Preventing Hospital-Acquired Pressure Injuries by Using a Tiered Protocol in Children Receiving ECMO in the Pediatric Intensive Care Unit.

Abstract

During the 1970s, extracorporeal membrane oxygenation (ECMO) was a prevalent therapy given to neonatal patients as treatment for meconium aspiration, persistent pulmonary hypertension, and respiratory distress syndrome.1 The use of ECMO, however, has recently increased among older infants and children. Internationally, more than 63 000 newborns, infants, and children younger than 18 years are supported on ECMO.1 The variability in ECMO practices— in part due to rapid technological advances and new clinical indications (eg, burns, malignancy, hematopoietic stem cell transplant)—makes ECMO ideal for standardization and protocols.1 Modifiable aspects of ECMO-related care that can be standardized should be. Pressure injury prevention is one of these aspects of care, and the increasing volume of patients receiving ECMO presents an opportunity to improve patient safety and reduce the undesirable outcome of hospital-acquired pressure injuries (HAPIs) within this population.Critically ill children are at risk for HAPIs—1.4% of hospitalized infants and children experience them—but they are preventable. A few researchers, however, posit that some pediatric HAPIs are an inevitable outcome of skin failure from multiorgan dysfunction syndrome.2–5 Both full-term and preterm infants, children, adolescents, and young adults (up to 21 years old) are at risk for both immobility-related (on bed rest for at least 24 hours) and device-related (at least 1 medical device traverses the skin) pressure injuries associated with ECMO therapy.4,6 The ECMO cannulas with sutures and monitoring equipment (eg, Spo2 probes, electroencephalography leads) are some of the obvious medical devices that contribute to these patients’ high risk of pressure injury.7 Providers may hesitate to reposition patients receiving ECMO because of the tenuous nature of cannulas. Listing a patient or performing what some call “mini-turns” to off-load at-risk areas such as the occiput and sacrum could be considered lesser care priorities. In addition, on the Braden QD Scale, for “repositionability” or inability to be moved or rotated and skin protection, ECMO cannulas are scored as a “potential problem” (score of 1) or a “problem” (score of 2).6 In the case of ECMO cannulas, whether the skin beneath the cannulas is protected determines the difference between a potential problem and an actual problem.The Data-Information-Knowledge-Wisdom (DIKW) framework served as the foundation for this evidence-based quality improvement project. The framework proposes that 4 metastructures—data (naming, collecting, organizing), information (organizing, interpreting), knowledge (interpreting, integrating, understanding), and wisdom (understanding, applying, applying with compassion)—have a dynamic linear relationship.8–11 Components of the framework mesh with organizing, interpreting, and understanding. As the metastructure data progresses toward that of wisdom, the interactions and interrelationships between the 4 metastructures increase in frequency and complexity.10,11We were presented with HAPI-related data for children receiving ECMO in our institution. We organized and interpreted those data, which presented opportunities for improving both patient safety and how we assess risk of pressure injury. The Braden Q Scale was in our hospital’s electronic health record at the inception of this project. Our organization participated in a multicenter prospective cohort study of 625 patients to validate a new pediatric pressure injury risk assessment tool: the Braden QD Scale.4,6 The clinical nurse specialist (CNS) in the pediatric intensive care unit (PICU) served as the site principal investigator. The knowledge and understanding of immobility- and device-related pressure injuries that we derived from that research advanced our wisdom that led to the development of a tiered pressure injury prevention protocol (Table 1); this protocol included family-centered care and an individualized electronic power plan for patients receiving ECMO (Table 2).Compared with other nursing informatics models, the DIKW framework has an important and appealing element: wisdom. Wisdom may be a somewhat controversial concept in the DIKW framework, but we believe that by interpreting data through a clinical lens (ie, expert collaboration among informatics nurse specialists, quality nurse specialists, certified wound ostomy nurses [CWONs], and a CNS), a care team can make compassionate, appropriate, and creative decisions about assessing the risk of and preventing pressure injury. Wherein lies wisdom. It is the why, the insight, and the intuition behind the knowledge. Moreover, such a team of professionals would recognize the importance of family’s involvement in the patient’s skin care and would encourage and support it, even with complex patients in the PICU.10,11Will a nurse-driven interdisciplinary HAPI prevention protocol that is tiered according to the day of ECMO therapy and predicted patient stability reduce the prevalence of immobility- and device-related pressure injuries among patients receiving ECMO in the PICU?The PICU-based skin care team collaborated with a CNS, informatics nurses, a quality nurse specialist, a perfusionist, and critical care physicians on this project. The PICU skin care team includes 2 wound treatment associates and the hospital’s CWONs. The hospital skin care council, evidence-based practice council, and PICU patient-quality-research-safety committee endorsed the project. The University of Pittsburgh Medical Center Quality Committee approved the project. Elements of this work partially fulfill a PICU skin care team member’s doctor of nursing practice degree (S.K.).At our organization, within a 7-month period, 12 immobility-and device-related pressure injuries occurred in patients who were receiving ECMO, were positioned supine, and had been cannulated via neck vessels. (No patients had been cannulated through the chest.) In response, we developed a tiered HAPI prevention protocol based on current, high-quality evidence and implemented it with patients receiving ECMO (Table 1).12 The purpose of the protocol was fourfold: (1) to improve proactive prevention measures before or concurrent with the initiation of ECMO; (2) to standardize prevention throughout the course of therapy for this patient population; (3) to improve patient safety by reducing the number of HAPIs, or eliminating them, in patients receiving ECMO; and (4) to enhance the family’s participation in their child’s skin care while the child is receiving ECMO.The first iteration of the protocol included the Braden Q Risk Assessment Scale. The second, current protocol includes the Braden QD Scale. Efforts to incorporate the newer Braden QD Scale into the integumentary band of the electronic health record were concurrent with the revision of an ECMO power plan that includes the protocol (Table 2). Conversion to the Braden QD Scale was completed in March 2020.A grouping of specific orders within our electronic health record is called a “power plan” or “order set.” These order groups are represented by a unique icon within the orders search window; that icon identifies them as a plan or set rather than a single order. The functionality of a power plan provides a way to organize and group multiple orders to direct a patient’s care and treatment according to a pathway, problem, diagnosis, process, or multidisciplinary therapy (eg, asthma, sepsis, ECMO therapy). The ordering provider can view reference text for guidance with decision support, and links can be made available so the provider can access additional reference sites that also provide support for clinical decisions. An opportunity exists for details to be improved regarding patient safety, specifically for skin care and HAPI prevention, and including the interdisciplinary protocol will fulfill this need. Elements that are most relevant to skin care for a patient receiving ECMO are included under “Patient care.”Upon cannulation of the neck vessels (eg, veno-arterial, veno-venous), a nurse on the PICU skin care team, the bedside nurse caring for the patient, and the perfusionist collaborate to place a foam dressing between the circuit cannula and the skin to protect the skin from the pressure of the cannula. Wet skin, typically associated with incontinence in infants and children, can be problematic at the ECMO cannulation site. Drainage (eg, serous, serosanguinous, sanguinous) can lead to macerated skin, which is at greater risk for pressure injury.13,14 The absorptive properties of foam are beneficial in such cases. Importantly, protecting the skin beneath a medical device that cannot be rotated or repositioned reduces medical device– related risk of pressure injury.6Foam dressings that were previously stocked in supply rooms are now available on perfusion carts for prompt, easy access. Before the inception of this protocol, foam dressings were considered too thick and cumbersome to place safely beneath the cannulas. We now know that foam dressings need not interfere with the heavy braided ties used to secure cannulas (they do not necessarily cause malpositioning or kinking), nor with visualization of the cannulation site.A consultation with a CWON is initiated on day 1. If the patient is already being followed by a CWON, a new consult is requested. Likewise, the nutrition service is consulted or reconsulted. Essentially, these consults are handled as though the patient has a new baseline integumentary status and a new baseline pressure injury risk assessment score.The CWON and PICU skin care nurse assess the patient’s skin head to toe to establish a new baseline pressure injury risk assessment score. Nurses must understand that a head-to-toe skin assessment is visualization of all of the skin, accomplished proficiently by more than 1 nurse, in a child ill enough to require ECMO. This visualization may entail removing clothing and safe repositioning of devices while ensuring patient privacy and comfort. During a head-to-toe skin assessment, the CNS or CWON should not simply ask the bedside nurse, “Does your patient have any skin issues today?” And the bedside nurse should not simply respond, “No” or “I have not assessed the patient yet” or “I was told at patient handoff that the patient doesn’t have any.” Open-ended questions by the CNS or CWON facilitate probing of clinical assessment findings. The CNS or the CWON can also ask the family questions about potential new findings to involve them in skin care rounds, because they know their child best. The nurses can use various questions or statements to gain additional information from the family: Such communication helps build the family’s confidence in their child’s health care providers and promotes the family’s participation in the patient’s care.The perfusionist assists the nurses with placing a fluidized positioner beneath the occiput and other bony prominences, as indicated, and offloads the heels before or immediately after cannulation. Fluidized positioners, when applied correctly, are molded to cradle the head so the occiput is off-loaded. A positioner can also be molded to create tracks for tubing and medical devices (eg, nasogastric tubes, endotracheal tube cuff balloons). Molding the positioner is counterintuitive to what nurses learn about ensuring a wrinkle-free surface, so nurses often make the common mistake of pulling the positioner taut to flatten it.The CWON develops individualized prevention plans of care that are based on each patient’s risk assessment score. Proactive semiweekly skin care rounds as part of a prevention bundle have reduced the incidence of pressure injury among critically ill patients.15Time 2 Turn is a rendering of a clock that resembles a friendly, somewhat immobile (but turned or side-lying) crocodile reminiscent of an animated character from a children’s movie.16,17 The “2” represents turning every 2 hours. The visually appealing clock is posted by the bedside so parents can schedule the repositioning of their child. Assisting providers with safely turning or repositioning their child is a small way parents can be involved with their child’s care during what may be an overwhelming and terrifying situation. Nurses educate families about the risk of pressure injury, the importance of scheduled turning, Time 2 Turn, and the value families contribute to care by knowing their child’s baseline integumentary status on day 3 of ECMO therapy. Nurses may choose to adjust this portion of the protocol depending on the family’s emotional availability.On day 3, the care team evaluates the patient’s support surface and considers changing to a higher-grade mattress such as an air mattress (if one is not already in place).18 Transfer of the child to a new surface requires a team of at least 1 perfusionist, who stabilizes the cannulas; 1 respiratory therapist, who manages the endotracheal tube; a physician, who monitors the patient; and at least 2 nurses, who monitor the patient, manage the move to the air mattress, care for catheters and tubing, reassure the child, and provide emotional support. The number of nurses depends on the child’s clinical stability, stature (which may be altered because of severe contractures or scoliosis), and weight.Day 7 of ECMO therapy includes the continuation of semiweekly skin care rounds, a head-to-toe skin assessment with a CWON, and a root cause analysis for any HAPIs with stage 3 or higher severity.18 The team reevaluates the prevention plan of care and modifies it according to the patient’s condition and any results of the root cause analysis.We were able to reduce the number of pressure injuries in patients receiving ECMO by implementing a tiered pressure injury prevention protocol in the PICU (see Figure). During the 3-year period of the project, 29 unique patients, ranging in age from 4 days to 21 years, began receiving ECMO in the PICU. The duration of ECMO therapy varied from 1 day to 81 consecutive days. Overall, patients received ECMO therapy for a mean of 15 days, although the duration was longer before we implemented the protocol. After implementation, patients in the PICU averaged 10 days of ECMO per month, but there were intermittent periods when no patients required ECMO.From January 2017 until the protocol was instituted at the end of August 2017, 8 patients received ECMO and we identified 12 distinct pressure injuries. During the 27-month period after the protocol was operationalized, we identified 11 pressure injuries among 21 patients receiving ECMO. The rate of pressure injuries per 100 days of ECMO therapy decreased from 6.78 to 4.49 during the project. Both before and after protocol implementation, instances occurred in which patients had more than 1 injury identified during ECMO therapy. Before implementation, 3 of the 8 patients (36%) receiving ECMO had 1 or more pressure injuries. After implementation, however, such injuries occurred in only 4 of the 21 patients (19%) receiving ECMO—an improvement of 17%.Before the protocol was implemented, the timing of when during ECMO a pressure injury was first identified ranged from day 10 to day 54, whereas during the intervention period injuries were identified as soon as day 2, though some were found as late as day 63. Both before and after implementation, the most frequent pressure injury location was the ear (n = 8, 35%), typically the ear opposite the cannula site because of head position, though in some cases both ears had pressure injuries. Because of earlier placement of a preventive foam dressing near the cannula site, only 1 injury was associated with the cannulas during the period after implementation. Other common sites of injury (ie, the parietal, occipital, and sacral/coccyx areas) did not change before and after implementation. The stage of injuries identified throughout the 3-year period are listed in Table 3.We found more device-related injuries after implementation (63%) than before implementation (8%); we attribute this increase to the use of the new Braden QD Scale, which improved our awareness and assessment of medical device– related injuries. In addition, we credit the decrease in the number of non–device-related injuries to improved use of specialty mattresses and reinforcement of microturns of patients as well as minor off-loading, which were previously thought to negatively affect patients.The coronavirus disease 2019 pandemic has affected our project, albeit in a minor way. Our PICU protocol was applied with fewer nurses in attendance during skin care bedside rounds.20 This staff reduction aimed to enhance patient safety, requiring fewer providers to enter patients’ rooms and conserving personal protective equipment.Pressure injury prevention is a nurse-sensitive indicator. It presents important and exciting opportunities for nurses to function autonomously and apply the best evidence to vulnerable patient populations. Although we were unable to eliminate pressure injuries among patients receiving ECMO in the PICU, we did achieve improvements in the overall incidence of injuries, including in patients receiving ECMO therapy for a long duration. Future HAPI-related data and new evidence may drive the need for additional protocol tiers beyond day 7 of ECMO therapy. For now, however, we continue to initiate prevention measures by day 7.Pediatric patients receiving ECMO require concerted, vigilant efforts to prevent HAPI. Clinical nurse specialists are ideal as researchers who contribute to the body of knowledge regarding skin care and pressure injury prevention, as mentors to students seeking higher degrees in nursing, as leaders of evidence-based practice projects, and as advocates for children and families. Informatics nurses and nurses in the field of information science are perfectly positioned to operationalize change via the electronic health record and promote population health using clinical effectiveness guidelines, protocols, and clinical pathways. The critically ill children receiving ECMO in our hospital benefited from the expertise of our CWONs and the providers in the critical care medicine and perfusion disciplines, all of whom ensured patient safety during the development and implementation of this tiered prevention protocol.