Elsevier

Journal of Pediatric Nursing

Volume 30, Issue 4, July–August 2015, Pages 620-623
Journal of Pediatric Nursing

Clinical Practice Column
Nursing and Respiratory Collaboration Prevents BiPAP-Related Pressure Ulcers

https://doi.org/10.1016/j.pedn.2015.04.001Get rights and content

In early 2012, an increase in the incidence of BiPAP-related pressure ulcers was noted in the progressive care unit of a large pediatric facility. An interdisciplinary team of nursing and respiratory staff and leadership formed a collaborative to address the gaps in practice, recommend, and implement evidence-based interventions using a quality improvement model. Interventions included piloting new masks, changing the skin barrier from a hydrocolloid dressing to a foam dressing and using a template for better fit, including skin assessments every 4 hours as part of nursing and respiratory therapists' workflow, and implementing a notification process that included Wound Ostomy Continence Nurses, respiratory, and nursing leadership for any redness of skin noted. Weekly rounding and communication by nursing and respiratory leadership ensured consistency and sustainability of practice. Aside from implementation of interventions, the primary focus was to develop a collaborative relationship between nursing and respiratory teams for shared ownership and accountability of patients on BiPAP support. Three months after the implementation of interventions, the occurrence of BiPAP-related pressure ulcers decreased from eleven in the first three quarters to one occurrence in the fourth quarter of fiscal year (FY) 2012. In 2013, the occurrence decreased to five for the entire fiscal year. Since the end of FY 2013, there has only been one occurrence of a BiPAP-related pressure ulcer in the progressive care unit. Close collaboration between respiratory and nursing has been the primary factor in decreasing BiPAP-related pressure ulcers. An important lesson learned is that interdisciplinary collaboration leads to improved patient outcomes.

Section snippets

Background

The Progressive Care Unit admits all patients requiring BiPAP initiation and those with complex medical conditions requiring intermittent or continuous BiPAP support. In early 2012, an increase in the number of pressure ulcers related to BiPAP masks prompted an investigation. Over a 4 month period, eleven pressure ulcers related to BiPAP with one being a reportable stage three ulcer and two unstageable pressure ulcers were noted. A multidisciplinary team of respiratory therapists, nursing staff,

Literature Review

A review of the published literature revealed a lack of studies on BiPAP therapy and skin breakdown in the pediatric population. Historically, pressure ulcer interventions and guidelines used in pediatrics were based on adult studies (Schindler et al., 2007). Only in the recent years have there been an increased focus on pediatric pressure ulcers. Multi-site studies have reported an incidence of pressure ulcers in critically ill children to be 18% to 27% (Schindler et al., 2007). The National

Quality Improvement Process

The Plan–Do–Study–Act (PDSA) model of quality improvement was used to implement interventions. The first PDSA cycle concentrated on identifying the problem and the gaps in both nursing and respiratory practices. It was noted that there were numerous masks available for use in the hospital with no standardized approach to application. There were also inconsistencies in the practice of applying the masks to the patient and the type of dressing used under the mask. The respiratory flowsheet in the

Outcomes

The interventions outlined by the collaborative were implemented during the third quarter of fiscal year 2012. Three months after implementation the incidence of BiPAP-related pressure ulcers decreased to one stage I occurrence. Since the beginning of the collaborative 3 years ago, there has only been one stage III reportable BiPAP-related pressure ulcer. Five occurrences were primarily stage I and stage II skin breakdown. The increased awareness and monitoring by both respiratory and nursing

Conclusion

The outcomes that have resulted from this quality improvement initiative have been a direct result of the teamwork and collaboration between nursing and respiratory disciplines. The standard of care for BiPAP patients at our institution has changed significantly over the past three years, and skin has become a priority. The collaborative continues to search for new and innovative products that prevent the common complication associated with noninvasive ventilation. Since most BiPAP patients

Acknowledgments

The success of the collaborative would not be possible without the diligence of the respiratory and nursing staff of the Progressive Care Unit and the support of nursing, respiratory, and medical leadership of Texas Children's Hospital. Special thanks to Richard Nguyen, RRT, John Alberto, RRT, Christopher Johnson, RRT, and the Wound Ostomy team for their continued efforts in improving patient outcomes.

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