Post Operative Tracheostomy Protocol for Obese and Low Braden Score Patients in ICU Setting

Post Operative Tracheostomy Protocol for Obese and Low Braden Score Patients in ICU Setting
Clinical Problem: 

Challenges for tracheostomy care exist with patients of all ages, but obese patients and those with low Braden scores are particularly susceptible to tracheostomy skin breakdown and erosion due to device movement/pressure, along with yeast infections due to consistent moisture.  These alterations in tissue integrity under trach flanges and twill tape seemed consistent and was not a protocol in place for identification and prevention. Description of Past Management:
In the past, care of patient’s skin was to apply a no sting barrier wipe surrounding the trach, apply fenestrated gauze, and secure with tape under the trach flanges.  These dressings would be changed several times a day when saturated.  The problem was that the device was still causing friction and pressure with skin maceration peristomaly and along the neck under the twill tape used for stabilization. 
Current Clinical Approach:
A protocol for tracheostomy care was developed for all intensive care units and the WOCN and the Respiratory Therapy (RT) department partnered to educate the protocol. It included accessing risk factors, then appropriately applying a fenestrated silver foam with silicone adhesive to be changed every 3 days and as needed along with a soft silver incorporated material between the trach ties and the skin. 
Patient Outcomes:  Before implementation of the protocol, the ICU had 11 patients in one month that were high risk and had tracheostomies.  Of the 11 patients, 45% of these patients developed skin complications around the trach site.  One month after implementation, we decreased our incidence of skin complications to 25%.  We have continued to lower the percent of incidence.
Conclusions:
With all the possible solutions available for this situation, the intention of this poster to provide an inexpensive, nursing time sensitive protocol that can be duplicated easily by the WOCN and RT.  This is an option that the WOCN can utilize to partner with Respiratory Therapy to assure positive outcomes for their patients with Tracheostomies.