Collaborating to Reduce Tracheostomy-Associated Pressure Injuries

Purpose: According to the National Pressure Ulcer Advisory Panel, a pressure injury is defined as “localized damage to the skin and/or underlying soft tissue, usually over a bony prominence or related to a medical or other device. The injury occurs as a result of intense and/or prolonged pressure or pressure in combination with shear.” In the acute care setting, hospital-acquired pressure injuries (HAPIs) occur in nearly 40 percent of patients. The cost of treating a single pressure injury can range between $40,000 and $90,000 depending on severity. In addition to the financial burden, a patient with a HAPI tends to have a longer length of stay and is at higher risk for mortality.

Over the first 3 quarters of calendar year 2018, this pulmonary acute care unit had four tracheostomy-associated pressure injuries (TRAPIs), a four-fold increase from the previous year. The clinical nurse specialist (CNS) initiated a workgroup for evaluation of current processes compared to best practice with a goal of reducing TRAPIs on this unit.

Description: An interdisciplinary workgroup consisting of nursing, respiratory, and surgery met in October 2018 to discuss the problem, review the literature, and create an action plan moving forward. Recurrent themes in literature included use of a pressure relieving dressing, timely removal of sutures, neutral neck positioning, and application of a moisture barrier. The team selected a non-adherent foam dressing to aid in pressure offloading and directed that it be changed every 12 hours and more frequently if soiled. The CNS approached the surgery team and asked that they place the dressing during the intraoperative period, increasing the likelihood that effective skin care and dressing changes could be performed postoperatively.

Moisture management is a significant concern in the tracheostomy patient. Not wanting to use any type of spray given the fragile respiratory condition of this patient population, the team instead opted to use moisture barrier swab sticks. Applying moisture barrier prior to each dressing change reduced maceration and moisture related skin breakdown. The unit obtained foam head cradles, promoting more neutral neck positioning compared to pillows alone. Finally, the team changed the practice of suture removal from seven to five days after insertion pending a stable airway. Weekly interdisciplinary tracheostomy rounds began following the identification of an action plan to assess compliance with recommended practice changes and provide “real-time” education on the new processes.

Evaluation/outcome: During the planning and implementation phases of the project, two additional TRAPIs occurred, totaling six for calendar year 2018. With consistent rounds by the interdisciplinary team and availability of necessary supplies, there were only four TRAPIs during calendar year 2019. That is an estimated $80,000 cost avoidance for 2019. During the first four months of 2020, the unit experienced only one TRAPI, putting them on track for further reduction and cost avoidance this year. Additionally, the workgroup is evaluating use of soft flange tracheostomy tubes to further reduce these costly and dangerous device-related injuries.