Retrospective review of the reduction of oral pressure ulcers in mechanically ventilated patients: a change in practice

Interventions and strategies to prevent medical device-related pressure injury in adult patients: A systematic review

BACKGROUND

Current evidence shows that medical device-related pressure injury (MDRPI) has a high prevalence (10%) and incidence (12%), and much research has been done to prevent MDRPI in recent years. However, to our knowledge, there is limited systematic review available on interventions and strategies to prevent MDRPI.

AIM

To synthesise research evidence on interventions and strategies used to prevent MDRPI.

METHODS

This systematic review adhered to the PRISMA Guidelines. We searched six databases including Medline, CINAHL, EMBASE, Cochrane library, Web of Science and ProQuest with no restriction to year of publication. Data were extracted and checked by two authors independently. A narrative summary technique was used to describe the findings. Implementation strategies were grouped into six classifications: dissemination/implementation process/integration/capacity building/sustainability/scale-up strategies.

RESULTS

Twenty-four peer-reviewed papers met the inclusion criteria, which comprised of 11 quality improvement projects and 13 original research. Types of devices included respiratory devices (non-invasive ventilation mask, CPAP/BiPAP mask, endotracheal tube), gastrointestinal/urinary devices and other devices. Interventions used included the use of dressing, hyperoxygenated fatty acids, full-face mask, training, and/or multidisciplinary education, use of special securement devices or tube holder, repositioning, application of stockinette, early removal and foam ring use. Common implementation strategies included ongoing staff education, audit and standardising documentation or guideline development.

CONCLUSION

Much work on MDRPI prevention strategies has been undertaken. There were a variety of devices reported, however, it is evident that higher quality research is needed.

RELEVANCE TO CLINICAL PRACTICE

Current evidence shows that interventions including use of dressing or special securement device, repositioning, and training/multidisciplinary education can be beneficial for MDRPI prevention. High-quality research, such as randomised controlled trials are needed to test the effectiveness of the interventions and their implementation strategies. No patient or public contribution.

Prevention of Endotracheal Tube-Related Pressure Injury: A Systematic Review and Meta-analysis

BACKGROUND

Hospital-acquired pressure injuries, including those related to airway devices, are a significant source of morbidity in critically ill patients.

OBJECTIVE

To determine the incidence of endotracheal tube-related pressure injuries in critically ill patients and to evaluate the effectiveness of interventions designed to prevent injury.

METHODS

MEDLINE, Embase, CINAHL, and the Cochrane Library were searched for studies of pediatric or adult patients in intensive care units that evaluated interventions to reduce endotracheal tube-related pressure injury. Reviewers extracted data on study and patient characteristics, incidence of pressure injury, type and duration of intervention, and outcomes. Risk of bias assessment followed the Cochrane Collaboration's criteria.

RESULTS

Twelve studies (5 randomized clinical trials, 3 quasi-experimental, 4 observational) representing 9611 adult and 152 pediatric patients met eligibility criteria. The incidence of pressure injury was 4.2% for orotracheal tubes and 21.1% for nasotracheal tubes. Interventions included anchor devices, serial endotracheal tube assessment or repositioning, and barrier dressings for nasotracheal tubes. Meta-analysis revealed that endotracheal tube stabilization was the most effective individual intervention for preventing pressure injury. Nasal alar barrier dressings decreased the incidence of skin or mucosal injury in patients undergoing nasotracheal intubation, and data on effectiveness of serial assessment and repositioning were inconclusive.

CONCLUSIONS

Airway device-related pressure injuries are common in critically ill patients, and patients with nasotracheal tubes are particularly susceptible to iatrogenic harm. Fastening devices and barrier dressings decrease the incidence of injury. Evidence regarding interventions is limited by lack of standardized assessments.

The impact of two distinct endotracheal tube fixation on the formation of pressure ulcer in the intensive care unit: A randomised controlled trial

The most common pressure ulcer associated with medical devices in the ICU is pressure injury associated with the endotracheal tube. We aimed to scrutinise the effects of two different techniques of endotracheal tube securement used in the ICU on the occurrence of pressure ulcers. This randomised clinical trial was conducted in 60 patients, 30 of which were intervention and 30 experimental, admittedin the ICU of a training and research hospitaldata were collected using the descriptive and clinical characteristics from the Braden Scale for predicting Pressure Sore Risk, the Pressure Ulcer Scale for healing, The International Staging System for Pressure Injuries and the Eilers Oral Assessment Guide. Based on the Braden Scale scores of the patients, we found that 98.3% of the cases were in the high‐risk group before and after the intervention. We also found that the recovery was higher among patients in whom the bandage fixation method was applied compared to those in whom the fixation was done with an endotracheal tube holder.

Systematic review: Incidence and prevalence of mucous membrane pressure injury in adults admitted to acute hospital settings

Mucous membrane pressure injury (MMPI) is associated with a history of medical device use at the site of injury. The current international guideline recommends they should be reported in incidence and prevalence studies. The aim of this systematic review was to analyse the incidence and prevalence of hospital-acquired MMPI in adults admitted to acute hospital settings. Database searches (EBSCO CINAHL Complete, EBSCO Medline Complete, Embase, Scopus and Web of Science) were undertaken between October 2019 and February 2021, using search terms related to hospital-acquired, mucosal and device-related pressure injury/ulcer incidence and prevalence. Searches were limited to the English language. Articles published between 2008 and 2020, reporting incidence or prevalence of mucous membrane or medical device-related pressure injury in non-interventional samples were selected. Two authors assessed study bias and extracted data, with a third reviewer as arbitrator. Twenty-one studies met inclusion criteria; most provided incidence data. No studies were found that specifically reported MMPI incidence or prevalence. It was possible to calculate incidence or prevalence from four studies; all were in intensive care settings. MMPI incidence of 0.8% and 30.4%, and prevalence of 1.7% and 3.7% were found. One study provided data that enabled calculation of prevalence of 0.1% in a non-intensive care sample. Only one other study provided specific data about MMPI. It is concluded that there is insufficient evidence available to enable estimation of MMPI incidence or prevalence in either acute hospital or intensive care settings.

The effect of adhesive tape versus endotracheal tube fastener in critically ill adults: the endotracheal tube securement (ETTS) randomized controlled trial

Background

The optimal securement method of endotracheal tubes is unknown but should prevent dislodgement while minimizing complications. The use of an endotracheal tube fastener might reduce complications among critically ill adults undergoing endotracheal intubation.

Methods

In this pragmatic, single-center, randomized trial, critically ill adults admitted to the medical intensive care unit (MICU) and expected to require invasive mechanical ventilation for greater than 24 h were randomized to adhesive tape or endotracheal tube fastener at the time of intubation. The primary endpoint was a composite of any of the following: presence of lip ulcer, endotracheal tube dislodgement (defined as moving at least 2 cm), ventilator-associated pneumonia, or facial skin tears anytime between randomization and the earlier of death or 48 h after extubation. Secondary endpoints included duration of mechanical ventilation and ICU and in-hospital mortality.

Results

Of 500 patients randomized over a 12-month period, 162 had a duration of mechanical ventilation less than 24 h and 40 had missing outcome data, leaving 153 evaluable patients randomized to tube fastener and 145 evaluable patients randomized to adhesive tape. Baseline characteristics were similar between the groups. The primary endpoint occurred 13 times in 12 (7.8%) patients in the tube fastener group and 30 times in 25 (17.2%) patients in the adhesive tape group (p = 0.014) for an overall incidence of 22.0 versus 52.6 per 1000 ventilator days, respectively (p = 0.020). Lip ulcers occurred in 4 (2.6%) versus 11 (7.3%) patients, or an incidence rate of 6.5 versus 19.5 per 1000 patient ventilator days (p = 0.053) in the fastener and tape groups, respectively. The endotracheal tube was dislodged 7 times in 6 (3.9%) patients in the tube fastener group and 16 times in 15 (10.3%) patients in the tape group (p = 0.03), reflecting incidences of 11.9 and 28.1 per 1000 ventilator days, respectively. Facial skin tears were similar between the groups. Mechanical ventilation duration and ICU and hospital mortality did not differ.

Conclusion

The use of the endotracheal tube fastener to secure the endotracheal tubes reduces the rate of a composite outcome that included lip ulcers, facial skin tears, or endotracheal tube dislodgement compared to adhesive tape.

Trial registration

ClinicalTrials.gov NCT03760510. Retrospectively registered on November 30, 2018

Understanding contextual barriers and enablers to pressure injury prevention practice in an Australian intensive care unit: An exploratory study

BACKGROUND

Skin integrity management is often a low clinical priority in the intensive care environment, possibly resulting in high pressure injury (PI) prevalence. This article reports the results of the first phase of a multiphased project, "Translating evidence-based pressure injury prevention strategies to the intensive care environment (SUSTAIN study)". The SUSTAIN study used a research translation framework to guide the assessment of research uptake, development, and monitoring of translational strategies to reduce PIs.

OBJECTIVE

The objective was to assess the enablers and barriers to research translation of evidence-based skin integrity management in one Australian tertiary referral intensive care unit (ICU).

METHODS

This exploratory study was conducted in an Australian metropolitan tertiary ICU on a sample of 204 registered nurses. Data were collected using (i) a descriptive cross-sectional cohort survey of barriers, enablers, and attitudes to PI prevention, (ii) a cross-sectional survey of PI knowledge, and (iii) focus groups to understand the local contextual factors impacting registered nurses' PI prevention practice.

RESULTS

Participants reported a moderate to high ability to rise above barriers in PI prevention, a positive attitude towards PI prevention, and considered this a priority in their care of patients. High patient acuity emerged as a barrier to implementing timely PI prevention strategies. In the knowledge, test participants with postgraduate qualifications answered more statements correctly. Focus group data revealed four themes: (i) team ICU, (ii) processes of care, (iii) education for consistency, and (iv) the patient.

CONCLUSIONS

It is essential that evidence-based PI prevention strategies are provided in the intensive care environment. Our findings indicate that despite positive attitudes and sound knowledge levels, high patient acuity is a significant barrier to evidence implementation.

Impact of the introduction of an endotracheal tube attachment device on the incidence and severity of oral pressure injuries in the intensive care unit: a retrospective observational study

BACKGROUND

Endotracheal tube (ETT) fasteners such as the AnchorFast™ claim to assist with the prevention of oral pressure injuries in intubated patients, however evidence to support their clinical efficacy is limited. This retrospective observational study aimed to investigate the impact of the introduction of the AnchorFast™ device on the incidence of oral pressure injuries in mechanically ventilated patients.

METHODS

Data was collected from patient case notes and clinical incident reports for October 2010 to June 2013 (pre-AnchorFast) and July 2013 to March 2016 (post-AnchorFast). Incidence and location of oral pressure injuries associated with securing device, and compliance with institutional policies related to reducing oral pressure injuries were recorded.

RESULTS

Incidence of oral pressure injuries increased from 1.53/100 intubated patients in the pre-AnchorFast period to 3.73/100 intubated patients in the post-AnchorFast period (IRR = 2.43, 95%CI = 1.35-4.38; p = 0.003). Across both study periods, patients with an ETT secured using AnchorFast™ had significantly increased risk of oral pressure injuries (IRR = 2.03, 95%CI = 1.17-3.51; p = 0.02). There was also a significant difference in location of pressure injuries sustained with ETTs secured using cloth tapes (53.6% in corner of the mouth) vs. AnchorFast™ (75% on the lips) (p = 0.008). Among patients with oral pressure injuries, compliance with institutional policies relating to the prevention of pressure injuries was significantly greater after the introduction of the AnchorFast™ (9.1% vs 64.5%, p = 0.004).

CONCLUSIONS

The incidence of oral pressure injuries increased significantly following the introduction of the AnchorFast™ device. Further research is required to establish the reasons for this observed increase to and identify ways to reduce the risk of pressure injuries with ETT securement devices.

Prevention of Medical Device-Related Pressure Injuries Associated With Respiratory Equipment Use in a Critical Care Unit: A Quality Improvement Project

Medical devices have been identified as an extrinsic risk factor for development of pressure injuries, with as many as 30% to 70% of medical device-related pressure injuries resulting from respiratory equipment. This article describes a quality improvement project undertaken to reduce the occurrence of respiratory device-related pressure injuries in a critically care unit. Multiple actions were implemented to achieve this goal. Respiratory therapists were trained to document occurrences on a daily basis, and apparent cause analyses were conducted on each occurrence. An interdisciplinary team conducted biweekly rounds on patients with respiratory devices and consulted other professionals as indicated. Nurses and respiratory therapists attended an evidence-based, collaborative, educational offering and completed a measure of team functioning before the program and at the end of the study period. The occurrence rates of respiratory device-related pressure injuries were reduced over the project period, and these changes were sustained over the subsequent 12 months.

Inter-rater reliability of the Reaper Oral Mucosa Pressure Injury Scale (ROMPIS): A novel scale for the assessment of the severity of pressure injuries to the mouth and oral mucosa

BACKGROUND

Patients who are intubated in the ICU are at risk of developing pressure injuries to the mouth and lips from endotracheal tubes. Clear documentation is important for pressure wound care; however, no validated instruments currently exist for the staging of pressure injuries to the oral mucosa. Instruments designed for the assessment of pressure injuries to other bodily regions are anatomically unsuited to the lips and mouth.

OBJECTIVES

This study aimed to develop and then assess the reliability of a novel scale for the assessment of pressure injuries to the mouth and oral mucosa.

METHODS

The Reaper Oral Mucosa Pressure Injury Scale (ROMPIS) was developed in consultation with ICU nurses, clinical nurse educators, Intensivists, and experts in pressure wound management. ICU nurses and portfolio-holders in pressure wound care from Peninsula Health (Victoria, Australia) were invited to use the ROMPIS to stage 19 de-identified clinical photographs of oral pressure injuries via secure online survey. Inter-rater reliability (IRR) was calculated using Krippendorff's alpha (α).

RESULTS

Among ICU nurses (n=52), IRR of the ROMPIS was α=0.307; improving to α=0.463 when considering only responses where injuries were deemed to be stageable using the ROMPIS (i.e. excluding responses where respondents considered an injury to be unstageable). Among a cohort of experts in pressure wound care (n=8), IRR was α=0.306; or α=0.443 excluding responses indicating that wounds were unstageable.

CONCLUSIONS

An instrument for the assessment and monitoring of pressure injuries to the mouth and lips has practical implications for patient care. This preliminary study indicates that the ROMPIS instrument has potential to be used clinically for this purpose; however, the performance of this scale may be somewhat reliant on the confidence or experience of the ICU nurse utilising it. Further validation is required.

Cephalic tetanus as a differential diagnosis of facial nerve palsy

Cephalic tetanus is defined as a combination of trismus and paralysis of one or more cranial nerves. Since it is a rare cause of facial nerve palsy, it is often overlooked as a differential diagnosis. We present the case of a 75-year-old man admitted to our emergency department with left facial nerve palsy, left ptosis and dysphagia 2 weeks after a head laceration. Soon after admission, he was orally intubated because of massive aspiration. A delayed diagnosis of cephalic tetanus was reached only when he was extubated and trismus and risus sardonicus were identified in addition to facial nerve palsy. The patient was re-intubated and successfully extubated on day 20 postadmission. In orally intubated patients, trismus and risus sardonicus may be overlooked, and although rare, cephalic tetanus should be considered to be a differential diagnosis of facial nerve palsy.

Identifying and Managing a Malpositioned Endotracheal Tube Bite Block in an Orotracheally Intubated Patient: A Case Report

The universal bite block is increasingly used in orotracheally intubated patients. Here, we report a case of pilot tube dysfunction caused by a malpositioned universal bite block in an orotracheally intubated patient. We summarize the key points on identifying and managing a malpositioned universal bite block from this case and literature review.A 74-year-old woman was emergently intubated during an episode of hyperkalemia-related cardiac arrest. A universal bite block was used for fixing the endotracheal tube. After her condition stabilized, ventilator weaning was attempted; however, a positive cuff-leak test result was observed.The cuff-leak test revealed a lack of elasticity of the pilot balloon, which was completely deflated after 2 mL of air was removed. Pilot tube dysfunction was highly suspected. The bite block was slightly pulled out, and 8 mL of air was aspirated from the pilot tube. The patient was successfully extubated without stridor and respiratory distress.Our case highlighted that a malpositioned bite block may obstruct the pilot tube, causing unfavorable consequences. While fixing the bite block on an endotracheal tube, it is crucial to ensure that the takeoff point of the pilot tube is located within the C-notch of the bite block.

Use of wound dressings to enhance prevention of pressure ulcers caused by medical devices

Medical device related pressure ulcers (MDR PUs) are defined as pressure injuries associated with the use of devices applied for diagnostic or therapeutic purposes wherein the PU that develops has the same configuration as the device. Many institutions have reduced the incidence of traditional PUs (sacral, buttock and heel) and therefore the significance of MDR PU has become more apparent. The highest risk of MDR PU has been reported to be patients with impaired sensory perception, such as neuropathy, and an impaired ability for the patient to communicate discomfort, for example, oral intubation, language barriers, unconsciousness or non-verbal state. Patients in critical care units typify the high-risk patient and they often require more devices for monitoring and therapeutic purposes. An expert panel met to review the evidence on the prevention of MDR PUs and arrived at these conclusions: (i) consider applying dressings that demonstrate pressure redistribution and absorb moisture from body areas in contact with medical devices, tubing and fixators, (ii) in addition to dressings applied beneath medical devices, continue to lift and/or move the medical device to examine the skin beneath it and reposition for pressure relief and (iii) when simple repositioning does not relieve pressure, it is important not to create more pressure by placing dressings beneath tight devices.