Pressure injury prevention

in the paediatric population

including neonates

Carmel Boylan RN, BN. STN. MN (NP)

Clinical Nurse Consultant

Stomal Therapy & Wound Management

Princess Margaret Hospital for Children

29 September 2014 Slide 2

29 September 2014 Slide 3

Objectives

• Incidence/prevalence rates

• Risk factors

• Device related PI

• Screening tools

• Preventative strategies

• Parent involvement

• Mucosal injury v pressure injury

29 September 2014 Slide 4

Incidence / prevalence

• Pressure injuries (PI) in paediatrics not documented as

well as in adults

• Paediatric patients often excluded from

prevalence/incidence studies

• Review of literature (2000-2010) revealed prevalence of

PI in paediatric patients as 1.6 - 27.7%

• Reported incidence in PICU was 18-27%

• Sick children can develop PI in less than 1 hr

Prevalence

• PMH PUPPS results:

• 2007 2.4% H/A 2.4%

• 2008 3.8% H/A 2.09%

• 2009 3.5% H/A 1.8%

• 2011 7.4% H/A 6.6%

29 September 2014 Slide 5

Pressure Injury Data reported via Clinical Incident

Managament system and/or the Stomal Therapy&

Wound Care CNC Stage II injuries and above.

29 September 2014 Slide 6

Vulnerable patient group

• Disproportionate head /

body in infant

• <36 mths head greater

portion body weight &

surface area

• Limited hair growth

• Under developed

epidermis

• Affected areas:

• Occipital

• Sacral

• Ear lobes

• Calcaneus region

29 September 2014 Slide 7

29 September 2014 Slide 8

Risk factors

• mechanical ventilation

• hypotension

• use of high frequency oscillatory ventilation (HFOV)

• chemical paralysis

• vasopressor therapy

• use of total parenteral nutrition (TPN)

29 September 2014 Slide 9

Risk factors

• extracorporeal membrane oxygenation in neonates

(ECMO)

• paediatric intensive care unit (PICU) length of stay

greater than 96 hours

• increasing positive end-expiratory pressure (PEEP)

• weight loss

• not turning the patient

• not using a specialty bed in turning mode

29 September 2014 Slide 10

Device related PI

• N/G tubes

• IV bungs

• Oxygen sats probe

• Plaster casts

• Traction

• Splints

• Ankle foot orthotics

(AFO)

• Braces

• Cervical Collars

29 September 2014 Slide 11

PMH review of hospital acquired

skin injuries 2008-2010

• Towel clip (14)

• IV related (9)

• Plaster (2)

• OT Burn (3)

• Name band (1)

• PU (19) (4 during/post

PICU)

• PU post surgery (6)

• Oxygen probe (3)

• ECG dot (1)

• ET tube (1)

• NGT (1)

• Abrasion (1)

• Cast removal (3)

• Other (4)

29 September 2014 Slide 12

Mucosal injury v pressure injury

• Mucosal injuries found in the mucous membranes with a

history of a medical device in use at the location of the

injury (ulcer)

• Injury can occur due to direct trauma

• Injured tissue bleeds → soft clot formation (coagulum)

• Soft clot (coagulum) may appear like slough

29 September 2014 Slide 13

Mucosal injury

• Cannot stage a mucosal injury – cannot distinguish

shallow injury from deeper injury

• Muscle is seldom seen on MI

• Bone not present in soft tissue

29 September 2014 Slide 14

Mucous membrane

29 September 2014 Slide 15

29 September 2014 Slide 16

Screening tools

• Braden Q (tissue perfusion & oxygenation)

• Glamorgan Scale

• Neonatal Skin Risk Assessment Scale for Predicting Skin

Breakdown (NSRAS)

• Burn Pressure Ulcer Skin Risk Assessment Scale

(BPUSRAS)

• Starkid Skin Scale

29 September 2014 Slide 17

Skin assessment

29 September 2014 Slide 18

Preventative strategies

• PI risk assessment

• Skin assessment

• Support surface

• Repositioning

• Nutrition

• Continence

• OT/Physio

• Orthotics

• Dietetics

• ‘Take the pressure down’

• Education +++

29 September 2014 Slide 19

Pressure relieving equipment

29 September 2014 Slide 20

Pressure relieving equipment

29 September 2014 Slide 21

Parent involvement

• ‘Health Facts’

• Demonstration

• Participation

• Simple small steps

29 September 2014 Slide 22

Audit of PI under plaster cast

PMH

Emergency 30%

PMH

Fracture Clinic 25%

PMH

Plastics Clinic 20%

PMH

Theatre 25%

Plaster Applied

Average age of child with plaster 10.9 years

Average time plaster on 16 days

Above

Elbow 18%

Below Elbow

46%

Above Knee

18%

Below Knee

18%

Injury Site

Slide 23

Audit Results (cont)

PMH

Emergency 45%

PMH

Fracture Clinic 32%

PMH

Plastics Clinic 18%

Ward

5%

Injury Identified

Stage 1 52%

Stage 2+ 48%

Skin Injury Stage

All Stage 2+ Skin Injuries have a Clinical Incident form

completed

Slide 24

Discussion

• Most skin injuries occurred when plasters were applied

below the elbow (this is probably the most common

plaster type – more data required to find % of injury per

number of plasters applied).

• Even spread of site where plaster applied in relation to

skin injury occurring.

• Almost half of injuries were identified in Emergency Dept

– patients returning with symptoms of pressure.

Slide 25

Pressure Injury Data reported via Clinical Incident

Managament system and/or the Stomal Therapy&

Wound Care CNC Stage II injuries and above.

29 September 2014 Slide 26

29 September 2014 Slide 27

29 September 2014 Slide 28

29 September 2014 Slide 29

29 September 2014 Slide 30

29 September 2014 Slide 31

Summary

• Ongoing risk assessment

• Prevention strategies

• Encourage reporting

• Multidisciplinary approach

• Parent education

• ‘Its not OK to get a pressure injury’

• ABC is important but so is PIP

29 September 2014 Slide 32

29 September 2014 Slide 33

29 September 2014 Slide 34