SummaryChildren's Healthcare of Atlanta developed and implemented a comprehensive skin care program to reduce pressure ulcers in its intensive care units. Major program elements include training nurses on ways to identify, prevent, and treat pressure ulcers; using a pediatric version of a common adult skin assessment scale (the Braden scale) to regularly assess and proactively identify patients at high risk of pressure ulcers; and providing early preventive therapy for at-risk patients, including turning them every 2 hours. The program led to a 59 percent reduction in pressure ulcer incidence in intensive care units.Moderate: The evidence consists of pre- and post-implementation comparisons of pressure ulcer incidence and the number of reports of hospital-acquired pressure ulcers, as well as achievement of pressure ulcer goals.
Developing OrganizationsChildren's Hospital of Atlanta
Date First Implemented2005
Vulnerable Populations > Children; Intensive care unit patients
Problem AddressedAlthough pressure ulcers are most common in adults, they can occur at any age, with newborns in intensive care units (ICUs) being at especially high risk; left untreated, pressure ulcers can cause infections that can lead to longer stays, higher costs, and even death.
- High rates of pediatric pressure ulcers, especially in ICUs: Studies of pediatric hospitals typically find prevalence rates of 3 to 7 percent among inpatients, with rates as high as 27 percent in ICUs.1 Most pressure ulcers occur within 2 days of admission.
- Serious consequences: Untreated pressure ulcers can lead to infections of muscle, blood, and bone, resulting in longer hospital stays, increased costs, permanent injury, and even death.2
Description of the Innovative ActivityThis multifaceted program focuses on early identification and preventive treatment of pediatric ICU patients at high risk of pressure ulcers. Key components include the following:
- Periodic assessment using standardized scales: On admission to the pediatric, technology-dependent, and cardiac ICUs and the comprehensive inpatient rehabilitation unit, nurses assess all patients for pressure ulcer history and risk in the admission database and then complete the Braden Q scale, a version of a commonly used tool for evaluating adult pressure ulcer risk that was adapted for pediatric use. The scale, which consists of seven areas (mobility, activity, sensory perception, moisture, friction/shear, nutrition, and tissue perfusion/oxygenation), yields a numerical value that puts patients into one of two categories: low-risk patients who do not need interventions (those with scores of 17 to 28) and high-risk patients in need of additional interventions (those with scores of 7 to 16). Following the admission screening, nurses perform a Braden Q scale every 12 hours for all patients in these four areas. For neonates in the neonatal ICU, nurses use a different assessment, the Neonatal Skin Risk Assessment Scale. This scale consists of six areas and takes into account neonates' gestational age, developmental differences, and physical needs. Patients scoring less than 13 indicate high risk for skin injury, requiring additional preventative interventions.
- Staging and wound, ostomy, and continence consults for those with pressure ulcers: If a nurse detects a preexisting (community-acquired) or hospital-acquired pressure ulcer during an assessment, the nurse consults the wound, ostomy, and continence (WOC) nurse to examine the patient, assist with proper documentation, facilitate preventive measures, and prepare a treatment plan. The WOC nurse documents the pressure ulcer using the new updated pressure ulcer staging system (stages I–IV, suspected deep tissue injury, and unstageable) and collaborates with the medical team to facilitate preventive measures and prepare a treatment plan.
- Preventive therapy protocols for those at high risk: Interventions designed to prevent pressure ulcers are proactively provided to patients whose assessment scores put them in the at-risk category, including the following:
- Turn the patient every 2 hours, with a shift of at least 15 degrees. Temporarily decrease the head of the bed while repositioning the patient.
- For patients in the comprehensive inpatient rehabilitation unit, the length of time between turns is increased by 30 minutes every week (i.e., every 2.5 hours for a week, then every 3 hours for the next week, and so forth) up to a maximum of every 4 hours.
- Neonates are turned slightly less often than the every 2-hour protocol.
- For wheelchair-bound patients, the chair is tilted or the patient shifts his/her weight every 20 to 30 minutes.
- Float the patient's heels off the mattress with pillows.
- Use a draw sheet to reposition the patient and avoid dragging him or her across the bed.
- Remove urine and stool every 2 hours.
- Prop all tubing off the patient.
- Evaluate pulse oximeter probe sites every 12 hours and alternate these sites every 24 hours.
- Cushion bony prominences with pillows or gel cushions. Avoid use of donut-shaped cushions on the patient's head or under bony prominences.
- Use moisturizers during morning care. (Neonates receive less moisturizer.)
- Evaluate the need for pressure reduction mattresses and obtain a physician's order for them when indicated.
- Minimize use of adhesives.
- Pressure ulcer prevention policy: Information provided in May 2011 indicates that a pressure ulcer prevention policy and procedure outlines and defines risk assessment and bundling interventions. A bed and mattress decision algorithm outlines proper use of the differentiating support surfaces. Other support surfaces assessed include bassinets, warmers, cribs, beds, and stretchers.
- Pressure ulcer prevention champions: Information provided in May 2011 indicates that the hospital has developed a program to designate pressure ulcer prevention champions, designed to empower selected clinical caregivers with the knowledge and skills for pressure ulcer prevention, skin risk assessment, and treatment modalities. Champions then serve as a resource to other staff members.
- Electronic reminders and support: Information provided in May 2011 indicates that, to delineate pressure ulcer prevalence upon admission, the admission database contains a section on skin where nurses document past history and/or current presence of pressure ulceration. Patients with a risk for or actual ulcer(s) are flagged for a WOC nurse consult. Nurses are prompted to perform the Braden Q scale or Neonatal Skin Risk Assessment Scale by the electronic medical record (EMR) system. When the nurse enters the score the EMR automatically adds each subscale, scores the patient, and indicates risk treatment recommendations so nurses may begin the appropriate prevention bundle. The EMR also facilitates charting on interventions such as turning a patient. Children's Healthcare of Atlanta now mandates that all hospital-acquired pressure ulcers be entered into the occurrence notification system, which facilitates distinguishing patients who have pressure ulcers at admission from those who acquire a pressure ulcer during the hospital stay. Self-reported data is entered and tabulated into an incidence database.
- Staff and family education: Information provided in May 2011 indicates that orientation for established and new nurses includes information on pressure ulcer assessment, prevention, and treatment in the form of a computer-based training module. A day-long advanced class provides education for pressure ulcer prevention champions. Parents of patients with risk for and/or actual ulceration receive teaching sheets and booklets with instructions on pressure ulcer prevention and skin care treatment. Active family involvement is encouraged during hands-on position changes and weight shifting. In collaboration with utilization management staff, outpatient referrals are made for home supplies (i.e., pressure redistribution mattress) and to facilitate continuation of further preventative and treatment needs.
- Pressure ulcer scorecard: Information provided in May 2011 indicates that a pressure ulcer scorecard is used to track and trend the most important measures related to pressure ulcer prevention. This scorecard is presented monthly at the pressure ulcer guiding team meeting and two of the measures roll up to the hospital's quality system scorecard. Pressure ulcer metrics and 2011 goals include the following:
- Reduce pressure ulcer never events by 20 percent
- Reduce pressure ulcer incidence by 15 percent
- Reduce serious pressure ulcer events by 25 percent
- Improve Braden Q compliance to 90 percent
- Improve wound consult compliance for serious pressure ulcers to 100 percent
Context of the InnovationChildren's Healthcare of Atlanta consists of three hospitals (Egleston, Hughes Spalding, and Scottish Rite) with a total of approximately 500 beds. The three hospitals have seven ICUs: two pediatric, two neonatal, two technology-dependent, and one cardiac. The program was prompted by an observed increase in pressure ulcers in the pediatric ICU at Scottish Rite Hospital in 2004, which led Children's Healthcare of Atlanta staff to launch a quality improvement project aimed at reducing pressure ulcers in all of its ICUs.
ResultsPre- and post-implementation comparisons show that this program significantly reduced the incidence of pressure ulcers and enhanced reporting of those hospital-acquired pressure ulcers that do occur; information provided in May 2011 indicates that the hospital is on target to meet pressure ulcer goals. Results are as follows:
Moderate: The evidence consists of pre- and post-implementation comparisons of pressure ulcer incidence and the number of reports of hospital-acquired pressure ulcers, as well as achievement of pressure ulcer goals.
- Fewer pressure ulcers: Pressure ulcer incidence in ICUs decreased by 59 percent from October 2005 to September 2006 (from about 7.4 to 3 percent). The reduction exceeded a preprogram goal of reducing pressure ulcers by 25 percent.
- Improved reporting: The number of nurse-reported, hospital-acquired pressure ulcers increased by 650 percent from 2004 to 2005.
- Achievement of pressure ulcer goals: Information provided in May 2011 indicates that as of the end of first quarter 2011, the hospital is on target to meet all but two pressure ulcer goals (serious pressure ulcer events and wound consult compliance). The hospital continues to evaluate serious pressure ulcer events to determine trends and address those issues at a pressure ulcer oversight meeting. Wound consult compliance is currently at 94 percent due to a serious event not having a wound consult in January 2011.
Planning and Development ProcessPlanning and development steps included the following:
- Team formation: In 2004, Children's Healthcare of Atlanta formed a quality improvement team to develop a plan to reduce pressure ulcers. The team, which met every 3 weeks, included the WOC nurse (who served as project leader), nurses from all ICUs, a patient safety coordinator, a performance improvement consultant, and an ICU physician.
- Identification of high-risk groups: Using historical occurrence reports, the team identified patients at high risk for pressure ulcers, including all bed- or chairbound patients; those whose ability to be repositioned is impaired (e.g., due to cerebral palsy or brain injury); premature infants; the critically ill; and those with neurologic impairment (e.g., due to myelomeningocele or spinal cord injury), nutritional deficits, or poor tissue perfusion or oxygenation.
- Staff education and training: The team conducted educational training for all ICU staff explaining why pressure ulcers are significant; what causes them; and how they can be identified, prevented, and treated, including use of the Braden Q scale (new ICU employees attend ongoing training sessions that are held periodically). To reinforce the information, staff were required to read articles on pressure ulcers and pass a quiz. A series of educational posters were also developed and placed around the units, and the subject of pressure ulcers was reviewed at regular staff meetings and via e-mail. The Braden Q scale was laminated and placed at patient bedsides. Information provided in May 2011 indicates that since September 2010, education has been provided for 98 unit-based pressure ulcer prevention champions for advanced training in pressure ulcer prevention.
- Standardization of supplies: Before the program's implementation, ICU nurses sometimes found that preferred supplies were not always on hand. To resolve this problem, Children's Healthcare of Atlanta standardized the skin care products it used, including wound dressings and topical wound care products (e.g., gels, antimicrobial ointments, and moisture barriers).
- Development of mattress and bed selection guidelines: The team created mattress and bed selection guidelines for patients with risk for and/or actual pressure ulcers, with selection guides and instructions on who to call to obtain the beds is placed at the bedside.
- Program rollout and adjustments: In August 2005, Children's Healthcare of Atlanta implemented the program on a pilot basis in one pediatric ICU. During the 1-month pilot, patients scoring 7 to 14 on the Braden Q were considered high risk. When the program was rolled out in September 2005 in all pediatric, neonatal, and technology-dependent ICUs, the team enlarged the high-risk group to include patients scoring 15 or 16 (to broaden the program's reach in preventing pressure ulcers). Additional changes were made once the program was underway, such as substituting the Neonatal Skin Risk Assessment Scale for the Braden Q in the neonatal ICUs (May 2006) and incorporating the cardiac ICU into the program (June 2006).
- Enhancement of pressure ulcer prevention team: Information provided in May 2011 indicates that the quality improvement team formed at program inception was restructured to create a pressure ulcer prevention guiding team comprising 4 subteams: equipment, risk assessment and intervention, discharge, and documentation.
- Creation of pressure ulcer prevention champion role: Information provided in May 2011 indicates that the hospital created a new pressure ulcer prevention champion role in order to create an ongoing resource for frontline caregivers.
- Development of pressure ulcer prevention plan: Information provided in May 2011 indicates that the initial focus for pressure ulcer prevention started with the highest risk areas within the ICUs. As prevalence and incidence data shifted, and further areas for improvement were identified, the pressure ulcer prevention team reconvened and developed a staged six-phase skin integrity/pressure ulcer prevention plan that was implemented between 2009 and 2011. This plan incorporated prior neonatal and pediatric pressure ulcer prevention in the ICUs but further included implementation of the Braden Q scale in the inpatient general care areas and evaluation of all support surfaces, including those in operating rooms.
Resources Used and Skills NeededResources required include the following:
- Staffing: Children's Healthcare of Atlanta hired an additional full-time WOC nurse and a half-time WOC nurse, for a total of 2.9 full-time equivalent positions to cover the system. ICU staff participate in the pressure ulcer program as part of their regular jobs.
- Costs: In addition to salaries and benefits for the WOC nurses, the program required increased spending on pressure ulcer supplies, such as wound dressings, wound care products, pillows, and mattresses. (Before the program, Children's Healthcare of Atlanta tended to rent pressure reduction mattresses for patients with pressure ulcers; a subsequent cost–benefit analysis showed it was more efficient to purchase the mattresses.) Information provided in May 2011 indicates that all youth bed mattresses were changed to pressure redistribution surfaces through the 2010 budget; an additional cost was associated with education for clinical staff who attended the pressure ulcer prevention champion class (8 hours of professional development).
Funding SourcesChildren's Hospital of Atlanta
Tools and Other ResourcesA PDF file of slides used during a September 2007 Webcast on the pressure ulcer program is available at: http://www.childrenshospitals.net/AM/Template.cfm?Section=Search§ion=Conference_Calls1&template=/CM
Information about Children's Healthcare of Atlanta at Egleston is available at: http://www.choa.org/About-Childrens/Locations-and-Directions/Childrens-Egleston
Information about the Braden Scale and the Braden Q Scale is available at:
- Bergstrom N, Braden BJ, Laguzza A, et al. The Braden Scale for predicting pressure sore risk. Nurs Res. 1987;36(4):205-10. [PubMed]
- Curley MA, Razmus IS, Roberts KE, et al. Predicting pressure ulcer risk in pediatric patients—the Braden Q scale. Nurs Res. 2003;52(1):22-3. [PubMed]
Information about the Neonatal Skin Risk Assessment Scale is available at: Huffines B, Logsdon MC. The Neonatal Skin Risk Assessment Scale for predicting skin breakdown in neonates. Issues Compr Pediatr Nurs. 1997;20(2):103-14. [PubMed]
Guidelines for pressure ulcer prevention and management are available at: Wound Ostomy and Continence Nurses Society (WOCN). Guideline for Prevention and Management of Pressure Ulcers. Glenview, IL; 2003.
Getting Started with This Innovation
- Enlist participation of key players: A WOC nurse is an effective choice to lead a pediatric pressure ulcer initiative, and the rest of the team should include staff with a broad spectrum of experience.
- Emphasize immediate skin care: Information provided in May 2011 indicates that most pressure ulcers occur within 12 to 24 hours of admission into a high risk setting, so skin care needs to be a priority from the moment a patient is deemed to be at risk. Prevalence should be assessed at the time of admission. Risk assessment should be performed utilizing neonatal and pediatric risk assessment tools, with implementation of bundled evidence-based prevention interventions.
- Make learning interesting: Being creative when designing pressure ulcer education for staff generates interest in the program. For example, Children's Healthcare of Atlanta posters that reinforce program elements use eye-catching artwork and headlines (e.g., "Night, Night Sleepyhead" for a poster on mattress selection). Information provided in May 2011 indicates that the pressure ulcer prevention champion logo, an inquisitive cartoon puppy (to reflect the acronym "PUP"), is utilized on education and ID badge stickers to easily identify unit-based champions.
Sustaining This Innovation
- Reinforce success: Sharing monthly pressure ulcer incidence data in staff meetings is a good way to show nurses that the program is working, thus encouraging ongoing support and compliance. Information provided in May 2011 indicates that as a system initiative, pressure ulcer prevention is part of the quality and safety monthly and quarterly scorecards; successes are noted in system-based correspondence, such as the hospital's newsletter and online through the internal intranet.
- Remain flexible: Children's Healthcare of Atlanta's willingness to modify the program after implementation led to improved patient care, ultimately leading to further improvements in patient care and safety.
Contact the InnovatorMaggie Killgore, RN, MSN
Clinical Process Improvement Specialist
Children’s Healthcare of Atlanta
1677 Tullie Circle NE
Atlanta, GA 30329
Phone: (404) 785-1728
Innovator DisclosuresMs. Killgore has not indicated whether she has financial interests or business/professional affiliations relevant to the work described in this profile.
References/Related ArticlesBaldwin KM. Incidence and prevalence of pressure ulcers in children. Adv Skin Wound Care. 2002;15(3):121-4. [PubMed]
Cloherty JP, Eichenwald, EC, Stark AR. Manual of Neonatal Care. Philadelphia, PA: Lippincott Williams & Wilkins; 2004.
Curley MA, Quigley SM, Lin M. Pressure ulcers in pediatric intensive care: incidence and associated factors. Pediatr Crit Care Med. 2003;4(3):284-384. [PubMed]
Gray M. Which pressure ulcer risk scales are valid and reliable in a pediatric population? J Wound Ostomy Continence Nurs. 2004;31(4):157-60. [PubMed]
Hess C. Wound Care Clinical Guide. Springhouse, PA: Springhouse; 2001.
McLane K, Bookout K, McCord S, et al. The 2003 national pediatric pressure ulcer and skin breakdown prevalence survey: a multisite study. J Wound Ostomy Continence Nurs. 2004;31(4):168-78. [PubMed]
McCord S, McElvain V, Sachdeva R, et al. Risk factors associated with pressure ulcers in the pediatric intensive care unit. J Wound Ostomy Continence Nurs. 2004;31(4):179-83. [PubMed]
National Pressure Ulcer Advisory Panel staging report. Available at: http://www.npuap.org
Quigley SM, Curley MA. Skin integrity in the pediatric population: preventing and managing pressure ulcers. J Soc Pediatr Nurs. 1996;1:7-18. [PubMed]
Samaniego IA. A sore spot in pediatrics: risk factors for pressure ulcers. Pediatr Nurs. 2003;29(4):278-82. [PubMed]
Dixon M, Ratliff C. Pediatric pressure ulcer prevalence—one hospital’s experience. Ostomy Wound Manage. 2005;51(6):44-50. [PubMed]
Reddy M, Gill SS, Rochon PA. Preventing pressure ulcers: a systematic review. JAMA 2006;296(8):974-84. [PubMed]
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Original publication: June 27, 2008.
Original publication indicates the date the profile was first posted to the Innovations Exchange.
Last updated: July 02, 2014.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.
Date verified by innovator: May 27, 2014.
Date verified by innovator indicates the most recent date the innovator provided feedback during the annual review process. The innovator is invited to review, update, and verify the profile annually.