Bridging Units and Disciplines to Decrease Tracheostomy Flange Device Related Pressure Ulcers

WOC nurses have key role in collaborating to reduce device relate pressure ulcers.  Patients are at risk for device-related pressure ulcers following initial percutaneous tracheostomy placement, specifically breakdown under the bottom edge of the flange.  A WOC nurse together with respiratory therapy, nursing, and physicians from two ICUs evaluated practice and developed prevention strategies.  The WOC nurse provided consultative recommendations on dressings that could assist a modified suturing technique and added the use of a hydrocolloid dressing to protect the skin under the flange from friction and shearing until the sutures where removed and standard trach care could be initiated.  The two ICU units shared RT, WOC nurse, and LIP personnel, supporting rapid implementation within one week of the index case.  Initial resistance to change was successfully addressed by emphasizing that the practice was being “tested” with further refinement to be based on comments from staff.   With minor revisions, this standard practice has now been utilized in 71 cases. In the 5 months prior to this intervention, review of quality data revealed an average of 1 to 2 tracheostomy-related pressure ulcers per month between the two units.  In the eleven months since standard practice implementation there have been no reports of skin breakdown.  Of importance, there have also been no reports of complications (for example, tracheostomy dislodgement) related to the new technique.  Future refinement of the standard practice includes emphasis on special populations such as patients with copious peri-stomal secretions and the burn population.