Eyes on the Ties: A QI Improvement Project to Reduce Unplanned Trach Dislodgements

Background: Since FY 2013 the respiratory care department has been tracking unplanned tracheostomy tube dislodgements (TD). By FY 2019, TD rate in the medical unit tripled from 0.15 to 0.5 with a continued steady rise in events. Apparent causes were reviewed showing trach care as a leading contributor to unplanned TDs. In 2020-2021, a PDSA was conducted to address trach care as an apparent cause, however iterative PDSA cycles or changes were unable to be implemented. Between Q3 of FY 2021 and Q3 of FY 2022, an increasing number of eFeedback reports described loose trach ties as the primary cause of dislodgement. Additional staff feedback noted concerns for loose ties just prior to dislodgement. Further investigation of this growing trend in TD cause revealed inconsistent securement practices and a clear trend where parents/staff preferred looser ties. We determined the current standard for ‘one-finger tightness’ needed further visual clarification and reinforcement due to varying understanding of what that standard looked like on a patient. Methods: A multi-disciplinary team came together to create a video presentation that demonstrated the standard definition of what one-finger tightness tracheostomy tie securement looked like on a real patient. Non-standard securement was also demonstrated for providers to ensure prevention of unplanned tracheostomy dislodgments from ties that are too loose and pressure injuries from ties that were too tight. The video was adopted into the medical unit training FY 23 with additional peer-to-peer demonstration. Appropriate standard was reiterated during staff meetings and huddles in the respiratory care department. Results: We continued to track unplanned TD primary causes and staff feedback in the medical unit following implementation of standardized messaging and video release. When reviewing trach TD rates, we saw a 63% decrease in total TD events from Q3 FY 22 to end of FY 23. Apparent causes contributing to unplanned trach dislodgements for FY 23 showed 0 cases involving loose ties. For FY 23 cases in the medical unit – feedback collected from staff did not allude to any concerns for loose ties as a secondary contributor to dislodgement events. Conclusions: Through communication and demonstration of a standard definition for one-finger tightness when evaluating trach tie tightness, the group was able to reduce incidence of TD associated with loose ties.