A national Patient Safety Collaborative programme, led by NHS England and delivered by the AHSN Network, commenced in 2020 to improve the care of patients with tracheostomies within acute hospitals. The programme focussed on ensuring that all patients had three elements:

  • a bedhead sign and emergency algorithm,
  • emergency equipment and
  • a daily care bundle.

A short-term Community of Practice (CoP) with the tracheostomy teams from across Bristol, North Somerset, South Gloucestershire; Gloucestershire and Bath, North East Somerset, Swindon and Wiltshire was set up by the West of England AHSN to facilitate shared learning across the teams to improve the care of tracheostomy patients.

What did the Tracheostomy CoP hope to achieve?

Following an audit to understand how the elements were used in the region’s hospitals, it was established that while most trusts did have the elements in place there was room for improvement in their consistency. The teams therefore set out to improve the consistency and efficiency of their internal systems and to align to the national guidelines for tracheostomy care.

What were the outcomes of the Tracheostomy CoP?

  • Positive multi-disciplinary collaboration for improvement projects
  • Alignment of paperwork to national guidance and inclusion of Response Team number
  • Making emergency equipment boxes the same colour throughout the trust
  • Sealing the emergency equipment boxes to ensure equipment is not removed and reduce the need for regular full checks
  • Training resources developed and delivered to targeted areas e.g. to oncology and ICU,
  • Improved processes for Datix
  • Updated policies
  • Development of a tracheostomy team with the Acute Care Response Team
  • Minimising variation between teams

In University Hospitals Bristol and Weston (UHBW), the tracheostomy programme spearheaded a larger Quality Improvement project involving a group of multidisciplinary enthusiasts. The project aims to reduce the number of preventable tracheostomy related incidents to zero by December 2022 through the change ideas shown in the driver diagram below:

Isabel Barfield, Patient Safety Improvement Nurse, at UHBW said:

“In UHBW it has been great to get the multidisciplinary team across the newly merged trust working together on such an important project. Tracheostomy care has needed streamlining for a while now, so far we’ve written new care plans, discharge documentation, incorporated the NTSP videos into our training, and identified emergency boxes and bedside trolleys to facilitate the best care.”

Mark Juniper, Respiratory Consultant and Clinical Lead at the West of England AHSN said:

“It’s always a privilege to bring acute teams together to enable sharing of learning and ultimately improve patient safety – COVID provided an additional challenge but I am proud of the work we’ve completed as a collaborative. The Tracheostomy Community of Practice has gone from strength to strength and the great work we’ve started will now continue – I am particularly looking forward to hearing more about the progress made in UHBW (as part of their on-going tracheostomy quality improvement work).

I know that any improvements or new ways of working will now be shared with acute trusts across the region, so all tracheostomy patients can benefit”.

What’s next?

The tracheostomy programme has now closed, however teams are continuing on their improvement journeys to enhance tracheostomy care safety with their own local projects.

The tracheostomy community of practice is one element of the national Adoption and Spread Patient Safety Improvement Programme. Find out more about our work on the programme here.

Posted on September 27, 2021

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