Kid-Sized Comfort

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March 2004

By C.A. Wolski

Although not as prevalent in pediatric patients as in adults, pressure ulcers can affect recovery time, cause scarring, and cost medical facilities hundreds of thousands of dollars in equipment purchases. In order to minimize the number of pressure ulcers it was seeing in its young patients, Texas Children’s Hospital, a 737-bed facility in Houston, recently completed a study comparing the interface pressures of various support surfaces.

A need for research
Compared to adult hospitals, where between 14% and 15% of patients develop pressure ulcers, the 4% rate for pediatric patients seems statistically less significant. However, it is important to note that 66% of these pressure ulcers in pediatric patients are facility acquired. About 70% of those pressure ulcers were acquired in the intensive care unit, says Kathy McLane, MSN, RN, CPNP, CWCN, COCN, a wound, ostomy, and continence pediatric nurse practitioner at Texas Children’s Hospital and the lead investigator for the hospital’s recent study.

One of the primary reasons for the study, says McLane, was the fact that there is little in the literature about the best surfaces available to clinicians to prevent pediatric pressure ulcers. “Unfortunately, for the bed companies that have no air loss beds, children are not the primary consumers of their products, so they have not invested a lot of research into finding a support surface to target that population,” she says.

There were also a host of practical concerns that motivated the study. “We were seeing pressure ulcers in our intensive care unit, and we really didn’t have any criteria for which patients go on these low air loss beds,” says McLane. “We were actually seeing young children, toddlers even, being placed on these huge air loss beds that were expensive. We were still seeing skin breakdown, we were having problems with the beds deflating, and we had to put in an artificial weight to keep the bed supporting the patient.

“We were also looking at how many different surfaces these kids were lying on, and we came up with six or seven different surfaces,” she says.

The study was designed to evaluate these various surfaces, using healthy children and measuring the interface pressure at several points on their bodies.

So many surfaces
The study specifically looked at issues related to the surfaces used in the ICU—not only because this is where most of the ulcers were occurring, but because of the variety of surfaces the children were being subjected to.

“The study originally was supposed to be for the pediatric intensive care unit patients, but when we realized there were so many different surfaces to study, we realized we couldn’t be flip-flopping these critically ill kids from surface to surface to measure their interface pressure,” says McLane. “That’s why we targeted healthy kids from the community where we could put them on five different surfaces and measure the interface pressure on all these surfaces.”

Subjects for the study were recruited through the hospital. McLane and her fellow investigators used the children of coworkers and advertised for participants in the Texas Children’s Hospital’s newsletter. There were a total of 54 children, from infants to 16-year-olds, who participated in the study. They were separated into groups of 10 to 15 based on their age group.

Age was a factor in determining the method by which the measurements were taken. “We found that body proportions of the child change around 6 years of age and become a little bit more like those of an adult, where the coccyx area and the heel are more at risk,” says McLane. “But younger than 6, the head is still the largest body surface area for them and thus the most at risk for pressure ulcers. So, for younger children, we just measured the occipital area, because we knew that was going to be the area most at risk. With the older children, we looked at the head, the coccyx, and the heels.”

The initial study was performed only at Texas Children’s Hospital. All the children presented the researchers with particular challenges. With their short attention spans, the younger ones were prone to moving around, while the older children tended to be more rigid and nervous. There were three measurements taken at each pressure point—head, coccyx, and heels—with the children lying completely supine.

Learning from results
The results of the study, which was conducted from October to November 1999, allowed investigators to recommend the ideal age-related surface for each pediatric group.

“We found that the foam overlay we use performed excellently,” says McLane. “In children less than 2 years old, the foam overlay had very low interface pressure. In children less than 6, with the foam overlay and the gel pillow, you got an even lower interface pressure in the occipital area. And they’re cheap. They’re one-time costs. For children 6 to 16, the foam overlay had pressures under the coccyx and heels similar to those of the low air loss bed we use. Our recommendation was that if you’re going for cost-effectiveness, the foam overlay…would be a great surface for pediatric patients.”

The study solved one of the fundamental problems the clinical staff had—lack of knowledge about pediatric surfaces. In addition, it had other, more practical implications.

“A lot of times we find that children in our intensive care unit are very critically ill, they’re intubated, they can’t be turned as much. Then they start getting [skin] breakdowns, and the physicians and the nurses start to panic and they want to do something for them,” says McLane. “So they start ordering low air loss beds to put them on and such. That’s an additional cost to the system. We have spent at our hospital over $150,000 a year on beds and low air loss beds, so this is a big savings if we can decrease our use of low air loss beds. But obviously we don’t want to compromise the patients and the care we provide for them. So this would help us to choose more accurately what types of patients are going to go on these beds—with a little more confidence.”

The study has standardized care at Texas Children’s Hospital with staff using the foam overlay and gel pillow more and the low air loss bed less, but McLane and her fellow investigators were still not finished with the subject.

Continuing studies
Beginning in October 2003, Texas Children’s Hospital spearheaded a nine-hospital study measuring the prevalence of pressure ulcers in pediatric patients. The prevalence study was completed in December.

Though the studies have helped clinicians at Texas Children’s Hospital make more informed decisions about support surfaces, it is still unclear whether the changes McLane and her colleagues have made are lessening the number of pressure ulcers in their pediatric patients. Because of this, McLane considers it an ongoing issue. “We may revisit our algorithm for how we are placing patients on surfaces,” she says. “If we want to make any future changes, we can do another prevalence study and compare numbers to see if that has made any difference in the rates of our pressure ulcers.”

The goal of the studies is simple: to eliminate pressure ulcers in pediatric patients as much as possible.

To that end, McLane says the next step is to look at the risk factors involved in the development of pressure ulcers. “When we did this prevalence study, one of the other things we did was collect data on potential risk factors that had been in the pediatric literature in the past and that we think might be significant. We wanted to see if that [information] still holds true,” she says. “We’ve collected that data, but we haven’t analyzed it yet. We will be analyzing that next.”

Reminiscent of the 1999 study, one of McLane’s colleagues conducted a study of use of interface pressures and support surfaces with premature babies in the Infant Care Unit in February. “I can’t wait to see what we find,” says McLane.

Since opening its doors in 1954, the not-for-profit Texas Children’s Hospital has treated more than 1 million children from around the world. Its clinical staff includes more than 1,580 primary care physicians, pediatric subspecialists, pediatric surgical subspecialists, and dentists. The hospital is affiliated with the nearby Baylor College of Medicine, serving as the school’s primary pediatric training site. Baylor professors play a role as service chiefs and staff physicians throughout the hospital system.

C.A. Wolski is associate editor of Rehab Management.

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March 2004