1. science
2. medicine
3. surgery

Prevention of Tracheostomy-related Pressure Ulcers
in Children
abstract
BACKGROUND AND OBJECTIVES: Pressure ulcers are commonly acquired in pediatric institutions, and they are a key indicator of the
standard and effectiveness of care. We recognized a high rate of
tracheostomy-related pressure ulcers (TRPUs) in our ventilator unit
and instituted a quality improvement program to develop and
test potential interventions for TRPU prevention, condensed them
into a clinical bundle, and then implemented the bundle into our
standard practice.
METHODS: The intervention model used a rapid-cycle, Plan-Do-StudyAct (PDSA), framework for improvement research. All tracheostomydependent patients admitted to our 18-bed ventilator unit from July
2008 through December 2010 were included. TRPU stage and
description, number of days each TRPU persisted, and bundle
compliance were recorded in real time. All TRPUs were staged by
a wound-care expert within 24 hours. The interventions incorporated
into the TRPU-prevention bundle included frequent skin and device
assessments, moisture-reducing device interface, and pressure-free
device interface.
RESULTS: There was a significant decrease in the rate of patients who
developed a TRPU from 8.1% during the preintervention period, to 2.6%
during bundle development, to 0.3% after bundle implementation.
There was a marked difference between standard and extended tracheostomy tubes in TRPU occurrence (3.4% vs 0%, P = .007) and days
affected by a TRPU (5.2% vs 0.1%, P , .0001).
CONCLUSIONS: Education and ongoing assessment of skin integrity
and the use of devices that minimize pressure at the tracheostomy–skin interface effectively reduce TRPU even among a population
of children at high risk. These interventions can be integrated into
daily workflow and result in sustained effect. Pediatrics 2012;129:
e792–e797
e792
BOESCH et al
AUTHORS: R. Paul Boesch, DO, MS,a,b Christine Myers, RN,c
Tonia Garrett, RRT,c AnnMarie Nie, RN, CNP, CWOCN,d
Natalie Thomas, BSN, RN,c Amrita Chima, MBA,a
Gary L. McPhail, MD,a Mathew Ednick, DO,a
Michael J. Rutter, MD, FRACS,b,e and Kathy Dressman, RN,
MS, NEA-BCc
aDivision of Pulmonary Medicine, bAerodigestive and Sleep
Center, cTransitional Care Center, dOutpatient Department,
and eDepartment of Pediatric Otolaryngology and Head and Neck
Surgery, Cincinnati Children’s Hospital Medical Center, Cincinnati,
Ohio
KEY WORDS
pressure ulcer, tracheostomy, quality improvement
ABBREVIATIONS
PDSA—Plan-Do-Study-Act
TRPU—tracheostomy-related pressure ulcers
www.pediatrics.org/cgi/doi/10.1542/peds.2011-0649
doi:10.1542/peds.2011-0649
Accepted for publication Oct 31, 2011
Address correspondence to R. Paul Boesch, DO, MS, Division of
Pulmonary Medicine, Cincinnati Children’s Hospital Medical
Center, ML 2021, 3333 Burnet Ave, Cincinnati, OH 45229-3039.
E-mail: [email protected]
PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275).
Copyright © 2012 by the American Academy of Pediatrics
FINANCIAL DISCLOSURE: The authors have indicated they have
no financial relationships relevant to this article to disclose.
FUNDING: No external funding.
QUALITY REPORT
Hospital-acquired pressure ulcers are
common in pediatric institutions. Reported prevalence rates are 4% to 27.7%,
and incidence rates are 0.29% to 32.8%.1–5
A 2003 national survey documented an
average 4% prevalence rate of stage 3
to 4 pressure ulcers among pediatric
hospitals.1 Data for 2010 from the National Database of Nursing Quality Indicators report a mean prevalence of
2.29% for hospital-acquired pressure
ulcers in “step down” units at academic
pediatric hospitals. Pressure ulcers are
associated with increased pain, infection, and prolonged hospitalization, and
they may result in permanent scarring.6–8
Pressure ulcers are considered a highcost, high-volume, preventable condition. They have received increasing
attention, and pediatric hospital days
associated with a facility-acquired pressure ulcer will be disqualified from
Medicare and Medicaid reimbursement
effective July 1, 2012.9
After recognition that our hospital’s rate
of all facility-acquired pressure ulcers
was greater than national averages, a
pressure ulcer collaborative, including
members from all high-risk units, was
convened. This collaborative is a multidisciplinary team focused on the prevalence and occurrence monitoring,
education, assessment of risk and skin
integrity, and the development of skin
care teams on high-risk units. Initial
interventions from this collaborative
resulted in a decreased prevalence of
pressure ulcers (from all sources) from
9.2% to 2.4% in our institution. The hospital collaborative identified that ∼75%
of remaining pressure ulcers in our
pediatric population were being caused
by medical devices; many of these were
due to respiratory devices such as tracheostomy tubes and positive-pressure
masks.
Tracheostomy tubes cause pressure
ulcers by creating a constant pressure
interface over the skin of the neck with
additional disruption of skin integrity
PEDIATRICS Volume 129, Number 3, March 2012
due to wetness from sweat and respiratory secretions. Furthermore, tracheostomy tubes are often used in children
with limited mobility and neurologic
responsiveness, which further increases the risk for ulcer development. There
are no published prevalence rates of
pressure ulcers specifically caused by
tracheostomy tubes, but one study
reported that 27% of complications before the first tube change were related
to skin breakdown.10 The baseline occurrence rate of tracheostomy-related
pressure ulcers (TRPUs), in our hospital unit with the greatest utilization of
tracheostomies, was determined to be
8.1% for all stages. We hypothesized
that quality improvement methodology
would both (1) identify those interventions that were most effective at
preventing TRPUs and (2) result in a reliable implementation that would sustainably decrease the occurrence of
TRPUs in our unit.
METHODS
This project was granted exemption from
the Institutional Review Board of Cincinnati Children’s Hospital Medical Center. All tracheostomy-dependent patients
admitted to the Transitional Care Center
at our hospital from July 2008 through
December 2010 were included.
tracheostomy patient days over the
study period: 3388 in 2008, 4097 in
2009, and 4441 in 2010. The clinical
and demographic characteristics of
the study population are presented in
Table 1.
Data Collection
All tracheostomy-dependent patients
from July 2008 through December 2010
were included. Demographic information, use of mechanical ventilation, and
underlying cause for mechanical ventilation were reviewed retrospectively.
Tracheostomy type, TRPU stage and description, number of days each TRPU
persisted, and bundle compliance were
recorded in real time. In most cases, the
TRPUs were photographed to document
the stage, location, and relationships
between the respiratory equipment and
the patient.
Definitions
A TRPU occurrence was defined as a
new pressure ulcer that developed after the patient was admitted or transferred to our unit, if the ulcer site was in
direct contact with the tracheostomy
tube, tracheostomy ties, or the connection to a ventilatorcircuit. To improve our
ability to detect an improvement, any
stage TRPU was considered an occurrence, even though national patient
Setting
Our hospital is a 490-bed academic
quaternary-care, free-standing children’s
hospital. The Transitional Care Center is
an 18-bed multidisciplinary unit whose
primary mission is the transition of
children requiring invasive and noninvasive mechanical ventilation to home.
This unit also serves as a stepdown ICU
for ventilation-dependent children admitted for acute illness, surgical procedures, or diagnostic testing. This unit
handles .400 admissions per year, the
majority of which are tracheostomy dependent, ventilator dependent, and
young. There was a gradual increase in
TABLE 1 Clinical and Demographic
Characteristics of Study
Population (N = 834)
Age, median (IQR)
Males/females
Ventilator dependent, n (%)
CNS disease, n (%)
Congenital syndrome, n (%)
Airway disease, n (%)
Neuromuscular disease, n (%)
Prematurity/BPD, n (%)
Congenital heart disease, n (%)
Thoracic insufficiency, n (%)
Congenital central
hypoventilation
syndrome, n (%)
2 y, 8mo
(13 mo to 9 y)
441/393
728 (87)
355 (43)
254 (31)
240 (29)
152 (18)
137 (16)
137 (16)
67 (8)
18 (2)
BPD, bronchopulmonary dysplasia; IQR, interquartile range.
e793
safety guidelines focus only on stage 3
and 4 pressure ulcers. All TRPUs were
identified by a bedside nurse or during
monthly unitwide surveys. All TRPUs
were reported to and staged by a
wound-care expert (AM.N.), based on
National Pressure Ulcer Advisory Panel
staging system, within 1 day of initial
diagnosis.11 The diagnosis and staging
were made independent of the clinical
service. TRPU occurrence rates were
expressed as the number of new
TRPUs per month divided by the
number of tracheostomy patients in
the unit that month. TRPU bed days
were expressed as the number of days
associated with a TRPU per month divided by the total number of unit bed
days with a tracheostomy tube.
Interventions
The intervention model used a rapidcycle, Plan-Do-Study-Act (PDSA), framework for improvement research.12 PDSA
cycles are designed to establish relationships between process changes
and outcomes by trialing and adapting
small-scale interventions over time.
This process was used both to determine the interventions most beneficial to prevent TRPU and to effectively
implement a TRPU-prevention bundle.
PDSA cycles were planned and executed by a multidisciplinary team including the medical director of the unit,
bedside nurse and respiratory therapist,
nurse educator, and the unit’s skin care
champion. Based on knowledge gained
from the literature, as well as results
previously obtained from our institution’s pressure ulcer collaborative
(preliminary work to reduce pressure
ulcers of all types), key drivers thought
to prevent TRPU development were
identified to guide our interventions.
These included (1) pressure ulcer risk
and skin assessment, (2) moisture-free
device interface, and (3) pressure-free
device interface. PDSA cycles testing
interventions in each of these drivers
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BOESCH et al
were undertaken in series. Once effective interventions were identified,
they were incorporated into a TRPUprevention “bundle” and implemented
with the use of quality improvement
methodology. All patients were monitored for any changes in their oxygenation or ventilation. In the event of a
decision to deviate from a component
of the bundle (because of an adverse
event, cost, or preference) the reason
was recorded. All other quality improvement initiatives on the unit continued
and their success was monitored.
On-line training modules on pressure
ulcer risk assessment (all types), skin
assessment, and identification were
completed by all nurses on the unit.
Specific education related to prevention
of TRPU was given to staff as part of
ongoing education and in printed form.
Details of the TRPU-prevention bundle
was well as data demonstrating time
since he last TRPU were displayed in the
staff break room. Nursing and respiratory therapists were given a brochure to share with parents describing
the risks and mechanism of TRPU development and explaining why we were
implementing this bundle. Pressure
ulcer risk assessment was performed
and documented via the Braden Q score
of pressure ulcer risk.13,14 In addition,
full body skin assessments and device
assessments were performed. Mepilex
lite (Mölnlycke Health Care, Norcross,
GA) was the hydrophilic barrier used
under the tracheostomy tube flanges
and around the stoma, cut to size from
the supplied sheets. As the strength of
the relationship between tracheostomy
tube type and TRPU was increasingly
recognized, consultation with a tracheostomy tube manufacturer was undertaken to develop a tube that meets
the needs of ventilator-dependent children and minimizes the pressure interface at each of the 3 locations where
TRPUs develop. Arcadia Extend Connect
Perfect Fit (Arcadia Medical, Crown
Point, IN) tracheostomy tubes were primarily used, although Bivona FlexTend
(Smiths Medical, London, UK) tracheostomy tubes were used as well. Both of
these brands of tracheostomy tubes
feature a flexible extension separating
the flanges and the 15-mm adapter and
are available in all pediatric and neonatal sizes (cuffed and uncuffed). Either brand of tube was designated
“extended” tracheostomy tubes for the
purpose of this study based on similar
mechanism of removing bulk from the
crowded anatomic location of a small
child’s neck (Fig 1). Tracheostomy tubes
were further modified to have thin
flanges at a 30% angle which conforms
well to the neck contours of an infant or
young child (Arcadia, Perfect Fit). Extended tracheostomy tubes were incorporated into our hospital storage
and distribution system such that there
are no delays in ability to change a
patient’s tracheostomy to such a tube if
indicated. Once the bundle was developed, multiple actions were taken to
impact sustainable implementation.
These actions included incorporation
of assessment into nursing workflow
via the electronic medical record, realtime reporting of each TRPU occurrence,
and a strategy to change tracheostomy
tubes in the unit based on patient anatomy and to place such tubes at the time
of tracheostomy (via collaboration with
Otolaryngology).
FIGURE 1
Fit of standard vs extended-style tracheostomy
tube in ventilated infant (Arcadia shown). Note
the crowding of the ventilator circuit in the neck
with focal pressure of the swivel adapter edge
against the sternum. This is the site of 73% of the
TRPUs that developed during the study period.
QUALITY REPORT
Statistical Analysis
TABLE 2 Characteristics of TracheostomyRelated Pressure Ulcers (N = 22)
A multiple time series analysis was
performed to determine whether the
occurrence rate of TRPU decreased
over the study period. Run charts were
created to document monthly TRPU
occurrence rate and percent of tracheostomy patient days affected by
a TRPU each month. Run charts display
and analyze variation in time-series
data. They can statistically identify
changes in variation that are attributable to a change in a system.15 A run
chart was used to graph the monthly
TRPU occurrence rate over time and
identify when a change in TRPU occurrence was emerged. Associations between TRPU development and age,
gender, and the clinical indications
for mechanical ventilation listed in
Table 1 were evaluated by multiple
logistic regression. The rate of TRPU
occurrence between those with a standard and extended-style tracheostomy
tubes was evaluated by Fisher’s exact
test.
RESULTS
From July 2008 to December 2010, there
were 834 tracheostomy patients and 10
132 tracheostomy patient days evaluated. Population characteristics are
shown in Table 1. During the 6 months
of data collection before intervention
there were 11 TRPUs in 136 patients for
an occurrence rate of 8.1 per 100. This
resulted in 212 bed days associated
with a TRPU (12.5% of all tracheostomy
days).
There were 22 TRPUs over the study
period (Table 2). Eight TRPUs were stage
3 or 4 in severity (36%). Most occurred
below the tracheostomy stoma (73%)
and in patients who were ,2 years old
(64%) and ventilator dependent (82%).
All of the pressure ulcers occurred in
children with a mature stoma (a mature
stoma is a requirement for the unit). No
associations were found between any of
the individual clinical or demographic
PEDIATRICS Volume 129, Number 3, March 2012
Location, n (%)
Below stoma
Above flanges
Above stoma
Under twill ties
Stage, n (%)
1
2
3
4
Patient underlying conditions, n (%)
Neuromuscular disease
Static encephalopathy
Trisomy 21 with congenital
heart disease
Chronic lung disease
Congenital heart disease
(nonsyndromic)
Traumatic brain injury
Glycogen storage disorder
Cystic hygroma
Thoracic insufficiency
Complex airway malformations
16 (73)
3 (14)
2 (9)
1 (4)
3 (14)
11 (50)
8 (36)
0 (0)
5 (23)
4 (18)
4 (18)
2 (9)
2 (9)
1 (4)
1 (4)
1 (4)
1 (4)
1 (4)
characteristics listed in Table 1 (including age and ventilator status) and
likelihood of developing a TRPU.
Based on the results of PDSA cycles,
interventions identified for incorporation into the TRPU-prevention bundle for
each key driver included the following:
skin assessment, Braden Q performed
and documented every 24 hours, full
body skin assessments performed daily,
and tracheostomy device assessments
every 8-hour shift; moisture-free device
interface, hydrophilic polyurethane foam
under tracheostomy tubes to wick
moisture from the stoma away from the
skin surface; pressure-free device interface, extended-style tracheostomy tubes
in children with anatomy in which the
neck was not clearly exposed in the
neutral position or those with behaviors
than repeatedly drove the tube down into
the sternum (Fig 1).
It was clear from PDSA cycles trialing
extended tracheostomy tubes that
there was much less visible pressure at
the tracheostomy–skin interface from
this style of tube. This was further
borne out over the entire study period
in which 22 of 638 (3.4%) patients with
standard tracheostomy tubes developed a new TRPU in comparison with
0 of 174 of patients with extended tubes
(P = .007). There was also a significant
difference in days affected by a TRPU
between the 2 groups (5.2% vs 0.1%,
P , .0001). One patient was transferred from an outside hospital during
the first study month in an extended
tracheostomy tube with an existing
TRPU that persisted for 5 days. The
intervention of extended-style tracheostomy was prioritized, and weekly
audits were initially performed to ensure that appropriate patients had
these tubes as soon as they were admitted or transferred to our unit. Once
a week, 2 authors (N.T. and R.P.B.) surveyed all the current patients on the
unit to determine which components of
the bundle had been completed or
were in place that day. Rates for each
component and the full bundle were
tracked. Within 4 months the culture of
the unit staff changed such that compliance with the bundle is consistently
100%, and audits are now done monthly.
This type of integration of positive change
into routine workflow is a hallmark of
sustainable improvement.
The TRPU-prevention bundle was well
accepted. There were no adverse events
associated with the use of extended
tracheostomy tubes. There were no
instances of change in ventilation or
oxygenation, no increased tube plugging, orany increased difficulty reported
with tracheostomy tube changes. The
cost per unit varies, but on average the
extended-style tracheostomy tubes cost
approximately twice as much as standard tubes. There were no instances of
inability to continue use of these tubes,
but in some circumstances patients
received only 1 tube per month (instead
of 2, which is our standard) and were
required to clean and replace tubes at
least once. This is a practice that is accepted, and there are manufacturer’s
recommendations for doing so. One
e795
parent requested to change back to
a standard tracheostomy tube for cosmetic reasons. The polyurethane barrier
was less well accepted. Three patients
changed back to a gauze barrier because contact dermatitis, and 12 additional patients changed because the cost
was not covered by insurance. This represents a small percentage of the total
population evaluated (2%).
Overall, during the study period, there
was a significant decrease in the rate of
tracheostomy patients who developed
a TRPU from 8.1% during the baseline
period to 0.3% over the final 6 months
of the study period (Fig 2). The percentage of tracheostomy patient days
affected by a TRPU also decreased from
12.5% to 0.2% during the same time
interval.
DISCUSSION
In our population of mostly young,
chronically ventilated infants and children, tracheostomy-related pressure
ulcers were common, but they proved to
be largely preventable by a culture of
prioritizing skin health and the use
of anatomically appropriate devices.
During the 6 months before initiation of
this study, there were 11 ulcers, 4 of
which were staged at 3 or 4. Based on
the newly accepted changes to Medicare and Medicaid reimbursement, the
entire direct care costs for hospital
days associated with these pressure
ulcers would have been disqualified.
Education of nursing staff in skin assessment and risks for pressure ulcer
development, with integration of these
assessments into daily documentation
workflow, has improved our ability to
anticipate and mitigate risks to skin
integrity. In addition to decreasing the
occurrence of TRPUs, there was a trend
toward shortening their duration.
During the first 6 months of the study,
each TRPU lasted an average of 19 days,
whereas the TRPU that developed during and after implementation lasted
only 7 days.
Pressure ulcers are a key clinical indicator of the standard and effectiveness of care, yet there have been no
guidelines as to prevention of pressure
ulcers from tracheostomy tubes. We
were able to use the risk factors for
pressure ulcer development, within
a quality improvement framework, to
guide the development and testing of
potential interventions for TRPU prevention.16–19 This framework allowed
us to evaluate the effectiveness of
different interventions, condense them
into a clinical bundle, and then implement this bundle into the clinical practice of the unit. The benefits of this
approach to TRPU prevention became
evident during development of the clinical bundle, and the improvement has
FIGURE 2
Run chart for TRPU rates per 100 tracheostomy patients (July 2008 to December 2010). Extended-style
tracheostomy tubes began to be used in March 2009, but were not fully implemented until March 2010.
Dashed line represents the mean rate for each period.
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BOESCH et al
been sustained. The biggest driver of
improvement was related to the use of
tracheostomy tubes that exert a minimum of focal pressure, although the
degree of improvement may not have
been as great outside of a context of
heightened attention to skin health. That
said, the use of an extended tracheostomy tube in appropriate patients would
be expected to be a highly reliable intervention, because, once placed, the
beneficial impact would be continuous
and would not rely on caregiver diligence or memory. We did not begin to
see a significant improvement in our
TRPU rates until these devices were
used with some frequency. For this
reason, this style of tracheostomy tube
is now placed at the time of surgery in
all anatomically appropriate children
in our institution as an anticipatory
measure. This has decreased the rate
of TRPUs that transfer to our unit from
the pediatric ICU that had previously
developed during the short period of
stoma maturation immediately after
tracheotomy.
This study is limited by its singlehospital unit design and because it
was not a randomized controlled trial.
However, this unit has the highest tracheostomy utilization of any other unit
in the institution. Several patients had
previous TRPUs with standard tracheostomy tubes that did not recur after a
change to an extended-style tube. Two
patients had prolonged TRPUs that did not
resolveuntilanextendedtubewasplaced.
These factors increase our confidence in
our results, in particular, the effectiveness of extended tracheostomy tubes.
Education and ongoing assessment of
skin integrity and the use of devices that
minimize pressure effectively reduces
TRPUs even among a population of
children at high risk for pressure ulcer
development. These interventions can
be integrated into daily workflow, resulting in long-term sustainment in
effectiveness.
QUALITY REPORT
REFERENCES
1. McLane KM, Bookout K, McCord S, McCain J,
Jefferson LS. The 2003 national pediatric
pressure ulcer and skin breakdown prevalence survey: a multisite study. J Wound
Ostomy Continence Nurs. 2004;31(4):168–178
2. Schlüer AB, Cignacco E, Müller M, Halfens RJ;
AB. The prevalence of pressure ulcers in
four paediatric institutions. J Clin Nurs.
2009;18(23):3244–3252
3. Curley MA, Quigley SM, Lin M. Pressure
ulcers in pediatric intensive care: incidence
and associated factors. Pediatr Crit Care
Med. 2003;4(3):284–290
4. Baldwin KM. Incidence and prevalence of
pressure ulcers in children. Adv Skin
Wound Care. 2002;15(3):121–124
5. 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
6. Schindler CA, Mikhailov TA, Fischer K,
Lukasiewicz G, Kuhn EM, Duncan L. Skin
integrity in critically ill and injured children. Am J Crit Care. 2007;16(6):568–574
7. Allman RM, Goode PS, Burst N, Bartolucci AA,
Thomas DR. Pressure ulcers, hospital complications, and disease severity: impact on
hospital costs and length of stay. Adv Wound
Care. 1999;12(1):22–30
PEDIATRICS Volume 129, Number 3, March 2012
8. Zollo MB, Gostisha ML, Berens RJ, Schmidt JE,
Weigle CGM. Altered skin integrity in children
admitted to a pediatric intensive care unit.
J Nurs Care Qual. 1996;11(2):62–67
9. Armstrong DG, Ayello EA, Capitulo KL, et al.
New opportunities to improve pressure ulcer prevention and treatment: implications
of the CMS inpatient hospital care present
on admission indicators/hospital-acquired
conditions policy: a consensus paper from
the International Expert Wound Care Advisory Panel. Adv Skin Wound Care. 2008;21
(10):469–478
10. Carr MM, Poje CP, Kingston L, Kielma D, Heard
C. Complications in pediatric tracheostomies. Laryngoscope. 2001;111(11 Pt 1):1925–
1928
11. Black J, Baharestani M, Cuddigan J, et al; National Pressure Ulcer Advisory Panel. National
Pressure Ulcer Advisory Panel’s updated
pressure ulcer staging system. Dermatol
Nurs. 2007;19(4):343–349, quiz 350
12. Langley GJ, Nolan KM, Nolan TW, Norman CL,
Provost LP. The Improvement Guide: A
Practical Approach to Enhancing Organizational Performance. San Francisco, CA:
Jossey-Bass; 1996
13. Pancorbo-Hidalgo PL, Garcia-Fernandez FP,
Lopez-Medina IM, Alvarez-Nieto C. Risk as-
14.
15.
16.
17.
18.
19.
sessment scales for pressure ulcer prevention: a systematic review. J Adv Nurs.
2006;54(1):94–110
Curley MA, Razmus IS, Roberts KE, Wypij D.
Predicting pressure ulcer risk in pediatric
patients: the Braden Q Scale. Nurs Res.
2003;52(1):22–33
Wheeler DJ. Understanding Variation: The
Key to Managing Chaos. Knoxville, TN: SPC
Press Inc; 1993
Elliott R, McKinley S, Fox V. Quality improvement program to reduce the prevalence of pressure ulcers in an intensive
care unit. Am J Crit Care. 2008;17(4):328–
334, quiz 335, discussion 336–337
Hiser B, Rochette J, Philbin S, Lowerhouse N,
Terburgh C, Pietsch C. Implementing a pressure ulcer prevention program and enhancing the role of the CWOCN: impact on
outcomes. Ostomy Wound Manage. 2006;52
(2):48–59
Reddy M, Gill SS, Kalkar SR, Wu W, Anderson PJ,
Rochon PA. Treatment of pressure ulcers:
a systematic review. JAMA. 2008;300(22):
2647–2662
Quigley SM, Curley MA. Skin integrity in the
pediatric population: preventing and managing pressure ulcers. J Soc Pediatr Nurs.
1996;1(1):7–18
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