INTRODUCTION

New York State’s first confirmed case of COVID-19 and hospitalization was on March 1, 2020, with cases and hospitalizations growing exponentially thereafter. New York City quickly became a pandemic epicenter. The city had 45,707 confirmed cases (9,775 hospitalizations) on April 1, 2020, and 166,883 cases (42,715 hospitalizations) on May 1, 2020.1

At the peak, the authors’ health system of 2,696 beds had 2,600 hospitalized patients with 900 in ICUs. At the intervention site, an urban academic medical center with 862 beds, ICU and step-down beds were created. Medical-surgical units, postanesthesia care units, pediatric units, ambulatory procedural areas, and ORs were converted to adult ICU care areas. Elective procedures were halted. The sheer volume of patients strained personnel and personal protective equipment use was guarded to avoid shortages. Practices implemented to minimize exposure led to less time with individual patients, increasing the risk of treatment complications.

Problem

The surge in patients with severe respiratory compromise increased the volume of intubations and prolonged mechanical ventilation. Ventilators were scarce, and healthcare professionals implemented innovative methods to ventilate. Patients with COVID-19 required protracted mechanical ventilation necessitating tracheostomy. There were few or no data about when best to perform a tracheostomy on patients with COVID-19-related acute respiratory distress syndrome.2 Most tracheostomies were performed at the bedsides of patients with COVID-19 to maintain closed-circuit ventilation and avoid putting providers at risk for contamination because the procedure can be aerosol-generating. It has since been shown that use of proper personal protective equipment protects caregivers and minimizes exposure.3

Early in the pandemic, nursing leadership had identified the need to upskill nurses and formed care teams of nurses with varying skills. More than 400 nurses were educated and trained to care for ICU and step-down patients.4 The challenge then encountered was nurses’ lack of experience and knowledge regarding care for patients with tracheostomies. There was concern for known complications such as tracheostomy-related pressure injury (TRPI), skin breakdown, and airway compromise.5,6 In 2016, the National Pressure Injury Advisory Panel—then known as the National Pressure Ulcer Advisory Panel—defined a medical device-related pressure injury (MDRPI) as a pressure injury (PI) that evolves “from the use of devices designed and applied for diagnostic or therapeutic purposes.”7 This type of PI commonly depicts the pattern of the device on the skin. In one facility, MDRPIs were found to account for half of all hospital-acquired PIs.8 Barakat-Johnson et al9 found a 29.7% incidence for MDRPI in adult ICU patients. Tracheostomy devices are known to cause MDRPI. A study using the 2016 International Pressure Ulcer Prevalence data found tracheostomy neck plates were responsible for 5.5% of MDRPIs,10 Rush University Medical Center identified a TRPI rate of 12.5%,11 and Heineger et al5 found a 22.5% incidence of TRPI.

Identification of this potential risk led to Tracheostomy Thursday, an organizational performance improvement initiative to prevent TRPI. Frontline staff alerted clinical leadership of the surge in volume of tracheostomies and their lack of experience and confidence in caring for patients with tracheostomies. In turn, the clinical practice coordinator (CPC) met with the clinical director of nursing and director of nursing quality (DONQ). Nursing leadership, with the support of the chief nursing officer, quickly galvanized a nursing core group to respond to the frontline nursing team.

METHODS Building the Team

The core group, consisting of the DONQ, CPC, and a certified wound ostomy nurse (CWON), met to strategize on how to prevent TRPI. This CWON had led a previous project on TRPI prevention in the surgical ICU, and the group drew on lessons learned from that project to form the Tracheostomy Thursday team. The team’s focus was airway safety and prevention of TRPI. As noted by Delmore and Ayello,12 “raising awareness that medical devices can cause pressure injuries is an important step in addressing the incidence of MDRPIs.”

With guidance from leadership, the CPC and CWON spearheaded the team. Having certified wound nurses can be an important factor in achieving better outcomes in acute care settings.13 As seen in the study by Monaco et al,14 the presence of a wound care nurse may decrease PI incidence and treatment costs and improve healing.14

The tracheostomy team leaders conducted a literature review and, with help from team members, explored best practices from other academic medical centers. They then assessed organizational policy to ensure that it reflected current evidence-based practice and evaluated existing and new products. The team’s purpose was to have an array of disciplines on board to address TRPI and create a solution. An interdisciplinary team was formed, consisting of frontline nurses, respiratory therapists (RTs), surgeons, and materials management led by the CPC and CWON. When seeking team members, leaders looked for staff nurses and RTs who were interested in skin care, engaged, and enthusiastic about patient care because studies have shown that nurse engagement leads to positive patient outcomes.15 Team members included nurses from various hospital units, including ICU, pediatrics, and medical-surgical.

Rounding

Once the team was created, rounds began. Staff who were part of the team came in for rounds separate from scheduled shifts, allowing them to focus on this initiative. They were compensated for their time based on their unit’s procedures. Rounds were performed weekly as a multidisciplinary team for all adults with a tracheostomy throughout the hospital. One challenge the team encountered was that, prior to the new electronic medical record, there was no systematic way to identify which patients had tracheostomies. Nurse leaders were asked to provide a list of patients with tracheostomies on their units, and the team added other patients they identified during rounds. Day 1 of the Tracheostomy Thursday team rounds included 100 patients with tracheostomies. During these initial rounds, with the organizational policy on hand, team members observed and assessed patient care and staff knowledge. They identified gaps in the knowledge and practice of frontline staff to prevent TRPI and manage a potential decannulation or another airway emergency and found many opportunities for improvement.

Identifying Issues

According to Heineger et al,5 a lack of adherence to procedures and guidelines or documentation by nursing staff can lead to a high percentage of skin injuries. Team members found that there was no standardized care protocol for a person with a tracheostomy. Sutures were placed for prolonged periods, there was a lack of preventive dressings, there was minimal tracheostomy safety equipment at the patient’s bedside, and some staff members were not familiar with the equipment. The team gathered and discussed evidence-based practices and the action plan to avoid an increase in TRPI.

Interventions used during the tracheostomy rounds were created based on evidence-based practice found in the literature. For example, the placement of a tracheostomy significantly increases the patient’s risk of developing a PI because of the immovability of the tracheostomy, its proximity to the bony prominences of the clavicles, and the increase in moisture surrounding the tracheostomy from tracheal secretions.11 To decrease the incidence of TRPI, evidence-based practice recommends the use of foam dressings to cushion and protect the area beneath the tracheostomy.16 The tracheostomy team noted that these dressings were sometimes missing.

Delayed suture removal was another identified issue. Routine practice is for initial sutures to be removed at 7 days. Leaving sutures longer may lead to tracheostomy-related skin injury from pulling or tension and an increase in TRPI.16 Limited personnel resources along with prioritization and triage of care created the risk of sutures remaining past 7 days. If sutures are in place for longer than the recommended time, clinicians are empowered to escalate concerns to the covering surgical team for prompt removal.17 To help with timely suture removal, the covering team was alerted to help assist with removal and prevent skin breakdown. Because of the high patient volume, a variety of surgeons performed tracheostomies, and at times, it was difficult to determine who had inserted the tracheostomy because of the increased number of patients and their varied locations throughout the hospital. These were the patients found to have sutures in place for an extended period.

Although skin breakdown is a major concern in patients with tracheostomies, patient safety was another issue identified when rounding began. A lack of safety supplies (obturator and backup tracheostomy kit) at the bedside was noted. In addition, some staff were unfamiliar with the use and function of an obturator. An obturator is a thin, curved piece of hard plastic or rubber that is inserted into the tracheostomy tube to help with placing the tube into the trachea and is used to maintain a patent airway if a tracheostomy is displaced. If the tracheostomy becomes dislodged, an obturator and backup tracheostomy kit are needed to protect the airway.

Upon rounding, staff noted that these gaps in care required action using a multidisciplinary approach to develop guidelines, provide education, and implement evidence-based tracheostomy care.4 The interdisciplinary team compiled and evaluated many aspects of TRPI prevention. They used different strategies to improve knowledge-sharing and maximize communication, including bedside safety checklists, bedside face-to-face education, peer-to-peer mentoring, hands-on direct care, and weekly team meetings.

Implementing Interventions

A cross-sectional study of ICU nurses found that comprehensive education positively influenced the nurses’ knowledge, attitudes, and practice in the prevention of MDRPI.18 With this in mind, the team’s plan drew on one another’s expertise and skills, developing and implementing a prevention bundle, and using peer-to-peer coaching and in-the-moment correction and education in a safe, supportive learning environment. Having staff from different units enabled the team to understand the workflow on those units. The team also included surgeons who inserted tracheostomies to help other team members understand the insertion process and postinsertion care.

The interventions started with the initial insertion of a tracheostomy. According to McEvoy et al,19 “to reduce the number of tracheostomy wounds… [the] wound care regimen begins in the operating room at the time of tracheostomy. Mepilex Lite is used around tracheostomy tube flanges and under the collar to protect the skin.”19 The surgical teams adapted similar practices by placing a foam dressing under the tracheostomy plate upon insertion and prior to suturing it into place. To ensure that an adequate supply of foam dressings and extra tracheostomy equipment was readily available for use, the team collaborated with materials management. They communicated with vendors to confirm that products were being used correctly and were the best products for TRPI prevention.

The Institute for Healthcare Improvement defines a care bundle as a structured way of improving care processes and patient outcomes, generally consisting of three to five evidence-based practices that, when performed collectively and reliably, improve patient outcomes.20 Implementation of a care bundle can significantly reduce TRPIs.4,12,19,21 The Tracheostomy Thursday team created the bundle components, including interprofessional collaboration, education, equipment standardization, and care protocols. Similar to Dixon et al,21 the team’s care bundle standardized suturing and timing of suture removal, use of a foam dressing under the tracheostomy flange, and skin assessment performed by nursing staff.

Another care bundle component was a bedside checklist (adapted from pediatrics) that includes both preventive and safety measures. The checklist has individualized tracheostomy information, such as current tracheostomy size, date of surgical tracheostomy, date sutures are to be removed, and the medical team responsible for tracheostomy placement (Figure 1). This standardized bundle and checklist promoted continuity of care and helped decrease the incidence of TRPI. The checklist was placed at the head of the bed. Direct care nurses and RTs rounded in pairs to ensure the checklist was visible at the bedside of every person with a tracheostomy upon assessment of tracheostomy sites. This ensured that all vital information could be viewed readily by all caregivers. During rounds, team members could directly observe each tracheostomy site, inspect the periwound skin, and note suture status to ensure sutures were removed within the 7-day period. There was also a safety check to ensure that an obturator and backup tracheostomy of the same size were at the bedside and that a thin-profile, soft, and conformable foam dressing was in place. It was recommended that dressings be changed daily or sooner as needed for soilage.

Figure 1:

BEDSIDE TRACHEOSTOMY CHECKLIST

Weekly team rounds provided an additional level of protection by offering a secondary assessment and perspective on the best care plan for each patient. If the team noted during weekly rounds that items from the checklist were not completed, they coached the staff nurse on the importance of all items and how to correct missing aspects. The team alerted the wound nurse of any redness or presence of skin breakdown. Wound care nurses closely followed any person with TRPI and recommended using a protective dressing, keeping the site clean and dry, maintaining close observation, and documenting any changes.

RESULTS

Significant improvements were noted during the 6 months of rounding and data collection on inpatient adult units. Prior to implementation of the Tracheostomy Thursday team in May 2020, there were 19 patients with TRPI. After months of interprofessional rounding, the number of patients with TRPI decreased significantly, and patient safety measures at the bedside increased.

Upon initiation of rounds in June 2020, only 49% of patients had an obturator at the bedside, 82% of patients had a backup tracheostomy at the bedside, and 72% of patients had a preventive dressing in place. In December 2020, safety measures had improved: 97% of patients had an obturator at the bedside, 90% of patients had a backup tracheostomy at the bedside, and 96% of patients had a preventive foam dressing in place (Figures 2 and 3).

Figure 2:

TRACHEOSTOMY PRESSURE INJURIES BY MONTH

Figure 3:

TRACHEOSTOMY SAFETY EQUIPMENT COMPLIANCE

Because of the team’s successful outcomes, enterprise changes occurred in all 10 hospitals in the system. Information about the tracheostomy team and their dedication to patient care was disseminated through unit-based shared governance councils and the hospital-wide Skin Care Council. The adult tracheostomy policy was updated to include suture removal 7 days postinsertion, unless otherwise indicated. The comprehensive checklist that was trialed during rounds proved helpful in preventing patient TRPI and engaging staff about tracheostomy care. Based on input from staff nurses about the bedside checklist, changes were made to adapt to nurses’ needs and concerns. Now the bedside checklist is included in the adult tracheostomy policy and has been implemented throughout the system to aid communication among the interprofessional team caring for patients with tracheostomies. The checklist is readily available through the health system’s information network and can be printed out and displayed at the patient’s bedside to promote adherence to the evidence-based care bundle and, in turn, improve patient outcomes.

DISCUSSION

Each week, the team grew to include more disciplines and dedicated individuals who wanted to help prevent TRPIs. Staff nurses and RTs became very engaged and encouraged their peers to join the team. With more members, the team became more efficient. When team members were well versed with rounds, the rounding structure shifted. After many weeks of multidisciplinary rounds, group rounding transitioned from weekly to monthly. Between monthly rounds, staff nurses and RTs performed rounds independently on a weekly basis on their assigned units. They reviewed all checklist items and entered information into a monitoring tool for tracking data. If they encountered challenges or discovered any tracheostomy-related skin care issues, team members would contact the nurse clinician or wound care nurse. Being autonomous in rounding empowered staff nurses and RTs to engage in real-time education of their peers to help decrease TRPI incidence.

Recognition is fundamental to a positive, healthy care environment and creates joy and resilience in the workplace.22 A culture of recognition of nurses and healthcare providers supports well-being. The American Association of Critical-Care Nurses has identified meaningful recognition as one of the six essential standards for a healthy work environment, and the American Nurses Credentialing Center acknowledges recognition’s contributions to a positive practice environment in its essential standard of well-being.23,24 Inherent in the Tracheostomy Thursday team’s framework was interprofessional recognition of the value each discipline contributed and respect for their knowledge and expertise. The tracheostomy team achieved and sustained their goals of reducing TRPI incidence and educating and empowering staff through interprofessional collaboration, a safety checklist, and a prevention care bundle. The team disbanded when no longer needed: when the bundle was hardwired and the data collected showed sustained improvement.

The Tracheostomy Thursday team compiled and analyzed the data and created a poster to present their success in decreasing TRPIs and increasing staff knowledge. The poster was accepted to the Weill Cornell College of Medicine’s Quality Improvement Poster session and the Northeast regional Wound, Ostomy, and Continence Nursing Society annual conference. It showcased the team’s work and enabled them to share knowledge and lessons learned from the performance improvement experience.

When Sigma’s call for nominations for International Awards of Nursing Excellence began on November 1, 2020, one award stood out: the Helen Henry Excellence of Interprofessional Care Award to recognize any interprofessional team composed of an RN with a baccalaureate degree or higher and other health professional(s) collaborating to deliver care at the bedside.25 The Tracheostomy Thursday team exemplified the Interprofessional Education Collaborative core competencies,26 one of the award criteria. The team framework was built on interprofessional collaboration and communication with mutual respect for individual expertise and roles.

The nomination was supported by corporate nursing leadership and interprofessional collaboration prevailed. The DONQ spearheaded the nomination with contributions by the chief nursing officer, associate chief quality officer/assistant professor of medicine, CWON, and a pediatric staff RN team member. The team received notification that they won the award for Sigma’s biennial meeting in Indianapolis in November 2021. Because of the ongoing pandemic, staff and leaders could not travel to receive the award, but the impact of receiving international recognition of excellence for their collaborative and innovative initiative while working in an epicenter of a pandemic was immeasurable.

CONCLUSIONS

The multifaceted approach and development of a safety bundle of interprofessional collaboration, education, bedside rounds, and standard preventive measures were key to the team’s success. A bedside safety checklist fostered team communication and supported the bedside nurses caring for patients with tracheostomies.

Nurses value nonfinancial recognition over financial reward, especially when it is an acknowledgement of patient care and comes from their work community.27 The team was honored to be recognized by professional organizations and Sigma, an esteemed nursing community, for nursing excellence in care at the bedside.

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