healthcare, pediatric nursing, plan-do-check-act (PDCA) cycle, pressure ulcer, prevention, quality assurance



  1. Peterson, Jennifer MS, RN, CCNS
  2. Adlard, Kathleen MN, RN, CPON, CNS
  3. Walti, Beverly Inge MSN, RNC-NIC, CPNP, CNS
  4. Hayakawa, Jennifer DNP, PCNS-BC, CCRN, CNRN
  5. McClean, Elyse MSN, RN-BC, CPN, CNS
  6. Feidner, Susan Carroll BSN, RN


Purpose/Objectives: The purpose of this quality improvement project was to reduce the incidence of pressure ulcers in a 232-bed, freestanding children's hospital in Western United States.


Background: Pressure ulcers have been an underappreciated hospital-acquired condition in children. Children have distinct anatomic, physiologic, and developmental factors that alter how pressure ulcers occur, but nurses may not recognize the pediatric patient as at risk because of lack of knowledge and tools to assess skin, identify risk factors, and recognize or stage pressure ulcers. Our initial efforts to develop organizational tools to reduce pediatric pressure ulcers were not sufficient, despite improvements in care. Interprofessional and intraprofessional collaboration, led by clinical nurse specialists, focused on documentation, tracheostomies, respiratory devices, and hemodynamically unstable or extracorporeal life support patients.


Rationale: Stage 3 and 4 and unstageable pressure ulcers are also "never events" in children. The unique factors involved with infant and pediatric pressure ulcers demand unique solutions.


Outcome: Our collaborative efforts led to a significant and sustained reduction in pressure ulcer incidence, from 3.3 per 1000 patient days in the first quarter of 2010 to 1.7 per 1000 patient days in the second quarter of 2014. Reportable pressure ulcers were reduced by 60%. Improved awareness and prevention strategies also led to significant reductions in extracorporeal life support patient pressure ulcers and respiratory device-related pressure ulcers.


Conclusion: Through intraprofessional and interprofessional collaboration, the clinical nurse specialists were able to implement sustained organizational change and improve care for infants and children.


Implications: Reduction in pressure ulcers is achievable but requires collaboration and creative solutions that involve multiple disciplines.