positive impact on the reduction of PI rates.19–24 Nurses at each pediatric hospital were tasked with implementing interventions, collecting data, and participating in monthly calls. Active nursing engagement was a constant throughout the data collection period. Findings also suggest that engagement of pediatric hospitals in the collaborative to prevent PIs has a positive effect on total incidence rates of PIs over time (Figure 1). The incidence of PIs steadily decreased as hospitals continued to participate in the collaborative, as did the frequency of reporting zero incidences of PI development (Figures 1 and 2). Other researchers have also reported that active involvement in a multifacility collaborative is effective for prevention of PIs.7 , 10 , 11 , 15 , 24–26
The nursing intervention implementation rate we found is similar to that reported by others.6 , 27 , 28 There is limited information on moisture management and device rotation in the literature.6 Similarly, moisture management is an evolving area of understanding in the prevention of skin injury.27 , 28 Increasing the compliance rate of device rotation and moisture management may further drive down PI rates.
Skin integrity assessment, patient positioning, and support surface were implemented on average in 96% of pediatric hospitals. Multiple researchers report that early skin integrity assessment and frequent patient positioning prevent PIs.1–6 , 10 , 12 , 13 , 24 , 29 , 30 Despite limited options for support surface selection in children,31 95% of the pediatric hospitals reported having appropriate surfaces. Additional research is needed to determine optimal surfaces for infants and children.
There were several limitations for this study. The first was the interrater reliability of the data collection. We had no opportunity to work with the nurses collecting the data and thus we cannot attest to interrater reliability of data collectors. A second limitation was the process of selecting medical records to review at the discretion of the children's hospitals. It is unclear whether this introduced bias into medical record selection. A third limitation was an assumption of the accuracy of the data provided by SPS, as we were unable to cross-check the prepared data with the original data set.
Study findings indicate that active participation in a collaborative dedicated to implementation of a bundle of nursing interventions directed toward risk factors identified in a PPIPB reduced PI rates over time. Even with 44% of the children's hospitals reporting partial implementation of nursing interventions to address risk factors, PI rates decreased by 57%. Analysis did not reveal whether any individual risk factor of the PPIPB exerted a greater effect on PI occurrences, supporting the need for intervention bundles for prevention of PIs. Pediatric hospitals can use these findings from the study to direct resources in addressing the 5 risk factors identified in the PPIPB to reduce PI rates.
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