A pressure injury or ulcer is defined by the National Pressure Ulcer Advisory Panel (NPUAP) as localized damage to the skin and underlying soft tissue usually over a bony prominence or injury related to medical or other devices.1 The injury occurs as a result of intense and/or prolonged pressure or pressure in combination with shear stress.1 The NPUAP has defined pressure ulcers based on the level of tissue injury using a staging system with uniform terminology for consistency in reporting.1 NPUAP defines a stage I injury as nonblanchable erythema of intact skin; stage II is partial-thickness skin loss with exposed dermis; stage III is full-thickness skin loss; stage IV is full-thickness skin and tissue loss; and a deep tissue injury is persistent nonblanchable deep red, maroon, or purple discoloration.1 NPUAP defines an unstageable as obscured full-thickness skin and tissue loss.1
The prevalence of pressure ulcers in critically ill children widely varies and is reported at 0.8% to 27%.2–4 Schindler et al2 reported pressure ulcer incidence per 1,000 patient days from 9 pediatric intensive care units ranging from 2.47 to 57.1. Patients at then greatest risk are those requiring mechanical ventilation or inotropic support; those who suffer a cardiac arrest following cardiac surgery; neonates requiring extracorporeal membrane oxygenation; those with nutritional deficits, weight loss, or anasarca; and patients with longer hospital lengths of stay.4–8 Medical device–associated pressure ulcers are frequent among pediatric patients with reported prevalence rates ranging from 50% to 69%.2,3,9–21
This quality project aimed to reduce the incidence of pressure ulcers > stage II in the cardiothoracic intensive care unit (CTICU) and, more importantly, sustain the reduction over time.
This quasi-experimental quality improvement work involved the development of a process to reduce pressure ulcers. No interventions involved a comparison of multiple devices or therapies, and patients were not subject to randomization. Medical records were accessed by healthcare staff and quality improvement team members as part of their normal responsibilities. Per policy, this project does not meet the definition of human subjects’ research. Therefore, institutional review board review was not required.
Nationwide Children’s Hospital is an academic, nonprofit, freestanding children’s hospital located in Columbus, Ohio. The CTICU is a 20-bed unit with over 600 admissions per year. The top 5 most common admission diagnoses are postoperative ventricular septal defect repair, hybrid palliation stage I, hybrid palliation comprehensive stage II, pulmonary valve replacement, and Fontan procedure. Approximately, 10% of our admissions are newborns, defined as less than 30 days of age. The CTICU staff includes a multidisciplinary team of critical care and cardiology physicians (n = 8), advanced nurse practitioners (n = 10), a dedicated clinical pharmacist (n = 1), registered nurses (n = 61), respiratory therapists (n = 14), cardiology and critical care physicians in fellowship training, clinical dieticians (n = 3), physical and occupational therapists, child life specialist, and social worker.
Planning the Intervention
We recruited a multidisciplinary team to develop and implement standardized surveillance of pressure ulcers in the pediatric CTICU. The team included physicians, advanced nurse practitioners, nursing, respiratory therapists, and quality team representatives. We began by creating a SMART (specific, measurable, achievable, realistic, timely) aim statement and key driver diagram.21 We identified patient factors, staff and family education, staff accountability, communication, and collaboration among the key stakeholders, standardized guidelines, specific documentation and follow-up, data/compliance analysis, and measurable outcomes as the relevant key drivers.
In March 2010, the hospital instituted multidisciplinary weekly skin rounds attended by the bedside nurse, unit specific pressure ulcer nurse champion, respiratory therapist, wound ostomy nurse, and quality improvement representative. Subsequently, hospital leadership implemented a hospital-wide pressure ulcer bundle in April 2010. Pressure ulcers hospital-wide are staged by the wound team. The pressure ulcer bundle included: (1) barrier cream use for diapered patients; (2) pulse oximeter probe rotation every 8 hours; (3) patient turning schedule every 2 hours; (4) use of pressure reduction surfaces; (5) heel pressure relief; (6) elevation of head of the bed; and (7) wound ostomy nurse consult for all pressure ulcers > stage II. A multidisciplinary team reviewed all pressure ulcers > stage II identified during huddles beginning in October 2011. Huddle team members included a representative from each of the following: physician, advanced nurse practitioner, pharmacist, clinical nurse leader, bedside nurse, respiratory therapist, and quality project manager. This group collaborated to review events and suggest interventions in a factual, blameless, nonthreatening environment. It was beneficial to have multiple disciplines involved in the review process, as each discipline looked at the event from their unique perspective. Huddles are organized by the clinical nurse leader with the goal to occur within 2 weeks of the event. The huddle process starts with a chart review of events leading to the pressure ulcer and caregiver input regarding attributable clinical or situational factors. The goal of each huddle was to identify factors that may have contributed to the pressure ulcer and interventions aimed at preventing event recurrence with consensus agreement of the huddle participants. Representatives from the huddle would then communicate and discuss their findings and proposed interventions with the CTICU staff via email and staff meetings. The CTICU quality committee created in spring 2010, with accountability for guiding improvement and quality process education, would assist the staff in the implementation of the interventions as appropriate. Also, the CTICU quality committee periodically updates a bulletin board with actual photographs of pressure ulcers in our patients (with parental approval) in the CTICU staff-only area as a visual tool to raise staff awareness and engagement.
The first Plan-Do-Study-Act Cycle (August 2012) aimed to increase participation in the multidisciplinary weekly skin rounds. The day and time of skin rounds were changed to accommodate the multidisciplinary staff members. A nurse and advanced nurse practitioner champion receive dedicated nonpatient care hours to work on pressure ulcer prevention. Therefore, they are always available to participate in weekly skin rounds and pressure ulcer huddles and represent the unit at the institutional pressure ulcer meetings. They also participate in the creation, education, and monitoring of action plan compliance, and coaching, mentoring, and collaborating with other stakeholders.
The second Plan-Do-Study-Act Cycle (October 2012–December 2012) includes the creation of a multidisciplinary (physician, bedside nurse, advanced nurse practitioner, respiratory therapist, and quality representative) unit specific pressure ulcer work group to discuss leadership involvement, bedside accountability, and develop patient-specific interventions. This group developed the caregiver input form (Fig. 1) that allows all caregivers to provide input on the cause and potential prevention of each pressure ulcer.
After review of our pressure ulcers from 2012, the third Plan-Do-Study-Act Cycle (January 2013) was a revision of the pressure ulcer bundle. Secondary to the increased incidence of medical device–related pressure ulcers, the following interventions were added: (1) a head-to-toe skin assessment every 12 hours; (2) removal of each respiratory device every 4 hours to monitor for pressure injury or skin breakdown; and (3) skin inspection around each medical device including all lines, tubes, and drains every 12 hours.
Method of Evaluation and Analysis
Random monthly nursing audits tracked pressure ulcer bundle compliance. Each component of the bundle is tracked for appropriate documentation in the electronic medical record.
Between 2010 and 2014, pressure ulcers > stage II in the CTICU decreased from 15.7 events per 1,000 patient days to a new baseline of 2.9 events per 1,000 patient days. We sustained this new rate for 3 years (Fig. 2). The severity of pressure injury events also reduced over time with only one stage III pressure ulcer in 3 years (Fig. 3). Pressure ulcers related to immobility decreased. Pressure ulcers related to medical devices also decreased but not as markedly (Fig. 4).
Figure 5 depicts the overall compliance with the pressure ulcer bundle elements. Compliance with the following individual components of the pressure ulcer bundle are consistently greater than 90% and near 100% for 2017: wound ostomy nurse consult, skin inspection, pressure reduction surface usage, heel pressure relief, head-to-toe assessment, and barrier cream use. Notably, removal of respiratory devices every 4 hours for pressure-related skin breakdown assessment is the least compliant bundle element followed by scheduled turning and pulse oximeter rotation. These 3 components of the pressure ulcer bundle consistently have suboptimal compliance with only minimal improvement over the years as shown in Figure 6.
Using quality methodology we were successful in reducing pressure ulcers > stage II causing patient harm and have sustained the reduction for 3 years. “Zero Hero” is our previously published institutional goal of striving for zero preventable harm events.22 The philosophy is the belief that system failures require corrective action plans including an “owner,” timeline, and a monitoring plan. The hospital leadership valuing quality improvement, transparency, and individual unit accountability was the foundation for this hospital-wide quality initiative. Hospital-wide multidisciplinary quality process education was mandatory for all staff. Hospital-wide behavioral expectations included making a personal commitment to safety, accountability for clear, complete communication, and supporting a questioning attitude.22
The CTICU pressure ulcer bundle complies with the Children’s Hospital’s Solutions for Patient Safety pressure ulcer prevention bundle recommendations.23 In addition to the Solutions for Patient Safety bundle elements, the CTICU has unit specific interventions. An early unit specific intervention was the creation of a multidisciplinary CTICU quality committee with unit champions that enabled all CTICU staff members to become accountable and active participants in the quality improvement process. A work group from this committee is responsible for the evaluation and reduction of pressure ulcers resulting in patient harm in the CTICU. Institutional quality improvement measures posted on the intranet are markers of internal and external transparency. Unit-based quality improvement measures appear on bulletin boards in prominent public places in every unit.
Perpetual education cycles, continual real-time feedback during weekly skin rounds, transparency with quality process measures, and accountability are imperative for sustainable success. The nonpunitive huddle process and the bulletin board with actual photographs of pressure ulcers in our patients as a visual tool are effective in raising staff awareness and engagement. Review of pressure ulcers resulting in patient harm in the first several months following the first set of interventions resulted in robust discussions of the situation surrounding the pressure ulcer, possible confounding factors, and additional potential interventions.
Pressure ulcer bundle compliance for the individual components that were already a part of routine charting (ie, no additional charting was required) was better compared with those elements that require additional charting. The bundle elements part of routine charting included: skin inspection, pressure reduction surface, head-to-toe assessment, and barrier cream use. Heel pressure relief was utilized only in muscle-relaxed patients who comprised only a very small number of patients. The bundle elements that require additional charting include turning schedule, respiratory devices, and pulse oximeter probe rotation. Secondary to the reduction of pressure ulcers in the CTICU, we speculate that compliance with these bundle elements occur more frequently than the audits would suggest. We believe that failure to appropriately chart these elements contributed more to the poor compliance issue rather than bundle element execution.
These interventions were successful in reducing pressure ulcers secondary to immobilization; however, pressure ulcers secondary to medical devices remain challenging. To address this ongoing problem, we recently adopted the practice of utilizing a thin layer of Mepelex (Mölnlycke Health Care, Norcross, Ga.) as a barrier between the respiratory device (CPAP or BiPAP mask) and the patient’s skin as well as removing the mask for detailed skin assessment every 4 hours. At this time if there is evidence of pressure injury, the clinical team discusses the utilization of a different mask type.
This work was done using quality improvement methodology, and therefore no control group. Multiple interventions were undertaken simultaneously with no attempt made to ascertain which intervention was most or least effective. This quality initiative performed in a single unit utilizing specific interventions designed to address specific areas of weakness. Therefore, this may not be fully generalizable to other units. However, the quality improvement methodology utilized is valuable to all.
Education and process improvement strategies directed specifically at reducing pressure ulcers and staff engagement were successful in reducing pressure ulcers causing patient harm. We sustained the reduction in pressure ulcers for 3 years. Further steps include continued vigilance with reporting of pressure ulcer events, interventions aimed at the reduction of pressure ulcers caused by medical devices and huddles to strive for “Zero” patient harm events.
We acknowledge Dr. Richard McClead for his guidance and support of this quality project, and for critically reviewing the manuscript.
The authors have no financial interest to declare in relation to the content of this article.
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