Background: Mucus plugging after tracheostomy is a known, but preventable complication, and typically the result of inadequate tracheostomy care. At our institution, tracheostomy care was previously variable and non-standardized, placing patients at risk for obstructive events. We hypothesized that developing a standardize and uniformly adopted post tracheostomy care protocol would reduce mucous plugging events in our patients, improving the quality of patient care.
Methods : As a multidisciplinary group, we designed a standardized hospital-wide tracheostomy care/suctioning protocol (Figure 1). To determine the impact of the protocol, we sought to compare the number of respiratory “rapid response” calls on tracheostomy patients before and after the implementation. To determine the efficacy of the protocol, we performed an IRB-approved retrospective chart review including all tracheostomy and total laryngectomy patients at our institution for one year prior to and one year after a 4-month protocol implementation period. Tracheostomy indication, rapid responses, length of stay and time spent in escalated levels of care (e.g. intensive care unit) were obtained.
Figure 1: Trachestomy Care Protocol.
Results: A total of 247 patients met inclusion criteria; 117 pre-protocol and 130 post protocol. There were no significant differences in the indication for airway surgery between the pre-protocol and post protocol groups; planned surgeries (70% vs 70%), treatment of obstruction (30% vs 28%). Penetrance of protocol utilization was seen in 123 (93%) of the post-protocol patients.
A total of 21 (18%) rapid responses (RR) occurred in the pre-protocol group; 8 (7%) due to mucus plugging. Protocol implementation resulted in reductions in RR with a total of 12 (9%) RR occurred in the post protocol group with only 1 (0.8%) due to mucus plugging. In addition, the one patient with a RR for mucus plugging in the post protocol group was not on protocol. The successful reduction in overall RR in the post protocol group resulted almost exclusively from the near elimination of respiratory events (0.8%)
Intragroup significance tests were conducted to compare times spent within the various units in the hospital. For the pre-protocol group, patients with a RR spent a significantly longer time in the ICU (p= 0.0030) and Stepdown units (p=0.0022), compared to patients who did not have an event. Specifically, patients, who experienced a respiratory RR also spent significantly longer time in the ICU (p=0.0183) than patients who did not have an event. For the post-protocol group, similar significant differences were seen in ICU stay (p= 0.0029) and stepdown stay (p= 0.0220) for the overall RR groups. However, as the respiratory specific rapid responses were nearly eliminated, no significance tests could be calculated between that sole individual with a respiratory event and the non RR group.
Conclusion: Implementation of a standardized tracheostomy care protocol successfully reduced the occurrence of rapid response calls for life threatening mucus plugging in our institution, and thereby the overall RR rate, improving the quality of patient care and reducing burden to the intensive care units. Future projects will focus on protocol developments to address other preventable RR events.