Accidental decannulation following placement of a tracheostomy tube.

BACKGROUND Accidental decannulation is a cause of substantial morbidity and mortality in patients in long-term acute care hospitals who require a tracheostomy tube. OBJECTIVE To analyze features of accidental decannulation (AD) following placement of a tracheostomy tube, and to implement strategies to reduce the problem. METHODS An analysis of data collected prospectively for quality management in a long-term acute care hospital was performed. RESULTS AD occurred at a rate of 4.2 ± 0.9/1,000 tracheostomy days over a 7 month period. Factors associated with AD included mental status changes, increased secretions, and change of shift. Following the implementation of a series of interventions (staff education on risk factors for AD and best tracheostomy care practice; increased availability of telemetry and oximetry; and signage to identify patients at high risk of AD), the incidence of AD over a subsequent 7 month period was significantly reduced, to 2.7 ± 1.9/1,000 tracheostomy days. In addition the numbers of multiple, unmonitored, unreported, and night shift ADs were all significantly reduced. CONCLUSIONS Targeted interventions can significantly reduce both the incidence of AD following tracheostomy and associated morbidity. Best practice guidelines to help minimize AD in patients with tracheostomy tubes are proposed.