Transcript

Hello, my name is Kelly McFee. I am a family nurse practitioner and wound care provider at Mosaic Life Care. I'm also the director of wound care for Mosaic Health System.

What are some common types of medical equipment that can lead to medical device-related pressure injuries (MDRPIs)? 

There’s actually a lot of different medical equipment that we see in relation to medical device-related pressure injuries. Probably the most common types of devices that we see are respiratory devices. And we really saw this a lot with COVID and we’re seeing it more as we’re getting closer to the cold weather months where we’re seeing more respiratory illnesses.

So things like, you know, nasal cannulas, for example, endotracheal tubes, oxygen masks, BIPAPs, CPAPs, things that are more fixed to the patient's face to provide oxygen. And then of course there’s other options as well because we know there's a whole host of medical devices.

We see orthopedic devices. Patients on our ortho -neuro floor may have splints or other kind of orthopedic devices after surgical procedures. And then of course, you know, most patients come in and they have, you know, an IV or they might have like a foley catheter. So we have seen medical device related pressure injuries related to just standard devices such as a foley and maybe it wasn't positioned well and it causes some issues with that as well. So, all kinds of different devices related with medical device related pressure injuries.

What are the primary factors that contribute to MDRPI?

It's just the fact that there is a medical device in play. And so we have to be really cognizant that having that medical device on the patient is adding an extra risk factor to that patient's care.

When we have those medical devices, then we're educating our nursing staff and our caregivers here in the hospital that we have to make sure that we're looking at the skin and underneath those medical devices so making sure that things fit well and that we're doing a routine skin assessment underneath those devices. So really it's just the fact that the device is there and we have to be cognizant that that is a risk factor.

What measures can clinicians take to prevent MDRPIs, specifically those caused by oxygen delivery devices?

We work really closely with our respiratory team, number one to make sure that everybody is well-educated and the use of respiratory devices. So making sure that respiratory devices fit well, making sure that they're being applied correctly, and then making sure that we have alternatives when appropriate because maybe it's not necessarily appropriate for every patient given the circumstances.

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But having the option to be able to swap out every once in a while so that's something that we've actually been working on as an organization. Maybe the patient has the ability and has the respiratory status to be able to alternate from let's say a nasal cannula to an oxygen mask and we try to alternate those every 2 to 3 hours depending on the circumstances.

Or making sure that the BIPAP mask fits appropriately and we've also been looking into changing the kind of masks that we have so that we have a couple different alternatives that we can utilize. Maybe one that is like our standard BIPAP mask but then something that we can change it out with that doesn't apply pressure in the same places at all times. Just making sure that things fit well and that everybody understands how to utilize those especially for respiratory purposes.

What should wound care professionals look for with respect to regular device maintenance and inspection to prevent MDRPIs?

So there’s a lot of parts to that question and I think the wound care piece is different than maybe looking at device maintenance. For example when we're talking about respiratory equipment, our respiratory team probably takes control of making sure that the respiratory equipment is well maintained.

So our respiratory team and then of course our bio med folks. So, those are the people that are in charge of making sure that respiratory equipment is working well. But as a wound care clinician, I'm making sure that areas that look like they're high friction areas or high pressure areas are going to be prevented and that they're being assessed on a regular basis.

So we have medical device related pressure injury prevention protocols that we utilize. We actually utilize prophylactic foam dressings when appropriate. And so we work together with those team, maybe not with bio med per se, if they're looking at, doing PM and preventing a maintenance on our on our equipment, but we're working with respiratory staff to make sure that we're all identifying and regularly assessing to make sure that we're implementing medical device related pressure injury prevention protocols when appropriate for those patients.

So they're checking out the equipment and then we're making sure that we're using the preventative protocols.

What other tools or strategies can clinicians implement to prevent these injuries in patients using medical devices?

We have fairly robust pressure injury prevention protocols in place and then especially for medical device related pressure injury prevention protocols. And we do use a bunch of different tools. Respiratory has, you know, their toolbox of things that they like to use to prevent pressure with their respiratory devices. But then we also use prophylactic foam dressings.

Back in COVID, we put together prone packets. So we had packets of prophylactic dressings that we like to use, let's say for a COVID patient, because that's when we develop these. So we would pressure proof our patient, let's say for COVID, they would pad them all up at anterior pressure points, but then they would also go back through and make sure that they're using prophylactic dressings like on the face so on the across the cheeks across the forehead the bridge of the nose and the chin. We just kind of put these packages all together so they were easy grab packs and they could hit everything at one time and make sure that they were all padded up for the prone position.

We still educate the same way. So even if it's a standard patient who's going to be an ICU and they're not prone, maybe they were a trauma patient, we still have these tools available for those patients that are going to have high -risk devices so everything is still available. It's still the same kind of education, but they're just not being prone, so we're still educating that we need to utilize prophylactic dressings underneath the edge of dressings or maybe it's just someone who's going to have a nasal cannula so we're educating that you can actually wrap the tubing with a prophylactic foam dressing to protect behind the ears. Still the same thought process.

We still work with a multidisciplinary approach, it just depends on what medical devices we're looking at. We also work very closely with you know orthopedic surgery team and the trauma team when we're working with our ortho patients that have those extra devices on the ortho neuro unit. We're still looking for ways that we can work with those devices, and it might be that we're having to have caregivers call and ask “can I remove this for a period of time to do a skin check and then put it right back on?” It's always a work in progress, but it involves a lot of skin assessment.

If a patient does develop a MDRPI, what are some of the next steps?

Honestly, it's interesting because we do a lot of the same treatments, depending on the severity of the pressure injury, that we use to prevent. If we didn't prevent , we're still use a lot of foam dressings depending on the level. Certainly, it also depends on the location. The wound care team is involved throughout the process. Let’s say we've developed a stage II or a stage III in a particular area, we're managing exudate, we're still trying to manage pressure because certainly offloading or being able to get rid of that medical device is going to be key moving forward to trying to help with that healing process. But it is always a little bit of a struggle, of course, if we have developed a MDRPI, because how long are we are going to have to utilize that particular medical device? So, it's a case -by -case basis. Certainly, we're utilizing that multi -disciplinary team approach to figure out what the best case is moving forward for that patient.

Can you share an example of when interventions successfully prevented or managed a MDRPI?

We see patients in the ICU develop on occasion pressure injuries of the mucosa related to endotracheal tubes. And I think that one is a struggle at times because you need to maintain a patent airway. And so then you've got the endotracheal tube there. And that one is always a struggle for us. But providers should get that respiratory team involved and make sure that the endotracheal tube is the correct size. There's actually a pathway that Joint Commission recommends for managing devices.

But anyway, we get respiratory team involved and they're making sure that it's the correct fit. And then they're managing that endotracheal tube. Sometimes we can move things around a little bit and we can manage to securement my devices a little bit better so that you can get those mucosal pressure injuries to heal up pretty quickly.

About the Speaker

Kelly McFee, DNP is a Board-Certified Family Nurse Practitioner, Certified Wound Specialist and Advanced Practice Certified Wound Care Nurse who has been practicing Wound Care and Hyperbaric Medicine in Northwest Missouri. She received a BSN from Missouri Western State University, MSN from the University of Missouri – Kansas City, and DNP from the University of South Alabama. Kelly serves as the Director of Wound Care for Mosaic Life Care and practices wound care both in the acute care and outpatient settings. She is an active member of the American Professional Wound Care Association, Association of Advancement of Wound Care, and the Wound, Ostomy and Continence Nurses Society. She serves on the Board of Directors for the American College of Clinical Wound Specialists and will be serving the college as the Chair-elect in 2022. She is also a member of the Prophylactic Dressing Standards Initiative, a joint collaboration between the NPIAP and EPUAP.