1. Kim Palmer RN BSN

2.  A group of nurses within the PICU took on the initiative to improve patient outcomes with PU.  We originally started out with a team of 12 nurses with various years of experience.  We held a 4 hour blitz to decided what to focus our efforts on.  We decided to split the group into an education group and an surveillance group within the PU committee.

3.  We decided as a team we would change the unit policy of rotating the Sat probes from Q shift (q 12 hrs) to Q 6 hrs.  The group decided to begin using the product Z-flow to help off load the heals, sacrum and occiput of our patient.  The surveillance group decided to start monthly surveillance.  To be trained they would round with a WOC hospital team member and be checked off on an assessment and then teach another member within the PICU PU team how to do an assessment.  The education group also decided to educate on padding the hubs of our devices.

4.  We had originally thought that majority of the PU were in our spinal patients who had long Operating room times.  We found that actually they were a small percent of them.  The highest numbers were actually the occipital of patients 2 years and under and who had decreased perfusion.  That most of our PU were device related vs. pressure.

5.  We also found that our Bipap masks caused issues on the bridge of the nose.  ET tubes causing mucosal injuries  G-Tubes  We reassessed the following year and decided that we actually were not as compliant with the monthly surveillance.  It was decided to being twice monthly surveillance.

6. PICU PU Team Currently 19 members including 2 CA’s All team members qualified to do surveillance Focusing on device padding & education Twice monthly surveillance with results emailed to staff Twice weekly skin rounds with WOC and managers Event analysis on all Stage III, IV and Unstageable PU’s Serious Harm PU’s added to Event Calculator

8. Pressure Ulcer Causes

9. High Risk Area

10. StageNumberPercentage I6246% II3828% Suspected Deep Tissue Injury 1713% III54% IV1<1% Unstageable118% PICU 2014

11. 3 masks 2 nasal ETT’s 3 IV hubs2 G-tubes 2 NG’s 1 OG tube 17 Serious Harm PU’s (13%) (Stages III, IV & Unstageable)

12. 23 different devices noted for 107 PU’s Bipap mask caused 33 (25%) All other devices caused (10 or less) Other PU Data Facts

13. PICU Mask Related Pressure Ulcers 2014

14.  We have a wonderful team work with our core RT’s in the PICU.  We make every attempt to alternate the Bipap mask’s q 4 hrs.  Assess the patients skin q 4 hrs.  Apply Mepilex under every mask.  Changed from the servo vent to the V 60 trilogy.

17. As of June 11, 2015 It has been 7 days since our last CLABSI event: 1 – 5ST It has been 171 days since our last CAUTI event It has been 116 days since our last VAP event Pressure Ulcers: (6/1/15 - 6/7/15) – 1 1-ICN: Stage- SDTI (Device/IV Hub) Best Practice: EACH DAY discuss the need for your patient to have continued central line access with the attending physician. Cheri

18. PICU Quality Event Calculator 6/12/2015 CA-BSIUnExCA-UTIVAPPU CVL-Associated Bloodstream Infx. Unplanned Extubations Catheter- Associated Urinary Tract Infections Ventilator- Associated Pneumonia Pressure Ulcers Serious Harm (Stage III, IV and Unstageable DAYS SINCE 14 DAYS SINCE 9 172 DAYS SINCE 116 DAYS SINCE 48 Record104Record111Record237Record352Record103 # This month 0 1 0 0 0 # This year 5 9 0 2 9 # Last Year 5 19 # Last Year 12 # Last Year 1 17 Last Event:5/29/2015Last Event:6/3/2015Last Event:12/22/2014 Last Event:2/15/2015Last Event:4/24/2015

19. Stage 2

20. Example of Mucosal Injury. It is also an example of what we view with our monthly meetings.

21. 1. Do you think there was anything that put this patient at higher risk for a pressure ulcer? 2. If we had unlimited time and resources, is there anything that you think would have been helpful to prevent this pressure ulcer? 3. Any other information or thoughts about this PU?

22.  We use these when we are on shift and also when the managers and the hospital WOC team member do rounds twice weekly.  Have you completed your skin assessment today? 1. Did you note any areas of concern or any breakdown/redness noted? 2. Are all of your sites padded?-PIV’s, NG/OG’s, CVL dressing intact? 3. Pressure points padded w/Z-Flo, etc

23.  Check surface for pt needs. Is it appropriate for the patients acuity? 1. Need dolphin bed? 2. Need Accumax convertible?  Do you have any questions or other concerns about skin?

24.  We have the full support of our administration at CMH.  Our group is always “on” with this committee.  Our culture in the PICU is changing. As well as hospital wide.  All of the floors, NICU, PICU, and OR has representation at a meeting once a month. In the meeting we go over all of the Stage 2 and greater and discuss them by viewing the pictures.