A quality-improvement collaborative project to reduce pressure ulcers in PICUs

Abstract

Background and objective: Pediatric patients are at risk for developing pressure ulcers (PUs) and associated pain, infection risk, and prolonged hospitalization. Stage III and IV ulcers are serious, reportable events. The objective of this study was to develop and implement a quality-improvement (QI) intervention to reduce PUs by 50% in our ICUs.

Methods: We established a QI collaborative leadership team, measured PU rates during an initial period of rapid-cycle tests of change, developed a QI bundle, and evaluated the PU rates after the QI implementation. The prospective study encompassed 1425 patients over 54 351 patient-days in the PICU and NICU.

Results: The PU rate in the PICU was 14.3/1000 patient-days during the QI development and 3.7/1000 patient-days after QI implementation (P < .05), achieving the aim of 50% reduction. The PICU rates of stages I, II, and III conventional and device-related PUs decreased after the QI intervention. The PU rate in the NICU did not change significantly over time but remained at a mean of 0.9/1000 patient-days. In the postimplementation period, 3 points were outside the control limits, primarily due to an increase in PUs associated with pulse oximeters and cannulas.

Conclusions: The collaborative QI model was effective at reducing PUs in the PICU. Pediatric patients, particularly neonates, are at risk for device-related ulcers. Heightened awareness, early detection, and identification of strategies to mitigate device-related injury are necessary to further reduce PU rates.

Keywords: ICU; bundle; device; intervention; neonatal; pressure ulcer; quality improvement; skin; wound.

FIGURE 1

The key drivers and design changes that were tested during development of the QI intervention are shown for the aim of reduction in PU rate by 50% in both units.

FIGURE 2

A control chart of PUs in the PICU shows a sustained reduction from the period of QI development to implementation.

FIGURE 3

A control chart of stage II PUs in the PICU shows a sustained reduction from QI development to implementation.

FIGURE 4

A control chart of device-associated PUs in the PICU shows a sustained reduction from QI development to implementation.

FIGURE 5

A control chart of PUs in the NICU shows no changes over time. After the QI implementation, 3 points were above the upper control limit. The majority were PUs due to pulse oximeters and the increase was attributed to a hospital change in the product supplier.