Reducing the Incidence of Noninvasive Face Mask-Related Skin Breakdown

Abstract

Background: Noninvasive ventilation (NIV) is a common respiratory modality used for patients with acute respiratory failure. It involves use of an oronasal mask, held in place with straps on patient’s face to provide ventilatory support without using artificial airways. NIV use for longer duration and mask strap tension are associated with increased risk of skin breakdown at the nose bridge as well as cheeks, leading to reportable medical device-related injuries. The development of medical device-related skin injuries among hospitalized patients is a growing concern. The primary aim of this quality improvement project was to reduce the incidence of NIV related reportable, pressure ulcers among adult patients with acute respiratory failure.

Methods: This was a collaborative, quality improvement (QI) project conducted at an academic medical center from July 2018–June 2020. All adult patients who received continuous NIV for acute respiratory failure were enrolled. The QI plan was devised to include key drivers of change: 1) prophylactic use of a foam dressing (Mepilex Lite) at the initiation of NIV; 2) Q4H skin assessment by bedside nurse and respiratory therapists, and 3) mask rotation for patients receiving NIV > 24 h. Mask rotation refers to sequential use of different masks (eg, oronasal to full face mask) to offload and redistribute the pressure on the underlying skin. The incidence of reportable, stage II and above, hospital acquired pressure injuries related to NIV mask occurred during pre-QI phase (July 2019–June 2019) were compared with the post- QI phase (July–June 2020).

Results: During the pre-implementation phase, a total of 8 NIV mask-related, Stage II and above, skin injuries were reported (incidence rate 0.04 per 1,000 patient days). In the post implementation phase, there were total 2 NIV mask-related, Stage II and above, skin injuries identified (incidence rate 0.01 per 1,000 patient days). With the QI plan focused on the prophylactic measures and collaborative efforts between respiratory therapists and nurses, reportable NIV mask related injuries were reduced by 25%. The median Braden Score for pre-QI cohort was 14.5 (IQR 14.5–15) and 13 (13–13) for post-QI cohort representing moderate risk level for developing pressure sores in both the groups.

Conclusions: The bundle-based QI plan including prophylactic foam dressing, Q4H skin assessments, and mask rotation was beneficial in reducing the incidence of NIV mask-related, reportable skin injuries in an adult population.