FRINK Linked Data Fragments server

Matches in SemOpenAlex for { <https://semopenalex.org/work/W4379879080> ?p ?o ?g. }

• W4379879080 endingPage "153" @default.
• W4379879080 startingPage "148" @default.
• W4379879080 abstract "In the early 15th century, Italian physician Antonio Musa Brasslova performed the first successful tracheostomy procedure to relieve airway obstruction caused by enlarged tonsils.1 Standardized in the early 1900s by otolaryngologist Chevalier Jackson, the procedure is now used frequently in the pediatric population to provide a safe airway for children with respiratory compromise or failure or those with airway obstruction.1 Of the 100 000 tracheostomies performed annually, approximately 4000 are performed on children, with one-third on infants, specifically premature infants.1 The availability of technically advanced ventilation equipment for invasive and noninvasive airway management has allowed many more infants and children to survive a serious illness than in the past.1 Many children require prolonged intubation as a result of chronic respiratory failure and inability to wean from ventilator support, contributing to acquired tracheomalacia (breakdown of the rigid tracheal structures) and acquired subglottic stenosis (weakening of the area below the glottis), leading to the need for a tracheostomy as a safe airway, and moreover, a means to discharge to home. Other indications for tracheostomy include airway obstruction, airway protection, and secretion management, as well as chronic conditions including neurological impairment and congenital heart and lung disease.1,2Tracheostomy is not without its complications, however, including in particular the development of pressure injury (PI) under the tracheostomy flange and tracheostomy ties. A PI is a localized injury to the skin and/or underlying tissue, usually over a bony prominence, due to pressure in combination with shear and friction.3 In children, the development of PI is typically related to the presence of medical devices and not to immobility as seen in adult populations.4 Medical device–related PI (MDRPI), specifically tracheostomy-related PI, was a significant problem at our children’s hospital. In the 2 years before this initiative, 37% of children with newly placed tracheostomies developed skin breakdown under the tracheal interfaces (tracheostomy flange and tracheostomy ties) during the first critical week postoperatively. At the time, intraoperative dressing placement was not usual practice; gauze dressings were applied after the first tracheostomy tube change. Contributing factors to the development of skin breakdown included diminished neurologic status/responsiveness and associated immobility, age, constant interface pressure over the neck tissues, exacerbated by moisture from sweat and secretions, and the weight of the ventilator circuit and other oxygen devices.4,5 Studies have shown that placing a preventative dressing on the neck area intraoperatively and using nursing care bundles improve patient outcomes, decreasing discomfort, cost, and length of stay4,5 and development of MDRPIs.6 Therefore, a quality improvement (QI) project was initiated with the goal of reducing the development of tracheostomy-related PI in patients with newly placed tracheostomies by 50%.UF Health Shands Children’s Hospital uses 3 intensive care units (ICUs) to care for children with tracheostomies: the pediatric intensive care unit (PICU), the pediatric cardiac intensive care unit (PCICU), and the neonatal intensive care unit (NICU). The PICU is a 24-bed unit with staff that cared for 22 patients with newly placed tracheostomies between January 2017 and October 2019. The pediatric critical care team comprises 7 pediatric intensivists, 6 pediatric fellows, 2 nurse practitioners (NPs), and 1 physician assistant (PA). There are 76 registered nurses (RNs), and 10 support technicians (ST) employed in this unit. The PCICU is a 23-bed unit caring for children and adults with congenital heart defects. Between January 2017 and October 2019, the PCICU cared for 7 children with newly placed tracheostomies. The pediatric congenital heart team consists of 7 pediatric intensivists, 6 pediatric fellows, 7 NPs, and 2 PAs. This unit employs 65 RNs and 15 STs. The NICU is a 72-bed unit that cared for 10 patients with newly placed tracheostomies between January 2017 and October 2019. The neonatal care team comprises 6 neonatologists, 9 neonatal fellows, and 15 NPs. The NICU employs 149 RNs and 16 STs. UF Health Shands Children’s Hospital models family-centered care and is a “baby friendly” institution.Key stakeholders, including pediatric otolaryngologists, pediatric surgeons, registered nurses, and pediatric respiratory care staff in the PICU, PCICU, and the NICU, were included in the project design. A plan for intraoperative dressing placement was discussed with the otolaryngologists and pediatric surgeons.There is evidence in the literature supporting the use of preventative dressings under medical devices to aid in the prevention of PI.6 Skin breakdown and ulceration around the tracheal stoma is a common wound complication with a new tracheostomy.4,5 The resulting soft tissue damage is due in part to prolonged pressure from the tracheostomy flange, ties, and the weight of the ventilator circuit. Multiple commercial dressings under the interfaces, as well as gauze, were used at our institution as a means of protecting the skin. We found that these dressings were either too bulky or did not stay in place, resulting in friction and shearing under the device. Allevyn Gentle Border Lite dressings (Smith & Nephew) were previously implemented to aid in the prevention of MDRPI, the most common pressure-related injuries in the pediatric population, but these had not been used around the tracheal stoma.7 The Allevyn Gentle Border Lite dressing is low profile, stays in place, and is removed easily without causing significant adhesive skin irritation. Therefore, this dressing seemed ideal for use around the newly placed tracheostomy.During the implementation period, each patient who received a new tracheostomy tube went to the operating suite with a premade intraoperative dressing kit. Contents of the kit included Allevyn Gentle Border Lite dressings in sizes 7.5 cm by 7.5 cm and 5.5 cm by 12 cm with placement instructions (the 7.5 cm by 7.5 cm dressing to be split and placed under the tracheostomy flange; the 5.5 cm by 12 cm dressing to be placed around the neck under the tracheostomy tie), as well as the evidence-based rationale for dressing use (Figure). Use of the dressing kit was at the discretion of the surgeon performing the tracheostomy procedure. The dressing remained in place for 7 days, at which time the first tracheostomy tube exchange was conducted at the bedside by the surgical team. The old dressing was removed, the skin assessed for breakdown, and a split gauze dressing placed under the tracheostomy flange after cleaning the stoma and neck areas. Documentation in the electronic medical record (EMR) reflected any positive or negative findings. Allevyn Gentle Border Lite dressing placement continued above and below the tracheostomy stoma, especially in infants with short necks, to protect the chin and chest from irritation caused by friction from the tube and ventilator circuit if in use. The skin assessments continued until discharge, per the bundle guidelines.The use of nursing care bundles can improve patient outcomes.8 Care bundles consist of a set of evidence-based interventions, intended for a defined patient population—in this case, patients with tracheostomy tubes—and a care setting that, when implemented together, will result in better outcomes than when implemented individually.8 O’Toole et al9 developed a standardized tracheostomy care bundle for the adult population that reduced the rate of tracheostomy-related PIs. A tracheostomy bundle for pediatric patients was developed for this project based on the elements of that study (Table 1).10 Bundle elements included turning patients every 2 to 4 hours and as needed, completing tracheostomy care every shift, and documenting the skin risk assessment. Tracheostomy care is performed and documented every 8 to 12 hours and includes assessing the underlying skin for evidence of skin breakdown and intervening before complications arise.For easy reference, the tracheostomy care bundle was posted in the room of each hospitalized patient who had a tracheostomy. Documentation auditing occurred twice weekly to track compliance with the bundle elements. A tip sheet outlining tracheostomy essentials (Table 2) was posted along with the bundle to remind staff to assess the tracheal stoma and peristomal area at least every shift, provide tracheostomy stoma and neck care, change the tracheostomy ties daily, and document any concerning findings.Bedside ICU registered nurses and respiratory therapists shared responsibility for assessing the skin postoperatively. Prior to implementation, the ICU nursing staff (290) and the pediatric respiratory care staff (40) were offered initial education about the tracheostomy care bundle, tracheostomy essentials, and the Braden QD scale. Subsequent re-education was provided 2 months into the project to improve bundle compliance.Skin risk assessment tools are routinely used to predict the risk of developing skin breakdown and PI. The first skin risk assessment tool, the Braden scale, was developed by Braden and Bergstrom in 1987 to predict the risk of skin breakdown in the adult population. It consists of 6 subscales—sensory perception, moisture, activity, mobility, nutrition, and friction/shear—as measures to predict the risk of skin breakdown.11 Patients are deemed to be at risk with a score of 18 or less. The Braden Q scale was a modification of the Braden scale developed by Quigley and Curley and specific to the pediatric population. It incorporated the 6 subscales in the Braden and added a seventh, tissue perfusion and oxygenation.12 Children are deemed to be at risk with a score of 16 or less. Lund and Osborne developed the Neonatal Skin Condition Score (NSCS) in 2004. It identifies 3 subscales—dryness, erythema, and breakdown/excoriation—to predict the risk of skin breakdown in the neonatal population.13 Scores range from 3, minimal risk, to 9, greatest risk. All 3 of these scales were used in this project because of the wide age range of children at our hospital (Table 3).The Braden QD risk assessment tool combines all the elements of the Braden Q and adds a component for identifying the risk of MDRPI; it is validated for premature infants and children through age 21, regardless of the underlying condition.7,14 An advantage of this scale is that it addresses both the risk of immobility and device-related PI as a prediction of the risk of pressure injury. It comprises 7 subscales—mobility, sensory perception, friction and shear, nutrition, tissue perfusion and oxygenation, number of medical devices, and repositionability/skin protection. Scores range from 0 to 20, with lower scores indicating less risk of developing a PI. Children with scores greater than or equal to 13 are considered at risk for PI development.7,14 For the purpose of this project only, all children at our hospital with tracheostomy tubes were scored using the Braden QD scale (the scale had not yet been implemented in all patient care areas hospital-wide).During the 2 years prior to initiation of the project, 27 children received new tracheostomies: 4 in the NICU, 18 in the PICU, and 5 in the PCICU. Of those 27 children, 10 (37%) developed a PI during the first postoperative week. During the QI project time period, 19 children received tracheostomies: 7 in the NICU, 9 in the PICU, and 3 in the PCICU. All were sent to the operating room (OR) with the premade dressing kit and dressing placement instructions. Of those 19, 11 (58%) had Allevyn Gentle Border Lite dressings placed intraoperatively. Overall, 8 patients (42%) developed a tracheostomy-related PI during the first postoperative week. However, of those children who had an Allevyn Gentle Border Lite dressing placed intraoperatively, only 2 (18%) developed a tracheostomy-related PI during that critical first week. The average Braden QD score for these 19 patients was 12, just under the “at risk” parameter. Compliance with the tracheostomy bundle as a whole averaged 90.5% over the course of the project.The placement of Allevyn Gentle Border Lite dressings intraoperatively at our children’s hospital reduced the development of tracheostomy-related MDRPI by 50%, and this improvement continues to date. In fact, during the first 9 months of 2022, only 1 (7%) of the 14 patients who had an Allevyn Gentle Border Lite dressing placed in the OR developed a PI under the tracheostomy tube interfaces during the first postoperative week. Our institution averages 20 new tracheostomies per year; a reduction in the percentage of patients who develop a PI is achievable.Not all patients receiving a tracheostomy during the implementation had the Allevyn Gentle Border Lite dressing placed intraoperatively. Reasons for nonuse of the dressing kit include surgeon preference based on patient stability in real time, and the OR circulating staff not being aware of the newly implemented practice as relayed by the OR charge nurse. A meeting was held with the OR charge nurse, resulting in the incorporation of the Allevyn Gentle Border Lite dressings into the OR par stock. This eliminated the need to send dressing kits to the OR after the intervention period.Since the completion of the project, the adoption of the Braden QD scale is now a standard in all patient care areas of the children’s hospital, with the exception of the NICU, which continues to use the NSCS. Documented compliance with the tracheostomy bundle remains a challenge but has improved. The current EMR system does not easily facilitate documentation of the bundle elements, leading to variances in individual charting. Next steps will include incorporating the bundle into the hospital’s EMR, increasing the likelihood of compliance.This QI project was limited due to the small sample size and the short time frame for completion of the project. In addition, staff turnover in both the nursing and respiratory care departments may have contributed to some nonadherence to the bundle guidelines. Continued vigilance with posting bundle elements, placement of Allevyn Gentle Border Lite dressings on all tracheostomy patients both new and existing, and requirement of yearly education for tracheostomy care has resulted in improvement in assessment and documentation of any tracheostomy-related skin issues. Incorporation of the tracheostomy care bundle into the EMR is in process, and once built, should improve documentation compliance.Parental decision for tracheostomy is not a decision made lightly, because it is life altering for both parents and the child. However, the procedure is often necessary to provide a safe airway for the child and facilitate discharge to home and resumption of home life. Complications may arise, including the development of MDRPI under the tracheostomy tube and ties, leading to pain and discomfort, increased costs, and increased length of hospital stay. Implementing Allevyn Gentle Border Lite dressing placement intraoperatively during tracheostomy placement, incorporating a tracheostomy care bundle, and interdisciplinary teamwork can help prevent these complications.This author wishes to thank Leah Royak Kuchak, MPH, BSN, RN, RN-NIC; Jodi Mullen, MS, RN-BC, CCRN-K, ACCNS-P, FCCM; Jean Bulmer, DNP, RN, NDP-BC; and Thomas Schrepfer, MD, MSC, for their wisdom, leadership, contributions, and guidance over the past 3 years." @default.
• W4379879080 created "2023-06-09" @default.
• W4379879080 creator A5087720333 @default.
• W4379879080 date "2023-06-15" @default.
• W4379879080 modified "2023-09-27" @default.
• W4379879080 title "Preventative Dressings Reduce Postoperative Tracheostomy-Related Pressure Injury" @default.
• W4379879080 cites W1718400381 @default.
• W4379879080 cites W1935171506 @default.
• W4379879080 cites W2070080552 @default.
• W4379879080 cites W2084186475 @default.
• W4379879080 cites W2090023817 @default.
• W4379879080 cites W2108127923 @default.
• W4379879080 cites W2120376911 @default.
• W4379879080 cites W2588794966 @default.
• W4379879080 cites W2617352795 @default.
• W4379879080 cites W2773191507 @default.
• W4379879080 cites W2897582096 @default.
• W4379879080 cites W3144990584 @default.
• W4379879080 doi "https://doi.org/10.4037/aacnacc2023188" @default.
• W4379879080 hasPubMedId "https://pubmed.ncbi.nlm.nih.gov/37289628" @default.
• W4379879080 hasPublicationYear "2023" @default.
• W4379879080 type Work @default.
• W4379879080 citedByCount "0" @default.
• W4379879080 crossrefType "journal-article" @default.
• W4379879080 hasAuthorship W4379879080A5087720333 @default.
• W4379879080 hasConcept C17744445 @default.
• W4379879080 hasConcept C177713679 @default.
• W4379879080 hasConcept C194828623 @default.
• W4379879080 hasConcept C199539241 @default.
• W4379879080 hasConcept C2779473830 @default.
• W4379879080 hasConcept C2909464295 @default.
• W4379879080 hasConcept C71924100 @default.
• W4379879080 hasConceptScore W4379879080C17744445 @default.
• W4379879080 hasConceptScore W4379879080C177713679 @default.
• W4379879080 hasConceptScore W4379879080C194828623 @default.
• W4379879080 hasConceptScore W4379879080C199539241 @default.
• W4379879080 hasConceptScore W4379879080C2779473830 @default.
• W4379879080 hasConceptScore W4379879080C2909464295 @default.
• W4379879080 hasConceptScore W4379879080C71924100 @default.
• W4379879080 hasIssue "2" @default.
• W4379879080 hasLocation W43798790801 @default.
• W4379879080 hasLocation W43798790802 @default.
• W4379879080 hasOpenAccess W4379879080 @default.
• W4379879080 hasPrimaryLocation W43798790801 @default.
• W4379879080 hasRelatedWork W159247329 @default.
• W4379879080 hasRelatedWork W1798870981 @default.
• W4379879080 hasRelatedWork W1970371692 @default.
• W4379879080 hasRelatedWork W2025193597 @default.
• W4379879080 hasRelatedWork W2026095104 @default.
• W4379879080 hasRelatedWork W2042489430 @default.
• W4379879080 hasRelatedWork W2083479052 @default.
• W4379879080 hasRelatedWork W2115778339 @default.
• W4379879080 hasRelatedWork W2626766173 @default.
• W4379879080 hasRelatedWork W3092184698 @default.
• W4379879080 hasVolume "34" @default.
• W4379879080 isParatext "false" @default.
• W4379879080 isRetracted "false" @default.
• W4379879080 workType "article" @default.