Recommendations and Guidance

October 17, 2013

Device-Related Pressure Ulcer Prevention — Respiratory Devices Recommendations and Guidance

These recommendations are intended to provide guidance to improve the consistency of pressure ulcer prevention related to devices across Minnesota hospitals and to address issues identified through the reporting of pressure ulcer events. The recommendations are not intended to address all clinical and regulatory requirements related to wound prevention and care. Product examples within this document are not inclusive nor intended as endorsement of a specific product.

In reporting year 2011-2012, 30% of Stage III, IV and unstageable pressure ulcers reported under Minnesota’s Adverse Health Care Event Reporting Law were classified as device-related pressure ulcers. The majority of the devices involved were either cervical collars or respiratory devices. The purpose of this document is to provide guidance and recommendations to assist hospitals in implementing practices to decrease the likelihood of the development of pressure ulcers related to respiratory devices.

Contents

General Recommendations...... 2 Nasal Cannulas and Oxygen Face Masks...... 2 Respiratory Assist Device Masks; Life-Sustaining CPAP and NPPV (i.e. BIPAP)...... 3 Tracheostomy Straps/Ties, Flanges and Sutures...... 4 Endotracheal Tubes (ETT) ...... 5 Special Populations (Neonatal, Pediatric and Bariatric)...... 6 Role of the Respiratory Therapist...... 6 References...... 7

1 I. General Recommendations for all populations

A. Inspect the skin of the head and neck for pressure damage related to medical devices (1) specifically beneath and around respiratory devices (including skin folds): o At admission (during head-to-toe skin inspection); o Prior to application of the device(s) (inspect skin integrity in areas that may be affected by the medical device); and o Every shift (at least every 8-12 hours). B. Check strap tension and skin integrity beneath and around life sustaining CPAP and NPPV masks at least every 4 hours coordinating with oral intake and with oral cares. C. Educate patient and caregivers on the importance of frequent skin inspection beneath and around the respiratory device as well as the importance of informing the staff if the patient experiences discomfort or pain beneath or around the device (2). D. It is critical to consider patient size and weight when selecting respiratory devices; see Section III Special Populations (2-6). E. Monitor edema and adjust straps and tubing as needed (2). F. Consider the application of a protective product (i.e., hydrocolloid, foam, gel, or silicone based pads, cushions and dressings) as indicated for prevention of friction/shear or management of skin damage (7-8). Note: Protective dressings help reduce friction and shear but do not reduce pressure. Protective dressings that allow for routine skin inspection under and around the device are preferred. G. Clearly assign responsibility (to a specific clinical discipline) for inspection and documentation of skin integrity around and under respiratory devices. H. Abnormal skin integrity findings, site cares and interventions should be documented in the patient’s medical record in a location that is accessible to all relevant clinical disciplines. Note: pressure ulcers found on mucous membranes should be documented as mucosal pressure ulcers but are not staged (9). I. Develop and implement an inter-professional approach to preventing respiratory device- related pressure ulcers. J. Develop and communicate clear expectations, roles and hand-off communication processes related to the prevention and management of device-related pressure ulcers.

II. Device-Specific Recommendations

A. Nasal Cannulas and Oxygen Face Masks (see section IIB for recommendations specific to continuous/life-sustaining CPAP and NPPV, i.e., BIPAP, therapy)

General Recommendations

a. Thoroughly inspect the skin beneath and around respiratory devices on admission, prior to application of device, and at least every shift (8-12 hours) with close attention to the back and top of the ears, back of neck (including skin folds), bridge of nose, under nose and inside nares as applicable for device used.

2 Masks

a. Secure mask straps to minimal required pressure/tension to obtain adequate placement. b. Visually inspect masks on a regular basis and replace if soiled or defective. Note: Replace masks with straps that have lost elasticity. Do not tie knots in the straps – this practice may increase the risk of pressure ulcer development. c. Consult with respiratory therapist for proper sizing and fitting at first sign of skin damage under the mask. d. Consider the application of a protective product (i.e., skin sealant, hydrocolloid, foam, gel, or silicone based pads, cushions and dressings) as needed if skin integrity above the ear or behind the neck is at risk. Note: Protective dressings help reduce friction and shear but do not reduce pressure. Protective dressings that allow for routine skin inspection under and around the device are preferred.

Nasal Cannulas

a. Consider the use of, AND facilitate easy access to, commercially available ear protectors that can be attached (10), or purchased pre-attached (11), to the oxygen tubing (e.g., stock near oxygen tubing). b. Consider purchasing soft oxygen cannula tubing intended for pressure ulcer prevention (12). Note: advisory group members found soft tubing easier to work with and more effective than ear pads and protectors. c. Consider alternative stabilizing methods for oxygen cannula tubing devices (13). One example of an alternative stabilizing method that anchors the tubing to the cheek instead of the ear is pictured below.

3 B. Respiratory Assist Device Masks; continuous/life-sustaining CPAP and NPPV (i.e. BIPAP) Therapy

a. Check strap tension and skin integrity beneath and around the mask (especially the nasal bridge) minimally every 4 hours coordinating with oral intake and oral cares (7). b. Masks are designed to rest on the face — over-tightening can cause excessive air leaks and potential for pressure ulcers. c. Secure mask straps to minimal required pressure/tension to obtain adequate fit (small leaks are acceptable). d. Consult with respiratory therapist for proper sizing, fitting, and any sign of discomfort or skin damage under the device. e. Visually inspect masks on a regular basis and replace if soiled or defective, including if the mask strap has lost elasticity. Note: Masks straps should not be adjusted by tying a knot in the strap – this practice may increase the risk of pressure ulcer development. f. Consider the application of a protective product (i.e., hydrocolloid, foam, gel, or silicone based pads, cushions and dressings) over the nasal bridge for prevention of friction/shear and management of skin damage (7, 8, 15). An example of a protective product is picture below.

Note: Protective dressings help reduce friction and shear but do not reduce pressure. Protective dressings that allow for routine skin inspection under and around the device are preferred. g. If standard equipment cannot be sized and adjusted to avoid skin breakdown or if prolonged respiratory assist device is anticipated, consider utilizing alternative masks, such as those that incorporate gel cushions (15), full face masks, or rotating between two different styles of masks in order to change pressure points.

C. Tracheostomy Straps/Ties, Flanges and Sutures

General Reco mmendations

a. During routine tracheostomy site care every shift (at least every 8-12 hours) assess skin integrity and tension under the straps/ties/twill tape, around and in

4 back of the neck, around the stoma, and under the tracheostomy tube flange/faceplate (16). b. Commercially available foam/collar-type adjustable straps (see examples below) are preferable to tape/twill ties for comfort, easy adjustment, prevention of skin breakdown, and prevention of accidental tube displacement (17, 18).

c. Manufacturers’ instructions vary and should be followed for appropriate application and replacement of straps d. If using tape/twill ties for initial trach insertion, secure ties to minimal required pressure/tension to obtain adequate stabilization. e. Replace products that secure the tubes when soiled, wet, or no longer able to hold the tube properly AND per manufacturer’s instruction. f. Manage moisture beneath/around trach straps/ties by use of moisture wicking textile or dressing. g. Monitor edema and adjust straps and tubing as needed (2).

Tracheostomy Tube Flange/Faceplate

a. Collaborate with respiratory therapist to determine the most appropriate position to off-load trach faceplate pressure. b. Use appropriate methods to offload pressure from the drag of ventilator tubing such as a ventilator arm and a rolled towel to the chest (16). c. Manage moisture beneath/around faceplate (i.e., secretions, drainage) by changing dressings routinely and as needed.

Tracheostomy Sutures (if used for initial stabilization of the faceplate/flange)

a. Collaborate with surgeons to create a standard procedure for management of tracheostomy sutures (i.e., number of days sutures must remain in place before converting from suture stabilization to other stabilization). b. Inform the healthcare provider if sutures are irritating the skin or preventing routine skin inspection and care (16, 19). c. Obtain an order for suture removal, if sutures have not been removed, within 7 days after tracheostomy tube insertion (16, 19). d. Consult respiratory therapist or wound specialist if skin integrity issues are noted.

5 e. During post-operative hand-offs (e.g., OR to PACU; PACU to floor), include orders for suture removal.

D. Endotracheal tubes (ETT) (Orally intubated patients only)

a. Clearly assign responsibility (to a specific clinical discipline) for repositioning the ETT to prevent injury to the lip. b. Every 2 hours (during routine oral cares), check the tension and skin integrity under and around the ETT and straps, tape or ties with close attention to the neck, lips and mouth. c. Use appropriate methods, such as ventilator arm, to offload pressure from the drag of ventilator tubing (16). d. Replace products that secure tubes when soiled, wet, or no longer able to hold the tube properly (17, 18, 20) AND per manufacturer’s instruction. e. Consider using a commercial stabilizer for comfort, easy adjustment, prevention of skin breakdown, and prevention of accidental tube displacement (18). When commercial stabilizers are used: i. ETT clamps/stabilizers should be positioned approximately 1/2" from (not touching) the patient’s lip (21). ii. Manufacturer’s instructions vary and should be followed for appropriate application of stabilizers and change frequency (for example, at least one commercial stabilizer recommends rotating ETT (right, middle, left) every 2 hours during routine oral cares (21)).

E. Special Populations (Neonatal, Pediatric and Bariatric)

Neonatal and Pediatric - General Considerations

. Pediatric pressure ulcers occur primarily on the head/occipital region (3). . More than 50% of all pediatric pressure ulcers are related to equipment and devices (4). . General Recommendations (Section I) can be applied to neonatal and pediatric patients. . Specific interventions intended for adults may NOT be safe for neonatal and pediatric patients (i.e., rotating ETT); always follow pediatric specific recommendations and manufacturers’ instructions when available. . Consider size and weight when selecting respiratory devices (5); use commercially available pediatric products when available rather than adapting standard equipment. . In the absence of commercially available solutions, Respiratory Therapists, Nurses, and Neonatologist/Pediatric Intensivists should collaborate to identify alterative products/methods.

Bariatric – General Considerations

6 . Pressure ulcers from respiratory equipment can result from pressure within skin folds (5). . Consider size and weight when selecting respiratory devices; instead of adapting standard equipment, use commercially available bariatric products such as longer tracheostomy tubes and bariatric tracheostomy collars (5). . General and device specific recommendations in sections I and II can be applied to the bariatric patient population.

F. Role of the Respiratory Therapist

Respiratory therapists should be represented on the organization’s pressure ulcer prevention team. Sample activities include: a. Development and implementation of organization-wide policies and processes to prevent respiratory device-related pressure ulcers; b. Education and training of respiratory therapy staff in best practice respiratory device- related pressure ulcer prevention and documentation; c. Auditing of respiratory therapy staff compliance with best practice respiratory device- related pressure ulcer prevention; d. Involvement in review, discussion and action plan implementation of pressure ulcers prevention practices related to respiratory devices; e. Consideration of skin care in review of new respiratory device purchases; involvement of respiratory therapists in purchases of pressure ulcer prevention devices/materials related to respiratory cares; f. Development of processes for shared documentation/collaboration during reports between nursing and respiratory therapy staff using common terminology; g. Partnering with other inter-professionals to provide education on identification and prevention of pressure ulcers; h. Educating patients and families on their role in preventing respiratory device related pressure ulcers and what they can expect from their caregivers to prevent respiratory device related pressure ulcers; i. Participating in Root Cause Analysis teams as applicable.

7 References

1. National Pressure Ulcer Advisory Panel (NPUAP) and European Pressure Ulcer Advisory Panel (EPUAP) and Prevention and Treatment of Pressure Ulcers. Washington D.C.: National Pressure Ulcer Advisory Panel; 2009. 2. Bryant, R. Nix D. Developing and Maintaining a Pressure Ulcer Program. In Bryant, R. Nix, D. Coeditors: Acute and Chronic Wounds: Current Management Concepts, 4th Edition. St. Louis, Mosby, January, 2012. 3. McLane K et al: The 2003 National Pediatric Pressure Ulcer and Skin Breakdown Prevalence Survey: A multisite study. J Wound Ostomy Continence Nurs. 2004; 31:168-177. 4. Baharestani MM et al: Pressure ulcers in neonates and children: an NPUAP white paper, Adv Skin Wound Care 20:208, 2007. 5. Camden SG: Skin care need of the obese patient. In Bryant, R. Nix, D. Coeditors: Acute and Chronic Wounds: Current Management Concepts, 4th Edition. St. Louis, Mosby, January, 2012. 6. AARC Clinical Practice Guideline: Selection of an Oxygen Delivery Device for Neonatal and Pediatric Patients – 2002 Revision & Update Respir Care 2002;47(6):707–716. 7. Respironics BiPap user manual. http://global.respironics.com/UserGuides/BiPAPautoSVUserManualPN1040200.pdf 8. Pierce: Management of the Mechanically Ventilated Patient, 2nd ed., Saunders, An Imprint of Elsevier, 2006. 9. National Pressure Ulcer Advisory Panel (NPUAP): Mucosal pressure ulcers an NPUAP position statement, 2009. Available at: http://www.npuap.org/Mucosal_Pressure_Ulcer_Position_ Statement_fi nal.pdf, accessed September 8, 2013. 10. Example of foam ear protectors for oxygen tubing: http://www.medline.com/jump/product/x/Z05-PF01712 accessed September 8, 2013. 11. Example of foam ear protectors pre-attached to oxygen tubing: http://www.salterlabs.com/index.cfm? fuseaction=products.product&product_id=26&category_id=16 accessed September 8, 2013. 12. Example of soft oxygen cannula tubing: http://www.westmedinc.com/linesheets/Cannula %20&%20Biflo%20Rev.08.pdf. accessed September 8, 2013. 13. Example of alternate stabilizing method: http://www.beeversonline.com/products/products.htm accessed September 8, 2013. 14. Respironics Comfort Gel Medium Nasal CPAP Mask. http://comfortgel.respironics.com/. http://www.heart-valve-surgery.com/ 15. Example of nasal pad: http://www.cpap.com/productpage/Gecko-Nasal-Pad.html? gclid=CIemxdq0wbkCFfA7MgodpHsA0Q accessed September 8, 2013. 16. Dennis-Rouse and Davidson. An evidence-based evaluation of tracheostomy care practices. Critical Care Nurse Q Vol. 31, No. 2 pp. 150-160. 2008. 17. Example of Tracheostomy Tube Holder: http://dalemed.com/Products/TracheostomyTubeHolder.aspx. accessed September 8, 2013. 18. 2005 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Circulation. 2005;112 [Suppl I]:IV-51-IV-57.

8 19. Regan, E. N., & Dallachiesa, L. (2009). How to care for a patient with a tracheostomy. Nursing2012, 39(8), 34-39. 20. Example of Endotracheal Tube Holder-and Instructions for use: http://www.betterlivingnow.com/images/products/itmmmImages/88047000270-2.PDF accessed September 8, 2013. 21. Example of Endotracheal Tube Fastener-Instructions for use: http://www.hollister.com/us/files/care_tips/tips_Anchor%20Fast%20Oral%20Endotracheal %20Tube%20Fastener_1.pdf accessed September 8, 2013.