Tracheostomy Skin Assessment and Off-loading Prevention

Alanna Valadez, MBA, MSN, RN, PHN, APRN, CNP, CWOCN, WOC Program, HealthEast Bethesda Hospital, St. Paul, MN, Kathleen Borchert, MS, ACNS-BS, CWOCN, CFCN, WOC Program, University of Minnesota, Fairview IMS, Minneapolis, MN and Lynne Bausman, RRT, RT, HealthEast Bethesda Hospital, St. Paul, MN
TOPIC:  Our long-term acute care (LTAC) facility has a high prevalence of tracheostomy patients.  A guide was developed for our multidisciplinary team, to assist with correctly identifying stomal/peristomal skin concerns at the tracheostomy site. 

PURPOSE:  WOC team noted an increase in tracheostomy consults.  Nursing, respiratory therapists (RT) and physicians were identifying concerns incorrectly at the trach, classifying concerns mostly as pressure related.  Nursing wanted the WOC team to assess all concerns as staff did not feel confident differentiating between erythema related to pressure injury, blanchable vs. non-blanchable and other concerns. The increased calls and incorrect skin assessments prompted the WOC team and lead RT to partner.  Gaps were found in staff education and visual teaching tools.  Our improvement plan was to develop a visual teaching tool. 

OBJECTIVE:  To develop an educational document which provided guidance to staff on Tracheostomy Skin Abnormalities. The document included a description of stomal/peristomal skin concerns, reason concern occurs, photo of concern, interventions and how to document staffs’ assessment/interventions in the EHR.  After the tool was developed, it was presented during huddle to nursing and RTs and a laminated copy hung on respiratory unit as a quick reference guide.                                                        

OUTCOME:  Staff provided positive feedback and consistently identified stomal/peristomal skin concerns correctly at the tracheostomy site.  Staff members were able to express the new concerns that could be assessed during a weekly WOC visit versus a more urgent issue, such as a suspected pressure injury under a tracheostomy faceplate.  The new Tracheostomy Skin Abnormalities tool helped staff intervene with prevention sooner; however, the WOC nurses began to note dressings being placed incorrectly under the faceplate. A second document was developed; Off-loading the Tracheostomy Faceplate which assisted staff with applying the correct pressure injury prevention intervention under respiratory equipment, and in time decreased WOC consults.