New Approaches to Reduce Occiput Pressure Injuries on Pediatric ECMO Patients

Significance to Practice: Pediatric patients on extracorporeal membrane oxygenation (ECMO) therapy are at an increased risk of developing hospital-acquired pressure injuries (HAPIs). At a large, free-standing academic children’s hospital, ECMO skin protocols were in place to prevent HAPIs on these fragile patients. Despite previous interventions, severe occiput HAPIs continued, causing significant patient harm.

Current state analysis: In 2019, the rate of occiput HAPIs amongst ECMO patients was 17.72 per 1000 ECMO patient days. Unfortunately, most of the HAPIs were deep tissue injuries (DTI), stage 3, or higher. Previously, there was no standard device for occiput HAPI prevention, however, fluidized positioners were frequently used. Due to ECMO cannula location, these fluidized positioners were often unable to be remolded adequately to redistribute pressure.

Process:  A multidisciplinary approach to reduce HAPIs by optimizing surfaces under the occiputs of ECMO patients. A trial protocol was initiated at the start of 2020 utilizing a non-powered reactive air pressure redistribution cushion to offload the occiput for patients over the age of 1 year, and a gel cushion used for patients under the age of 1 year.

Outcomes: ECMO occiput HAPI rate decreased by 56.7% during the first 6 months of utilizing non-powered reactive air pressure redistribution cushions and gel cushions. After implementation, occiput HAPI rate dropped from 17.72 to 7.67 per 1000 ECMO patient days. Of the post intervention HAPIs, only 3 injuries occurred, and they all occurred shortly after implementation, potentially indicating a learning curve.

Implications for Practice: Innovation is important in pediatrics due to lack of supporting evidence for this population. Utilizing reactive air pressure redistribution cushions and gel pillows decreased occiput pressure injuries on some of the most high risk patients. Nursing engagement and sustainable practice changes occurred under the leadership of the WOC nurses and ECMO team.