1. Quality improvement initiative to prevent accidental tracheostomy decannulations in the Transitional ICU th Annual TCH Professional Day
Anne Lam MSN, RN, CPNP
Royanne Lichliter MSN, RN, CPN
Venessa Pinto MBBS, FAAP

2. Objectives
Define accidental decannulations and recognize potential adverse events
Identify opportunities for improvement and proposed plan for improvement
Learn how to integrate multidisciplinary teams in QI work at the unit level

3. Background
Patient story
What is a tracheostomy decannulation?

4. Problem Decannulations require emergent replacement
Patient harm- local site trauma, hypoxia, cardio- pulmonary arrest
Preventable
Reportable quality metric

6. Background Aligns to: IOM Domains Access to Care Care Coordination
Safe, Patient-Centered
Effective, Equitable, Effective, Timely

7. Model for Improvement (IHI)
1. What are we trying to accomplish?
-Decrease the number of accidental decannulations
-Be on par with the national average for decannulation rates
-Decrease the number of adverse events for patients with tracheostomies
2. How will know that a change is an improvement?
-By measuring the frequency and rate of accidental decannulations and adverse outcomes
3. What change can we make that will result in improvement?
-Will be discussed with PDSA Cycles

8. Project Aim Aim Statement:
We aim to reduce the rate of accidental decannulation for patients with tracheostomies, in the Transitional ICU, by 25%, by March 17th 2019.

11. Project Metrics Outcome Measures:
Incidence and rate of accidental decannulations
Adverse events:
hypoxia requiring bag ventilation or increased FiO2
bradycardia or CPR
local trauma to stoma
Balancing Measures:
Complaints of tightness of trach ties from families
Stoma site breakdown
Process Measures:
Number of loose ties identified on quality rounds

12. PDSA #1 1 finger room under trach tie 2 people to secure for infants
Education of nurses with a campaign
January 21st to February 3rd
and communication went to RN’s in the TICU
Involved the TICU nursing leadership , clinical specialists and educators.
What was learned? s inefficient, posters can create information info overload
communication reminders were sent out to the nurses and posters were made and displayed in nurse breakrooms
1 finger room under trach tie
2 people to secure for infants
3 times a day assessments (q4hrs)

13. PDSA #2 Weekly Quality Rounds by Clinical Specialist
Introduction of assessment of trach securement as part of weekly quality rounds by Clinical specialist
February 4th -17th
Rounds were conducted with bedside RN’s
Rounds were completed on patients in the TICU
Hands-on demonstration for optimal securement
Opportunity to provide in the moment feedback
Complains of tightness from patient on quality rounds. Will remain on-going through future cycles

14. PDSA #3 Mobile simulation Practice optimal trach tie securement
February 18th – March 3rd
Simulations were completed with RN’s, RT’s, and leaders
Carried out in the Transitional ICU at bedside
Novel approach that hadn’t been trialed in TICU prior
Nurses most receptive when they got to simulate

15. PDSA Cycles #4 Family/ Caregiver involvement in trach care
March 4th – 17th
The clinical specialist met with families to reinforce assessment and securement of trach ties involved
What was learned?
Difficult to implement as families are not consistently at bedside
Potential for long term benefits as families may have misconceptions about how tight to secure trach ties, and can prevent decannulations at home

18. Pre data displayed monthly
Pre data displayed monthly. Project data displayed in 2 week intervals since we would only have 3 data points if displayed monthly due to short time frame

19. 1 patient Self decannulation

21. Hypoxic event rate in 2018: 2.73/ 1000 trach days
Pre-Data- This data was for a full year, whereas our post-data is for 3 months- this is not definitive a decrease, but still important to discuss
If we look at averages, we can look at this:
Average /wk: Pre data average 0.3 episodes / week, project average episode /week
Pre- rate of 2.73% adverse events
Post, 0.75 adverse events
Hypoxic event rate in 2018: 2.73/ 1000 trach days
Hypoxic event rate in 2019 YTD: 0.75/ 1000 trach days

22. Improvement Opportunities
Most impactful intervention: Mobile simulation
Adult learning methods
Simulation
In the moment feedback
Second most helpful intervention was incorporating assessment of trach ties in quality rounds
Another means to evaluate in real time and provide direct feedback
Allows the nurses to see first hand opportunities for improvement
Real life environments, better retention
Adult learners prefer self paced, hand on learning 22

23. Study: What did you learn?
What does the data (baseline, post implementation) tell the team?
Data (lack thereof) forced us to change our project
Trend towards improvement
Describe any limitations of the data
Narrow time interval to gather data
Short duration of PDSA cycles
Compare data/outcome to predictions
The rate dropped from a median of 7 decannulations/ 1000 trach days in to 4 decannulations/ 1000 trach days for the project duration, which is over 25% reduction, as initially aimed for.
. We will need to continue measuring over time to determine the impact of the project as well as further changes that may need to be made

24. Lessons learned
Multidisciplinary teams can successfully implement QI projects at the local unit level
A project is likely to come to fruition when the team members involved are invested in the outcomes
Validate data independently
Effectiveness of mobile simulation
Nurses rely on subjective assessment of trach tie securement rather than objective measures
There are misconceptions even amongst nurses
Extraneous factors may interrupt/ delay a project
Misconceptions on how tight trach ties need to be

25. Sustainability
Assessment of trach securement will be incorporated in to quality rounds conducted by the clinical specialist in the TICU
In-situ simulations carried out weekly in the TICU SIM room.
TCH has a new position of trach coordinator who will be involved with the education of staff and families

26. Expansion
Expand incorporation of trach assessment on quality rounds in other ICUs on LT floors 9-11
Start quality rounds on night shift
Involve Tracheostomy Care process team to disseminate information house-wide

27. Overall Impact of Project
The aim of the project was met in the short time frame
Each decannulation prevented is a step in the right direction for patient safety
Improves patient and family satisfaction
Improves standing in national collaboratives
Adverse events decreased after project implementation
Decreased patient harm
Minimizes prolongation in LOS which saves $
Accidental decannulation life threatening event, detrimental to patients

28. Questions