1. 11 Tiny Steps: Improving Neonatal Skin Through Prevention & Early Intervention Pamela Dozier-Young, BSN, RNC, NIC; Pamela Allen, RN, NIC; June Amling, MSN, RN, CNS, CWON, CCRN Washington, DC Introduction Background Interventions Implications to practice f Figure 1. Child Health Corporation of America (CHCA) Collaborative Figure 2. National Database of Nursing Quality Indicators (NDNQI) Since 2007 the NICU Wound Team has taken a proactive approach in consistently identifying neonates who are “at risk” for skin injuries with daily rounds. Our high risk neonates include the very low birth weight infants; patients with medical surgical, genetic, musculoskeletal disorders; the ECMO and HFOV patients, and patients undergoing therapeutic hypothermia. Patients’ outcomes were improved by raising staff awareness, implementing preventive measures, and provision of early intervention. As shown in Figures 1 and 2 the number and/or severity of the pressure ulcers in the NICU decreased in the CHCA and NDNQI Prevalence Studies. It was also concluded that the majority of the pressure ulcers in the NICU were device related; therefore, further education was focused in this direction. Conclusion Next Steps Interventions Methods Introduction Education: Resource binder with EBP information and standardized care plans. Sought opportunities to educate staff on wound care during NICU Skills Day/staff orientation. Designation of 5 NICU team members as Pressure Ulcer experts (formerly CHCA champions 2009-2010). NDNQI Pressure Ulcer Initiative-3 pronged approach (Full prevalence, Modified prevalence and Education) APN delivered education to Attendings/Fellows and NNPs on skin care prevention. strategies. Resources: Enhanced the availability of products and resources in the NICU (ie:Neoprep barrier). Shared ideas through various forums: Magnet/Academy of Neonatal Nursing/CHCA. Skin Care, fluidized positioners,and Tracheostomy Nurse Practice Guidelines available on intranet. Accessibility of the Wound APNs and NICU Wound Team members. Communication: Daily skin/wound rounds. “Top Ten List” and clinical reminders emailed to staff, all emphasizing preventive practices. Information shared via email once a week to include NICU medical team and multidisciplinary teams as mentioned in planning. Ongoing communication with Wound APNs and NICU staff on appropriate skin care management. Leadership support: Collaborated with nursing leadership to include CHCA and NDNQI Pressure Ulcer updates at staff meetings /displayed on dashboard. Ongoing support in purchase of NICU specific wound supplies and fluidized positioners as needed. Children’s National is currently involved in a hospital wide initiative to increase awareness and implement preventive measures to reduce hospital acquired tissue injuries. National efforts have been underway the past few years to reduce unintended iatrogenic injury. Far fewer studies of the incidence and prevalence of pressure ulcers have been done in infants and children than in adults. Injury to either the epidermis or the dermis can predispose neonates to systemic infections, increase morbidity, delay discharge, and escalate health care costs. In 2006, an Advanced Practice Nurse (APN) was introduced to lead a hospital wide initiative to reduce hospital acquired wounds, develop prevention strategies, and introduce evidence-based practice (EBP) for wound and skin care at Children’s National. The Wound APN collaborated with interested NICU staff to form the NICU Wound Team and focus on the specific needs of the neonates in a level III 54 bed Neonatal Intensive Care Unit (NICU). Frequent communication exists between the Wound Care APN and NICU Wound Team to enhance the necessary care. Annual education/competency for basic skin care/prevention strategies to reduce skin excoriations/pressure ulcers. Initiate a journal club focus on EBP skin care management in the neonate. Biweekly communication corner in NICU’s education newsletter. Assessment: Identify patients who are “at risk” for skin breakdown through daily rounds and the use of Neonatal Skin Risk Assessment (NSRAS)Tool. Follow through with transparency of data and daily dialogue with team members and APN’s. Collaborate with multidisciplinary teams and clinical educators. Identify products needed for preventive measures/wound care. Planning: Daily rounds for risk assessment screening. Wound APNs to have frontline access to multidisciplinary teams to provide education, and encourage an open dialogue regarding the plan of care. Collaborate with multidisciplinary teams to include Wound APN, RN staff, RT,OT, PT, nutritionists, neonatologists, specific surgical team, and clinical educators. Confer with APNs for appropriate action/plan of care and products as needed. Contact Information: Pam Dozier-Young/Staff Nurse - pdozier@childrensnational.orgpdozier@childrensnational.org Pam Allen/Staff Nurse - pallen@childrensnational.orgpallen@childrensnational.org June Amling/Wound Care APN - jamling@childrensnational.orgjamling@childrensnational.org Results Objectives 1) Heighten prevention awareness amongst staff nurses/families through education in order to foster accountability to impact patient care. 2) Identify potential “at risk” patients for skin injuries with daily rounds and assessment, and to develop a multidisciplinary plan of care. 3) Communicate effectively to Wound APN’s, physicians, nutritionists, respiratory therapists, occupational and physical therapists, nurses and leadership. ACKNOWLEDGEMENTS Tara E. Taylor, MPH, RN – NICU Director Billie Lou Short, MD - Division Chief of Neonatology Juanda Pryor, MSN, RN, CPN, CPHQ – Quality Improvement Manager : n = 21 Reference Schindler, C. A. (2011) Protecting Fragile Skin; Nursing interventions to decrease development of pressure ulcers in pediatric intensive care; American Journal of Critical Care 20:26-33