PEDIATRIC PRESSURE ULCERS

Kim Palmer RN BSN

How the PICU PU team was started A group of nurses within the PICU took on the initiative to

improve patient outcomes with PU.

We originally started out with a team of 12 nurses with various years of experience.

We held a 4 hour blitz to decided what to focus our efforts on.

We decided to split the group into an education group and an surveillance group within the PU committee.

FIRST GOALS WE SET

We decided as a team we would change the unit policy of rotating the Sat probes from Q shift (q 12 hrs) to Q 6 hrs.

The group decided to begin using the product Z-flow to help off load the heals, sacrum and occiput of our patient.

The surveillance group decided to start monthly surveillance.

To be trained they would round with a WOC hospital team member and be checked off on an assessment and then teach another member within the PICU PU team how to do an assessment.

The education group also decided to educate on padding the hubs of our devices.

Our findings of the biggest issues.

We had originally thought that majority of the PU were in our spinal patients who had long Operating room times.

We found that actually they were a small percent of them.

The highest numbers were actually the occipital of patients 2 years and under and who had decreased perfusion.

That most of our PU were device related vs. pressure.

Findings cont.

We also found that our Bipap masks caused issues on the bridge of the nose.

ET tubes causing mucosal injuries G-Tubes We reassessed the following year and

decided that we actually were not as compliant with the monthly surveillance.

It was decided to being twice monthly surveillance.

PICU PU Team•Currently 19 members including 2 CA’s

•All team members qualified to do surveillance•Focusing on device padding & education•Twice monthly surveillance with results emailed to staff

•Twice weekly skin rounds with WOC and managers

•Event analysis on all Stage III, IV and Unstageable PU’s•Serious Harm PU’s added to Event Calculator

Reporting

NDNQI –Everything except Stage I

SPS – Stage III, IV and Unstageable(Serious Harm)

20142014

PressureDevice

20%

80%

Pressure Ulcer Causes

2014

Head/NeckOther63%

27%

High Risk Area

Stage Number Percentage

I 62 46%II 38 28%

Suspected Deep Tissue

Injury17 13%

III 5 4%IV 1 <1%

Unstageable

11 8%

PICU 2014

3 masks

2 nasal ETT’s

3 IV hubs 2 G-tubes

2 NG’s

1 OG tube

17 Serious Harm PU’s (13%) (Stages III, IV & Unstageable)

•23 different devices noted for 107 PU’s

•Bipap mask caused 33 (25%)

•All other devices caused (10 or less)

Other PU Data Facts

Q1 Q2 Q3 Q40

2

4

6

8

10

12

Stage 1

Stage II

Unstageable

PICU Mask Related Pressure Ulcers 2014

What changes have we made to help reduce these.

We have a wonderful team work with our core RT’s in the PICU.

We make every attempt to alternate the Bipap mask’s q 4 hrs.

Assess the patients skin q 4 hrs. Apply Mepilex under every mask. Changed from the servo vent to the V 60

trilogy.

0.000

0.100

0.200

0.300

0.400

0.500

0.600

0.700

0.800

PU's St III+/ 1000 Pt Days

Month/Year

PU

's/1

000 P

t D

ays

0.000

0.200

0.400

0.600

0.800

1.000

1.200

1.400

PICU Pressure Ulcers Stage II or greater

Month/Year

# P

U's

(2+

) per

1000 p

ati

ent

days

As of June 11, 2015

It has been 7 days since our last CLABSI event: 1 – 5ST

It has been 171 days since our last CAUTI event

It has been 116 days since our last VAP event

Pressure Ulcers: (6/1/15 - 6/7/15) – 11-ICN: Stage- SDTI (Device/IV Hub)

Best Practice: EACH DAY discuss the need for your patient to have continued central line access

with the attending physician.Cheri

PICU Quality Event Calculator6/12/2015

CA-BSI UnEx CA-UTI VAP PU

CVL-Associated Bloodstream

Infx.Unplanned Extubations

Catheter-Associated

Urinary Tract Infections

Ventilator-Associated Pneumonia

Pressure Ulcers Serious Harm (Stage

III, IV and Unstageable

DAYS SINCE 14 DAYS

SINCE 9 DAYS SINCE 172 DAYS

SINCE 116 DAYS SINCE 48

Record 104 Record 111 Record 237 Record 352 Record 103

                  # This month 0

# This month 1

# This month 0

# This month 0

# This month 0

# This year 5

# This year 9

# This year 0

# This year 2

# This year 9

# Last Year

5# Last

Year19

# Last Year

12# Last

Year1

# Last Year

17

Last Event:5/29/2015 Last Event:6/3/2015 Last Event:12/22/2014Last

Event:2/15/2015 Last Event: 4/24/2015

Remember to move the sat probeAT LEASTQ 6 hrs

Stage 2

Stage 2

Rotate between MULTIPLE

sites when possible

Example of Mucosal Injury. It is also an example of what we

view with our monthly meetings.

EXAMPLE OF THE QUESTIONS WE ASK FOR THE RCA’S

1. Do you think there was anything that put this patient at higher risk for a

pressure ulcer?2. If we had unlimited time and

resources, is there anything that you think would have been helpful to

prevent this pressure ulcer?3. Any other information or thoughts

about this PU?

Skin Round Questions

We use these when we are on shift and also when the managers and the hospital WOC team member do rounds twice weekly.

Have you completed your skin assessment today?

1. Did you note any areas of concern or any breakdown/redness noted?

2. Are all of your sites padded?-PIV’s, NG/OG’s, CVL dressing intact?

3. Pressure points padded w/Z-Flo, etc

Skin Round questions cont.

Check surface for pt needs. Is it appropriate for the patients acuity?

1. Need dolphin bed?2. Need Accumax convertible? Do you have any questions or other

concerns about skin?

Other information that has lead to our success.

We have the full support of our administration at CMH.

Our group is always “on” with this committee.

Our culture in the PICU is changing. As well as hospital wide.

All of the floors, NICU, PICU, and OR has representation at a meeting once a month. In the meeting we go over all of the Stage 2 and greater and discuss them by viewing the pictures.