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The Impact of Pediatric Pressure Injury Prevention Bundle on Pediatric Pressure Injury Rates: A Secondary Analysis

Singh, Charleen, Deo; Anderson, Cheryl; White, Earla; Shoqirat, Noordeen

Journal of Wound Ostomy & Continence Nursing: May/June 2018 - Volume 45 - Issue 3 - p 209–212
doi: 10.1097/WON.0000000000000439
Wound Care

PURPOSE: The primary aim of this study was to explore the relationship between a pediatric pressure injury prevention bundle (PPIPB) implemented by pediatric hospitals across the nation and pressure injury (PI) rates over a 6-year period. A secondary aim of this study was to identify whether any one risk factor addressed in the PPIPB had a greater effect on PI occurrences than any other factor.

DESIGN: Nonexperimental, retrospective correlation analysis of secondary data.

SUBJECTS AND SETTING: Analysis of data from 99 pediatric hospitals participating in the national initiative Solutions for Patient Safety (SPS).

METHODS: Data were extracted from the SPS, an initiative designed to reduce PI rates in pediatric hospitals. We analyzed data related to nursing interventions implemented to ameliorate 5 factors associated with PI development. They were presence of medical devices, moisture, immobility, skin integrity, and absence of pressure redistribution with some support surfaces. Paired t test and correlation analysis were used to determine the relationship between the use of a PPIPB and PI incidence per 1000 patient-days.

RESULTS: Findings indicated a 57% reduction in PI incidence when the PPIPB was used. A significant inverse relationship between the PPIPB and PI incidence was found. None of the 5 risk factors addressed by the PPIPB had a stronger correlation with PI occurrences than any other factor.

CONCLUSIONS: Study findings strongly suggest the use of a PPIPB decreases PI incidence in pediatric hospitals and should be considered when implementing a PI prevention program.

Charleen Deo Singh, PhD, RN, FNP-BC, CWOCN, Betty Irene Moore School of Nursing, UC Davis, Sacramento, California and Cottage Hospital, Santa Barbara, California.

Cheryl Anderson, PhD, Walden University, Minneapolis, Minnesota.

Earla White, PhD, Walden University, Minneapolis, Minnesota.

Noordeen Shoqirat, PhD, RN, Mutah University Karak, Jordan.

Correspondence: Charleen Deo Singh, PhD, RN, FNP-BC, CWOCN, Betty Irene Moore School of Nursing, UC Davis, 2570 48th St, Sacramento, CA 95817 (

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Preventing pressure injuries (PIs) is a priority for pediatric hospitals across the United States. Hospital-acquired pressure injuries (HAPIs) negatively affect the child, family, and the hospital system.1–4 The child suffers from the often-painful healing process and disfigurement associated with an HAPI.5 Medically fragile children are vulnerable and can die from a PI, emphasizing the need for effective prevention.5 , 6 Further compounding the issue of PIs is the cost pediatric hospitals incur related to healing.6 , 7 Thus, pediatric hospitals are engaging in a variety of strategies to prevent HAPIs.

Researchers of adult PI prevention suggest implementing a bundle of nursing interventions aimed at mitigating known risk factors as effective for prevention.7–9 Typically, a PI prevention bundle addresses the highest risk factors for PIs, which can include the presence of medical devices, moisture, nutrition, tissue oxygenation, immobility, skin integrity, and support surface.7 , 10 In pediatrics, researchers have demonstrated a decrease in PI rates with interventions aimed at mitigating risks associated with immobility, skin integrity, and nutrition.2 , 3 , 11 Without preventive interventions, PI rates can be as high as 27% in pediatric critical care settings.3 , 12 In contrast, implementation of interventions aimed at high-risk pediatric critical care units has demonstrated the ability to decrease PI rates to 6.8%.4 , 13

The purpose of this study was to explore the relationship between PI occurrences and implementation of a pediatric pressure injury prevention bundle (PPIPB) across children's hospitals participating in national quality improvement initiative over a 6-year period. The PPIPB addressed the following risk factors: presence of medical devices, moisture, immobility, skin integrity, and use of support surfaces. A secondary aim of this study was to identify whether one risk factor addressed in the PPIPB had a greater effect on PI occurrences than another factor.

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We analyzed data from the Solutions for Patient Safety (SPS)11 data bank. Solutions for Patient Safety is a nonprofit consortium of over 100 pediatric hospitals collaborating to reduce harm experienced by children while hospitalized.11 Data are collected and maintained regarding PPIPB implementation and PI rates of pediatric hospitals across the nation between 2009 and 2016 as participating hospitals collaborated to decrease PI rates.11 We used a nonexperimental, retrospective correlation design in our analysis. Data for this study were collected between August 2010 and August 2016. Inclusion criteria for a pediatric hospital included the following: participating in SPS for a year and submitting data monthly on an ongoing basis for a year. Exclusion criteria included a pediatric hospital not participating in SPS for less than 1 year and more than 2 consecutive months of missing data. The internal review board from both SPS and Walden University's Office for Research Ethics Office approved the study.

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Study Procedures

Each hospital designated the nursing staff to collect data weekly by reviewing charts on nursing interventions implemented to address the risk factors identified in the PPIPB and PI incidence. Each pediatric hospital quality department submitted data to SPS monthly. The hospitals held monthly virtual meetings to review data entered as part of the quality review process.

The pediatric hospitals collaborating through SPS created the data collection form during the development phase in 2009. No adjustments were made to the data collection form between 2010 and 2016. Each hospital designated clinical nurses to collect data regarding 5 risk factors deemed essential to a PPIPB. The 5 risk factors included presence of medical devices, moisture, immobility, skin integrity, and support surface selection. Each hospital trained nurses to review the medical record for documentation of nursing interventions. Each hospital determined the number of medical records to review on either a daily basis or a weekly basis. Medical record selection was based on discretion of the hospital, and hospitals had the flexibility to do medical record reviews either daily or weekly. However, data collection forms were submitted weekly to the hospital's quality department for entering and submission to SPS monthly. On average, pediatric hospitals aimed to complete 10 forms per unit as the census allowed on a weekly basis. The data form required a “yes” or “no” response to whether a nursing intervention was documented as being implemented for each of the 5 risk factors. Only completed forms were accepted. The only PI-related data collected were stage and date; data concerning the suspected cause of the PI, its anatomic location, the unit on which a PI developed, or the acuity of the child's illness were not collected.

The SPS initiative started in 2009 with a few pediatric hospitals. Each pediatric hospital was required to participate in the quality improvement process activities as outlined by SPS and complete the data collection forms on a weekly basis. Over the course of 7 years, the number of participating pediatric hospitals steadily increased. Data aggregation from each hospital mitigated seasonal variances and facilitated analysis.14 , 15

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Data Analysis

Using a power analysis software program (G*Power analysis; University of Dusseldorf, Dusseldorf, Germany)16 for an effect size of 0.3 and α probability of .05 for a power of 0.80, a minimum sample size of 74 pediatric hospitals was found necessary to answer the first aim of this study and 88 pediatric hospitals were needed to answer the second aim of this study. Analysis of data was performed using IBM SPSS (Statistical Package for the Social Sciences, Chicago, Illinois) version 22.0.17 Paired t test was conducted to compare mean PI rates for a pediatric hospital before and after PPIPB implementation. The rate of PIs was reported as the number of incidence per 1000 patient-days. Pearson's coefficient (P = .05) was used to examine the effect of the PPIPB on PI rates. The Bonferroni ad hoc approach was used to control for type I error.

In order to address the second aim, Analysis of Variance (ANOVA) (α = .05, 2-tailed) was used. The implementation of nursing interventions addressing the risk factors of the PPIPB that were reported as “yes” and “no” was translated to the number of variables and aggregated per year.

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One hundred two children's hospital submitted data, but 3 pediatric hospitals did not meet inclusion criteria, resulting in a sample size was 99 pediatric hospitals. The number of pediatric hospitals reporting on the implementation of nursing interventions to mitigate the risk factors of the PPIPB increased over the 6-year span. The mean rate of PIs at the beginning of the initiative was significantly higher than the mean rate of PIs at the end of the data collection period (P < .001). The mean incidence of PIs fell by 57%, and there was a significant inverse relationship between implementation of the PPIPB and PI incidence (95% CI, 3.22-1.03; P < .01; Figures 1 and 2).

Figure 1

Figure 1

Figure 2

Figure 2

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).

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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.

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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.

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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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Bundle; Interventions; Outcomes; Pediatric pressure injuries; Prevention; Prevention bundle

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