Patient Safety Moment – Fresh Tracheostomy Patients

Situation

Reported incidents involving patients with fresh tracheostomies (trachs) raising concerns over airway compromise.

Background

If vital pieces of equipment are not present at the bedside, there can be a delay in providing proper ventilation to the patient. There is enhanced risk for patients traveling to a test away from the room where the equipment was kept.

Assessment

There was a need to assure consistent practice and knowledge regarding the proper equipment to have on hand for tracheostomy patients. A multidisciplinary team met to review best practices in the care of fresh tracheostomy patients.

Recommendations

  • A spare tracheostomy tube of the same size/style that was placed in OR should be kept at the bedside as well as Velcro tie, Surgilube, and Yankauer suction. The spare tube should travel with the patient.
  • Obturator should be taped to the wall at the head of bed and transported with patient if patient leaves the floor.
  • Size 5 cuffed endotracheal tube should be kept at the bedside (for emergent ventilation if trach comes out).

Related Policies

Patient Safety Moment – Fresh Tracheostomy Patients

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