Pressure Ulcer Risk and Prevention Practices in Pediatric Patients: A Secondary Analysis of Data from the National Database of Nursing Quality Indicators®

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Ostomy Wound Management 2017;63(2):26–36
Ivy Razmus, PhD, RN, CWOCN; and Sandra Bergquist-Beringer, PhD, RN, CWCN

Abstract

Little is known about pressure ulcer prevention practice among pediatric patients. To describe the frequency of pressure ulcer risk assessment in pediatric patients and pressure ulcer prevention intervention use overall and by hospital unit type, a descriptive secondary analysis was performed of data submitted to the National Database for Nursing Quality Indicators® (NDNQI®) for at least 3 of the 4 quarters in 2012.

Relevant data on pressure ulcer risk from 271 hospitals across the United States extracted from the NDNQI database included patient skin and pressure ulcer risk assessment on admission, time since the last pressure ulcer risk assessment, method used to assess pressure ulcer risk, and risk status. Extracted data on pressure ulcer prevention included skin assessment, pressure-redistribution surface use, routine repositioning, nutritional support, and moisture management. These data were organized by unit type and merged with data on hospital characteristics for the analysis. The sample included 39 984 patients ages 1 day to 18 years on 678 pediatric acute care units (general pediatrics, pediatric critical care units, neonatal intensive care units, pediatric step-down units, and pediatric rehabilitation units). Descriptive statistics were used to analyze study data. Most of the pediatric patients (33 644; 89.2%) were assessed for pressure ulcer risk within 24 hours of admission. The Braden Q Scale was frequently used to assess risk on general pediatrics units (75.4%), pediatric step-down units (85.5%), pediatric critical care units (81.3%), and pediatric rehabilitation units (56.1%). In the neonatal intensive care units, another scale or method was used more often (55% to 60%) to assess pressure ulcer risk. Of the 11 203 pediatric patients (39%) determined to be at risk for pressure ulcers, the majority (10 741, 95.8%) received some kind of pressure ulcer prevention intervention during the 24 hours preceding the NDNQI pressure ulcer survey. The frequency of prevention intervention use among those at risk ranged from 99.2% for skin assessment to 70.7% for redistribution surface use. Most pediatric patients are being assessed for pressure ulcer risk, but the implementation of interventions to prevent pressure ulcers among children needs to be improved. Future qualitative research should be conducted to determine how and when clinical judgment is used to assess pressure ulcer risk and the type of pressure-redistribution surfaces used among younger pediatric patients.

 

Critically and acutely ill children develop hospital-acquired pressure ulcers (HAPU). Pressure ulcer incidence among pediatric patients has been reported to be 0.29% to 7.3%,1-3 with 3.9% to 16% among children in neonatal intensive care units (NICUs),4,5 and 0.8% to 27% among children in pediatric critical care units (PCCUs).6,7 A recent descriptive analysis8 (N = 39 984) found a 1.1% rate of HAPU among pediatric patients ages 1 day to 18 years, but the rate varied by pediatric unit type, ranging from 0.57% in general pediatric units to 4.6% in pediatric rehabilitation units. The detrimental iatrogenic effects of pressure ulcers in children include compromised skin protection, altered thermoregulation, metabolism deficiencies, compromised immunity, and decreased sensation. A retrospective study of 5346 pediatric intensive care patients by Schindler et al6 found compromise of the epidermis or dermis from a pressure ulcer injury increases the risk for infection, other care complications, and later psychosocial effects related to tissue damage and scarring.

Clinical practice guidelines have served as the foundation for pressure ulcer prevention practice and treatment for more than 20 years; however, their application to pediatric patients is unknown because there are limited descriptive cohort, nondescriptive studies, such as comparative, correlational, case control, or case studies.9-11 Moreover, research on pressure ulcer prevention for children is scarce. Little is known about pressure ulcer risk and skin assessment practice or the frequency of pressure-redistribution surface use, repositioning, moisture management, nutritional support, and ongoing skin assessment practice among pediatric patients in the acute care setting. 

Risk assessment. According to the European Pressure Ulcer Advisory Panel (EPUAP), National Pressure Ulcer Advisory Panel (NPUAP), and the Pan Pacific Pressure Injury Alliance (PPPIA), the first step in pressure ulcer prevention is to identify persons at risk.11 Risk factors for pressure ulcers may be different for infants and children relative to adults. This has resulted in an assortment of risk assessment instruments (scales) that enable health care professionals to identify pediatric patients pressure ulcer risk by age group.12 Instruments (scales) include the Braden Q Scale, the Neonatal Skin Risk Assessment Scale (NSRAS), the Glamorgan Scale, and the Waterlow Scale.2,13-15 It is presumed the most commonly used scales to assess pressure ulcer risk among children in the United States are the Braden Q Scale and the NSRAS, but no studies confirm this. The Braden Q was developed by Quigley and Curley7 for use in pediatric patients and adapted from the adult-based Braden Scale to add a seventh subscale, Tissue Oxygenation and Perfusion, by modifying the pediatric-specific subscale descriptors and revising the friction and shear subscale to be a 4-point scale.13 The Braden Q was validated among 322 patients 1 month to 8 years of age and found to be 0.88 sensitive and 0.58 specific.7 Although the Braden Q was validated for this age group, Noonan et al16 encourage its use in all pediatric populations. The NSRAS was developed by Huffines and Logsdon14 for neonatal patients. The adult-based Braden Scale was modified to add the subscale General Condition, which is based on gestational age; neonate-specific subscale descriptors were provided, and the subscale Friction and Shear was removed. The validity and reliability of the NSRAS was tested among 32 neonates based on gestational age between 6 and 40 weeks, with higher scores indicating higher risk. 

The NPUAP10,11 recommends assessment of pressure ulcer risk on admission and periodically thereafter and should be considered with risk factors not included on assessment tools such as prematurity, birth weight, temperature and humidity, medical device use, critical illness, perfusion and oxygenation, neurological deficits, and length of hospital stay. The Institute for Healthcare Improvement17 (IHI) published a how-to guide for pressure ulcer prevention in pediatric patients that suggests the NSRAS be used in combination with individualized and subjective methods to assess pressure ulcer risk among neonates. The IHI also recommends assessment of pediatric patient pressure ulcer risk on admission to the hospital and every 48 hours thereafter or when a pediatric patient’s condition changes. Presently, it is unknown if children receive routine patient pressure ulcer risk assessment on admission or routine reassessment or the method by which this risk is assessed.

Interventions to prevent pressure ulcers. The aim of pressure ulcer prevention is to reduce or inhibit factors that may cause injury or tissue loss. Interventions to prevent pressure ulcers include support surface use, routine repositioning, moisture management, nutritional support, and ongoing skin and tissue assessment.10,11,17 Recommendations on pressure ulcer prevention in pediatric patients often have been extrapolated from what is known about adult pressure ulcer prevention. 

Pressure-redistribution surface use. The areas of the body at risk for pressure ulcers in children differ from adults, and evidence-based standards for children are lacking with regard to their different pressure points when compared to adult pressure points, rendering the adult redistribution surface nontherapeutic for children. Standard foam hospital mattresses are stiffer than the soft tissues of the infant’s and child’s body and may not adjust or conform to accidentally misplaced tubes. Using a quasi-experimental design, Turnage-Carrier et al18 examined interface pressures between the occiput of 13 healthy premature infants and 5 different bed surfaces and found standard crib mattresses had high interface pressure (>100 mm Hg), supporting the need for an alternative pressure-relief support surface. Levy et al19 used computational modeling to evaluate the deformation characteristics of flat foam and air cell-based mattresses when a tube is accidently left between an infant’s skin and the mattress. The study found the tubing was stiffer than infant soft tissues, highlighting the need for adjustable, adaptable, conformable mattresses among critically ill neonates and children. In the study by Schindler et al,6 multiple logistic regression analysis showed use of specialty beds was associated with a lower risk of pressure ulcers.

Routine repositioning. The strategy of pressure relief involves patient repositioning, and usual practice is to reposition patients every 2 hours, although this frequency rate may be increased or decreased based on patient risk or use of support surfaces.11 Schindler et al6 found patients who were positioned every 2 to 4 hours using repositioning aids were less likely to develop a pressure ulcer. Repositioning medical equipment is also important to reducing tissue pressure and preventing medical device-related pressure ulcers that can be caused by respiratory devices, oximetry probes, casts, intravenous arm boards and tubing, and equipment such as cervical collars.20 In an intervention study with the focus on pressure ulcer reduction, Pittman et al21 reported medical device-related pressure ulcers accounted for >50% of pressure ulcers in adults and children at 1 health care facility. Following the implementation of a quality improvement project to define and reduce medical device-related pressure ulcers, overall HAPU rates decreased 33% between 2011 and 2012.21

Moisture management. Moisture management to prevent pressure ulcers includes prompt cleansing of the skin using nonalkaline agents followed by application of a barrier cream.22 However, neonates are at risk for absorption of products applied to the skin because of the skin’s immaturity, condition, and sensitization.8 Few products have been tested in this vulnerable population; it is not clear whether barrier creams reduce the risk of pressure ulcer development in pediatric patients.22-25 Schindler et al6 found interventions to manage moisture, such as use of dry-weave diapers, urinary catheters, and disposable underpads, were associated with lower pressure ulcer rates among pediatric intensive care patients. 

Nutritional support. Nutrition is not well understood as it relates to prevention of pressure ulcers in pediatric patients. Adult criteria applied to the pediatric population may result in inappropriate nutrition management. Moreover, infants and children are thought to experience fluid and electrolyte imbalances more rapidly than older children and adults. In a prospective, cohort study of 102 infants with a birth weight <1250 g, Thibault et al26 found early protein and energy intake in the first week of life improves electrolyte homeostasis and phosphorus requirements, suggesting parenteral nutrition guidelines for very low birth weight infants should be revised.

The 2014 NPUAP11 guidelines recommend initiation of an age-appropriate nutritional assessment for at-risk pediatric patients and reassessment of the nutritional requirements of critically ill neonates and children at risk for pressure ulcers. Schindler et al6 reported an 80% decrease in risk for pressure ulcers when a registered dietitian was consulted during the admission process for those at risk. 

Routine skin assessment. NPUAP guidelines10,11 recommend skin and tissue assessment as part of risk assessment screening; this entails the evaluation of the patient’s entire skin (from head to toe) with emphasis on bony prominences and other areas at risk for pressure ulcer development for signs or symptoms of tissue injury.27 Frequent assessment under and around blood pressure cuffs, transcutaneous oxygen probes, continuous positive airway devices, tracheostomies, traction, or tubes is important in the prevention of pressure ulcers from medical devices in children.20 

Study Purpose and Research Questions

This study was intended to add to knowledge regarding the frequency of pressure ulcer risk assessment in hospitalized pediatric patients and pressure ulcer prevention intervention use, overall and by unit type. Questions for the study included: 

  1. What was the frequency of patient skin and pressure ulcer risk assessments among pediatric patients in US hospitals in 2012? Specifically: a) What is the frequency of patient skin and pressure ulcer risk assessment within 24 hours of admission overall and by unit type? b) What is the timing of the last (ie, the most recent) assessment previous to the patient pressure ulcer risk assessment overall and by unit type? c) What methods are used to assess patient pressure ulcer risk overall and by unit type?
  2. What is the frequency of pressure ulcer prevention intervention use among pediatric patients who are at risk for pressure ulcers by intervention and unit type in US hospitals? 

Methods

The study was a secondary analysis of existing de-identified 2012 National Database of Nursing Quality Indicators® (NDNQI) data on patient pressure risk and prevention, unit type, and hospital characteristics. Approval for the study was granted by the University of Kansas Medical Center Institutional Review Board. Conceptually, the NDNQI is based on a model developed by Donabedian28 that asserts the structure of care affects the processes of care; both, in turn, affect the outcomes of care. Participation in NDNQI data collection on pressure ulcer risk and prevention is voluntary. Submitted data are analyzed by NDNQI in order to provide participating hospitals standardized results across patient care units and hospitals for comparison purposes and use in quality improvement activities.

This study was limited to pediatric critical care units (PCCU), step-down units, medical units, surgical units, medical-surgical units, neonatal intensive care units IIIs (NICU IIIs), neonatal intensive care units IV (NICU IVs), and rehabilitation units that submitted pressure ulcer data to the NDNQI for a minimum of 3 out of 4 quarters in 2012. The NICU IIIs provide advanced care for premature, low birth weight, and critically ill infants; NICU IVs provide the highest level of care for premature and ill newborns. PCCUs provide the highest level of intensive care for pediatric patients; pediatric step-down units provide a higher level of care compared to medical, surgical, and medical-surgical pediatric units.27

Data on pressure ulcer risk and prevention. NDNQI data on pressure ulcers are collected quarterly by trained nurses during a cross-sectional survey that is performed on 1 specified day. The data on pressure ulcer risk and prevention are gathered through chart review by members of the pressure ulcer data collection team who review each patient record to determine if a skin assessment and a pressure ulcer risk assessment were documented in the patient’s chart within 24 hours of admission (yes, no, or pending). The assessment was pending if the patient had been admitted within the last 24 hours and the admission assessment had not yet been completed. The method used to assess patient pressure ulcer risk (Braden Scale, Braden Q Scale, NSRAS, or other scale/clinical factors) and score (if applicable) also were recorded. Selection of “other scale/clinical factors” indicated a scale other than the Braden, Braden Q, or NSRAS was used to assess pressure ulcer risk; otherwise, clinical factors (eg, premature age) were used to determine pressure ulcer risk. To estimate the frequency of pressure ulcer risk reassessment among pediatric patients, documentation in the patient record was reviewed to identify how long before the NDNQI pressure ulcer survey the last risk assessment was performed. Patient pressure ulcer risk status was determined from the last pressure ulcer risk assessment.27 

If the patient was at risk for pressure ulcers, members of the pressure ulcer data collection team reviewed the patient record for documentation of pressure ulcer prevention performed within the 24-hour period before the NDNQI pressure ulcer survey. Type of pressure ulcer prevention interventions also were recorded and included daily skin assessment, pressure-redistribution surface use, routine repositioning, nutritional support, and moisture management.27

Pressure-redistribution surface use was the application of any specialized support surface to redistribute pressure on skin and subcutaneous tissue or other parts of the body exposed to pressure. Routine repositioning involved determining the frequency of patient turning and repositioning relative to the plan of care or hospital unit policy. Nutritional support and moisture management entailed review of the patient’s chart for evidence of these interventions.27 Response options for the prevention interventions included yes, no, documented contraindication, unnecessary for patient, or patient refused.27 Evidence for the reliability of NDNQI data collection methods on pressure ulcer risk and prevention has been established.29 

Data analysis. Descriptive statistics were used to analyze patient and unit characteristics. Data on patient age were recoded regarding gestational age: 1 day to 30 days, 1 month to 11 months, 1 year to 2 years, 3 years to 4 years, 5 years to 8 years, and 9 years to 18 years of age. Gestational age included patients for whom gestational age only was reported; most were located in the NICU IIIs and NICU IVs. 

Units are categorized by the NDNQI according to acuity level. A unit such as a medical unit or pediatric step-down unit is characterized as such if at least 90% of the patients receive this level of care. A unit such as pediatric rehabilitation may be characterized as a specialty unit if >80% of patient care services were related to the specialty category.27 For this study, data from medical and medical-surgical pediatric units were aggregated to create a new unit type called General Pediatric Unit. No data on pressure ulcers from pediatric surgical units were available for inclusion in this study. 

Descriptive statistics were used to determine the overall frequency of pressure ulcer risk assessments and their occurrence by unit type. Methods used to assess patient pressure ulcer risk (Braden Scale, Norton Scale, Braden Q Scale, NSRAS, or another scale/other clinical factors) and their frequencies were summarized, as was the frequency of pressure ulcer prevention by unit type. All analyses were performed in SPSS, Version 21 (SPSS, Chicago, IL).

Results

The study sample included 39 984 patients ages 1 day to 18 years from 678 pediatric care units in 271 US hospitals that participate in the NDNQI. Most of the hospitals were located in metropolitan areas (263, 97%), were general hospitals by type (229, 84.5%), >100 beds in size (258, 95.2%), and had non-Magnet status (146, 53.9%). Among the 678 reporting units, most were general pediatric units (289, 42.6%), 182 (26.8%) were NICUs III, 154 (22.7%) were PCCUs, 9 (1.3%) were NICUs IV, and 6 (0.9%) were pediatric rehabilitation units. 

Frequency of skin and pressure ulcer risk assessment in pediatric patients. Most patients received a skin assessment (36 464, 96.7%) within 24 hours of hospital admission. Skin assessment on admission by unit type showed like distribution except for the pediatric rehabilitation unit where 5.7% did not receive a skin assessment on admission compared to 2.6% overall (see Table 1). Fewer patients (33 644, 89.2%) were assessed for pressure ulcer risk as compared to skin assessment within 24 hours of hospital admission; 3755 (10.0%) were not (see Table 2). Patients from the pediatric rehabilitation units (98.4%), the general pediatric care (94.6%), and pediatric step-down units (93.1%) most often received a pressure ulcer risk assessment within 24 hours of admission.

owm_0217_razmus_table1owm_0217_razmus_table2

A similar proportion of patients (35 367, 89.2%) was assessed for pressure ulcer risk within the 24-hour period before the pressure ulcer survey. Interestingly, 2483 patients (6.3%) never were assessed for pressure ulcer risk. By unit type, NICU IV patients were assessed for pressure ulcer risk more frequently (1071, 92.1%) within this 24-hour period than NICU III patients (12 192, 81%). 

Method used to assess pressure ulcer risk. The majority of patients (72.7 %) were assessed for pressure ulcer risk by means of a risk assessment scale. The Braden Q was used most frequently on pediatric step-down (85.5%), PCCU (81.3%), and general pediatric units (75.4%) (see Table 3). The NSRAS was used less frequently, even on NICUs III and NICUs IV. For 27% to 28% of all pediatric patients, pressure ulcer risk was assessed using a different scale or by clinical judgment (see Table 4). 

owm_0217_razmus_table3owm_0217_razmus_table4

Pressure ulcer risk status. Among the 37 077 study patients with available data on pressure ulcer risk, 11 203 (30.2%) were determined to be at risk for a pressure ulcer based on the last pressure ulcer risk assessment (see Table 5). By unit type, the proportion of patients at risk for pressure ulcers was highest among patients in the NICUs III (45.5%) and PCCUs (44.6%). The lowest proportion of patients at risk for pressure ulcers were located in the NICUs IV (22.5%), pediatric step-down units (18.1%), and general pediatric units (12.3%). owm_0217_razmus_table5

Pressure ulcer prevention in pediatric patients. Of the 11 203 pediatric patients at risk for pressure ulcers, 10 741 (95.8%) received some kind of pressure ulcer prevention within the 24-hour period before the survey. The type of intervention received varied among at-risk patients (see Table 6). Most patients had received a skin assessment (99.2%) within the 24-hour period before the survey. The intervention least frequently employed was pressure-redistribution surface use (70.7%). Interestingly, a pressure-redistribution surface was determined to be unnecessary for 15.4 % of the at-risk patients and not used for an additional 13.6%. The frequency of moisture management, nutritional support, and routine repositioning for pressure ulcer prevention ranged from 84.6% to 89.5%. owm_0217_razmus_table6

 Pressure ulcer prevention intervention use varied by unit type except for skin assessment, which was high across all unit types (see Table 7). A pressure-redistribution surface was in use most often in the pediatric rehabilitation units (95%) and PCCUs (85%) and least often in NICUs III (67%) and general pediatric units (61%). Patients were repositioned as prescribed more often in units where the patient might be less mobile, such as in PCCUs (86.6%) and NICUs (96.3% to 100%). Moisture was managed most often in units where patients may be incontinent, such as in the rehabilitation units (92.1%) and those in the NICUs (85.5% to 88.8%). Patients were reported to have received nutritional support more often on units where patients are less likely to feed themselves, such as the rehabilitation units (100%) and the neonatal units (93.7% to 96%). owm_0217_razmus_table7

Discussion

This is the first known study to evaluate the frequency and timing of skin and pressure ulcer assessment among pediatric patients or the method by which pressure ulcer risk is assessed in pediatric patients. This is also the first known study to evaluate current pediatric pressure ulcer prevention practices among different pediatric units. 

Skin and pressure ulcer risk assessment. Study results revealed skin and pressure ulcer assessments were performed as recommended by NPUAP guidelines,10,11 skin assessment was performed within 24 hours of pediatric patient admission an average of 96.7% of the time, and a pressure ulcer risk assessment was performed within 24 hours an average of 89.2% of the time across pediatric units. Although still high, the lower proportion of neonates (92.1%) that were assessed for pressure ulcer risk in NICUs is a little concerning, given the 1.11% rate of HAPUs in the NICUs IV previously reported.8 Pressure ulcer risk assessment in this study was lower than the 92.9% reported across adult units such as critical care, step-down, medical, surgical, and medical-surgical units.30

The NPUAP10,11 guidelines recommend patient assessment for pressure ulcer risk status using a structured approach based on the use of clinical judgment and informed by knowledge of relevant risk factors. Among the patients assessed, approximately half (49.3%) were assessed using a pressure ulcer risk assessment scale and the other half (50.1%) were assessed per another scale or clinical judgment. The Braden Q was used most frequently in this study to assess pressure ulcer risk in children. The Braden Scale was used to assess pressure ulcer risk approximately 10% of the time, mostly on units and where one would expect older children such as general pediatric units and pediatric rehabilitation units. This is different than the frequency of scale use in the adult population, where 90% of the patients were assessed for risk using the Braden Scale.30 Interestingly, only 25% of the neonatal patients were assessed for risk using the NSRAS; the majority of the neonatal patients were assessed using other scales or clinical judgment. Further research is needed to understand the role of pressure ulcer risk assessment in the neonatal population, scales used, and what factors are considered when determining pressure ulcer risk. 

Among the sample of pediatric patients, 11 203 (30.2%) were determined to be at risk for pressure ulcers based on the last risk assessment. This was much higher than the 6% of hospitalized pediatric patients (14 out of 252) reported to be at risk by Noonan et al.31 This difference in findings may be related to dissimilarities in study sample size, unit type, and number of participating hospitals, but it also may be related to the method of risk assessment. In this study, risk status was determined by Braden Scale, Braden Q, and NSRAS scale score and also considered clinical factors, whereas in the Noonan study, risk status was determined by Braden Q score. However, the proportion of pediatric patients determined to be at risk for pressure ulcers (30.2%) in this study was somewhat lower than the 39.7% of adult acute care patients (282 500 of 710 626) reported to be at risk by Bergquist-Beringer et al.30

NICUs III had the lowest proportion of patients assessed for pressure ulcer risk on admission, but they had the highest proportion of patients determined to be at risk for pressure ulcers. Interestingly, the lowest proportion of patients determined to be at risk for pressure ulcers was on the NICUs IV. This difference in pressure ulcer risk may be due to the variation in the methods by which nurses assessed patients for pressure ulcer risk in each unit. The majority of the NICU III patients were assessed for risk on admission by other scale/clinical judgment, as were NICU IV patients. It is unclear what clinical factors were used in determining risk among these patients. Moreover, 16.2% of the NICU IV patients were assessed for risk using the Braden Scale and 28.4% were assessed for risk using the Braden Q. However, the Braden Scale and Braden Q have not been validated for use in neonates. Additional information is needed on how nurses judge pressure ulcer risk in neonatal patients.

Frequency of pressure ulcer prevention. Most (95.8%) of the pediatric patients at risk for a pressure ulcer received at least 1 type of pressure ulcer prevention intervention. The frequency of pressure ulcer prevention interventions used for pediatric patients in the 24 hours before the survey was greater in the higher acuity units such as neonatal units, PCCUs, and pediatric step-down units where mobility might have been a factor. This study noted missing data for pressure ulcer prevention interventions was 15%, which is higher than the recorded 7% to 13% of missing data for pressure ulcer prevention interventions in a previous study of adult patients by Bergquist-Beringer et al.30 

For 70.7% of the pediatric patients at risk for pressure ulcers, a pressure-redistribution surface was applied. This is lower than the 81.8% of adult patients for whom a pressure-redistribution surface was in use as reported by Bergquist-Beringer et al.30 Pressure-redistribution surfaces were used more often in pediatric rehabilitation units and PCCUs relative to the other pediatric units, which may be related to the acuity level of these patients populations. The EPUAP, NPUAP, PPPIA10,11 guidelines recommend use of a pressure-redistribution surface compatible with the care setting and individual patient size and weight. It is not clear whether the pressure-redistribution surfaces used in the PCCUs or pediatric rehabilitation units were designed for pediatric or adult patients or whether pediatric redistribution surfaces were available. More quasi-experimental, cohort, nonexperimental descriptive, comparative, correlation, case control, and case series studies are needed to better understand the use of pressure-redistribution surfaces in pediatric patients, including which type of pressure-redistribution surface decreases HAPU in younger populations.

To prevent pressure ulcers, the EPUAP, NPUAP, PPPIA11 guidelines recommended repositioning (turning) patients regardless of the type of support surface in use unless it is contraindicated. In this study, 90% of the pediatric patients were repositioned as prescribed, which is higher than the 82% of the patients repositioned as prescribed reported by Bergquist-Beringer et al.30 Currently, scant research supports repositioning as an intervention to prevent pressure ulcers among children, although it is thought to reduce pressure, thereby increasing capillary blood flow; however, no studies met criteria for meta-analysis to support its association with pressure injury reduction.32 

Patients were most frequently repositioned as prescribed in the neonatal units. This is logical, because infants are not able to reposition themselves by rolling over or turning to their sides. Rolling over is a developmental task achieved during the first year of life; therefore, infants would need nursing assistance with repositioning. For 5.5% of pediatric patients, it was determined the intervention was unnecessary, likely because the patient was developmentally or physically able to reposition on his/her own. Interestingly, for 15.4% of the patients in the step-down units, repositioning was unnecessary. However, per previous research by Razmus8 the overall HAPU rate among pediatric step-down units was 1.03%. The frequency of medical device repositioning to alleviate pressure from skin surface also requires further exploration.

Moisture management is designed to maintain a patient’s tissue integrity. In this study, moisture was managed for 84.6% of the at-risk patients. This is higher than the 65% of adult patients receiving moisture management reported by Bergquist-Beringer et al.30 The difference in study results may be associated with the large proportion of pediatric patients who were developmentally or situationally incontinent in this study. Moisture was managed most often among patients in NICU IIIs (88.8%), NICU IVs (85.5%), and pediatric rehabilitation units (92.1%). Although the NPUAP10,11 guidelines recommend keeping the skin clean and dry while also protecting the skin from excessive moisture, no study has examined the use of moisture management as a pressure ulcer prevention intervention in unit types outside of PCCUs or with a larger sample. For example, neonatal skin is still developing and products may be absorbed through their skin; however, most products intended for moisture management have not been tested in this vulnerable population.8 Additional quasi-experimental, cohort, non-experimental descriptive, comparative, correlation, case control, case series, and qualitative studies are needed to determine the type of moisture management being used to prevent pressure ulcers among at-risk pediatric patients.

Close to 90% of the pediatric patients at risk for HAPU received nutritional support, which is substantially higher than what was reported in the adult population (56.3%) by Bergquist-Beringer et al.30 The frequency of nutritional support was highest among NICU IIIs (96.0%) and NICU IVs (93.7%), suggesting this is standard care for neonatal patients due to the inability of these patients to feed themselves independently and often due to their low birth weight. In addition to neonatal patients, all rehabilitation patients at risk for pressure ulcers received nutritional support but only 68.3% of general pediatric and 78.7% of pediatric step-down patients received this support. This may occur because patients in general pediatric units and pediatric step-down units were independently able to feed themselves and reflected in the finding the intervention was determined to be unnecessary in 13.1% to 20.7% of these patients. Included in the NPUAP10,11 guidelines was a recommendation for an individualized plan of nutritional support for patients at risk for pressure ulcers. However, no known studies have evaluated nutritional support as a preventive pressure ulcer nursing intervention for pediatric patients. Future research could evaluate what type of nutritional support is integrated into the prevention of pressure ulcers for different pediatric populations. As identified by Bernable,33 prevention strategies in the pediatric patient need to be judicially studied, such as specific types of nutritional support, repositioning, and pressure-redistribution surface use and not solely adapted from adult care without more evidence-based data. 

Clinical Implications and Research

This study provides data on pressure ulcer risk and prevention practices in acutely ill pediatric patients overall and by unit type from a large sample of patients and hospitals. These data can be used for comparison in future studies and quality improvement projects. However, more research regarding pressure ulcer risk and prevention practices in the pediatric population is needed, especially on pediatric units where medical devices are in frequent use, because emerging evidence shows repositioning medical devices to decrease skin surface pressure reduces HAPU.

Future studies are needed to validate established risk assessment tools in the pediatric population and further explore methods for determining pressure ulcer risk among neonates and the important clinical factors considered in establishing risk status. Because the least-used intervention in this study was a pressure-redistribution surface, more research is needed on support surfaces to prevent pressure ulcers, especially among NICU patients and hospital or unit policies governing their use and accessibility among children. More research evidence also is needed regarding the frequency of repositioning to prevent pressure ulcers in these populations. Future research describing the types of moisture management and their association with HAPU would provide important information for health care providers in caring for at-risk infants and children. Furthermore, the role of nutritional support in pediatric pressure ulcer prevention that describes best practices based on gestational age and developmental level would be meaningful in guiding practice. 

Limitations

The study data are unique in that previous pressure ulcer studies have not focused on neonatal or general pediatric units. In this study, the reporting of pressure ulcer risk and prevention intervention data to NDNQI was voluntary. Therefore, data submitted may not be representative of all hospitals nationally and also resulted in instances of missing data. Not all of the pressure ulcer prevention interventions were available for analysis by the NDNQI, limiting the generalizability of this study. Information on interventions related to medical devices and pressure ulcers was not obtained. NDNQI provides detailed collection guideline directions for pressure ulcer data, but these guidelines might not have been followed. Although the data were thoroughly evaluated for errors by the NDNQI, a possibility for errors exists in the data submitted to the database. Since these data were collected, the pressure ulcer prevention guidelines were revised by the NPUAP, EPUAP, and PPPI and released in 2014, with increased focus on medical device-related pressure ulcer injury. This was important because the new guidelines include information on preventing pressure ulcers in children. However, more evidence is needed to support which pressure ulcer interventions are most beneficial in neonates and children.

Conclusion

A descriptive, secondary analysis of NDNQI data revealed most pediatric patients are being assessed for pressure ulcer risk, but there is room for improvement in pressure ulcer prevention among these patients. In addition, more information is needed on how pressure ulcer risk and prevention interventions are implemented across different at-risk pediatric patients in the acute care setting. n

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Potential Conflicts of Interest: none disclosed 

 

Dr. Razmus is a wound ostomy continence nurse, Saint Francis Health System, Tulsa, OK. Dr. Bergquist-Beringer is a professor, University of Kansas School of Nursing, Kansas City, KS. Please address correspondence to: Ivy Razmus, PhD, RN, CWOCN, 305 N. Birch Court, Jenks, OK 74037; email: Ivy.Razmus@gmail.com.

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