SKIN INTEGRITY IN CRITICALLY ILL AND INJURED CHILDREN. Evidence-Based Practice in Critical Care

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1 Evidence-Based Practice in Critical Care SKIN INTEGRITY IN CRITICALLY ILL AND INJURED CHILDREN By Christine A. Schindler, RN, MSN, CPNP-AC, Theresa A. Mikhailov, MD, Kay Fischer, RN, MSN, Gloria Lukasiewicz, RN, MS, Evelyn M. Kuhn, PhD, and Linda Duncan, RN Background Skin breakdown increases the cost of care, may lead to increased morbidity, and has negative psychosocial implications because of secondary scarring or alopecia. The scope of this problem has not been widely studied in critically ill and injured children. Objectives To determine the incidence of skin breakdown in critically ill and injured children and to compare the characteristics of patients who experience skin breakdown with those of patients who do not. Methods Admission and follow-up data for a 15-week period were collected retrospectively on children admitted to a large pediatric intensive care unit. The incidence of skin breakdown was calculated. The risk for skin breakdown associated with potential risk factors (relative risk) and 95% confidence intervals were determined. Results The sample consisted of 401 distinct stays in the intensive care unit for 373 patients. During the 401 stays, skin breakdown occurred in 34 (8.5%), redness in 25 (6.2%), and breakdown and redness in 13 (3.2%); the overall incidence was 18%. Patients who had skin breakdown or redness were younger, had longer stays, and were more likely to have respiratory illnesses and require mechanical ventilatory support than those who did not. Patients who had skin breakdown or redness had a higher risk of mortality than those who did not. Conclusions Risk factors for skin breakdown were similar to those previously reported. Compared with children of other ages, children 2 years or younger are at higher risk for skin breakdown. (American Journal of Critical Care. 2007;16: ) 568 AJCC AMERICAN JOURNAL OF CRITICAL CARE, November 2007, Volume 16, No. 6

2 Outstanding skin care is a nurse-sensitive outcome measure established by the American Nurses Association. 1 Maintaining skin integrity in the critical care environment is difficult because of the acuity of the patients and the highly invasive interventions and therapies they receive. The prevalence, prevention, and treatment of skin breakdown in adults have been widely studied. 2-5 Validated risk assessment tools, such as the Braden Scale, 6 are used in adults to identify patients at risk for pressure ulcers. Pediatric nurses continue to extrapolate from the literature on skin integrity in adults even though the information and methods may not fully meet the needs of infants and children. 7 Recently, more research has been done on skin breakdown in children. For example, Quigley and Curley 7 developed the Braden Q Scale for use in children, and Curley et al 8 reported that the performance of the Braden Q Scale in children is similar to the performance of the Braden scale in adults. The prevalence of pressure ulcers in infants and children was as high as 13.1% in a descriptive study 9 from a single institution and as low as 4% in a descriptive multisite study. 10 In another multisite study, 11 the incidence of pressure ulcers in patients in the pediatric intensive care unit (PICU) was 27%; however, children with congenital heart disease were not included in the study. The prevalence studies also indicated that children experience numerous skin problems in addition to pressure ulcers. Other types of skin breakdown not related to pressure in infants and children include diaper dermatitis, skin tears, and extravasation of fluid being infused intravenously. 10 Previously reported risk factors for development of pressure ulcers include cardiac arrest after cardiothoracic surgery, extracor - poreal membrane oxygenation in neonates, higher risk of mortality according to scores on the Pediatric About the Authors Christine A. Schindler is a pediatric critical care nurse practitioner and Theresa A. Mikhailov is a pediatric intensivist in the Division of Pediatric Critical Care, Medical College of Wisconsin, Children s Hospital of Wisconsin, Milwaukee. Kay Fischer is the patient care manager and Linda Duncan is a clinical enhancements and quality coordinator in the pediatric intensive care unit at Children s Hospital of Wisconsin. Gloria Luka siewicz is a National Association of Childrens Hospitals and Related Institutions analyst III and Evelyn M. Kuhn is a biostatistician at National Outcomes Center, Inc, Children s Hospital and Health Systems, Milwaukee, Wisconsin. Corresponding author: Christine Schindler, Children s Hospital of Wisconsin, PO Box 1997, Milwaukee, WI MS 681 ( cschindl@mcw.edu). Risk of Mortality 2 (PRISM 2) instrument, white race/ethnicity, edema, PICU length of stay longer than 96 hours, increasing positive end-expiratory pressure, not turning the patient or not using a specialty bed in the turning mode, weight loss, and use of high-frequency oscillatory ventilation The potential impact of skin breakdown is great in cost and human suffering. Children in the PICU are at high risk for skin breakdown, but the true incidence of this condition in this population is unknown. The purposes of our study were to explore the scope of skin breakdown in patients in the PICU and to determine the characteristics of those who had skin breakdown. Our objectives were to determine the incidence of skin breakdown, to compare the characteristics of patients who did and did not have skin breakdown, and to evaluate the sensitivity and specificity of the Braden Q Scale for predicting skin breakdown in critically ill and injured children. Materials and Methods Setting This prospective cohort study was conducted in the PICU at Children s Hospital of Wisconsin, a large tertiary care center in Milwaukee. The hospital s institutional review board approved the research protocol. Consent from parents and assent of children were waived. Sample and Study Period Each patient admitted to the PICU from April 15 through July 15, 2005, was enrolled in the The Braden Q, used in pediatrics, performs similarly to the Braden scale used in adults. In addition to pressure ulcers, children experience diaper dermatitis, skin tears, and IV extravasations. AJCC AMERICAN JOURNAL OF CRITICAL CARE, November 2007, Volume 16, No

3 Table 1 Characteristics of the sample Characteristic No. of distinct intensive care unit admissions No. of patients Sex Male Female Age, y 1 >1 but 3 >3 but 6 >6 but 11 >11 but 16 >16 but 20 >20 Race/ethnicity b African American American Indian Asian/Pacific Islander White Hispanic Other/mixed Risk of mortality, c mean (SD) Length of stay, mean (SD), d Higher risk of mortality was associated with development of skin breakdown or redness. Younger children and those with a longer length of stay had higher rates of skin breakdown and redness. Value a (54) 84 (46) 120 (29.9) 54 (13.5) 41 (10.2) 52 (13.0) 74 (18.5) 47 (11.7) 13 (3.2) 68 (17.3) 5 (1.3) 12 (3.1) 243 (61.7) 40 (10.2) 26 (6.6) 0.06 (0.15) 4.1 (8.9) a Unless indicated otherwise, values are number of admissions (%). Because of rounding, percentages do not all total 100. b Data missing for 7 patients. c Based on scores on the Pediatric Risk of Mortality 2. study; data were collected from April 15 through July 30, 2005, for every patient who remained in the PICU at the end of the study period. No patients were excluded from the study because our intention was to gain an understanding of the problem regardless of diagnosis, sex, race/ethnicity, age, or length of stay. Data Collection All data collected were entered in the Virtual PICU Performance System (VPS) database. Admission data included demographic characteristics: patient s date of birth, age at admission, sex, race/ethnicity, medical record number, primary diagnosis, and admission and discharge dates. The PRISM 2 score was used to classify the severity of illness. This score is calculated on the basis of 14 separate physiological indicators collected during the first 24 hours of admission and is predictive of risk for mortaity. 17 Follow-up data included secondary diagnoses, clinical and therapeutic characteristics (cardiac or respiratory arrest, noninvasive ventilatory support, mechanical ventilation, high-frequency oscillatory ventilation, inotropic support, and extracorporeal membrane oxygenation), daily Braden Q scores (see Appendix), and documented skin breakdown (type and description). At the time of the study, PICU nurses did not use a standard grading scale for pressure ulcers. Instead, they indicated the location of skin breakdown on a graphic representation of a child and then described the area in the integumentary section of the flow sheet. Protocol Each PICU nurse was required to attend an inservice review of the Braden Q Scale, its clinical applications, and appropriate documentation. Quick reference cards on the scale were placed in each chart to facilitate appropriate documentation. Before the study started, nursing flow sheets were updated to include more detailed assessment and intervention data. Skin assessments made by using the Braden Q Scale were completed by the nursing staff for each patient at the time of each admission and again every 24 hours throughout the PICU stay. Location and type of skin breakdown were documented on the flow sheet. Data Analysis For continuous variables, such as the PRISM 2 scores and PICU length of stay, means and standard deviations were calculated. The incidence of skin breakdown was calculated. The association between skin breakdown and potential risk factors (relative risk) and 95% confidence intervals were determined. Statistical significance was determined by using χ 2 analysis. Unpaired t tests were used to compare the risk of mortality (based on PRISM 2 scores) and PICU length of stay between patients who did or did not have skin breakdown. Patterns of scores on the Braden Q Scale were described. Analyses were conducted by using SAS, version 8.2 (SAS Institute Inc, Cary, North Carolina), and SPSS, version 11.5 (SPSS Inc, Chicago, Illinois). P values less than.05 were considered significant for all statistical comparisons. Multiple logistic regression was used to assess the simultaneous effects of multiple risk factors. Results The study sample consisted of 401 distinct ICU stays for 373 patients (Table 1). During these 401 stays, skin breakdown occurred in 34 (8.5%), redness in 25 (6.2%), and breakdown and redness in 570 AJCC AMERICAN JOURNAL OF CRITICAL CARE, November 2007, Volume 16, No. 6

4 13 (3.2%) at some point during the stay; the overall incidence was 18%. In the univariate analysis, risk factors associated with skin breakdown or redness included age 2 years or younger, length of stay 4 days or longer, requirement for mechanical ventilation, and a respiratory diagnosis at admission (Table 2). A higher risk of mortality (based on PRISM 2 scores) also was associated with development of skin breakdown or redness: 12.3% in patients with skin breakdown or redness and 4.6% in those without (unpaired t test, P <.001). Factors not associated with skin breakdown or redness included race/ethnicity, sex, requirement for bilevel positive airway pressure, and Braden Q score less than 16 (Table 2). We also evaluated surgical patients (both cardiac and noncardiac) and determined that surgery itself was not a risk factor for skin breakdown (Table 2). According to multivariate analysis, controlling for race/ethnicity, sex, and severity of illness (PRISM 2 score), age 2 years or younger and length of stay 4 days or longer were strongly associated with skin breakdown or redness (Table 3, model 1). These associations remained unaffected when use of mechanical ventilation in addition to race/ethnicity, sex, and severity of illness were controlled for (Table 3, model 2). At least one Braden Q score was entered at some time for 324 (81%) of the 401 ICU stays, and a Braden Q score was entered for 68% (1442/2121) of potential assessment days. On the first day of skin breakdown, the Braden Q score, which is predictive of pressure ulcers, was less than 16 in 8 of 31 ICU stays (25.8%). On the first day that the Braden Q score was less than 16, which is predictive of pressure ulcers, 9 out of 98 (9.2%) had skin breakdown and 2 of 98 (2.0%) had skin redness. We did not have sufficient data to evaluate the sensitivity and specificity of the Braden Q score for predicting skin breakdown in critically ill and injured children. Discussion Skin integrity is a nurse-sensitive outcome, and in the critical care environment, skin breakdown is a substantial iatrogenic injury. In our study, the incidence of skin breakdown or redness was 18%, which is similar to previously reported data. 11 Furthermore, younger age and longer stay in the PICU were associated with increased risk for skin breakdown or redness. Both of these risk factors have been previously identified. 13 These characteristics should help nurses target their interventions to those children who are at higher risk for breakdown. Our findings on skin integrity in critically ill and injured children differ from findings in other studies Table 2 Association of potential risk factors with skin breakdown or redness (univariate analysis) Factor Relative risk 95% CI P White vs other Sex Age 1 vs >1 year Age 2 vs >2 years Length of stay 2 days or longer Length of stay 4 days or longer Respiratory admission Bilevel positive airway pressure Mechanical ventilation Braden Q score <16 Surgery (noncardiac) Surgery (cardiac) Table 3 Association of potential risk factors with skin breakdown or redness (multivariate analysis) Model 1 a Effect Odds ratio 95% CI P Sex (male) Race/ethnicity (white) Risk of mortality b Age 2 years or younger Length of stay 4 days or longer Model 2 c Sex (male) Race/ethnicity (white) Risk of mortality b Mechanical ventilation Age 2 years or younger Length of stay 4 days or longer on hospitalized children. Previous researchers 13,16 identified mechanical ventilation as a risk factor for skin breakdown. In our study, mechanical ventilation was significant in the univariate analysis but not in the multivariate analysis. In addition, our findings did not support white race/ethnicity as a significant risk factor for the development of skin breakdown or redness. We hypothesized that bilevel positive airway pressure would be a risk factor, but this hypothesis Effect Odds ratio 95% CI P a Controlling for sex, race/ethnicity, and severity of illness. b Based on scores on the Pediatric Risk of Mortality 2. c Controlling for sex, race/ethnicity, severity of illness, and mechanical ventilation. AJCC AMERICAN JOURNAL OF CRITICAL CARE, November 2007, Volume 16, No

5 Table 4 Recommendations of the National Pressure Ulcer Advisory Panel for grading pressure ulcers 18 Stage I II III IV Nonblanchable erythema not resolving within 30 minutes of pressure relief; epidermis remains intact Partial-thickness loss of skin layers involving epidermis and possibly penetrating into but not through dermis; may present as blistering Full-thickness tissue loss extending through the dermis to involve subcutaneous tissue Deep tissue destruction extending through subcutaneous tissue to fascia; may involve muscle layers, joint, and/or bone Among 401 PICU patients, overall incidence of skin breakdown was 18%. Description was not supported. Our sample size may have been too small to show these associations. Our study had insufficient power to detect a statistically significant effect (relative risk) for some risk factors if we assume that the true relative risk is the one found in the study. For example, the power to detect a relative risk of 1.73 for bilevel positive airway pressure (Table 2) when the proportion of patients treated with bilevel positive airway pressure is 5% was only The power to detect the relative risk of 1.41 for cardiac surgery, when the proportion of patients with cardiac surgery is 29%, was Limitations of the study include missing data on Braden Q scores (because of a lack of adherence to the study protocol) and a lack of data on the pressure ulcer grading in those children who had skin breakdown or redness. Consequently, we could not evaluate the sensitivity and specificity of Braden Q scores for predicting development of pressure ulcers in critically ill and injured children. Although skin integrity has been identified as an important nurse- sensitive outcome measure, 1 we hypothesize that skin assessment and comprehensive documentation may generally be a lower priority in the critical care environment, especially during the initial admission and stabilization phase. Our findings helped identify several gaps in education and documentation within the PICU that were addressed after the results were analyzed. The PICU nurses had a knowledge deficit related to grading pressure ulcers, because no formal grading system was used within the unit. To address this need, we adopted the recommendations of the National Pressure Ulcer Advisory Panel 18 (Table 4). An online self-study was developed to review the grading system for pressure ulcers and its clinical applications. Each nurse was required to complete the self-study and then a test to demonstrate basic competency. The nursing flow sheet did not include an area to document pressure ulcer grading or a sufficient area to document nursing interventions specifically related to skin care. The flow sheet was revised to address both of these needs, and documentation was reviewed during the annual nursing education day. The results of our study were communicated to the staff during staff meetings, and to improve compliance with documentation, members of the clinical practice committee conducted audits of the skin-related documentation. Further research is needed on skin integrity to improve patients outcomes. In particular, the validity of the Braden Q Scale as a risk assessment tool in children after cardiac surgery and in other hospitalized children should be explored. Further research also is needed to evaluate the protective strategies that nurses are currently using to prevent skin breakdown. A multicenter study in collaboration with the PICU focus group of the National Association of Children s Hospitals and Related Institutions is in progress to address these concerns. Intensity and Duration of Pressure Score Mobility The ability to change and control body position 1. Completely immobile: Does not make even slight changes in body or extremity position without assistance 2. Very limited: Makes occasional slight changes in body or extremity position but unable to completely turn self independently 3. Slightly limited: 4. No limitations: Makes frequent though Makes major and frequent changes in posi- slight changes in body or extremity position tion without assistance independently Appendix The Braden Q Scale. Reprinted from Quigley and Curley, 7 with permission. Continued 572 AJCC AMERICAN JOURNAL OF CRITICAL CARE, November 2007, Volume 16, No. 6

6 Activity The degree of physical activity 1. Bedfast: Confined to bed Intensity and Duration of Pressure 2. Chair fast: Ability to walk severely limited or nonexistent. Cannot bear own weight and/or must be assisted into chair or wheelchair 3. Walks occasionally: Walks occasionally during day, but for very short distances, with or without assistance. Spends majority of each shift in bed or chair 4. All patients too young to ambulate or walks frequently: Walks outside the room at least twice a day and inside room at least once every 2 hours during waking hours Score Sensory perception The ability to respond in a developmentally appropriate way to pressure-related discomfort Moisture Degree to which skin is exposed to moisture Friction and Shear Friction: occurs when skin moves against support surfaces Shear: occurs when skin and adjacent bony surface slide across one another Nutrition Usual food intake pattern Appendix continued 1. Completely limited: Unresponsive (does not moan, flinch, or grasp) to painful stimuli, due to diminished level of consciousness or sedation or limited ability to feel pain over most of body surface 1. Constantly moist: Skin is kept moist almost constantly by perspiration, urine, drainage, etc. Dampness is detected every time patient is moved or turned 1. Significant problem: Spasticity, contracture, itching, or agitation leads to almost constant thrashing and friction 1. Very poor: NPO and/or maintained on clear liquids, or IVs for more than 5 days or albumin <2.5 mg/dl or never eats a complete meal. Rarely eats more than 1/2 of any food offered. Protein intake includes only 2 servings of meat or dairy products per day. Takes fluids poorly. Does not take a liquid dietary supplement 2. Very limited: Responds only to painful stimuli. Cannot communicate discomfort except by moaning or restlessness or has sensory impairment which limits the ability to feel pain or discomfort over 1/2 of body 2. Very moist: Skin is often, but not always moist. Linen must be changed at least every 8 hours 2. Problem: Requires moderate to maximum assistance in moving. Complete lifting without sliding against sheets is impossible. Frequently slides down in bed or chair, requiring frequent repositioning with maximum assistance 2. Inadequate: Is on liquid diet or tube feedings/tpn which provide inadequate calories and minerals for age or albumin <3 mg/dl or rarely eats a complete meal and generally eats only about 1/2 of any food offered. Protein intake includes only 3 servings of meat or dairy products per day. Occasionally will take a dietary supplement 3. Slightly limited: Responds to verbal commands, but cannot always communicate discomfort or need to be turned or has some sensory impairment which limits ability to feel pain or discomfort in 1 or 2 extremities Tolerance of the Skin and Supporting Structure 3. Occasionally moist: Skin is occasionally moist, requiring linen change every 12 hours 3. Potential problem: Moves freely or requires minimum assistance. During a move, skin probably slides to some extent against sheets, chair, restraints, or other devices. Maintains relative good position in chair or bed most of the time but occasionally slides down 3. Adequate: Is on tube feedings or TPN, which provide adequate calories and minerals for age or eats over half of most meals. Eats a total of 4 servings of protein (meat, dairy products) each day. Occasionally will refuse a meal, but will usually take a supplement if offered 4. No impairment: Responds to verbal commands. Has no sensory deficit which limits ability to feel or communicate pain or discomfort 4. Rarely moist: Skin is usually dry, routine diaper changes, linen only requires changing every 24 hours 4. No apparent problem: Able to completely lift patient during a position change. Moves in bed and in chair independently and has sufficient muscle strength to lift up completely during move. Maintains good position in bed or chair at all times 4. Excellent: Is on a normal diet providing adequate calories for age. For example: eats/drinks most of every meal/feeding. Never refuses a meal. Usually eats a total of 4 or more servings of meat and diary products. Occasionally eats between meals. Does not require supplementation Continued AJCC AMERICAN JOURNAL OF CRITICAL CARE, November 2007, Volume 16, No

7 Tolerance of the Skin and Supporting Structure Score Tissue perfusion and oxygenation Appendix continued 1. Extremely compromised: Normotensive; oxygen 2. Compromised: Hypotensive (MAP saturation may be <50mmHg; <40 in a <95% or hemoglobin newborn) or the patient may be <10 mg/dl or does not physiologically capillary refill may be tolerate position changes >2 seconds. Serum ph is < Adequate: Normotensive; oxygen saturation may be <95% or hemoglobin may be <10 mg/dl or capillary refill may be >2 seconds. Serum ph is normal 4. Excellent: Normotensive, oxygen saturation >95%; normal hemoglobin; and capillary refill <2 seconds Total: ACKNOWLEDGMENTS We gratefully acknowledge Dr Thomas B. Rice, chief of the Division of Critical Care Medicine, for his support. We also acknowledge the members of the PICU focus group of the National Association of Children s Hospitals and Related Institutions for identifying skin care in infants and children as an important research area. We thank our nursing colleagues at Children s Hospital of Wisconsin for their continued work to improve the quality of care delivered in the PICU. Finally, we acknowledge the Department of Advanced Practice Nursing and Research for its support, with a special thanks to the director, Shelly Malin, RN, PhD, for her ongoing support of the project. FINANCIAL DISCLOSURES None reported. eletters Now that you ve read the article, create or contribute to an online discussion about this topic using eletters. Just visit and click Respond to This Article in either the full-text or PDF view of the article. REFERENCES 1. American Nurses Association. Nursing Report Card for Acute Care. Washington, DC: American Nurses Association; Schue RM, Langemo DK. Pressure ulcer prevalence and incidence and a modification of the Braden Scale for a rehabilitation unit. J Wound Ostomy Continence Nurs. 1998;25(1): Hunter S, Anderson J, Hanson D, Thompson P, Langemo D. Klug MG. Clinical trial of prevention and treatment protocol for skin breakdown in two nursing homes. J Wound Ostomy Continence Nurs. 2003;30(5): Clever K, Smith G, Bowser C, Monroe K. Evaluating the efficacy of a uniquely delivered skin protectant and its effect on the formation of sacral/buttock pressure ulcers. Ostomy Wound Manage. 2002;48(12): Cole L, Nesbitt C. A three-year multiphase pressure ulcer prevalence/incidence study in a regional referral hospital. Ostomy Wound Manage. 2004;50(11):32, 34, 36-38, Defloor T, Grypdonck MF. Pressure ulcers: validation of two risk assessment scales. J Clin Nurs. 2005;14(3): Quigley SM, Curley MAQ. Skin integrity in the pediatric population: preventing and managing pressure ulcers. J Soc Pediatr Nurs. 1996;1(1): Curley MAQ, Razmus IS, Roberts KE. Wypij D. Predicting pressure ulcer risk in pediatric patients. Nurs Res. 2003;52(1): Groeneveld A, Anderson M, Allen S, et al. The prevalence of pressure ulcers in a tertiary care pediatric and adult hospital. J Wound Ostomy Continence Nurs. 2003;31(3): McLane KM, Bookout K, McCord S, McCain J, Jefferson LS. The 2003 national pediatric pressure ulcer and skin breakdown prevalence study: a multisite study. J Wound Ostomy Continence Nurs. 2004;31(4): Curley MAQ, Quigley SM, Lin M. Pressure ulcers in pediatric intensive care: incidence and associated factors. Pediatr Crit Care Med. 2003;4(3): Gershan LA, Esterly NB. Scarring alopecia in neonates as a consequence of hypoxaemia-hypoperfusion. Arch Dis Child. 1993;68(5): McCord S, McElvain V, Sachdeva R, Schwartz P, Jefferson LS. Risk factors associated with pressure ulcers in the pediatric intensive care unit. J Wound Ostomy Continence Nurs. 2004;31(4): Neidig JRE, Kleiber C, Oppliger RA. Risk factors associated with pressure ulcers in the pediatric patient following openheart surgery. Prog Cardiovasc Nurs. 1989;4(3): Schmidt JE, Berens RJ, Zollo MB, Weisner M, Weigle CGM. Skin breakdown in children and high-frequency oscillatory ventilation. Arch Phys Med Rehabil. 1998;79: Zollo MB, Gostisha ML, Berens RJ, Schmidt JE, Weigle CG. Altered skin integrity in children admitted to the pediatric intensive care unit. J Nurs Care Qual. 1996;11(2): Tibby SM, Taylor D, Festa M, et al. A comparison of three scoring systems for mortality risk among retrieved intensive care patients. Arch Dis Child. 2002;87(5): National Pressure Ulcer Advisory Panel. Pressure ulcers prevalence, cost and risk assessment: consensus development conference statement. Decubitus. 1989;2(2): To purchase electronic or print reprints, contact The InnoVision Group, 101 Columbia, Aliso Viejo, CA Phone, (800) or (949) (ext 532); fax, (949) ; , reprints@aacn.org. 574 AJCC AMERICAN JOURNAL OF CRITICAL CARE, November 2007, Volume 16, No. 6