• No results found

Prevention of Tracheostomy-related Pressure Ulcers in Children

N/A
N/A
Protected

Academic year: 2020

Share "Prevention of Tracheostomy-related Pressure Ulcers in Children"

Copied!
8
0
0

Loading.... (view fulltext now)

Full text

(1)

in Children

abstract

BACKGROUND AND OBJECTIVES:Pressure ulcers are commonly ac-quired in pediatric institutions, and they are a key indicator of the standard and effectiveness of care. We recognized a high rate of tracheostomy-related pressure ulcers (TRPUs) in our ventilator unit and instituted a quality improvement program to develop and test potential interventions for TRPU prevention, condensed them into a clinical bundle, and then implemented the bundle into our standard practice.

METHODS:The intervention model used a rapid-cycle, Plan-Do-Study-Act (PDSA), framework for improvement research. All tracheostomy-dependent patients admitted to our 18-bed ventilator unit from July 2008 through December 2010 were included. TRPU stage and description, number of days each TRPU persisted, and bundle compliance were recorded in real time. All TRPUs were staged by a wound-care expert within 24 hours. The interventions incorporated into the TRPU-prevention bundle included frequent skin and device assessments, moisture-reducing device interface, and pressure-free device interface.

RESULTS:There was a significant decrease in the rate of patients who developed a TRPU from 8.1% during the preintervention period, to 2.6% during bundle development, to 0.3% after bundle implementation. There was a marked difference between standard and extended tra-cheostomy tubes in TRPU occurrence (3.4% vs 0%,P= .007) and days affected by a TRPU (5.2% vs 0.1%,P,.0001).

CONCLUSIONS: Education and ongoing assessment of skin integrity and the use of devices that minimize pressure at the tracheos-tomy–skin interface effectively reduce TRPU even among a population of children at high risk. These interventions can be integrated into daily workflow and result in sustained effect. Pediatrics 2012;129: e792–e797

AUTHORS:R. Paul Boesch, DO, MS,a,bChristine Myers, RN,c Tonia Garrett, RRT,cAnnMarie Nie, RN, CNP, CWOCN,d Natalie Thomas, BSN, RN,cAmrita Chima, MBA,a Gary L. McPhail, MD,aMathew Ednick, DO,a

Michael J. Rutter, MD, FRACS,b,eand Kathy Dressman, RN, MS, NEA-BCc

aDivision of Pulmonary Medicine,bAerodigestive and Sleep Center,cTransitional Care Center,dOutpatient Department, andeDepartment of Pediatric Otolaryngology and Head and Neck Surgery, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio

KEY WORDS

pressure ulcer, tracheostomy, quality improvement

ABBREVIATIONS

PDSA—Plan-Do-Study-Act

TRPU—tracheostomy-related pressure ulcers www.pediatrics.org/cgi/doi/10.1542/peds.2011-0649

doi:10.1542/peds.2011-0649

Accepted for publication Oct 31, 2011

Address correspondence to R. Paul Boesch, DO, MS, Division of Pulmonary Medicine, Cincinnati Children’s Hospital Medical Center, ML 2021, 3333 Burnet Ave, Cincinnati, OH 45229-3039. E-mail: paul.boesch@cchmc.org

PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275).

Copyright © 2012 by the American Academy of Pediatrics

FINANCIAL DISCLOSURE:The authors have indicated they have nofinancial relationships relevant to this article to disclose.

(2)

Hospital-acquired pressure ulcers are common in pediatric institutions. Repor-ted prevalence rates are 4% to 27.7%, and incidence rates are 0.29% to 32.8%.1–5 A 2003 national survey documented an average 4% prevalence rate of stage 3 to 4 pressure ulcers among pediatric hospitals.1Data for 2010 from the Na-tional Database of Nursing Quality Indi-cators report a mean prevalence of 2.29% for hospital-acquired pressure ulcers in“step down”units at academic pediatric hospitals. Pressure ulcers are associated with increased pain, infec-tion, and prolonged hospitalizainfec-tion, and they may result in permanent scarring.6–8 Pressure ulcers are considered a high-cost, high-volume, preventable con-dition. They have received increasing attention, and pediatric hospital days associated with a facility-acquired pres-sure ulcer will be disqualified from Medicare and Medicaid reimbursement effective July 1, 2012.9

After recognition that our hospital’s rate of all facility-acquired pressure ulcers was greater than national averages, a pressure ulcer collaborative, including members from all high-risk units, was convened. This collaborative is a multi-disciplinary team focused on the prev-alence and occurrence monitoring, education, assessment of risk and skin integrity, and the development of skin care teams on high-risk units. Initial interventions from this collaborative resulted in a decreased prevalence of pressure ulcers (from all sources) from 9.2% to 2.4% in our institution. The hos-pital collaborative identified that∼75% of remaining pressure ulcers in our pediatric population were being caused by medical devices; many of these were due to respiratory devices such as tra-cheostomy tubes and positive-pressure masks.

Tracheostomy tubes cause pressure ulcers by creating a constant pressure interface over the skin of the neck with additional disruption of skin integrity

due to wetness from sweat and respi-ratory secretions. Furthermore, trache-ostomy tubes are often used in children with limited mobility and neurologic responsiveness, which further increa-ses the risk for ulcer development. There are no published prevalence rates of pressure ulcers specifically caused by tracheostomy tubes, but one study reported that 27% of complications be-fore thefirst tube change were related to skin breakdown.10 The baseline oc-currence rate of tracheostomy-related pressure ulcers (TRPUs), in our hospi-tal unit with the greatest utilization of tracheostomies, was determined to be 8.1% for all stages. We hypothesized that quality improvement methodology would both (1) identify those inter-ventions that were most effective at preventing TRPUs and (2) result in a re-liable implementation that would sus-tainably decrease the occurrence of TRPUs in our unit.

METHODS

This project was granted exemption from the Institutional Review Board of Cin-cinnati Children’s Hospital Medical Cen-ter. All tracheostomy-dependent patients admitted to the Transitional Care Center at our hospital from July 2008 through December 2010 were included.

Setting

Our hospital is a 490-bed academic quaternary-care, free-standing children’s hospital. The Transitional Care Center is an 18-bed multidisciplinary unit whose primary mission is the transition of children requiring invasive and non-invasive mechanical ventilation to home. This unit also serves as a stepdown ICU for ventilation-dependent children ad-mitted for acute illness, surgical proce-dures, or diagnostic testing. This unit handles.400 admissions per year, the majority of which are tracheostomy de-pendent, ventilator dede-pendent, and young. There was a gradual increase in

tracheostomy patient days over the study period: 3388 in 2008, 4097 in 2009, and 4441 in 2010. The clinical and demographic characteristics of the study population are presented in Table 1.

Data Collection

All tracheostomy-dependent patients from July 2008 through December 2010 were included. Demographic informa-tion, use of mechanical ventilainforma-tion, and underlying cause for mechanical ven-tilation were reviewed retrospectively. Tracheostomy type, TRPU stage and de-scription, number of days each TRPU persisted, and bundle compliance were recorded in real time. In most cases, the TRPUs were photographed to document the stage, location, and relationships between the respiratory equipment and the patient.

Denitions

A TRPU occurrence was defined as a new pressure ulcer that developed af-ter the patient was admitted or trans-ferred to our unit, if the ulcer site was in direct contact with the tracheostomy tube, tracheostomy ties, or the connec-tion to a ventilator circuit. To improve our ability to detect an improvement, any stage TRPU was considered an oc-currence, even though national patient

TABLE 1 Clinical and Demographic Characteristics of Study Population (N= 834)

Age, median (IQR) 2 y, 8mo

(13 mo to 9 y)

Males/females 441/393

Ventilator dependent,n(%) 728 (87)

CNS disease,n(%) 355 (43)

Congenital syndrome,n(%) 254 (31)

Airway disease,n(%) 240 (29)

Neuromuscular disease,n(%) 152 (18)

Prematurity/BPD,n(%) 137 (16)

Congenital heart disease,n(%) 137 (16) Thoracic insufficiency,n(%) 67 (8) Congenital central

hypoventilation syndrome,n(%)

18 (2)

BPD, bronchopulmonary dysplasia; IQR, interquartile range.

(3)

identified by a bedside nurse or during monthly unitwide surveys. All TRPUs were reported to and staged by a wound-care expert (AM.N.), based on National Pressure Ulcer Advisory Panel staging system, within 1 day of initial diagnosis.11The diagnosis and staging were made independent of the clinical service. TRPU occurrence rates were expressed as the number of new TRPUs per month divided by the number of tracheostomy patients in the unit that month. TRPU bed days were expressed as the number of days associated with a TRPU per month di-vided by the total number of unit bed days with a tracheostomy tube.

Interventions

The intervention model used a rapid-cycle, Plan-Do-Study-Act (PDSA), frame-work for improvement research.12PDSA cycles are designed to establish rela-tionships between process changes and outcomes by trialing and adapting small-scale interventions over time. This process was used both to de-termine the interventions most

bene-ficial to prevent TRPU and to effectively implement a TRPU-prevention bundle. PDSA cycles were planned and exe-cuted by a multidisciplinary team in-cluding the medical director of the unit, bedside nurse and respiratory therapist, nurse educator, and the unit’s skin care champion. Based on knowledge gained from the literature, as well as results previously obtained from our institu-tion’s pressure ulcer collaborative (preliminary work to reduce pressure ulcers of all types), key drivers thought to prevent TRPU development were identified to guide our interventions. These included (1) pressure ulcer risk and skin assessment, (2) moisture-free device interface, and (3) pressure-free device interface. PDSA cycles testing interventions in each of these drivers

they were incorporated into a TRPU-prevention“bundle”and implemented with the use of quality improvement methodology. All patients were moni-tored for any changes in their oxygena-tion or ventilaoxygena-tion. In the event of a decision to deviate from a component of the bundle (because of an adverse event, cost, or preference) the reason was recorded. All other quality improve-ment initiatives on the unit continued and their success was monitored.

On-line training modules on pressure ulcer risk assessment (all types), skin assessment, and identification were completed by all nurses on the unit. Specific education related to prevention of TRPU was given to staff as part of ongoing education and in printed form. Details of the TRPU-prevention bundle was well as data demonstrating time since he last TRPU were displayed in the staff break room. Nursing and re-spiratory therapists were given a bro-chure to share with parents describing the risks and mechanism of TRPU de-velopment and explaining why we were implementing this bundle. Pressure ulcer risk assessment was performed and documented via the Braden Q score of pressure ulcer risk.13,14In addition, full body skin assessments and device assessments were performed. Mepilex lite (Mölnlycke Health Care, Norcross, GA) was the hydrophilic barrier used under the tracheostomy tube flanges and around the stoma, cut to size from the supplied sheets. As the strength of the relationship between tracheostomy tube type and TRPU was increasingly recognized, consultation with a trache-ostomy tube manufacturer was un-dertaken to develop a tube that meets the needs of ventilator-dependent chil-dren and minimizes the pressure in-terface at each of the 3 locations where TRPUs develop. Arcadia Extend Connect Perfect Fit (Arcadia Medical, Crown

(Smiths Medical, London, UK) tracheos-tomy tubes were used as well. Both of these brands of tracheostomy tubes feature aflexible extension separating theflanges and the 15-mm adapter and are available in all pediatric and neo-natal sizes (cuffed and uncuffed). Ei-ther brand of tube was designated “extended”tracheostomy tubes for the purpose of this study based on similar mechanism of removing bulk from the crowded anatomic location of a small child’s neck (Fig 1). Tracheostomy tubes were further modified to have thin

flanges at a 30% angle which conforms well to the neck contours of an infant or young child (Arcadia, Perfect Fit). Ex-tended tracheostomy tubes were in-corporated into our hospital storage and distribution system such that there are no delays in ability to change a patient’s tracheostomy to such a tube if indicated. Once the bundle was devel-oped, multiple actions were taken to impact sustainable implementation. These actions included incorporation of assessment into nursing workflow via the electronic medical record, real-time reporting of each TRPU occurrence, and a strategy to change tracheostomy tubes in the unit based on patient anat-omy and to place such tubes at the time of tracheostomy (via collaboration with Otolaryngology).

FIGURE 1

(4)

Statistical Analysis

A multiple time series analysis was performed to determine whether the occurrence rate of TRPU decreased over the study period. Run charts were created to document monthly TRPU occurrence rate and percent of tra-cheostomy patient days affected by a TRPU each month. Run charts display and analyze variation in time-series data. They can statistically identify changes in variation that are attribut-able to a change in a system.15A run chart was used to graph the monthly TRPU occurrence rate over time and identify when a change in TRPU occur-rence was emerged. Associations be-tween TRPU development and age, gender, and the clinical indications for mechanical ventilation listed in Table 1 were evaluated by multiple logistic regression. The rate of TRPU occurrence between those with a stan-dard and extended-style tracheostomy tubes was evaluated by Fisher’s exact test.

RESULTS

From July 2008 to December 2010, there were 834 tracheostomy patients and 10 132 tracheostomy patient days evalu-ated. Population characteristics are shown in Table 1. During the 6 months of data collection before intervention there were 11 TRPUs in 136 patients for an occurrence rate of 8.1 per 100. This resulted in 212 bed days associated with a TRPU (12.5% of all tracheostomy days).

There were 22 TRPUs over the study period (Table 2). Eight TRPUs were stage 3 or 4 in severity (36%). Most occurred below the tracheostomy stoma (73%) and in patients who were,2 years old (64%) and ventilator dependent (82%). All of the pressure ulcers occurred in children with a mature stoma (a mature stoma is a requirement for the unit). No associations were found between any of the individual clinical or demographic

characteristics listed in Table 1 (in-cluding age and ventilator status) and likelihood of developing a TRPU.

Based on the results of PDSA cycles, interventions identified for incorpora-tion into the TRPU-prevenincorpora-tion bundle for each key driver included the following: skin assessment, Braden Q performed and documented every 24 hours, full body skin assessments performed daily, and tracheostomy device assessments every 8-hour shift; moisture-free device interface, hydrophilic polyurethane foam under tracheostomy tubes to wick moisture from the stoma away from the skin surface; pressure-free device inter-face, extended-style tracheostomy tubes in children with anatomy in which the neck was not clearly exposed in the neutral position or those with behaviors than repeatedly drove the tube down into the sternum (Fig 1).

It was clear from PDSA cycles trialing extended tracheostomy tubes that there was much less visible pressure at the tracheostomy–skin interface from this style of tube. This was further borne out over the entire study period in which 22 of 638 (3.4%) patients with

standard tracheostomy tubes devel-oped a new TRPU in comparison with 0 of 174 of patients with extended tubes (P= .007). There was also a significant difference in days affected by a TRPU between the 2 groups (5.2% vs 0.1%,

P , .0001). One patient was trans-ferred from an outside hospital during the first study month in an extended tracheostomy tube with an existing TRPU that persisted for 5 days. The intervention of extended-style trache-ostomy was prioritized, and weekly audits were initially performed to en-sure that appropriate patients had these tubes as soon as they were ad-mitted or transferred to our unit. Once a week, 2 authors (N.T. and R.P.B.) sur-veyed all the current patients on the unit to determine which components of the bundle had been completed or were in place that day. Rates for each component and the full bundle were tracked. Within 4 months the culture of the unit staff changed such that compli-ance with the bundle is consistently 100%, and audits are now done monthly. This type of integration of positive change into routine workflow is a hallmark of sustainable improvement.

The TRPU-prevention bundle was well accepted. There were no adverse events associated with the use of extended tracheostomy tubes. There were no instances of change in ventilation or oxygenation, no increased tube plug-ging, or any increased difficulty reported with tracheostomy tube changes. The cost per unit varies, but on average the extended-style tracheostomy tubes cost approximately twice as much as stan-dard tubes. There were no instances of inability to continue use of these tubes, but in some circumstances patients received only 1 tube per month (instead of 2, which is our standard) and were required to clean and replace tubes at least once. This is a practice that is ac-cepted, and there are manufacturer’s recommendations for doing so. One TABLE 2 Characteristics of

Tracheostomy-Related Pressure Ulcers (N= 22)

Location,n(%)

Below stoma 16 (73)

Aboveflanges 3 (14)

Above stoma 2 (9)

Under twill ties 1 (4)

Stage,n(%)

1 3 (14)

2 11 (50)

3 8 (36)

4 0 (0)

Patient underlying conditions,n(%)

Neuromuscular disease 5 (23)

Static encephalopathy 4 (18)

Trisomy 21 with congenital heart disease

4 (18)

Chronic lung disease 2 (9)

Congenital heart disease (nonsyndromic)

2 (9)

Traumatic brain injury 1 (4)

Glycogen storage disorder 1 (4)

Cystic hygroma 1 (4)

Thoracic insufficiency 1 (4)

Complex airway malformations 1 (4)

(5)

metic reasons. The polyurethane barrier was less well accepted. Three patients changed back to a gauze barrier be-cause contact dermatitis, and 12 addi-tional patients changed because the cost was not covered by insurance. This rep-resents a small percentage of the total population evaluated (2%).

Overall, during the study period, there was a significant decrease in the rate of tracheostomy patients who developed a TRPU from 8.1% during the baseline period to 0.3% over thefinal 6 months of the study period (Fig 2). The per-centage of tracheostomy patient days affected by a TRPU also decreased from 12.5% to 0.2% during the same time interval.

DISCUSSION

In our population of mostly young, chronically ventilated infants and chil-dren, tracheostomy-related pressure ulcers were common, but they proved to be largely preventable by a culture of prioritizing skin health and the use of anatomically appropriate devices. During the 6 months before initiation of this study, there were 11 ulcers, 4 of which were staged at 3 or 4. Based on the newly accepted changes to Medi-care and Medicaid reimbursement, the entire direct care costs for hospital

Education of nursing staff in skin as-sessment and risks for pressure ulcer development, with integration of these assessments into daily documentation workflow, has improved our ability to anticipate and mitigate risks to skin integrity. In addition to decreasing the occurrence of TRPUs, there was a trend toward shortening their duration. During thefirst 6 months of the study, each TRPU lasted an average of 19 days, whereas the TRPU that developed dur-ing and after implementation lasted only 7 days.

Pressure ulcers are a key clinical in-dicator of the standard and effective-ness of care, yet there have been no guidelines as to prevention of pressure ulcers from tracheostomy tubes. We were able to use the risk factors for pressure ulcer development, within a quality improvement framework, to guide the development and testing of potential interventions for TRPU pre-vention.16–19 This framework allowed us to evaluate the effectiveness of different interventions, condense them into a clinical bundle, and then imple-ment this bundle into the clinical prac-tice of the unit. The benefits of this approach to TRPU prevention became evident during development of the clin-ical bundle, and the improvement has

tracheostomy tubes that exert a mini-mum of focal pressure, although the degree of improvement may not have been as great outside of a context of heightened attention to skin health. That said, the use of an extended tracheos-tomy tube in appropriate patients would be expected to be a highly reliable in-tervention, because, once placed, the beneficial impact would be continuous and would not rely on caregiver dili-gence or memory. We did not begin to see a significant improvement in our TRPU rates until these devices were used with some frequency. For this reason, this style of tracheostomy tube is now placed at the time of surgery in all anatomically appropriate children in our institution as an anticipatory measure. This has decreased the rate of TRPUs that transfer to our unit from the pediatric ICU that had previously developed during the short period of stoma maturation immediately after tracheotomy.

This study is limited by its single-hospital unit design and because it was not a randomized controlled trial. However, this unit has the highest tra-cheostomy utilization of any other unit in the institution. Several patients had previous TRPUs with standard tracheos-tomy tubes that did not recur after a change to an extended-style tube. Two patients had prolonged TRPUs that did not resolve until an extended tube was placed. These factors increase our confidence in our results, in particular, the effective-ness of extended tracheostomy tubes.

Education and ongoing assessment of skin integrity and the use of devices that minimize pressure effectively reduces TRPUs even among a population of children at high risk for pressure ulcer development. These interventions can be integrated into daily workflow, re-sulting in long-term sustainment in effectiveness.

FIGURE 2

(6)

REFERENCES

1. McLane KM, Bookout K, McCord S, McCain J, Jefferson LS. The 2003 national pediatric pressure ulcer and skin breakdown preva-lence survey: a multisite study. J Wound Ostomy Continence Nurs. 2004;31(4):168–178 2. Schlüer AB, Cignacco E, Müller M, Halfens RJ; AB. The prevalence of pressure ulcers in four paediatric institutions. J Clin Nurs. 2009;18(23):3244–3252

3. Curley MA, Quigley SM, Lin M. Pressure ulcers in pediatric intensive care: incidence and associated factors. Pediatr Crit Care Med. 2003;4(3):284–290

4. Baldwin KM. Incidence and prevalence of pressure ulcers in children. Adv Skin Wound Care.2002;15(3):121–124

5. Willock J, Hughes J, Tickle S, Rossiter G, Johnson C, Pye H. Pressure sores in children—the acute hospital perspec-tive.J Tissue Viability. 2000;10(2):59–62 6. Schindler CA, Mikhailov TA, Fischer K,

Lukasiewicz G, Kuhn EM, Duncan L. Skin integrity in critically ill and injured chil-dren.Am J Crit Care. 2007;16(6):568–574 7. Allman RM, Goode PS, Burst N, Bartolucci AA,

Thomas DR. Pressure ulcers, hospital com-plications, and disease severity: impact on hospital costs and length of stay.Adv Wound Care. 1999;12(1):22–30

8. Zollo MB, Gostisha ML, Berens RJ, Schmidt JE, Weigle CGM. Altered skin integrity in children admitted to a pediatric intensive care unit.

J Nurs Care Qual. 1996;11(2):62–67 9. Armstrong DG, Ayello EA, Capitulo KL, et al.

New opportunities to improve pressure ul-cer prevention and treatment: implications of the CMS inpatient hospital care present on admission indicators/hospital-acquired conditions policy: a consensus paper from the International Expert Wound Care Advi-sory Panel. Adv Skin Wound Care. 2008;21 (10):469–478

10. Carr MM, Poje CP, Kingston L, Kielma D, Heard C. Complications in pediatric tracheosto-mies.Laryngoscope. 2001;111(11 Pt 1):1925– 1928

11. Black J, Baharestani M, Cuddigan J, et al; Na-tional Pressure Ulcer Advisory Panel. NaNa-tional Pressure Ulcer Advisory Panel’s updated pressure ulcer staging system. Dermatol Nurs. 2007;19(4):343–349, quiz 350 12. Langley GJ, Nolan KM, Nolan TW, Norman CL,

Provost LP. The Improvement Guide: A Practical Approach to Enhancing Organi-zational Performance. San Francisco, CA: Jossey-Bass; 1996

13. Pancorbo-Hidalgo PL, Garcia-Fernandez FP, Lopez-Medina IM, Alvarez-Nieto C. Risk

as-sessment scales for pressure ulcer pre-vention: a systematic review. J Adv Nurs. 2006;54(1):94–110

14. Curley MA, Razmus IS, Roberts KE, Wypij D. Predicting pressure ulcer risk in pediatric patients: the Braden Q Scale. Nurs Res. 2003;52(1):22–33

15. Wheeler DJ.Understanding Variation: The Key to Managing Chaos. Knoxville, TN: SPC Press Inc; 1993

16. Elliott R, McKinley S, Fox V. Quality im-provement program to reduce the preva-lence of pressure ulcers in an intensive care unit.Am J Crit Care. 2008;17(4):328– 334, quiz 335, discussion 336–337 17. Hiser B, Rochette J, Philbin S, Lowerhouse N,

Terburgh C, Pietsch C. Implementing a pres-sure ulcer prevention program and en-hancing the role of the CWOCN: impact on outcomes.Ostomy Wound Manage. 2006;52 (2):48–59

18. Reddy M, Gill SS, Kalkar SR, Wu W, Anderson PJ, Rochon PA. Treatment of pressure ulcers: a systematic review. JAMA. 2008;300(22): 2647–2662

19. Quigley SM, Curley MA. Skin integrity in the pediatric population: preventing and man-aging pressure ulcers.J Soc Pediatr Nurs. 1996;1(1):7–18

(7)

DOI: 10.1542/peds.2011-0649 originally published online February 20, 2012;

2012;129;e792

Pediatrics

Dressman

Amrita Chima, Gary L. McPhail, Mathew Ednick, Michael J. Rutter and Kathy

Services

Updated Information &

http://pediatrics.aappublications.org/content/129/3/e792

including high resolution figures, can be found at:

References

http://pediatrics.aappublications.org/content/129/3/e792#BIBL

This article cites 17 articles, 2 of which you can access for free at:

Subspecialty Collections

sub

http://www.aappublications.org/cgi/collection/quality_improvement_ Quality Improvement

e_management_sub

http://www.aappublications.org/cgi/collection/administration:practic Administration/Practice Management

following collection(s):

This article, along with others on similar topics, appears in the

Permissions & Licensing

http://www.aappublications.org/site/misc/Permissions.xhtml

in its entirety can be found online at:

Information about reproducing this article in parts (figures, tables) or

Reprints

http://www.aappublications.org/site/misc/reprints.xhtml

(8)

DOI: 10.1542/peds.2011-0649 originally published online February 20, 2012;

2012;129;e792

Pediatrics

Dressman

Amrita Chima, Gary L. McPhail, Mathew Ednick, Michael J. Rutter and Kathy

R. Paul Boesch, Christine Myers, Tonia Garrett, AnnMarie Nie, Natalie Thomas,

Prevention of Tracheostomy-related Pressure Ulcers in Children

http://pediatrics.aappublications.org/content/129/3/e792

located on the World Wide Web at:

The online version of this article, along with updated information and services, is

by the American Academy of Pediatrics. All rights reserved. Print ISSN: 1073-0397.

Figure

TABLE 1 Clinical and Demographic
FIGURE 1Fit of standard vs extended-style tracheostomytube in ventilated infant (Arcadia shown)
TABLE 2 Characteristics of Tracheostomy-Related Pressure Ulcers (N = 22)
FIGURE 2Run chart for TRPU rates per 100 tracheostomy patients (July 2008 to December 2010)

References

Related documents

However, in this paper we will study the optical properties of the structure at normal incidence, the oblique incidence and a small symmetrical deformation of geometrical

FOLFIRI plus cetuximab versus FOLFIRI plus bevacizumab as first-line treatment for patients with metastatic colorectal cancer (FIRE-3): a randomised, open-label, phase 3

To further investigate the association of Sec20p, Sec39p, and Dsl1p with peroxisomes, we coexpressed the peroxisome marker Pex3p-mRFP with Sec20p-GFP, Sec39p-GFP, or Dsl1p-GFP in

Characterization of Fe (III)- chelate reductase activities of plasma membrane preparations isolated from leaves of iron-sufficient and iron-deficient sugar beet ( Beta vulgaris

influenced Indian literary texts, from Sanskrit literature to modern literature in Indian English.. This influence continues even till the

The SEM analysis showed morphologies of the samples indicating activated carbon that is heterogeneous in nature (i.e consisting of both micropore and mesopore structures). The

The primary use of large, industrial cooling towers is to remove the heat absorbed in the circulating cooling water systems used in power plants,petroleum refineries,

products tangible and physical goods High potential differentiation. Low