Strategy for improvement. PDSA cycle summary. Fishers exact 2-tailed p reported for comparisons.
| PDSA Cycle | Aim | Plan | Prediction | Do | Study | Act | |
|---|---|---|---|---|---|---|---|
| 1 | Educational | Increase familiarity with emergency T algorithms. | Cycle 1 baseline familiarity 15.0% (n=37 staff). | Trust-wide tracheostomy education will double staff familiarity. | Half day training for any staff. Voluntary. | Increased familiarity to 40.0% ( n=37 staff, p<0.01). Lots of wards needed training. | Target training to only those staff on cohort wards. Easier to deliver training. Fewer staff. |
| Patient-centred | All new T & L patients would be referred to SLT. | Lead site had comprehensive SLT team working in ICU and Head & Neck Surgery. Cycle 1 baseline 76% referral rate. | Implementing the GTC project would increase SLT referral. Target 90%. | Promotion of the benefits of early SLT involvement: Patient stories/videos at teaching sessions. Baseline data fed back. | Time to SLT referral captured by GTC database. 100% compliance by month 3. | TMDT ward rounds would increase awareness of SLT role and pick up all relevant cases. | |
| Organisational | Standardise site tracheostomy policies. | TMDT steering groups review current T policies and compare with GTC examples. 23 potential T wards at lead site. | Different clinical areas within same Trusts likely to have different T policies. | Trust-wide TMDT steering groups established. Multidisciplinary review as per 'Plan'. | Policies reduced from 7 to 4. Updated to reflect current best practice. Six 'cohort' wards identified at lead site. | Designated tracheostomy 'cohort' wards established at all sites. | |
| 2 | Educational | Increase familiarity with emergency T algorithms. | Cycle 2 baseline familiarity 39.2% (n=171 staff). | Cohort wards would improve education. Reduce education sessions to 2 hours, based on feedback. | Targeted staff training to cohort wards. | Increased familiarity to 59.1% ( n=181 staff, p=0.01). Shorter educational sessions resulted in increased attendance. | Shorter sessions improved attendance, but content was reduced. NTSP e-learning modules adapted for staff. |
| Patient-centred | All new T & L patients would continue to be referred to SLT (cycle 2). | Maintain 100% referral rate. TMDT ward rounds made service more visible to referring ward staff. | TMDT ward rounds would maintain compliance at 100% | TMDT ward rounds reviewed all new T patients, facilitating SLT referral. | 100% compliance from month 6 to 12. Significant positive trend ( ANOVA p=0.02. | SLT referral at the time of T proposed, rather than when ready for assessment. | |
| Organisational | All T & L patients would have a bedside 'T Box' of emergency kit. | Cycle 2 baseline from interim analysis - 65% 'T Box' present (n=50 patient reviews) | TMDT ward rounds would improve compliance. Target 100%. | TMDT ward rounds at 2 sites. | Increased to 100% compliance ( n=84 reviews, p<0.01) | Propose TMDT ward rounds at all sites. | |
| 3 | Educational | Increase algorithm familiarity - specifically anatomy knowledge. | Cycle 3 baseline: 40.9% (n=66 staff) identified key differences between T & L. | e-Learning modules would improve ease of access to training. | e-Learning modules uploaded to Trust mandatory training platforms. Staff in cohort wards 'encouraged' to complete ( see text). | Increased identification of key differences to 79.3% (n=87 staff). | Sites asked to consider mandatory training for staff on designated cohort wards. |
| Patient-centred | Earlier and better communication for T patients through continued SLT involvement. | Encourage SV use on TMDT ward round and by explaining benefits to patients and staff. | SV use would act as a surrogate for vocalisation. Earlier SV use may encourage earlier oral intake. | Time to first use of SV measured using GTC database. | Non-significant trend towards earlier use of SV following tracheostomy. | Continue to monitor any SV adverse incidents. Incorporate positive patient communication stories into teaching. | |
| Organisational | All T & L patients would be managed exclusively on designated 'cohort' wards. | MDTT steering groups engaged with bed managers. Cycle 3 baseline 15/88 (17.0%) patients on non-cohort wards. | Updating bed management algorithms would reduce or eliminate incidents where patient was managed in non-cohort wards. | Presentation to bed managers. Harm data presented (cohort vs non-cohort). Breaches reported as 'incidents' and measured. | Lead site data compliance increased: 3/102 (2.9%) patients on non-cohort wards. | Positive feedback to bed managers. Agreed 6-monthly reports and incident monitoring would continue. |
Abbreviations:
MDT - Multidisciplinary Tracheostomy Team. T - Tracheostomy.
L - Laryngectomy.
NTSP - National Tracheostomy Safety Project. SLT - Speech & Language Therapy.
SV - Speaking Valve.