Tracheostomy Complications as a Trigger for an Airway Rapid Response: Analysis and Quality Improvement Considerations

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Abstract

Objective

To analyze the subset of airway rapid response (ARR) calls related to tracheostomy identified over a 46-month period from August 2011 to May 2015 to determine proximate cause, intervention, and outcome and to develop process improvement initiatives.

Design

Single-institution multidisciplinary retrospective cohort study.

Setting

Tertiary care academic medical center in a large urban setting.

Subjects

Hospital inpatients with an in situ tracheostomy or laryngectomy who experienced an ARR.

Methods

Detailed review of operator, hospital, and patient records related to ARR system activations over a 46-month period.

Results

ARR was activated for 28 patients with existing tracheostomy. The cohort included open tracheostomy (n = 14), percutaneous tracheostomy (n = 8), laryngectomy stoma (n = 3), and indeterminate technique (n = 3). The most frequent triggers for emergency airway intervention were decannulation (n = 16), followed by mucus plugging (n = 4). The mean body mass index of ARR patients was higher than that of a comparator tracheostomy cohort (32.9 vs 26.3, P < .001). BMI was >40 in 9 ARR patients. There was 1 mortality in the series.

Conclusions

Tracheostomy is a major trigger for ARR with potential fatal outcome. Factors that may contribute to tracheostomy emergencies include high body mass index, surgical technique for open tracheostomy or percutaneous tracheostomy, tracheostomy tube size, and bedside tracheostomy management. Results have triggered a hospital-wide practice improvement plan focused on tracheostomy awareness and documentation, discrete process changes, and implementation of guidelines for emergency management.

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