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National Tracheostomy Safety Project

National Tracheostomy Safety Project. Brendan McGrath University Hospital of South Manchester, Wythenshawe. National Tracheostomy Safety Project Introduction. What is it?. Accessible, multi-disciplinary, educational resources for medical, nursing & allied health staff

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National Tracheostomy Safety Project

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  1. National Tracheostomy Safety Project Brendan McGrath University Hospital of South Manchester, Wythenshawe

  2. National Tracheostomy Safety Project Introduction

  3. What is it? • Accessible, multi-disciplinary, educational resources for medical, nursing & allied health staff • Simple algorithms for dealing with tracheostomy emergencies • Training package • Web-based resources – ‘just in time’ • RCoAeLA e-Learning modules • Optional courses (with simulation) • Equipment standardisation

  4. Why is it needed? NPSA data • Over 5000 tracheostomies per year • Over 600 tracheostomy incidents per year • 60-70% of incidents result in some harm • Depending on location • 32 deaths reported in 2006/7 • Limitations of a voluntary reporting system1 1. Sari B, BMJ, 2007;334: 79-82

  5. Why is it needed? Why us? • 4 trachy-related deaths in Manchester ICU/HDU • Prompted regional survey • Research with NPSA1,2,3 • Recurring themes • NAP 4 has picked up ICU Airway Incidents • HM Coroner • 1. Thomas & McGrath Anaesthesia. 2009 Apr;64(4):358-65, 2.McGrath & Thomas PMJ. 2010 Sep; 86(1019): 522-5 • 3. McGrath & Thomas British J Anaesthesia 2010 (in press)

  6. Why is it needed? • It is unacceptable for a patient with a tracheostomy to come to harm due to • A lack of staff education • Eg not attempting standard oral airway manoeuvres in an emergency with an obstructed trachy • Confusion with laryngectomies • A simple lack of equipment

  7. What are you going to do in an emergency?

  8. Must be some guidance?

  9. UK National Guidance to date • NPSA 2005 • Highlighted need for appropriate staff & equipment • ICS 2008 • Standards of care • NPSA 2009 (never published) • Safer practice notice • Environment, risk assessment, training, equipment • Other • Individual UK Trusts (St George’s) • International

  10. The ICS guidance 2008 Review date July 2011 Emergency management section

  11. What have we done? Regional multi-site multi-disciplinary working party

  12. Information resource • On-line • Interactive • Comprehensive • ‘One-stop shop’

  13. Defining competencies • What knowledge & skills are required to • Insert tracheostomies • Care for patients with a tracheostomy • Manage tracheostomy emergencies • Immediate emergency care • Advanced interventions • Allow us to target appropriate teaching

  14. Simple bedside information • Similar to ‘Nil by Mouth’ signs at the patient bed-head • This patient has • A TRACHEOSTOMY • A LARYNGECTOMY • Essential information required by NPSA / ICS • Simple emergency algorithms

  15. Emergency Algorithms • Working party • Tested and refined over 3 years • Hi-Fi Simulation and Clinical roll-out • Version 10 • Over 40 Faculty • Anaesthesia & Critical Care • ENT, MaxFax • Experienced & Specialist Nursing staff • Physiotherapy, Speech Therapy • Resus council UK

  16. www.tracheostomy.org.uk

  17. Collate the existing and unpublished guidance into a ‘one-stop-shop’ tracheostomy resource • Invitation: comment or get involved • www.tracheostomy.org.uk • Email: comments@tracheostomy.org.uk • DAS and ICS websites

  18. Thank you www.tracheostomy.org.uk

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