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

Abstract

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.

Effectiveness of interprofessional tracheostomy teams: A systematic review

“…Adverse events related to tracheostomy management are often devastating as they may lead to hypoxic brain injury and death. Common adverse events include tracheostomy tube blockage from mucus plugs, bleeding, tube dislodgments, airway injury and infections (Brenner et al, 2020; Jung et al, 2022; Kumar et al, 2019; Moser et al, 2022). Regular assessments of the tracheostomy tube site and timely suctioning of tracheostomy tubes can prevent several of these adverse events.…”

Improving airway management and tracheostomy care through interprofessional collaboration: aligning timing, technique, and teamwork

“…The need for an unplanned tracheostomy tube exchange suggests an extreme safety risk of respiratory compromise, partial dislodgment, accidental decannulation, or device-related pressure injury. Incorrect caliber, angulation, or length can lead to unintended endobronchial placement, erosion of the luminal surface, and patient discomfort (16)(17)(18)(19). Furthermore, an inadequate seal can result in loss of positive end-expiratory pressure (PEEP), derecruitment, and aerosolization of virus-laden particles, with risk of transmission to healthcare workers.…”

Intervenções de enfermagem na prevenção de complicações da via aérea na pessoa com traqueostomia em unidade de cuidados intensivos

“…A exteriorização acidental da cânula de traqueostomia é uma das maiores complicações, podendo provocar lesões catastróficas na pessoa (Jung et al, 2022). É descrito na evidência, que atrasos na gestão da deslocação de cânula de traqueostomia podem levar ao compromisso da VA, a lesões neurológicas e à morte (Jung et al, 2022).…”

“…A exteriorização acidental da cânula de traqueostomia é uma das maiores complicações, podendo provocar lesões catastróficas na pessoa (Jung et al, 2022). É descrito na evidência, que atrasos na gestão da deslocação de cânula de traqueostomia podem levar ao compromisso da VA, a lesões neurológicas e à morte (Jung et al, 2022). Esta condição revela-se mais perigosa em pessoas com traqueostomia recente, inferior a uma semana (Jung et al, 2022), e pode levar à morte em quase 100% das pessoas (Silva et al, 2009).…”

“…É descrito na evidência, que atrasos na gestão da deslocação de cânula de traqueostomia podem levar ao compromisso da VA, a lesões neurológicas e à morte (Jung et al, 2022). Esta condição revela-se mais perigosa em pessoas com traqueostomia recente, inferior a uma semana (Jung et al, 2022), e pode levar à morte em quase 100% das pessoas (Silva et al, 2009). Identifica-se que 50% das mortes relacionadas com a VA estavam associadas com a deslocação da cânula de traqueostomia (McDonough et al, 2016).…”