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 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.

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 Bridge of nose Tracheostomy Neck Under face plate ETT Q 2 hrs (During Oral Cares) 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 pre-attached 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.