Sustaining excellence in prevention of pressure ulcers in a pediatric population

Purpose:
Effective 10/1/08 CMS announced they would no longer pay for hospital-acquired pressure ulcers. This resulted in clinicians at Riley Hospital for Children initiating a multi-pronged approach to reduce overall incidence of pressure ulcers and to eliminate Stage III & IV pressure ulcers.

Significance:
Prior to 2008 children were considered to be at much lower risk for pressure ulcers and they were not tracked. In 2008, we had 5 Stage III or IV pressure ulcers and an unknown total number of pressure ulcers.

Strategy and Implementation:
We implemented daily risk assessment using the Braden Q for all inpatients and daily rounding by the CNS to identify patients at risk. Monthly prevalence audits were initiated and a Wound and Skin Care Committee was established. They developed prevention interventions for each subscale of the Braden Q and established a process to initiate appropriate interventions based on the patient's risk in each subscale. Electronic notification to the CNS for a Braden Q of less than 18 was put in place. A wound and skin protocol and order sets were developed for prevention and treatment of wound and skin care issues. Education and competency assessment was completed for staging pressure ulcers and choosing the appropriate bed surface. Wound and Skin Care Committee members served as the primary champions for all interventions. Current efforts are focused on improving accuracy of assessment and documentation of wounds, Braden Q inter-rater reliability, as well as decreasing device-related injury.

Evaluation:
We have had 2 Stage III or IV pressure ulcers since 2009, both in extremely high risk patients. Our pressure ulcer prevalence rate (all types) is consistently less than 1%.

Implications for Practice:
Sustaining this practice for more than 3 years has been the result of changing the priority for protection of skin integrity as a nurse-sensitive outcome. This change in practice has required multiple interventions, support from nursing leadership, constant vigilance and measurement.