A New York hospital reduced the incidence of medical device-related pressure injuries (MDRPIs) following a tracheostomy to zero for four years, according to a study published in AACN Advanced Critical Care.
“Reducing Tracheostomy Medical Device-Related Pressure Injury: A Quality Improvement Project” details how NewYork-Presbyterian Westchester, Bronxville, achieved the results in its 18-bed adult intensive care unit (ICU), in part by integrating MDRPI prevention into the bedside procedure for tracheostomies that used the percutaneous dilation technique (PDT).
The intervention used evidence-based resources from the Preventing Pressure Injuries Toolkit funded by the Agency for Healthcare Research and Quality, part of the U.S. Department of Health and Human Services.
A key part of the new clinical process was a revised PDT tracheostomy procedural kit and documentation. During insertion, a polyurethane foam dressing was placed under the tracheostomy flange and secured with sutures and a flexible holder. The foam dressing remained in place for seven days, with primary care nurses assessing the site at least every 12 hours. As clinically indicated, the dressing was changed to a standard nonwoven gauze drain sponge after seven to 10 days.
The results showed that suturing a foam dressing as part of PDT tracheostomy insertion can reduce the incidence of associated MDRPIs.
The authors are Hazel Holder, DNP, MSN, RN, ACCNS-AG, CCRN, and Brittany “Ray” Gannon, PhD, MSN, AGPCNP-BC. Holder is a critical care clinical nurse specialist at NewYork-Presbyterian Westchester, and Gannon is a nurse scientist at NewYork-Presbyterian Hospital, New York City.
“When COVID-19 increased demand for healthcare equipment, we were able to refine our processes, transition to a revised PDT tracheostomy kit and maintain the integrity of the initiative,” Holder says. “We took a multidisciplinary approach that engaged all related specialties, with surgical site assessment and any clinician concerns discussed during daily rounds.”
Before the initiative, in 2018, the incidence of healthcare-associated pressure injuries (HAPIs) was 1.39% for all ICU patients. Tracheostomy MDRPIs accounted for 0.19% of the incidents (15 HAPIs, including two MDRPIs in 1,077 patients). However, of the two PDT tracheostomies performed, both patients experienced MDRPIs.
In 2019, the overall HAPI incidence decreased to 1.30%, with nine tracheostomies and no MDRPIs. The tracheostomy MDRPI incidence remained at zero for the next three years.
During the four years of this project, 22 PDT tracheostomies were performed in the ICU, with the foam dressing placed at the point of insertion in all procedures.
The project was conducted with another unit-based program to address the overall rate of unit-acquired HAPIs, which may have contributed to increased vigilance.
Patients critically ill with COVID-19 are at exceptionally high risk for developing healthcare-associated pressure injuries (HAPrIs). Therefore, nurses and other clinicians should be extra vigilant with assessments and protective interventions, according to a study published in AACN Advanced Critical Care.
“Pressure Injury Risk Assessment and Prevention in Patients With COVID-19 in the Intensive Care Unit” retrospectively examined pressure injury risk in a sample of 1,920 adult patients admitted to one of two intensive care units (ICUs) at a Utah teaching hospital between April 2020 and April 2021.
The study is part of the research team’s ongoing work to develop ways to determine pressure injury risk among ICU patients more accurately. The researchers compared the Braden Scale for Predicting Pressure Sore Risk for patients with COVID-19 with patients who were negative for the disease and identified additional risk factors for device-related HAPrIs in critically ill patients with COVID-19.
“This study and others provide further evidence that patients with severe COVID-19 are at even greater risk for pressure injuries than the general ICU patient population,” says co-author Jenny Alderden, Ph.D., APRN, CCRN, CCNS, associate professor at Boise State University School of Nursing.
Accurately Determining Risk for Pressure Injuries
She says prevention begins with accurately determining risk, and clinicians must consider additional factors beyond those assessed with common classification tools.
Since its development in 1987, the Braden Scale has become the most widely used tool in the United States to determine pressure injury risk across all care settings. Still, a growing body of literature shows that it lacks predictive validity in the ICU population, finding that nearly all ICU patients are at high risk.
The study sample included 1,920 patients, and 407 patients were diagnosed with COVID-19. In the entire sample, at least one HAPrI developed in 354 patients (18%), with a third of those considered device-related. Among the 407 patients with COVID-19, at least one HAPrI developed in each of 120 patients (29%), with nearly half (46%) considered device-related.
The research team looked at data related to demographics, diagnoses, comorbidities, hospital length of stay, treatment interventions, laboratory tests, nutrition, and the results of skin assessments conducted by nurses.
Statistical analysis revealed two variables as potential risk factors for device-related HAPrIs: fragile skin and prone positioning during mechanical ventilation.
The researchers also point to the potential for machine learning methods and explainable artificial intelligence to improve the accuracy of HAPrI risk assessments to provide additional information for clinicians to incorporate into their patient care decisions
When it comes to staging pressure injuries (PI) and identifying moisture-associated skin damage (MASD) it can be challenging. Both types of wounds have similar presentation and show up consistently on the same parts of the body.
Pressure Injury Basics
Pressure injuries (PI) result when prolonged pressure impairs blood flow to an area by compressing tissues/vessels. These injuries are found over bony prominences in the body such as the coccyx, sacrum, scapula, and heels. Medical devices or other foreign objects that put pressure against the body can also cause a pressure-related injury. Common culprits for medical device-related pressure injuries are nasal cannulas, gastric tubes, and indwelling catheters. Other factors such as moisture and nutrition also play a big part in the formation and treatment of pressure-related wounds.
- Stage I: Skin is still intact with non-blanchable redness or erythema. The area may be painful, soft, warmer or cooler than the rest of the body.
- Stage II: Partial thickness loss of dermis presenting as a shallow open ulcer with red and/or pink wound bed. The wound bed is without slough. It may also present as intact or open serum-filled blister.
- Stage III: Full thickness tissue loss in which subcutaneous fat may be visible but bone, tendon, or muscle are not exposed. Slough may be present, but the visible slough does not obscure depth. May include undermining and tunneling at this stage.
- Stage IV: Full thickness tissue loss with exposed bone, tendon, and/or muscle. Slough or eschar may be present on some parts but not enough to cover the wound bed. This stage often has undermining and/or tunneling.
- Deep Tissue Injury: Purple or maroon localized area of discolored intact skin. Could also be seen as a blood-filled blister due to damage or underlying soft tissue from pressure and/or shear. Ultimately the skin is still intact, and the depth is unknown at this point in time.
- Unstageable: There is full thickness tissue loss in which the base of the ulcer is covered by at least 50% slough and/or eschar. Most of the wound bed cannot be seen and therefore cannot yet be staged.
Moisture Associated Skin Damage Basics
MASD develops when the top layer of skin is damaged first. Top-down skin injury (outer layers of skin are damaged first): The inflammation and erosion of the skin is caused by prolonged exposure to moisture. The sources of moisture may include urine or stool perspiration, wound exudate, mucus, or saliva. The moist and often macerated skin is in a weakened state that is easily damaged by friction. MASD is common between skin folds, around stomas and peri-wounds, and to the peri-region in incontinent patients.
MASD and PIs can be easily confused with one another. It is common for MASD to contribute to the formation of a pressure injury since the tissue has become compromised. A pressure injury with a lot of drainage can also lead to MASD to the peri-wound. While it may be hard to decipher between the two types of skin injuries, here is a quick reference to refer to during an assessment that can help a nurse decide.
Moisture Associated Skin Damage
- Cause, Prevent, Treatment: Too much moisture has compromised the skin and led to breakdown. Find a way to control the source of moisture that is damaging the tissues.
- Location: Diffusely distributed over an area. Wound margins are often irregular.
- Color: Pink or red but is still blanchable.
- Depth: Partial thickness tissue loss. Blisters with serous fluid might be present.
- Necrosis: None.
- Pain: Pain is common. The patient may also complain of burning or itching.
- Cause: Pressure is the cause, and the priority is to offload the area or to remove the source of pressure.
- Location: Usually over a bony prominence or from a medical device. Wound edges are well circumscribed.
- Color: Wound bed may be red, blue, or purple. The wound bed could also be obscured by slough or eschar which would be yellow, white, tan, brown, or black.
- Depth: Partial or full thickness depth. Blisters may be present over pressure areas or from equipment or devices. Blisters could be filled with either serous fluid or blood.
- Necrosis: May potentially have slough or eschar.
- Pain: May or may not be present. Some wounds may not have much feeling if the wound is too deep, and the nerve endings are damaged.