Volume 27 Number 2

Key messages

• Describing the paper: Development and implementation process of an evidence-based practice guideline for nurses to prevent PIs in children.
• Aim: reducing PIs in hospitalised children through a multi-step quality improvement project
• Results: increased PIs when respiratory support, parenteral nutrition or inotropic drugs were necessary and when patients were diagnosed with prematurity. After the education of nurses, a significant increase in risk assessments performed was achieved and grade 2 PIs were completely avoided.

Introduction

Hospital-acquired pressure ulcers (HAPU) have long been identified as a problem in adult patients. However, due to the often poor health status of hospitalised children, they are also at high risk of developing pressure ulcers (PU).^1,2 A meta-analysis published in 2021 shows a prevalence of PU in newborns of 27% and in children under one year of age of 19.2%. In addition, newborns had an incidence of 9.8% and children 3 A HAPU is an adverse event that increases the suffering of children and can also increase the risk of complications.⁴ There are also significant economic implications for healthcare systems, as pressure ulcers lead to prolonged hospital stays and higher costs.^5,6

Studies involving adult patients showed that the implementation of evidence-based guidelines prevented up to 95% of pressure ulcers. In addition, the quality of care and satisfaction increased, patient outcomes improved, and costs were reduced.^7,8 These findings demonstrate the high relevance and necessity of implementing patient-oriented prevention strategies. The implementation of evidence-based guidelines should aim to achieve a zero incidence of PU in pediatric inpatient care.

Aim

This study aimed to reduce pressure ulcers in hospitalised children by standardising nursing practice. Specific objectives included developing and implementing a practical guideline for nurses based on current evidence to enable them to take appropriate measures to prevent HAPUs in children. Further objectives were to improve nurses´ knowledge of the causes of PU and the preventive interventions. The following research question, according to the PICOT scheme, was conducted: Does the training and continuing education of nurses in conjunction with the implementation of an evidence-based, standardised practice guideline reduce the incidence of HAPUs in children over a period of six months?

Methods

Context

This quality improvement project was conducted as a single-center study at a mixed neonatal and pediatric intensive care unit in a children´s hospital in Germany. The implementation process followed the seven steps of evidence-based practice described by Melnyck et al.⁹ The study is reported following the SQUIRE 2.0 recommendations for reporting quality improvement projects.¹⁰

Interventions

In the first step, a research team of three nursing scientists searched for evidence to gain an overview of interventions to prevent PU in children. For this reason, a systematic review was conducted, following the research question: Which nursing interventions prevent pressure ulcers in the clinical pediatric setting?.¹ At this time, the Braden-Q-Scale was used in German-speaking countries to assess the risk of pressure ulcers in children. As the Braden-Q-scale excluded several pediatric cohorts in validation studies (such as premature and newborn infants), the Neonatal Skin Risk Assessment Scale (NSRAS) was used to assess the risk in preterm infants and newborns. In addition, the Braden-Q-scale did not consider pressure ulcers associated with medical devices. During the literature search, the researcher became aware of the Braden-QD-scale,¹¹ which was not available in the German language. For this reason, the translation process was conducted based on the ISPOR guidelines¹² to make the assessment available in German-speaking countries as well.¹³ The Braden-QD-scale considers the risk of device-related pressure ulcers and the risk of immobility in children from the first day of life. It has been validated for premature babies up to the age of 21 years,¹¹ which means that only one risk assessment now needs to be used in practice for all age groups.

The systematic search in PubMed, CINAHL and Cochrane from March to May 2023 yielded a total of 37 studies, which were reviewed, and the interventions for the prevention of PU were summarised in a further step. The interventions were extracted, and a practice guideline for nurses was created. The information required for the implementation process was summarised in a document and made available to all nurses in the hospital. In addition, training sessions were held for nurses. The nursing leaders asked all nurses to take part in training on pressure ulcers as part of the project. The project management team developed the training content based on the results of the literature review. The education content included general information on pressure ulcers, the various stages of pressure ulcers, and the risk factors for pressure ulcers in children. In addition, the assessment tool (Braden-QD-scale) was explained in detail, and its correct application was presented. Since the current European Pressure Ulcer Advisory Panel (EPUAP) guideline hardly addresses specific interventions for children in detail, a practice guideline with evidence-based nursing interventions, based on the subcategories ‘mobility’, ‘sensory perception’, ‘friction and shear’, ‘nutrition’, ‘tissue perfusion and oxygenation’, and ‘medical devices’ of the Braden-QD-scale, was developed and the various interventions were also discussed in detail. The practice guideline with all necessary nursing interventions (such as repositioning every two hours; regular repositioning of medical devices; individual adapted nutrition plan) was available as a flowchart (see Figure 1). After this, the Braden-QD-scale and the practice guide were stepwise implemented in nursing practice over six months (July to Decemebr 2023). During the implementation period, ´power learning sessions´ were also conducted directly on the wards, where nurses were reminded of the new features and could ask questions if anything was unclear. Three months after the beginning of the implementation process, a survey of nursing staff was conducted for evaluation. The practice guide was then adapted based on the feedback and previous experience in clinical practice.¹⁴

 

Figure 1.  Intervention guide for pressure ulcer prevention

 

Conducting the screening

Based on the recommendations of Curley and coleagues¹¹, a complete skin assessment was performed within 24 hours of admission, including the use of the Braden-QD-scale. Curley et al also describe that the frequency of risk assessment using the Braden-QD-scale should be adapted to the patient population and that children who have limited mobility, or are critically ill could benefit from more frequent examinations. Therefore, risk assessment was performed at least once per shift and the frequency of assessment was adjusted whenever there was a change in the clinical condition of the patients.

Data analysis

To determine the impact of the implementation of the evidence-based guideline, patient data were collected retrospectively from medical records six months before the start of the implementation process (January to June 2023) and six months after completing the implementation process (January to June 2024). The data was exported to SPSS version 29.0.2.0 for further analysis. First, the absolute and relative frequencies were determined. For ordinal data, the median and range were also calculated. If there were multiple possibilities per variable, a multiple-response analysis was conducted. Nominal scaled variables were tested using the Pearson chi-square test, and the phi coefficient was used to determine the effect size for 2x2 cross tables. The effect size was rated with values between 0.1 (small effect), 0.3 (medium effect), and 0.5 (large effect).¹⁵ A p-value of <0.05 was considered statistically significant.¹⁶

Ethical consideration

The study was reviewed and approved by the Joint Ethics Committee of the Bavarian Universities (GEHBa-202305-V-113-R). In accordance with the Declaration of Helsinki, this study aimed to improve the health and well-being of hospitalised children. The quality improvement project was associated with minimal risk and did not cause any potential harm or discomfort to the study participants beyond what they would normally experience in the hospital. The project design protected against potential risks through the development of standardised practice guidelines. In the interest of data minimisation, only a small amount of personal data was collected, thus avoiding any inferences about individual patients.

Results

In total, 403 patient records (185 before and 218 after the implementation) were reviewed, and the data extracted. The following information was collected: age, ICU length of stay (LOS), gender, diagnosis, nutritional status, and need for respiratory support. The mean duration of ICU-LOS was 9 days (SD=18.04) in the pre-intervention group and 7 days (SD=20.38) in the post-intervention group. The characteristics of the patients are shown in Table 1.

 

Table 1. Characteristics of patients
Abbreviations: HFNC = High flow nasal canula; NIV = non-invasive ventilation; MV= mechanical ventilation

 

In the entire population (pre- and post-intervention group; N=403), there was a significantly increased incidence of PUs when any type of respiratory support was necessary (p<0.001). A significant effect was also observed when inotropic medication was administered (p<0,001). Sedatives or relaxants did not affect the incidence of pressure ulcers. In addition, significantly more PUs were recorded in patients diagnosed with prematurity and those requiring parenteral nutrition (see Table 2).

 

Table 2. Pressure ulcer occurrence in the pre- and postintervention group (n=403)

 

After the education sessions, the provision of further information material for nurses, and the implementation of the Braden-QD-Scale, there was a significant increase in the number of PU risk screenings performed in the post-intervention group (p<0.001). In addition, the data show that in the pre-intervention screenings, significantly more patients at risk were identified than in the post-intervention screenings (p<0.001). In 95.2 % of the PUs identified, a screening had been performed beforehand (see Table 3).

 

Table 3. Results on risk-screening frequency and patients at risk

 

Overall, PUs were documented in 11.4 % of children (n=21) in the pre-intervention group. Of these, 76.2 % were grade 1, and 23.8 % grade 2 PUs. In the post-intervention group, pressure ulcers were recorded in 18.8 % of children (n=41), all of which were grade 1. The PUs were mainly located on the nose bridge, the knee, the legs or the head. The age group particularly affected by PUs was premature and newborn infants. Further information on PU-specific parameters can be seen in Table 4. As shown in Table 5, the PU occurrence increases significantly with a longer ICU-LOS (r(401)=-0.414; p=<0.001 (95% KI [-0.494; 0.327]).

 

Table 4. Pressure ulcer-specific parameters

 

Table 5. ICU-LOS to pressure ulcer occurrence

 

Discussion

Summary

In this Quality Improvement Project, we implemented a practice guide for preventing PUs in a German children´s hospital based on current evidence. Parts of the entire process were educational sessions for nurses, providing additional information, training and implementing a new risk assessment tool, and holding power learning sessions on the wards during the implementation process. These measures led to an increased knowledge about pressure ulcer prevention interventions and the implementation of the practice guideline in clinical practice.

Interpretation

In correlation with existing literature^17–19, our study showed a high incidence of pressure ulcers in children. Premature and newborn infants, in particular, are at especially high risk of developing PUs during their stay in the ICU. Similar to previous publications,⁵ an increased incidence of PU was observed with increasing ICU-LOS.

Contrary to the results of Uysal and colleagues,²⁰ our study showed significantly more pressure ulcers when inotropic drugs or parenteral nutrition were administered. Children who are at risk of developing or already suffer from PUs are more likely to have additional comorbidities (including malnutrition).²⁰ Studies show a correlation between the prevalence of malnutrition and PUs^{21, 22}, but also clearly reports a research gap in the implementation of adequate strategies in neonatal or pediatric ICUs.^{23, 24}

During the development and publication of the Braden-QD-scale,¹¹ medical devices were highlighted as a risk factor for the occurrence of PUs. Based on our results, it should therefore be emphasized that 96.8% of patients with PUs required respiratory support. On the one hand, this naturally points to the (probably) poorer general condition of the children, but on the other hand, it also points to the high risk of pressure ulcers caused by medical devices. In addition, the most common location of PU was on the nose bridge, caused by NIV masks. The interventions carried out by nurses specifically for the category of medical devices were:

1. regular repositioning of medical devices
2. hydrocolloid dressing on exposed areas to reduce pressure
3. correct size for medical devices
4. NIV masks, every 4 hours: control redness, clean the mask, keep it dry
5. change the position of pulse oximetry at least after 8 hours

These interventions resulted in grade 2 pressure ulcers being avoided in the post-intervention group.

The Quality Improvement Project showed a significant effect on the frequency of screenings performed. In the pre-intervention group, only 55.1 % of patients underwent PU risk screening. After the intervention, the frequency increased to 87.2 %. Since two different assessments were used in the ICU before the start of the project (NSRAS for premature and newborn infants; Braden-Q for children older than 4 weeks), the screening results are difficult to compare. When the two assessments in the pre-intervention group were combined, a moderate to high risk was identified in a total of 58.8 %. In the post-intervention group, it was significantly lower (36.8 %). Although risk was identified more frequently in the pre-intervention group, 23.8 % of the documented PUs were classified as grade 2, while only grade 1 PUs occurred in the post-intervention group.

Unfortunately, unlike other studies^17,19,25, we were not able to achieve a reduction in PUs in the post-intervention group. We attribute this to the fact that, before the Quality Improvement Project, the documentation of grade 1 pressure ulcers was very rarely carried out. Current literature²⁶ reports that documentation is one of the most frequently missed elements of nursing care. Through training and emphasising the importance of adequate documentation, nurses were made aware of the need to document PUs in patient records. This is (probably) the reason why higher PU rates were recorded in our study.

Limitations

Our study has several limitations. First, the low level of evidence provided by the retrospective, single-center design chosen should be mentioned. Second, it is difficult to compare the pre- and post-intervention groups in terms of risk assessments, as significantly different instruments with different ratings were used. Third, it was clear during data extraction that grade 1 PUs in particular were hardly documented before the project, which led to a distortion of the results. Fourth, we focused our data collection on the overall impact of the quality improvement project and did not check which of the recommended interventions from the guideline were carried out by nurses.

Conclusion

Preventing pressure ulcers offers numerous benefits, including shorter hospital stays, lower costs and reduced pain and suffering for children. Our Quality Improvement Project demonstrates that the high relevance of PU prevention can be shown by implementing various measures and training nursing staff. This resulted in a higher frequency of PU-risk screenings. The implementation of evidence-based interventions led to a zero incidence of grade 2 pressure ulcers in the post-intervention group. Even though the total number of PUs has increased, the project has led to a significant improvement in adequate documentation.

Implications for clinical practice

• Nurses must be aware of causes, risks and prevention strategies for PU to provide high-quality care
• The implementation of assessments and evidence-based practice guidelines enables the reduction of higher-grade PUs
• For the implementation of PU prevention in children, it is recommended to bundle interventions

Further research

Currently available literature on pressure ulcers in children is mainly limited to monocentric intervention studies. In order to obtain better evidence on this topic, there is a high need for randomised controlled multicentre studies. In addition, due to the bundled interventions in most of the studies, it is often unclear which specific measures actually led to a reduction in pressure ulcers. For this reason, it is recommended that further research examine the individual interventions separately.

Author contributions

Conception and design: LB, StS, CR. Data analysis and interpretation: LB, JW, SiS. Manuscript draft: LB, StS; Critical revision of the manuscript: LB, StS, JW, SiS, CR. Final approval of the manuscript: LB, StS, JW, SiS, CR.

Conflict of Interest

The authors declare no conflicts of interest.

Funding

The authors received no funding for this study.

Author(s)

Lydia Bauernfeind¹* PhD, RN, Stefan Schoenstein¹ MSc, RN, Julia Wistl² BSc, RN, Simon Schoenbrunner² BSc, RN, Christian Rester¹ PhD, RN
¹ Faculty of Advanced Healthcare Sciences, Deggendorf Institute of Technology, Germany
²Children’s Hospital Dritter Orden Passau, Technical University Munich, Germany

*Corresponding author email lydia.bauernfeind@th-deg.de

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