1. Tracheostomy Audit Clinical Audit DepartmentNovember 2011 Head and Neck Airways Team

2. Aim The aim of the audit is to determine if the patient safety measures detailed in the new Trust Policy are being adhered to.

3. Objectives The objectives of the audit are to: Monitor the completion of the tracheostomy care documentation Assess compliance with the guidelines in terms of:  Checklist for emergency equipment,  Checklist for care on each shift,  Airway identification poster.

4. Standards Local Trust Guidelines: Clinical Guidelines for the Preparation and Ongoing Care of Patients with a Tracheostomy

5. Methodology Data was collected prospectively via a case note review for all tracheostomy patients on the ward on a Friday. Data was collected for the audit period 7 th October to 4 th November 2011. A total of 12 patients were included in the results.

6. Results

7. Patient details complete N12

8. Tracheostomy or Laryngectomy N12

9. Trolley checklist complete N12

10. No. of trolley checklists there should be N12

11. No. of trolley checklists not completed N12

12. Tracheostomy checklist completed for today/shift N12

13. No. of care checklists there should be N12

14. No. of care checklists not completed N12

15. Poster above bed N12

16. Comments One patient had a tracheostomy care checklist but it was the wrong form – not the traffic lights. One patient had a poster, but nothing was written on it to identify it belonged to the patient. One patient had a tracheostomy poster belonging to the previous patient. N12

17. Conclusions Only 59% of patients had patient details completed properly 67% of patients had the poster above the bed A third of patients had trolley / care checklists completed 67% of trolley checklist hadn’t been completed on the day of audit. 50% of patients didn’t have the correct amount of care checklists completed Extra impetus to be given to clinical area in its push for greater compliance with Trust standard.

18. Recommendations Discussions with appropriate clinical staff. Awareness of Airway standards in trust to be re disseminated to clinical staff. Further re-audit in six months time. Larger time period for audit recommended.

19. Discussion Time of the audit was staggered but was always carried out on the early shift – this could affect the results Day audit was carried out tended to be a Friday – this would not affect the results we should be getting but may affect sample size. Small time period of audit – six weeks

20. Action Plan (from recommendations or discussion) Is there a need for a Re-audit  if yes D ate of Re-audit  /  /  Changes in practice/ systems or protocols Changes made  Planned Changes  Person Responsible Date to be Implemented 1. Planned re-audit. Lengthier data capture window Airways group End May 2012 2. Increased communication regarding airways issues via newsletters / ward meetings etc Airways group End May 2012

21. References Clinical Guidelines for the preparation and ongoing care of patients with a tracheostomy transferred to wards from the Critical Care Unit, Accident and Emergency Department, Medical Assessment Unit and external Trusts. http://intranet.aht/polproc/Clinical/Microsoft%20Word%20- %20Clinical%20Guideline%20Tracheostomy%202011.pdf. http://intranet.aht/polproc/Clinical/Microsoft%20Word%20- %20Clinical%20Guideline%20Tracheostomy%202011.pdf http://www.headandneckcancer.co.uk/For+professionals/PDU/A intree+Head+and+Neck+Airways+Group.aspx. http://www.headandneckcancer.co.uk/For+professionals/PDU/A intree+Head+and+Neck+Airways+Group.aspx