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A2048 - Standardized Tracheostomy Assessment Rounds in the Pediatric Intensive Care Unit
Author Block: T. J. Vece1, A. W. Plum2, M. J. Bruehl1, C. Reilly1, K. Abode3; 1Department of Pediatrics, University of North Carolina, Chapel Hill, NC, United States, 2Otolaryngology, University of North Carolina, Chapel Hill, NC, United States, 3University of North Carolina, Chapel Hill, NC, United States.
Rationale: Patients that require a tracheostomy for respiratory support often have complex medical issues and are at risk for adverse events from medical errors during hospitalization. A systematic approach is needed to ensure optimal tracheostomy care is delivered consistently. In 2000, the American Thoracic Society (ATS) developed guidelines for tracheostomy use in children, including the use of suctioning and humidification. We describe a quality improvement initiative by the NC Children’s Airway Center to optimize tracheostomy safety by initiating weekly tracheostomy assessment rounds utilizing portions of the ATS guidelines.
Methods: A multidisciplinary team including representatives from pediatric pulmonology, NC Children’s Airway Center, pediatric otolaryngology, pediatric critical care medicine and respiratory therapy applied Quality Improvement methodology with the aim to improve tracheostomy care of hospitalized children. The initial site of intervention was the Pediatric Intensive Care Unit (PICU). A checklist for weekly tracheostomy assessment rounds was developed, implemented and revised through Plan-Do-Study-Act cycles. Any checklist deficiencies were corrected real-time by the tracheostomy assessment rounds team and changes were communicated to the PICU team.
Results: The multidisciplinary team assessed current processes, issues and barriers to change. Tracheostomy assessment rounds with a nine question checklist were implemented with a tenth item added Week 2. The checklist included items on the current tracheostomy tube, back-up tracheostomy tubes, bedside documentation of tracheostomy information, and necessary tracheostomy care items such as suctioning and humidification as described in the ATS guidelines. 13 assessments were performed the first month, of which 7 were initial assessments and 6 were follow-up assessments. 4/7 initial patient assessments identified a deficiency in a checklist item. Only 1/6 follow-up encounters identified a deficiency. Other interventions included modification of communication of findings to the primary team and bedside documentation.
Conclusions: Institution of a standardized tracheostomy assessment rounds that incorporate portions of the ATS guidelines led to early identification of potential patient harm and prompt correction of issues in a PICU. Deficiencies were found more often on initial encounters, which demonstrates the need for ongoing weekly rounds. Rounds were effective in reducing the amount of deficiencies found on follow-up. Expanding rounds outside of the PICU will likely improve care in other areas of the hospital and allow for consistent tracheostomy care for these patients across hospital settings. Future work could also look into how similar tools could be utilized in the care of tracheostomy patients in outpatient settings.