Assessment tools employed in the pediatric intensive care unit (PICU), the neonatal intensive care unit (NICU) and general pediatrics did not account for medical devices when calculating the risk of skin breakdown. Depending on the patient’s chronological age, either the Braden or Braden Q scales were used. Reviews of pressure injuries in fiscal year 2020 showed that the majority of the six hospital-acquired pressure injuries (HAPIs) were due to medical devices. Moreover, an informal survey of the PICU, NICU and general pediatrics nursing staff demonstrated that there is confusion about the previous tools and a lack of understanding regarding how to interpret patient scores.
In November 2021, using the Iowa Model as a guide, the Braden QD scale was implemented in the PICU, NICU and general pediatrics. The Braden QD skin breakdown risk assessment tool was chosen since it applies to the entire age range of patients in all three units, eliminating the need for two age-based tools. Additionally, when compared to the tools previously used, the Braden QD scale includes the number of medical devices a patient has and whether the devices can be repositioned.
Before implementation, an initial assessment of staff knowledge was conducted. These results were used to guide pre-implementation instruction by the project director and PICU skin team to address gaps in knowledge demonstrated by the staff members who were surveyed.
Pre-implementation instruction consisted of an e-learning module and in-services for staff. Six months after implementation, two HAPIs occurred in July 2022 and another six were found, four of which were related to medical devices. Case reviews demonstrated an opportunity for re-instruction regarding the use of the Braden QD scale and the multiple reasons for the uptick in HAPIs. Mandatory workshops for staff highlighting the subscales of the Braden QD and preventative measures for skin breakdown were conducted. A super-user team also was created to support the employment of the Braden QD scale. Monthly chart audits, practice evaluations and instruction continue with the goal of recording zero HAPIs over a 12-month period.