Association of Standardized Tracheostomy Care Protocol Implementation and Reinforcement With the Prevention of Life-Threatening Respiratory Events | Critical Care Medicine | JAMA Otolaryngology–Head & Neck Surgery | JAMA Network
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Original Investigation
June 2018

Association of Standardized Tracheostomy Care Protocol Implementation and Reinforcement With the Prevention of Life-Threatening Respiratory Events

Author Affiliations
  • 1Department of Otolaryngology–Head and Neck Surgery, University of North Carolina School of Medicine, Chapel Hill
  • 2Department of Respiratory Therapy, University of North Carolina School of Medicine, Chapel Hill
JAMA Otolaryngol Head Neck Surg. 2018;144(6):527-532. doi:10.1001/jamaoto.2018.0484
Key Points

Question  What is the effect of implementation of a tracheostomy care protocol on the occurrence of life-threatening respiratory compromise?

Findings  A cohort study of 247 patients (117 preprotocol and 130 postprotocol) who received tracheostomy was conducted. More patients in the preprotocol group experienced a mucus plugging rapid response than in the postprotocol group, showing a reduction of mucus plugging events after protocol implementation.

Meaning  Implementation of a standardized tracheostomy care guideline was associated with the reduction in the occurrence of life-threatening respiratory compromise.


Importance  Mucus plugging after tracheostomy is a preventable cause of respiratory distress. Implementation of standardized tracheostomy care guidelines may reduce the occurrence of fatal respiratory compromise.

Objective  To determine the effect of implementing and reinforcing a standardized tracheostomy care protocol on the occurrence of acute life-threatening respiratory events.

Design, Setting, and Participants  Retrospective cohort study of adult patients who received a tracheostomy between May 2014 and August 2016 at a tertiary care center.

Main Outcomes and Measures  Patient demographics, tracheostomy indication, rapid response for mucus plugging and other acute events, duration of hospital stay, and levels of care that the patients received were recorded through examination of clinical logs. Statistical analysis was conducted between patients before protocol implementation and patients after protocol implementation in terms of rapid-response use, and intragroup comparison of the mean length of stay in various hospital units was also analyzed.

Results  A total of 247 patients (89 women [36%]; mean [SD] age, 58.5 [12.3] years), 117 preprotocol and 130 postprotocol, met inclusion criteria. Of the 130 patients in the postprotocol cohort, 123 (93%) were on the new tracheostomy care protocol. Preprotocol rapid-response rate was 21 of 117 patients (17.9%) and postprotocol response rate was 12 of 130 patients (9.2%) for a difference of 8.7% (95% CI, 0.2%-18.0%). In terms of mucus plugging, preprotocol rate was 8 of 117 patients (6.8%) and the postprotocol rate was 1 of 130 patients (0.8%) for a difference of 6.0% (95% CI, 1.3%-12.2%). Intragroup difference of the mean time spent (days) in various care units between patients in the no rapid-response group vs rapid-response group demonstrated clinically meaningful longer stay for rapid responses in both preprotocol and postprotocol groups for the intensive care unit (preprotocol, 2.03; 95% CI, 1.03-3.03 vs postprotocol, 3.02; 95% CI, 1.49-4.45) and step down units (preprotocol, 1.40; 95% CI, 0.77-2.02 vs postprotocol, 2.11; 95% CI, 0.78 to 3.44).

Conclusions and Relevance  Implementation and reinforcement of a standardized tracheostomy care protocol was associated with a reduction in the occurrences of rapid-response calls for life-threatening mucus plugging and is recommended for clinical practice. In addition, length of stay in the intensive care unit and intermediate surgical care unit was increased in a clinically meaningful way for patients who experienced a rapid-response event.