Sandy Quigley

Pressure ulcers in pediatric intensive care: incidence and associated factors.

Objective To describe the incidence, location, and factors associated with the development of pressure ulcers in patients cared for in the pediatric intensive care unit (PICU). Design Multisite prospective cohort study. Setting Three PICUs contained within freestanding children’s hospitals. Patients A total of 322 patients, 21 days to 8 yrs of age, on bed rest in the PICU for at least 24 hrs without preexisting pressure ulcers or congenital heart disease. Intervention Patients were observed up to three times a week for 2 wks, then once a week until PICU discharge for a median of two observation periods (interquartile range, 1–4), reflecting 877 skin assessments. Skin assessments were independently rated, and data collectors were blinded to the assessments of the others. Measurements and Main Results Pressure ulcers were staged according to the American National Pressure Ulcer Advisory Panel Consensus Development Conference recommendations. Eighty-six patients (27%) developed 199 pressure ulcers; 139 (70%) were Stage I, 54 (27%) were Stage II, and 6 (3%) were Stage III. Of the 60 Stage II/III pressure ulcers, 19 (32%) involved the head. Stage III pressure ulcers involved the occiput, ear, chest, and coccyx. An additional 27 pressure-related injuries were caused by medical devices. Statistically significant Stage I pressure ulcer predictor variables include the use of mechanical ventilation, mean arterial pressures ≤50 mm Hg, and lower Braden Q scores. Conclusions PICU patients at risk include those supported on mechanical ventilation, those with hypotension, and those who have low Braden Q scores. This study provides unique benchmark data for the general PICU population from which pediatric interventional studies can be designed to reduce the incidence of pressure ulcers in this vulnerable patient population.

Using the Braden Q Scale to Predict Pressure Ulcer Risk in Pediatric Patients

The Braden Q Scale for Predicting Pediatric Pressure Ulcer Risk (Braden Q Scale) is a widely used, valid, and reliable pediatric-specific pressure ulcer risk assessment tool. Since its original publication, requests for clarification on how best to use the tool across the wide spectrum of pediatric patients commonly cared for in health care systems have been received. Common clarifications focus on using the Braden Q Scale as originally designed; specifically, not using untested derivations of the tool, and not using the Braden Q Scale to predict medical device-related pressure damage. The purpose of this article is to provide practical information on how best to use the Braden Q Scale and how to score a pediatric patients risk for pressure ulcers. Accurate assessment of patient risk for pressure ulcers is the first step in guiding appropriate nursing interventions that prevent pressure ulcers. Patient assessment, scoring, and common clinical scenarios are presented.

Medical Device-Related Hospital-Acquired Pressure Ulcers in Children: An Integrative Review

The management, cost, physical and emotional suffering associated with pressure ulcers have a significant impact on the health status of patients-especially infants and children. The purpose of this integrative review was to identify factors associated with medical device-related (MDR) hospital acquired pressure ulcers (HAPUs) in the pediatric population. Pediatric MDR HAPUs are becoming more prevalent and require further exploration in terms of describing devices which cause injury and preventive interventions to improve patient outcomes. Opportunities to uncover new methods for addressing this important problem and to inform and advance the state of the science in this evolving area exist.

Use of negative pressure wound therapy for abdominal wounds in neonates and infants

BACKGROUND Negative pressure wound therapy (NPWT) is an established and effective tool in the management of complicated abdominal wounds. This management approach has been used in infants, but few large series reports exist in the literature. METHODS The outcomes of infants with abdominal wounds receiving NPWT over the last 10 years at our institution were evaluated. Overall survival, time between initiation of NPWT, and discharge/death were examined. RESULTS We identified 18 infants who had abdominal wounds treated with NPWT. Diagnoses were varied, as was the duration of therapy. The median NPWT duration of treatment was 34.0 ± 92.1 days. Forty-four percent of the infants had a stoma before application of NPWT, and 22% of the infants had enterocutaneous fistulas before use of NPWT. There were only 2 cases in which a new fistula developed during the use of NPWT, and both of these omphalopagus conjoined twins had undergone the Bianchi procedure. No additional NPWT-related complications were identified. Of 18 infants, 6 died in this cohort. CONCLUSION Negative pressure wound therapy is an important therapeutic tool for the management of abdominal wounds in infants.

Predicting Pressure Injury Risk in Pediatric Patients: The Braden QD Scale

Objective To describe the development and initial testing of the Braden QD Scale to predict both immobility‐related and medical device–related pressure injury risk in pediatric patients. Study design This was a multicenter, prospective cohort study enrolling hospitalized patients, preterm to 21 years of age, on bedrest for at least 24 hours with a medical device in place. Receiver operating characteristic curves using scores from the first observation day were used to characterize Braden QD Scale performance, including areas under the curve (AUC) with 95% CIs. Results Eight centers enrolled 625 patients. A total of 86 hospital‐acquired pressure injures were observed in 49 (8%) patients: 22 immobility‐related pressure injuries in 14 (2%) patients and 64 medical device–related pressure injuries in 42 (7%) patients. The Braden QD Scale performed well in predicting immobility‐related and medical device–related pressure injuries in the overall sample, with an AUC of 0.78 (95% CI 0.73‐0.84). At a cutoff score of 13, the AUC was 0.72 (95% CI 0.67‐0.78), providing a sensitivity of 0.86 (95% CI 0.76‐0.92), specificity of 0.59 (95% CI 0.55‐0.63), positive predictive value of 0.15 (95% CI 0.11‐0.19), negative predictive value of 0.98 (95% CI 0.97‐0.99), and a positive likelihood ratio of 2.09 (95% CI 0.95‐4.58). Conclusions The Braden QD Scale reliably predicts both immobility‐related and device‐related pressure injuries in the pediatric acute care environment and will be helpful in monitoring care and in guiding resource use in the prevention of hospital‐acquired pressure injuries.

Re: Risk and associated factors of pressure ulcers in hospitalized children over 1 year of age.

As clinicians and researchers interested in hospitalacquired pressure ulcers (HAPUs) in children, we continually seek collaborative opportunities nationally and internationally to address this important issue and advance the state of the science as it relates to this evolving area of pediatric nursing. We appreciate the ongoing efforts by AnnaBarbara Schlüer, MScN, and colleagues to identify factors related to the development of HAPUs in the pediatric population. In a JSPN early view (online version of record published before inclusion in an issue) publication, Schlüer, Schols, and Halfens (2014) conducted a multicenter, cross-sectional, descriptive study to explore factors associated with HAPUs in children and adolescents. The authors used the Braden Scale vs. the Braden Q Scale for predicting pediatric pressure ulcer risk, which is a widely used, valid, and reliable pediatric-specific pressure ulcer risk assessment tool (Noonan, Quigley, & Curley, 2006). It is unclear why Schlüer and colleagues would use the original Braden Scale, which has never been psychometrically tested with any age group in the pediatric population. Instead, it was developed and tested for the adult population. It is also unclear why the authors did not use the Braden Q Scale, which has been translated into German (Die Braden Q-skala: Dekubitus-risiko bei kindern, 2005). Additionally, Schlüer and colleagues (2014) did not separate traditional immobility-related from devicerelated pressure ulcers. The Braden Scale does not predict device-related injuries. Researchers have emphasized the importance of clinicians recognizing that riskassessment,prevention,andmanagementof immobility-related and medical device-related pressure ulcers are different (Kohr & Curley, 2010). In order to avoid confusion regarding implementation of best practice recommendations for HAPU prevention and quality monitoring, it is critically important to differentiate the two phenomena (Murray, Noonan, Quiqley, & Curley, 2013). As nursing experts continue to contribute to the science of HAPUs in the pediatric population, greater collaboration and open dialogue is needed so that the experiencesofallwhoare interested in this important issue are considered. The enduring commitment to refining a psychometrically sound risk assessment tool forHAPUs iscritical to informingnursingpractice and optimizing prevention and treatment (Murray et al., 2013).