Anne Lam MSN, RN, CPNP Royanne Lichliter MSN, RN, CPN Venessa Pinto MBBS, FAAP

1. Quality improvement initiative to prevent accidental tracheostomy decannulations in the Transitional ICU2019 4th Annual TCH Professional Day Anne Lam MSN, RN, CPNP Royanne Lichliter MSN, RN, CPN Venessa Pinto MBBS, FAAP

2. Objectives • Define accidental decannulations and recognize potential adverse events • Identify opportunities for improvement and proposed plan for improvement • Learn how to integrate multidisciplinary teams in QI work at the unit level

3. Background • Patient story • What is a tracheostomy decannulation?

4. Problem • Decannulations require emergent replacement • Patient harm- local site trauma, hypoxia, cardio-pulmonary arrest • Preventable • Reportable quality metric

6. Background Aligns to: Access to Care Care Coordination IOM Domains Safe, Patient-Centered Effective, Equitable, Effective, Timely

7. Model for Improvement (IHI) 1. What are we trying to accomplish? -Decrease the number of accidental decannulations -Be on par with the national average for decannulation rates -Decrease the number of adverse events for patients with tracheostomies 2. How will know that a change is an improvement? -By measuring the frequency and rate of accidental decannulations and adverse outcomes 3. What change can we make that will result in improvement? -Will be discussed with PDSA Cycles

8. Project Aim Aim Statement: We aim to reduce the rate of accidental decannulation for patients with tracheostomies, in the Transitional ICU, by 25%, by March 17th 2019.

11. Project Metrics Outcome Measures: Incidence and rate of accidental decannulations Adverse events: hypoxia requiring bag ventilation or increased FiO2 bradycardia or CPR local trauma to stoma Balancing Measures: Complaints of tightness of trach ties from families Stoma site breakdown Process Measures: Number of loose ties identified on quality rounds

12. PDSA #1 Education of nurses with a 1-2-3 campaign January 21st to February 3rd Email and communication went to RN’s in the TICU Involved the TICU nursing leadership , clinical specialists and educators. What was learned? Emails inefficient, posters can create information info overload

13. PDSA #2 Weekly Quality Rounds by Clinical Specialist Introduction of assessment of trach securement as part of weekly quality rounds by Clinical specialist February 4th -17th Rounds were conducted with bedside RN’s Rounds were completed on patients in the TICU Hands-on demonstration for optimal securement Opportunity to provide in the moment feedback

14. PDSA #3 Mobile simulation Practice optimal trach tie securement February 18th – March 3rd Simulations were completed with RN’s, RT’s, and leaders Carried out in the Transitional ICU at bedside Novel approach that hadn’t been trialed in TICU prior Nurses most receptive when they got to simulate

15. PDSA Cycles#4 Family/ Caregiver involvement in trach care March 4th – 17th The clinical specialist met with families to reinforce assessment and securement of trach ties involved What was learned? Difficult to implement as families are not consistently at bedside Potential for long term benefits as families may have misconceptions about how tight to secure trach ties, and can prevent decannulations at home

21. Hypoxic event rate in 2018: 2.73/ 1000 trach days Hypoxic event rate in 2019 YTD: 0.75/ 1000 trach days

22. Improvement Opportunities Most impactful intervention: Mobile simulation Adult learning methods Simulation In the moment feedback Second most helpful intervention was incorporating assessment of trach ties in quality rounds Another means to evaluate in real time and provide direct feedback Allows the nurses to see first hand opportunities for improvement

23. Study: What did you learn? What does the data (baseline, post implementation) tell the team? Data (lack thereof) forced us to change our project Trend towards improvement Describe any limitations of the data Narrow time interval to gather data Short duration of PDSA cycles Compare data/outcome to predictions The rate dropped from a median of 7 decannulations/ 1000 trach days in 2018 to 4 decannulations/ 1000 trach days for the project duration, which is over 25% reduction, as initially aimed for.

24. Lessons learned • Multidisciplinary teams can successfully implement QI projects at the local unit level • A project is likely to come to fruition when the team members involved are invested in the outcomes • Validate data independently • Effectiveness of mobile simulation • Nurses rely on subjective assessment of trach tie securement rather than objective measures • There are misconceptions even amongst nurses • Extraneous factors may interrupt/ delay a project

25. Sustainability • Assessment of trach securement will be incorporated in to quality rounds conducted by the clinical specialist in the TICU • In-situ simulations carried out weekly in the TICU SIM room. • TCH has a new position of trach coordinator who will be involved with the education of staff and families

26. Expansion • Expand incorporation of trach assessment on quality rounds in other ICUs on LT floors 9-11 • Start quality rounds on night shift • Involve Tracheostomy Care process team to disseminate information house-wide

27. Overall Impact of Project • The aim of the project was met in the short time frame • Each decannulation prevented is a step in the right direction for patient safety • Improves patient and family satisfaction • Improves standing in national collaboratives • Adverse events decreased after project implementation • Decreased patient harm • Minimizes prolongation in LOS which saves $

28. Questions