Improving tracheostomy care in the United Kingdom: results of a guided quality improvement programme in 20 diverse hospitals

McGrath, Brendan A., Wallace, Sarah, Lynch, James, Bonvento, Barbara, Coe, Barry, Owen, Anna, Firn, Mike, Brenner, Michael J., Edwards, Elizabeth, Finch, Tracy, Cameron, Tanis, Narula, Antony and Roberson, David W. (2020) Improving tracheostomy care in the United Kingdom: results of a guided quality improvement programme in 20 diverse hospitals. British Journal of Anaesthesia, 125 (1). e119-e129. ISSN 0007-0912

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Abstract

Background
Inconsistent and poorly coordinated systems of tracheostomy care commonly result in frustrations, delays, and harm. Quality improvement strategies described by exemplar hospitals of the Global Tracheostomy Collaborative have potential to mitigate such problems. This 3 yr guided implementation programme investigated interventions designed to improve the quality and safety of tracheostomy care.

Methods
The programme management team guided the implementation of 18 interventions over three phases (baseline/implementation/evaluation). Mixed-methods interviews, focus groups, and Hospital Anxiety and Depression Scale questionnaires defined outcome measures, with patient-level databases tracking and benchmarking process metrics. Appreciative inquiry, interviews, and Normalisation Measure Development questionnaires explored change barriers and enablers.

Results
All sites implemented at least 16/18 interventions, with the magnitude of some improvements linked to staff engagement (1536 questionnaires from 1019 staff), and 2405 admissions (1868 ICU/high-dependency unit; 7.3% children) were prospectively captured. Median stay was 50 hospital days, 23 ICU days, and 28 tracheostomy days. Incident severity score reduced significantly (n=606; P<0.01). There were significant reductions in ICU (−;0.25 days month−1), ventilator (−;0.11 days month−1), tracheostomy (−;0.35 days month−1), and hospital (−;0.78 days month−1) days (all P<0.01). Time to first vocalisation and first oral intake both decreased by 7 days (n=733; P<0.01). Anxiety decreased by 44% (from 35.9% to 20.0%), and depression decreased by 55% (from 38.7% to 18.3%) (n=385; both P<0.01). Independent economic analysis demonstrated £33 251 savings per patient, with projected annual UK National Health Service savings of £275 million.

Conclusions
This guided improvement programme for tracheostomy patients significantly improved the quality and safety of care, contributing rich qualitative improvement data. Patient-centred outcomes were improved along with significant efficiency and cost savings across diverse UK hospitals.

Clinical trial registration
IRAS-ID-206955; REC-Ref-16/LO/1196; NIHR Portfolio CPMS ID 31544.

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