QAPI 159 - The Tracheostomy Task Force: A Collaborative Approach to Improve Tracheostomy Maintenance and Care Compliance

Background: In 2022, our 317-bed facility identified gaps related to tracheostomy care and maintenance. While completing tracheostomy care, respiratory therapists (RTs) were reporting grossly soiled tracheostomy sites, dried blood, and copious respiratory secretions. We created a Tracheostomy Task Force (TTF) in September of 2022 with the objective of creating a rounding tool that could improve our care and maintenance.

Methods: We conducted a literature review on tracheostomy care and maintenance, incorporating literature from the past 20 years and our facility standard operating procedures to construct an audit tool due to limited research on this topic. Our tool focused on two key areas: physical observation of the tracheostomy site and documentation in the electronic medical record (EMR). Weekly rounding was conducted by the TTF, which included nursing, infection prevention, RTs and the head/neck coordinator. Rounds were captured electronically via Microsoft Forms and integrated into a Microsoft Power Business Intelligence dashboard.

Results: From October-November 2022, we collected a total of 43 observations to set a baseline for our facility. For the physical observations, 65% of tracheostomies were clean/dry. For EMR documentation, 79.1% of staff documented the inner cannula being changed/cleansed (day and night shift), and 86% (day shift) and 83.7% (night shift) documented performing tracheostomy care.

From December 2022 to October 2023, we continued our TTF weekly multidisciplinary rounds and a total of 201 observations were collected. For the physical observation, 91.5% of tracheostomies were clean/dry, which showed a 26% improvement. For EMR documentation, 85.1% (day shift) and 89.2% (night shift) documented the inner cannula being changed/cleansed. 90.6% (day shift), and 91.7% (night shift) documented performing tracheostomy care.

Conclusions: Our taskforce and rounding tool findings demonstrate the impact of intentional auditing and quality assurance. In addition, it highlights the role that data visualization and electronic rounding can play in improving the quality-of-care tracheostomy patients receive.