According to the National Pressure Ulcer Advisory Panel in conjunction with European and Pan-Pacific peer organizations,3 anyone provided medical equipment should be deemed a high-risk patient. Strategies to reduce risk include correct fit and positioning, frequent assessments, keeping skin dry and clean, applying a nonirritant barrier (dressings that do not gel are recommended to avoid skin stripping or maceration), and clinician awareness of the tubing and the position of the supporting structure. Researchers have supported frequent assessments, repositioning, nursing education, and barriers as preventive methods. Many researchers have concluded nursing care is paramount to injury prevention. Yet despite the importance of nursing vigilance and expertise, studies do not support its efficacy in fully eliminating PI.4
The literature supports the success of pressure-relieving barriers in eliminating PI from tracheostomy, gastrostomy, PIV, miscellaneous tubing, and noninvasive respiratory devices. Hydrocolloid and foam barriers represent the most commonly used products. Soft, thin silicone or polyurethane foam is a product of choice for many (over bony prominence, to offload extracorporeal membrane oxygenation [ECMO] cannulas, under gastrostomy tubes, and under tracheostomy ties and flanges),5 and it is a commonly used barrier under CPAP masks. Others have used hydrocolloid dressings to decrease friction and sheer. Both options have drawbacks when used under noninvasive ventilatory devices, especially in humidified isolettes (hydrocolloids increase the risk of epidermal stripping, they are difficult to reposition, and not recommended to remove frequently; foam may not stay in place, become moist, or prevent appropriate fit).
Device-specific options. Weng at al6 reported decreased PI when hydrocolloid and film dressings were used (versus none). Hsu7 suggested caution when using a hydrocolloid because epidermal stripping was prevalent during dressing changes, and a sticky residue remained, especially in humidified environment. Hsu7 noted the lowest injury rate when soft silicone was used, followed by hydrocolloid and no barrier. Gunlemez et al8 had success using a silicone gel sheet at the nasal surface to alleviate direct pressure. My unit found the use of Neoseal (Neotech, Valencia, CA) foam a reasonable barrier for various biprong respiratory interphases, as well occasional use of a hydrocolloid for lip and cheek areas, and Mepilex Lite foam (Mölnlycke Health Care, Norcross, GA) worked well with mask devices. We use Mepilex Lite foam as a prophylactic barrier with tracheostomies, casts, and gastrostomies (if erythema is noted) and to offload catheters. A hydrocolloid sheet also can be used if very thin material is required. We offload all PIV hubs with sterile stretchable foam tape strips (Veni-Gard kits; Con-Med, Utica, NY). We use nonalcohol skin polymers if a hydrocolloid is used, and adhesive dressings are always removed using a silicone-based dressing remover.
Care bundles. A collection of processes can be combined to effectively and safely address a particular condition or prevent one from occurring. Consistent delivery of combined interventions has been shown to improve reliability of a process; a PI prevention bundle — a collection of actionable items required for every patient at risk — should be an integral part of PI program. Since 2012, many pediatric hospitals participate in The Children’s Hospitals Solutions for Patients Safety National Children’s Network, a group of 135+ hospitals that focus on sharing their efforts in preventing hospital-acquired harm, including PI, by implementing a PI bundle.
In my hospital, we have a general PI bundle (Actionable items: Assessment scale/Device Assessment/Reposition/Patient Turning/Repositioning/Bed Surface/Moisture/Nutrition), an ECMO-specific PI bundle, and a Respiratory Devices PI Prevention bundle. It is imperative that all components are followed. The literature supports that if nurses do not know about PI prevalence, do not understand importance of PI prevention, believe it is time-consuming or that many PIs are not avoidable, or in general are less interested in PI prevention than other aspects of nursing care, they will not follow bundle actions. Extensive nursing education highlighting prevention and recognition of PI is paramount for bundle compliance. A culture of “zero tolerance of PI” should be promoted, highlighting preoccupation with prevention and nontolerance of complacency. This culture change remains the most critical yet hardest component of any successful PI prevention program.