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Tracheostomy manipulations: Impact on tracheostomy safety
Alexandra G Espinel1, Kelly Scriven1, Rahul K Shah1
1Division of Otolaryngology Children's National Medical Center Washington DC USA.
Insights
Reducing tracheostomy tube manipulations in pediatric patients may decrease serious complications and shorten hospital stays. Frequent manipulation increases the risk of adverse events like accidental decannulation and airway loss.
Area of Science:
- Pediatric Otolaryngology
- Quality Improvement Initiatives
- Patient Safety
Background:
- Tracheotomy is a high-risk procedure in pediatric otolaryngology.
- Tracheostomy tube manipulation poses a risk for patient morbidity, including accidental decannulation and airway loss.
Purpose of the Study:
- To determine the frequency of tracheostomy tube manipulations in pediatric patients from placement to discharge.
- To identify if increased manipulation correlates with higher morbidity rates.
Main Methods:
- A 12-month quality improvement initiative mapped tracheostomy care.
- Reviewed tracheostomy care, manipulation by providers, complications, wound care, and respiratory treatments.
Main Results:
- Patients averaged 39 days hospitalization; first tube change at 6 days.
- Tracheostomy tubes were manipulated an average of 6 times/day (216 total).
- Increased manipulation (>4/day) correlated with higher complication risk (OR: 12.5, P=0.0349).
Conclusions:
- Reducing tracheostomy manipulations can enhance postoperative care safety.
- Fewer manipulations may decrease morbidity and mortality, and shorten hospital length of stay.
- Physicians performed only 2% of the average 6 daily manipulations.
Importance:
Tracheotomy is one of the riskiest procedures for composite morbidity within pediatric otolaryngology. During the postoperative period, each time the tracheostomy tube is manipulated, there is opportunity for morbidity (e.g. a patient is vulnerable to accidental decannulation and airway loss).
Objective:
To identify areas of improvement in caring for "fresh tracheostomy" patients by determining the number of times a tracheostomy tube is manipulated from placement until discharge. The hypothesis is that the more a tracheostomy is manipulated, the higher probability of morbidity.
Methods:
A quality improvement initiative was conducted to map the care of patients who underwent tracheostomy placement over 12 months. Tracheostomy care and manipulation by all providers were reviewed. Complications, wound care, and respiratory treatments were also evaluated.
Results:
Patients were hospitalized for an average of 39 days (7-140) following tracheostomy. The first tracheostomy tube change occurred on average 6 days (5-10) following placement. Tracheostomy tubes were manipulated an average of 6 (2.5-11.9) times a day to amount to 216 (51-1091) times between placement and discharge. Bedside nurses and respiratory therapists were responsible for 95% of these actions; physicians accounted for 4%. There were 6 tracheostomy related complications. Three were accidental decannulations resulting in cardiopulmonary arrest. One of these caused long term patient morbidity. Patients with more than 4 manipulations per day during the 2 weeks following tracheostomy tube placement, were more likely to have a tracheostomy related complication than those with less than 4 (OR: 12.5; 95% CI: 1.2-130.6; P = 0.0349).
Interpretation:
While uncommon, complications related to tracheostomy can have serious long term effects and at best prolongs length of stay for patients. Reducing the number of tracheostomy manipulations may provide safer postoperative care ultimately reducing morbidity and potentially mortality; children on average have 6 tracheotomy manipulations/day with only 2% being by the physician.
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