Utilization of a standardized tracheostomy capping and decannulation protocol to improve patient safety.

OBJECTIVES/HYPOTHESIS: To develop and assess the feasibility of a new standardized protocol to guide tracheostomy decannulation. STUDY DESIGN: Descriptive review of quality improvement project. METHODS: A quality improvement project was conducted in the inpatient setting of a tertiary urban academic hospital. Adult patients who had received a tracheostomy and for whom the indication for tracheostomy had resolved were included. A multidisciplinary task force reviewed input from clinicians caring for tracheostomy patients and developed a protocol for screening, capping, and decannulation. The primary outcome measured was successful decannulation. RESULTS: Fifty-seven patients were screened for a capping trial over a 12-month period; 54 were capped. Six patients were lost to follow-up. Fifty patients passed the capping trial, and all 50 were decannulated successfully. When decannulation was pursued in one patient who had twice failed the screening criteria and subsequent capping trials, the patient failed decannulation and ultimately required reintubation for the management of secretions. The screening tool had high sensitivity (90%) and positive predictive value (100%) for successful decannulation. Additionally, the number of reported patient safety concerns decreased from seven in the 6 months preceding implementation of the program to one report in the 6 months after implementation. CONCLUSION: The new tracheostomy capping and decannulation protocol assisted in predicting both successful and failed decannulation. Although several patients failed certain capping criteria initially, the protocol stipulated modifications of care that enabled successful decannulation. The screening tool had high sensitivity and promoted communication, standardization of practice, and patient safety.

Model for best practice: nurse practitioner facilitated percutaneous tracheostomy service.

CONTEXT: In 2007, a tracheostomy nurse practitioner role was created to facilitate the percutaneous tracheostomy service that was established in 2005 at an urban academic tertiary care facility. The purpose of the tracheostomy nurse practitioner's role was to provide comprehensive care to tracheostomy patients. OBJECTIVE: To determine whether the addition of a tracheostomy nurse practitioner to the percutaneous tracheostomy service improves (i) standard of care (ii) efficiency of care, and (iii) patient outcomes. DESIGN: Retrospective electronic patient record and chart review comparing data before and after the addition of a tracheostomy nurse practitioner to the percutaneous tracheostomy service. METHODS: A total of 110 patients who underwent percutaneous tracheostomy in 2006 and 2008 (n = 55) were randomly selected for the study. Data were collected regarding standard of care, efficiency (n = 55) of care, and patient outcomes. SETTING: Urban, academic, tertiary care medical center OUTCOME MEASURES: Standard of care: (1) use of tracheostomy screening tool, 2) obtaining consent, 3) completeness of consent with patient's name, date, time, and signatures of patient/family, provider and witness, 4) performance of timeout, 5) use of tracheostomy postoperative order set, 6) documentation of a procedure note in the chart, and 7) and documentation of operative note in electronic patient record), efficiency of care: timeliness of the service, and patient outcomes: intensive care unit and hospital length of stay, and documented complications. RESULTS: Between 2006 and 2008, there were statistically significant improvements in 4 of 7 measures of standard of care, use of a tracheostomy screening tool, completeness of consent (documentation of time when consent was completed and presence of signature of witness), performance of time outs, and use of postoperative order set. Between 2006 and 2008, there was also a statistically significant improvement in timeliness of the service. However, there were no significant differences in the three patient outcome measures before and after the addition of the service. CONCLUSIONS: The nurse practitioner facilitated tracheostomy service significantly improved standard of care and efficiency. Relevance to Nursing: Nurse Practitioner facilitated tracheostomy service is an innovative approach to managing tracheostomy patients. The role of the advanced practice nurse as described in this study can be adopted by other institutions to improve the standard of care and efficiency of care.