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bundle, hospital-acquired injury, pressure injury, prevention, quality improvement, tracheostomy



  1. Urquhart, Anne E. MS, APRN, AGCNS-BC, CCRN, CMC
  2. Savage, Elizabeth MSN, APRN, ACNS-BC, CWON, IIWCC-NYU
  3. Danziger, Keri MA, CCC-SLP
  4. Easter, Tara MA, RN
  5. Terala, Anish BS
  6. Nunnally, Mark MD, FCCM


OBJECTIVE: An interprofessional team known as the Tracheostomy Steering Committee (TSC) was established to prevent tracheotomy-related pressure injuries (TRPIs) and standardize practice for tracheostomy insertion and care of patients with tracheostomies. In addition to reducing the number TRPIs, the TSC sought establish an escalation process for all clinicians to raise concerns about the care and management of patients with tracheostomies.


METHODS: This quality improvement initiative used the Define, Measure, Analyze, Improve, and Control framework with a pre- and postintervention design. The TSC created a TRPI-prevention bundle that included recommendations for protective foam dressing and skin barrier film use, suture tension, timing of suture removal, stoma care, offloading and positioning, escalation, documentation, and dual skin assessment. An electronic tracheostomy report was developed to track patients with a tracheostomy across the enterprise.


RESULTS: A total of 289 patients had a tracheostomy during their inpatient hospital stay from January 2018 through December 2019. There was an observed a reduction in the daily rate of TRPIs by 50% with the use of the standardized TRPI-prevention bundle.


CONCLUSIONS: Use of the bundle resulted in a significant reduction in the incidence of TRPI. Timely escalation of possible tracheostomy injuries or tracheostomies at risk enabled rapid intervention, likely preventing many injuries, and real-time feedback to clinicians reinforced best practices. Interprofessional collaboration is necessary to provide optimal tracheostomy care and ensure the best outcomes.