Table 2

Strategy for improvement. PDSA cycle summary. Fishers exact 2-tailed p reported for comparisons.

PDSA CycleAimPlanPredictionDoStudyAct
1EducationalIncrease 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-centredAll 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.
OrganisationalStandardise 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.
2EducationalIncrease 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-centredAll 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.
OrganisationalAll 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.
3EducationalIncrease 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-centredEarlier 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.
OrganisationalAll 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.