Quality improvement strategies for preventing tracheostomy-related pressure injuries in children: a systematic review and meta-analysis

Background Children with tracheostomies represent a high-risk population for medical device-related pressure injuries (MDRPI) due to prolonged cannulation, immature skin, limited mobility, and exposure to secretions, consistent with NPIAP/EPUAP definitions. The development of pressure injuries not only prolongs hospitalization and escalates healthcare costs but may also precipitate severe infectious complications. Although diverse preventive strategies have been implemented in clinical settings, evidence-based synthesis specifically targeting the pediatric population remains scarce, and the comparative effectiveness of these interventions continues to be debated. Objective To systematically evaluate the efficacy of interventions for preventing pressure injuries in tracheostomized children and to compare, through meta-analysis, the impact of different preventive measures (including securement methods and dressing types) on pressure injury incidence and severity, thereby furnishing an evidence base for clinical nursing practice. Methods A comprehensive computerized search of Chinese and international databases was conducted to identify clinical studies examining preventive interventions for pressure injuries in children (aged ≤18 years) with tracheostomies. Meta-analyses of pressure injury incidence were performed using R software and STATA. Results A total of 6 studies encompassing 736 participants were included. Direct Bayesian meta-analysis of three studies comparing Velcro® ties with conventional twill ties showed a reduction in adverse event risk favoring the Velcro® group (OR = 0.26, 95% CrI 0.07–0.94), with a continuity correction of 0.5 applied for zero events. Bayesian network meta-analysis comparing Mepilex®, Mepilex® Ag, and standard care revealed that, relative to control, the OR for Mepilex® was 0.83 (95% CrI: 0.02–21.48) and for Mepilex® Ag was 0.32 (95% CrI: 0.003–11.37). Node-splitting analyses indicated no significant inconsistency between direct and indirect evidence (all p 0.05). The OR for Mepilex® Ag compared to Mepilex® was 0.37 (95%CI: 0.01–11.11), with none achieving statistical significance. SUCRA rankings indicated that Mepilex® Ag demonstrated the highest probability of being the optimal intervention (SUCRA = 97.6%), followed by standard care (SUCRA = 52.2%) and Mepilex® (SUCRA = 0.1%). These findings suggest that Mepilex® Ag had a higher cumulative probability across rank distributions compared with other interventions; however, none of the pairwise comparisons were statistically significant, and credible intervals were wide, indicating substantial uncertainty. The SUCRA ranking should be interpreted as indicative rather than definitive. Conclusion This systematic review and meta-analysis provides preliminary evidence supporting the potential value of silver-containing foam dressings and Velcro®-type securement devices in preventing tracheostomy-related pressure injuries among pediatric patients. However, the certainty of evidence remains moderate, constrained by the limited number of available studies, variable methodological quality, and substantial heterogeneity. Clinical decision-makers should integrate individual patient characteristics, resource availability, and cost-effectiveness considerations when selecting appropriate preventive regimens. High-quality randomized controlled trials and real-world studies are urgently warranted to establish standardized clinical practice guidelines for preventing tracheostomy-related pressure injuries in children, ultimately improving outcomes for this vulnerable population. Systematic Review Registration INPLASY202650137 ( INPLASY.COM , DOI: 10.37766/inplasy2026.5.0137 ).