Tracheostomy Thursday: Journey of a Staff-driven COVID-19 Initiative to International Recognition.

OBJECTIVE: To use evidence-based practice and an interprofessional approach to improve outcomes for adult patients with tracheostomies and enhance staff knowledge during the COVID-19 pandemic. METHODS: The core interprofessional Tracheostomy Thursday team included staff nurses, respiratory therapists, and nursing leadership who collaborated with surgeons and materials management staff at an urban academic medical center in New York, the epicenter of the COVID-19 pandemic in the US. The team implemented hospital-wide bedside rounds on all adults with tracheostomies. Skin and safety assessments were performed with peer-to-peer coaching. Data were collected and analyzed to understand areas of improvement. RESULTS: After 6 months of hospital-wide rounding, implementation of a bedside tracheostomy safety checklist, and a continued interprofessional approach, safety measures increased by 48%, and preventive dressing use increased by 24% with improvement in preventing tracheostomy-related medical device-related pressure injuries. The team's work was professionally recognized through institutional policy change, conference poster presentations, and Sigma's international excellence award. CONCLUSION: Bundling an interprofessional approach, staff education, bedside rounds, and standard preventive measures was key to the team's success. A bedside safety checklist fostered team communication and supported direct care nurses in managing individuals with a new tracheostomy.

Skin Failure Among Critically Ill Patients Afflicted with Coronavirus Disease 2019 (COVID-19).

Objective: To characterize skin integrity among coronavirus disease 2019 (COVID-19) patients treated in the intensive care unit (ICU), and identify risk factors for skin failure (SF) in these patients. Design: The characteristic, profound pro-inflammatory, hypercoagulable state of COVID-19 is manifested by the high severity of illness and extensive organ dysfunction observed in these patients. SF in critically ill patients, although described previously, exhibits a uniquely complex pathogenesis in this population. Patients: Retrospective review of all COVID-19 patients (confirmed positive for severe acute respiratory syndrome coronavirus-2 [SARS-CoV-2]) admitted to a single surgical ICU for at least 48 hours between March-June 2020. Interventions: Data were extracted from a COVID-19 institutional data repository that harvested data from electronic health records and other clinical data sources. Demographics; coagulation/inflammation biomarkers; number, location, and stage of SF lesions; resource utilization; and outcomes were captured. Measurements and Main Results: 64 patients met inclusion criteria; 51 (80%) developed SF (SF+ ). Forty-three (85%) developed stage 3 or higher SF (χ2 = 22.66, P < .0001). Thirty-nine of 51 (76%) SF+ patients developed more than one SF lesion (χ2 = 13.26, P = .0003). SF+ patients manifested a profound pro-inflammatory, hypercoagulable phenotype (lower serum albumin and higher ferritin, interleukin [IL]-6 and D-dimer concentrations [all, P < .001]). Durations of mechanical ventilation, vasopressor therapy, and ICU length of stay were significantly longer (all, P < .05) in the SF + patients. Conclusions: The unique characteristics of COVID-19 dermatopathology and the strong correlation between markers of inflammation and development of SF reflect COVID-19-related organ dysfunction and its deleterious effects on the microcirculation. Considering that skin is invaded directly by SARS-CoV-2 and affected by COVID-19-related immune complex deposition and microthrombosis, SF may reflect disease as opposed to pressure injuries related to processes of care. In the context of COVID-19 critical illness, SF should not be considered a "never event."