The Science Journal of the American Association for Respiratory Care

2009 OPEN FORUM Abstracts

POTENTIAL SAFETY ISSUES ASSOCIATED WITH MANAGEMENT OF TRACHEOSTOMIZED PATIENTS ON THE GENERAL WARDS—A PROCESS IMPROVEMENT PROJECT

Dean Holland1, Joanna Brown2, Jennifer De La Garza1, John Boynton1, Kenneth Hawkins1, Curtis Carey1, Marissa Drees3, Sharla Turner5, Valeria Hart4; 1Respiratory Care, Parkland Hospital, Dallas, TX; 2Speech Therapy, Parkland Health and Hospital System, Dallas, TX; 3Nursing Education, Parkland Health and Hospital System, Dallas, TX; 4Clinical Research, Parkland Health and Hospital System, Dallas, TX; 5Trauma Acute Care, Parkland Health and Hospital System, Dallas, TX

Introduction Care of tracheostomized patients in our 980-bed county facility is multidisciplinary with care delivered on several medical/surgical units. Our team identified communication problems between disciplines, lack of equipment knowledge and varying patient care skill levels as factors placing patients at risk for safety events. We addressed the variances in clinicians’ care to reduce the safety risks. Method Assessment of current practice was completed in two steps. First, we determined if appropriate safety equipment was at the bedside. Thirty-nine patient rooms assigned to tracheostomized patients were screened for 6 types of essential equipment: suction, humidity, and spare trachs. Second, we evaluated staff ’s knowledge of trach equipment and skills. A committee was formed & updated trach care procedures. Staff education, including a new protocol for safety equipment and multi-disciplinary flow sheet for equipment and patient interventions, was completed. Results Pre-intervention data showed 87.2% of the patient care rooms (n=39) had at least one safety issue with missing equipment. Over 50% of the rooms had missing spare tracheostomy tubes (see figure). Knowledge testing (n = 44) showed 98% were unable to identify bedside safety equipment and 68% were unable to correctly answer a skills question. Discussion We identified a number of potential patient safety issues related to communication, equipment, staff education and care process. Of particular concern was the high percentage of rooms missing the required safety equipment and the deficiency in staff knowledge concerning basic tracheostomy skills. The primary interventions were to standardize tracheostomy care procedures housewide and to re-educate all clinical care staff. A multi-disciplinary tracheostomy safety committee is in the process of collecting data to measure the results of our interventions. Sponsored Research - None

You are here: RCJournal.com » Past OPEN FORUM Abstracts » 2009 Abstracts » POTENTIAL SAFETY ISSUES ASSOCIATED WITH MANAGEMENT OF TRACHEOSTOMIZED PATIENTS ON THE GENERAL WARDS—A PROCESS IMPROVEMENT PROJECT