A QI project to improve patient outcomes: Preventing tracheotomy related skin breakdown

Purpose:
Under our current practice, we are required to use hydrocolloid under tracheotomies. We believed that split gauze worked better at preventing breakdaown than the thin hydrocolloid. We wanted to collect data to measure the incidence of breakdown depending on which type of intervention was used.

Background/Significance:
Within a one year period we had an increased incidence of tracheotomy related skin breakdown while using only thin hydrocolloid under the tracheotomies in a Step Down Unit. The ENT service stated a preference for using thin hydrocolloid, to decrease manipulation of the tracheotomy. A literature search revealed little existing research comparing the effectiveness of gauze versus thin hydrocolloid. The goal of this project was to prevent tracheotomy skin breakdown by improving current practice.

Methods:
We did a quantitative descriptive randomized study involving a total of 45 patients comparing the use of thin hydrocolloid versus split gauze under tracheotomies. If the patient's tracheotomy was placed by ENT, nurses used thin hydrocolloid underneath and if general surgery placed the tracheotomy the nurse used split gauze underneath. The following information was collected for all patients with tracheotomies: Patient name, date the tracheotomy was placed and who placed it. Signs were placed bedside denoting which dressing to use for each individual patient. Tracheotomy skin checks were implemented weekly and tracheotomy breakdown that occurred was noted.

Results:
Out of 45 patients that we evaluated during our study, we used thin hydrocolloid on 24 patients and split gauze on 21 patients. From this study we found that the incidence of breakdown was much higher when using hydrocolloid(32%) than using gauze(10%). We decided to go a step further to look at the nutritional status. We checked patient's prealbumin level. We went back and recorded each patient's prealbumin level closest to admission and if they acquired breakdown the prealbumin level closest to their date of breakdown. We did not see a significant difference in prealbumin levels with those that developed tracheotomy related skin breakdown compared to those who did not develop breakdown.

Conclusions and Implications for Practice:
The results support the use of split gauze under the tracheotomies as more effective in preventing skin breakdown than thin hydrocolloid. Some limitations: physician preference, original tracheotomy ties not being changed within 7 days and tracking length of patient stay in relation to breakdown.