CSW Pressure Injury Prevention Pathway Approval & Citation

Pressure Injury Prevention Pathway v1.3: Overview

Approval & Citation Summary of Version Changes Explanation of Evidence Ratings

OVERVIEW Primary Reference · GOC: Skin Care and Wound Inclusion Criteria Go to Management (for SCH only) · All patients admitted to Procedural the hospital Care · All patients admitted to or transferred from procedural areas Exclusion Criteria ! · Any patient with a serious ! History of If patient / disorder of the integumentary Stage 3, 4 or caregiver refuses and mucous membranes Unstageable skin assessment or (Stevens–Johnson Pressure Injury pressure injury preventive syndrome, etc.) · Identify location on body care, notify Provider, CN · Consult Wound Care and Unit Leadership Assessments · Notify CNS · Complete Skin Assessment (all patients) and Braden QD Scoring (inpatients): · Add to problem list · On admission · On every shift · General head-to-toe skin assessment and focus areas (additional information): Focus Areas Assessment Occiput • Assess for bogginess, redness, warmth, and scabs • Braids and matted hair increase risk of pressure injury • Look with penlight through the hair and under dressings (with surgery if surgical dressings) • Assess any area around tubing/ears/head, if applicable Shoulder Blades • Assess the shoulder blades Elbows • Assess elbows for any pressure areas or redness from lines/tubes Coccyx / Sacrum • Assess sacrum area, between folds • Hold at hips during turns and gently separate buttocks to assess for pressure areas/injuries Heels • Assess heels for redness or breakdown Toes • Assess toes for any redness or breakdown · Document assessment under Skin Assessment in EHR

Factors for High Risk of Pressure Injury Provide Provide High risk of prevention · Braden QD score ≥ 13 standard care No pressure Yes measures for · History of Stage 3 or 4 pressure injury high risk · Devices (respiratory, orthopedic, lines/tubes) injury? · Limited mobility, immobile and/or insensate · Vasoactive / inotropic medications · Platelet count < 50,000 cells/mcL · On Eating Disorder Refeeding pathway · On Obese Care pathway Manage · Current corticosteroids use (> 0.5 mg/kg/day) Provide · ECLS, CRRT, HFOV Pressure pressure standard care No Yes · Procedure ≥ 3 hours (within last 24 hours) injury found? injury · Generalized edema · Recent hypoxic event (within last 72 hours) · Chronic hypoxia · Admitted to ICU (within last 48 hours) Key Acronyms CN: Charge Nurse EHR: Electronic Health Record CNS: Clinical Nurse Specialist GOC: Guideline of Care

For questions concerning this pathway, Last Updated: February 2021 contact: [email protected] Next Expected Review: November 2023 © 2021 Seattle Children’s Hospital, all rights reserved, Medical Disclaimer Pressure Injury Prevention Pathway v1.3: Standard Care

Approval & Citation Summary of Version Changes Explanation of Evidence Ratings

STANDARD PREVENTION MEASURES Primary Reference · GOC: Skin Care and Wound Management (for SCH only)

Pressure Injury Prevention

· Keep skin clean and dry · Apply moisturizing lotion to dry areas daily and as needed ! · Perineal Care: · Apply barrier cream with each diaper change for patients who are incontinent Avoid using (NICU and < 44 weeks gestation excluded) blankets or · See Job Aid: Diaper Dermatitis Treatment (for SCH only) foam donuts · Skin Prep: · Apply a no sting barrier film under tape or transparent dressings · Reposition: · Turn/reposition at least every 2 hours if insensate or immobile (per protocol in NICU and Rehab) ! · See GOC: Immobilized or Limited Mobility (for SCH only) · Offload: Avoid direct skin · Use fluidized positioners, gel cushions or pillows for bony prominences contact with · Choose appropriate sleep surface/bed options for pressure relief or reduction offloading devices · Use Z-Flo™ devices as position assistive devices

Shear Injury Prevention

· Recognize at-risk patients: fragile skin, poor tissue turgor, reduced mobility, or insensate areas · Keep head of bed less than 30 degrees elevated unless clinically contraindicated · Use the knee gatch on the bed when head of bed is elevated · Prevent shearing injury by using a lift sheet or lift assist devices to move or reposition patients

Provide Manage standard care Pressure pressure No Yes every shift injury found? injury

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Approval & Citation Summary of Version Changes Explanation of Evidence Ratings

HIGH RISK OF PRESSURE INJURY Primary Reference · GOC: Skin Care and Wound Management (for SCH only) !

Prevention Measures If RN is unable to complete high risk . prevention measures, For All Patients notify CNS

Preventive Dressings . · Apply any silicone border foam on Devices (if applicable) high risk areas (as appropriate): · Occiput Respiratory Devices · Shoulders · RT to manage / document · Coccyx · Prevention: · Sacrum · Apply a no sting barrier film · Heels · Apply protective dressing · Any hard and bony surface · Assess skin and release pressure every 4 hours · Assess each site every shift by gently lifting the with RT dressing and checking for blanching, bogginess, · If unable or pressure injury found, temperature and scabs contact RT Supervisor · Document interventions under Pressure Injury · For new trach, see Job Aid: Tracheotomy Phase 2 Prevention in EHR (Until 1st Trach Change) (SCH only) Appropriate Bed Surface · Apply waffle overlay on standard hospital bed or crib Orthopedic Devices · Discuss specialty bed/mattress with CN and CNS · Fully assess site and surrounding skin every shift · Apply silicone border foam or sacral silicone while brace removed for care border foam (do not use non-border foam) · If unable to visualize skin under a brace and/or the · Handle skin gently ! brace cannot be removed, consult orthotics clinician · Use gel pads (after hours, weekends and holidays, page via Do not use operator on call orthotist) to assist with brace mobilization options and pressure risk assessment Positioning silicone non-border foam · See GOC: Brace, Care of Patient (SCH only) · Turn/reposition at least every 2 hours · See GOC: Immobilized or Limited Mobility (SCH only) · Keep head of bed less than 30 degrees elevated Non-RT Lines / Tubes unless clinically contraindicated ! · Assess where lines/tubes are in proximity to skin · Use bariatric waffle cushion (green) · Apply silicone border foam (do not use non-border) under head (avoid standard pillow) Avoid · See GOC: EEG Monitoring After Intracranial Lead standard pillow Placement (SCH only) Moisture Management under head · Apply barrier cream with each diaper change Casts (NICU and < 44 weeks gestation excluded) · See GOC: Casts Including Spica Casts (SCH only) · See Job Aid: Diaper Dermatitis Treatment (SCH only) · If issues, contact orthopedic surgery team

Provide Manage standard care Pressure pressure No Yes every shift injury found? injury

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Approval & Citation Summary of Version Changes Explanation of Evidence Ratings

MANAGEMENT OF PRESSURE INJURIES Primary Reference · GOC: Skin Care and Wound Management (for SCH only)

Stage Pressure Injury and Provide Care . . Stage 1 or 2 Stage 3, 4 or Unstageable

When Pressure Injury is Found... When Pressure Injury is Found...

Escalate ! Escalate · Notify Provider and CN · Notify Provider and CN · Enter an eFeedback (CNS notified) Do not use · Enter an eFeedback (CNS notified) silicone · Provider to order Wound Care consult after assessing non-border foam Perform Initial Management Perform Initial Management · Apply silicone foam border (do not use non-border · Apply silicone foam border (do not use non-border) foam) · Assess dressing integrity and replace as needed until · Document new pressure injury under Wound in EHR Wound Care consult · Document new pressure injury under Wound in EHR · Add to Problem List in EHR

Ongoing Care Every Shift Ongoing Care Every Shift

· Assess skin under dressing If Wound Care instructions are NOT available · Review care guidelines in Orders · Assess dressing integrity and replace as needed · Discuss concerns/issues with CNS · Document care under Wound in EHR · Document care under Wound in EHR If Wound Care instructions are available When pressure injury is healed · Review Wound Care Orders for wound management · Document skin findings · Change dressing per Orders · Deactivate dynamic group under Wound in EHR · Discuss concerns/issues with Wound Care Consultant · Document care under Wound in EHR

When pressure injury is healed · Document skin findings · Deactivate dynamic group under Wound in EHR

Provide prevention measures for high risk

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Approval & Citation Summary of Version Changes Explanation of Evidence Ratings

PREprocedural

Complete Pre Operative Assessment Form

Go to tab for Other Risk Assessments · Select “Yes” if patient has history of stage 3, 4 or unstageable pressure injury · Automatic Wound Care consult · Assess patient’s skin (head-to-toe) · If pressure injury found · Identify and document each skin abnormality · Select “Pressure injury present on admit”

Procedure No Yes ≥ 3 hours?

INTRAprocedural

Standard INTRAprocedural Care INTRAprocedural High Risk of · Complete pre and post procedure Skin Pressure Injury Care Assessment · Apply silicone border foam to the high risk area · Use pressure redistribution devices as needed AND / OR ! · Use pressure redistribution devices · Document INTRAprocedural assessment For patients in an · Discuss position change(s) with surgical and ICU crib that require anesthesia team every 3 hours limited mobility POSTprocedure, place a waffle mattress on crib

POSTprocedural

Inpatient Handoff Post- Procedural / PACU Handoff · Complete IR / OR to ICU Handoff · Complete OR to PACU RN Handoff No Procedure in Yes Procedure · Report area(s) of concern OR history of · Identify any skin issues or concerns PACU? pressure injury to receiving RN

Provide prevention measures for high risk

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Skin Assessment

When assessing the common pressure points, consider:

· Any bony prominence · Thorough exam of the skin

In most immobilized patients in the hospital, patients are placed in the supine position The high risk areas for patients in the supine position include (but not limited to):

· Occiput · Scapula (Shoulder Blades) · Elbows · Coccyx / Sacrum · Calcaneus (Heels)

While these are high risk areas, any device or position change can present new areas of pressure not outlined above Skin assessment tips:

· Occiput: o Assess color differences on the scalps, noting any redness, scabs or loss of hair . If there are dressings, assess the area under the dressing at least once a shift or as ordered by the provider team o Palpate the area around and on the occiput, trying to locate any area of bogginess which may indicate a pressure injury · Coccyx / Sacrum: o Hold hips when assessing this area o Gently separate gluteal muscle to assess for pressure areas / injury · All other pressure areas, assess for redness or any skin breakdown

Return to Overview CSW Pressure Injury Prevention Pathway Approval & Citation

Approved by the CSW Pressure Injury Prevention Pathway team for go-live on Nov. 12, 2018

CSW Pressure Injury Prevention Pathway Team:

Pediatric ICU, Owner Hector Valdivia, MN, ARNP, ACCNS-P, CCRN Interventional Radiology, Stakeholder Carolyn Ahl, BSN, RN Orthotics and Prosthetics, Stakeholder Greg Becker, CPO, LPO Nursing Informatics, Stakeholder Ali Berger, MSN, RN-BC Operating Room, Team Member Christine Burnett, MSN, RN, CNOR Post-Anesthesia Care Unit, Team Member Pam Christensen, MN, ACCNS-PC, RN-BC, CPN Cardiac ICU, Team Member Colin Crook, BSN, RN Neonatal ICU, Team Member Karen Kelly, MN, RN, CCRN-K Nursing Practice, Team Member Kristi Klee, DNP, MA, RN, CPN Medical Unit, Team Member Ellie McMahon, MSN, RN, CPN Wound Care, Team Member Leslie Newell, BSN, RN, CWCN, CCRN Patient Safety, Stakeholder Ally Nisbet, MSN, RN, CPN, CPPS Rehabilitation Unit, Stakeholder Lyn Sapp, MN, RN, CRRN Orthotics and Prosthetics, Stakeholder Diane Simons, CO, LO Medical Unit, Stakeholder Ashley Turner, MN, RN, CPN Wound Care, Team Member Amie Wilson, RN, BSN, CPN, CWCN Respiratory Therapy, Stakeholder Joe Zimmerman, BS, RRT-NPS

Clinical Effectiveness Team:

Consultant Lisa Abrams, RN, MSN, ARNP Project Manager Ivan Meyer, PMP Data Analyst James Johnson Librarian Sue Groshong, MLIS Program Coordinator Kristyn Simmons

Clinical Effectiveness Leadership:

Medical Director Darren Migita, MD Operations Director Karen Rancich Demmert, BS, MA

Retrieval Website: http://www.seattlechildrens.org/pdf/pressure-injury-prevention-pathway.pdf

Please cite as: Seattle Children’s Hospital, Valdivia, H., Burnett, C., Christensen, P., Crook, C., Kelly, K., Klee, K., McMahon, E., Newell, L., Wilson, A., Migita, D., 2018 November. Pressure Injury Prevention Pathway. Available from: http://www.seattlechildrens.org/pdf/pressure-injury-prevention- pathway.pdf.

Return to Overview Evidence Ratings

This pathway was developed through local consensus based on published evidence and expert opinion as part of Clinical Standard Work at Seattle Children’s. Pathway teams include representatives from Medical, Subspecialty, and/or Surgical Services, Nursing, Pharmacy, Clinical Effectiveness, and other services as appropriate.

When possible, we used the GRADE method of rating evidence quality. Evidence is first assessed as to whether it is from randomized trial or cohort studies. The rating is then adjusted in the following manner (from: Guyatt G et al. J Clin Epidemiol. 2011;4:383-94.):

Quality ratings are downgraded if studies: · Have serious limitations · Have inconsistent results · If evidence does not directly address clinical questions · If estimates are imprecise OR · If it is felt that there is substantial publication bias

Quality ratings are upgraded if it is felt that: · The effect size is large · If studies are designed in a way that confounding would likely underreport the magnitude of the effect OR · If a dose-response gradient is evident

Guideline – Recommendation is from a published guideline that used methodology deemed acceptable by the team.

Expert Opinion – Our expert opinion is based on available evidence that does not meet GRADE criteria (for example, case-control studies).

Return to Overview To Bibliography Summary of Version Changes

· Version 1.0 (11/12/2018): Go live. · Version 1.1 (10/24/2019): Updated factors for high risk of pressure injury: removed Malnutrition Screening pathway, added Eating Disorder Refeeding pathway, added Obese Care pathway and added ICU admission within 48 hours. Updated Approval & Citation page. · Version 1.2 (5/7/2020): Renamed GOC 10201 and GOC 10965. Removed GOC 11163. Removed references to Allevyn™, Cavilon™, Mepilex®, and Optifoam® brands; used generic names instead. · Version 1.3 (2/19/2021): Aligned verbiage to correspond with Epic: changed Braden Q to Braden QD and CAREDEX to Orders.

Return to Overview Medical Disclaimer

Medicine is an ever-changing science. As new research and clinical experience broaden our knowledge, changes in treatment and drug therapy are required.

The authors have checked with sources believed to be reliable in their efforts to provide information that is complete and generally in accord with the standards accepted at the time of publication.

However, in view of the possibility of human error or changes in medical sciences, neither the authors nor Seattle Children’s Healthcare System nor any other party who has been involved in the preparation or publication of this work warrants that the information contained herein is in every respect accurate or complete, and they are not responsible for any errors or omissions or for the results obtained from the use of such information.

Readers should confirm the information contained herein with other sources and are encouraged to consult with their health care provider before making any health care decision.

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Search Methods, Pressure Injury Prevention Pathway, Clinical Standard Work

Studies were identified by searching databases using search strategies developed and executed by a medical librarian, Susan Groshong. Searches were performed in March 2018, in the following databases: Ovid Medline, Ovid Joanna Briggs Institute, Embase, Cochrane Database of Systematic Reviews, National Guideline Clearinghouse, TRIP, Cincinnati Children’s Evidence-Based Recommendations and Registered Nurses’ Association of Ontario Best Practice Guidelines. In Medline and Embase, appropriate Medical Subject Headings (MeSH) and Emtree headings were used respectively, along with text words, and the search strategy was adapted for other databases using text words, for the concept of pressure injuries. Retrieval was limited to humans, English language, 2008 to current and further limited to certain evidence categories, such as relevant publication types, index terms for study types and other similar limits.

Susan Groshong, MLIS August 20, 2018

Flow diagram adapted from Moher D et al. BMJ 2009;339:bmj.b2535

Return to Evidence Ratings To Bibliography, Pg 2 Bibliography

Prevention of pressure ulcers. In: National Pressure Ulcer Advisory Panel, European Pressure Ulcer Advisory Panel, Pan Pacific Pressure Injury Alliance, eds. Prevention and Treatment of Pressure Ulcers: Clinical Practice Guideline. Washington, D.C.: National Pressure Ulcer Advisory Panel; 2014:42-78. Special populations. In: National Pressure Ulcer Advisory Panel, European Pressure Ulcer Advisory Panel, Pan Pacific Pressure Injury Alliance, eds. Prevention and Treatment of Pressure Ulcers: Clinical Practice Guideline. Washington, D.C.: National Pressure Ulcer Advisory Panel; 2014:209-252. Garcia-Fernandez FP, Pancorbo-Hidalgo PL, Agreda JJS. Predictive capacity of risk assessment scales and clinical judgment for pressure ulcers: A meta-analysis. J Wound Ostomy Continence Nurs [PIP]. 2014;41(1):24-34. Accessed 3/19/2018 12:22:48 PM. https://dx.doi.org/ 10.1097/01.WON.0000438014.90734.a2. McInnes E, Jammali-Blasi A, Bell-Syer Sally EM, Dumville Jo C, Middleton V, Cullum N. Support surfaces for pressure ulcer prevention. Cochrane Database of Systematic Reviews [PIP]. 2015(9). McNichol L, Watts C, Mackey D, Beitz JM, Gray M. Identifying the right surface for the right patient at the right time: Generation and content validation of an algorithm for support surface selection. J Wound Ostomy Continence Nurs [PIP]. 2015;42(1):19-37. Accessed 3/19/2018 12:22:48 PM. https://dx.doi.org/10.1097/WON.0000000000000103. Moore Zena EH, Cowman S. Risk assessment tools for the prevention of pressure ulcers. Cochrane Database of Systematic Reviews [PIP]. 2014(2). Moore Zena EH, Webster J. Dressings and topical agents for preventing pressure ulcers. Cochrane Database of Systematic Reviews [PIP]. 2013(8). Park S, Choi Y, Kang C. Predictive validity of the braden scale for pressure ulcer risk in hospitalized patients. J Tissue Viability [PIP]. 2015;24(3):102-113. Park S, Lee HS. Assessing predictive validity of pressure ulcer risk scales- A systematic review and meta-analysis. Iran J Public Health [PIP]. 2016;45(2):122-133. Qaseem A, Mir TP, Starkey M, Denberg TD, Clinical Guidelines Committee of the American College of Physicians. Risk assessment and prevention of pressure ulcers: A clinical practice guideline from the american college of physicians. Ann Intern Med [PIP]. 2015;162(5):359-369. Accessed 3/19/2018 12:22:48 PM. https://dx.doi.org/10.7326/M14-1567. Shi C, Dumville JC, Cullum N. Support surfaces for pressure ulcer prevention: A network meta- analysis. PLoS ONE [PIP]. 2018;13(2):e0192707. Accessed 3/19/2018 12:22:48 PM. https:// dx.doi.org/10.1371/journal.pone.0192707. Slade, Susan [BScApp (Physio), Grad Dip Manip Ther,M.Musc Ther, PhD.]. Pressure ulcers (prevention): Intensive care unit (ICU). [PIP]. 2017. Wound Healing and MN, Haesler E[. Pressure injuries: Preventing heel pressure injuries with prophylactic dressings. [PIP]. 2017. Wound Healing and MN, Haesler E[. Pressure injuries: Preventing medical device related pressure injuries. [PIP]. 2017. Wound, Ostomy and Continence Nurses Society (WOCN). Guideline for Prevention and Management of Pressure Ulcers (Injuries). Mt. Laurel, NJ.: Wound, Ostomy and Continence Nurses Society (WOCN); 2016.

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