764 - Reduction of Postoperative Tracheostomy Related Pressure Injuries in a Level IV NICU and PICU

Publication Number: 1740.764

Amanda Carroll, St. Christopher's Hospital for Children, Philadelphia, PA, United States; Rhonda Gibson, St. Christopher's Hospital for Children, Philadelphia, PA, United States; Ogechukwu Menkiti, St Christopher's Hospital for Children, cherry hill, NJ, United States; Christine M. Schlichting, St. Christopher's Hospital for Children, Philadephia, PA, United States; Alyssa Terk, Drexel University College of Medicine, Philadelphia, PA, United States; Vilmaris Quinones-Cardona, Drexel University College of Medicine, Philadelphia, PA, United States

Background: Pediatric patients are at high risk of developing pressure injuries related to medical devices and the risk increases when preventative measures are not utilized. In 2021, the NICU had an increase in tracheostomy related pressure injuries (TRPI) in the NICU.

Objective: Our aim was to reduce TRPIs in the 7-day post-operative window by 20% within a 2-year period.

Design/Methods: This quality improvement initiative utilized the plan-do-study-act (PDSA) cycle model for improvement to establish best practices related to postoperative tracheostomy care. In 2021, an interprofessional team was assembled to identify TRPI causes in the NICU. Practice gaps were identified and a TRPI prevention bundle including the use of foam ties, barrier dressing, first tie change at day 3-4, and 1st tracheostomy change no later than day 7 was developed and implemented in PDSA 1. Adherence to the bundle was challenging given differences in NICU and PICU care. We expanded the team to include perioperative and PICU nurses, and intensivists for PDSA cycle 2. A bedside visual of the bundle was implemented (Figure 1). The outcome measure was the rate of TRPI per 1000 (PD). The process measure was percent bundle element compliance. The balancing measure was accidental decannulation in the 7-day post-operative window.

Results: A total of 38 patients from April 2021 to October 2025 underwent tracheostomy placement, 17 in the NICU and 21 in the PICU. After interventions, the NICU TRPI reduced from 0.7 to 0 per 1000PDs (Figure 2a) and PICU from 0.94 to 0 per 1000PDs (Figure 2b). These results have been sustained >2 years. Bundle compliance improved across all bundle elements (Figure 3). There was hesitance with trach tie change at day 3-4 due to the perceived risk of accidental decannulation without a mature stoma. However, this element adherence improved with the expansion of the team to include the peri-operative and PICU team, and a visual bedside bundle. There were no accidental decannulations during the initiative.

Conclusion(s): Standardization of post-operative tracheostomy care and hospital-wide interdisciplinary collaboration reduces TRPI in the NICU and PICU. A TRPI prevention bundle including day 3 tracheostomy tie change are effective interventions to reduce post-operative TRPIs without the risk of decannulation. Next steps include evaluation of TRPI beyond the 7-day post-operative period and integration of a TRPI prevention bundle for long-term tracheostomy care.

Figure 1
Post-operative tracheostomy (A) standard of care visual for patients returning from the operating room to the NICU and PICU and (B) Day 3 tracheostomy tie change checklist

Figure 2
X-bar charts demonstrating a special cause reduction in TRPIs (A) in the NICU from 0.7 to 0 TRPIs per 1000PDs and (B) in the PICU from 0.94 TRPIs to 0 per 1000PDs.

Figure 3
TRPI prevention bundle elements compliance improved with interventions.