EBP Project – Finding the Evidence

Under pressure: prevent ing pressure ulcers in crit ically ill infants Christine A. Schindler, Theresa A. Mikhailov, Susan E. Cashin, Shelly Malin, Melissa Christensen, and Jill M. Winters

Christine A. Schindler, PhD, RN, CPNP-AC, isAcute Care Pediatric Nurse Practitioner; TheresaA. Mikhailov, MD, PhD, isAssociate Professor, Division of Critical Care, Medical College of Wisconsin, Milwaukee; Susan E. Cashin PhD, isAssociate Professor, University of Wisconsin-Milwaukee, Milwaukee, Wisconsin; Shelly Malin, PhD, RN, NEA-BC, isProfessor, Mennonite College of Nursing at IllinoisState University, Normal, Illinois; MelissaChristensen, BS, CCRC, isClinical Research Coordinator, Medical College of Wisconsin, Milwaukee; and Jill M. Winters, PhD, RN, isDean and Professor, ColumbiaCollege of Nursing, Glendale, Wisconsin, USA

Search terms Pediatric, pressure ulcer, prevention.

Author contact cschindl@mcw.edu, with acopy to the Editor: roxie.foster@ucdenver.edu

Acknowledgement No external or intramural funding wasreceived. We appreciate the fabuloushard workof Children’sHospital of WI PUPteam in improving skin care in the PICU; also to ThomasB. Rice for hissupport to thisproject.

Conflict of Interest: The authors report no actual or potential conflictsof interest.

First Received January 3, 2013; Final Revision received June10, 2013; Accepted for publication June11, 2013.

doi: 10.1111/jspn.12043

Abstract Pu rp ose . To determine whether a pressure u lcer prevention bundle was associated with a sign ificant reduction in pressure u lcer development in infan ts in the pediatric in tensive care unit. Design an d Met h od s. Quasi-experimental design involving 399 infan ts 0 to 3 months of age at a large tertiary care medical cen ter. Resu lt s. The implementation of the care bundle was associated with a sign ificant drop in pressure u lcer incidence from 18.8 to 6.8% . Pract ice Im p lica t ion s. Pressure u lcers can be prevented in the most vulnerable patien ts with the consisten t implementation of evidence- based in terventions and system supports to assist nurses with the change in practice.

Pressure u lcer development is a sign ificant hospital- acquired in jury that has far-reaching consequences for infan ts who develop pressure u lcers as a resu lt of hospitalization . Pressure u lcers are localized areas of tissue destruction that develop when soft tissue is compressed between a bony prominence and an external surface for a prolonged period of time (National Pressure Ulcer Advisory Panel, 2007). When there is local tissue destruction and necrosis, in fan ts experience ulcer-related pain and are at profound risk for developing systemic infection , as well as secondary scarring or alopecia at the site of the ulcer (Curley, Quigley, & Lin , 2003; Gershan & Esterly, 1993; McCord, McElvain , Sachdeva, Schwartz, & Jefferson , 2004). The estimated cost of managing a single fu ll-th ickness pressure u lcer in the adult population is as h igh as $70,000, and the total cost for treatment of pressure u lcers in the United States is estimated at $11 billion per year

(Reddy, Gill, & Rochon, 2006). The adverse health outcomes and high financial costs associated with th is condition have led the Institu te for Healthcare Improvement and the Join t Commission to identify pressure u lcer prevention as a priority area for patien t safety (McCannon, Hackbarth , & Griffin , 2007; The Join t Commission , 2007). The incidence of pediatric pressure u lcer develop-

ment in the critical care population has been reported to be as h igh as 10.2–27% (Curley et al., 2003; McCord et al., 2004; Reddy et al., 2006; Schindler et al., 2011). Attempts have been made to adapt information learned from adult studies to fit characteristics of the neonatal and pediatric popula- tions in an effort to decrease pressure u lcer develop- ment in these populations (Razmus, Lewis, & Wilson , 2008). Infan ts are a vulnerable population , especially those less than 2 years of age who tend to be at h igher risk of developing pressure u lcers


Journal for Specialists in Pediatric Nursing

329Journal for Specialists in Pediatric Nursing 18 (2013)329–341 © 2013, Wiley Periodicals, Inc.

(McCord et al., 2004; Schindler et al., 2007, 2011). Neonates (ages 0 to 3 months) are especially vulner- able (Gershan & Esterly, 1993; McLane, Krouskop, McCord, & Fraley, 2002; Willock & Maylor, 2004). Infan ts face special challenges in the critical care environment because the epidermal layer in infan ts is th inner and functionally immature compared with toddlers and older ch ildren , placing them at h igh risk for excess water loss and higher permeabil- ity to chemicals (Curley &Maloney-Harmon, 2001; Lund, 1999; Lund et al., 2001). This is problematic because one of the skin’s primary functions is to provide a barrier to the outside environment. Given the increased permeability of the skin , in fan ts are more vulnerable to the harsh chemicals used in the hospital; understanding these developmental differ- ences is key to providing optimal skin care for hospi- talized infan ts. The aim of th is study was to evaluate the effect of

implementing a pressure u lcer prevention bundle on the incidence of pressure u lcer development in a high-risk subset of patien ts (infan ts 0 to 3 months of age) in the Pediatric In tensive Care Unit (PICU) at a large tertiary care children’s medical cen ter. Investigators previously conducted a multisite study exploring nursing in terventions associated with lower pressure u lcer incidence in the PICU popula- tion (Schindler et al., 2011). Results from this study were used to design the Pressure Ulcer Prevention Program (PUPP) which was implemented in th is PICU. The components of the PUPP included: (a) assuring patien ts were main tained on the correct support surface in order to decrease tissue in terface pressure, (b) frequent turn ing, (c) incontinence management, (d) appropriate nutrition , and (e) education . The hypothesis was that a sign ificant reduction in pressure u lcer incidence would be evident in the group receiving the PUPP bundle when compared with the standard care group.



In an earlier study, investigators from this hospital conducted a large multisite study exploring nursing in terventions associated with lower pressure u lcer incidence in the PICU population (Schindler et al., 2011). The overall incidence of pressure u lcer devel- opment in infan ts 0–3 months of age was 18.8% . In an effort to reduce th is h igh incidence, th is prospec- tive, quasi-experimental study was conducted to determine the effect of the PUPP bundle on pressure

u lcer development. There were 149 infan ts ages 0–3 months in the control group (Table 2). These infan ts were cared for in the PICU between April 24, 2006, and December 31, 2006. Infan ts from 0–3 months of age admitted to the PICU between August 1, 2009, and December 31, 2009, were enrolled in the experi- mental arm of th is study. No infan ts were excluded from enrolling in th is study because the in ten tion was to gain an understanding of the efficacy of the PUPP bundle in reducing pressure u lcer incidence regardless of diagnosis, gender, risk of mortality, or length of PICU stay.


The PICU at a large tertiary care center was selected as the site for data collection . The hospital was a 294- bed free-standing children’s hospital with a 72-bed PICU. In 2009, the hospital had 2,751 admissions to the PICU, and 372 of those admissions were infan ts between the ages of 0 and 3 months. A power analy- sis to determine adequate sample size for t-tests, which guided enrollment, was completed prior to the start of the study. Although all in fan ts admitted to the PICU received the in tervention , data were only collected on the first 250 infan ts during the study time frame. Protection of human subjects was approved by the institu tional review board of the participating hospital, and a waiver of paren tal consent was obtained. The infan ts in the control group were part of a pre-

vious study conducted to determine the incidence of pressure u lcer development in the PICU. During th is study, the nurses received education about the Braden Q risk assessment scale and pressure u lcer staging, but they did not receive any education about skin care or pressure u lcer prevention in hos- pitalized children . The Braden Q scale is a modifica- tion of the adult Braden Scale used to quantify risk of pressure u lcer development that was developed and tested in the pediatric population (Quigley &Curley, 1996). There are seven discrete categories, and each category includes a risk factor and concept descrip- tor. The minimum score for each item is “1” (more risk), and the maximum score is “4” (less risk), with poten tial scores ranging from 7–28. The subcatego- ries include mobility, activity, sensory perception , moisture, friction and shear, nu trition , and tissue oxygenation and perfusion (Quigley & Curley, 1996). The infan ts in the control group received standard skin care. Standard care included the use of standard infan t warmer mattresses that were not pressure relief/pressure redistribu tion mattresses.

Under Pressure: Preventing Pressure Ulcers in Critically Ill Infants C. A. Schindler et al.

330 Journal for Specialists in Pediatric Nursing 18 (2013)329–341 © 2013, Wiley Periodicals, Inc.

There was no set standard for bath ing, use of barrier creams, or moisturizing of infan ts. Nurses used their own nursing judgment to address these components of care. The standard nutrition consult occurred if the infan t was on total paren teral nu trition , receiv- ing tube feeds, or on the fourth day of their PICU admission . Infan ts were turned or were repositioned every 4 hr. There were no skin care champions or unit-based skin resources at the time of the data col- lection for the control group. The Institu te for Healthcare Improvement (IHI)

defined a bundle as a grouping of several scien tifi- cally grounded elements, essen tial for improving clin ical outcomes. Ideally, the bundle should be a set of three to five evidence-based practices, or precau- tionary steps, that when used together, may resu lt in sign ificant improvement (Institu te for Healthcare Improvement, 2011). The in tervention in the study was a skin care bundle that included five compo- nents: (a) ensuring patien ts were on the correct support surface to decrease tissue in terface pressure, (b) frequent turn ing, (c) incontinence management, (d) appropriate nutrition , and (e) education . In order to relieve pressure, particu larly over bony prominences, it was essen tial to place infan ts on a pressure relieving surface. Infan ts in th is study were placed on a Delta-202 Warmer Overlay (29″¥ 23.75″ ¥ 2.25″). This particu lar overlay was found to reduce the occipital in terface pressure in infan ts less than 2 years of age (McLane et al., 2002; Turnage-Carrier, McLane, & Gregurich , 2008). Another strategy to limit pressure over bony prominences was frequent turn ing. Reposition ing was used to reduce or elimi- nate pressure in order to main tain circu lation to areas of the body at risk for pressure u lcer develop- ment (Lund et al., 2001). Gel-filled pillows were used by nurses to assist with position ing and padding bony prominences (McLane et al., 2002; Reddy et al., 2006). The th ird component of the in terven- tion was to improve moisture and incontinence management. Wet skin has been associated with development of rashes, is softer, and tends to break down more easily. In addition , fecal incontinence is a risk factor for pressure u lcer development, as stool contains bacteria and enzymes that are caustic to the skin (Wound Ostomy and Continence Nurses Society, 2003). In order to ameliorate the risk of incontinence contribu ting to pressure u lcer devel- opment, zinc-based barrier cream was used with each diaper change. Although the goal was to keep the patien t dry, it was importan t to keep the skin moisturized. Bath ing was minimized, and when the infan ts were bathed, mild, non-alkaline cleansing

agents were gently used to minimize dryness of the skin . Finally, any child who scored a “1” (defined as very poor nutrition , which includes noth ing by mouth status or main tained on clear liqu ids for more than 5 days or serum albumin < 2.5 mg/L), or “2” (defined as inadequate nutrition with liqu id diet or total paren teral nu trition , which provides inad- equate calories and minerals or serum albumin < 30 mg/L) in the nutrition subcategory of the Braden Q received nutrition consultation by a registered dietician . The registered dietician would complete a nutritional assessment as well as make recommen- dations for improving the infan t’s nutritional in take and would share the recommendations with the in terdisciplinary team. Once the consultation was made, the registered dietician continued to follow the child until nu trition goals were met. In the in tervention group, nursing staff partici-

pated in an online educational module about the Braden Q pressure u lcer risk assessment, pressure u lcer identification and grading, as well as education on the components of the PUPP in tervention . The education module was an in teractive online tu torial developed by the investigators and placed on an online educational platform. The online education took approximately 60 min , and nurses were com- pensated by the hospital for their time. The online platform automatically generated a report of those nurses who completed the education that was for- warded to the unit supervisors. The supervisors would follow up with any nurses who had not com- pleted the education to assure that it was completed. New nurses received in-person education as a part of their orien tation . Pediatric risk assessments were completed every 24 hr, as assessing risk provides caregivers the opportun ity to re-evaluate the child’s risk; the child’s condition can change rapidly in the in tensive care setting (Ayello &Braden , 2001). A pressure u lcer prevention order set was placed

in the computerized provider order en try system to facilitate compliance with the bundle. Additionally, skin care champions, who were registered nurses in the PICU, were identified in order to facilitate com- pliance with the bundle and provide additional supports on the unit. Two day-sh ift nurses and two night-sh ift nurses were recru ited from each of the three ICUs to serve as skin care champions. Skin care champions received additional education regarding the PUPP bundle, participated in month ly skin champions’ meetings, and main tained e-mail contact with the principal investigator throughout the duration of the study. During the month ly meet- ings, the skin care champions received education on

C. A. Schindler et al. Under Pressure: Preventing Pressure Ulcers in Critically Ill Infants

331Journal for Specialists in Pediatric Nursing 18 (2013)329–341 © 2013, Wiley Periodicals, Inc.

the science related to the prevention strategies and on the available skin care products, reviewed any pressure u lcers identified in the previous month , and planned what would be the focus of staff educa- tion for the month . Each skin care champion was assigned six bed spaces for which they were respon- sible for conducting weekly skin rounds. Rounding on the patien ts included reviewing the Braden Q score for the patien t and if the score was � 21, the skin care champion would do a fu ll skin assessment with the bedside nurse caring for the child. As part of the assessment, the skin care champion reviewed the preventive measures to assure they were imple- mented. If during the assessment, a pressure u lcer was identified, the skin care champion implemented an appropriate treatment plan and discussed the plan with the bedside nurse and, if necessary, the medical team. The skin care champions received reimbursement for the time they spent at the month ly meeting (2 hr/month) as well as for the time they spent conducting skin care rounds (2 hr/ week). While they worked in the unit on their regularly scheduled sh ifts they served as skin care resources for the unit. Another importan t study partnersh ip was collabo-

ration between the principal investigator and the unit-based Advanced Practice Nurses (APNs). APNs were given a weekly list of patien ts who developed pressure u lcers, and then they conducted a root cause analysis (Figure 1) on all Stage 3 and Stage 4 pressure u lcers to determine if there were any iden- tifiable factors that could have contribu ted to the development of pressure u lcers, including but not limited to breaks in the PUPP bundle. There was one APN for every 24 ICU beds. Each root cause analysis took approximately 30 min to complete through a combination of chart review, discussion with the primary nurses, and patien t assessment. The root cause analyses revealed several common character- istics of the patien ts who developed pressure u lcers. These characteristics included use of h igh-dose ino- tropes, the use of cooling mattresses, and in tubated infan ts who were believed to be under-sedated, which made the nurses reluctan t to move them. The resu lts of the root cause analyses were shared at the month ly skin care champions’ meeting so that the skin care champions would be more aware of infan ts who had one of the identified risk factors.

Data collection

The investigators u tilized two methods of data collection for the study. The VPS© (Virtual PICU

Systems) is a clin ical database dedicated to standard- ized data sharing and benchmarking among PICUs. Data abstracted from the VPS for th is study included age, race, length of stay, primary and secondary diagnoses, use of extracorporeal membrane oxygen- ation (ECMO), use of non-invasive positive pressure ventilation (NIPPV), use of conventional ventila- tion , oscillatory ventilation , previous cardiac or res- piratory arrest, and Pediatric Index of Mortality 2 (PIM2) score. The PIM 2 is a risk of mortality tool that uses 10 physiologic indicators and diagnoses collected at admission to calcu late risk of death of groups of patien ts admitted to the PICU (Slater, Shann , & Pearson , 2003). The principal investigator also developed an instrument to collect additional study data from participants, including use of vaso- active infusions, Braden Q subcategory scores, loca- tion , and grade of pressure u lcer, application of lotion , use of a specialty mattress, frequency of turn ing, and documentation of the skin care in itia- tive. To compile the complete data set, study data were entered in to an Access database and linked with the VPS database by VPS ID number.

Data analysis

Descriptive statistics were used to analyze demo- graphic data and describe the sample. Data were analyzed using PASW Statistics for Windows 18.0 (SPSS Inc., 2010). To meet the necessary assump- tions for subsequent testing, range, mean , variance, and standard deviation were determined for all data sets. An independent t-test was used to compare differences in participants between groups.

Main outcome measures

There were 149 patien ts enrolled in the control arm of the study, and 250 patien ts enrolled in the experi- mental arm (see Table 1). Demographic characteris- tics were compared using t-tests, whereby study (experimental) means were compared to population (control) means. The PIM 2 risk of mortality scores were not sign ificantly differen t between the control group1 and experimental group2 (M1 = 7.2% vs. M2 = 6% , t(249) = – 1.64, p = .10). Although the overall risk of mortality was not sign ificantly differ- en t between the groups, there were some significant differences in the types of mechanical support provided for the infan ts. The control group1 had a higher percentage of patien ts requiring mecha- n ical ventilation than the experimental group2 (M1 = 54.4% vs. M2 = 44.4% , t(249) = – 1713.60,

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