Offload the Head! Eliminating Occipital Pressure Ulcers in Critical Care through use of an Off-loading Cushion

Background: Patients who are admitted to the cardiothoracic intensive care unit (CTICU) are at very high risk for skin breakdown. Risk factors that these patients have include time on vasopressors, friction and shear, cardiovascular disease and mechanical ventilation. It is often challenging to implement basic pressure ulcer prevention such as turning side to side as CTICU patients can be too unstable to tolerate such maneuvers. The development of a pressure ulcer can have an impact on the patients’ length of stay, risk for infection and overall satisfaction. An effective pressure ulcer prevention plan must be implemented for these highly compromised patients to minimize the risk of skin breakdown. Problem: The CTICU was noted to be experiencing a high rate of reportable (stage III or greater) occipital pressure ulcers. There were no identified solutions captured in a literature review. Methods: An offloading cushion, originally designed for wheelchairs, was brought in and placed under the heads of high-risk patients in the cardiothoracic intensive care unit. Criteria for use   included patients with cardiac surgery, malnutrition, and vasopressors. However, staff were encouraged to utilize this cushion under any patient deemed to be at high risk. The patients were tracked for risk factors, placement and duration of use, and outcome. The staff received in-service education on proper use and correct placement technique and had follow up education through rounding by pressure ulcer prevention champions and the leadership team. A partnership was developed with the operating room so that the waffle cushion may be placed on post- operative patients immediately prior to transfer to the CTICU.  Results: There have been no documented occipital pressure ulcers since the implementation of this cushion. The use of this cushion has spread to other intensive care units for prevention of occipital pressure ulcers.