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Pressure injury prevention for paediatric cardiac surgical patients using a nurse-driven standardized clinical assessment and management plan

  • Lindyce A. Kulik (a1), Jean A. Connor (a2) (a3), Dionne A. Graham (a4) and Patricia A. Hickey (a2) (a3)



The description of pressure injury development is limited in children with CHD. Children who develop pressure injuries experience pain and suffering and are at risk for additional morbidity.


The objective of this study was to develop a standardized clinical assessment and management plan to describe the development of pressure injury in paediatric cardiac surgical patients and evaluate prevention strategies.


Using a novel quality improvement initiative, postoperative paediatric cardiac surgical patients were started on a nurse-driven pressure injury prevention standardized clinical assessment and management plan on admission. Data were recorded relevant to nursing assessments and management based on pre-defined targeted data statements and algorithm. Nursing feedback regarding diversions was recorded and analysed.


Data on 674 congenital paediatric cardiac surgical patients who met criteria were collected between May, 2011 and June, 2012. In 5918 patient days, a total of 4603 skin assessments were completed by nurses from the cardiac ICU and the cardiac inpatient unit, representing 77% of the expected assessments. The majority (70%, 21/30) of the 30 pressure injuries were medical-device-related and 30% (9/30) were immobility-related. The overall incidence of pressure injury was 4.4%: device-related was 3.1% and immobility-related was 1.3%. Most pressure injuries were Stage 1 (40%), followed by Stage 2 (26.7%), mucosal membrane injury (26.7%), and suspected deep tissue injuries (6.7%).


A nurse-driven pressure injury prevention standardized clinical assessment and management plan supported a programme-based evaluation of nursing practice and patient outcomes. Review of practices highlighted opportunities to standardise and focus prevention practices and ensure communication of patient vulnerabilities.


Corresponding author

Author for correspondence: L. Kulik, Boston Children’s Hospital, 300 Longwood Ave, 8 South, Boston, MA 02115, USA. Tel: 617 355 9860; Fax: 617 730 1909; E-mail:


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Cite this article: Kulik LA, Connor JA, Graham DA, Hickey PA. (2018) Pressure injury prevention for paediatric cardiac surgical patients using a nurse-driven standardized clinical assessment and management plan. Cardiology in the Young 28: 1151–1162. doi: 10.1017/S1047951118000975



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1. Kiss, E, Heiler, M. Pediatric skin integrity practice guideline for institutional use: a quality improvement project. J Pediatr Nurs 2014; 29: 362367.
2. Schindler, C, Mikhailov, T, Kuhn, E, et al. Protecting fragile skin: nursing interventions to decrease development of pressure ulcers in pediatric intensive care. Am J Crit Care 2011; 20: 2634.
3. Visscher, M, King, A, Nie, A, et al. A quality-improvement collaborative project to reduce pressure ulcers in PICUs. Pediatrics 2013; 131: e1950e1960.
4. National Pressure Ulcer Advisory Panel. National Pressure Ulcer Advisory panel announces a change in terminology from pressure ulcer to pressure injury and updates the stages of pressure injury, 2016. Retrieved September 27, 2017, from ulcer-advisory-panel-npuap-announces-a-change-in-terminology-from-pressure-ulcer-to- pressure-injury-and-updates-the-stages-of-pressure-injury.
5. Allman, R, Goode, P, Burst, N, Bartolucci, A, Thomas, D. Pressure ulcers, hospital complications, and disease severity: impact on hospital costs and length of stay. Adv Wound Care 1999; 12: 2230.
6. Reddy, M, Gill, S, Rochon, P. Preventing pressure ulcers: a systematic review. JAMA 2006; 296: 974984.
7. Curley, MAQ, Razmus, I, Roberts, K, Wypij, D. Predicting pressure ulcer risk in pediatric patients: the Braden Q scale. Nurs Res 2003; 52: 2232.
8. Centers for Disease Control and Prevention. Congenital heart defects: data & statistics, 2016. Retrieved September 27, 2017, from
9. Gilboa, S, Devine, O, Kucik, J, et al. Congenital heart defects in the United States - estimating the magnitude of the affected population in 2010. Circulation 2016; 134: 101109.
10. Hickey, PA, Gauvreau, K, Tong, E, Schiffer, N, Connor, JA. Pediatric cardiovascular critical care in the United States: nursing and organizational characteristics. Am J Crit Care 2012; 21: 242250.
11. Black, J, Edsberg, L, Baharestani, M, et al. Pressure ulcers: avoidable or unavoidable? Results of the National Pressure Ulcer Advisory Panel consensus conference. Ostomy Wound Manage 2011; 57: 2437.
12. Coleman, S, Gorecki, C, Nelson, E, et al. Patient risk factors for pressure ulcer development: systematic review. Int J Nurs Stud 2013; 50: 9741003.
13. Schoonhoven, L, Defloor, T, van der Tweet, I, Buskens, E, Grypdonck, M. Risk indicators for pressure ulcers during surgery. Appl Nurs Res 2002; 15: 163173.
14. Swafford, K, Culpepper, R, Dunn, C. Use of a comprehensive program to reduce the incidence of hospital-acquired pressure ulcers in an intensive care unit. Am J Crit Care 2016; 25: 152164.
15. Aronovitch, S. Intraoperatively acquired pressure ulcers: are there common risk factors? Ostomy Wound Manage 2007; 53: 5769.
16. O’Connell, M. Positioning impact on the surgical patient. Nurs Clin North Am 2006; 41: 173192.
17. Rao, A, Preston, A, Strauss, R, Stamm, R, Zalman, D. Risk factors associated with pressure ulcer formation in critically ill cardiac surgery patients: a systematic review. J Wound Ostomy Continence Nurs 2016; 43: 242247.
18. Ahern, J, Hickey, PA. Implementation of a pressure ulcer prevention program in a pediatric hospital. Chinese Nurs Manage 2011; 2: 2628.
19. Galvin, P, Curley, MAQ. The Braden Q + P: a pediatric perioperative pressure ulcer risk assessment and intervention tool. AORN J 2012; 96: 261270.
20. Centers for Medicare and Medicaid Services. Eliminating serious, preventable and costly medical errors-never events, 2006. Retrieved September 27, 2017, from
21. Massachusetts Legislature. Chapter 305 of the Acts of 2008, an act to promote cost containment, transparency, and efficiency in the delivery of quality health care, 2008. Retrieved September 27, 2017, from
22. Connor, JA, Gauvreau, K, Jenkins, K. Factors associated with increased resource utilization for congenital heart disease. Pediatrics 2005; 116: 689695.
23. Hickey, PA, Gauvreau, K, Jenkins, K, Fawcett, J, Hayman, L. Statewide and national impact of California’s staffing law on pediatric cardiac surgery outcomes. J Nurs Adm 2011; 41: 218225.
24. Schindler, C, Mikhailov, T, Cashin, S, Malin, S, Christensen, M, Winters, J. Under pressure: preventing pressure ulcers in critically ill infants. J Spec Pediatr Nurs 2013; 18: 329341.
25. National Pressure Ulcer Advisory Panel and European Pressure Ulcer Advisory Panel. Prevention and Treatment of Pressure Ulcers. Clinical Practice Guideline. National Pressure Ulcer Advisory Panel, Washington, DC, 2009.
26. Baharestani, M, Ratliff, C. Pressure ulcers in neonates and children: a NPUAP white paper. Adv Skin Wound Care 2007; 20: 208220.
27. Neidig, J, Kleiber, C, Oppliger, R. Risk factors associated with pressure ulcers in the pediatric patient following open-heart surgery. Prog Cardiovasc Nurs 1989; 4: 99106.
28. Rathod, R, Farias, M, Friedman, K, et al. A novel approach to gathering and acting on relevant clinical information: SCAMPs. Congenit Heart Dis 2010; 5: 343353.
29. Curley, MAQ, Hickey, PA. The Nightingale metrics. Am J Nurs 2006; 106: 6670.
30. Agency for Health Care Policy and Research. Pressure Ulcer in Adults: Prediction and Prevention. Clinical Practice Guideline Number 3. Public Health Service, US Department of Health and Human Services, Rockville, MD, 1992.
31. Institute for Healthcare Improvement. 5 million lives getting started kit: prevent pressure ulcers, how to guide, 2007. Retrieved September 27, 2017, from
32. Institute for Healthcare Improvement. How to guide: pediatric supplement. Preventing pressure ulcers: 5 million lives campaign, 2011. Retrieved from resources/Pages/Tools/HowtoGuidePreventPressureUlcersPediatricSupplement.aspx.
33. National Pressure Ulcer Advisory Panel. Mucosal pressure ulcers - An NPUAP position statement, 2008. Retrieved September 27, 2017, from content/uploads/2012/01/Mucosal_Pressure_Ulcer_Position_Statement_final.pdf.
34. Fischer, C, Bertelle, V, Hohlfeld, J, Forcada-Guex, M, Stadelmann-Diaw, C, Tolsa, J. Nasal trauma due to continuous positive airway pressure in neonates. Arch Dis Child Fetal Neonatal Ed 2010; 95: F447F451.



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