Critical Care Nurse. 2008;28: 125-135
Copyright © 2008 by the American Association of Critical-Care Nurses.
Pediatric Care
Skin Care Team in the Pediatric Intensive Care Unit: A Model for Excellence
Tracy Ann Pasek, RN, MSN, CCRN
Amanda Geyser, RN, BSN
Maria Sidoni, RN, BSN
Patricia Harris, RN, BSN, CCRN, CWOCN, CCTN
Julia A. Warner, RN, CWOCN, CFCN
Ann Spence, RN, MS
Allison Trent, RN, BSN, WOCN
Libby Lazzaro, RN, BSN
Julianne Balach, RN
Alicia Bakota, RN, BSN
Shana Weicheck, RN, BSN
All authors are from Children’s Hospital of Pittsburgh, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania. Tracy Ann Pasek is an advanced practice nurse in the pediatric intensive care unit. Amanda Geyser and Julianne Balach are clinical leaders in the pediatric intensive care unit. Maria Sidoni, Libby Lazzaro, Alicia Bakota, and Shana Weicheck are professional staff nurses in the pediatric intensive care unit. Patricia Harris and Julia A. Warner are certified wound ostomy care nurses. Ann Spence was a performance improvement specialist and Allison Trent was a wound ostomy care nurse when this article was originally submitted for publication.
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To learn more about skin care in critically ill children, read "Skin Integrity in Critically Ill and Injured Children" by
Christine A. Schindler, Theresa A. Mikhailov, Kay Fischer, Gloria Lukasiewicz, Evelyn M. Kuhn, and Linda Duncan in the American Journal of Critical Care, 2007;16(5):568–574.[Abstract/Free Full Text]
Available online at www.ajcconline.org.
Financial Disclosures
None reported.
Corresponding author: Tracy Pasek, RN, MSN, CCRN, Pediatric Intensive Care Unit, Children’s Hospital of Pittsburgh, 3705 Fifth Ave, Pittsburgh, PA 15213-2583 (e-mail: tracy.pasek{at}chp.edu).
The skin is the largest organ of the body and has many complex functions.1 Intact skin is a barrier to infection; thus, alteration in skin integrity predisposes patients to infection and poor outcomes. Pressure ulcers are an important iatrogenic problem in health care with substantial financial costs.2,3 In a study of adverse events, Cho et al4 reported that pressure ulcers had the greatest effect on length of stay, with a 1.84-fold increase in stay for patients with such ulcers. Among the 7 groups of adverse events examined, pressure ulcers were the third most significant determinant of increased costs, after sepsis and pneumonia.4 Impaired perfusion, altered nutrition, unstable hemodynamic status, limited mobility, immunosuppression, and medications contribute to risk associated with altered skin integrity for critically ill children. Immature bowel and bladder control and large heads are inevitable contributory risk factors specific to children. Concomitant pain and altered appearance are physical and emotional burdens for patients and families already experiencing stress associated with hospitalization in a pediatric intensive care unit (PICU).
Pressure ulcers have an incidence of 7% and a prevalence of 7% among acutely ill children.5 The occurrence of pressure ulcers is associated with nutritional status, mobility, and level of consciousness. In infants and young children, pressure ulcers occur most often on the head and heels.5 Noonan et al3 reported a 27% incidence of pressure ulcers, of which 32% of the more significant ulcers involved the head. Fifty-seven percent of all ulcers were detected during the first skin assessment on the second day in the PICU.3
Indeed, children who are patients in a technology-rich environment such as a PICU may experience pressure ulcers early in hospitalization.6 Moreover, the adverse effects of immobility and physiological instability on a patient’s skin do not discriminate by age or developmental level.6 Noonan et al3 reported that more than 50% of medical devices that contributed to pressure-related skin injuries were pulse oximetry probes, artificial airways, and masks for bilevel positive airway pressure (BiPAP). These devices are often placed when the patient is admitted to a PICU, so tracking quality of care is imperative to prevent and identify problems.
Consumers are encouraged to learn about the law in relation to adverse health events and reporting. Bedsores are considered an adverse health event.7 Health care providers’ assessment methods and prevention strategies are defined and described so that consumers are empowered to make safe health care decisions. For example, a recent consumer report7 from the Minnesota Department of Health includes an easy-to-read pie chart indicating that serious bedsores account for 43% of adverse health events.
Benchmark data are available to pediatric critical care nurses. Moreover, skin care is a nursing research priority.8 Yet life-saving measures may preclude attention to less emergent skin and wound therapies in a critical care setting. At Children’s Hospital of Pittsburgh, in Pennsylvania, a large tertiary care hospital, a unit-based skin care team was established in the PICU. The team strives to maintain skin care as a top priority, thereby modeling excellence in skin care.
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Purpose of a PICU Skin Care Team
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A PICU skin care team provides a core group with the expertise to provide care for patients with complex and variable skin care needs. In a high-acuity unit with approximately 140 professional staff nurses, a team committed to a specific entity such as skin care enhances resource availability, communication, and follow-through. Nurses provide direct patient care, conduct staff education, promote policy, and lead evidence-based initiatives. The team members or "champions" proactively identify and avert potential adverse clinical outcomes.
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Structure of the Skin Care Team
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The PICU skin care team is made up of professional staff nurses. An advanced practice nurse and clinical leader direct the team. Two certified wound ostomy care nurses (CWOCNs) support the team as consultants. The advanced practice nurse has pain as a specialty, augmenting skin care with comfort as another important team focus.
Selection of new nurses for the skin care team is a joint effort between PICU leaders and nurses currently on the team; consideration is given to having members representative of all shifts and of weekend staffing. Because expertise is primarily developed through direct patient care, modest effort is directed at limiting the team’s size to approximately 8 nurses. This limitation increases the number of opportunities for nurses to lead and participate in rounds.
The PICU skin care team is accountable to 2 hospital councils—a nurse skin care council made up of nurses from all inpatient care areas and a nurse practice council. Skin-and wound-related initiatives involving prescribed medication require approval by the hospital’s pharmacy and therapeutics committee.
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Skin Care Rounds
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Skin care rounds take place each Tuesday morning. Preparation begins with the clinical leader Monday night. Skin assessment findings, plans of care, and Braden Q scores (documented every 12 hours within the critical care service center) are routine components of the change-of-shift report (Table 1
). This information is recorded by the night clinical leader or charge nurse and is used by the skin care team during rounds the next morning.
Routinely conducting rounds early in the week yields consistency for PICU staff and provides the remainder of the week for follow-up of patients. The team cares for as many as 31 patients during rounds, a process that often consumes 3 to 4 hours. An 8-week schedule is posted to identify nurses to serve as rounds leaders. The schedule is determined in collaboration with the unit’s scheduling committee. The nurse who leads rounds is not assigned a patient for the first 4 hours of the Tuesday daylight shift (7 AM to 11 AM).
The team accomplishes a variety of work (Table 2). At the conclusion of rounds, either the professional staff nurse leader or the advanced practice nurse prepares an electronic summary and disseminates it to all PICU nurses (Table 3). For patients who are off the unit for operative or diagnostic procedures or whose condition is too unstable for a full skin assessment, a member of the team returns later in the day to complete rounds.
A full skin assessment includes but is not limited to the examinations listed in Table 4 as applicable. A member of the team asks to be called for complex dressing changes scheduled to happen during times other than rounds (eg, a fasciotomy dressing at 2 PM). Bedside nurses communicate valuable information, augmenting the team’s assessments.
A skin care supply bag (Figure 1 and Table 5) is carried by the team to enhance product procurement for nurses and to minimize unnecessary, time-consuming trips to the supply room. Busy nurses appreciate on-the-spot delivery of products. Keeping the bag stocked and monitoring expiration dates of supplies are tasks well suited to new team members. Working with skin care supplies fosters familiarity with products.
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Table 5 Items in skin care supply bag (Specify quantity of each, include list inside bag, and adapt to your unit’s needs)
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Education of Nursing Staff
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The skin care team assumes responsibility for education of nursing staff. Venues for such education include in-service training (eg, process for "windowing" or "picture framing" a site for central catheter insertion with transparent and hydrocolloid dressings), updates at monthly staff meetings (eg, new products), electronic management updates (reminders to document Braden Q scores), and bedside education (eg, explaining how to operate a vacuum-assisted wound closure device). New PICU nurses are required to attend skin care rounds 1 time as part of a nurse residency program or orientation. Less urgent or supplemental information is reserved for the PICU edition of a critical care newsletter11 (Figure 2). Skin care may be the topic of monthly critical care evidence-based review clubs or journal clubs. Educating physicians about support surface indications is a primary role of the hospital’s CWOCNs, but nurses on the skin care team also share in this responsibility.
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Figure 2 Pediatric intensive care unit (PICU) edition of critical care newsletter.
Reprinted with permission from Children’s Hospital of Pittsburgh.
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Performance Improvement
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Hospital-wide prevalence rounds occur monthly. Skin impairment is recorded on prevalence day, the first Tuesday of each month. Data are submitted to the quality services department and reviewed as part of the hospital’s report card (Figure 3). They serve as a gauge for benchmarking against other hospitals of like size and acuity level. The prevalence form reflects new definitions from the National Pressure Ulcer Advisory Panel.12
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Figure 3 Skin integrity prevalence form.
Reprinted with permission from Children’s Hospital of Pittsburgh.
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For the first time, 2 quality indicators during fiscal year 2006 included prevention of epidermal stripping (skin tears) and prevention of BiPAP-related skin impairment (nose and other mask pressure points). Epidermal stripping was brought to the team’s attention by an increased number of reports of events related to patient safety. Both underuse of adhesive removers and the practice of taping devices (eg, urinary catheter tubing) directly to the skin instead of atop a hydro-colloid dressing were problems. During the first quarter, the incidence of epidermal stripping was 5%; in the second quarter, the incidence increased to a high of 19%. BiPAP-related skin impairment had a prevalence of 5% during the first quarter. BiPAP skin impairment was proactively adopted as a process improvement indicator in anticipation of the high-census/high-acuity respiratory illness season.
Once the underlying causes of epidermal stripping and BiPAP-related skin impairment were identified, education initiatives and refined skin care standards resulted in elimination of these problems for the remaining quarters of fiscal year 2006. This success was described at local conferences and was showcased as part of the nursing annual report of Children’s Hospital of Pittsburgh.
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Assessment of Support Surfaces
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A support surface is a bed, mattress, or seating surface that can decrease tissue interface pressure.13 The goal of a support surface is to remove localized pressure (pressure relief ) or to redistribute pressure evenly over the contact surface (pressure reduction).13 Selecting a mattress or seating surface on the basis of the assessment of a patient’s risk for pressure ulcers can be both efficacious and cost-effective.13 Regardless of the support system used and recommended for a patient, follow-up is imperative. When patients are not repositioned, pressure on bony prominences leads to skin impairment. This skin impairment does not indicate failure of a support surface to prevent breakdown.13
Decisions related to support surfaces are made by nurses. The PICU skin care team is proactive and strategic, placing patients on support surfaces depending on the evaluation of the patients’ risk for pressure ulcers. Assessment of a support surface includes determining the patient’s underlying medical condition and current medical status, the ability to safely provide pressure redistribution for the patient, the patient’s current risk score for pressure ulcers, and significant existing comorbid diseases. Support surfaces are ordered preemptively if risk for pressure ulcers is anticipated (eg, before starting continuous renal replacement therapy). Challenges include patients whose condition deteriorates too quickly to procure the best surface in time (eg, use of extracorporeal membrane oxygenation in a child). Ideally, advanced planning prevents patients in a highly unstable condition from being moved at less than optimal times.
The critical care service center has 4 low-air-loss beds. These beds are used only for critically ill patients and are ordered at the discretion of the team and the hospital’s CWOCNs. Patients’ support surface requirements are communicated as a free text message in the computerized data system. Patients with scores of 15 or less on the Braden Q scale are considered at high risk for pressure ulcers (Table 1
). Once a patient is at high risk, a PICU nurse notifies a nurse on the skin care team and decision making about selection of a support surface starts (Figure 4).
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Figure 4 Algorithm for selection of support surfaces.
Generic names: Accucair Overlay, continuous airflow system; Clinitron CII, air fluidized therapy; Clinitron Rite Hite, air fluidized therapy: head elevation, low to floor for easy exit out of bed; Egg Crate, convoluted foam overlay 2–3 in (5–8 cm) in depth: prevention; Flexicair Eclipse, mobile, 5-zoned low-air-loss bed; Geomattress, foam mattress overlay for infants <30 lb (<15 kg); Hard Crib, upgraded foam crib mattress: pressure redistribution; Magnum II, pressure redistribution for bariatric patients; Pressure Guard II, static alternating air mattress; Sheepskin, friction shear reduction; Total Care, static alternating air: pressure redistribution; Total Care Sport, alternating air: pressure redistribution; V-Cue, continuous lateral rotation therapy: low air loss, rotation, percussion, vibration.
Reprinted with permission from Children’s Hospital of Pittsburgh.
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Consider the following scenarios.
An oncology patient with unstable hemodynamic status is admitted to the PICU and requires emergent endotracheal intubation with eventual high-frequency oscillatory ventilation. Her Braden Q score is 16. This child requires a pressure redistribution support surface, but her condition prevents using this procedure. Maintenance with soft gel pillows, maximal turning as tolerated, and rigorous skin inspection can be offered to this patient until an appropriate support surface can be instituted safely.
A patient who has undergone laryngotracheal reconstruction is expected from the operating room at 3 PM. Another PICU patient will be started on continuous renal replacement therapy at 1 PM. The skin care team must evaluate current use of support surfaces and decide if other PICU patients can relinquish support surfaces or if new support surfaces must be rented. If new surfaces must be rented, then the team must evaluate company delivery time in relation to the operating room admission and continuous renal replacement therapy goals.
Nurses on the skin care team, CWOCNs, and physicians may order support surfaces. Orders and charges are tracked by the CWOCNs via a computerized system. Occasionally, a patient’s family may ask that the patient be permitted to stay on a therapeutic surface for comfort when skin and wound condition no longer warrants such treatment. These situations are thoughtfully evaluated by the involved health care providers. Gentle education is provided to help patients and their families understand the indications for use of support surfaces. Families’ requests may prevail. Once, an overlay support surface was ordered for a solid-organ transplant recipient who had severe pain from rheumatoid arthritis. Pain rather than pressure redistribution was the primary indication for a support surface.
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Influence and Future Work of the PICU Skin Care Team
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The skin care team had a primary role in developing the computerized form for collection of data on skin impairment for the hospital (Figure 5). It is an electronic rendering of the current skin integrity prevalence form (Figure 3) and may be used in the future.
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Figure 5 Computerized form used to collect data on skin impairment.
Reprinted with permission from Children’s Hospital of Pittsburgh.
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In 2006, PICU professional staff nurses reported that physicians’ orders did not include where to apply topical medications. At any given time, a critically ill child may have several topical medications ordered, which could include a combination of analgesics, antifungal medicines, antibiotics, steroids, diaper dermatitis prescriptives, and vasodilator ointments to promote wound healing. A team member collaborated with a clinical pharmacy specialist and a clinical effectiveness specialist to develop an order set for topical medications for PICU patients. This order set provides specific directions for the application of topical medications (eg, a "drop-down menu" listing face, buttocks, heels, and so on) and is being considered for hospital-wide use.
The Advanced Burn Life-Saving course was offered to nurses at the hospital in 2006. In an effort to be prepared to manage patients with minor burns and burnlike skin conditions and to learn how to apply associated dressings, nurses on the PICU skin care team were among the first to attend. Having several PICU nurses who are certified in Advanced Burn Life-Saving is also in keeping with the hospital’s plan for disaster preparedness.
The PICU skin care team’s role with intravenous therapy is expanding. The nurses collaborated with the hospital nurse intravenous team to lead hospital-wide education related to dressings at new intravenous cannulation sites. The skin care team currently manages mild cases of intravenous infiltration; a surgical service manages severe cases. The team is working with surgical physicians to improve communication when caring for shared patients. A digital camera has been purchased for the team to improve the tracking of wound healing by nurses and physicians.
A clinical effectiveness guideline for diaper dermatitis (Figure 6) is the result of a collaborative effort among CWOCNs and skin care nurses. This guideline targets prevention rather than treatment. The hospital’s prevalence rate for diaper dermatitis for 2007 is 2.5% whereas the national prevalence rate is 16% to 42%.14
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Figure 6 Clinical effectiveness guideline for prevention and treatment of diaper dermatitis.
* Physician’s order required.
Based on data from Agrawal and Sammeta,14 Baharestani,15 Gray et al.16 Hoggarth et al.17 Lund et al.18 and Lekan-Rutledge.19
Reprinted with permission from Children’s Hospital of Pittsburgh.
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Last, to assist with documentation of participation on the PICU skin care team and the hospital’s nurse skin care council, an agreement form is completed by all skin care nurses (Figure 7). The forms are kept on file with PICU leaders. These records support nurses’ annual performance reviews and clinical advancement.
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Figure 7 Agreement form completed by all nurses on the skin care team.
Reprinted with permission from Children’s Hospital of Pittsburgh.
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PRIME POINTS
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- Alteration in skin integrity predisposes patients to infection and poor outcomes.
- Pressure ulcers can almost double patients’ length of stay.
- A pediatric skin care team provides expertise, trains staff, promotes policy, and leads evidence-based initiatives.
- Having a team committed to a specific entity such as skin care enhances resource availability, communication, and follow-through.
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Acknowledgments
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We are grateful to Janet Aradine, RN, MSN, clinical effectiveness specialist, Children’s Hospital of Pittsburgh of University of Pittsburgh Medical Center.
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References
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- Halpin-Landry J. Anatomy and physiology of the skin. In: Milne CT, Corbett, LQ, Dubuc DL, eds. Wound, Ostomy, and Continence Nursing Secrets: Questions and Answers Reveal the Secrets to Successful WOC Care. Philadelphia, PA: Hanley & Belfus Inc; 2003:1–5.
- Carnevale FA. Pressure ulcers in pediatric critical care: examining the evidence. Pediatr Crit Care. 2003;4(3):383–384.
- Noonan C, Quigley S, Curley MAQ. Skin integrity in hospitalized infants and children: a prevalence survey. J Pediatr Nurs. 2006;21(6):445–453.[Medline]
- Cho SH, Ketefian S, Barkauskas VH, Smith DG. The effects of nurse staffing on adverse events, morbidity, mortality, and medical costs. Nurs Res. 2003;52(2):71–79.[Medline]
- Willock J, Hughes J, Tickle S, Rossiter G, Johnson C, Pye H. Pressure sores in children: the acute hospital perspective. J Tissue Viability. 2000;10(2):59–62.[Medline]
- Curley MAQ, Quigley SM, Ming L. Pressure ulcers in pediatric intensive care: incidence and associated factors. Pediatr Crit Care Med. 2003;4(3):284–290.[Medline]
- Minnesota Department of Health, Division of Health Policy, Adverse Health Events. Consumer guide to adverse health events. http://www.health.state.mn.us/patientsafey/publications/consumerguide.pdf. Published January 2008. Accessed March 5, 2008.
- Harrison MB, Wells G, Fisher A, Prince M. Practice guidelines for the prediction and prevention of pressure ulcers: evaluating the evidence. Appl Nurs Res. 1996;9(1):9–17.[Medline]
- Braden B, Bergstrom M. Braden Scale for predicting pressure ulcer risk. 1988. http://www.bradenscale.com/braden.PDF. Accessed March 5, 2008.
- Curley MA, Razmus IS, Roberts KE, Wypij D. Predicting pressure ulcer risk in pediatric patients: the Braden Q Scale. Nurs Res. 2003;52:22–33.[Medline]
- Pasek T. Print or store to folder? Critical care newsletter. Crit Care Nurse. 2003;23(1):88–87.[Free Full Text]
- National Pressure Ulcer Advisory Panel. NPUAP announces new pressure ulcer definition and staging. Advances in Skin and Wound Care eNews. http://www.nursingcenter.com//upload/static/403753/ASWC_BreakingNews_Feb07.htm. Published February 2007. Accessed March 5, 2008.
- Brienza DM, Geyer MJ, Sprigle S. Seating, positioning and support surfaces. In: Baranoski S, Ayello EA, eds. Wound Care Essentials: Practice Principles. Philadelphia, PA: Lippincott Williams & Wilkins; 2004:187–212.
- Agrawal R, Sammeta V. Diaper dermatitis. http://www.emedicine.com/ped/topic2755.htm. Accessed March 5, 2008.
- Baharestani MM. An overview of neonatal and pediatric wound care knowledge and considerations. Ostomy Wound Manage. 2007;53(6):34–55.[Medline]
- Gray M, Bliss D, Doughty D, Ermer-Seltun J, Kennedy-Evans K, Palmer M. Incontinence-associated dermatitis: a consensus. J Wound Ostomy Continence Nurs. 2007;34(1):45–54.[Medline]
- Hoggarth A, Waring M, Alexander J, Greenwood A, Callaghan TA. Controlled, three-part trial to investigate the barrier function and skin hydration properties of six skin protectants. Ostomy Wound Manage. 2005;51(12):30–42.[Medline]
- Lund CH, Osborne JW, Kuller J, Lane AT, Lott JW, Raines DA. Neonatal skin care: clinical outcomes of the AWHONN/NANN evidence-based clinical practice guideline. J Obstet Gynecol Neonat Nurs. 2001;30(1):41–51.[Medline]
- Lekan-Rutledge D. Management of urinary incontinence: skin care, containment devices, catheters, absorptive products. In: Doughty DB, ed. Urinary and Fecal Incontinence: Current Management Concepts. St Louis, MO: Mosby Elsevier; 2006:309–339.
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