Global Tracheostomy Collaborative: The Future of Quality Improvement Strategies

Tracheostomy clinical practices and patient outcomes in three tertiary metropolitan hospitals in Australia

BACKGROUND

There is a paucity of literature in Australia on patient-focused tracheostomy outcomes and process outcomes. Exploration of processes of care enables teams to identify and address existing barriers that may prevent earlier therapeutic interventions that could improve patient outcomes following critical care survival.

OBJECTIVES

The objectives of this study were to examine and provide baseline data and associations between tracheostomy clinical practices and patient outcomes across three large metropolitan hospitals.

METHODS

We performed a retrospective multisite observational study in three tertiary metropolitan Australian health services who are members of the Global Tracheostomy Collaborative. Deidentified data were entered into the Global Tracheostomy Collaborative database from Jan 2016 to Dec 2019. Descriptive statistics were used for the reported outcomes of length of stay, mortality, tracheostomy-related adverse events and complications, tracheostomy insertion, airway, mechanical ventilation, communication, swallowing, nutrition, length of cannulation, and decannulation. Pearson's correlation coefficient and one-way analyses of variance were performed to examine associations between variables.

RESULTS

The total cohort was 380 patients. The in-hospital mortality of the study cohort was 13%. Overall median hospital length of stay was 46 days (interquartile range: 31-74). Length of cannulation was shorter in patients who did not experience any tracheostomy-related adverse events (p= 0.036) and who utilised nonverbal communication methods (p = 0.041). Few patients (8%) utilised verbal communication methods while mechanically ventilated, compared with 80% who utilised a one-way speaking valve while off the ventilator. Oral intake was commenced in 20% of patients prior to decannulation. Patient nutritional intake varied prior to and at the time of decannulation. Decannulation occurred in 83% of patients.

CONCLUSIONS

This study provides baseline data for tracheostomy outcomes across three large metropolitan Australian hospitals. Most outcomes were comparable with previous international and local studies. Future research is warranted to explore the impact of earlier nonverbal communication and interventions targeting the reduction in tracheostomy-related adverse events.

Factors associated with short versus prolonged tracheostomy length of cannulation and the relationship between length of cannulation and adverse events

BACKGROUND

Tracheostomy management and care is multifaceted and costly, commonly involving complex patients with prolonged hospitalisation. Currently, there are no agreed definitions of short and prolonged length of tracheostomy cannulation (LOC) and no consensus regarding the key factors that may be associated with time to decannulation.

OBJECTIVES

The aims of this study were to identify the factors associated with short and prolonged LOC and to examine the number of tracheostomy-related adverse events of patients who had short LOC versus prolonged LOC.

METHODS

A retrospective observational study was undertaken at a large metropolitan tertiary hospital. Factors known at the time of tracheostomy insertion, including patient, acuity, medical, airway, and tracheostomy factors, were analysed using Cox proportional hazards model and Kaplan-Meier survival curves, with statistically significant factors then analysed using univariate logistic regression to determine a relationship to short or prolonged LOC as defined by the lowest and highest quartiles of the study cohort. The number of tracheostomy-related adverse events was analysed using the Kaplan-Meier survival curve.

RESULTS

One hundred twenty patients met the inclusion criteria. Patients who had their tracheostomy performed for loss of upper airway were associated with short LOC (odds ratio [OR]: 2.30 (95% confidence interval [CI]: 1.01-5.25) p = 0.049). Three factors were associated with prolonged LOC: an abdominal/gastrointestinal tract diagnosis (OR: 5.00 [95% CI: 1.40-17.87] p = 0.013), major surgery (OR: 2.51 [95% CI: 1.05-6.01] p = 0.038), and intubation for >12 days (OR: 0.30 [95% CI: 0.09-0.97] p = 0.044). Patients who had one or ≥2 tracheostomy-related adverse events had a high likelihood of prolonged LOC (OR: 5.21 [95% CI: 1.95-13.94] p = ≤0.001 and OR: 12.17 [95% CI: 2.68-55.32] p ≤ 0.001, respectively).

CONCLUSION

Some factors that are known at the time of tracheostomy insertion are associated with duration of tracheostomy cannulation. Tracheostomy-related adverse events are related to a high risk of prolonged LOC.

Association of a Multidisciplinary Care Approach With the Quality of Care After Pediatric Tracheostomy

Importance

Incidence of tracheostomy placement in children is increasing, and these children continue to have high incidences of morbidity and mortality. A multidisciplinary tracheostomy program may help improve the quality of care received by these patients.

Objective

To determine whether implementation of a multidisciplinary tracheostomy program can improve the care of children who received a tracheostomy through reduction in tracheostomy-related adverse events (TRAEs), improved tracheostomy education, and caregiver preparedness.

Design, Setting, and Participants

A prospective cohort study was conducted from January 2015 to June 2018 at a pediatric tertiary referral center in Boston, Massachusetts. The participants included 700 children who had received a tracheostomy, most of whom were aged birth to 18 years, but some patients with congenital disorders were much older.

Exposures

Institution of a multidisciplinary tracheostomy team (MDT) whose activities included conducting staff meetings, organizing outpatient clinics, conducting inpatient tracheostomy ward rounds, and conducting inpatient tracheostomy rounds at a local rehabilitation hospital. Quality improvement initiatives included monitoring standardized TRAEs and distributing standardized tracheostomy "go-bags."

Main Outcomes and Measures

Reduction of TRAEs and improved caregiver preparedness through distribution of tracheostomy go-bags were assessed following the establishment of a multidisciplinary tracheostomy program.

Results

In total, 700 children who had received a tracheostomy during the study period were actively followed up by the MDT. Of these children, 378 (54.0%) were males and 322 (46.0%) were females; mean (SD) age was 4.1 (6.1) years. More than 60 new pediatric tracheostomies were performed annually at the referral center. Reported TRAEs were reduced by 43.0% from the first to the third year after the implementation of a standardized, closed-loop monitoring system (from a mean [SD] of 6.1 [5.2] TRAEs per 1000 inpatient tracheostomy-days in 2015 to a mean [SD] of 4.0 [2.5] in 2018). The most common TRAE was unplanned decannulation, which occurred 64 times during the study period. On average, 10 patients were seen in each monthly multidisciplinary tracheostomy clinic. Clinic interventions included continuing care (146 [52.5%]), communication enhancement (67 [23.6%]), plans for decannulation (52 [18.6%]), and referrals for comorbidities (13 [4.6%]). Approximately 19 inpatients were seen during biweekly rounds and 8 during monthly rounds at a local rehabilitation hospital. A total of 297 patients received standardized tracheostomy go-bags, and more than 70 positive bag checks were performed in the monthly MDT clinics. A positive bag check refers to the incidence when a family is given a go-bag and also uses it. In contrast, a negative bag check refers to when a family is given a go-bag but neither brings it to the clinic nor acknowledges that they use it.

Conclusions and Relevance

This study's findings suggest that a multidisciplinary tracheostomy program may be a powerful tool for enhancing patient safety and quality improvement. Ongoing studies will develop measurable pediatric tracheostomy outcome metrics and assess long-term outcomes.

Enhancing care of patients requiring a tracheostomy: A sustained quality improvement project

INTRODUCTION

Within the UK approximately 5000 surgical and 12,000 percutaneous tracheostomies are performed annually. Whilst an essential component of patient care, the presence of a tracheostomy is not without concern. Landmark papers have demonstrated recurrent themes related to the provision of training, staff and equipment, leading to avoidable patient harm, life-altering morbidity and mortality. The development of the Global Tracheostomy Collaborative (GTC) and the Improving Tracheostomy Care (ITC) project have provided the necessary infrastructure to make improvements, with individual organizations responsible for its implementation.

METHOD

This quality improvement project, funded by the NHS Wales Critical Care and Trauma Network, developed a dedicated tracheostomy team to improve the quality of care provided to those patients requiring a tracheostomy through staff education, equipment standardisation and multidisciplinary tracheostomy ward rounds. Global Tracheostomy membership was funded through involvement in the ITC project.

RESULTS

Formal tracheostomy teaching was delivered by the tracheostomy team to 165 clinicians involved in tracheostomy care. Improvements in self-assessed confidence with knowledge and were observed for all aspects of tracheostomy care. Standardisation and centralisation resulted in reduction in waste and unnecessary variation. Compliance with 'emergency tracheostomy blue box' availability with an increase from 5% to 100%. Comparison of data from the QI period against baseline data, demonstrated improvement in rates of decannulation, and non-significant improvements in time to decannulation, critical care and hospital length of stay. Additionally, there were associated reductions in adverse events.

CONCLUSION

This QI project, supported by involvement with the GTC and ITC, resulted in reductions in adverse events, improved patient safety, non-significant reduction in time to achieve weaning milestones and a reduction in hospital length of stay.

The efficacy of tracheostomy tube changes by speech-language pathologists: A retrospective review

Background/Aims:

The number of tracheostomised patients in the acute care setting are increasing, resulting in an equal need of providers who can safely change tracheostomy tubes without complications. The objective of this retrospective study was to ascertain if trained speech-language pathologists were able to safely and efficiently perform tracheostomy tube changes in the acute care setting with minimal adverse events.

Methods:

Our retrospective case series spans from June 2010 to March 2015 and was completed at an academic hospital with a level 1 trauma designation. A total of 107 consecutive referrals undergoing a tracheostomy tube change, with a speech-language pathologist, were identified. Success was defined as the placement of the tracheostomy tube into the tracheal lumen with confirmation of placement. Only complications occurring at the time of the tracheostomy tube change were considered and were defined as an airway loss event: oxygen desaturation <85%; uncontrollable bleeding >5mL; and the inability to perform the attempted tracheostomy tube change for any other reason.

Results:

All of the tracheostomy tubes changes were performed at the bedside at a mean of 13 days post tracheotomy (range 3–28). A total of 106 (99%) of 107 tracheostomy tubes changes were successfully completed without complications; 83 (79%) of the tracheostomy tubes changes performed were the initial tracheostomy tubes change completed post tracheotomy. The remaining 23 (21%) were a combination of either the second or third change. One, (less than 1%), of the procedures was attempted and discontinued before the removal of the tracheostomy tubes, and referred back to the surgical services and was successfully managed with no untoward effects to the patient.

Conclusions:

This is the first study to audit the outcome of speech-language pathologists' ability to successfully change a tracheostomy tube. The findings suggest that specially trained speech-language pathologists, acting as part of a multi-disciplinary care team, have the potential to safely change tracheostomy tubes in an acute care setting with the availability of immediate physician and respiratory therapy support. Additional clinical benefits of the speech-language pathologist changing tracheostomy tubes may include earlier facilitation of communication, decannulation and initiation of nutrition/hydration.

Improving the quality of tracheostomy care

Educational aims

To understand the current challenges in the care of tracheostomy patients

To understand principles of quality improvement collaboration and how this can improve the quality of care for tracheostomy patients

Summary

The UK National Confidential Enquiry into Patient Outcomes and Death illustrates that there remains significant morbidity and mortality relating to patients with a tracheostomy, with much preventable harm. Challenges include the inherent complexity of the patient's underlying condition, wide variations in tracheostomy management, variable delivery of education for staff, patients and families, and difficult coordination of care between such a variety of individuals involved in performing, managing and ultimately removing tracheostomies.

Quality-improvement collaboratives are groups of institutions with a common purpose who work together to drive positive change. They help support clinicians in developing skills and teams necessary to design and sustain quality-improvement cycles. They are a cost-effective way of rapidly disseminating improvement strategies and engaging in shared learning across institutions around the world. The Global Tracheostomy Collaborative aims to improve quality of care and outcomes through five interdependent key drivers: coordinated multidisciplinary team care, education, institution-wide protocols, family and patient-centred care, and metrics and outcomes using a specifically designed database.