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ADC Online First, published on September 1, 2016 as 10.1136/archdischild-2015-309661
Quality reports

Implementation of the TRACHE care bundle:

improving safety in paediatric tracheostomy
Andrew Hall, James Bates, Sonna Ifeacho, Benjamin Hartley, David Albert,
Christopher Jephson, Richard J Hewitt, Lesley Cochrane, Michelle Wyatt,
Joanne Cooke

Great Ormond Street Hospital, INTRODUCTION paediatric intensive care, respiratory, oncology and
London, UK Tracheostomy management has been the focus of a otolaryngology wards. A designated ‘care bundle’
Correspondence to number of reviews in the UK over the last decade; proforma with pass/fail outcomes in each of the
Andrew Hall, Great Ormond however, paediatric patients have thus far been TRACHE domains was used to record results for
Street Hospital, Great Ormond excluded from the analysis.1 2 Currently, there are analysis. Subsequent feedback was given to the
Street, London WC1N 3JH, UK; no formally accepted national standards in the UK ward team as to their performance and areas of
for paediatric tracheostomy management. potential improvement. All statistical analyses were
Received 15 November 2015 Paediatric tracheostomies are associated with risks performed in GraphPad Prism (V.6).
Revised 11 August 2016 and complications in the order of two to three
Accepted 12 August 2016 times higher than morbidity and mortality rates RESULTS
reported in adults. The mortality rate for a compli- The baseline assessment for each outcome measure
cation directly related to a paediatric tracheostomy in 2007 demonstrated deficiencies in ward trache-
is 0.7%.3 The majority of reported adverse inci- ostomy care: incorrect tension of tracheostomy
dents do not occur in the immediate postoperative ties in 35% of patients, incorrect humidity in 7%
period; late complications over a week from inser- of cases, incorrect suctioning technique in 15%,
tion are four times more common.4 Our aim was evidence of neck skin or stoma breakdown in
formalising standards of optimal paediatric tracheo- 20% of patients, incomplete or incorrect emer-
stomy management to minimise future morbidity. gency box use in 35% of patients and incomplete
understanding of tracheostomy resuscitation in
METHODS 27% of cases.
Assessments of paediatric tracheostomy care were In total, 359 paediatric tracheostomies have been
collected from 40 consecutive patients at a tertiary assessed at multiple intervals from 2007 to 2013
specialist paediatric institution in 2007. An initial with consistent improvements shown across all
multidisciplinary root cause analysis of morbidity domains. The results from 2013 show a 92%–
associated with paediatric tracheostomy was carried 100% compliance with the six aspects of the care
out by the senior authors. Main areas of concern bundle (figure 2). χ2 test of independence was per-
relating to tracheostomy care were identified, and formed demonstrating statistically significant
from these, proposed minimum standards of best increases in compliance with the TRACHE care
practice were developed. The recommendations bundle guideline in 2013 in comparison with that
were neatly encompassed in the mnemonic in 2007, as shown.
‘TRACHE’ promoted as the recommended paediat- Since the implementation of the TRACHE proto-
ric tracheostomy ‘care bundle’ (figure 1). col, there has been no tracheostomy-related morta-
This ‘TRACHE’ care bundle was communicated lity at our institution. Risks of decannulation events
widely within our hospital using the following have been minimised through ongoing dedication
means: to achieving correct tape tension. Documented
▸ Standardised ‘TRACHE’ approach teaching on neck trauma and excoriation reduced from 20% to
the Trust Paediatric Immediate Life Support 8% of the 50 cases assessed in 2013, showing a
course and reoccurring biannual 1-day course reduction in tracheostomy-related morbidity,
on tracheostomy care. although this did not attain statistical significance in
▸ Monthly tracheostomy simulation training pro- our analysis.
gramme, designed to teach competence through
▸ Clinical guidelines published on the hospital The role of the TRACHE ‘care bundle’ was to
intranet. create a simple, memorable and effective tool used
Further assessments were performed at regular across all hospital wards and departments to
intervals by the tracheostomy nurse specialist and enhance patient safety. The ‘care bundle’ approach
To cite: Hall A, Bates J,
Ifeacho S, et al. Arch Dis
senior authors on ward nursing staff caring for has previously been used to standardise ward man-
Child Published Online First: paediatric inpatients with a tracheostomy (figure 2). agement in adult tracheostomy care.5
[please include Day Month All paediatric patients under the age of 16 with a T=Tapes: keeping the tracheostomy tube secure
Year] doi:10.1136/ paediatric tracheostomy were included with no Security of the tracheostomy tube is a key prin-
archdischild-2015-309661 further exclusion criteria. Areas assessed included ciple in maintaining airway safety with accidental
Hall A, et al. Arch Dis Child 2016;0:1–3. doi:10.1136/archdischild-2015-309661 1
Copyright Article author (or their employer) 2016. Produced by BMJ Publishing Group Ltd (& RCPCH) under licence.
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Quality reports

Figure 1 Promotional poster

summarising ‘TRACHE’ care bundle

Figure 2 Compliance with ‘TRACHE’ care bundle guidelines 2007–2013.

2 Hall A, et al. Arch Dis Child 2016;0:1–3. doi:10.1136/archdischild-2015-309661
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Quality reports

decannulation occurring in around 5% of paediatric tracheosto- The contents of the emergency tracheostomy box are
mies.1 It had been noted that Velcro neck tapes were more designed to be the essential equipment required in case of an
easily undone by the patient and were associated with a higher accidental decannulation or for an emergency tube change. This
rate of accidental decannulation. A departmental policy for the includes one tube of the same type and size, one tube a size
exclusive use of hand-tied cotton tapes to secure tracheostomy smaller, scissors, lubricating jelly, spare pair of tracheostomy
tubes was implemented. Tape tension is an essential factor; the ties, a suction catheter and 10 mL syringe (if cuffed tube). This
tapes need to be tight enough to secure the tube appropriately, emergency box accompanies the child at all times.
but not too tight that the skin is excoriated. The ideal tape
tension should allow one finger to fit underneath the tapes at
the back of the neck.
Implementing sustained change
A challenge to the introduction of any new policy is the uptake
R=Resus: know the resuscitation process
by the professionals required to implement it long term. A key
The mandatory Paediatric Intermediate Life Support course
concept in the successful sustained use of the TRACHE
for all clinical staff includes resuscitation in a child with a
approach was widespread multidisciplinary senior engagement
throughout paediatric intensive care, otolaryngology and
In addition, parental resuscitation training is completed prior
respiratory teams. This was further supported through enthusi-
to discharge for all children with a new tracheostomy. The aim
asm in teaching and regular training of nursing and medical
of parental education and training is to impart both the confi-
dence and skills to deal with an airway emergency.
A=Airway: demonstrate the correct suction technique
Precise suctioning is important in paediatric tracheostomy CONCLUSION
care. If the suction length is too short, the patient is at risk of Delivering and maintaining consistently safe, high-quality
tube occlusion; yet, if the suction length is too long, it may lead tracheostomy care are essential in both the hospital and commu-
to tracheal trauma with distal soft tissue trauma and subsequent nity environments. The results reported here demonstrate the
formation of granulation tissue. Optimal tracheostomy tube care benefits gained from the structured ‘TRACHE’ paediatric care
involves measuring the tracheostomy tube length (to the nearest bundle approach used in this institution over a 6-year period.
millimetre) with a suction catheter prior to tube insertion and This represents an embedded change within practice for the
using this measurement for future suctioning. This information improvement of patient care.
is documented on the operation note and communicated ver- A key factor in its success is in its simplicity and repeatability,
bally and in writing to all staff and parents caring for the ensuring day-to-day tracheostomy management is standardised.
patient. This demonstrates that the core principles of the paediatric
C=Care of the site: stoma and neck TRACHE care bundle appear applicable within the hospital
It is important to review the stoma, assess the skin of the setting and could be replicated by other centres and settings
neck and clean the local area around a tracheostomy thoroughly worldwide where experience in dealing with paediatric tracheos-
each day. Cases of trauma and excoriation to the skin surround- tomy may vary.
ing the child’s neck and stoma were carefully documented.
Neonates and those with increased susceptibility to skin trauma, Contributors AH, JB, SI, LC, DA, BH and CJ were involved in the conception,
drafting and review of the article. RJH, LC and MW were involved in the revision/
for example, vascular and lymphatic malformations are most at
analysis and approval of the article.
Competing interests The Great Ormond Street department developed with
We found that stay sutures, placed intraoperatively to aid the
Marpac (a medical company specialising in medical device securement) modified
postoperative management of the stoma and facilitate reinser- tracheostomy ties to offer increased comfort and safety. These were implemented
tion of a dislodged or displaced tube, could ‘cheese wire’ the across the hospital from 2012.
stomal skin edges if pulled too tightly. Damage to the skin Provenance and peer review Not commissioned; externally peer reviewed.
around the neck was usually related to tape tension, usually
overtightening, and not cleaning the skin regularly.
H=Humidity: essential to keep the tube clear REFERENCES
1 Thomas AN, McGrath BA. Patient safety incidents associated with airway devices in
In the first week after a new tracheostomy, warm humidifica-
critical care: a review of reports to the UK National Patient Safety Agency.
tion should be used to counter thick secretions that can occlude Anaesthesia 2009;64:358–65.
the tracheostomy tube. This is a potential cause of an emergency 2 NCEPOD (On the Right Trach) 2014 Royal College of Nursing, London.
first tracheostomy tube change before the stoma has matured. 3 Alladi A, Rao S, Das K, et al. Pediatric tracheostomy: a 13-year experience. Pediatr
After the first tube change, it is recommended that an appro- Surg Int 2004;20:695–8.
4 Corbett HJ, Mann KS, Mitra I, et al. Tracheostomy—A 10-year experience from a UK
priately sized heat moisture exchange device is used. The size is pediatric surgical center. J Pediatr Surg 2007;42:1251–4.
calculated from the estimated tidal volume for the patient. 5 Cetto R, Arora A, Hettige R, et al. Improving tracheostomy care: a prospective study
E=Emergency box of the multidisciplinary approach. Clin Otolaryngol 2011;36:482–8.

Hall A, et al. Arch Dis Child 2016;0:1–3. doi:10.1136/archdischild-2015-309661 3

Downloaded from on March 26, 2017 - Published by

Implementation of the TRACHE care bundle:

improving safety in paediatric tracheostomy
Andrew Hall, James Bates, Sonna Ifeacho, Benjamin Hartley, David
Albert, Christopher Jephson, Richard J Hewitt, Lesley Cochrane, Michelle
Wyatt and Joanne Cooke

Arch Dis Child published online September 1, 2016

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Topic Articles on similar topics can be found in the following collections

Collections Epidemiologic studies (1818)
Surgery (307)
Guidelines (127)
Neonatal and paediatric intensive care (388)
Paediatric intensive care (104)


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