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Nursing Excellence

The Online Newsletter for Children's Nurses
e-Edition, Issue 9 

Judy MasonShared Governance: PICU Skin Care Program

By Judy Mason, BSN, RN, CCRN

        Over the last few years the pediatric intensive care unit (PICU) at Children’s Hospital Central California has adopted measures to improve safety and standards in the prevention of central blood stream infection (CLABSI), ventilator associated pneumonia (VAP), catheter associated urinary tract infection (CAUTI), and most recently in the area of pressure ulcer prevention.

The PICU population is at high risk for developing pressure ulcers due to mobility restrictions, critical illness and nutritional status. Pressure ulcers have an incidence of 7 percent and a prevalence of 7 percent among acutely ill children.1  Predisposition to developing pressure ulcers is contributory to prolonged hospitalization, poor outcomes and potential litigation. In a study of adverse events, Cho et al2 reported pressure ulcers have the greatest effect on length of stay, increasing stays by 1.84 percent for patients with such ulcers. The Whole System Measures of the Child Health Corporation of America (CHCA) in 2009 revealed that pressure ulcers were the most commonly reported “never events.” The cost of managing a single full thickness pressure ulcer has been estimated to be as high as $70 thousand. Most pressure ulcers are preventable by identifying patients at risk and reliably implementing prevention strategies.3

The creation of the PICU’s skin care program came as a result of risk assessment and incidents that identified an area where best practice could be implemented. This was championed by Carole Cooper, MSN, MHA, RN, CPN, CNS, clinical practice specialist, and Gloria Lu, MSN, RN, CWOCN, wound and ostomy nurse specialist. Unit champions and a physician joined both registered nurses as part of the core group. With an aim to enhance patient care by decreasing the incidence of skin breakdown, the first goal established was to increase the level of awareness of this program and facilitate education, use and implementation of new and available products.

A change in culture on how nurses look at pressure ulcer risk or prevalence in children requires dedication of a team of champions in campaigning for this issue. Skin care rounds are done every Monday to assess and identify high risk patients. The certified wound and ostomy nurse consults and provides education and recommendations to staff on skin care and treatments including products to be utilized for patients who have outstanding wound issues. The PICU Practice Council is instrumental in supporting this program by raising its profile through huddle topics, poster boards and review and adherence of Children’s wound policies.

Products have been made available, such as the Gel-E-Donut positioning aids, Mepitel and Mepilex dressing. Likewise, three new beds with pressure redistribution mattresses have been purchased for the unit to be utilized for high risk patients. According to the CHCA study, consistent application of basic prevention practices such as skin assessment, risk assessment, minimizing pressure, managing clinical risk factors and maximizing team function, have achieved a remarkable 65 percent reduction in intensive care unit ulcer prevalence among the participating hospitals.3

The PICU skin care program is still in its stage of infancy. Through collaborative practice and an ongoing campaign, we will be able to reduce the incidence of pressure ulcers, if not completely eliminate it. “First, to do no harm” is a Hippocratic Oath used by the medical profession but is equally applicable to all caring healthcare professionals who aspire for best practice and quality outcomes.



1 Willock J, Hughes J, Tickle S, Rossiter G, Johnson C, Pye H. Pressure sores in children: the acute hospital perspective. J Tissue Viability. 2000;10(2):59-62.

2 Cho SH, Ketefian S, Barkauskas VH, Smith DG. The effects of nurse staffing on

adverse events, morbidity, mortality, and medical costs. Nurs Res. 2003;52(2):71-79.

3 Child Health Corporation of America/CHCA: Preventing Pressure Ulcers Collaborative; September 2010.



In This Issue

A Recipe for Advanced Clinical Systems

Code of Ethics for Nurses

Champions… A Key to Success

Optimizing the Wound Healing Environment

Electronic Documentation

The Pace of Regulatory Change

Alphabet Soup in the Ambulatory Division

Shared Governance: PICU Skin Care Program

Striving for Excellence in Children's Asthma Care

Patient Satisfaction Comments