The Tracheostomy Box: Always Ready,Ever Ready

Abstract

Background:

A tracheostomy tube (TT) has been the solution to free patients from ventilatory support and maximize scarce resources in ICU. Adverse events such as TT dislodgement or obstruction are not rare. An article by Hess (2014) stated that caregivers should ensure that humidifiers and suction are set up correctly and that spare TTs of the same size and smaller are at the bedside for emergencies. With the increased tracheostomized population, there is a need for references for the nurses and a box for keeping emergency accessories.

Methods:

We audited tracheostomy emergency accessories in a 700-bed tertiary care adult hospital in Singapore. Data were obtained from the tracheostomy study between May 2022 and March 2023. Observations recorded were the incorrect set-up of humidification, and missing or inaccurate emergency accessories, including TTs at the bedside. The NHG Domain-Specific Review Board (DSRB) approved the study (DSRB 2020-01138).

Results:

Preliminary results found that preparing tracheostomy emergency accessories could be challenging for nurses who seldom care for tracheostomized patients. This has resulted in high incidences (42.1%) of standby emergency TTs at the bedside being incorrect and (63.8%) not having proper tracheostomy accessories at the bedside. This is because TTs have many sizes and types; some use the Jackson sizing system, while others use the ISO system. We have standardized and use Shiley 4FEN (OD: 9.4mm) and Shiley 6FEN (OD: 10.8 mm) as emergency TTs. As a study has shown that adult females can accommodate a TT with an outer diameter (OD) of 10 mm, whilst an OD of 11 mm for adult males. All our patients have a TT inserted with OD ≤11.5 mm. A tracheostomy box, notably Trachi-Case, has been used in healthcare institutions. The case allows for placing additional TTs and all essentials in a handy carrying case, which the nurses can bring with the patient for transport. We created a cost-effective box with a reference guide that can be placed at the patient's bedside and used for transport. The tracheostomy box with all required emergency accessories was implemented in all wards in December 2022. There were significant reductions of 47.3% from an average of 1.9 errors per tracheostomized patient (6 months pre) to 0.8 errors per tracheostomized patient (6 months post).

Conclusions:

A standardized tracheostomy box with a reference guide is useful for keeping a patient’s tracheostomy requisites together while providing useful instruction for inexperienced caregivers and providing contacts for tracheostomy care support.