1. Tiny Steps Towards Improving Neonatal Skin Through Prevention & Early Intervention Pamela Dozier-Young, BSN, RNC, NIC; Pamela Allen RN; June Amling, MSN, RN, CNS, CCRN As part of the nursing process, Registered Nurses have a professional obligation to advocate. The Children’s National Neonatal Intensive Care Unit established a wound team in 2007. The goal of the team is to improve patient outcome by taking a proactive approach in skin care, wound prevention, and to intervene early if necessary with skin/wound care management. Interventions: Education: CHCA 2009-2010 Key Prevention Strategies Wound Care Products used in the NICU Created a resource binder with evidence-based practice information and standardized care plans Provided “one-on-one” teaching with bedside nurses on neonatal skin/risk assessment, and hand off report Delivered a skin/wound update during the multiple NICU Skills Days in 2010 and provided education to new NICU nurses during their orientation Trained 5 members to be the NICU NDNQI Pressure Ulcer Experts (2010-current); formerly CHCA NICU Wound Care Champions (2009-2010) Resources: Developed a wound closet to store products needed specific for our population Increased the number of redistribution surfaces and wound products needed for the neonate Developed a nurse practice guideline on Z-Flo Positioners used frequently in the NICU Reviewed and enhanced the current nurse practice guideline on Skin Care highlighting the neonate Introduction Objectives Background Interventions Among neonates and children, more than 50% of pressure ulcers are related to equipment and medical devices. Medical devices known to cause pressure ulcers include: Blood pressure cuffs Pulse oximeter probes Cerebral sat monitoring probes Nasal CPAP/BiPAP prongs ID bands; IV tubing, hubs Tracheostomy tubes Other challenges for our patient population include: Surgical wounds Skin excoriations from gastrostomy tubes/PEG tubes Ostomy sites IV extravasations Diaper dermatitis. Epidermal stripping Conclusion Providing education, accessibility to resources, leadership support and consistent communication have been the major key factors in promoting a positive outcome for our patients and their families. Being proactive with screening “ at risk” patients during skin rounds and intervening early has been instrumental in delivering increased quality care to our patients. References To protect and improve the skin integrity of the high risk neonate: Raise prevention awareness amongst staff nurses/families through education in order to foster accountability to impact patient care Maintain consistent communication to hospital’s Wound Care APN, physicians, nutritionists, respiratory therapists, RN staff and leadership Reduce device related injuries Increase supply and availability of resources Create a model of care that is in alignment with Children’s National organizational strategic plan as well as our service excellence goals Results The NICU had a significant reduction in pressure ulcer prevalence during the CHCA Pressure Ulcer Collaborative from 13.3% to 2.5% in 2010.The unit’s compliance stayed close to 100% each month in the following areas: skin assessment, risk assessment, management of moisture, optimizing nutrition and hydration, repositioning, using pressure-redistribution surfaces as appropriate, and minimizing device-related pressure. It was through education, daily rounds by a wound care member, and heightened awareness by all team members that provided these good results. Monthly prevalence data collections continued in the NICU when the NDNQI Pressure Ulcer Prevention project began in August 2010. To date, the NICU has had between zero to two pressure ulcers identified during the monthly data collections. Addressing the classification of pressure ulcers, there were four Stage 1, one Stage 3 and one Unstageable pressure ulcer in the last nine months. This is a significant improvement from the past. Planning: Screen “at risk patients” at least 2-3 times per week and consult with hospital’s Wound Care APN Achieve effective nursing interventions through one-on-one guidance and ongoing education Provide accessibility to staff the necessary resources: list of team members and availability of products Evaluation: Sense of heightened awareness amongst staff Overall staff improvement with prevention efforts and wound management Staff pride and accountability of preventive practices and wound care Effective Communication: Skin/wound rounds Skin/wound clinical reminders sent electronically to staff emphasizing the type of patient acuity and reemphasizing preventive practices. Broadening our community to include Nutritionists and Neonatologists in the electronic communication of the identified high risk neonates for skin integrity and their plan of care Assessment: Identify patients whom are “at risk” for skin breakdown through daily rounds and NSRAS < 16 Identify the need for improvement in staff education Identify the need for improvement in available resources Provide effective communication amongst team members Leadership Support : Collaborated with leadership to add skin/wound issues to the staff meeting agenda National Pressure Ulcer Advisory Panel and European Pressure Ulcer Advisory Panel. (2009). Prevention and treatment of pressure ulcers: Clinical practice guideline. Washington DC Pressure Ulcers in Neonates and Children An NPUAP White Paper. (2007). Mona Mylene Baharestani, PhD, ANP, CWOCN, FCCWS, FAPWCA; and Catherine R. Ratliff, PhD, APRN-BC, CWOCN Advances in Skin and Wound Care vol 20 NO 4 Schindler, C.A. (2011). Protecting fragile skin: Nursing interventions to decrease development of pressure ulcers in pediatric intensive care American Journal of Critical Care. 20:26-33