In the Pediatric Intensive Care Unit (PICU), we work in close partnership with Pediatric Surgery to care for children with complex burn injuries. Among these patients, those with inhalational injuries present unique challenges. To date, they accounted for nearly 10% of our pediatric burn population at Children’s Wisconsin in 2024 and 2025.

Recognizing an opportunity to improve consistency and outcomes, we formed a multidisciplinary group to revise our approach. Providers from Pediatric Surgery, Critical Care, Emergency Medicine, Pulmonology and Hospital Medicine came together to develop standardized care guidelines for children with suspected inhalational injuries. Finalized in April 2024, these new guidelines were implemented in the PICU and used to care for five children with significant inhalational injuries. This initiative exemplifies the value of subspecialty collaboration to strengthen care delivery for critically ill pediatric patients.

Reducing Cervical Collar-Associated Pressure Injuries

Hospital-acquired pressure injuries (HAPIs) have long been a focus of our quality improvement efforts, particularly in trauma patients requiring cervical spine precautions. In reviewing our HAPI data, we identified a concerning trend: an increase in injuries related to cervical collars.

To address this, clinical nurse specialists from trauma, wound and skin and the PICU partnered with stakeholders across neurosurgery, surgery, neurology and critical care. Together, we introduced a set of targeted interventions designed to improve risk detection, reduce time to prevention and standardize best practices across teams.

One key change was the development of a clinical guideline to expedite cervical spine clearance in trauma patients with isolated gunshot wounds, cases in which the risk of cervical injury is extremely low. By allowing earlier collar removal in these patients, we were able to reduce unnecessary device time and prevent skin breakdown without compromising safety.

We also enhanced our order sets to include automatic wound and skin consults for all trauma patients and created a rounding algorithm to ensure early identification of high-risk patients. PICU nurses received focused education and bedside coaching to reinforce the timely use of pressure-relieving products beneath cervical collars and in other vulnerable areas.

In partnership with device vendors, we reviewed sizing, application and maintenance procedures to reinforce optimal collar fit. These efforts have paid off. As of mid-2025, we have recorded only one collar-associated HAPI in the PICU since implementing these changes.

From early recognition to real-time prevention, this initiative represents the power of coordinated practice and nursing leadership. We continue to review and refine these practices to ensure that trauma care remains both safe and skin safe.