105 - Implementation of a Care Bundle to Prevent Skin Injuries in Neonates Undergoing Continuous Electroencephalogram

Publication Number: 3100.105

Nancy Ornelas, Parkland Health, Dallas, TX, United States; Katherine L.. Bloodgood, Parkland Health, Denton, TX, United States; Linda AL. Castleman, a6897961dbcbbe002f2ef9baae96191d, Garland, TX, United States; Katherine Stumpf, UTSW, Dallas, TX, United States; Jesse Banales, University of Texas Southwestern Medical School, Dallas, TX, United States; Cari Brown, Parkland Hospital, Dallas, TX, United States; Aimee Russell, Parkland, Dallas, TX, United States; Rachel L.. Leon, University of Texas Southwestern Medical School, Dallas, TX, United States; Maricel N. Maxey, Parkland Health, Dallas, TX, United States; Janice R. Owen, Parkland Hospital, Dallas, TX, United States; Bino Benjamin, Parkland Health, Forney, TX, United States; Debbie Cedillo, University of Texas - Southwestern Medical Center, Red Oak, TX, United States; Sheri Jones, Parkland Hospital, Arlington, TX, United States; Agnes J. Todd, Parkland Health & Hospital System, Lancaster, TX, United States; Venkatakrishna Kakkilaya, UT Southwestern Medical Center, Dallas, TX, United States

Background: The neonatal population is specifically at risk for skin injuries due to medical device use, skin integrity, and prolonged hospitalization. Neonates with hypoxic-ischemic encephalopathy (HIE) have increased risk for skin injury due to therapeutic hypothermia (TH) and the need for continuous electroencephalography (EEG) monitoring. Implementing a care bundle for NICU patients on EEG may reduce skin injuries.

Objective: This quality improvement project aimed to reduce EEG-related skin injuries by 12% in all neonates, and by 30% in infants undergoing TH over a 6-month period at Parkland Health Level III NICU.

Design/Methods: A multidisciplinary team worked to create an EEG bundle to reduce skin injuries. An EEG bundle was developed including: formal scalp assessments with bedside nurse and EEG technician every 3-4 hours, standardized lead marking, nursing 1:1 status with patients on EEG during cooling therapy, prompt EEG removal when seizure-free x 24 hours, removal of unnecessary EEG leads, consistent use of wound consult service, consistent use of CPAP hats, silicone-based wound contact dressing (Mepitel©), and a change from silver/ silver chloride EEG electrodes to gold cup electrodes. The primary outcome was skin breakdown associated with EEG placement. Balancing measures were nursing and EEG technician satisfaction with increased care needs. Primary drivers included consistent use of the bundle, bedside caregiver education, and patient safety. The EEG bundle was implemented in PDSA cycle 1 (Jan 2025). PDSA cycle 2 began March 2025 to provide ongoing education. We used descriptive statistics and process control charts to monitor data regarding EEG-related skin injuries.

Results: 109 patients on EEG from Jan-Dec 2024, and 35 (32%) developed an EEG-related skin injury; 58% of patients who underwent TH acquired skin injury from EEG use. After PDSA cycle 1, skin breakdown associated with EEG use dropped from 32% to 0%. Infants on EEG who also underwent cooling therapy had a reduction in skin breakdown from 70% to 0%. EEG technicians accommodated additional assessments by altering their workflow without incident. Data from PDSA 2 shows sustained improvement through September 2025, and data collection is ongoing.

Conclusion(s): Development of an EEG care bundle focused on maintaining neonatal skin integrity was associated with a significant drop in EEG-related skin injuries. The change to gold cup EEG electrodes and consistent use of Mepitel© were instrumental in the reduction of EEG-related skin injuries.

HIE Infants with Skin Breakdown
Total number of HIE infants and Infants with Skin breakdown during study period

Infants Undergoing Cooling with Skin Breakdown
Control chart showing skin breakdown decrease during study period in cooling infants

All Infants on EEG with Skin Breakdown
Control chart showing decrease in overall skin breakdown on all babies undergoing EEG during study period