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.

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.

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.

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.