Better Together: Preventing pressure injuries in the PICU

Last year, faculty and staff in the pediatric intensive care unit were noticing a concerning trend: Many of the critically-ill patients with non-invasive ventilation were experiencing pressure injuries during their stay.

“Our quality indicators showed that pressure injuries were fairly common among our patients with non-invasive ventilators, and it was something that we wanted to find a solution for,” said Tonie Owens, R.N., clinical nurse specialist in the PICU. “So we brought together experts from a variety of fields — nurses, respiratory therapists, doctors and quality specialists — to completely rethink the way we were providing care.”

The results speak for themselves. Over the past 10 months, only one pressure injury from non-invasive ventilation has been reported, a significant drop from the months before.

Identifying best practices

When the patient safety problem was identified, a PICU nurse began researching best practices regarding skin injuries, with a focus on respiratory devices.

She brought her findings to unit committees, where they collaborated to meet the needs of patients and clinicians at Michigan Medicine. It was a process that involved feedback from a number of different specialists.

“Our respiratory therapists have specialized knowledge related to ventilation, while our nurses have expertise in pressure injury prevention,” Owens said. “By putting our heads together, we were able to find ways to get better outcomes for our patients.”

So what were some of the changes that were implemented?

First, there is now a standard of taking off a patient’s mask every six hours, cleaning the skin underneath it and repositioning it when it is placed back on.

There is also improved education among clinicians, who are now better equipped to spot skin injuries and know when to reposition a mask.

“Our clinicians can take the information they now know and inform parents what the plan is, why we are implementing it and how they can help,” Owens said. “Parents are partners in the care of their children and it has led to a stronger relationship and an improved experience for everyone involved.”

Revamping the workflow

Such improved practices carried with them a multitude of other adjustments. For instance, whenever a mask is being removed and cleaned, at least two staff members must be in the room.

“Even though it is just the mask being removed and not the ventilator itself, we need to ensure that our patients remain as safe as possible when their mask is not on,” said Jeff Cain, respiratory therapy supervisor for the PICU. “So both a nurse and RT must be present during that process.”

That led to a change in workflow, giving team members the bandwidth to carry out the cleanings and, eventually, reduce patient harm.

“The key was communication,” Cain said. “We talked about these processes every day at our DMS huddle, so our clinicians knew what was coming and what was going to be expected from them, and they all bought in.”

Physicians also have served as partners in the process, as have members of the quality team.

“We are constantly measuring data to ensure that our new practices are having the desired effect and that these improvements are sustainable,” Cain said.

Team members are also encouraged to speak up at the daily huddle if there are any issues with the workflows or new procedures.

It’s a group effort that is paying off for patients.

“We’ve empowered our faculty and staff to make a difference and improve the care we provide,” Owens said. “When we work together as a team, we do our best work. This whole experience is proof of that.”