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Skin Care Team in the Pediatric Intensive Care Unit: A Model for Excellence

2008; American Association of Critical-Care Nurses; Volume: 28; Issue: 2 Linguagem: Inglês

10.4037/ccn2008.28.2.125

1940-8250

Tracy Ann Pasek, Amanda Geyser, Maria Sidoni, Patricia Harris, Julia A. Warner, Ann Spence, Allison Trent, Libby Lazzaro, Julianne Balach, Alicia Bakota, Shana Weicheck,

Infection Control and Ventilation

A team committed to a specific entity such as skin care can enhance resource availability, communication, and follow-through.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.3Indeed, 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.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.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.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.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.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.12For 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.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.13Decisions 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).Consider the following scenarios.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.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.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%.14Last, 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.We are grateful to Janet Aradine, rn, msn, clinical effectiveness specialist, Children’s Hospital of Pittsburgh of University of Pittsburgh Medical Center.