Pressure Ulcers in Neonatal Patients - Rene Amaya, MD Pediatric Specialists of Houston - Infectious Disease/Wound Care

Pressure Ulcers in Neonatal Patients

           Rene Amaya, MD
   Pediatric Specialists of Houston –
   Infectious Disease/Wound Care

Objectives
 Review skin anatomy and understand why neonatal
  skin is at increased risk for injury

 Define pressure ulcers and review the stages of
  pressure ulcers in neonates

 Explain the serious legal nature of pressure ulcers and
  how they are a recognized “Never Event”

 Examine current staging tools used to screen patients
  for pressure ulcer development.

 Explain which factors among neonates place them at
  risk for pressure ulcer development

 Address the potential for development of a neonatal
  skin care teams

Functions of Skin
 Provides physical barrier to protect
  underlying tissue and organs.
 Provides a key role in immune system

 Involved in temperature regulation

 Key role in sensory perception

Neonatal Skin vs Mature skin
      Some critical differences

       Structural differences
increase risk of trauma and infection

Neonatal Skin Differences
                                         Epidermis
• Fibrils connect the                                Fibrils
 epidermis and dermis
• More widely spaced and
 fewer in neonates than in
 mature skin
• Diminished cohesion leaves
 the neonate more susceptible
 to injury from shear and       Dermis
 pressure forces

Neonatal Skin Differences
                                Stratum Corneum
 Stratum Corneum is
  thinner in neonates
  especially premature
  infants

 Increases susceptibility to
  infections and topical
  agents

 Also predisposes to
  excessive evaporative
  heat and fluid loss

Neonatal Skin Differences

 Dermis of newborn is
  60% thinner than
  than that of mature
  skin

 Deficient in collagen

 Increases risk for
  injury to underlying
  tissues
                          Dermis

So what is a
   pressure ulcer?

I thought these only
     arose in the
       elderly?

Definition
A pressure ulcer is localized injury to the skin and/or
underlying tissue usually over a bony prominence, as a result
of pressure, or pressure in combination with shear.

A number of contributing or confounding factors are also
associated with pressure ulcers – moisture, nutrition, tissue
perfusion, mobility and activity.

        Tissue
        Injury

Incidence and Prevalence
 The literature on the incidence and prevalence of
  neonatal pressure ulcers remains limited.

 From pediatric data that does exist, most of the
  studies have focused on populations considered
  high-risk for pressure ulcers: NICU, PICU and Pedi
  cardiac.

 Most available studies cite an incidence rate
  ranging from 5% to 23% in neonatal patients.

 Regardless of the incidence, the goal should be
  zero

Staging of Pressure Ulcers

             Stage I
             Stage II
             Stage III
            Stage IV
   Suspected Deep Tissue Injury
          Unstageable

Staging of Pressure Ulcers

 The staging of pressure ulcers as
  defined by national guidelines
  (NPUAP, CMS) allows for uniform
  documentation and classification of
  pressure ulcers by healthcare
  professionals
 The staging of pressure ulcers reflects
  the amount of tissue damage

Stage I: Non-blanchable erythema
 Intact skin with non-blanchable
  redness of a localized area usually
  over a bony prominence.

 Darkly pigmented skin may not
  have visible blanching; its
  color may differ from the
  surrounding area.

 The area may be painful, firm, soft,
  warmer or cooler as compared to
  adjacent tissue.

 Category I may be difficult to
  detect in individuals with dark skin
  tones.

 May indicate “at risk” persons.

Stage II: Partial thickness
 Partial thickness loss of dermis
  presenting as a shallow open
  ulcer with a red pink wound
  bed, without slough.

 May also present as an intact or
  open/ruptured serum-filled or
  sero-sanginous filled blister.

 Presents as a shiny or dry
  shallow ulcer without slough or
  bruising*. *Bruising indicates
  deep tissue injury.

 This category should not be used
  to describe skin tears, tape
  burns, incontinence associated
  dermatitis, maceration
  or excoriation.

Stage III: Full thickness skin loss

 Full thickness tissue loss.

 Subcutaneous fat may be
  visible but bone, tendon
  or muscle are not
  exposed.
 Slough may be present
  but does not obscure the
  depth of tissue loss.
 May include undermining
  and tunneling.
 Bone/tendon is not visible
  or directly palpable.

Stage IV: Full thickness tissue loss
 Full thickness tissue loss
  with exposed bone,
  tendon or muscle.
 Slough or eschar may be
  present.
 Often includes
  undermining and
  tunneling.
 Category/Stage IV ulcers
  can extend into muscle
  and/or supporting
  structures (e.g., fascia,
  tendon or joint capsule)
  making osteomyelitis
  likely to occur.

Unstageable: Full thickness skin or tissue loss
              – depth unknown
 Full thickness tissue loss in
  which actual depth of
  the ulcer is
  completely obscured by
  slough (yellow, tan, gray,
  green or brown) and/or
  eschar (tan, brown or
  black) in the wound bed.
 Until enough slough
  and/or eschar are
  removed to expose the
  base of the wound, the
  true depth cannot be
  determined; but it will
  be either a
  Category/Stage III or IV.

Suspected Deep Tissue Injury –
              depth unknown
 Purple or maroon localized area of
   discolored intact skin or blood-
   filled blister due to damage of
   underlying soft tissue from pressure
   and/or shear.

 The area may be preceded by
   tissue that is painful, firm, mushy,
   boggy, warmer or cooler as
   compared to adjacent tissue.

 Deep tissue injury may be difficult
   to detect in individuals with dark
   skin tones.

 Evolution may include a thin blister
   over a dark wound bed. The
   wound may further evolve and
   become covered by thin eschar.

 Evolution may be rapid exposing
   additional layers of tissue even
   with optimal treatment.

Pressure Ulcers and
                   CMS/Medicare
 Pressure ulcers have been classified as a NEVER-EVENT by
  CMS

 Never-Events are defined as hospital associated problems
  that can be prevented.

 Other examples of Never-Events include surgery on wrong
  patient, surgery on wrong limb, foreign object left in pt
  after surgery, infant discharged to the wrong person, ….

 Never-Events will NOT be reimbursed by insurance

 Never-Events must be reported and can lead to mistrust
  by public.

Why bring a Decubitus Ulcer Lawsuit? It’s about exposing patient
neglect. Decubitus ulcers (or pressure sores) are preventable by good
care. Unfortunately, it is the most vulnerable patients who cannot
complain about the negligent care they receive. This is known as
nursing home abuse or hospital patient neglect. Patients get neglected
when nurses are understaffed and overworked. When nurses are too
busy, they ignore the most vulnerable patients, who in turn develop
bedsores. Because pressure sores are so preventable, decubitus
ulcer lawsuits may be valued in the hundreds of thousands of dollars.

Skin Assessment Scales

The key to keeping neonatal
 pressure ulcer rates low lies in
reliable skin assessment scales
and identification of risk factors
     associated with ulcer
         development.

Skin Assessment Scales
 Skin assessment scales are tools that can be used to
  identify patients at risk for pressure ulcers.

 Unfortunately, many of the recognized risk factors are not
  captured by skin assessment scales.

 Nonetheless, NICU personnel should adopt and utilize
  these tools to identify babies at risk early and this prevent
  an ulcer from developing.

 Three pediatric skin assessment tools that have been
  validated include the Braden Q Scale, Glamorgan Q
  scale and the Neonatal Skin Risk Assessment Scale
  (NSRAS).

Neonatal Skin Risk Assessment Scale

             (NSRAS)

NSRAS
 NSRAS modeled after the Braden Scale, measures 6
  subscales pertinent to neonates

 Reliability and validity testing of the NSRAS was performed
  with 32 NICU patients (26-40 weeks of gestation)

 Using a cutoff score of 5, the sensitivity and specificity of
  NSRAS was 83% and 81% respectively.

 Limitations of the NSRAS scale includes a small sample size,
  the need for further clarification in subscales’ operational
  definitions, and improved reliability.

NSRAS
Gestational Age
 Mental Status
   Mobility
    Activity
   Nutrition
   Moisture

NSRAS
 Gestational Age
   < 28 weeks ………. > 38 weeks posterm

 Mental Status
   Unresponsive even to pain……… Alert and Active

 Mobility
   Completely immobile ….. Major changes in
                            position w/o assistance

NSRAS
 Activity
   Isolette under Saran wrap……………………….….Open Crib

 Nutrition
   NPO/TPN ………................... Bottle/Breast feeds every meal

 Moisture
   Skin constantly wet ………………………… Mostly dry/q24 hr
                                               bedding change

NSRAS
A score of >13 should prompt the unit to monitor
carefully for signs of a pressure ulcer.

Initiatives to reduce the risk for acquiring a pressure
ulcer should to be started.

Risk factors for Neonatal Pressure Ulcers
 Identifying babies at risk for pressure ulcers is the key to their
  prevention

 Among neonates and children, 50% of pressure ulcers are
  equipment and device related (nasal prongs, CPAP masks,
  tubing, lines, tracheostomy devices, O2 monitors and
  bedding)

 Acutely ill and immobilized neonates are at high risk for
  pressure injuries. Such patients are often nutritionally
  challenged which directly affects skin integrity.

 Extremely premature infants less than 32 weeks

Risk Factors - Bedding

Risk Factors - Bedding

Risk Factors - Devices

Risk Factors - Devices

Risk Factors - Devices

Risk Factors - Devices

Risk Factors - Edema

Risk Factors – Extreme Preemie

Risk Factors – Hydrocephalus

Risk Factors - Hydrocephalous

NICU Pressure Ulcer Prevention
              Team
 The goal of each institution is to reduce the incidence of
  stage 2-4 pressure ulcers in neonates to 0%
 One intervention which has resulted in good success is the
  creation of a Pressure Ulcer Prevention Team “PUP”
 Multidisciplinary teams composed of nursing staff,
  respiratory care, nutrition specialists, NNP/Physicians whose
  role includes frequent assessment with rounding and data
  collection.
 Function to provide education, identify babies at risk and
  initiate interventions to prevent PU from developing.

NICU Pressure Ulcer Prevention
               Team
 Would provide proper reporting, staging and
  documentation of pressure injuries

 Analyze trends to determine if a change in
  equipment, bedding or procedures is necessary to
  prevent additional PU from developing.

 Ensure that proper wound care intervention is
  initiated if WC team is not available in the facility.

Summary
 Neonatal skin has unique properties which increase the
  risk for trauma and injury

 Pressure ulcers arise on susceptible areas of the body due
  to combination of pressure, moisture, immobility, shear
  forces as well as direct injury from medical devices.

 Pressure ulcers are classified as Grades1-4 and also
  include Unstagable and Suspected Deep Tissue Injury

 Pressure ulcers may have significant legal implications
  that directly affect nurses and are considered a “Never
  Event” by CMS/Medicare.

Summary

 Identifying babies at risk using various skin
  assessment tools such as NSRAS can determine
  which babies require close observation and
  monitoring.

 Creating a multidisciplinary team to prevent
  pressure ulcers from developing is one way
  neonatal ICU’s lower rates to ZERO!

Thank You!

 Dr. Rene Amaya

  713-464-9776