Prevention of nostril lacerations in endonasal drilling procedures by use of a conventional protective ear speculum.

PURPOSE: Injuries of the nasal vestibular skin caused by the rotating burr shafts can represent a tedious complication following endonasal drilling and is experienced sooner or later by every rhino-surgeon. MATERIAL AND METHODS: To protect the nasal entrance from laceration by the free rotating drill shaft we position an otology speculum in the nasal entrance. The speculum is held in place by the scrub nurse during the critical phase of bone drilling. RESULTS: Following the introduction of the ear speculum protection, we successfully treated our dacryocystostamia procedures (n = 27) and median maxillectomia procedures (n = 6) without any further soft tissue erosions. DISCUSSION: Preventive measures for injuries by endonasal drilling procedures are not reported extensively in literature. This stands in contrast to the fact that these injuries are prone to cause significant suffering as amply described in the case of nostril laceration due to nasogastric intubation or nasogastric feeding tubes. CONCLUSION: The use of a readily available, reusable ear speculum in endonasal drill application eliminated the complication of nasal entrance lacerations throughout our institution, hitherto.

Study on an Onset Mechanism of MDRPU by Wearing Elastic Stockings: Numerical Simulation by Two-Dimensional Mechanical Model.

As compared with pressure injuries, the mechanism the development of medical device related pressure ulcers (MDRPU) is not revealed enough. According to studies on severity and frequent site of occurrence, MDRPUs are surmised to occur the surface of the skin. In this study, we assess theoretical and experimental analysis by two-dimensional mechanical model for elastic stockings (ES) wear the lower limbs with or without dug into the skin by the wrinkles and curling up of ES. The Finite Element Method (FEM) was used to calculate the stress on the skin and subcutaneous tissue, because of elucidating the mechanism of MDRPU. The FEM used a triple-layered cylindrical model simulating the skin, subcutaneous tissue, and bone. Regarding the interface pressure (compression pressure), two samples were created: the one is applying a uniform pressure of 5.3 kPa on the skin surface simulating the correct wearing of ES, and the other is applying a pressure of 16 kPa on the part of the skin on which ES dug in. The results were as follows: the internal stress on the skin and subcutaneous tissue was maximum at the site where ES dug in, producing stresses of 54 kPa, 50 kPa, and 21 kPa in the circumferential, longitudinal, and radial directions, respectively. The uniform pressure produced an internal stress of 5-9 kPa on the skin surface. Unlike the mechanism of pressure injury formation, we considered compressive strength from tensile of the circumferential and longitudinal directions, furthermore the additive radial pressure at the digging site on the skin due to the wrinkles and curling of ES, which is one of the factor to cause strong external force in the MDRPU formation. (This is secondary publication from Jpn J Phlebol 2021; 32(1): 119-126.).

Changes in Transcutaneous Oxygen Pressure in the Lower Limb Associated with the Use of Elastic Compression Stockings.

Objective: Elastic compression stockings are used to prevent venous thrombosis in postsurgical patients. However, they have been associated with skin complications, such as medical device-related pressure ulcers. This study aimed to assess the effect of elastic compression stockings on the skin tissue status of the lower limbs. Methods: Transcutaneous oxygen pressure (TcPO2) was measured in the anterior tibia and corresponding soft skin of healthy subjects before, during, and after continuous use of elastic stockings for 30 min. Results: Wearing elastic stockings significantly reduced TcPO2 in the skin of the anterior tibia, and removal of the stockings restored TcPO2 values. Both individuals who exercised regularly and men had lower TcPO2 at all measurement points than both individuals who did not exercise and women. Older subjects (50-60 years) had reduced TcPO2 in the sural region than younger ones (20-30 years). Conclusion: The use of elastic compression stockings caused an early decrease of TcPO2 in healthy subjects. Clinical patients were predicted to be at a high risk of wounding.

Barriers and facilitators to reporting medical device-related pressure ulcers: A qualitative exploration of international practice.

BACKGROUND: Pressure ulcers are a complex healthcare issue. Hospital-acquired pressure ulcers are used as proxy measurements for the quality and safety of nursing care. Medical device-related pressure ulcers are mostly facility acquired, but their reporting has only recently been widely adopted. Consequently, we do not yet know what factors impact their reporting by registered nurses. OBJECTIVES: To identify and systematically report determinants of the practice of medical device-related pressure ulcers reporting using the Tailored Implementation for Chronic Diseases checklist. DESIGN: Descriptive, explorative design using semi-structured interviews to explore barriers and facilitators to reporting medical device-related pressure ulcers. SETTING: We undertook online, telephone, and face-to-face interviews with participants from 11 different countries. PARTICIPANTS: We interviewed 17 participants who represented acute care (Adult, Paediatrics), academia, and industry. Eleven participants were healthcare professionals with more than 10 years' experience in wound care. METHODS: The interview recordings were transcribed and coded by the lead researcher. Data were analysed thematically using the codebook approach, and themes were developed inductively and deductively. RESULTS: Participants identified determinants of practice which clustered around four domains of the Tailored Implementation for Chronic Diseases checklist i) individual health professional factors, ii) professional interactions, iii) incentives and resources, and iv) capacity for organisational change. Knowledge, attitudes, workload, time, staffing, and perception of consequences, including financial, were identified as the main barriers to reporting. Factors supporting the practice were education, openness, and teamwork. Device procurement could take on characteristics of a barrier or facilitator depending on the organisation. CONCLUSIONS: Reporting medical device-related pressure ulcers has been adopted in healthcare institutions worldwide. Understanding what drives the reporting practice enables improvements in incident reporting, which consequently can lead to improvements in the quality of nursing care and patient safety.

The aetiology of medical device-related pressure ulcers and how to prevent them.

This article provides an introduction to the aetiology of medical device-related pressure ulcers (MDRPUs), describes the vicious cycle that leads to these injuries and highlights bioengineering methodologies and findings that connect the aetiology to the clinical practice of preventing MDRPUs. Specifically, the vicious cycle of MDRPUs is triggered by the sustained tissue deformations induced by a skin-contacting device. The primary, deformation-inflicted cell damage leads to a secondary inflammatory-oedema-related damage and then to tertiary ischaemic damage. Each of these three factors contributes to cumulative cell death and tissue damage under and near the applied device. The damage therefore develops in an escalated manner, as a result of the added contributions of the above three factors. This phenomenon is exemplified through two common clinical scenarios. First, through the use of continuous positive airway pressure (CPAP) masks, which are being applied extensively in the current COVID-19 pandemic, and, second, through the use of doughnut-shaped head positioners, which are applied to surgical patients and sometimes to bedridden individuals who receive intensive care in a supine position. These two medical devices cause intense, localised mechanical loads in the facial skin and underlying tissues (CPAP mask) and at the occipital scalp (doughnut-shaped positioner), where the soft tissues cannot swell in response to the inflammatory oedema as, in both cases, the tissues are sandwiched between the device and the skull. Accordingly, the two device types result in characteristic MDRPUs that are avoidable through appropriate prophylactic interventions, that is, preventive dressings under the CPAP mask and replacement of the doughnut device by a soft, shape-conforming support aid to alleviate and disperse the localised soft tissue deformations. Hence, understanding the aetiology of MDRPUs targets and focuses effective clinical interventions.

Physiological measurements of facial skin response under personal protective equipment.

Medical device-related pressure ulcers (MDRPUs) were traditionally associated with skin-contacting medical devices applied to patients, eventually causing tissue damage. The coronavirus-2019 pandemic has brought a new variant of MDRPUs: facial skin irritation or damage associated with extended use of protective personal equipment (PPE), e.g. facemasks and respirators. In this context, we report here a comprehensive experimental evaluation including facial contact forces, skin temperatures and sub-epidermal moisture (SEM) measurements pre/post-PPE usage, to determine how these physiological parameters change under the effects of surgical facemasks and KN95 respirators and whether such potential changes can explain the commonly reported skin irritation or damage. We found that a surgical mask is potentially less irritating to facial skin than the KN95 respirator, as it applies lower forces and facilitates faster return of facial temperatures to their basal levels. Further, we demonstrated that use of dressing cuts for padding under a KN95 respirator considerably reduced localized forces and did not worsen the thermal and SEM readings at the skin-device contact sites. This study provides a basis for improvement of PPE designs, as it describes physiological measurement methodologies for quantitative comparisons of the effects of different PPE types on facial skin status.

A 3D registration methodology to evaluate the goodness of fit at the individual-respiratory mask interface.

Respiratory masks are used to deliver non-invasive ventilation for cardiorespiratory pathologies. Masks must minimize skin tissue compression while maintaining a seal at the interface. Ill-fitting masks or those applied too tightly are implicated in pressure ulcer formation. This study aimed to analyse respiratory mask goodness of fit in a cohort of face shapes. A number of parameters were identified and analysed with a novel registration protocol. In the majority of cases, mask indentation exceeded the thickness of the interface material and significant gapping was observed. The size range was most appropriate for males, with only one size suitable for females.

The bioengineering theory of the key modes of action of a cyanoacrylate liquid skin protectant.

The objective of this article is to formulate a new bioengineering theoretical framework for modelling the biomechanical efficacy of cyanoacrylate skin protectants, with specific focus on the Marathon technology (Medline Industries, Inc., Northfield, Illinois) and its modes of action. This work details the bioengineering and mathematical formulations of the theory, which is based on the classic engineering theories of flexural stiffness of coated elements and deformation friction. Based on the relevant skin anatomy and physiology, this paper demonstrates: (a) the contribution of the polymerised cyanoacrylate coating to flexural skin stiffness, which facilitates protection from non-axial (eg, compressive) localised mechanical forces; and (b) the contribution of the aforementioned coating to reduction in frictional forces and surface shear stresses applied by contacting objects such as medical devices. The present theoretical framework establishes that application of the cyanoacrylate coating provides considerable biomechanical protection to skin and subdermally, by shielding skin from both compressive and frictional (shearing) forces. Moreover, these analyses indicate that the prophylactic effects of the studied cyanoacrylate coating become particularly strong where the skin is thin or fragile (typically less than ~0.7 mm thick), which is characteristic to old age, post-neural injuries, neuromuscular diseases, and in disuse-induced tissue atrophy conditions.

Under (less) pressure - Facial pressure ulcer development in ventilated ICU patients: A prospective comparative study comparing two types of endotracheal tube fixations.

INTRODUCTION: The development of medical device-related pressure ulcers (MDR PUs) as a result of an endotracheal tube fixator (ETTF) use affects patients particularly in the intensive care unit (ICU). STUDY DESIGN AND DATA COLLECTION: Prospective comparative study followed two similar groups of ventilated ICU patients: Group A treated with cloth tape ETTF (CT-ETTF) and Group B treated with Anchorfast Hollister-ETTF (AH-ETTF). Data were collected regarding PU development, location, grade, time from intubation and hospitalisation. RESULTS: Significant differences in PU development (p < 0.01), hospital LOS until PU development (p < 0.01), and ventilation days until PU development (p < 0.01) were found between the two groups all in favour of Group B. Linear regression conducted to identify the primary reason for these findings, revealed that the key factor responsible for more than 40% of the difference in ventilation days until ETT MDR PU formation between the groups was the usage of AH-ETTF (R2 = 0.436, p = 0.000). CONCLUSIONS: There was a significant advantage to AH-ETTF over CT-ETTF in pressure ulcer development. This should be taken into consideration when deciding which ETTF type to use.

Use of dermal gel pads in preventing and managing pressure ulcers in ICU: an audit.

Most of the pressure ulcers (PUs) that developed in the intensive care unit (ICU) of an acute trust were medical-device related. While use of a dermal pad was recommended as part of its pressure ulcer prevention strategy, staff were concerned that it tended to tear or split while in use. An alternative gel pad (Dermisplus® Prevent, Frontier Medical), that was cost-effective and appeared to be more robust, was identified. A 4-week non-comparative audit involving 37 patients was therefore undertaken to investigate the effect of this alternative gel pad on PU incidence in the ICU. With the exception of the change in the gel pad used, there was no difference to the overall PU prevention strategy. No new PUs developed during the audit period with the new gel pad, although there was also no reduction in incidence compared with the previous 3 months. None of the four patients (11%) with blanching erythema developed category 1 PUs. There were also no reports of tearing or splitting with the new gel pad. The ICU staff commented that they found the new gel pad simpler to use, easier to clean and more robust than the previous product used. Following the audit, the ICU incorporated the new gel pad into its PU prevention strategy.

Medical device-related pressure ulcers: a clear case of iatrogenic harm.

There is growing evidence that medical device-related pressure ulcers (MDRPUs) are an increasing healthcare concern. Prevention and management is complicated, as they are caused by devices that are often an essential part of treatment. All clinical staff have a duty of care to do no harm. Damage caused by medical devices is iatrogenic, that is, caused through treatment, and may be exacerbated by a lack of assessment and care. This paper details a proposal to reduce the incidence of MDRPU in one UK healthcare trust. Drivers for change are identified, local organisational culture is explored and the potential impact of the change is outlined. Kotter's eight-step method for managing change and Prochaska's transtheoretical model are used to underpin the proposed change. These models were chosen due to their clearly structured approaches to change management and will enable flexible engagement with stakeholders. The article lists the resources required, sets out a possible action plan for creating change and suggests nurse-sensitive indicators and outcomes. MDRPUs are a significant and increasingly recognised issue that is within the power of healthcare teams to resolve. There is a need for collaborative working between health professionals, patients and their families to develop a solution.

The risk management of medical device-related pressure ulcers based on the Australian/New Zealand Standard.

Objective To analyse medical device-related pressure ulcer (MDRPU) management modes and their possible risks and provide references to treat MDRPUs. Methods The Australian/New Zealand Standard (AS/NZS) 4360:2004 risk management standard is the first national risk management standard in the world. Zhongshan Hospital adopted the standard to establish risk management modes to improve the MDRPU risk management process and to register, assess and analyse the key risks for MDRPUs. Eight risk types were identified and registered: organization management risk, environment risk, patient safety risk, human resource risk, infection risk, occupational safety risk, legal risk and reputational risk. Results Following the implementation of the AS/NZS 4360:2004 risk management standard in our institution, the organization management risk value decreased from 25 to 5; the environment risk value decreased from 25 to 5; the patient safety risk value decreased from 20 to 3; the human resource risk value decreased from 16 to 4; the infection risk value decreased from 9 to 1; the occupational risk value decreased from 9 to 6; the legal risk value decreased from 9 to 4; and the reputational risk value decreased from 12 to 2. Conclusion The AS/NZS 4360:2004 risk management standard was effective in managing the risk of MDRPUs.

Development of Personalized Fitting Device With 3-Dimensional Solution for Prevention of NIV Oronasal Mask-Related Pressure Ulcers.

BACKGROUND: Pressure ulcers related to oronasal masks used with noninvasive ventilation (NIV), along with patient discomfort, occur due to improper fit of the mask. We developed a personalized fitting device using a 3-dimensional (3D) scanning solution to prevent the formation of NIV mask-related pressure ulcers. This study aimed to evaluate the effectiveness of the proposed personalized fitting device. METHODS: We conducted a randomized crossover experimental study of 20 healthy participants to study the use of this personalized fitting device between the face and an NIV mask designed with 3D solutions. The fitting device was not used under the NIV mask for the control. The outcome measures were the presence of blanchable erythema, standardized redness intensity, discomfort level, and contact pressure. RESULTS: The incidence of blanchable erythema and standardized redness intensity values were significantly lower for subjects who used the fitting device when worn for 30 min (P < .001). The discomfort levels at the forehead, nasal bridge, and both cheeks, as well as leakage, were significantly reduced as well (P = .008, P < .001, P = .001, P = .002, P = .001, P = .02, P < .001, P < .001, P < .001). Contact pressure at the nasal bridge, where pressure ulcers most frequently develop, was significantly decreased with the fitting device (P < .001). CONCLUSIONS: Personalized fitting devices that incorporate 3D scanning solutions may contribute to the prevention of NIV mask-related pressure ulcers and the reduction of discomfort.