HSC Section 3 - Trauma, Critical Care and Sleep Medicine

Research Original Investigation

Standardized Tracheostomy Care and Life-Threatening Respiratory Events

Table 3. Time Spent in Each Hospital Unit Based on Location and Rapid Response Event

Preprotocol (n = 117) No Rapid Response, Mean (SD), d

Postprotocol (n = 130) No Rapid Response, Mean (SD), d

Rapid Response, Mean (SD), d

Rapid Response, Mean (SD), d

Unit

Difference (95% CI) 2.03 (1.03 to 3.03) 1.40 (0.77 to 2.02) 1.89 (−1.09 to 4.87)

Difference (95% CI) 3.02 (1.49 to 4.54) 2.11 (0.78 to 3.44) 2.89 (0.53 to 5.25)

ICU

1.54 (1.75) 0.60 (0.97) 6.97 (5.16)

3.57 (3.26) 2.00 (2.32) 8.86 (9.87)

0.48 (1.42) 2.06 (2.07) 6.11 (3.57)

3.5 (7.35) 4.17 (3.41) 9.00 (6.67)

ISCU Floor

Abbreviations: ICU, intensive care unit; ISCU, intermediate surgical care unit.

col, including hands-on staff education as to the importance of the policy, therewas an associated clinicallymeaningful re- duction in the occurrence of mucus plugging acute respira- tory emergencies. Paramount to the success of the study was the 93% penetrance of protocol adoption, which we credit to the continued vigilance of the senior respiratory therapist as a champion of the initiative during the 4-month implementa- tion and the year following. In addition, we believe creation of unit-based champions strengthened the initiative. Airway obstruction after tracheostomy is a preventable complication which can rapidly progress resulting in signifi- cant morbidity and potential mortality. Tracheostomy com- plications remain a cause of acute medical emergencies re- quiring a specialized team to intervene in immediate care. 11 Many hospitals have developed methods to teach various health care providers how to care for patients who received tracheostomy with a variety of resources. 12,13 Suctioning care prevents the development of mucus obstruction. However, standardized guidelines for tracheostomy suctioning do not exist, and the policies vary between institutions. Seeing the need to improve patient safety, our teamsought to create a standardizedprotocol as outlined in theBox, thereby reducing the occurrence of acute airway emergencies on pa- tients following tracheostomy. Mucus plugging remains a dan- gerous event in patients who received tracheostomy that can cause fatal respiratory compromise. 14 Frequent and sched- uled suctioning is a critical aspect to maintain a patent and viable airway for patients who received tracheostomy. 6 There was no additional quantifiable cost to the develop- ment of our protocol. The success of our protocol is credited to all those involved in development and implementation. These members sawthe necessity of improving patient quality of care and voluntarily chose to lead, develop, and implement a hos- pital-wide protocol without any compensation or incentive. We strongly believe reducing these events not only improves the care, outcomes, and quality of life of for our pa- tients, but also the quality of life for the physicians. The up- front work decreases downstream resource utilization (less code team activations, family discussions, phases-of-care escalations). Therefore, an important aspect to the success of our quality improvement study is the selfless teamwork and collaborative effort by all those involved. Acareprotocolisonlyeffectivewhenused,andthediligence applied to hospital-wide education inservices on this protocol was critical to its success. Despite thehigh rateof protocol adop- tion, the signal event in the postprotocol groupwas ona patient not placedontheprotocol. This furtherunderscoresnot only the importance and efficacy of a standardized protocol for airway

rapid-response calls during the specified study time frame. Preprotocol rapid-response rate was 21 of 117 cases (17.9%), and postprotocol response rate was 12 of 130 cases (9.2%) for a difference of 8.7% (95% CI, 0.2%-18%). In terms of mucus plugging, preprotocol rate was 8 of 117 cases (6.8%), and the postprotocol rate was 1 of 12 cases (0.8%) for a dif- ference of 6.0% (95% CI, 1.3%-12.2%). The 1 patient in the postprotocol group that experienced a mucus plugging rapid-response team call was 1 of the 7 patients not on the proper tracheostomy suctioning protocol. In the preprotocol group, a total of 21 rapid responseswere called: 18 (85%) occurring on the floor, 1 (5%) in the ISCU, and 2 (10%) in the ICU. Of the 8 mucus plugging events, 7 (88%) occurred on the floor and 1 (12%) in the ICU. In the postproto- col group, a total of 12 rapid responses occurred, with 9 (75%) on the floor, 3 (25%) in the ISCU, and none in the ICU. The sole mucus plugging event occurred on the floor. Level-of-care changes consisted of unit changes of either floor to ISCU, floor to ICU, or ISCU to ICU. In the preprotocol group, 7 level changes occurred with rapid responses with 4 (57.1%) of them due to mucus plugging. In the postprotocol group, there were 3 total level-of-care changes, with none of them due to mucus plugging. Three hospital locations (ICU, ISCU, and the floor) were of interest, and mean length of stay (days) in each unit was cal- culated. Datawere stratifiedbasedonwhether the patients had a rapid-response event within the preprotocol and postpro- tocol group ( Table 3 ). The difference inmean of length of stay for each unit was also calculated within the preprotocol and postprotocol group. The difference inmean length of staywas determined by taking the mean length of stay of the rapid- response group and subtracting it by the mean length of stay in the no rapid-response group. In the preprotocol group, the difference inmean length of stay (days) between the no rapid-response group and rapid- response group was 2.03 (95% CI, 1.03 to 3.03) for the ICU; 1.40 (95%CI, 0.77 to 2.02) for the ISCU; and 1.89 (95%CI, −1.09 to 4.87) for the floor. In the postprotocol group, the differ- ence in mean length of stay (days) between the no rapid- response group and rapid-response group was 3.02 (95% CI, 1.49 to4.54) for the ICU; 2.11 (95%CI, 0.78 to 3.44) for the ISCU; and 2.89 (95% CI, 0.53 to 5.25) for the floor.

Discussion Our study demonstrated that after the careful creation and thorough implementation of our tracheostomy care proto-

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

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