Title : Improving compliance with on the right trach? guidelines through implementation of a tracheostomy passport in the intensive care unit
Abstract:
Objective: A tracheostomy is a surgically created airway in which a stoma is formed, and a tracheostomy tube is inserted to establish a secure airway1 . Common indications include upper airway obstruction, prolonged mechanical ventilation, and airway protection2 . The National Confidential Enquiry into Patient Outcome and Death (NCEPOD) produced a review entitled On the Right Trach?, critiquing and recommending guidance on the care pathway for tracheostomies3 . We conducted an audit of our practices to determine whether any changes to our tracheostomy procedure and pathway were necessary.
Methods: A retrospective study was conducted on all tracheostomies performed in the intensive therapy unit (ITU) within Darent Valley Hospital from January 2023 to February 2024, assessing adherence to 12 of the On the Right Trach? recommendations. Data from 31 patients were collected by reviewing case notes from our intranet portal. The recommendations against which we compared our patients' care pathways included correct documentation and coding, presence of consent forms, use of a Local Safety Standards for Invasive Procedures (LocSSIP) checklist, use of capnography and endoscopy, whether extubation trials were conducted and documented, correct discharge documentation, and whether speech and language therapy (SALT) referrals were made under the correct indications.
Results: 33 patients underwent a tracheostomy in Darent Valley Hospital ITU from January 2023 to February 2024, excluding repatriations. All 33 patients had their tracheostomies recorded and coded as an operative procedure; however, an additional 3 patients were incorrectly coded as having a tracheostomy, and only 31 of the 33 had notes available for review. The following results relate to these 31 patients. 26 (83.9%) had the reason for their tracheostomy documented. 28 (90.3%) had their consent discussion documented, with 17 (54.8%) having had a Consent Form 4 completed. Regarding the procedure itself, all patients had a LocSSIP checklist used, and all patients had capnography used, though only 20 (64.5%) had endoscopy. 13 (41.9%) underwent a trial of extubation during their admission; of the 18 who did not have a trial of extubation, only 6 (33.3%) had documentation explaining why. All patients who required a SALT referral (n=21), i.e., those with dysphagia had a SALT referral made. However, only 7 of the 21 (33.3%) had their referrals made the next working day. The mean time between sedation being turned off and the SALT referral being made was 5.86 days.
Conclusions: Our retrospective study revealed relatively good overall adherence to the recommendations assessed. However, compliance with these guidelines was notably reduced in areas relating to documentation. It should be noted that lack of documentation does not equate to lack of practice. Furthermore, there was no assessment of the causation or clinical outcomes of nonadherence. Therefore, to mitigate potential poor clinical outcomes, our recommendations included the implementation of a tracheostomy passport as an essential piece of documentation for consent, tracheostomy procedure details, tracheostomy tube details, extubation trials, swallowing assessments, and SALT referrals. This tracheostomy passport has been in use since October 2025, and following its use for 12 months, a re-audit will be conducted to assess its effects.
