HSC Section 3 - Trauma, Critical Care and Sleep Medicine

O’Toole et al

Figure 1. Photographs showing how the 2 barrier dressings were applied in the postoperative period: A, hydrocolloid dressing, DuoDERM Signal, as it would be in the immediate postoperative period; B, polyurethane foam dressing, PolyMem, in place as it would be after tra- cheostomy suture removal.

skin moisture, and exposure to friction or shear forces are thought to be at higher risk for pressure ulcer development. 3 These risk factors form the basis for the Braden scale, which has become the most widely used predictor of pressure ulcer risk. Patients who require tracheotomies frequently have multiple risk factors for the development of pressure ulcers, including impaired mobility, malnutrition, and neurologic injury. Additionally, there are factors specific to both the tracheotomy procedure and tracheostomy tube care that may place the skin around a tracheostomy tube at an increased risk for pressure ulcer development. These factors include the proximity of the tracheostomy tube flange to the bony prominences of the clavi- cles, immobility of the tracheostomy tube flange when secured by sutures, and the presence of moisture from expelled tracheal secretions. Patients receiving tracheostomies are often cared for in an intensive care setting for at least part of their hospita- lization. Evidence-based guidelines for the prevention of TRAPUs have not been established for the adult population. The purpose of this study was to determine if standardi- zation of perioperative tracheostomy care procedures decreased the incidence of hospital-acquired TRAPUs. While this has been recently studied in the pediatric tra- cheostomy patient population, to date no objective studies on this subject have been published for the adult tracheost- omy patient population. 4-7 Methods A standardized posttracheostomy care bundle for the pre- vention of tracheostomy-related hospital-acquired pres- sure ulcers was proposed and approved for hospital-wide use as a quality improvement initiative starting on July 1, 2014. The protocol included the following 4 elements: (1) placement of a hydrocolloid DuoDERM Signal dressing (ConvaTec, Greensboro, North Carolina) underneath the tracheostomy tube flange ( Figure 1A ) in the immediate postoperative period, (2) removal of all plate sutures by the surgical service within 7 days of the tracheostomy procedure, (3) placement of a polyurethane PolyMem foam dressing

(Ferris Mfg Corp, Fort Worth, Texas) after suture removal ( Figure 1B ), and (4) neutral positioning of the head and neck. The complete bundle protocol can be reviewed in Figure 2 . Educational initiatives to role out implementation of the bundle included multiple steps. The bundle was developed after the assembly of a multidisciplinary task force, including all interested parties from nursing (professional leadership, WOCN [wound, ostomy, and continence nursing], floor units, intensive care unit, operating room), otolaryngology, general surgery, cardiothoracic surgery, information technology, respiratory therapy, and hospital administrative leadership. Care provider surveys, multidisciplinary expert opinion discus- sions, and research of the existing evidence in the literature all were used in creation of the bundle. 8-10 Hospital committees, including the Medical Surgical Quality Committee, Surgical Quality Improvement Committee, and Nursing Quality Improvement Committee, subsequently all approved the plan after final resolution of the bundle initiative. Nursing staff was educated through an online educational module. Physicians were educated through direct presentation of the initiative at the respective morbidity and mortality conference for each department. The physician team leader on the project from the otolaryngology service gave the presentation to each department. Data regarding the development of TRAPUs was collected during the quality improvement project. TRAPUs were detected through a standard reporting process. Floor and intensive care unit registered nurses (RNs) performed routine tracheostomy wound care in the postoperative period every 8 hours or as needed per institutional policy. Suspected pres- sure ulcers were noted and reviewed by the RN unit leader during daily nursing rounds. Physicians could also report ulcers through the same pathway if detected. Cases were then reported to the WOCN-certified nurse, who was then con- sulted to care for the patient. Suspected pressure ulcers were then reviewed at the monthly WOCN care conference for final validation and ulcer staging based on the National Pressure Ulcer Advisory Panel’s pressure ulcer staging system. 11 Ulcers were staged from I to IV, with unstageable

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