Abstract
Background The project commenced in 2020 after a tracheostomy safety lapse led to a near miss event. Subsequently the four T’s handover tool was developed. The four T’s consisted of the checks needed to keep a tracheostomy patient safe: Tube patent and in-situ. Tape tension correct, Tube bedside chart present and completed, Tracheostomy emergency box contents correct. These checks were to be completed at start of the shift and when handing over care. The purpose of this Quality Improvement project is to improve consistency with tracheostomy safety box equipment and bedspace signage to 100% compliance.
Method We extracted data to review three months of safety check compliance. We monitored the pilot ward usage to gauge ongoing improvements with compliance when safety checks installed on the Electronic Patient Records (EPR). I manually cross-referenced tracheostomy boxes with the audit tool, comparing paper checks to staff nurse input in EPR.
Findings Baseline compliance on the pilot ward was 42.5%. Following interventions such as posters and education increased to 85%. After implementing Epic safety checks trust wide in July 2022, the pilot ward achieved 91.5% compliance. While all necessary resuscitation equipment was present, some boxes did not have the required prompt images as per policy. Trust wide EPR data showed 96.4% compliance for staff self-checks indicating ‘Yes’ for completed checks, 1.3% for ‘No’ indicating checks not completed, and 1.2% with incomplete sections. Some ‘No’ entries were used incorrectly (decannulated patients or patients who never had a tracheostomy).
Conclusion This work underscores the four T’s of tracheostomy handover as a valuable tool for enhancing patient safety check compliance. We recommend adding a ‘not applicable’ section to account for situations where tracheostomy is no longer present or never was. We recommend removing the tracheostomy prompt image from the policy as it does not support accuracy.
Acknowledgements for funding or support Chief Nurse Junior Fellowship 2020 GOSH
