Determining Incidence and Risk Factors of Pressure Injury After Orthopaedic Surgery in Children and Adolescents With Neuromuscular Complex Chronic Conditions.

BACKGROUND: Pressure injuries are serious yet often preventable alterations in skin integrity prevalent in orthopaedics, especially in pediatric patients with neuromuscular complex chronic conditions (NCCC). The aims of this study were to (1) estimate incidence of pressure injury in children with NCCC after orthopaedic surgery; (2) determine risk factors for pressure injury development; and (3) describe severity and location of pressure injuries. METHODS: Children and adolescents (<22 y old) with NCCC who underwent orthopaedic surgery at a single tertiary-care children's hospital between 2016 and 2020 were retrospectively identified. A matched case-control design was used to match patients who developed a pressure injury within 1.5 months after surgery to subjects who did not develop a pressure injury using a 1:1 matching based on neuromuscular diagnosis, age, sex, and type of surgery. Patient characteristics, comorbidities, pressure injury characteristics, and a pressure injury risk assessment score utilizing the Braden QD scale were compared across pressure injury groups. RESULTS: Of 564 children with NCCC who underwent orthopaedic surgery, 43 (7.6%) developed a postoperative pressure injury. Pressure injuries were primarily located on the heel, followed by sacral/groin/buttocks, then knee. The most common diagnosis was cerebral palsy with associated neuromuscular scoliosis, and hip reconstruction was the most common surgical procedure. The pressure injury cohort had significantly more patients who were non-ambulatory (GMFCS IV/V), with a seizure disorder, g-tube, nonverbal status, wheelchair usage, and had additional medical devices. Median Braden QD risk score was higher in the injury cohort and a cutoff ≥12 was optimal for predicting pressure injury development. CONCLUSIONS: Pressure injuries after orthopaedic surgery are not uncommon in children with NCCC. The entire care team should be aware of additional risk factors associated with pressure injury development, including the diagnosis of cerebral palsy with neuromuscular scoliosis, seizure disorder, nonverbal status, g-tube, and the presence of multiple medical devices. Implementation of evidence-based pressure injury prevention guidelines on identified high-risk children with NCCC may reduce pressure injury risk and improve the postoperative course. LEVEL OF EVIDENCE: Level III.

Medical Device-Related Pressure Injuries in Infants and Children.

PURPOSE: The purpose of this study was to describe medical device-related pressure injuries (MDRPIs) in hospitalized pediatric patients. DESIGN: A prospective, descriptive study. SAMPLE/SUBJECTS AND SETTING: The sample comprised 625 patients cared for in 8 US pediatric hospitals. Participants were aged preterm to 21 years, on bed rest for at least 24 hours, and had a medical device in place. METHODS: Two nursing teams, blinded to the other's assessments, worked in tandem to assess pressure injury risk, type of medical devices in use, and preventive interventions for each medical device. They also identified the presence, location, and stage of MDRPI. Subjects were observed up to 8 times over 4 weeks, or until discharge, whichever occurred first. RESULTS: Of 625 enrolled patients, 42 (7%) developed 1 or more MDRPIs. Two-thirds of patients with MDRPIs were younger than 8 years. Patients experiencing MDRPIs had higher acuity scores on hospital admission, were more frequently cognitively and/or functionally impaired, or were extreme in body mass index. Respiratory devices caused the most injuries (6.19/1000 device-days), followed by immobilizers (2.40/1000 device-days), gastric tubes (2.24/1000 device-days), and external monitoring devices (1.77/1000 device-days). Of the 6336 devices in place, 36% did not have an MDRPI preventive intervention in place. Clinical variables contributing to MDRPI development included intensive care unit care (odds ratio [OR] 8.9, 95% confidence interval [CI] 1.9-43.6), use of neuromuscular blockade (OR 3.7, 95% CI 1.7-7.8), and inotropic/vasopressor medications (OR 2.7, 95% CI 1.7-4.3). Multivariable analysis indicated that Braden QD scores alone predicted MDRPI development. CONCLUSION: Medical devices are common in hospitalized infants and children and these medical devices place patients at risk for MDRPI.

Hospital-Acquired Pressure Injuries in Children With Congenital Heart Disease: Prevalence and Associated Factors.

OBJECTIVES: To explore the prevalence, location, and clinical factors associated with hospital-acquired pressure injuries among pediatric patients with congenital heart disease. DESIGN: Secondary analysis of data from a multicenter prospective cohort study of pediatric pressure injury risk, including patients with congenital heart disease. SETTING: Eight acute care academic pediatric hospitals. PATIENTS: Patients were preterm to 21 years old with congenital heart disease and on bed rest for at least 24 hours after hospital admission with a medical device attached to or traversing the skin or mucous membrane. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Patients were evaluated for a maximum of eight observations during a 4-week period to identify Braden QD risk and pressure injury development. Hospital-acquired pressure injuries were staged according to the National Pressure Ulcer Advisory Panel guidelines. Stepwise logistic regression was used to explore risk factors associated with hospital-acquired pressure injuries development, accounting for site as a cluster variable using generalized estimating equations. Overall, 279 pediatric cardiac patients provided 919 observations (median, 2 per patient [interquartile range, 2-5 per patient]). Thirty-eight hospital-acquired pressure injuries occurred in 27 patients (9.7%). Most injuries (28/38 [74%]) were related to medical devices. The most common medical devices that caused injury were oxygen saturation probes. The remaining hospital-acquired pressure injuries were immobility-related pressure injuries (10/38 [26%]) located primarily on the buttock, sacrum, or coccyx (5/10 [50%]). In multivariable analyses, being non-Hispanic white (odds ratio, 3.54; 95% CI, 2.15-5.84), experiencing operating room time greater than 4 hours (odds ratio, 2.91; 95% CI, 1.13-7.49), having oxygen saturation levels less than 85% (odds ratio, 2.65; 95% CI, 1.01-6.96), and having worse Braden QD scores (odds ratio, 1.25 per 1 point increase; 95% CI, 1.17-1.34) were significantly associated with hospital-acquired pressure injuries development. CONCLUSIONS: In this multicenter observational study of pediatric patients with congenital heart disease, we describe a hospital-acquired pressure injury prevalence of 9.7% with approximately 75% of injuries related to medical devices. These data can be used to inform practice and target interventions to decrease pressure injury risk and prevent pressure injuries in this vulnerable pediatric population.

CE: How to Predict Pediatric Pressure Injury Risk with the Braden QD Scale.

: The Braden QD Scale is a conceptually based, pediatric-specific, risk assessment instrument that reliably predicts both immobility-related and medical device-related pressure injuries in the pediatric acute care environment. A revision and simplification of the commonly used Braden Q Scale, the Braden QD Scale can be used to assess risk among the wide range of infants, children, and adolescents commonly treated in acute care environments. As part of a comprehensive program to prevent hospital-acquired pressure injuries, the Braden QD Scale promotes patient safety, quality of care and care monitoring, and effective resource use in pediatric hospitalized patients. The authors provide guidance on using the Braden QD Scale to assess pediatric patients and score their risk of pressure-related injury in numerous scenarios frequently encountered in acute care practice.

Predicting Pressure Injury Risk in Pediatric Patients: The Braden QD Scale.

OBJECTIVE: To describe the development and initial testing of the Braden QD Scale to predict both immobility-related and medical device-related pressure injury risk in pediatric patients. STUDY DESIGN: This was a multicenter, prospective cohort study enrolling hospitalized patients, preterm to 21 years of age, on bedrest for at least 24 hours with a medical device in place. Receiver operating characteristic curves using scores from the first observation day were used to characterize Braden QD Scale performance, including areas under the curve (AUC) with 95% CIs. RESULTS: Eight centers enrolled 625 patients. A total of 86 hospital-acquired pressure injures were observed in 49 (8%) patients: 22 immobility-related pressure injuries in 14 (2%) patients and 64 medical device-related pressure injuries in 42 (7%) patients. The Braden QD Scale performed well in predicting immobility-related and medical device-related pressure injuries in the overall sample, with an AUC of 0.78 (95% CI 0.73-0.84). At a cutoff score of 13, the AUC was 0.72 (95% CI 0.67-0.78), providing a sensitivity of 0.86 (95% CI 0.76-0.92), specificity of 0.59 (95% CI 0.55-0.63), positive predictive value of 0.15 (95% CI 0.11-0.19), negative predictive value of 0.98 (95% CI 0.97-0.99), and a positive likelihood ratio of 2.09 (95% CI 0.95-4.58). CONCLUSIONS: The Braden QD Scale reliably predicts both immobility-related and device-related pressure injuries in the pediatric acute care environment and will be helpful in monitoring care and in guiding resource use in the prevention of hospital-acquired pressure injuries.

Medical device-related hospital-acquired pressure ulcers in children: an integrative review.

The management, cost, physical and emotional suffering associated with pressure ulcers have a significant impact on the health status of patients-especially infants and children. The purpose of this integrative review was to identify factors associated with medical device-related (MDR) hospital acquired pressure ulcers (HAPUs) in the pediatric population. Pediatric MDR HAPUs are becoming more prevalent and require further exploration in terms of describing devices which cause injury and preventive interventions to improve patient outcomes. Opportunities to uncover new methods for addressing this important problem and to inform and advance the state of the science in this evolving area exist.

Use of negative pressure wound therapy for abdominal wounds in neonates and infants.

BACKGROUND: Negative pressure wound therapy (NPWT) is an established and effective tool in the management of complicated abdominal wounds. This management approach has been used in infants, but few large series reports exist in the literature. METHODS: The outcomes of infants with abdominal wounds receiving NPWT over the last 10 years at our institution were evaluated. Overall survival, time between initiation of NPWT, and discharge/death were examined. RESULTS: We identified 18 infants who had abdominal wounds treated with NPWT. Diagnoses were varied, as was the duration of therapy. The median NPWT duration of treatment was 34.0 ± 92.1 days. Forty-four percent of the infants had a stoma before application of NPWT, and 22% of the infants had enterocutaneous fistulas before use of NPWT. There were only 2 cases in which a new fistula developed during the use of NPWT, and both of these omphalopagus conjoined twins had undergone the Bianchi procedure. No additional NPWT-related complications were identified. Of 18 infants, 6 died in this cohort. CONCLUSION: Negative pressure wound therapy is an important therapeutic tool for the management of abdominal wounds in infants.

Using the Braden Q Scale to Predict Pressure Ulcer Risk in pediatric patients.

The Braden Q Scale for Predicting Pediatric Pressure Ulcer Risk (Braden Q Scale) is a widely used, valid, and reliable pediatric-specific pressure ulcer risk assessment tool. Since its original publication, requests for clarification on how best to use the tool across the wide spectrum of pediatric patients commonly cared for in health care systems have been received. Common clarifications focus on using the Braden Q Scale as originally designed; specifically, not using untested derivations of the tool, and not using the Braden Q Scale to predict medical device-related pressure damage. The purpose of this article is to provide practical information on how best to use the Braden Q Scale and how to score a pediatric patient's risk for pressure ulcers. Accurate assessment of patient risk for pressure ulcers is the first step in guiding appropriate nursing interventions that prevent pressure ulcers. Patient assessment, scoring, and common clinical scenarios are presented.

Coordination of multiple services for a patient with severe lymphedema of the right lower extremity.

Surgical resection of the right lower extremity in an adult with severe lymph-edema of the extremity required intensive coordination of multiple services and specialists because of the medical and surgical complexity of the patient's condition, massive limb size, and surgical location in a children's hospital. Early and prolonged planning was necessary to anticipate problems and provide optimal care. The patient had a successful surgical outcome, improvement in medical comorbid conditions postoperatively, and improvement in the quality of life upon discharge. This coordinated effort will be used in the future as a template for patients with complex conditions whose care requires lengthy planning and involves multiple services and specialists.

Skin integrity in hospitalized infants and children: a prevalence survey.

The purpose of this paper was to describe the spectrum of alterations in skin integrity and skin care needs of hospitalized infants and children. A 1-day skin prevalence audit was conducted in the spring of 2005 in a tertiary care university-affiliated children's hospital. Patient skin was assessed for any alterations. The Braden Q Scale was used to assess patient risk for pressure ulcer development. Alterations in skin integrity included diaper dermatitis, pressure ulcers, intravenous infiltrations, device-related injuries, and epidermal injuries. Many patients required additional skin care, including wound/incision care, ostomy care, and care related to invasive devices. Alterations in skin integrity represent a serious problem in the pediatric inpatient setting. The data presented identify skin integrity challenges in the hospitalized patient and can help guide staff education and resource allocation, encourage evidenced-based management protocols, and serve as a benchmark for similar pediatric facilities.

Pressure ulcers in pediatric intensive care: incidence and associated factors.

OBJECTIVE: To describe the incidence, location, and factors associated with the development of pressure ulcers in patients cared for in the pediatric intensive care unit (PICU). DESIGN: Multisite prospective cohort study. SETTING: Three PICUs contained within freestanding children's hospitals. PATIENTS: A total of 322 patients, 21 days to 8 yrs of age, on bed rest in the PICU for at least 24 hrs without preexisting pressure ulcers or congenital heart disease. INTERVENTION: Patients were observed up to three times a week for 2 wks, then once a week until PICU discharge for a median of two observation periods (interquartile range, 1-4), reflecting 877 skin assessments. Skin assessments were independently rated, and data collectors were blinded to the assessments of the others. MEASUREMENTS AND MAIN RESULTS: Pressure ulcers were staged according to the American National Pressure Ulcer Advisory Panel Consensus Development Conference recommendations. Eighty-six patients (27%) developed 199 pressure ulcers; 139 (70%) were Stage I, 54 (27%) were Stage II, and 6 (3%) were Stage III. Of the 60 Stage II/III pressure ulcers, 19 (32%) involved the head. Stage III pressure ulcers involved the occiput, ear, chest, and coccyx. An additional 27 pressure-related injuries were caused by medical devices. Statistically significant Stage I pressure ulcer predictor variables include the use of mechanical ventilation, mean arterial pressures < or =50 mm Hg, and lower Braden Q scores. CONCLUSIONS: PICU patients at risk include those supported on mechanical ventilation, those with hypotension, and those who have low Braden Q scores. This study provides unique benchmark data for the general PICU population from which pediatric interventional studies can be designed to reduce the incidence of pressure ulcers in this vulnerable patient population.