1. Schindler, Christine A. PhD, CPNP

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As an acute care pediatric nurse practitioner, I have focused on preventing pressure injuries in hospitalized children as a clinician and a researcher. This interest grew out of caring for critically ill and injured children who experienced the pain, infection, and scarring associated with the development of hospital-acquired pressure injuries (HAPIs). This clinical interest aligned with an increased focus on the prevention of HAPIs by our regulating bodies and professional organizations alike during the early 2000s. Influential organizations including The Joint Commission, the American Nurses Association, and the Institute for Healthcare Improvement prioritized pressure injuries as a target for improving patient safety. Starting in 2008, the Centers for Medicare & Medicaid Services no longer reimbursed for "reasonably preventable" conditions including HAPIs,1 and the National Database of Nursing Quality Indicators collected robust data on pressure injury prevalence as a nurse-sensitive indicator. The prevention of pressure injuries has traditionally been in the purview of nursing, so the stage was set to research pediatric pressure injuries and how nurses could prevent them.

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The incidence of pressure injuries in the pediatric critical care population has been reported to be as high as 10.2% to 27%.2,3 Research and quality improvement efforts have demonstrated that there are some specific interventions including frequent repositioning, moisture management, appropriate surface selection, adequate nutrition, and medical device rotation that certainly contribute to improved skin outcomes.3,4 There has been extensive interprofessional quality improvement collaboration between children's hospitals through the Solutions for Patient Safety in which at least 100 children's hospitals are collaborating to decrease serious safety events including pressure injuries.


While making substantial inroads in decreasing both ischemic and medical device-related pressure injuries, there are still children who develop pressure injuries despite the implementation of best practices. In 2017, the phenomenon of pediatric skin failure was described for the 1st time.5 Although the traditional paradigm is that pressure injuries are preventable, a subset of pressure injuries in critically ill children may represent acute skin failure as a consequence of multiple organ dysfunction syndrome (MODS).5 These results suggest that skin failure is most likely unavoidable in relation to MODS and, ultimately, the dying process. While many of the injuries appeared similar to traditional pressure injuries, they were unique in the sense that pressure injuries suddenly (within 24 hours of having intact skin) were of full-thickness severity and occurred in the context of dysfunction of 2 or more organ systems.5


While pressure injury prevention has historically been in the nursing purview, it is time to looks at these indicators from a much wider interprofessional lens, particularly in the context of skin failure. When we focus on pressure injuries as an avoidable outcome linked with the quality of nursing care, we are missing that a subset of pressure injuries is an unavoidable manifestation of MODS. When we reframe the discussion, there are several important points that nursing leaders should consider. Nurses experience a significant amount of distress when they believe that their care or lack of care was associated with a serious safety event such as a pressure injury.6 This distress should be modified as appropriate for unavoidable injuries and thought of and understood within the context of MODS. There are significant financial implications for hospitals related to HAPIs. Hospitals may be financially penalized unfairly when unavoidable pressure injuries related to skin failure are indiscriminately categorized with ischemic or medical device-related pressure injuries.


By continuing to categorize unavoidable pressure injuries as a nurse-sensitive quality metric, we may be missing an opportunity for nurses to focus on managing this life transition. We should be helping nurses to focus on palliative wound care, pain and symptom management, and care for the whole family. Because pressure injuries have historically been in the purview of nurses, nurses have the opportunity to lead the interprofessional team in the care of the child with skin failure. This is a new concept in pediatric nursing, but one that has many clinical and research implications that can improve the care that we provide for our pediatric patients and families and may have similar implications for adult populations as well.




1. CMS Improves Patient Safety for Medicare and Medicaid by Addressing Never Events. Released August 4, 2008. Accessed December 8, 2017. [Context Link]


2. Curley MAQ, Quigley SM, Lin M. Pressure injuries in pediatric intensive care: incidence and factors. Pediatr Crit Care Med. 2003;4(3):284-290. [Context Link]


3. Schindler CA, Mikhailov TA, Kuhn EM, et al. Protecting fragile skin: nursing interventions to decrease pressure injury development in the pediatric intensive care unit. Am J Crit Care. 2011;20(1):26-35. [Context Link]


4. Razmus I, Bergquist-Beringer S. Pressure injury risk and prevention practices in pediatric patients: a secondary analysis of data from the National Database of Nursing Quality Indicators(R). Ostomy Wound Manage. 2017;63(2):26-36. [Context Link]


5. Cohen KE, Scanlon MC, Bemanian A, Schindler CA. Pediatric skin failure. Am J Crit Care. 2017;20(4):320-328. [Context Link]


6. Quillivan RR, Burlison JD, Browne EK, Scott SD, Hoffman JM. Patient safety culture and the second victim phenomenon: connecting culture to staff distress in nurses. Jt Comm J Qual Patient Safety. 2016;42(8):377-386. [Context Link]