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We extend the healing ministry of Christ by caring for those who
are ill and by nurturing the health of the people in our communities.
Trach the Pressure Down a Notch: Implementation of a Tracheostomy
Pressure Injury Prevention Care Bundle
Emily Iakovakis, BSN, RN, OCN
Shelly Rose, BSN, RN, CNOR
Kristen Oster, MS, RN, APRN, ACNS-BC, CNOR, CNS-CP
Porter Adventist Hospital
Denver, Colorado
11th Annual Centura EBP, Research, and Innovation Conference
November 2, 2018
© 2018 Centura Health
Introduction
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• Pressure injuries are a painful, costly, and preventable complication.
• Pressure injury prevention is now expanding to include pressure injuries related to medical devices (Black & Kalowes, 2015). Includes:
o Tracheostomy tubes
o Naso-gastric tubes
o Gastric tubes
• Tracheostomy sites present a unique challenge for adult head/neck oncology patients.
Fig 1: Tracheostomy Site, March 2017
© 2018 Centura Health
Background
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• 8 pressure injuries related to tracheostomy tubes
o CY2015: 0
o CY2016: 3
o January – May 2017: 5
• 6 of the 8 pressure injuries performed by head/neck surgeons
• Identified need to develop and implement process to mitigate risk of pressure injury development in adult surgical head/neck oncology patients Fig 2: Pressure Injury Related to Tracheostomy January 2015- May 2017
© 2018 Centura Health
Materials and Methods
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• Interdisciplinary team assembled to investigate and evaluate additional measures to mitigate pressure injury development related to medical device –tracheostomy tube.
• Completed review on
• Current standard practice
• Evidence-based practice
o NPUAP/EPUAP
o Society of Head/Neck
• Assessment of adult surgical head/neck population
• Assessment of supplementary products addressing
o Pressure
o Moisture
• Development of pressure injury prevention care bundle for tracheostomy.
© 2018 Centura Health
Outline
5
• IRB Approved Study
o Exploratory study comparing pre and post patient population receiving tracheostomy from designated surgeon providers.
• Patient population: 40 head/neck surgical oncology patients receiving tracheostomy over the age of 18.
• Timeline: June 2017 to Present.
• Purpose
o Describe the effects of a nurse driven evidence based postoperative tracheostomy pressure injury prevention care bundle on pressure injury occurrence at the tracheostomy site.
• Research Question
o In postoperative head/neck service line tracheostomy patients staying in the hospital after surgery does application of a nurse driven evidence based tracheostomy pressure injury prevention care bundle compared to standard of care postoperative tracheostomy care lead to less pressure injury as measured by number of pressure injuries at the tracheostomy site?
© 2018 Centura Health
Tracheostomy Care Bundle Components
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1. Placement of a Mepilex Lite dressing between the flange of the tracheostomy and the patient’s skin at time of tracheostomy placement in the Main Operating Room.
2. An interdisciplinary approach to tracheostomy tube changes in the ICU and 1 North unit to include physicians, physician assistants, and clinical staff nurses.
3. Wound Care RN rounding on all tracheostomy tubes placed and application of Marathon skin protectant as needed by patient’s needs in ICU and 1 North.
4. Diligent clinical assessment of the peristomal skin by all care providers in Main Operating Room (PeriOperative Services), ICU, and 1 North. Including clinical staff nurses, wound care nurses, respiratory therapists, surgeons, and physician assistants.
© 2018 Centura Health
Education
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• Provided by RN Oncology Clinical Coordinator and Assistant Nurse Manager to clinical staff:
o Unit Based Practice Councils
o One on One education opportunities
o Education Hand Outs
Fig 5: Bundle Education Hand Out for Respiratory TherapyFig 3: Marathon Education Hand Out Fig 4: Bundle Education Hand Out for RN
© 2018 Centura Health
Data Collection
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• Weekly rounding by:
o RN Oncology Clinical Coordinator to ICU and 1North
o OR Assistant Nurse Manager to Operating Room
o PeriOp CNS as needed
• Retrospective chart review to assess care bundle compliance by
o RN Oncology Clinical Coordinator
Fig 6: Tracheostomy PIP Audit Form
© 2018 Centura Health
Clinical Application
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Fig 7: Lateral View of Tracheostomy SiteFig 8: Anterior View of Tracheostomy Site
© 2018 Centura Health 10
• 33 head/neck surgical oncology patients enrolled in IRB approved study and received care bundle
• 0 pressure injuries related to tracheostomy tube
Outcomes
Fig 9: Pre/Post Care Bundle Intervention Implementation Occurrences
© 2018 Centura Health
Patient Age
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Average age 62.91 years
Fig 10: Patient Age Range
© 2018 Centura Health
Patient Gender
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More male patients than female patients
Fig 11: Patient Gender
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Patient History of Cancer Diagnosis
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Cancer diagnosis more prevalent than no diagnosis
Fig 12: Patient history cancer diagnosis
© 2018 Centura Health
Key Findings from Audit
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• Early Implementation Gaps
• Component #2 - Multidisciplinary Care o Changing of Mepilex Lite at tracheostomy tube changing on inpatient unit
• Component #3 – Wound Care Order
o Consistency - Input of wound care order into Electronic Health Record
• Current State Gaps
• Documentation
o Mepilex Lite
o New clinical team members
© 2018 Centura Health
Conclusions
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• Use of the Tracheostomy Pressure Injury Prevention Care Bundle may be an effective nurse driven evidenced-based care bundle in the prevention of pressure injuries
o Zero pressure injuries
• Implications for Practice
o Utilization of care bundle for all surgical tracheostomy patients beyond selected patient population for study
o Potential adaptation for other medical devices
• Next Steps
o Postoperative order set inclusion
© 2018 Centura Health
References
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• Beckman, B., Fisher, M., & Amendolia, O. (2014). EB109 Sustainable Practice Change: Reduction in Tracheostomy
Peristomal Breakdown. Critical Care Nurse, 34(2), e32-e32.
• Black, J., & Kalowes, P. (2015). Low hanging fruit: Medical device related pressure ulcers. National Pressure Ulcer
Advisory Panel. Retrieved June 15, 2017, from http://npuap.org/wp-content/uploads/2015/06/FINAL-MDRPU-Webinar-
June-2015.pdf
• National Pressure Ulcer Advisory Panel, European Pressure Ulcer Advisory Panel and Pan Pacific Pressure Injury Alliance.
In: Haesler E, ed. Prevention and treatment of pressure ulcers: clinical practice guideline. Osborne Park, Western
Australia: Cambridge Media; 2014.
• Ondrejko, M. (2013). The use of Cyanoacrylate based skin barrier in the protection of the skin around a tracheostomy.
Educare wound & skin care education. (Presented at the Symposium on Advanced Wound Care SAWC Spring, Denver,
CO, 2013. Study #LIT1011R)
• Pittman, J., Beeson, T., Kitterman, J., Lancaster, S., & Shelly, A. (2015). Medical device-related hospital-acquired pressure
ulcers: development of an evidence-based position statement. Journal of Wound, Ostomy, and Continence Nursing:
Official Publication of The Wound, Ostomy And Continence Nurses Society, 42(2), 151.
doi:10.1097/WON.0000000000000113
© 2018 Centura Health
Contact Information
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Emily Iakovakis, BSN, RN, OCN
Oncology Clinical Coordinator
Shelly Rose, BSN, RN, CNOR
Assistant Nurse Manager Head/Neck, Neuro, ENT, Skullbase, and Dental Service Lines
Kristen Oster, MS, RN, APRN, ACNS-BC, CNOR, CNS-CP
Clinical Nurse Specialist – PeriOperative Services
Porter Adventist Hospital
2525 S. Downing St.
Denver, CO 80210
