HSC Section 3 - Trauma, Critical Care and Sleep Medicine

Reprinted by permission of Otolaryngol Head Neck Surg. 2017; 156(4):642-651.

Patient Safety/Quality Improvement—General Otolaryngology

Otolaryngology– Head and Neck Surgery 2017, Vol. 156(4) 642–651 American Academy of Otolaryngology—Head and Neck

Prevention of Tracheostomy-Related Hospital-Acquired Pressure Ulcers

Surgery Foundation 2017 Reprints and permission:

sagepub.com/journalsPermissions.nav DOI: 10.1177/0194599816689584 http://otojournal.org

Thomas R. O’Toole, MD 1 , Natalie Jacobs, MSN 2 , Brian Hondorp, MD 3 , Laura Crawford, DNP 2 , Lisa R. Boudreau, MSN 2 , Jill Jeffe, MD 1 , Brian Stein, MD, MS 4 , and Phillip LoSavio, MD, MS 1

O ver the past decade, there has been an increasing emphasis placed on improving the quality of health care delivered in the United States. As part of quality improvement initiatives, health care organizations have been focusing on reducing the incidence of avoidable complica- tions. On February 8, 2006, the president of the United States signed the Deficit Reduction Act of 2005. With it, the federal government provided financial motivation for health care organizations to improve on the incidence of hospital- acquired conditions by allowing the Centers for Medicare & Medicaid Services to halt the practice of reimbursing incre- mentally for conditions that were both acquired during an inpatient hospitalization and that could have reasonably been prevented by following evidence-based guidelines. 1 A list of hospital-acquired conditions deemed preventable has been published by Centers for Medicare & Medicaid Services and includes stage III and IV pressure ulcers. 2 At our institution, in early fiscal year 2014 (July 1, 2013–June 30, 2014), it was noted during routine quality control audits that the hospital was experiencing a high rate of tracheostomy-related acquired pressure ulcers (TRAPUs). Upon further inquiry, data from the previous fiscal year (July 1, 2012–June 30, 2013) revealed a 12.5% TRAPU rate. This observation prompted a careful review of posttracheostomy care and the eventual development of a standardized tracheostomy care ‘‘bundle’’ that was initiated on July 1, 2014. Pressure ulcers occur as a consequence of localized ischemic injury to tissues. Patients with impaired sensory per- ception, immobility, limited activity, malnutrition, increased 1 Department of Otorhinolaryngology–Head and Neck Surgery, Rush University Medical Center, Chicago, Illinois, USA 2 Division of Nursing, Rush University Medical Center, Chicago, Illinois, USA 3 Department of Otolaryngology–Head and Neck Surgery, Loma Linda Medical Center, Loma Linda, California, USA 4 Department of Medicine, Division of Pulmonary Medicine, Rush University Medical Center, Chicago, Illinois, USA This article was presented at the 2016 AAO-HNSF Annual Meeting & OTO EXPO; September 18-21, 2016; San Diego, California. Corresponding Author: Phillip LoSavio, MD, MS, Department of Otorhinolaryngology–Head and Neck Surgery, Rush University Medical Center, 1611 W Harrison St, Suite 550 Orthopedic Building, Chicago, IL 60612, USA. Email: phillip_losavio@rush.edu

No sponsorships or competing interests have been disclosed for this article.

Abstract Objective. To determine if standardization of perioperative tracheostomy care procedures decreased the incidence of hospital-acquired tracheostomy-related pressure ulcers. Methods. All patients at least 18 years old who underwent placement of a tracheostomy tube in the operating room from July 1, 2014, through June 30, 2015, were cared for postoperatively through an institutionally adopted quality improvement protocol. This included 4 elements: (1) place- ment of a hydrocolloid dressing underneath the tracheostomy flange in the postoperative period, (2) removal of plate sutures within 7 days of the tracheostomy procedure, (3) pla- cement of a polyurethane foam dressing after suture removal, and (4) neutral positioning of the head. One year after the bundle was initiated, a retrospective analysis was performed to compare the percentage of tracheostomy patients who developed pressure ulcers versus the preintervention period. Results. The incidence of tracheostomy-related pressure ulcers decreased from 20 of 183 tracheostomies (10.93%) prior to use of the standardized protocol to 2 of 155 tra- cheostomies (1.29%). Chi-square analysis showed a signifi- cant difference between the groups, with a P value of .0003. Discussion. Adoption of this care bundle at our institution resulted in a significant reduction in the incidence of hospital-acquired tracheostomy-related pressure ulcers. The impact of any single intervention within our protocol was not assessed and could be an area of further investigation. Implications for Practice. Adoption of a standardized posttra- cheostomy care bundle at the institution level may result in the improved care of patients with tracheostomies and spe- cifically may reduce the incidence of pressure ulcers.

Keywords tracheostomy, pressure, ulcer, prevention, hospital, acquired, PS/QI, bundle

Received June 30, 2016; revised December 8, 2016; accepted December 28, 2016.

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