title: Prevention of tracheostomy-related pressure ulcers in children.
abstract: OBJECTIVE
  Pressure ulcers are commonly acquired in pediatric institutions, and they are a key indicator of the standard and effectiveness of care. We recognized a high rate of tracheostomy-related pressure ulcers (TRPUs) in our ventilator unit and instituted a quality improvement program to develop and test potential interventions for TRPU prevention, condensed them into a clinical bundle, and then implemented the bundle into our standard practice.
  
  
  METHODS
  The intervention model used a rapid-cycle, Plan-Do-Study-Act (PDSA), framework for improvement research. All tracheostomy-dependent patients admitted to our 18-bed ventilator unit from July 2008 through December 2010 were included. TRPU stage and description, number of days each TRPU persisted, and bundle compliance were recorded in real time. All TRPUs were staged by a wound-care expert within 24 hours. The interventions incorporated into the TRPU-prevention bundle included frequent skin and device assessments, moisture-reducing device interface, and pressure-free device interface.
  
  
  RESULTS
  There was a significant decrease in the rate of patients who developed a TRPU from 8.1% during the preintervention period, to 2.6% during bundle development, to 0.3% after bundle implementation. There was a marked difference between standard and extended tracheostomy tubes in TRPU occurrence (3.4% vs 0%, P = .007) and days affected by a TRPU (5.2% vs 0.1%, P < .0001).
  
  
  CONCLUSIONS
  Education and ongoing assessment of skin integrity and the use of devices that minimize pressure at the tracheostomy-skin interface effectively reduce TRPU even among a population of children at high risk. These interventions can be integrated into daily workflow and result in sustained effect.
authors.affiliation: Division of Pulmonary Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH 45229-3039, USA. paul.boesch@cchmc.org
authors.forename: R Paul
authors.initials: RP
authors.lastname: Boesch
authors.forename: Christine
authors.initials: C
authors.lastname: Myers
authors.forename: Tonia
authors.initials: T
authors.lastname: Garrett
authors.forename: AnnMarie
authors.initials: A
authors.lastname: Nie
authors.forename: Natalie
authors.initials: N
authors.lastname: Thomas
authors.forename: Amrita
authors.initials: A
authors.lastname: Chima
authors.forename: Gary L
authors.initials: GL
authors.lastname: McPhail
authors.forename: Mathew
authors.initials: M
authors.lastname: Ednick
authors.forename: Michael J
authors.initials: MJ
authors.lastname: Rutter
authors.forename: Kathy
authors.initials: K
authors.lastname: Dressman
mesh_terms: D002648:Child; D002675:Child, Preschool; D016638:Critical Illness / Q000628:therapy; D005260:Female; D006302:Health Services Research; D006801:Humans; D007223:Infant; D015278:Intensive Care Units, Pediatric; D016015:Logistic Models; D008297:Male; D015999:Multivariate Analysis; D003668:Pressure Ulcer / Q000209:etiology / Q000517:prevention & control*; D011322:Primary Prevention / Q000379:methods*; D011379:Prognosis; D058996:Quality Improvement; D012121:Respiration, Artificial / Q000379:methods; D018570:Risk Assessment; D017751:Safety Management / Q000379:methods; D014139:Tracheostomy / Q000009:adverse effects* / Q000379:methods