Association of Standardized Tracheostomy Care Protocol Implementation and Reinforcement With the Prevention of Life-Threatening Respiratory Events

Implementation of an evidence-based accidental tracheostomy dislodgement bundle in a community hospital critical care unit

BACKGROUND

Tracheostomy dislodgment can lead to catastrophic neurological injury or death. A fresh tracheostomy amplifies the risk of such events, where an immature tract predisposes to false passage. Unfortunately, few resources exist to prepare healthcare professionals to manage this airway emergency.

AIM

To create and implement an accidental tracheostomy dislodgement (ATD) bundle to improve knowledge and comfort when responding to ATD.

MATERIALS & METHODS

A multidisciplinary team with expertise in tracheostomy developed a 3-part ATD bundle including (1) Tracheostomy Dislodgement Algorithm, (2) Head of Bed Tracheostomy Communication Tool and (3) Emergency Tracheostomy Kit. The team tested the bundle during the COVID-19 pandemic in a community hospital critical care unit with the engagement of nurses and Respiratory Care Practitioners. Baseline and post-implementation knowledge and comfort levels were measured using Dorton's Tracheotomy Education Self-Assessment Questionnaire, and adherence to protocol was assessed. Reporting follows the revised Standards for Quality Improvement Reporting Excellence (SQUIRE).

RESULTS

Twenty-four participants completed pre-test and post-test questionnaires. The median knowledge score on the Likert scale increased from 4.0 (IQR = 1.0) pre-test to 5.0 (IQR = 1.0) post-test. The median comfort level score increased from 38.0 (IQR = 7.0) pre-test to 40.0 (IQR = 5.0) post-test). In patient rooms, adherence was 100% for the Head of Bed Tracheostomy Communication Tool and Emergency Tracheostomy Kit. The adherence rate for using the Dislodgement Algorithm was 55% in ICU and 40% in SCU.

DISCUSSION

This study addresses the void of tracheostomy research conducted in local community hospitals. The improvement in knowledge and comfort in managing ATD is reassuring, given the knowledge gap among practitioners demonstrated in prior literature. The ATD bundle assessed in this study represents a streamlined approach for bedside clinicians - definitive management of ATD should adhere to comprehensive multidisciplinary guidelines.

CONCLUSIONS

ATD bundle implementation increased knowledge and comfort levels with managing ATD. Further studies must assess whether ATD bundles and other standardised approaches to airway emergencies reduce adverse events. Relevance to Clinical Practice A streamlined intervention bundle employed at the unit level can significantly improve knowledge and comfort in managing ATD, which may reduce morbidity and mortality in critically ill patients with tracheostomy.

Tracheostomy and Laryngectomy Airway Safety Events: An Analysis of Patient Safety Reports From 84 Hospitals

Background: Tracheostomy- and laryngectomy-related airway safety events can lead to life-threatening situations, permanent harm, or death. We conducted a statewide population-based study to learn about these events and the relationship with associated factors, interventions, and outcomes to identify potential areas for improvement. Methods: We queried the Pennsylvania Patient Safety Reporting System (PA-PSRS) to find tracheostomy- and laryngectomy-related airway safety event reports involving adults age 18 years and older that occurred between January 1, 2018, and December 31, 2020. Results: Reports related to tracheostomies and laryngectomies accounted for 97.3% and 2.7% of the total, respectively. The four most frequent tracheostomy-related complications were unplanned decannulations, 71.4%; uncontrolled bleeding/hemorrhage, 9.2%; and partial/total occlusion and mucus plug/thick secretions, which each accounted for 6.9%. Conclusions: Safe airway management for patients with a tracheostomy or laryngectomy requires staff who are knowledgeable and confident, and have the necessary skills and equipment to provide immediate attention when complications arise. We discuss potential safety strategies to reduce the risk of unplanned decannulations, uncontrolled bleeding/hemorrhage, and partial/total occlusions, as well as issues related to equipment, knowledge/training, and communication.

Multidisciplinary Safety Recommendations After Tracheostomy During COVID-19 Pandemic: State of the Art Review

OBJECTIVE

In the chronic phase of the COVID-19 pandemic, questions have arisen regarding the care of patients with a tracheostomy and downstream management. This review addresses gaps in the literature regarding posttracheostomy care, emphasizing safety of multidisciplinary teams, coordinating complex care needs, and identifying and managing late complications of prolonged intubation and tracheostomy.

DATA SOURCES

PubMed, Cochrane Library, Scopus, Google Scholar, institutional guidance documents.

REVIEW METHODS

Literature through June 2020 on the care of patients with a tracheostomy was reviewed, including consensus statements, clinical practice guidelines, institutional guidance, and scientific literature on COVID-19 and SARS-CoV-2 virology and immunology. Where data were lacking, expert opinions were aggregated and adjudicated to arrive at consensus recommendations.

CONCLUSIONS

Best practices in caring for patients after a tracheostomy during the COVID-19 pandemic are multifaceted, encompassing precautions during aerosol-generating procedures; minimizing exposure risks to health care workers, caregivers, and patients; ensuring safe, timely tracheostomy care; and identifying and managing laryngotracheal injury, such as vocal fold injury, posterior glottic stenosis, and subglottic stenosis that may affect speech, swallowing, and airway protection. We present recommended approaches to tracheostomy care, outlining modifications to conventional algorithms, raising vigilance for heightened risks of bleeding or other complications, and offering recommendations for personal protective equipment, equipment, care protocols, and personnel.

IMPLICATIONS FOR PRACTICE

Treatment of patients with a tracheostomy in the COVID-19 pandemic requires foresight and may rival procedural considerations in tracheostomy in their complexity. By considering patient-specific factors, mitigating transmission risks, optimizing the clinical environment, and detecting late manifestations of severe COVID-19, clinicians can ensure due vigilance and quality care.