Transcript Pressure Ulcer Prevention – Respiratory Devices

Pressure Ulcer
Prevention Respiratory
Devices
Larry Kula
Denise Nix
Vicki Haugen
www.mnhospitals.org
Minnesota AHE Reporting
 Mandatory state reporting system
 NQF 28 Serious Reportable
Events
 Serious pressure ulcer reportable

Stage III, IV and Unstageable
Reported events,
Oct. 2008-Oct 2009
Retained
objects
38
Falls
76
Medication
Errors
4
Other
19
Wrong site
surgery
27
Wrong
procedure
15
Pressure
ulcers
122
301 Events
4 Deaths
Pressure Ulcer – Added Qs
 Stage III, IV, Unstageable Pressure Ulcers
 Submit RCA/CAP
 Additional information
 Patient Characteristics
 Pressure Ulcer Development
 Additional Patient Questions
 Device-related Questions
 Surgery/Procedure Questions
Types of Pressure
Ulcers
 Last year, 25% of reportable pressure
ulcers were device-related.
 Majority of devices involved were
cervical collars and respiratory devices.
G Tube
11%
Rectal
Tube
11%
ETT strap
11%
Nasel Cannula
11%
Bipap Mask
11%
Cervical collar
45%
Case Examples
 Stage IV pressure ulcer behind the ear
from oxygen tubing.

Skin inspection behind ears not completed; early redness
not communicated when seen.
 Stage III pressure ulcer under
tracheostomy device.

Skin under tracheostomy device not inspected on a
regular basis.
 Stage III pressure ulcer on bridge of
nose from BiPap mask.

Staff not aware of mask alternatives for high-risk patients
or most effective strategies for reducing pressure under
masks.
Safe Skin Call-to-Action
 Statewide approach to implementing
best practices
 Roadmap of Best Practices
 Additional Recommendations added
this year based on AHE learnings:
 Pressure Ulcer Prevention in the OR
 Device-related Pressure Ulcer Prevention –
Cervical Collars
 Device-related Pressure Ulcer Prevention –
Respiratory Devices
What’s in it?
Device-Related
Pressure Ulcer Prevention
Respiratory Devices
Recommendations and Guidance
Role of Respiratory Therapy
 Member of Skin Safety Team
 Types of involvement:
 Involvement in developing policies to prevent respiratory
device-related pressure ulcers
 Regular education and training of respiratory staff on
pressure ulcer prevention; partner with wound care staff
for training, grand rounds, etc.
 Process to consider skin safety when purchasing
respiratory equipment
 Involvement in root cause analyses when pressure ulcer
involving respiratory equipment occur
Skin Inspection
Respiratory
Device
Inspections
Frequency
Inspection
Locations
Nasal Cannula
Q shift 8-12 hrs
Back of ears
Mask
During oral Cares
Back of ears
Bridge of nose
Tracheostomy
Q shift 8-12 hrs
Neck
Under face plate
ETT
Q 2 hrs (During
Oral Cares)
Neck
Lips/face
Device Fit
 Secure straps with least amount of
tension/pressure to obtain adequate
placement/seal.
 Consult with respiratory therapy for proper
re-fitting at first sign of skin damage
 Consider utilizing alternative product such
as full face masks or those that
incorporate gel or silicone based cushions
if standard equipment cannot be sized and
adjusted to avoid skin breakdown.
Device Inspection
 Visually inspect masks and tubing on
a regular basis.
 Replace if straps lose elasticity,
become soiled, or defective.
 Do not tie knots in straps to tighten.
Tips to Minimize Friction/ Pressure
(websites, references, photos)
 Commercially available ear
protectors to attach to oxygen tubing.
 Oxygen tubing with protectors preattached
 Foam tracheostomy straps designed
to hold oxygen cannula away from
the ears.
 Commercially available foam/collar
type adjustable straps are preferable
to traditional methods (tape/twill ties)
of securing trachs and ETT (AHA
Guidelines)
Tips to Minimize Friction/ Pressure
(websites, references, photos)
 Silicone stoma pad (cushion between the
flange and the tracheostomy site) for
pressure redistribution
 A ventilator arm and rolled towel to the
chest to offload pressure and drag of
ventilator tubing.
 Gel pads sold separately or incorporated
into masks
 Application of wound dressings over
vulnerable or affected area (dressings
reduce friction-not pressure; continue
routine skin inspection
Trach Sutures
 Create standard procedure and timeline
for management of tracheostomy sutures.
 If standard timeline is not in place, contact
the surgeon/provider after 7-10 days or
sooner if skin irritation near the sutures
occurs.
 During hand-off to next level of care,
include instructions for converting from
suture stabilization to other means for
securing and stabilizing flange.
Special Populations
 Neonatal/Pediatric:
 Pediatric pressure ulcers occur primarily on the
head/occipital region.
 More than 50% of all pediatric pressure ulcers are
related to equipment and devices .
 Use commercially available pediatric products when
available rather than adapting standard equipment.
 Specific interventions intended for adults may NOT be
safe for neonatal and pediatric patients (i.e. rotating
ETT); always follow pediatric specific recommendations
and manufacturers’ instructions when available
Special Populations
 Bariatric:
 Pressure ulcers from respiratory equipment can
result from pressure within skin folds.
 Consider use a of silver textile product to wick
away moisture from skin folds.
 Instead of adapting standard equipment, use
commercially available bariatric products such
as longer tracheostomy tubes and bariatric
tracheostomy collars.