Reduction in harm from tracheostomy‐related incidents after implementation of the paediatric National Tracheostomy Safety Project resources: A retrospective analysis from a tertiary paediatric centre

Doherty, Catherine; Bowler, M.D.; Monks, S.; English, Christine; Sadadcharam, Mira; Perkins, Russell; Bateman, Neil; Bruce, Iain; Atkinson, D.; McGrath, Brendan A.

doi:10.1111/coa.12994

Cited by 6 publications

(5 citation statements)

References 8 publications

(15 reference statements)

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“…In the 6 cases of IVP in our study, no distinct clinical features may have alerted the clinician to this diagnosis. Furthermore, radiologically, the typical feature on CT imaging associated with IVP is that of focal hyperostosis 11 which was not present on any of the scans.…”

Section: Discussionmentioning

confidence: 94%

Diagnostic challenges of antrochoanal polyps: A review of sixty‐one cases

Choudhury

Hariri

Saleh

et al. 2017

Clinical Otolaryngology

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Section: Discussionmentioning

confidence: 94%

Diagnostic challenges of antrochoanal polyps: A review of sixty‐one cases

Choudhury

Hariri

Saleh

et al. 2017

Clinical Otolaryngology

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“…Although there are clear differences between adult and paediatric tracheostomy care and practice, the recurrent themes we have identified are likely similar at an institutional and organisational level . Many of these adverse events are avoidable , and are also amenable to prospective quality improvement strategies .…”

Section: Introductionmentioning

confidence: 86%

Multidisciplinary guidelines for the management of paediatric tracheostomy emergencies

et al. 2018

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Summary Temporary and permanent tracheostomies are required in children to manage actual or anticipated long‐term ventilatory support, to aid secretion management or to manage fixed upper airway obstruction. Tracheostomies may be required from the first few moments of life, with the majority performed in children < 4 years of age. Although similarities with adult tracheostomies are apparent, there are key differences when managing the routine and emergency care of children with tracheostomies. The National Tracheostomy Safety Project identified the need for structured guidelines to aid multidisciplinary clinical decision making during paediatric tracheostomy emergencies. These guidelines describe the development of a bespoke emergency management algorithm and supporting resources. Our aim is to reduce the frequency, nature and severity of paediatric tracheostomy emergencies through preparation and education of staff, parents, carers and patients.

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“…The bundle algorithm provides step‐by‐step actions and interventions for responding to accidental tracheostomy tube dislodgement (Bontempo & Manning, 2019 ; Hood et al, 2017 ; McDonough et al, 2016 ; McGrath et al, 2012 ). The HOB Tracheostomy Communication Tool provides critical information for clinical decision‐making (Darr et al, 2012 ; Doherty, Bowler, et al, 2018 ; Doherty, Neal, et al, 2018 ; McGrath et al, 2012 ; Rajendram & McGuire, 2006 ). The Emergency Tracheostomy Kit contained necessary emergency supplies within arm's reach from the patient bed (McGrath et al, 2012 ; Mitchell et al, 2013 ; Morris et al, 2013 ; Rajendram & McGuire, 2006 ).…”

Section: Methodsmentioning

confidence: 99%

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

Jung

Grubb

Moser

et al. 2022

Journal of Clinical Nursing

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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.

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Reduction in harm from tracheostomy‐related incidents after implementation of the paediatric National Tracheostomy Safety Project resources: A retrospective analysis from a tertiary paediatric centre

Cited by 6 publications

References 8 publications

Diagnostic challenges of antrochoanal polyps: A review of sixty‐one cases

Diagnostic challenges of antrochoanal polyps: A review of sixty‐one cases

Multidisciplinary guidelines for the management of paediatric tracheostomy emergencies

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

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