Clinical Practice ColumnNursing and Respiratory Collaboration Prevents BiPAP-Related Pressure Ulcers
Section snippets
Background
The Progressive Care Unit admits all patients requiring BiPAP initiation and those with complex medical conditions requiring intermittent or continuous BiPAP support. In early 2012, an increase in the number of pressure ulcers related to BiPAP masks prompted an investigation. Over a 4 month period, eleven pressure ulcers related to BiPAP with one being a reportable stage three ulcer and two unstageable pressure ulcers were noted. A multidisciplinary team of respiratory therapists, nursing staff,
Literature Review
A review of the published literature revealed a lack of studies on BiPAP therapy and skin breakdown in the pediatric population. Historically, pressure ulcer interventions and guidelines used in pediatrics were based on adult studies (Schindler et al., 2007). Only in the recent years have there been an increased focus on pediatric pressure ulcers. Multi-site studies have reported an incidence of pressure ulcers in critically ill children to be 18% to 27% (Schindler et al., 2007). The National
Quality Improvement Process
The Plan–Do–Study–Act (PDSA) model of quality improvement was used to implement interventions. The first PDSA cycle concentrated on identifying the problem and the gaps in both nursing and respiratory practices. It was noted that there were numerous masks available for use in the hospital with no standardized approach to application. There were also inconsistencies in the practice of applying the masks to the patient and the type of dressing used under the mask. The respiratory flowsheet in the
Outcomes
The interventions outlined by the collaborative were implemented during the third quarter of fiscal year 2012. Three months after implementation the incidence of BiPAP-related pressure ulcers decreased to one stage I occurrence. Since the beginning of the collaborative 3 years ago, there has only been one stage III reportable BiPAP-related pressure ulcer. Five occurrences were primarily stage I and stage II skin breakdown. The increased awareness and monitoring by both respiratory and nursing
Conclusion
The outcomes that have resulted from this quality improvement initiative have been a direct result of the teamwork and collaboration between nursing and respiratory disciplines. The standard of care for BiPAP patients at our institution has changed significantly over the past three years, and skin has become a priority. The collaborative continues to search for new and innovative products that prevent the common complication associated with noninvasive ventilation. Since most BiPAP patients
Acknowledgments
The success of the collaborative would not be possible without the diligence of the respiratory and nursing staff of the Progressive Care Unit and the support of nursing, respiratory, and medical leadership of Texas Children's Hospital. Special thanks to Richard Nguyen, RRT, John Alberto, RRT, Christopher Johnson, RRT, and the Wound Ostomy team for their continued efforts in improving patient outcomes.
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