Reducing Device-Related Pressure Ulcers: Leveraging Data and Innovation to Improve Adult/Pediatrics Outcomes

Sunday, 8 November 2015: 4:00 PM

Peggy Kalowes, PhD, RN, CNS, FAHA
Nursing Administration, Long Beach Memorial Miller Children's & Women's Hospital Long Beach, LONG BEACH, CA, USA
Raquel Paige, MSN, RN, CPN, CRRN
Pediatrics, Long Beach Memorial Miller Children's & Women's Hospital Long Beach, Long Beach, CA, USA
Valerie Messina, BSN, RN, CWCN
wound service, Long Beach Memorial Miller Children's & Women's Hospital Long Beach, Long Beach, CA, USA

Significance and Background

Pressure ulcers are acquired among high-risk patients in pediatric and adult hospitals, and are key indicators of the effectiveness of care. The NPUAP 1 recognizes that PUs can occur on any tissue under pressure, including beneath medical devices (MDs) used for diagnostic/therapeutic purposes. In the past two years we have reduced our quarterly prevalence of PUs (sacral, coccyx, and heel) to zero to 0.3% using an EB Skin Bundle5 plus a 5-Layered Silicone Border Dressing* thus the direct impact of MDR PUs has become more transparent.  Stage III, IV, and Unstageable PUs are reportable as sentinel events, and are linked with litigation and lack of Medicare/Medicaid reimbursement. In 2012, using our CALNOC (Collaborative Alliance for Nursing Outcomes) nurse indicator PU data, we found a surge of MDR PUs >benchmark in Pediatrics and Adult units, (5-Tracheostomy; 2-Noninvasive Ventilation Masks (NIVM); 1-IV Hub). Thus as we strive to be a high-reliability organization, we have intensified efforts to improve safety through better process re-design, changing practice to EB therapies 1-4 and building a culture of safety.


The aim of this Interprofessional performance improvement (PI) project, was to examine our on-going rate of medical device related (MDR) pressure ulcers (PUs) among pediatric and adult patients; and to institute a novel PI program for MDR PU prevention, based on evidence and innovation. 


The adult/pediatric advance practice nurses and the director of nursing research, convened an interprofessional team (staff nurses; MDs; PT; PI nurses; wound care specialist) who reviewed the literature, and a subsequent development of an intervention model using a rapid-cycle, Plan-Do-Study-Act (PDSA) framework.  A root cause analysis of all 8 MDR PUs in 2012 was conducted reviewing stage, location, device involved, and compliance with our standard SKIN Bundle.4 Because of the urgency to reduce NIVM and tracheostomy-related MDR PUs, we immediately (2nd Q, 2012), deployed the use of Mepilex® Transfer or Lite, beneath all tracheostomy neck plates and NIVM. We finalized our comprehensive MDR Prevention Model (2013), to include a new MDR PU Prevention Bundle1,3,4 with EB interventions, including frequent skin/device assessments, moisture -reducing device interface and pressure-free device interface.

* Evaluation and Discussion

Our MDR Prevention Model was fully launched in 3rd quarter, 2013. We’ve closely tracked point-prevalence/and incidence data, along team compliance with the MDR prevention bundle for the past 3 Quarters. There was an absolute reduction of MDR PUs from 0.06% incidence of stage 3+ MDR HAPU's per 1000 patient days to zero in pediatrics (benchmark 0.0 – 0.04%); and among adults from 0.28% incidence to zero with (benchmark 0.05-0.09 %,).  Thus, thru interprofessional team implementation of the MDR prevention program, and deployment of EB therapies to relieve pressure at the device–skin interface effectively,1,3,4,5  rigorous education and continuous monitoring, we have sustained a ‘zero’ incidence among adults and pediatric patients. These interventions can be integrated into daily workflow and result in sustained effect on nursing practice, teamwork and patient outcomes.