The Science Journal of the American Association for Respiratory Care

2005 OPEN FORUM Abstracts


Brenda L. Graham, RRT, Michael R. Jackson, RRT-NPS, Paul F. Nuccio, RRT, FAARC, Zara Cooper, MD, MSc, Selwyn Rogers, MD, MPH, Department of Respiratory Care, Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts.

Background: Advances in critical care and resuscitation have resulted in a growing number of patients who require prolonged ventilatory support. For those patients, a tracheotomy is usually performed. Once a patient's critical care issues are resolved, many patients can be managed outside of an intensive care unit (ICU), on a designated step-down ward or in a rehabilitation facility. At a 755-bed academic medical center, variability in the management of post-tracheotomy patients prompted a need for quality improvement.

Hypothesis: A formal, multidisciplinary trach care plan can significantly impact the care provided to this subset of the respiratory patient population.

Method: Over a six-week pre-intervention period, one respiratory therapist conducted daily surveys of all inpatients that had received a tracheotomy during that hospitalization. Daily surveys included data regarding the presence of orders and goals for tracheostomy care, presence of manual resuscitation bag at the bedside, and the employment of teaching aids prior to discharge. A total of 144 surveys were completed. An intervention was developed, which included a practice algorithm and a standardized tracheostomy care progress note and care plan. An educational booklet was distributed to patients at discharge, and respiratory therapists conducted bedside teaching. During the six-week intervention period, the same respiratory therapist completed 146 surveys of post-tracheotomy patients in the surgical and medical ICUs and the wards.

Results: In 144 surveys completed before the evaluation in the intervention, 0 (0%), patients had tracheostomy orders entered by a physician, 52 (36%) had a FiO2 or SaO2 documented during that shift, 29 (20%) had their sutures removed after 7 days, and 7 (5%) had their equipment changed every 48 hours. No patients had documentation of a daily tracheostomy plan, reason for the tracheotomy clearly documented, or teaching aids available at discharge. One hundred and forty four (100%) had a manual resuscitator bag at the bedside (figure 1). After the intervention, 146 (100%) of patients had physician orders regarding tracheostomy care. One hundred and forty-five patients (99%) had a FiO2 or SaO2 recorded during that shift, 136 (93%) had sutures removed by 7 days, and 142 (97%) had equipment changed every 48 hours. All patients had a daily plan, the reason for the tracheotomy clearly documented, and all patients received teaching aids before discharge (figure 1).

Conclusion: A simple multi-faceted intervention, consisting of a practice algorithm, standardized tracheostomy care progress note and care plan, and an educational booklet, can improve the quality of post-tracheotomy care in hospitals throughout the United States.