Rates of head and neck cancer in Indonesia are high relative to the Western world and the formation of a tracheostomy is not an uncommon procedure. This procedure, while lifesaving can be the cause of significant patient morbidity and mortality, which is in part preventable. The St. Mary’s tracheostomy care bundle has been shown to reduce adverse events. We have assessed compliance with the guideline in the Dr. Sardjito Hospital, Yogyakarta, Indonesia, and will introduce the necessary equipment, with the aim to reduce complications and ultimately improve patient outcomes.
The Yogyakarta region of Indonesia located near the southern coast of Java and has a population of 3,452,390 at the last census in 2010. Rates of head and neck cancer remain high in this part of the world and it is not unusual to see a patient on a ward with a tracheostomy.
The formation of a tracheostomy can be a lifesaving operation however it is not without complications ,. Many of the causes of significant patient morbidity and mortality centre on the subsequent ward management of the tracheostomy. Though some of these complications are unavoidable a large component can be prevented through relatively simple measures.
There has been a large drive for standardised tracheostomy care, namely through the protocol known as the St. Mary’s tracheostomy care bundle and the work of the Global Tracheostomy Collaborative (GTC), and outcomes are improving.
We propose bringing this deliverable care bundle to the Dr. Sardjito Hospital, Yogyakarta. We have completed cycle one of the audit of current clinical practice which showed that during a 3 month retrospective review of patient notes no one case was adherent to the guidelines proposed by the St. Mary’s group. In particular there was a lack of documentation. A personalised care plan was introduced for each patient however the much needed emergency bedside equipment was not available.
AIMS AND OBJECTIVES:
The overall aim of this quality improvement project is in line with the GTC goal to “disseminate best practices and improve tracheostomy outcomes”. We hope that this project will be a preliminary one leading in future to larger, prospective studies and strong international links. There are two main objectives:
- To formally introduce and implement the St Mary’s tracheostomy care bundle including emergency airway equipment and the tracheostomy daily care chart.
- Reaudit: To repeat step one after introduction of the care bundle.
Dr. Mozaffari has completed a retrospective audit of current tracheostomy care at the hospital as well as a clinical elective and highlighted the areas in which tracheostomy patient safety could be improved.
Mr Sutton will deliver essential emergency airway equipment and work with local staff to ensure each patient with a tracheostomy has the appropriate ward management as described by the care bundle and necessary documentation which has been proven to reduce adverse events.
A number of studies have been published demonstrating the positive effect of introducing ‘Best Practice Guidelines’. In 2008, Hettige et al. introduced the St Mary’s Tracheostomy Care Bundle and audited its effect prospectively, showing a significant reduction in severe clinical incidents from 27% to 10% annually . The same group in a preliminary  and a further 38 month prospective cohort study  assessed the effect of implementing the St. Mary’s tracheostomy checklist, a dedicated tracheostomy MDT and an educational programme. With these interventions the authors show an expedited decannulation process and a reduction in clinical incidents.
As such, we expect to show significant improvements in tracheostomy care and in particular significant reduction in clinical incidents with this quality improvement project.
The following equipment would be required for each bedside pack:
- Spare tracheostomy tubes (same size and one size smaller)
- Disposable tracheal dilators
- Re-breathe bag with swivel connector
- Ambu bag and facemask
- Oxygen tubing and mask
- Suction unit – This must be checked each shift
- Suction catheters
- 10 ml syringe
- Stitch cutter/scissors
- KJ jelly
We expect 10 patients at any one time to have a tracheostomy and as thus require ten of each item to assemble ten packs. While these items may seem basic they can be potentially lifesaving and we hope their provision will yield similar results to the aforementioned studies.
 Das P, Zhu H, Shah RK, Roberson DW, Berry J, Skinner ML. Tracheotomy-Related Catastrophic Events: Results of a National Survey. Laryngoscope. 2012; 122(1): 30-37
 Hettige R, Arora A, Ifeacho S, Narula A. Improving tracheostomy management through design, implementation and prospective audit of a care bundle: how we do it. Clinical Otolaryngology. 2008;33(5):488-91
 Arora A, Hettige R, Ifeacho S, Narula A. Driving standards in tracheostomy care: A preliminary communication of the St Mary’s ENT-led multi disciplinary team approach. Clinical Otolaryngology. 2008; 33:596–599
 Cetto R, Arora A, Hettige R, Nel M, Benjamin L, Gomez CM, Oldfield WL, Narula AA. Improving tracheostomy care: a prospective study of the multidisciplinary approach. Clinical Otolaryngology 2011; 36(5) 482-8
Liam Sutton, Mona Mozaffari, Sagung Indrasari & Matt Lechner