TRACH SAFE-- Eliminating unanticipated death in pediatric tracheostomy patients at home Leslie Elder, MSN, RN, CCM; Leslee Hill, RRT, LRCP; John Dahl, M.D.; Kelly Evans M.D., Kaalan Johnson, M.D.; Sanjay R. Parikh, M.D.; Amanda Striegl, M.D.; Thida Ong, M.D.
Trach Safe is a model of patient safety, support and education--so we may all breathe easier
Trach Safe Airway Diagram
Pre-discharge airway endoscopy in the OR for all children with a new tracheostomy tube Answers two vital airway emergency questions : Can the child be intubated through the upper airway? Can the child be mask ventilated through the upper airway? Parents, home nursing agencies and first responders receive the medical diagnosis, the explanation of the airway findings, and a defined emergency airway intervention plan In review of 29 Trach Safe airway evaluations: • 51% (n=15) had a finding that was either more severe or previously unknown • 43% (n=3) received tracheal granulation debridement • 24% (n= 2) had an unplanned airway intervention. This was information not known or gathered on patients prior to Trach Safe
Trach Safe Near Miss Data Collection
Trach Safe Emergency Airway Management Class
• More than 150 nurses instructed on emergency airway management to date • Classes have increased from twice to four times per year to meet demand • Fills a safety gap in education for nurses in the community who are without reliable access to emergency airway management via high/low fidelity simulation
• We’re sending patients home with better information and a clear resuscitation plan based on this OR evaluation • Information from this procedure guides the training to parents and home nurses on emergency airway management specific to their child • Children are discharging home with their airway understood and optimized to support recovery with an airway emergency
Pre/Post course validation of increased confidence in airway emergencies —5 point Likert scale, 8 survey questions on routine and emergency care: --Pre course confidence scores improved from a mean of 2 to 4, except suction, improved from a mean of 3 to 5 (Median improvement of 2 points, 95% CI 0.99-2.99 points, all p<0.0001).
--3 months after the course—78.9% of respondents had a moderate to complete change in trach care practices due to this airway training
In a review of four months of data from the Trach Safe Check (n=53): •
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61% (n=31) of families have unstaffed home nursing shifts in the past two weeks. We found in our review of deaths that not having a nurse at home occurred in 47% (n=8) of the accidental deaths at home The trach tube accidentally came out of the stoma 41% (n=22). This has the potential to increase risk of death in children with a critical upper airway 25% (n=13) experienced equipment failure at home. Most common was the suction machine, followed by the primary ventilator and the oximeter. Suction machines are vital to maintain airway patency 350 TRACH SAFE CHECKS ARE BEING REVIEWED FOR TREND ANALYSIS
CONCLUSIONS: ZERO ACCIDENTAL DEATHS AT HOME IN TRACHESTOSTOMY DEPENDENT CHILDREN FROM JUNE 2014 - NOVEMBER, 2018 NURSE CONFIDENCE WITH AIRWAY EMERGENCIES INCREASES FOLLOWING DIRECTED EDUCATION AND SIMULATION DATA FROM THE EXAMINATION OF NEAR MISS EVENTS CAN IMPROVE CARE PRACTICES TO IMPROVE HOME SAFETY