Preventing Endotracheal Tube Device-Related Pressure Injuries: A Practice-Based Approach

Background: Critically ill patients are at risk for hospital acquired pressure injuries (HAPIs) due to the unique risk factors and treatments used in the intensive care unit. Intubated patients need endotracheal tube attachment devices (ETADs) to secure and maintain an artificial airway during mechanical ventilation. ETADs have been associated with development of HAPIs. There is a lack of standardized guidelines or protocols to support safe application and maintenance of ETADs. Within our facility 95% of ETADs applied were bite block ETADs (BB ETADs) and 42% of the 19 respiratory device-related HAPIs (RDRPIs) resulted from ETADs. We aimed to reduce ETAD RDRPIs by implementing a practice for device selection and management in a 766-bed academic level 1 trauma center. Methods: An IRB exempt retrospective evaluation analyzed documented RDRPIs for July 1, 2022 through June 30, 2023 (FY23). Data showed BB and standard ETADs were associated with the highest instance of RDRPIs. A root-cause analysis was performed and practice standards were developed. Staff education occurred in July 2023 and again in January 2024 on practice standards (PS) supporting selection, application, management, and removal of ETADs. An overview of HAPI identification was provided. Supply of ETADs available in the ED and ICUs was changed to meet the PS. Total ETAD injuries/1,000 ventilator days (VD) were compared for FY23 and FY24. Total rate of BB ETAD use pre- and post-intervention were compared. Findings were considered significant with P < .05. Results: Following PS implementation, rate of BB ETADs had a statistically significant decrease by 81.8% (pre- 95%, post- 17.3%; P = < .01) and total HAPIs/1,000 VD decreased 30.6% (P = .09). Overall ETAD associated HAPIs decreased by 25% (P = .69) and injuries associated with BB ETADs decreased 33.3% (P = .85). Overall RDRPIs reduced by 42.1%. Conclusions: Establishing ETAD PS and education led to a statistically significant reduction in BB ETAD use. The 42.1% decrease in overall FY24 RDRPIs may be attributed to heightened awareness of HAPI risks. Through this quality improvement initiative, we were able to decrease our total ETAD HAPIs by 33.3%, which resulted in a 30.6% reduction in ETAD associated HAPIs/1,000 VD in our institution. Although not statistically significant, reduction in RDRPIs bring added patient value and have the potential to save in healthcare costs, LOS, and mortality. Standardized practices may improve patient outcomes and reduce cost.Fig. 1: Comparison of fiscal year ETAD associated HAPIs and bite block utilization&nbsp;FY 23FY 24Percentage ChangeP ValueTotal RDRPIs191142.1%&nbsp;ETAD associated HAPI (BB)8 (6)6 (4)25% (33.3%)P=.69(P=.85)Prevalence of Bite Block ETADs (%)95%17.3%81.8%P=.01ETAD HAPIs/1000 ventilator days.49.3430.6%P=.09