Medical device-related pressure injuries (MDRPIs) may now be almost completely preventable in patients undergoing tracheostomy. The addition of a simple foam device resulted in a total reduction in tracheostomy-related pressure injuries to nil in one hospital, according to an article published in Advanced Critical Care.1
Development of pressure injuries represents a serious challenge to postsurgical care. The prevalence of pressure injuries among intensive care unit (ICU) patients is higher than among general admission patients (16.9% to 23.8% vs 12% to 18%),2 with approximately 10.9% of all hospital-related cases associated with tracheostomy.3 Multiple factors contribute to development of MDRPIs specifically associated with the presence of a tracheostomy tube, including the downward pressure of the ventilator tubing during mechanical ventilation, accumulated moisture at the insertion site, and proximity to the bony prominences of the clavicles as well as immobilization of the secured tube flange.1,3
The study authors Hazel Holder, DNP, MSN, RN, ACCNS-AG, CCRN, a critical care clinical nurse specialist, and Brittany “Ray” Gannon, PhD, MSN, AGPCNP-BC, a nurse scientist assessed the implementation of a quality improvement project designed to significantly reduce the occurrence of tracheostomy-related MDRPIs. The retrospective study evaluated data collected over 4 years in patients from an 18-bed, mixed-adult ICU at NewYork-Presbyterian Westchester, Bronxville, in which a change in medical device practice showed a complete reduction of MDRPIs associated with tracheostomy from 13% to 0%.
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Study Design and Results
A multidisciplinary team of clinical nurses, a cardiothoracic surgeon, and a respiratory therapist developed an intervention and clinical support protocol for the placement of a fenestrated polyurethane foam dressing beneath the tracheostomy device during surgery. A polyurethane foam dressing (Lyofoam Max precut T) was attached below the flange of the tracheostomy tube, secured by a soft flexible tracheostomy tube holder and 4 size 0 sutures. Two of the sutures were removed on day 5 and the remaining 2 sutures were removed between days 7 and 10. The foam device was then removed and replaced with a standard nonwoven gauze drain sponge for continued care.
At the beginning of the study in 2018, the hospital-acquired pressure injuries incidence was 1.4% for 1077 ICU patients, 2 of whom received percutaneous dilation tracheostomy. Both of these patients developed MDRPIs, which initiated the subsequent change in protocol study. Over the next 3 years of observation of the implementation of the new tracheostomy device with modifications to the support practices, 22 more patients underwent tracheostomy in the ICU. Including the initial cases in 2018, a total of 30 developed hospital-acquired pressure injuries associated with tracheostomy, for an incidence of 6.7%.
Table. Incidence of Tracheostomy-Related MDRPIs Over a 4-Year Period in ICU Patients
| Total MDRPIs | Tracheostomy Patients | Tracheostomy- Related MDRPIs | |
| 2018 | 15 | 2 | 2 |
| Intervention – Addition of Lyofoam Max T dressing and clinical support protocols | |||
| 2019 | 15 | 9 | 0 |
| 2020 | – | 5 | 0 |
| 2021 | – | 8 | 0 |
| Total | 22 | 2 |
Source: Holder et al.1
The authors noted that study results were highly dependent on the facilities and the engagement of multidisciplinary providers to support the application of polyurethane foam dressing in broader tracheostomy practice.
“Our initiative provided a clear process for the bedside percutaneous tracheostomy procedure and tracheostomy MDRPI prevention interventions, which became an established clinical process in the ICU,” the authors said. “The success of this initiative has resulted in clinical practice and policy changes, influencing all hospitals in the system.”
“When COVID-19 increased demand for health care equipment, we were able to refine our processes, transition to a revised percutaneous dilation technique tracheostomy kit and maintain the integrity of the initiative,” Dr Holder said. “We took a multidisciplinary approach that engaged all related specialties, with surgical site assessment and any clinician concerns discussed during daily rounds.”
The authors determined that the successful outcomes of this study can be readily replicated to reduce the incidence of MDRPIs associated with percutaneous dilation tracheostomies performed outside of the ICU. “Although some process modifications may be necessary, the protective elements of the polyurethane foam dressing may benefit other patient populations as well, including pediatric, neonatal, and surgical [patients],” they concluded.
References
1. Holder H, Gannon BR. Reducing tracheostomy medical device-related pressure injury: a quality improvement project. AACN Adv Crit Care. 2022;33(4):329-335. doi:10.4037/aacnacc2022874
2. Chaboyer WP, Thalib L, Harbeck EL, et al. Incidence and prevalence of pressure injuries in adult intensive care patients: a systematic review and meta-analysis. Crit Care Med. 2018;46(11):e1074-e1081. doi:10.1097/CCM.0000000000003366
3. O’Toole TR, Jacobs N, Hondorp B et al. Prevention of tracheostomy-related hospital-acquired pressure ulcers. Otolaryngol Head Neck Surg. 2017;156(4):642-651. doi:10.1177/0194599816689584
4. 2. Initiative prevents tracheostomy-related pressure injuries. News release. American Association of Critical-Care Nurses. February 14, 2023. Accessed March 6. 2023. https://www.aacn.org/newsroom/initiative-prevents-tracheostomy-related-pressure-injuries
