Tracheotomy Management Update

A multidisciplinary committee composed of surgeons, intensivists, and nurses at Montefiore undertook a systematic review of monthly morbidity and mortality conference records and retrospective chart reviews to identify commonalities in tracheotomy-related mortalities. In alignment with Accreditation Council for Graduate Medical Education core competencies, otorhinolaryngology residents were included at every step. From July 2004 to July 2005, eight post-tracheotomy mortalities were identified, an increase of more than 100% over each of the three previous years.

To address the problems that were brought to light, the team worked to establish a plan whereby tracheotomy patients were placed postoperatively in one of three designated units in which experienced nurses and house staff were always available, and the Department of Otorhinolaryngology–Head and Neck Surgery developed and implemented a hospital-wide educational initiative aimed at increasing knowledge of tracheotomy-related issues.

One reason that respiratory therapists, registered nurses, and medical house staff were often confused when managing tracheotomy patients was that a variety of tracheotomy devices were being used throughout the institutional system. After their research, a hospital-wide uniform tracheotomy tube policy was implemented for all the facilities in the system. “We may not hear [feedback] about complications,” Dr. Schiff said, “but from what we see in our morbidity and mortality conference, we have not had any confusion since they made the change.”

The Montefiore team devised a system for educating the general medical population. “In our department, we noticed that there was an increase in what we thought were complications on the medical floors of the hospital [in regard to] managing patients with a tracheotomy,” said Dr. Schiff. The team thought it was likely that these nurses and other providers did not understand the basics—why a tracheotomy is done, how a tracheotomy is done, and how patients with tracheotomies are cared for.

“People who don’t have a lot of practice or exposure to tracheotomy patients may be afraid to manage these patients,” said Marvin P. Fried, MD, Professor and University Chairman of the Department of Otorhinolaryngology–Head and Neck Surgery at Montefiore Medical Center, Albert Einstein College of Medicine. Therefore, the department developed a procedures programatica that was an educational tool. Initially designed as a PowerPoint presentation, it was given to residents, the ICU staff, respiratory therapists and nurses on certain floors that had issues with tracheotomies. Because feedback was positive, they took it one step further. “One of our residents has currently completed a research project with a preliminary DVD for training, which is absolutely magnificent,” said Dr. Fried. “We hope to share that with other hospitals for their educational benefit.”