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Tracheostomy Audit: Factors affecting tracheostomy outcome in

critically ill patients

Dr Carren Teh Dr Lye Meng Hon

Dr Megalah a/p Selvamani

Dr Sobani Bin Din Dr Fadzilah Ismail

Improving post tracheostomy

complication rates in Hospital Sungai Buloh

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OUTLINE OF PROBLEM

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• 20 May 2006 – commencement of service• 3 sub-units : ENT, Audiology dan Speech and swallowing therapy

Problems Identification

1. High post tracheostomy complication rate2. Synechia post nasal operations3. High incidence of hearing impairment not

detected at birth

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Prioritization of ProblemsS M A R T total

High post trachestomy complications

15 15 15 15 15 75

Synechia post nasal surgery 12 15 12 15 15 69

High incidence of hearing impairment not detected at birth

12 13 14 11 10 60

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Reason for Choosing

Seriousness Complications Increased post operative morbidity / mortalityTracheostomy is frequently done by ORL team in emergency / semi-emergency setting

Measurable Data is available from eHIS system and quantifiable

Appropriateness Improve clinical outcome of patients

Remedial Remedial action can be done with active involvement from multidiscipline

Timeliness The study can be completed within the short period of time

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Reasons for Rejection

• Synechia post nasal surgery– Less severe complication– Infrequent number of cases

• High incidence of hearing impairment not detected at birth– Remedial measures require increase in resources

(beyond control of department)– High risk screening program already in place

2008 2009 2010 2011 2012 2013 20140

20

40

60

80

100

120

140

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65 64

113119 124 124

Number of open tracheostomies performed in Hospital Sg Buloh

Data for 2014 is up to end of August

A clinical audit was recently conducted

and the findings led us to believe a QA

will be beneficial

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Tracheostomy done 106

mortality 47 (44.3%)

Weaned off tracheostomy

40 (37.7%)

NCEPOD Tracheostomy Care: On the Right Trach? (2014)

HSgB findings:

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Mortality rates

Overall 30 day mortality rate is 15-25%

AE Kejner, Castellanos PF, Rosenthal EL, MT Hawn. All-Cause Mortality after Tracheostomy at a Tertiary Care Hospital over 10- Month period. ORL-

Head and Neck Surg. 2012; 146 (6): 918-22

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• Factors significantly improving survival– Indian race– Absence of co-morbidities– Normal platelet values

• Factors significantly improving success of weaning– Presence of co-morbidities

• Factors giving rise to failure of weaning– Duration of intubation less than 7 days

POSSIBLE KEY MEASURES FOR IMPROVEMENT

NOT PRACTICAL!

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Complication rates

Tracheostomy-related complications were reported for 6.3% and most common complication was bleeding

D Young, DA Harrison, B Cuthberson, Effect of Early vs Late Tracheostomy Placement on Survival

in Patients Receiving Mechanical Ventilation The TracMan Randomized Trial. JAMA. 2013;309(20):2121-2129

HSgB Post operative complication : 10.4%

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Complication rates

• The 6% rate of major or serious insertion complications – major bleeding, posterior tracheal wall injury, pneumothorax and death

• The majority (5% overall rate) of the major insertion complications were related to bleeding

AJ Glossop, TC Meekings, SP Hutchinson, SJ Webber Complications following tracheostomy insertion in critically ill patients – experience from a large teaching hospital. JICS The Intensive Care Society 2011 Volume 12, Number

4, October 2011

Complication rates

Overall, complication rates in this study were 5.6%, for early complications.

SL Halum. A Multi-Institutional Analysis of Tracheotomy Complications . Laryngoscope, 122:38–45, 2012

2.8%

3.8%

2.8%

In HSgB

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Improving post tracheostomy complication rates in Hospital

Sungai Buloh

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Nursing Care

Excellent nursing care is the cornerstone for reducing the morbidity and postoperative complications of tracheostomy.

B Huffman, H Emam, M Stevens. Tracheostomy with emphasis on perioperative nursing care. Journal of Nursing Education and Practice, 2014,

Vol. 4(3). 13-19

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STANDARDIZED TRAINING

A standardized education module for tracheostomy care teaching resulted in significant increases in provider knowledge and confidence.

JC Yelverton, JH Nguyen, W Wan, MC Kenerson, TA Schuman. Effectiveness of a standardized education process for tracheostomy care. Laryngoscope 2014

Jul 8. Epub 2014 Jul 8.

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Problem Statement

• What: high post trachestomy complication rate• Who: critically ill patients, healthcare providers,

family members• When: pre-, intra- and post-op• Why: to improve patient outcome• How: proper pre-op preparation, improving post

operative nursing care, provide adequate training

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Goal

• To reduce post tracheostomy complication rates.

• To reduce mortality rate of post tracheostomy patients.

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Improve post tracheostomy complication rates

improve surgical technique

Improve training among surgeons Improve training

among OT staff

Anticipate Difficult cases

Optimize blood parameters

Evaluate difficult

anatomy

Improve pre-operative conditions

Withhold anti-platelet / anti-

coagulant

improve post operative care

improve nursing care Educate

family members

Problem AnalysisSpecialist to

standby during anticipated

difficult cases

Review patients post-op

Improve communication

between referral team and ORL

team

Revamp tracheostomy care course

Initiate online referral letter with checklist

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Study Objectives

General objective:• To reduce the percentage of post tracheostomy

complication in Hospital Sungai Buloh

Specific objectives:• To identify contributing factors• To formulate intervention strategies• To carry out remedial action efficiently

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Key Measures For Improvement

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Ideal Process of Care

Referral from primary care team

Assessment and examination

Plan and pre-operative preparation

Patient not optimized

Surgery

Post operative care

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Model of Good CareProcess Criteria StandardReferral from primary team Patient referred with

documented referral letter100%

Primary teams justify indication for tracheostomy

100%

Referred patient assessed within 24Hours

80%

Assessment and examination Complicated cases assessed by specialist

100%

All patients with anterior neck swelling to undergo USG -neck

100%

Results of lab tests and previous results are ready

100%

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Process Criteria StandardPlan and pre-operative preparation

Surgical candidates with Hb > 10.0 80%

Surgical candidates with PLT > 100 80%Surgical candidates with urea < 23 80%Surgical candidates with INR < 1.5 80%Withhold anti-platelets and anti-coagulants for adequate duration

80%

Surgery Non-credentialed medical officer to be supervised during tracheostomy

100%

Specialist to standby during anticipated difficult tracheostomy

100%

Post operative care Post –op assessment by surgeon on post op Day 1

100%

ORL medical officer to review patient during trachy tube first change

100%

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Indicator and Standard

• Indicator:= number of patients with post tracheosotmy complications total number of patients undergoing tracheostomy

• Standards:– Post tracheostomy early complications: 5.6%

x 100

SL Halum. A Multi-Institutional Analysis of Tracheotomy Complications . Laryngoscope, 122:38–45, 2012

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PROCESS OF GATHERING INFORMATION

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Methodology

Study design cross-sectional study from 1 January 2014 to 31 December 2014

Study sample all patients underwent semi-emergency / emergency open tracheostomy

Sampling technique universal samplingInclusion Criteria Patients who underwent tracheostomy

from Jan 2014 to Dec 2014

Exclusion Criteria ENT CasesElective CasesIncomplete data

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Data Collection Method

• Duration of study– Verification Study: 2 weeks– Remedial measures : 3 months– First phase study: 1 month

• Instrument– IT recorded sources (eHIS)– Checklist with data tabulation

• Data analysis– SPSS / Excel

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Data Collection

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Strategies

• To initiate a new online referral letter form in eHIS which incorporates a checklist– Valid indication for tracheostomy.– Lastest blood investigation .

• To revamp tracheostomy care courses / workshop – Tracheostomy care courses for health care

providers.

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Gantt Chart

Mar15

Apr15

May15

Jun15

Jul15

Aug15

Sept15

Proposal and verification

Briefing and training

Data collection

Analysis of data

Remedial measures

Reevaluation 2nd stage

Report writing

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THANK YOU