S.K.I.N.D.E.E.P Tool for Pressure Ulcer Prevention in Critical Neonatal and Pediatric Population Undergoing Extracorporeal Membrane Oxygenation (ECMO)

Neonatal and pediatric patients undergoing Extracorporeal Membrane Oxygenation (ECMO) for provision of cardiopulmonary support possess many risk factors for pressure ulcer development. An initiative to reduce Pressure Ulcers in this high-risk population was conducted. After the review of current statistics/guidelines the PU Prevention Bundle was developed, incorporating 6 elements that National PU Advisory Panel (NPUAP) endorses. Compliance with bundle elements was unsatisfactory. Incidence of PUs was significant. Culture of eliminating “unacceptable” hospital acquired conditions (HAC) was not widespread and embraced; complacency instead of pro-activity prevailed. Suboptimal knowledge of preventative measures, risk factors and poor compliance with assessment and documentation were noted. Treatment was inconsistent. ICU patients represented majority, specifically cardiac and ECMO recipients. An educational program was put together, including bundle modification into a simple one-page tool  ”S.K.I.N.D.E.E.P”, demonstrating a pictorial of at risk areas and preventative products. It was printed in ECMO manual and placed by bedside of every ECMO recipient.

SKINDEEP was piloted ECMO recipients. Review of pre-implementation era (03/12-06/13) revealed 15 PUs.14 patients undergone 149 ECMO days. (6 patients were PU-free, 8 had 1 or more PU). SKINDEEP was implemented in 06/2013. ECMO staff was educated on PU prevention, shifting the thinking that PU in ICU is unavoidable. Emphasis was placed on mandatory prevention, parent involvement in skin care, decreasing morbidity &cost of care and avoiding reportable “never events”.

Post-Implementation era (07/13—10/15) included 24 ECMO recipients, 183 ECMO days and only 1PU.We know that average cost of Stage3 or 4PU is ~$40.000 -70.000/stay. Therefore, decrease in incidence by ~99% translated into potential savings of $500.000/year for our hospital.

Cultural shift is slow, but decrease in numbers inspires bedside caregivers to embrace change for the sake of patient’s safety. We know that most PU are avoidable and the key is education, culture change, constant audits and feedback element.