The Science Journal of the American Association for Respiratory Care

2003 OPEN FORUM Abstracts

SKIN INTEGRITY DURING THE APPLICATION OF CONTINUOUS POSITIVE AIRWAY PRESSURE (CPAP) IN THE TREATMENT OF BRONCHIOLITIS.

Kim Bennion BS RRT, Glenna McKinley BS RRT, Julie Ballard BS RRT and Cindy Heffner RN. Primary Children's Medical Center (PCMC), Salt Lake City, UT.

Introduction:
In utilizing various forms of non-invasive ventilation over the past several years at PCMC, skin breakdown (severe in some cases) had been reported. Between 1999-2002, eleven patients (pts) were tracked on non-invasive ventilation (NIV), 5 (46%) of which had reported open wounds. Prior to July 2002, skin integrity was poorly documented. A clinical practice guideline (CPG) for the use of CPAP in bronchiolitis pts was written to be used during the 2002-2003 bronchiolitis season (Nov-April). It included procedures to protect skin integrity such as: (1) removing the head gear & delivery device (mask/prongs) every 4 hrs, (2) educating caregivers to utilize the least amount of strap-down pressure as possible, (3) placing thick Duoderm patches over areas of skin exposed to pressure (i.e. bridge of nose where masks rest and around the prongs to protect the nares), (4) utilizing NeoBars with V-Sil prongs and (5) placing foam pads between the ventilator tubing and the head. Skin integrity was to be assessed and documented prior to CPAP placement and every 4 hours thereafter.

Methods:
A data system was developed to track the skin integrity of all bronchiolitis pts on CPAP. Inclusion criteria were: (1) primary diagnosis of bronchiolitis, (2) < 24 months of age, (3) placed & managed on CPAP in a non-ICU. There were 11 pts previously tracked from 1999-2002 (prior to the CPG implementation).

RESULTS:
There were 43 pts placed on CPAP, seven of which were excluded for co-morbidities which made them ineligible for placement using the bronchiolitis CPAP CPG. Nine pts were excluded as they were started on CPAP in non-ICU areas but were eventually transferred to the ICU before skin integrity was noted. This left us with 27 pts to analyze. Skin integrity was reported by site and defined as red, skin sheering or open wound. Results are reported in Table 1.

CONCLUSION:
It is our experience that accurate outcome measures are valuable in identifying areas for process improvement as well as tracking the effectiveness of education and procedural changes targeted at improving care. Raising awareness of pressure induced skin damage probably had a marked effect on decreasing the incidence of open wounds; however, we feel the skin integrity assessments every four hours may account for the increased reports of redness. Frequent assessments coupled with the use of skin protective barriers had the most profound effect. This has now become our standard of care for all patients on NIV.

Table 1: Skin Integrity Results

   Skin Integrity Prior to Skin Integrity CPG Implementation 1999-July 2002 # (%) Post Skin Integrity CBG Implementation July 2002-April 2003 # (%)
Normal 2 (18)  6 (22)
Red   4 (36) 21 (78)
Skin Sheering   0 (0) 0 (0)
Open wound   5 (46) 0 (0)
Total Pts # (%) 11 (100)  27 (100)

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