Simplified Assessment of Pressure Ulcer Risk in Hospitalized Children: Development of The Pediatric Pressure Ulcer Trigger Tool (PPUTT)
Xiumei Qi1,2*, Jianhong Qiao1, Xiaolin Xu1, Xueyuan Cao2, Scott C. Howard2
1Shandong Provincial Qianfoshan Hospital, 250014 Jinan,
Shandong Province, P.R China
2University of Tennessee Health Sciences Center, Memphis, TN, USA
*Corresponding author: Xiumei Qi, Department of Pediatrics, Shandong Provincial Qianfoshan Hospital, 250014, Jinan, China. Tel: +15715258205; Fax: +8653189268238; Email: qixiumei10@163.com
Received Date: 21 May, 2018; Accepted Date: 28 May, 2018; Published
Date: 06 June, 2018
Citation: Qi X, Qiao J, Xu X, Cao X, Howard SC (2018) Simplified Assessment of Pressure Ulcer Risk in Hospitalized Children: Development of The Pediatric Pressure Ulcer Trigger Tool (PPUTT ). Arch Pediatr 3: 149. DOI: 10.29011/2575-825X.100049
1. Abstract
1.1. Purpose: Complicated existing valid tools proved problematic when the hospital census and patient-to-nurse ratio were high. The purpose of this study is to develop a screening tool that can be learned easily and implemented quickly relative to the Braden Q Scale.
1.2. Material and Methods: We developed the Pediatric Pressure Ulcer Trigger Tool (PPUTT) with three trigger questions following consensus method, which was used to select the questions, refine the language used (in Chinese), and determine face validity. The resulting PPUTT was then refined to include more explanations for each question based on input from nursing leaders and a pediatric physician, and revalidated by a team of experienced pediatric nurses. Bedside nurses and a domain expert completed the PPUTT and the Braden Q Scale for a series of pediatric inpatients at a large tertiary care hospital in China through August 8th to 15th of 2017, the time required to perform the assessment was measured, and implementation barriers were noted.
1.3. Results: 184 pediatric patients from the pediatric wards (n=171) and pediatric intensive care unit (n=13) ware accessed by using PPUTT and Braden Q Scale. The mean time required for each assessment was 12.10±3.87 seconds for the PPUTT and 42.36±8.16 seconds for the Braden Q Scale, t=46.9, P<0.001.
1.4. Conclusions: Implementation of PPUTT was feasible for pediatric inpatients in China and could be performed in 12 seconds by bedside nurses after minimal training. Future research is needed to evaluate the sensitivity and specificity of PPUTT to predict pressure ulcers.
2. Keywords: Pediatric; Pressure Ulcer; Trigger Tool; Simplified
Figure 1: Gingival pressure ulcer caused by
pressure from the endotracheal tube on the gums of a sedated child in the
pediatric intensive care unit (original photo taken by Xiumei Qi on 1st August
2017).
Figure 2: Consensus methodology used to develop the Pediatric
Pressure Ulcer Trigger Tool.
Figure 3: Time (seconds) required to
assess pressure ulcer risk using the Pediatric Pressure Ulcer Trigger Tool
(PPUTT, blue) or the Braden Q Scale (red).
Author |
Instrument |
Settings |
Based on |
Subscales |
Scoring |
Results |
Curley et al. [19] (2003)
|
Braden Q Scale |
Pediatric intensive care unit, mean age 3 years (21 days to 8 years) |
Adult Braden and Expert panel |
Seven subscales: Patient mobility, Patient activity, Sensory perception, Moisture, Friction and shear, Nutrition Tissue perfusion and oxygenation |
Each subscale incurs a score of 1~4, the total score varies from 7 to 28, with the critical cut off point of ≤16 indicating “at risk”. |
Incidence 86/322 (26.7%); for stage II and higher PUs AUC = 0.83. at a cut-off 16 sensitivity = 0.88, specificity = 0.58,
|
Willock et al. [20] (2009) |
Glamorgan Scale
|
Pediatric patients; Age from 1 day to 17 years 11 months |
Literature review, Expert panel, and Pediatric pressure ulcer risk factors study |
Ten subscales: Mobility, Equipment/objects/hard surface pressing or rubbing on skin, Significant anemia (Hemoglobin<9g/dl), Persistent pyrexia (temperature>38°C for more than 4 hours), Poor peripheral perfusion (cold extremities/capillary refill > 2seconds or cool mottled skin), Inadequate nutrition (discuss with dietician if doubt), Low serum albumin (<35 g/l), Weight < 10th percentile, Incontinence (inappropriate for age) |
The item ‘Mobility’ has four categories that can be rated with 0 (normal mobility for age), 10 (some mobility, but reduced for age), 15(unable to change his/her position without assistance/cannot control body movement) and 20 (child cannot be moved without great difficulty). The item ‘Equipment/objects/hard surface pressing or rubbing on skin’ can be rated with 0 (no) or 15 (yes) points. Remaining dichotomous items are rated with 0 or 1. Total score: 0~42, the higher the sum score, the higher the pressure ulcer risk. |
Incidence 61/336(18.15%) AUC=0.91 At a cut-off 15, sensitivity =0.98 specificity = 0.67
|
Huffines and Logsdon. [22] (1997) |
Neonatal Skin Risk Assessment Scale (NSRAS) |
Neonates, mean age 33 weeks’ gestation |
Adult Braden |
Six subscales: General Physical Condition, Mental State, Mobility, Activity, Nutrition, Moisture. |
All subscales are rated on a scale ranging from 1 to 4, and Potential scores range from 6 to 24, with higher scores indicating lower levels of risk.
|
Incidence 6/32(19%) Using only the subscales of general physical condition, activity, and nutrition, and having a cut off score of 5, sensitivity =0.83, Specificity =0.81. Interrater reliability was 0.97. |
David. et al. [23] (2014) |
Pediatric Pressure Ulcer Prediction and Evaluation Tool |
Pediatric patients, age from birth to 18 years |
Braden Q Scale, literature review and expert panel |
Nine subscales: Seven Subscales of Braden Q Scale, Adding “external medical devices” and “Skin condition”.
|
Each item of the subscale has a minimum score of 1 (less risk) and a maximum score of 2 or 3, the range of scores is 9-26.
|
Incidence 59/273(21.61%) with the critical cut off point of ≥18 or nutrition score = 2; or any item score = 3] puts a patient at risk, sensitivity= 74.58% specificity =57.94% |
Table 1: Pediatric pressure ulcer risk assessment tools.
|
Item |
Trigger Tool of ICSI[36] |
Trigger Tool of NICU[37] |
PPUTT |
Explanation vision of PPUTT |
Is the patient |
Mobility |
Moving extremities and/or body appropriately for developmental age? |
Moving extremities and/or body appropriately for developmental age? |
Limited mobility (unappropriated for developmental age/weak/cannot change position/cannot control posture/under sedation or anesthesia/ body restrain, et al)? |
Limited mobility (Answering “Yes” to any of the following questions: Does the patient have developmental delay that impacts mobility? Is the patient weak? Does the patient have difficulty changing position? Can the patient not control her/his own posture? Is the patient sedated or anesthetized? Is the patient in restraints? Does the patient have any other factor that would limit mobility?) |
Responsiveness |
Responding to discomfort in a developmentally appropriate manner? |
Responding to discomfort in a developmentally appropriate manner? |
X |
X |
|
Tissue perfusion |
Demonstrating inadequate tissue perfusion with evidence of skin breakdown? |
Demonstrating adequate tissue perfusion based on the clinical formula (mean arterial pressure, gestational age and/or capillary refill<3s)? |
Demonstrating inadequate tissue perfusion (capillary refill time >2 s /cool mottled skin)? |
Demonstrating inadequate tissue perfusion (CRT>2 s /cool mottled skin)? |
|
Abrasion |
X |
X |
Equipment/objects/hard surface pressing or rubbing on skin? |
Equipment/objects/hard surface pressing or rubbing on skin? |
|
|
If any of the 3 criteria are met, the patient is considered to be at risk |
If any of the 3 criteria are met, the patient is considered to be at risk |
If any of the 3 criteria are met, scored 1, and represents a patient at risk. The total score of PPUTT was 3. |
If any of the 3 criteria are met, scored 1, and represents a patient at risk. The total score of PPUTT was 3. |
|
Scoring system |
|||||
X, No trigger question in this item. ICSI, Institute for Clinical Systems Improvement. NICU, Neonatal intensive care unit. PPUTT, Pediatric pressure ulcer trigger tool. |
Table 2: Pressure ulcer trigger tools.
Variable |
Number |
Percentage (%) |
Gender |
|
|
Male |
99 |
53.8 |
Female |
85 |
46.2 |
Department |
|
|
Regular ward |
89 |
48.4 |
Neurology ward |
33 |
17.9 |
Oncology ward |
49 |
26.6 |
PICU |
13 |
7.1 |
Disease |
|
|
Respiratory tract infection |
112 |
60.9 |
Cancer |
39 |
21.2 |
Central neurologic disease |
20 |
10.9 |
Diarrhea |
6 |
3.3 |
Other diseases |
7 |
3.7 |
Age (Year) |
|
|
Median |
1.8 |
|
Inter quartile range |
1~3.9 |
|
Table 3: General information of participants (n=184).
- Kottner J, Hauss A, Schlüer A-B, Dassen T (2013) Validation and clinical impact of paediatric pressure ulcer risk assessment scales: A systematic review. Int J Nurs Stud 50: 807-818.
- Baharestani MM (2007) An overview of neonatal and pediatric wound care knowledge and considerations. Ostomy Wound Manage 53: 34-36, 38, 40, passim.
- Razmus I and Bergquist-Beringer S (2017) Pressure Injury Prevalence and the Rate of Hospital-Acquired Pressure Injury Among Pediatric Patients in Acute Care. J Wound Ostomy Continence Nurs 44:110-117.
- Habiballah L and Tubaishat A (2016) The prevalence of pressure ulcers in the paediatric population. J Tissue Viability 25: 127-134.
- de Souza Pellegrino DM, Chacon JMF, Blanes L, Ferreira LM (2017) Prevalence and incidence of pressure injuries in pediatric hospitals in the city of São Paulo, SP, Brazil. J Tissue Viability 26: 241-245.
- Kottner J, Wilborn D, Dassen T (2010) Frequency of pressure ulcers in the paediatric population: a literature review and new empirical data. Int J Nurs Stud 47: 1330-1340.
- Schlüer AB, Schols JM, Halfens RJ (2014) Risk and associated factors of pressure ulcers in hospitalized children over 1 year of age. J Spec Pediatr Nurs 19: 80-89.
- Schlüer AB, Halfens RJ, Schols JG (2012) Pediatric pressure ulcer prevalence: a multicenter, cross-sectional, point prevalence study in Switzerland. Ostomy Wound Manage 58: 18.
- Schlüer AB (2017) Pressure ulcers in maturing skin-A clinical perspective J Tissue Viability 26: 2-5.
- Schindler CA, Mikhailov TA, Kuhn EM, Christopher J, Conway P, et al. (2011) Protecting fragile skin: nursing interventions to decrease development of pressure ulcers in pediatric intensive care. Am J Crit Care 20: 26-35.
- Zheng XL and Guo R (2012) Current status and reflection of pediatric nurse's allocation. Chinese Nurs Manage 12: 9-12.
- Wan X and Feng X (2015) A survey on the current status of pediatric nursing human resources in Sichuan province of China. J Evid Based Med. 8: 209-214.
- Spetz J (2004) California's minimum nurse‐to‐patient ratios: the first few months. J Nurs Adm 34: 571-578.
- Aiken LH, Sloane DM, Cimiotti JP, Clarke SP, Flynn L, et al. (2010) Implications of the California nurse staffing mandate for other states. Health Serv Res 45: 904-921.
- Chen YL, Hsu LL, Hsieh SI (2012)
Clinical nurse preceptor teaching competencies: relationship to locus of
control and self-directed learning. J Nurs Res 20: 142-151.
- Wang WQ, Tang YE, Wang Y, Meng D (2013) Reason Ananlysis and precautionary measures for nurse-patient disputes in pediatric surgical ward. Chinese Medical Ethics 26: 567-569.
- Zhu XZ and Zhang YL (2014) Effect of “Zero inventory”of medical supplies management to promote quality care. Journal of nurses Training 29: 1757-1758.
- Baharestani MM and Ratliff CR (2007) Pressure ulcers in neonates and children: an NPUAP white paper. Adv SkinWoundCare 20: 208-220.
- Curley MA, Razmus IS, Roberts KE, Wypij D (2003) Predicting pressure ulcer risk in pediatric patients: the Braden Q Scale. Nurs Res 52: 22-33.
- Willock J, Baharestani M, Anthony D (2009) The development of the Glamorgan paediatric pressure ulcer risk assessment scale. J Wound Care 18: 17-21.
- Huffines B and Logsdon MC (1997) The neonatal skin risk assessment scale for predicting skin breakdown in neonates. Issues Compr Pediatr Nurs 20: 103-114.
- Sterken DJ, Mooney J, Ropele D, Kett A, Vander Laan KJ (2015) Become the PPUPET Master: mastering presure ulcer risk assessment with the pediatric pressure ulcer prediction and evaluation tool (PPUPET). J Pediatr Nurs 30: 598-610.
- Willock J, Habiballah L, Long D, Palmer K, Anthony D (2016) A comparison of the performance of the Braden Q and the Glamorgan paediatric pressure ulcer risk assessment scales in general and intensive care paediatric and neonatal units. J Tissue Viability 25: 119-126.
- de Lima EL, de Brito MJA, de Souza DMST, Salomé GM, Ferreira LM (2016) Cross-cultural adaptation and valiation of the neonatal/infant Braden Q risk assessment scale. J Tissue Viability 25: 57-65.
- Tume LN, Siner S, Scott E, Lane S (2014) The prognostic ability of early Braden Q Scores in critically ill children. Nurs Crit Care 19: 98-103.
- Gu X, Kuang X, Wang C, Lou J (2009) Applicability of Braden-Q Scale for the Prediction of Pressure Ulcers Development in Children in Mainland China [J]. Journal of Nursing Science 4: 005.
- Lu YF, Yang Y, Wang Y, Gao LQ, Qiu Q, et al. (2015) Predicting pressure ulcer risk with the Braden Q Scale in Chinese pediatric patients in ICU. Chinese Nursing Research 2: 1-5.
- Galvin PA and Curley MA (2012) The Braden Q+ P: a pediatric perioperative pressure ulcer risk assessment and intervention tool. AORN journal 96: 261-270.
- Kottner J, Kenzler M, Wilborn D (2014) Interrater agreement, reliability and validity of the Glamorgan paediatric pressure ulcer risk assessment scale. J Clin Nurs 23: 1165-1169.
- Anthony D,
Willock J, Baharestani M (2010) A comparison of Braden Q, Garvin and Glamorgan
risk assessment scales in paediatrics. J Tissue Viability. 19: 98-105.
- Anthony D, Papanikolaou P, Parboteeah S, Saleh M (2010) Do risk assessment scales for pressure ulcers work? J Tissue Viability 19: 132-136.
- Leonard P, Hill A, Moon K, Lima S (2013) Pediatric pressure injuries: does modifying a tool alter the risk assessment outcome? Issues Compr Pediatr Nurs 36: 279-290.
- Classen DC, Pestotnik SL, Evans RS, Burke JP (1991) Computerized surveillance of adverse drug events in hospital patients. Jama 266: 2847-2851.
- GriffinFAResarRK I (2009) Global Trigger Tool for measuring adverse events: IHI Innovation Series white paper. Cambridge, MA: Institute for Healthcare Improvement.
- US Department of Health and Human Services. Health care protocol: Skin safety protocol: Risk assessment and prevention of pressure ulcers (2007) Institute for Clinical Systems Improvement 2: 1926-1944.
- Schumacher B, Askew M, Otten K (2013) Development of a pressure ulcer trigger tool for the neonatal population. J Wound Ostomy Continence Nurs 40: 46-50.
- Miske LJ, Stetzer M, Garcia M, Stellar JJ (2017) Airways and Injuries: Protecting Our Pediatric Patients from Respiratory Device-Related Pressure Injuries. Crit Care Nurs Clin North Am.
- Willock J, Harris C, Harrison J, Poole C (2005) Identifying the characteristics of children with pressure ulcers. Nurs Times 101: 40-43.
- Delmore BA and Ayello EA (2017) CE: Pressure Injuries Caused by Medical Devices and Other Objects A Clinical Update. Am J Nurs 117: 36-45.
- Murray JS, Noonan C, Quigley S, Curley MA (2013) Medical device-related hospital-acquired pressure ulcers in children: an integrative review. J Pediatr Nurs 28: 585-595.
- Coleman S, Nixon J, Keen J, Wilson L, McGinnis E, et al. (2014) A new pressure ulcer conceptual framework. J Adv Nurs 70: 2222-2234.
- Parnham A (2012) Pressure ulcer risk assessment and prevention in children: Alison Parnham discusses the need for continuous improvement and better outcomes for children and young people at risk of avoidable tissue damage. Nursing children and young people 24: 24-29.
- Waterlow J (1998) Pressure sores in children: risk assessment: The need for risk assessment and documentation of risk of pressure sores in children is discussed by Judy Waterlow. Paediatric Nursing 10: 22-23.
- Stansby G, Avital L, Jones K, Marsden G (2014) Prevention and management of pressure ulcers in primary and secondary care: summary of NICE guidance. BMJ 348: g2592.
- Visscher M, King A, Nie AM, Schaffer P, Taylor T, et al. (2013) A quality-improvement collaborative project to reduce pressure ulcers in PICUs. Pediatrics k131: e1950-e1960.