environments—Austin Health in Melbourne, Australia, and St. Mary’s Hospital in London, U.K.—built
hospitalwide care systems that reduced tracheostomy-related adverse events by 90 percent or more.
Although these hospitals serve different populations with different clinical issues, the programs
that they developed are strikingly similar in their
4-5 Similar programs aimed at reducing tracheostomy-related adverse events have been
developed in the U.S., such as the program at Johns
Hopkins Medicine, Baltimore, MD.
Keys to tracheostomy quality improvement
Drawing on these experiences, the GTC has adopted
five key drivers of tracheostomy care improvement:
•Team-based care. Representatives of all specialties
involved in the care of these patients, including surgery
(otolaryngology–head and neck, general, thoracic), pul-monology, intensive care, nursing, speech pathology,
respiratory therapy, and others depending on hospital staffing, must meet face-to-face at least weekly to
review the inpatient tracheostomy census and make
joint decisions. With so many services involved, there
is no practical way to have consistent and clear care
decisions without regular in-person meetings. In
addition, every hospital should have a tracheostomy
committee that meets monthly to review adverse
events and address systemic issues.
•Standard protocols. Hospitals must establish pro-
tocols so that—barring patient-specific needs or
complications—every trach patient receives the
same preoperative, perioperative, and postopera-
tive care. When every department, and in some cases
every physician, applies different postoperative care
standards, important aspects of follow-up care will
invariably fall through the cracks because so many
different people are involved in tracheostomy care.
For example, deaths have occurred because the night
shift staff was unaware that in a particular patient,
should the tracheostomy dislodge, oral intubation
was still an option.
•Staff education and assignment. A hospital must
develop a training and staff assignment system so that
when a tracheostomy occludes at 2:00 am, someone
trained to manage this emergency situation will be
at the bedside within minutes, before hypoxic injury
ensues. An informal poll of approximately 150 attendees at a tracheostomy seminar at the American College
of Surgeons Clinical Congress in 2016 showed that less
than 2 percent of respondents were confident that this
type of training and assignment system was in place
at their hospital.
•Patient and caregiver involvement. Patients and their
families should be involved in all aspects of this process. In particular, patient and family representatives
should be on the institutional tracheostomy committee. At Boston Children’s Hospital, the addition of a
family member to our tracheostomy committee has
prompted us to recognize and address many care vul-nerabilities of which we were not previously aware.
Due to the fact that the availability of tracheostomy
emergency equipment in residential homes varies, we
developed an institution-wide “Go Bag” with standard
emergency equipment. Our nurses now unpack and
review each family’s bag during each visit to the tracheostomy clinic to ensure they are always equipped
•Data collection. The GTC has a worldwide database that is compliant with protections in the Health
Insurance Portability and Accountability Act, as well
as with U.K. and Australian privacy laws. This registry contains key data from member hospitals on each
admission for patients with tracheostomies. The GTC
issues regular reports to member hospitals that allow
them to track their own progress and compare their
outcomes with similar hospitals.
SEP 2017 BULLETIN American College of Surgeons
GLOBAL TRACHEOSTOMY COLLABORATIVE