Abstract
Background: An unplanned decannulation (UD) event represents the uncontrolled and/or accidental removal of a tracheostomy tube. Tracheostomy tubes are essential interventions in patients with airway needs. UD events can have serious consequences but are not as well studied as unplanned extubations (UE) of endotracheal tubes. At our free-standing pediatric hospital (260-bed pediatric hospital, Level 1 Trauma, Level IV NICU), we recognized that despite a robust review system for UE events, we had no standardized method of reporting and analyzing UD events. We aimed to implement a multidisciplinary quality improvement (QI) workgroup to review its effect on UD events and target ongoing QI to prevent UD.
Methods: In January 2024, we convened a multidisciplinary UD leadership QI workgroup, which included RNs, MDs, patient safety specialists, and RTs. Using QI methodology, key tasks were created. The workgroup began by creating and implementing an IRB-exempt data collection form for completion following any UD event, which included instruction to notify the leadership QI group post event and submit the form for review. As forms were completed, the workgroup documented UD rates by recording UD events per tracheostomy patient days. Forms were reviewed by the group and analyzed for common causes and linked to our institution’s quality and safety dashboard. To ensure that all events were captured, more precise reasons for tracheostomy tube removal, including UD, were added as documentation options in the electronic medical record (EMR).
Results: Before the formation of a UD leadership QI workgroup in January 2024, there was no standardized documentation of UD events. After the workgroup’s implementation we captured 30 UDs in all hospital areas for the first 5 months of 2024. UDs occurred in all units with tracheostomy patients except the NICU. Behavioral challenges were cited as the most common reason for UD. Associated consequences ranged from no impact to CPR. Some patients had multiple UD events.
Conclusions: Formation of a UD leadership group has allowed for improved awareness of UD events. Accurate data collection and focus on the issue of UD has led to interventions designed to lessen the frequency of UDs including requiring sitters to take a tracheostomy education course, increasing nursing staffing ratios for certain airway patients, and providing simulations including UD to multidisciplinary staff.
Footnotes
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