2018 Quality Week Awareness Poster Competition Raising Awareness on Tracheostomy Patient Safety and Best Clinical Practices

1. Quality Assurance Week 2018
©Omayra M. Perez, BSHA/HM, RRT

2. Patient Safety Week 2018
Adult Tracheostomy Patient Safety and Quality Care Improvement
Initiative Program
Promote and support the implementation of hospital wide care
systems that reduce tracheostomy-related adverse events. This
education poster aims to:
 Understand the current challenges in the care of tracheostomy
patients.
 Identify principles of tracheostomy care quality improvement
initiative and collaboration and how this can improve the
quality of care for this patient population.
Five Key Drivers
Understanding tracheostomy care management and procedural risk factors
associated with tracheostomy in acute care facilities will help guide safety
and quality improvement initiative. The following are five interdependent
key drivers at the core of a tracheostomy patient safety and quality
improvement program:
 Team-based care
 Standard protocol
 Staff education and assignment
 Patient and caregiver involvement
 Data collection
Respiratory
Therapist

3. In 2015, the American Thoracic Society reported the United
States performed 1,352,432 adults tracheostomy from 1993 –
2012 (9.1 % of Mechanically Ventilated patients). (Mehata et al
American Thoracic Society, 2015)
10-
20%
Tracheostomy-
related adverse
events including
preventable
injury to death.
(Mehata et al
American
Thoracic Society,
2015)
Tracheotomy
performed on critically
ill patients performed
because of the need
for mechanical
ventilation. (Shah et al
Laryngoscope 2012)
24%
Case Study Report:
Returned verdict
against hospital and
doctors in negligent
removal of a patient’s
tracheostomy tube.
The jury returned a
verdict in favor of the
plaintiff for $15.26
Million. (Relias, 2014)
$15
Million

4. Care of Adult Tracheostomy Patients in Acute care
Facilities
• Maintaining a patent airway
• Stabilization of the tracheostomy tube
• Cuff management
• Maintaining humification
• Suction of respiratory secretions
• Care of inner cannula
• Changing tracheostomy tube
• Prevention of infection
 Oral Hygiene
 Stoma care
 Visual inspection of stoma site
• Swallowing
 Swallowing Assessment
 Speaking Valves/ Capping
• Facilitating Communication
 Achieving speech in non-ventilated patients.
• Weaning to decannulation
• Management of complications and emergencies
• Patient-caregiver education and support
Occluded
Tracheostomy
Tube with dried
secretions
Suprastomal/Tracheal
Granuloma
Tracheostomy
Infection
Sterile
Tracheostomy
Tube

5. Adult Tracheostomy
Indications, Risks
Complications
Incident Classification
Infrastructure (staffing
and patient location)
Incidents.
Blockage or
displacement of the
tracheostomy tube
after placement.
Equipment incidents
(usually lack of proper
equipment or
inappropriate use).
Competency (lack of
skills and knowledge)
related incidents.
General Indications
• Acute respiratory failure with the expected need for prolonged
mechanical ventilation.
• Failure to wean from mechanical ventilation.
• Upper airway obstruction, difficult airway.
• Copious secretions.
Tracheostomy-Related Pressure Ulcer (TRPU)
• 2.5 million patients develop pressure ulcers annually in the United
States (AHRQ, 2014)
• Percentage of Tracheostomy-related pressure ulcer statistics
unavailable due to lack of data collection by hospitals.
Nosocomial Infection
• Infections most frequently associated with tracheostomies are
either tracheobronchitis or pneumonia. (i.e. Ventilator-associated
pneumonia (VAP) and Hospital-acquired pneumonia (HAP).
Late Complications
• Tracheomalacia, stenosis, development of granuloma/s,
infection of trachea and around trachesotomy tube, trachea-
esophageal fistula.

6. Tracheostomy Stoma Infection
• Redness
• Weeping
• Purulent drainage
• Fever
• Swelling
• Heat
• Maggots
Subcutaneous Emphysema (SE)
.
• Air trapping in tissues under the skin.
• Visual sign of SE is swelling around
the neck accompanied with pain in
the chest.
• Immobility of the tube flange to the bony prominences
of the clavicles (i.e. trach tube tie and twill tie secured
to tightly.)
• Immobility of the trachesotomy flange when secured
by sutures.
• Presence of moisture from expelled tracheal secretions.
Tracheostomy
Risks
Complications
maggots
Velcro Trach
Tie or Twill
trach Tie
Tracheostomy-Related Pressure Ulcer

7. Tracheostomy
Patient
Safety
• Patients undergoing tracheostomies are at a
higher risk for both inpatient and outpatient
complications, as well for recurring 30-day hospital
readmission. (Spartaro et al, Laryngoscope 2017)

8. Team-Base Care
1st Key Driver
Tracheostomy Care Management Takes a Team
Outcome
Standardize care provided by a specialized
multidisciplinary tracheostomy team,
following patients to their discharge was
associated with fewer tracheostomy-
related complications and increase in use
of a speaking valve and decannulation.
(Mestral et al., 2011)
Why implement a Tracheostomy Care
Management Multidisciplinary Team?
.
Policy & Procedures
Healthcare system wide
implementation of policies and
evidence-based practices (EBP)
and procedures, which outline
the expected management of
patients with a tracheostomy or
laryngectomy.
Team meets twice a week for
rounds involving patients
transitioned from intensive care
unit (ICU) to medical and surgical
wards leading up to patient
discharge.
Multidisciplinary
Tracheostomy Team
• Surgeon
• Surgical Resident
• Respiratory Therapist
• Speech-Language Pathologist
• Clinical Nurse Specialist
• Social Worker
National Patient Safety Week 2018
Benefits of a
Multidisciplinary
Team
Goal
Tracheostomy
Patient
Management
Trachesotomy patients are often lost to follow-
up on transfer from the ICU to medical and
surgical wards staff with varying levels of
experience and skills are than required to
assume the responsibility of tracheostomy care

9. Standard of Care
2nd Key Driver: Policies & Procedures
Change of Shift Check
The tracheostomy patient requires diligent
observation & assessment. The following
information should be readily available:
• Why does the patient have a trachesotomy?
• Date tracheotomy was performed. Last date
changed.
• Bed-head sign posted above pt.’s HOB
(pertinent tracheostomy information (i.e. may
have implication for ease of re-insertion).
• Type and size of tracheostomy tube (i.e. Shiley,
Portex, cuffed, fenestrated.) Availability of
spare tracheostomy kit, emergency trach box,
and emergency equipment (i.e. BVM, 10 ml
syringe, functioning Oxygen flow meter.)
• Patient cough effort
• Ability to swallow
• Sputum characteristics
• Check and/or change inner cannula if occluded
with buildup of secretions.
• Check trachesotmy tube is secured and clean.
• Check tracheostomy inner tube is clean and
secured.
• Document cuff deflated and if inflated.
• Document cuff pressure
Suction
Suctioning Systems care be ‘open’ or ‘closed’.
• Open system (Single-use catheter)
• Closed system (Multiple uses)
 Clean closed system catheter
following use with sterile water.
 Respiratory Therapist (RT) will
changed closed-system suction
catheter every 72 hrs. per policy.
• Suction Catheter Selection:
 (Size of tracheostomy tube -2) x 2=
Correct French gauge
Pressures for suctioning
• Adult patient suction regulator normal
range 80-120 mmHg.
• Most published research agree a pressure
exceeding 150 mmHg should be avoided.
Pre-hyper oxygenate patient prior to
suctioning
• Periods of suctioning should not exceed 10
seconds to avoid mucosal damage.
• Limit suctioning episodes to no more than 3,
when suctioning in succession.
Emergency Equipment
The following emergency equipment must
be kept at a tracheostomy patients’ bedside,
and when patient transport internally:
• Functioning suction regulator and oxygen
flow meter in patient room.
• Appropriate sized suction catheters (e.g.
closed vs open suction catheter system).
• Yankauer
• Adult bag valve-mask with reservoir and
tubing.
• Spare tracheostomy tube (one of the
same size and one tube one size down)
with obturator and inner cannula.
• Tracheostomy neck tie
• 10 ml syringe
• Tracheostomy Intubation Emergency Box
(e.g. end-tidal co2, pink tape, etc.)

10. Standard of Care
2nd Key Driver: Policies & Procedures
Stoma Care
• Stoma should be checked and cleaned every
12 hrs. or as needed.
• Stoma skin should be assessed for bleeding,
appearance of stoma edges, and peristomal
skin for infection or redness.
• Two clinicians must always be present when
changing a patient’s trach tie. One person
changes the tie while the other hold the
trachesotmy tube in place.
• Pre-hyper oxygenate patient before, during
if required, and reassess post stoma care.
• Clean the stoma site with a gauze or cotton-
tip applicator soaked in normal saline.
• Dry stoma site surrounding area if required.
• Assess the stoma site to assess if barrier film
is required.
• Apply Allevyn tracheostomy dressing.
Humification
Bypassing, the upper airway produces a
detrimental humidity deficit in the airways.
• Humification of the bypassed airway is a
standard of care for tracheostomy patients.
Stabilization of the Tube
• The tube has to be maintaining in a
neutral position, avoiding angling and
contact between the tracheal mucosa and
the tube.
• The trach tie should be changed at least
once daily (except within the first 72 hrs.
of a new tracheostomy)
• Assessment of the neck every 12 hrs. and
documented with abnormalities reported
to MD.
• Closed-suction catheters system when
used the suction tube, should be
supported to prevent lateral drag on the
trach tube.
• If the patient is on a ventilator, the tubing
should be supported by a ventilator arm.
Maintain tube in central position with no
lateral drug.
• Inspired gases must be humified to maintain
effective mucociliary function and gas
exchange and prevent complications.
• Water-bottle humifiers must not be left to
run dry due to risk of airway burns.

11. Posey Cufflator
Pressure Manometer
Cuff Pressure Management
• Tracheal capillary pressures lies between 20 – 30 mmHg an impairment of
this blood flow will be caused by an obstruction between 22 -37 mmhg.
• The complications from the continued use of an over inflated cuff
include:
 Tracheal stenosis/Tracheal Malacia
 Tracheo—esophageal fistula
 Tracheo–innominate artery fistula (an artery near the trachea can
get damaged due to prolong pressure.
• The accepted pressure is the minimum pressure required to prevent a leak
but which must not exceed 35 cmH20.
• The research suggest that the cuff pressure should be kept between
15–25 cmH2o.
• Check cuff pressure every 8 hrs.
Cuff Leaks/Sources of leaks:
• Defective or damaged cuff
• Cuff not adequately inflated
• Patient is requiring high ventilatory pressures and/or PEEP/CPAP which
exceed the sealing capacity of the cuff.
• Tube does not fit the airway:
 Tube too small
 Positional change can cause a leak
 Tracheomalacia or wound breakdown

12. Standard of Care:
Documents
.
Tracheostomy-Related Pressure Ulcer Bundle
(TRAPU) (RUSH University Medical Center, 2014)
Emergency Tracheostomy Management –
Patent Upper Airway Algorithm Sign
Displayed
above the
head-of-the-
bed (HOB)
Displayed in
visual area, Inside
tracheostomy
patient room
Tracheostomy Transfer of Care Checklist

13. 3rd Key
Driver
 Ensuring that all bedside
clinical staff for tracheostomy
patients are competent to
recognize and manage
common airway complications
including tube obstruction and
displacement.
 Provide Clinical Simulation lab
education sessions to clinicians
on medical and surgical wards
that frequently see
trachesotomy patients.
Track Progress
Staff Education
&
Competencies
01 02 03
Measure Competence
Outcome
 Decrease in
tracheostomy-related
incidences.
 Decrease in hospital-
length-of-stay (LOS).
 Improved
tracheostomy patient
outcome.
 Overall cost savings
Improve patient outcome
 Participant demonstrates
clinical knowledge and skill
in tracheostomy care
with/o assistance and/or
direct supervision.

14. Patient & Caregiver: Education
4th Key Driver
Critical Care Tracheostomy Patient
Information Leaflet
Patient/ Caregiver interactive
video education
Patient Engagement Apps
According to the Agency for Healthcare
Research and Quality (AHRQ)1, patients being
discharged from the hospital are 30% less likely
to be readmitted or visit the emergency
department when they have a clear
understanding of their after-hospital care
instructions (AHRQ, 2014)
• The aim of the leaflet is to provide
information on the procedure and its
benefits and risks.
• Educate patient on home tracheostomy
care.
• Tracheostomy emergency
preparedness training and
management.
Tracheostomy is still
socially stigmatized
and can intimidate
both the patient and
family members/
caregivers.
(Lindman et al., 2017)
• Interactive multimedia programs that
use animations, illustration, and full
narration to simplify tracheostomy
home care information.
• Videos can enhance retention up to
50%. (Elsevier, 2018)
• National Tracheostomy Safety Prospect App
 Passy Trach Tool App
 NTSP App
• JAB talk
 A free speech communication tool
that aids non-verbal children and
adults communicate.

15. What the Data Shows
5th Key Driver: Data Collection
Impact of a Specialized
Multidisciplinary Tracheostomy
Team on Tracheostomy Care in
Critically Ill Patients Case
Report
According to a study report published in 2010
by McGill University Health Center, a tertiary
care – level 1 trauma center and teaching
hospital, located in Montreal, Canada, the
following data resulted after a year long study
preceding the launch of the Multidisciplinary
Tracheostomy Team Program: Results
 Decrease in incidence of tube blockage/
obstruction (5.5% v.25% p= 0.001)
 Respiratory distress calls (16.7%v. 37.5%,
p < 0.001) after instituted team.
 The study reported a significantly increase
in the percentage of patients that were
weaned to speaking valves (67.4% v.
19.4%, p <0.001) post-implementation of
the team. (Mestral et al, Canadian Journal
of Surgery, 2010)
Hospital and Long-Term Outcome After
Tracheostom for Respiratory Failure
Study conducted by a urban, tertiary-care medical
center on four hundred twenty-nine adult patients
with tracheostomy for respiratory failure between
January 1, 1998 and December 31, 2000. The
following are the results of the study:
 Hospital mortality was 19%
 Only 57% of survivors were liberated from
mechanical ventilation.
 Patients liberated from mechanical ventilation
and having their tracheostomy tube decannulated
had the lowest mortality (8%) at year); the
mortality of ventilator-dependent patient was
highest (57%).
 Medium hospital direct variable cost was $29,340
(Engoren, 2004)
 60 Billion expected national bill in the year 2020
associated with prolonged mechanical ventilation
(Yu et al, 2010)
Prevention of Tracheostomy-
Related Hospital-Acquired
Pressure Ulcer (TRAPUs)
In 2014, RUSH University Hospital, located in
Chicago, adapted an institution wide
tracheostomy-related acquired pressure ulcer
bundle resulting in a significant reduction in
the incidence of TRAPUs.
The study aimed to determine if
standardization of perioperative
tracheostomy care procedure decreased the
incidence of hospital-acquired TRAPUs.
The Results:
Percentage (%) of Adult Tracheostomy
Surgery Patients with TRAPS
2013-14 Rate (Pre-Intervention): 10.93%
2014-15 Rate (Post-Intervention): 1.29%
P=.0003 (O’Toole et al, 2017)

16. Respiratory Department
Quality
Assurance
Quality Assurance
Week 2018
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