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. 2022 Oct 5:10.1111/jocn.16535. Online ahead of print. doi: 10.1111/jocn.16535

Implementation of an evidence‐based accidental tracheostomy dislodgement bundle in a community hospital critical care unit

Dawn Ta Un Jung 1, Lisa Grubb 2,3, Chandler H Moser 3, Jeanette T M Nazarian 2, Neesha Patel 2, Lisa E Seldon 2, Kristin A Moore 2, Brendan A McGrath 4, Michael J Brenner 5,6, Vinciya Pandian 7,✉
PMCID: PMC9874912  PMID: 36200145

Abstract

Background

Tracheostomy dislodgment can lead to catastrophic neurological injury or death. A fresh tracheostomy amplifies the risk of such events, where an immature tract predisposes to false passage. Unfortunately, few resources exist to prepare healthcare professionals to manage this airway emergency.

Aim

To create and implement an accidental tracheostomy dislodgement (ATD) bundle to improve knowledge and comfort when responding to ATD.

Materials & Methods

A multidisciplinary team with expertise in tracheostomy developed a 3‐part ATD bundle including (1) Tracheostomy Dislodgement Algorithm, (2) Head of Bed Tracheostomy Communication Tool and (3) Emergency Tracheostomy Kit. The team tested the bundle during the COVID‐19 pandemic in a community hospital critical care unit with the engagement of nurses and Respiratory Care Practitioners. Baseline and post‐implementation knowledge and comfort levels were measured using Dorton's Tracheotomy Education Self‐Assessment Questionnaire, and adherence to protocol was assessed. Reporting follows the revised Standards for Quality Improvement Reporting Excellence (SQUIRE).

Results

Twenty‐four participants completed pre‐test and post‐test questionnaires. The median knowledge score on the Likert scale increased from 4.0 (IQR = 1.0) pre‐test to 5.0 (IQR = 1.0) post‐test. The median comfort level score increased from 38.0 (IQR = 7.0) pre‐test to 40.0 (IQR = 5.0) post‐test). In patient rooms, adherence was 100% for the Head of Bed Tracheostomy Communication Tool and Emergency Tracheostomy Kit. The adherence rate for using the Dislodgement Algorithm was 55% in ICU and 40% in SCU.

Discussion

This study addresses the void of tracheostomy research conducted in local community hospitals. The improvement in knowledge and comfort in managing ATD is reassuring, given the knowledge gap among practitioners demonstrated in prior literature. The ATD bundle assessed in this study represents a streamlined approach for bedside clinicians – definitive management of ATD should adhere to comprehensive multidisciplinary guidelines.

Conclusions

ATD bundle implementation increased knowledge and comfort levels with managing ATD. Further studies must assess whether ATD bundles and other standardised approaches to airway emergencies reduce adverse events.

Relevance to Clinical Practice

A streamlined intervention bundle employed at the unit level can significantly improve knowledge and comfort in managing ATD, which may reduce morbidity and mortality in critically ill patients with tracheostomy.

Keywords: algorithms, coronavirus, COVID‐19, critical care, mechanical ventilation, patient care bundles, patient care team, patient safety, quality improvement, tracheostomy

What does this paper contribute to the wider global community?

  • Demonstrated the feasibility of implementing a standardised accidental tracheostomy dislodgement protocol bundle in a community critical care hospital setting.

  • Nurses' and Respiratory Care Practitioners' knowledge and comfort levels in managing accidental tracheostomy tube dislodgements improved after implementing the bundle.

1. BACKGROUND

Tracheostomy tube dislodgement is a leading cause of preventable harm in critical care units, which bears the potential for catastrophic injury (Cipriano et al., 2015; Cook et al., 2011; Rajendram & McGuire, 2006). In the United States, the rate of tracheostomy‐related adverse events is approximately 5.1 per 1000 tracheostomy days (Brenner et al., 2020). Delays in managing tracheostomy tube dislodgement can lead to airway compromise, neurological injury, or death (Cipriano et al., 2015; Rajendram & McGuire, 2006). Furthermore, accidental dislodgement can compromise even a patent airway if the malpositioned tube blocks airflow (Fernandez‐Bussy et al., 2015; McGrath, Lynch, Bonvento, et al., 2017; McGrath, Lynch, Templeton, et al., 2017). The rate of accidental dislodgement is reported as 2.3 per 1000 total bed days in adult patients (Brenner et al., 2020), although this figure likely does not reflect many self‐limited events. However, relatively few resources are available to identify and manage accidental tracheostomy dislodgement. In the past decade, the incidence of adverse events has improved alongside multidisciplinary tracheostomy care (McGrath et al., 2020). However, implementing team‐based strategies can prove challenging in low‐volume community hospital settings. Barriers to identifying and managing tracheostomy tube dislodgement have grown during the COVID‐19 pandemic amid safety concerns, personnel shortages, and supply chain disruptions (Bier‐Laning et al., 2021; McGrath et al., 2020; Meister et al., 2021; Pandian et al., 2020; Zaga et al., 2020).

Tracheostomy tube dislodgement is most perilous for patients with a fresh tracheostomy (Bontempo & Manning, 2019; Morris et al., 2013). A fresh tracheostomy is generally regarded as less than one week old, or before the first tracheostomy tube change (White et al., 2010). During this period, heightened vigilance is necessary for tracheostomy care as the tract—extending from the skin, through the soft tissue of the neck, and into the tracheal airway—is still immature. During this vulnerable window, attempts at reinserting the tracheostomy tube risk creating a false passage, usually as a dead‐end within the soft tissues anterior to the trachea (Bontempo & Manning, 2019; Hood et al., 2017). It is deceptively challenging to reinsert the tracheostomy tube into the tracheal airway when the tract is not mature, and entry into a false passage is fraught with the risk of bleeding, infection, subcutaneous emphysema, and—most importantly—cerebral hypoxia (Kutsukutsa et al., 2019; Medeiros et al., 2019; Omokanye et al., 2016; Singh et al., 2017). When the soft tissue of the anterior neck partially or entirely occludes the distal portion of the tube, the false passage location precludes ventilation and oxygenation (Bontempo & Manning, 2019; Fernandez‐Bussy et al., 2015).

Preventing such complications is predicated on clear and uniform practice guidelines (Mitchell et al., 2013). However, clinical practice often falls short of the ideal due to the complexity of guidelines and health professionals' lack of relevant knowledge, experience, or technical skills. In addition, evidence addressing the proper management of fresh tracheostomy tube dislodgement is scarce (Mitchell et al., 2013). There are no controlled studies testing interventions for emergency airway situations, and there are limited peer‐reviewed papers to guide interventions in these high‐risk instances (Mitchell et al., 2013). The purpose of this quality improvement project was to develop, implement and assess an accidental tracheostomy dislodgement (ATD) bundle to guide initial emergency actions for patients with a fresh tracheostomy in the ICU.

2. METHODS

2.1. Study aims, design and overview

This quality improvement project aimed to:

  1. Develop an evidence‐based ATD bundle for use in the community hospital critical care setting, focusing on nurse intervention during ATD emergencies prior to the arrival of airway specialists.

  2. Assess nurse and Respiratory Care Practitioner knowledge and comfort levels relating to ATD management before and after a 10‐week implementation of the ATD bundle.

  3. Measure nurse and Respiratory Care Practitioner adherence to the components of the ATD bundle.

The project utilised a pre‐test/post‐test study design to measure nurses' and Respiratory Care Practitioners' knowledge and comfort levels. The project included a pre‐implementation phase, during which the study team developed the bundle and assessed baselines; an implementation phase involving the bundle roll‐out in two critical care units at the same centre; and a post‐implementation phase, where the study team assessed outcomes of the intervention. Reporting follows the revised Standards for Quality Improvement Reporting Excellence (Ogrinc et al., 2015) (File S1). Ethical review approval was obtained from the Johns Hopkins School of Nursing DNP Scholarly Project Ethical Review Committee (#PERC82).

2.2. Setting

The project took place in the intensive care unit (ICU) and the step‐down care unit (SCU) of a Mid‐Atlantic, not‐for‐profit 225‐licensed‐bed community hospital between January and July 2021 amidst the COVID‐19 pandemic. The ICU and SCU had a combined 35 beds.

2.3. Sample

Critical care nurses and Respiratory Care Practitioners involved in caring for patients with a fresh tracheostomy were eligible to participate. The study team recruited these participants from the ICU and SCU. Exclusion criteria included travelling agency nurses and travelling respiratory practitioners.

2.4. Intervention

We developed and implemented the quality improvement tool using the Knowledge‐to‐Action (KTA) translational framework (Graham et al., 2018; Graham & Tetroe, 2007) (Figure 1). Before developing the tool, we conducted an integrative literature review to define the scope and significance of tracheostomy dislodgement. We then identified evidence‐based interventions. Finally, the project proceeded in pre‐implementation, implementation, and post‐implementation phases (Table 1).

FIGURE 1.

FIGURE 1

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The Knowledge to Action framework was used to guide the translation of evidence into practice. An extensive literature review was performed before synthesising the data and developing the Accidental Tracheostomy Dislodgement Bundle. The implementation involved seven structured aspects

TABLE 1.

Work breakdown structure

Weeks Activity Persons involved
Pre‐implementation Week 1

  • Informed the key stakeholders about the components of the project in various meeting platforms

 Study team members, unit managers, critical care nurse educator, organisational mentor, and the Director of the Respiratory Department
Week 2

  • Finalised the ATD bundle and education module

  • Developed 10 Emergency Tracheostomy Kits

 Study team members, respiratory department
Week 3

  • Administered pre‐test on knowledge and comfort level assessment via Qualtrics

 Study team members
Implementation Week 4–10

  • Released instructional and began execution of ATD bundle

 Study team members
Week 8–13

  • Audited ATD use, assessed for barriers

 Study team members, unit clinical coordinators
Post‐implementation Week 12–15

  • Administered post‐test on knowledge and comfort level assessment via Qualtrics

  • Collected bundle adherence data

 Study team members
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2.4.1. Pre‐implementation phase

The study team drafted an ATD bundle based on a primary literature review, systematic reviews and clinical practice guidelines relating to tracheostomy across the nursing, medical, and allied health professional literature. Stakeholder engagement was a key focus during this pre‐implementation phase. The team presented the draft ATD bundle to ICU and SCU managers, critical care nurse educators, the Director of Intensive Care Units, and the Director of Respiratory Therapy. Finally, the study team solicited frontline nurses, Respiratory Care Practitioners and patient and family members for additional input.

The ATD bundle had three components: Tracheostomy Dislodgement Algorithm, Head of the Bed Tracheostomy Communication Tool, and Emergency Tracheostomy Kit.

  • Tracheostomy Dislodgement Algorithm (Figure 2): The algorithm was printed on the back of the Head of the Bed (HOB) Tracheostomy Communication Tool to access step‐by‐step instruction for interventions immediately when emergencies arise. The algorithm emphasises early identification of tube dislodgement and rapid activation of the Code Team while avoiding tube manipulations that could create a false passage.

  • Head of the Bed (HOB) Tracheostomy Communication Tool (Figure 3): The HOB signage has patient‐specific information to guide the first responder in executing appropriate interventions. Information includes tracheostomy technique (percutaneous vs. surgical), suturing technique (e.g., stay suture), date of tracheostomy tube placement, tube size, tube type, cuff status (inflated vs. deflated) and date of the first tracheostomy tube exchange.

  • Emergency Tracheostomy Kit: This kit is a bag of emergency supplies in the patient's room that includes a replacement tracheostomy tube with obturator, a one‐size‐smaller tracheostomy tube with obturator, inner cannula, ten‐millilitre syringe, occlusive gauze and 4x4 dressing bag (Kohn et al., 2019; McGrath et al., 2012; Mitchell et al., 2013; Morris et al., 2013; Rajendram & McGuire, 2006; Rassekh et al., 2015; Wells et al., 2018). Additionally, suction apparatus, flexible suction catheter, bag‐valve‐mask, and oxygen source are within immediate reach at all times (McGrath et al., 2012; Mitchell et al., 2013; Morris et al., 2013; Rajendram & McGuire, 2006).

FIGURE 2.

FIGURE 2

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Accidental Tracheostomy Dislodgement Algorithm guides bedside staff when initially encountering tracheostomy dislodgement

FIGURE 3.

FIGURE 3

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The Head of the Bed (HOB) Tracheostomy Communication Tool is a document placed at the head of the patient's bed. It offers space for clinicians to document information about the patient's tracheostomy and serves as a communication tool at the time of accidental tracheostomy dislodgement

The study team assessed pre‐test knowledge on managing ATD using a questionnaire based on the contents of an educational video (Table S1). Additionally, we assessed comfort levels on managing ATD using Dorton's Tracheotomy Education Self‐Assessment Questionnaire (Table S2) (Dorton et al., 2014). On completing pre‐tests, video education was made available via email to critical care nurses and Respiratory Care Practitioners in the critical care units. The study team administered pre‐tests to participants using the Qualtrics online survey platform (“Qualtrics software,”, 2020) via a link delivered by email. Participating staff were oriented to the project via virtual meeting (Zoom), with nurses introducing the practice change, identifying roles, and highlighting the advantages. The study team also held virtual meetings with the Director and leaders among Respiratory Care Practitioners.

A hyperlink provided an educational video on the ATD bundle to nurses and Respiratory Care Practitioners. The video demonstrated (1) how to identify airway emergencies related to tracheostomy tube dislodgement, (2) ATD bundle use during emergencies and (3) how to perform hand‐off reports during the shift change using the HOB Tracheostomy Communication Tool. The video instructed nurses to prepare rooms prior to patient arrival, and a Respiratory Care Practitioner would place the Emergency Tracheostomy Kit. Next, the nurse, Respiratory Care Practitioner, and anaesthesia provider perform a hand‐off report at patient admission to the unit. This process entailed filling out the HOB Tracheostomy Communication Tool together. The group would then post the HOB Tracheostomy Communication Tool at the head of the bed. Finally, clinicians would use the HOB Tracheostomy Communication Tool at each shift change to perform hand‐off reports. The nurses and Respiratory Care Practitioner received identical instruction for the purposes of this study. However, nurses were responsible for HOB and tracheostomy dislodgement algorithm signage, while Respiratory Care Practitioners were responsible for the contents of the Emergency Tracheostomy Kit.

2.4.2. Implementation phase

The study team initiated the bundle following the KTA framework (Figure 1) (Jung & Grubb, 2021). The bundle algorithm provides step‐by‐step actions and interventions for responding to accidental tracheostomy tube dislodgement (Bontempo & Manning, 2019; Hood et al., 2017; McDonough et al., 2016; McGrath et al., 2012). The HOB Tracheostomy Communication Tool provides critical information for clinical decision‐making (Darr et al., 2012; Doherty, Bowler, et al., 2018; Doherty, Neal, et al., 2018; McGrath et al., 2012; Rajendram & McGuire, 2006). The Emergency Tracheostomy Kit contained necessary emergency supplies within arm's reach from the patient bed (McGrath et al., 2012; Mitchell et al., 2013; Morris et al., 2013; Rajendram & McGuire, 2006). The video contained information on identifying and assessing tracheostomy tube dislodgement.

During this phase, adherence to the bundle was assessed through in‐person audits by the study team. The audit consisted of unannounced visits to both ICU and SCU weekly during the eight weeks of the quality improvement project. The presence of the three components of the ATD bundle in patient rooms defined adherence. In addition, the study team communicated with nurses to assess barriers to using the ATD bundle.

2.4.3. Post‐implementation phase

During the last phase of the project, the study team evaluated outcomes using post‐tests at ten weeks to gauge the knowledge and comfort of managing ATD. In addition, the adherence rate was also calculated based on data collected during the implementation phase. Finally, data were analysed and presented to the stakeholders in the post‐implementation phase to establish the intervention's sustainability.

2.5. Data collection

2.5.1. Pre‐Implementation phase

The Qualtrics survey, which included demographics, a pre‐test on knowledge, and comfort levels related to ATD, was assigned to nurses and Respiratory Care Practitioners who met the inclusion criteria. The study team sent a reminder to complete the survey via email. Demographics included were home unit (ICU or SCU for nurses), highest degree achieved, work experience in years, and the number of fresh tracheostomy patients treated in 2020.

2.5.2. Implementation phase

Over eight weeks, we performed an in‐person compliance audit once each week from January to March and filled out the Tracheostomy Dislodgement Audit Sheet.

2.5.3. Post‐implementation phase

After ten weeks of implementation, the study team administered a post‐test on knowledge and comfort level related to accidental tracheostomy tube dislodgement via the Qualtrics platform to nurses and Respiratory Care Practitioners who completed the pre‐test. In addition, we reviewed the Tracheostomy Dislodgement Audit Sheet and Electronic Medical Records for protocol adherence and evidence of Code Blue responses.

2.6. Outcome measures

2.6.1. Assessment of knowledge

The study team, comprising both national and international experts, developed the Tracheostomy Dislodgment Knowledge‐Assessment Questionnaire. The instrument consisted of seven multiple‐choice questions covering material presented in the video (Table S1). The instrument was assessed for face validity and piloted by the study team; however, no further measures of validity were established. Nurses and Respiratory Care Practitioners completed the seven‐item multiple‐choice questionnaire via Qualtrics Survey software. Possible scores ranged from 0 to 7, with “0” representing no knowledge about ATD and “7” representing the best understanding. The goal was to improve post‐test knowledge scores compared with the pre‐test scores.

2.6.2. Assessment of comfort level with tracheostomy care

Nurses and Respiratory Care Practitioners completed a ten‐item Tracheotomy Education Self‐Assessment Questionnaire based on a five‐point Likert scale (Table S2) (Dorton et al., 2014). The instrument was used in a similar study by Dorton et al. (2014), in which it was reviewed for face validity and piloted before use. The scale uses ranked descriptors: strongly disagree, disagree, neutral, agree and strongly agree. We coded responses from “strongly disagree” to “strongly agree” as one to five, respectively. We aimed to increase the post‐test comfort level scores compared with the pre‐test scores.

2.6.3. Assessment of adherence to protocol

The study team defined adherence as using the ATD Bundle elements appropriately. Specifically, we audited the presence of the HOB Tracheostomy Communication Tool, Tracheostomy Dislodgement Algorithm and Emergency Tracheostomy Kit at the bedside table. In addition, the study team reviewed code blue documentation in electronic medical records for compliance with the Tracheostomy Dislodgement Algorithm during the code.

2.7. Statistical analysis

Analysis was performed with STATA 17. Statistical significance was set at the α = 0.05 level. Descriptive analyses included examining data distributions and reporting central tendency as median scores and interquartile ranges (IQR). In addition, we performed a Wilcoxon Signed‐Rank test to evaluate the difference between knowledge and comfort pre‐test and post‐test scores.

3. RESULTS

3.1. Participant characteristics

Out of 42 total participants, 23 nurses and one Respiratory Care Practitioner (57%) fully participated in this quality improvement project, with an additional 18 participants completing the pre‐test only and subsequently excluded from the analysis. Seven had under five years of professional experience in their role, nine had five to ten years of experience, and eight had 11 or more years of experience. Additionally, three participants did not care for patients with a new tracheostomy in the previous year (2020), twelve cared for two to five patients, six cared for six to ten patients, and three cared for more than ten patients (Table 2).

TABLE 2.

Baseline characteristics of survey participants

Characteristics Count (percentage)
n (%)
Home Unit of Health Professional
Step‐down Care Unit (SCU) 8 (33.3)
Intensive Care Unit (ICU) 16 (66.7)
Years of practice in current role
New graduate 2 (8.3)
<5 years 5 (20.8)
5–10 years 9 (37.5)
11–15 years 3 (12.5)
16–20 years 1 (4.17)
>20 years 4 (16.7)
Number of tracheostomy patients treated in year 2020
None 3 (12.5)
≤5 patients 12 (50)
6–10 patients 6 (25)
>10 patients 3 (12.5)
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3.2. Accidental tracheostomy dislodgement knowledge score

Pre‐intervention knowledge scores ranged from 1 to 6, out of 7 total possible points, with a median of 4.0 (IQR: 1.0). Post‐intervention knowledge scores ranged from 3 to 7, with a median score of 5.0 points (IQR: 1.0). The differences in pre‐ and post‐test scores ranged from −1 to 6 with no missing data. The median score improvement from pre‐ to post‐test was 2.0 points (IQR: 1.0; p < .001).

3.3. Comfort level with accidental tracheostomy dislodgement management

Pre‐intervention comfort levels ranged from 20 to 50, out of 50 total possible points, with a median score of 38.0 (IQR: 7.0). Post‐intervention comfort scores ranged from 28 to 50, with a median of 40.0 points (IQR: 5.0). The differences in pre‐ and post‐test comfort scores ranged from 0 to 9 with no missing data. The median score improvement was 2.0 points (IQR: 5.00; p < .001).

3.4. Compliance with accidental tracheostomy dislodgement bundle

Over the eight‐week audit period, there were nine patients with fresh tracheostomy tubes in the ICU and five patients with fresh tracheostomy tubes in the SCU (Table 3). No patients with fresh tracheostomy required Rapid Response team or Code Blue intervention in the ICU or SCU on inspection of medical records. Adherence rates with the Emergency Tracheostomy Kit and HOB Tracheostomy Communication Tool were 100 percent for both ICU and SCU. The Tracheostomy Dislodgement Algorithm should have been present on the reverse side of the HOB Tracheostomy Communication Tool; however, it was missing in half of the audited rooms.

TABLE 3.

Adherence to Accidental Tracheostomy Dislodgement Protocol Components

Locations Number of patients with fresh tracheostomy Head of the bead tracheostomy communication tool Emergency tracheostomy kit Tracheostomy dislodgement algorithm
n (%) n (%) n (%)
Intensive care unit 9 9 (100) 9 (100) 5 (55)
Step‐down care unit 5 5 (100) 5 (100) 2 (40)
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4. DISCUSSION

We developed and tested a simplified, structured approach for nurses to manage the early minutes of accidental tracheostomy tube dislodgement—the most common serious adverse event in patients with a fresh tracheostomy (Brenner et al., 2020). Our data show that nurses' and Respiratory Care Practitioners' knowledge and comfort level in managing accidental tracheostomy tube dislodgements improved after implementing the ATD bundle. Both ICU and SCU staff met the goal of 75% adherence to the ATD bundle. During the project implementation and post‐implementation stages, there were no reported incidences of accidental tracheostomy tube dislodgements to directly evaluate the effectiveness of the ATD bundle in improving patient safety. However, participants' heightened awareness of ATD may have reduced the odds of such an incidence. Few studies on tracheostomy are conducted in local community hospitals, and this ATD bundle can help fill that void with a streamlined approach to emergency tracheostomy care. This study was tailored for critical care nurses and focused on critical initial intervention during ATD. The following definitive management of tracheostomy airway emergency by respiratory specialists should adhere to comprehensive multidisciplinary guidelines (Figure 4) (McGrath et al., 2012). Prior literature documents a significant knowledge gap among clinicians concerning airway emergencies and tracheostomy tube dislodgements (Masood et al., 2018; McDonough et al., 2016). The improvement in knowledge in the present study is therefore reassuring.

FIGURE 4.

FIGURE 4

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Full algorithm to guide respiratory specialists in managing a tracheostomy emergency. Reprinted from “Multidisciplinary guidelines for the management of tracheostomy and laryngectomy airway emergencies,” by B. A. McGrath, L. Bates, D. Atkinson, et al., 2012, Anaesthesia, 67(9), 1025–1041. Copyright 2012 by John Wiley and Sons

A tracheostomy is one of the most performed procedures in critically ill patients (Brass et al., 2016; Chandrasena et al., 2020). The number of tracheostomies performed in resource‐rich countries likely exceeds 250,000 annually (Brenner et al., 2020), and tracheostomy accounts for half of all airway‐related deaths and hypoxic brain damage in critical care units (Bontempo & Manning, 2019; Brenner et al., 2020). Although accidental dislodgement is known to cause hypoxic brain injury and death in some patients (Bontempo & Manning, 2019; Chandrasena et al., 2020), the rate of significant complications relative to accidental dislodgement is unknown, as coding in administrative databases does not allow designation of tracheostomy‐related events as a primary cause of death (Cramer et al., 2019). An extrapolation of survey data suggests approximately 1000 catastrophic tracheostomy‐related complications and 500 tracheostomy‐related deaths occur in the United States annually (Das et al., 2012).

The surges in critically ill patients during the COVID‐19 pandemic, along with staff and resource scarcity, predispose patients with a tracheostomy to adverse events. The present study proactively improves hospital policy, bedside communication, and standardised code activation protocols. Healthcare professionals have long expressed concerns about their limited experience, lack of specialised knowledge, and inadequate comfort in managing emergency airway events such as tracheostomy dislodgement (Colandrea & Eckardt, 2016; Pritchett et al., 2016). Our integrated approach to tracheostomy‐related emergencies is part of a greater effort in continuing education and a quality improvement in this area. These efforts include prospective data collection, use of simulation and incorporating core principles of quality improvement collaboratives (Bedwell et al., 2019; Masood et al., 2018; McKeon et al., 2018; McKeon et al., 2019). Most morbidity and mortality related to the accidental dislodgement of tracheostomy tubes are preventable, and this study complements other international efforts (Mitchell et al., 2013; Mussa et al., 2021; White et al., 2012).

4.1. Limitations

This study demonstrates the feasibility of implementing standardised tracheostomy protocols in a community critical care setting, but it also leaves many questions unanswered. For example, the experience in the community may not generalise to tertiary academic centres or resource‐restricted settings in other geographies. Furthermore, our focus on knowledge and comfort was necessary due to the relatively low volume of tracheostomy care, with effects on clinical outcomes awaiting future study. Additionally, while our team piloted and established the face validity of the Tracheostomy Dislodgement Knowledge Assessment Questionnaire, lack of further validation is a salient limitation. A similar limitation exists for the Comfort Level tool, first developed by Dorton et al. (2014). Furthermore, in ATD bundle audits, the Tracheostomy Dislodgement Algorithm was sometimes missing on the reverse of the HOB Tracheostomy Communication Tool. This omission may reflect incomplete engagement, poor communication, or an inherent approach limitation. In addition, attrition (individuals not completing the post‐intervention survey) can contribute to bias, with possible underlying causes including survey fatigue, competing priorities amid the COVID‐19 pandemic, and unprecedented staff turnover in both critical care units. Finally, few Respiratory Care Practitioners participated due to competing work demands and reduced in‐person activity.

4.2. Further directions

This study sets the stage for further work on improving the care of critically ill patients with tracheostomy, particularly in community settings. In addition, this study's approach is likely applicable to other common tracheostomy adverse events, such as bleeding, device occlusion, device‐related pressure injuries and quality of life considerations such as rehabilitating speech, swallowing or other survivorship aspects (Cooper et al., 2020; Martin et al., 2021; Pandian et al., 2019; Pandian et al., 2020; Zaga et al., 2020). Such work is particularly relevant to “hospital at home” initiatives that aim to provide hospital‐level care in the home setting, as the presence of a tracheostomy is often a limiting factor in disposition to home. In addition, longitudinal study of ATD bundle implementation may illuminate its long‐term effects on nurse knowledge and comfort beyondthe ten weeks described in this study. Long‐term phenomena, such as nursing unit turnover, undoubtedly play a role in skill retention and patient outcomes as previously demonstrated (Bae et al., 2010). Finally, multi‐institutional studies are needed to assess clinical outcomes across care settings and further refine best practices.

5. CONCLUSION

Accidental tracheostomy tube dislodgement is the most common adverse event related to tracheostomies and can lead to airway compromise and mortality. Lack of clear and uniform guidelines and inconsistencies in practices among the different members of the healthcare team create confusion during airway emergencies. Implementing the accidental tracheostomy tube dislodgement bundle at a community hospital streamlined emergency airway management. This approach increased nurses' and Respiratory Care Practitioners' confidence in managing tracheostomy dislodgement emergencies.

6. RELEVANCE TO CLINICAL PRACTICE

Despite the dangers to the health and safety of patients with a fresh tracheostomy, a considerable knowledge deficit exists among clinicians managing airway emergencies (Masood, Farquhar, Biancaniello, & Hackman, 2018; McDonough et al., 2016). In addition, ATD is a common adverse event (Brenner et al., 2020). Therefore, there is a pressing need to improve decision‐making abilities during dislodgement. Nurses are often the first responders to an airway emergency, so their ability to think and act swiftly is paramount. While definitive care should follow comprehensive multidisciplinary guidelines, a streamlined, actionable set of interventions for the bedside nurse may improve their ability to respond quickly and confidently during emergencies. The present study demonstrates increased competency following a nurse‐led intervention consisting of (1) a streamlined ATD algorithm, communication tool, and emergency kit and (2) an educational video on identifying airway emergencies, using the intervention bundle, and hand‐off reporting. Future research is needed to link improved competency with patient outcomes. However, this study shows that a simple intervention bundle employed at the unit level in a community hospital can significantly improve knowledge and subjective comfort in managing ATD.

AUTHOR CONTRIBUTIONS

Dawn Ta Un Jung: Conception, design, and drafting of the work, acquisition, analysis, and interpretation of data for the work; critically revising the work for important intellectual content; approval of the final submission; agreement to be accountable for all aspects of the work. Lisa Grubb: Conception, design, and analysis and interpretation of data for the work; critically revising the work for important intellectual content; approval of the final submission; agreement to be accountable for all aspects of the work. Chandler H. Moser: Analysis and interpretation of data for the work; critically revising the work for important intellectual content; approval of the final submission; agreement to be accountable for all aspects of the work. Jeanette T. M. Nazarian: Conception, design, and analysis and interpretation of data for the work; critically revising the work for important intellectual content; approval of the final submission; agreement to be accountable for all aspects of the work. Neesha Patel: Conception, design, and analysis and interpretation of data for the work; critically revising the work for important intellectual content; approval of the final submission; agreement to be accountable for all aspects of the work. Lisa E. Seldon: Analysis and interpretation of data for the work; critically revising the work for important intellectual content; approval of the final submission; agreement to be accountable for all aspects of the work. Kristen A. Moore: Analysis and interpretation of data for the work; critically revising the work for important intellectual content; approval of the final submission; agreement to be accountable for all aspects of the work. Brendan A. McGrath: Analysis and interpretation of data for the work; critically revising the work for important intellectual content; approval of the final submission; agreement to be accountable for all aspects of the work. Michael J. Brenner: Analysis and interpretation of data for the work; critically revising the work for important intellectual content; approval of the final submission; agreement to be accountable for all aspects of the work. Vinciya Pandian: Conception, design, drafting, and analysis and interpretation of data for the work; critically revising the work for important intellectual content; approval of the final submission; agreement to be accountable for all aspects of the work.

FUNDING INFORMATION

Financial support for this study was provided by R01 NIH 5‐R017433 to Vinciya Pandian on the evaluation of laryngeal injury post‐extubation in intensive care unit settings. Additionally, the Uniformed Services University of the Health Sciences (USU), TriService Nursing Research Program award 11,052‐N2103GR supports Chandler H. Moser.

CONFLICT OF INTEREST

The authors have declared no conflict of interest for this article.

DISCLAIMER

This research was sponsored by the TriService Nursing Research Program, Uniformed Services University of the Health Sciences; however, the information or content and conclusions do not necessarily represent the official position or policy of, nor should any official endorsement be inferred by, the TriService Nursing Research Program, the Uniformed Services University of the Health Sciences, U.S. Army Medical Center of Excellence, the U.S. Army Training and Doctrine Command, or the Departments of Army, Department of Defense, or U.S. Government.

Supporting information

Table S1‐S2

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File S1

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Table S3

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Table S4

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ACKNOWLEDGEMENTS

The authors wish to thank the patients, families, frontline health professionals and hospital leadership for their perspectives on the ATD bundle and support for its implementation.

Jung, D. T. U. , Grubb, L. , Moser, C. H. , Nazarian, J. T. M. , Patel, N. , Seldon, L. E. , Moore, K. A. , McGrath, B. A. , Brenner, M. J. , & Pandian, V. (2022). Implementation of an evidence‐based accidental tracheostomy dislodgement bundle in a community hospital critical care unit. Journal of Clinical Nursing, 00, 1–13. 10.1111/jocn.16535

DATA AVAILABILITY STATEMENT

The data that support the findings of this study are available from the corresponding author upon reasonable request.

REFERENCES

  1. Bae, S. H. , Mark, B. , & Fried, B. (2010). Impact of nursing unit turnover on patient outcomes in hospitals. Journal of Nursing Scholarship, 42(1), 40–49. 10.1111/j.1547-5069.2009.01319.x [DOI] [PubMed] [Google Scholar]
  2. Bedwell, J. R. , Pandian, V. , Roberson, D. W. , McGrath, B. A. , Cameron, T. S. , & Brenner, M. J. (2019). Multidisciplinary tracheostomy care: How collaboratives drive quality improvement. Otolaryngologic Clinics of North America, 52(1), 135–147. 10.1016/j.otc.2018.08.006 [DOI] [PubMed] [Google Scholar]
  3. Bier‐Laning, C. , Cramer, J. D. , Roy, S. , Palmieri, P. A. , Amin, A. , Anon, J. M. , Bonilla‐Asalde, C. A. , Bradley, P. J. , Chaturvedi, P. , Cognetti, D. M. , Dias, F. , Di Stadio, A. , Fagan, J. J. , Feller‐Kopman, D. J. , Hao, S.‐P. , Kim, K. H. , Koivunen, P. , Loh, W. S. , Mansour, J. , … Brenner, M. J. (2021). Tracheostomy during the COVID‐19 pandemic: Comparison of international perioperative care protocols and practices in 26 countries. Otolaryngology and Head and Neck Surgery, 164(6), 1136–1147. 10.1177/0194599820961985 [DOI] [PubMed] [Google Scholar]
  4. Bontempo, L. J. , & Manning, S. L. (2019). Tracheostomy emergencies. Emergency Medicine Clinics of North America, 37(1), 109–119. 10.1016/j.emc.2018.09.010 [DOI] [PubMed] [Google Scholar]
  5. Brass, P. , Hellmich, M. , Ladra, A. , Ladra, J. , & Wrzosek, A. (2016). Percutaneous techniques versus surgical techniques for tracheostomy. Cochrane Database of Systematic Reviews, 7, CD008045. 10.1002/14651858.CD008045.pub2 [DOI] [PMC free article] [PubMed] [Google Scholar]
  6. Brenner, M. J. , Pandian, V. , Milliren, C. E. , Graham, D. A. , Zaga, C. , Morris, L. L. , Bedwell, J. R. , Das, P. , Zhu, H. , Allen, J. L. Y. , Peltz, A. , Chin, K. , Schiff, B. A. , Randall, D. M. , Swords, C. , French, D. , Ward, E. , Sweeney, J. M. , Warrillow, S. J. , … Roberson, D. W. (2020). Global tracheostomy collaborative: Data‐driven improvements in patient safety through multidisciplinary teamwork, standardisation, education, and patient partnership. British Journal of Anaesthesia, 125(1), e104–e118. 10.1016/j.bja.2020.04.054 [DOI] [PubMed] [Google Scholar]
  7. Chandrasena, A. N. , Goswamy, J. , Calder, N. , Khalil, U. , & McGrath, B. A. (2020). Our experience: Quantifying changes in tracheostomy tube position and orientation with repositioning of 14 patients (the lunar positioning study). Clinical Otolaryngology, 45(1), 143–147. 10.1111/coa.13474 [DOI] [PubMed] [Google Scholar]
  8. Cipriano, A. , Mao, M. L. , Hon, H. H. , Vazquez, D. , Stawicki, S. P. , Sharpe, R. P. , & Evans, D. C. (2015). An overview of complications associated with open and percutaneous tracheostomy procedures. International Journal of Critical Illness and Injury Science, 5(3), 179–188. 10.4103/2229-5151.164994 [DOI] [PMC free article] [PubMed] [Google Scholar]
  9. Colandrea, M. , & Eckardt, P. (2016). Improving tracheostomy care delivery: Instituting clinical care pathways and nursing education to improve patient outcomes. ORL‐Head and Neck Nursing, 34(1), 7–16. https://www.ncbi.nlm.nih.gov/pubmed/27164766 [PubMed] [Google Scholar]
  10. Cook, T. M. , Woodall, N. , & Frerk, C. (2011). Major complications of airway management in the UK: Results of the fourth National Audit Project of the Royal College of Anaesthetists and the difficult airway society. Part 1: Anaesthesia. British Journal of Anaesthesia, 106(5), 617–631. 10.1093/bja/aer058 [DOI] [PubMed] [Google Scholar]
  11. Cooper, K. D. , McQueen, K. M. , Halm, M. A. , & Flayter, R. (2020). Prevention and treatment of device‐related hospital‐acquired pressure injuries. American Journal of Critical Care, 29(2), 150–154. 10.4037/ajcc2020167 [DOI] [PubMed] [Google Scholar]
  12. Cramer, J. D. , Graboyes, E. M. , & Brenner, M. J. (2019). Mortality associated with tracheostomy complications in the United States: 2007‐2016. Laryngoscope, 129(3), 619–626. 10.1002/lary.27500 [DOI] [PubMed] [Google Scholar]
  13. Darr, A. , Dhanji, K. , & Doshi, J. (2012). Tracheostomy and laryngectomy survey: Do front‐line emergency staff appreciate the difference? The Journal of Laryngology and Otology, 126(6), 605–608; quiz 608. 10.1017/S0022215112000618 [DOI] [PubMed] [Google Scholar]
  14. Das, P. , Zhu, H. , Shah, R. K. , Roberson, D. W. , Berry, J. , & Skinner, M. L. (2012). Tracheotomy‐related catastrophic events: Results of a national survey. Laryngoscope, 122(1), 30–37. 10.1002/lary.22453 [DOI] [PMC free article] [PubMed] [Google Scholar]
  15. Doherty, C. , Bowler, M. , Monks, S. , English, C. , Sadadcharam, M. , Perkins, R. , Bateman, N. , Bruce, I. A. , Atkinson, D. , & McGrath, B. (2018). Reduction in harm from tracheostomy‐related incidents after implementation of the paediatric National Tracheostomy Safety Project resources: A retrospective analysis from a tertiary paediatric Centre. Clinical Otolaryngology, 43(2), 674–678. 10.1111/coa.12994 [DOI] [PubMed] [Google Scholar]
  16. Doherty, C. , Neal, R. , English, C. , Cooke, J. , Atkinson, D. , Bates, L. , Moore, J. , Monks, S. , Bowler, M. , Bruce, I. A. , Bateman, N. , Wyatt, M. , Russell, J. , Perkins, R. , McGrath, B. A. , & Paediatric Working Party of the National Tracheostomy Safety Project . (2018). Multidisciplinary guidelines for the management of paediatric tracheostomy emergencies. Anaesthesia, 73(11), 1400–1417. 10.1111/anae.14307 [DOI] [PubMed] [Google Scholar]
  17. Dorton, L. H. , Lintzenich, C. R. , & Evans, A. K. (2014). Simulation model for tracheotomy education for primary health‐care providers. The Annals of Otology, Rhinology, and Laryngology, 123(1), 11–18. 10.1177/0003489414521144 [DOI] [PubMed] [Google Scholar]
  18. Fernandez‐Bussy, S. , Mahajan, B. , Folch, E. , Caviedes, I. , Guerrero, J. , & Majid, A. (2015). Tracheostomy tube placement: Early and late complications. Journal of Bronchology & Interventional Pulmonology, 22(4), 357–364. 10.1097/LBR.0000000000000177 [DOI] [PubMed] [Google Scholar]
  19. Graham, I. D. , Kothari, A. , & McCutcheon, C. (2018). Moving knowledge into action for more effective practice, programmes and policy: Protocol for a research programme on integrated knowledge translation. Implementation Science, 13(1), 22. 10.1186/s13012-017-0700-y [DOI] [PMC free article] [PubMed] [Google Scholar]
  20. Graham, I. D. , & Tetroe, J. (2007). How to translate health research knowledge into effective healthcare action. Healthcare Quarterly, 10(3), 20–22. 10.12927/hcq..18919 [DOI] [PubMed] [Google Scholar]
  21. Hood, K. , Lewis, B. , & Bowens, C. D. (2017). Reducing fresh tracheostomy decannulations following implementation of a fresh tracheostomy guideline. Critical Care Nursing Clinics of North America, 29(2), 131–141. 10.1016/j.cnc.2017.01.001 [DOI] [PubMed] [Google Scholar]
  22. Jung, D. T. , & Grubb, L. (2021). Management of accidental tracheostomy tube dislodgement: An integrative review. ORL‐Head and Neck Nursing, 39(1), 5–11. [Google Scholar]
  23. Kohn, J. , McKeon, M. , Munhall, D. , Blanchette, S. , Wells, S. , & Watters, K. (2019). Standardization of pediatric tracheostomy care with "go‐bags". International Journal of Pediatric Otorhinolaryngology, 121, 154–156. 10.1016/j.ijporl.2019.03.022 [DOI] [PubMed] [Google Scholar]
  24. Kutsukutsa, J. , Kuupiel, D. , Monori‐Kiss, A. , Del Rey‐Puech, P. , & Mashamba‐Thompson, T. P. (2019). Tracheostomy decannulation methods and procedures for assessing readiness for decannulation in adults: A systematic scoping review. International Journal of Evidence‐Based Healthcare, 17, 74–91. 10.1097/XEB.0000000000000166 [DOI] [PubMed] [Google Scholar]
  25. Martin, K. A. , Cole, T. D. K. , Percha, C. M. , Asanuma, N. , Mattare, K. , Hager, D. N. , Brenner, M. J. , & Pandian, V. (2021). Standard versus accelerated speaking valve placement after percutaneous tracheostomy: A randomized controlled feasibility study. Annals of the American Thoracic Society, 18(10), 1693–1701. 10.1513/AnnalsATS.202010-1282OC [DOI] [PMC free article] [PubMed] [Google Scholar]
  26. Masood, M. M. , Farquhar, D. R. , Biancaniello, C. , & Hackman, T. G. (2018). Association of Standardized Tracheostomy Care Protocol Implementation and Reinforcement with the prevention of life‐threatening respiratory events. JAMA Otolaryngology. Head & Neck Surgery, 144(6), 527–532. 10.1001/jamaoto.2018.0484 [DOI] [PMC free article] [PubMed] [Google Scholar]
  27. McDonough, K. , Crimlisk, J. , Nicholas, P. , Cabral, H. , Quinn, E. K. , & Jalisi, S. (2016). Standardizing nurse training strategies to improve knowledge and self‐efficacy with tracheostomy and laryngectomy care. Applied Nursing Research, 32, 212–216. 10.1016/j.apnr.2016.08.003 [DOI] [PubMed] [Google Scholar]
  28. McGrath, B. A. , Bates, L. , Atkinson, D. , & Moore, J. A. (2012). Multidisciplinary guidelines for the management of tracheostomy and laryngectomy airway emergencies. Anaesthesia, 67(9), 1025–1041. 10.1111/j.1365-2044.2012.07217.x [DOI] [PubMed] [Google Scholar]
  29. McGrath, B. A. , Lynch, J. , Bonvento, B. , Wallace, S. , Poole, V. , Farrell, A. , Diaz, C. , Khwaja, S. , & Roberson, D. W. (2017). Evaluating the quality improvement impact of the global tracheostomy collaborative in four diverse NHS hospitals. BMJ Quality Improvement Reports, 6(1), 1–2. 10.1136/bmjquality.u220636.w7996 [DOI] [PMC free article] [PubMed] [Google Scholar]
  30. McGrath, B. A. , Lynch, K. , Templeton, R. , Webster, K. , Simpson, W. , Alexander, P. , & Columb, M. O. (2017). Assessment of scoring systems to describe the position of tracheostomy tubes within the airway—The lunar study. British Journal of Anaesthesia, 118(1), 132–138. 10.1093/bja/aew336 [DOI] [PubMed] [Google Scholar]
  31. McGrath, B. A. , Wallace, S. , Lynch, J. , Bonvento, B. , Coe, B. , Owen, A. , Firn, M. , Brenner, M. J. , Edwards, E. , Finch, T. L. , Cameron, T. , Narula, A. , & Roberson, D. 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. 10.1016/j.bja.2020.04.064 [DOI] [PubMed] [Google Scholar]
  32. McKeon, M. , Kohn, J. , Munhall, D. , Wells, S. , Blanchette, S. , Santiago, R. , Graham, R. , Nuss, R. , Rahbar, R. , Volk, M. , & Watters, K. (2019). Association of a Multidisciplinary Care Approach with the quality of care after pediatric tracheostomy. JAMA Otolaryngology. Head & Neck Surgery, 145(11), 1035–1042. 10.1001/jamaoto.2019.2500 [DOI] [PMC free article] [PubMed] [Google Scholar]
  33. McKeon, M. , Munhall, D. , Walsh, B. K. , Nuss, R. , Rahbar, R. , Volk, M. , & Watters, K. (2018). A standardized, closed‐loop system for monitoring pediatric tracheostomy‐related adverse events. Laryngoscope, 128(10), 2419–2424. 10.1002/lary.27251 [DOI] [PubMed] [Google Scholar]
  34. Medeiros, G. C. , Sassi, F. C. , Lirani‐Silva, C. , & Andrade, C. R. F. (2019). Criteria for tracheostomy decannulation: Literature review. Codas, 31(6), e20180228. 10.1590/2317-1782/20192018228 [DOI] [PubMed] [Google Scholar]
  35. Meister, K. D. , Pandian, V. , Hillel, A. T. , Walsh, B. K. , Brodsky, M. B. , Balakrishnan, K. , Best, S. R. , Chinn, S. B. , Cramer, J. D. , Graboyes, E. M. , McGrath, B. A. , Rassekh, C. H. , Bedwell, J. R. , & Brenner, M. J. (2021). Multidisciplinary safety recommendations after tracheostomy during COVID‐19 pandemic: State of the art review. Otolaryngology and Head and Neck Surgery, 164(5), 984–1000. 10.1177/0194599820961990 [DOI] [PMC free article] [PubMed] [Google Scholar]
  36. Mitchell, R. B. , Hussey, H. M. , Setzen, G. , Jacobs, I. N. , Nussenbaum, B. , Dawson, C. , Brown, C. A., III , Brandt, C. , Deakins, K. , Hartnick, C. , Merati, A. , & Merati, A. (2013). Clinical consensus statement: Tracheostomy care. Otolaryngology and Head and Neck Surgery, 148(1), 6–20. 10.1177/0194599812460376 [DOI] [PubMed] [Google Scholar]
  37. Morris, L. L. , Whitmer, A. , & McIntosh, E. (2013). Tracheostomy care and complications in the intensive care unit. Critical Care Nurse, 33(5), 18–30. 10.4037/ccn2013518 [DOI] [PubMed] [Google Scholar]
  38. Mussa, C. C. , Gomaa, D. , Rowley, D. D. , Schmidt, U. , Ginier, E. , & Strickland, S. L. (2021). AARC clinical practice guideline: Management of Adult Patients with tracheostomy in the acute care setting. Respiratory Care, 66(1), 156–169. 10.4187/respcare.08206 [DOI] [PubMed] [Google Scholar]
  39. Ogrinc, G. , Davies, L. , Goodman, D. , Batalden, P. , Davidoff, F. , & Stevens, D. (2015). SQUIRE 2.0 (standards for QUality improvement reporting excellence): Revised publication guidelines from a detailed consensus process. [DOI] [PubMed]
  40. Omokanye, H. K. , Dunmade, A. D. , Segun‐Busari, S. , Afolabi, O. A. , Habeeb, O. G. , Adegboye, M. B. , & Alabi, B. S. (2016). Accidental decannulation OF tracheostomy tubes—Case series. Journal of the West African College of Surgeons, 6(1), 108–118. https://www.ncbi.nlm.nih.gov/pubmed/28344941 [PMC free article] [PubMed] [Google Scholar]
  41. Pandian, V. , Boisen, S. , Mathews, S. , & Brenner, M. J. (2019). Speech and safety in tracheostomy patients receiving mechanical ventilation: A systematic review. American Journal of Critical Care, 28(6), 441–450. 10.4037/ajcc2019892 [DOI] [PubMed] [Google Scholar]
  42. Pandian, V. , Morris, L. L. , Brodsky, M. B. , Lynch, J. , Walsh, B. , Rushton, C. , Phillips, J. , Rahman, A. , DeRose, T. , Lambe, L. , Lami, L. , SPM, W. , Garza, F. P. , Maiani, S. , Zavalis, A. , Okusanya, K. A. , Palmieri, P. A. , BA, M. G. , Pelosi, P. , … Brenner, M. J. (2020). Critical care guidance for tracheostomy care during the COVID‐19 pandemic: A global, multidisciplinary approach. American Journal of Critical Care, 29(6), e116–e127. 10.4037/ajcc2020561 [DOI] [PubMed] [Google Scholar]
  43. Pritchett, C. V. , Foster Rietz, M. , Ray, A. , Brenner, M. J. , & Brown, D. (2016). Inpatient nursing and parental comfort in managing pediatric tracheostomy care and emergencies. JAMA Otolaryngology. Head & Neck Surgery, 142(2), 132–137. 10.1001/jamaoto.2015.3050 [DOI] [PubMed] [Google Scholar]
  44. Qualtrics software . (2020). https://www.qualtrics.com
  45. Rajendram, R. , & McGuire, N. (2006). Repositioning a displaced tracheostomy tube with an Aintree intubation catheter mounted on a fibre‐optic bronchoscope. British Journal of Anaesthesia, 97(4), 576–579. 10.1093/bja/ael188 [DOI] [PubMed] [Google Scholar]
  46. Rassekh, C. H. , Zhao, J. , Martin, N. D. , Chalian, A. A. , & Atkins, J. H. (2015). Tracheostomy complications as a trigger for an airway rapid response: Analysis and quality improvement considerations. Otolaryngology and Head and Neck Surgery, 153(6), 921–926. 10.1177/0194599815612759 [DOI] [PubMed] [Google Scholar]
  47. Singh, R. K. , Saran, S. , & Baronia, A. K. (2017). The practice of tracheostomy decannulation–A systematic review. Journal of Intensive Care, 5, 38. 10.1186/s40560-017-0234-z [DOI] [PMC free article] [PubMed] [Google Scholar]
  48. Wells, S. , Shermont, H. , Hockman, G. , Hamilton, S. , Abecassis, L. , Blanchette, S. , & Munhall, D. (2018). Standardized tracheostomy education across the Enterprise. Journal of Pediatric Nursing, 43, 120–126. 10.1016/j.pedn.2018.06.004 [DOI] [PubMed] [Google Scholar]
  49. White, A. C. , Kher, S. , & O'Connor, H. H. (2010). When to change a tracheostomy tube. Respiratory Care, 55(8), 1069–1075. https://www.ncbi.nlm.nih.gov/pubmed/20667154 [PubMed] [Google Scholar]
  50. White, A. C. , Purcell, E. , Urquhart, M. B. , Joseph, B. , & O'Connor, H. H. (2012). Accidental decannulation following placement of a tracheostomy tube. Respiratory Care, 57(12), 2019–2025. 10.4187/respcare.01627 [DOI] [PubMed] [Google Scholar]
  51. Zaga, C. J. , Pandian, V. , Brodsky, M. B. , Wallace, S. , Cameron, T. S. , Chao, C. , Orloff, L. A. , Atkins, N. E. , McGrath, B. A. , Lazarus, C. L. , Vogel, A. P. , & Brenner, M. J. (2020). Speech‐language pathology guidance for tracheostomy during the COVID‐19 pandemic: An international multidisciplinary perspective. American Journal of Speech‐Language Pathology, 29(3), 1320–1334. 10.1044/2020_AJSLP-20-00089 [DOI] [PubMed] [Google Scholar]

Associated Data

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Supplementary Materials

Table S1‐S2

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File S1

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Table S3

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Table S4

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Data Availability Statement

The data that support the findings of this study are available from the corresponding author upon reasonable request.

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