HSC Section 3 - Trauma, Critical Care and Sleep Medicine

Research Original Investigation

Standardized Tracheostomy Care and Life-Threatening Respiratory Events

T racheostomies are performed for a variety of reasons, including major surgical operations of the head and neck, airway obstructions, prolonged intubation, and aspiration. 1,2 While a tracheostomy provides the patient se- cure access to the airway, without proper care, the tracheos- tomy tube can become obstructed from secretions leading to emergent airway distress. 3 Obstructionof a tracheostomy tube with mucus plugging is a known preventable complication that results in rapid respiratory distress. In the hospital set- ting, this leads to rapid-response calls, escalation in the levels of care, and if not cleared, death from asphyxiation. It is therefore critical the tracheostomy tube remain patent to ensure safe respiration and patient convalescence. Tracheostomy alters the natural airway lining and there- fore can make the patient more vulnerable to mucus plugging caused by hypersecretion of the cell linings. 4 Untreated mu- cus plugging may become rapidly fatal. To reduce the occur- rence of mucus obstruction, tracheostomy care with saline flushes and suctioning remains a common practice in the hos- pital setting. 5 While no particular consensus exists as to exact frequency of suctioning for those with tracheostomies, gener- ally it is accepted that the tracheostomy tube inner cannula be removed twice daily for cleaning and the patient otherwise re- ceive frequent saline lavage and suctioning in between with a frequencyatthediscretionofthephysician. 6 Inthefirstfewdays after placement of the tracheostomy tube it is also recognized inthesurgicalliteraturethatpatientsecretionsaretypicallymore copious and thus require more frequent attention. 5 Emergency airway control poses a serious challenge for physicians in the hospital setting. Many health care institu- tions have adopted the practice of creating a specialized team to evaluate and treat patients that have serious complica- tions, including airway compromise. 7-10 Our institution has rapid-response teams that respond when called on by a member of the staff taking care of the patient. Ideally, proper management and care of the patient with a recent tracheos- tomy would reduce the chances of respiratory events and thus secondarily reduce the occurrence of these rapid- response team calls for life-threatening mucus plugging. In addition, avoidance of these preventable events reduces the physical and psychological stress to the patient and thereby improves the quality and safety of care. While the importance of tracheostomy care is common knowledge among otolaryngologists and respiratory thera- pists, such knowledge is not a pervasive within other medical disciplines, nursing staff, or ancillary providers. The senior au- thor (T.H.) recognized a series of patients inour institutionwho had suffered fromlife-threateningmucus pluggingwithindays following tracheostomy. Upon investigation of these cases by the surgeon and senior respiratory therapist, they uncovered a significant knowledge gap among the nursing staff on the floor and intensive care units, as well as nonotolaryngology physi- cians, with respect to appropriate tracheostomy care. While education across all health care professionals can address specificknowledgegaps andshouldbeperformed, toensurepa- tient safety, standardized care protocols are an excellent tool because they provide a concrete structure and reference for all health care professionals for a variety of situations.

The objective of this study was to examine whether implementation of a postoperative tracheostomy care proto- col would reduce the occurrence of life-threatening mucus plugging, as assessed by the occurrence of rapid-response calls. In addition, we aimed to examine how prevention of this sentinel event and the use of rapid-response calls could influence the duration and quality of care patients receive during their stay in the hospital. Methods The institutional review board of the University of North Carolina granted exemption for this retrospective cohort quality improvement study. Clinical logs were requested of adult patients who underwent fresh surgical airways from May 2014 to August 2016; written informed consent was not required because patient records were deidentified. Tracheostomy Care Root Cause Analysis and Assessment Amultidisciplinary collaborative airway task force of otolaryn- gology surgeons, nurse practitioners, and a senior respiratory therapistwas formed to investigate the respiratoryevents inpa- tientsfollowingtracheostomy.Aroot-causeanalysisofthesecases revealeda lackof clear orders on somepatients, but also that de- spiteactiveordersfor“routinetracheostomycare,”includingtra- cheostomy tube cleanings twicedailyand saline lavage and suc- tioning every 2 to4hours as needed inother patients, therewas lackof adherence to theordersby the floor staff, aswell asuncer- taintytopropertracheostomycarebythestaff.Clearly,therewas a significant patient safety issue due to both inconsistent and unclear orders by theprimary team, aswell as significant knowl- edgegapamongproviderscaringforpatientswithtracheostomies. Protocol Development In response to the results of the root cause analysis, the task force determined 2 objectives: (1) to design a clear standard- ized posttracheostomy care protocol, and (2) to develop an implementation plan to maximize adherence of the protocol by all hospital personnel. The task force developed an agreed upon current “best practice” guidelines for care of postopera- tive tracheostomy patients based upon their years of exper- tise in the management of these patients ( Box ). Key Points Question What is the effect of implementation of a tracheostomy care protocol on the occurrence of life-threatening respiratory compromise? Findings A cohort study of 247 patients (117 preprotocol and 130 postprotocol) who received tracheostomy was conducted. More patients in the preprotocol group experienced a mucus plugging rapid response than in the postprotocol group, showing a reduction of mucus plugging events after protocol implementation. Meaning Implementation of a standardized tracheostomy care guideline was associated with the reduction in the occurrence of life-threatening respiratory compromise.

JAMA Otolaryngology–Head & Neck Surgery June 2018 Volume 144, Number 6 (Reprinted)

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