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About this book Advances in Patient Safety: From Research to Implementation Volume 3. Implementation Issues Sections and articles in Advances in Patient Safety volume 3: Where the Rubber Meets the Road Using Specialized Information Technology to Reduce Errors in Emergency Cardiac Care Improving Patient Safety with the Military Electronic Health Record Decision Support System Design and Implementation for Outpatient Prescribing: The Safety in Prescribing Study Looking for Trouble in All the Right Places: The Legal Implications Associated with "Electronic Signatures" and High-risk Clinical Situations Clinical Informatics and Its Usefulness for Assessing Risk and Preventing Falls and Pressure Ulcers in Nursing Home Environments Barriers Associated with Medication Information Handoffs Using Reported Primary Care Errors to Develop and Implement Patient Safety Interventions: A Report from the ASIPS Collaborative The AAFP Patient Safety Reporting System: Development and Legal Issues Pertinent to Medical Error Tracking and Analysis Lessons Learned from the Evolution of Mandatory Adverse Event Reporting Systems Shared Learning and the Drive to Improve Patient Safety: Lessons Learned from the Pittsburgh Regional Healthcare Initiative Identifying Barriers to the Success of a Reporting System "Near-miss" Reporting System Development and Implications for Human Subjects Protection The Impact of a Web-based Reporting System on the Collection of Medication Error Occurrence Data Ten Considerations for Easing the Transition to a Web-based Patient Safety Reporting System Identifying, Understanding, and Communicating Medical Device Use Errors: Observations from an FDA Pilot Program Implementation of a Data-based Medical Event Reporting System in the U.S. Department of Defense The Impact of Personal Digital Assistant Devices on Medication Safety in Primary Care Implementation of an Evidence-based Protocol for Surgical Infection Prophylaxis Reducing the Use of Short-acting Nifedipine by Hypertensives Using a Pharmaceutical Database Can an Academic Health Care System Overcome Barriers to Clinical Guideline Implementation? Implementing a Systems Engineering Intervention for Improving Safety in Outpatient Surgeries Improving the Safety of Heparin Administration by Implementing a Human Factors Process Analysis Establishing a Culture of Patient Safety Through a Low-tech Approach to Reducing Medication Errors Cost Effectiveness of a Multifaceted Program for Safe Patient Handling Patient Safety Data Sharing and Protection from Legal Discovery Does Medical Error Disclosure Violate the Medical Malpractice Insurance Cooperation Clause? Beyond the Dusty Shelf: Shifting Paradigms and Effecting Change From Insight to Implementation: Lessons from a Multi-site Trial of a PDA-based Warfarin Dose Calculator Lessons in Safety Climate and Safety Practices from a California Hospital Consortium Systemwide Deployment of Medical Team Training: Lessons Learned in the Department of Defense Barcode Medication Administration: Lessons Learned from an Intensive Care Unit Implementation Institutional Review Board Approval of Practice-based Research Network Patient Safety Studies Behind the Scenes: Patient Safety in the Operating Room and Central Materiel Service During Deployments Surgical Safety: Addressing the JCAHO Goals for Reducing Wrong-site, Wrong-patient, Wrong-procedure Events Voluntary Hospital Coalitions to Promote Patient Safety Suicide Risk Response: Enhancing Patient Safety Through Development of Effective Institutional Policies A New Model of Tracheostomy Care: Closing the ResearchPractice Gap Peer ReviewersVolume 3

Advances in Patient Safety: From Research to Implementation Advances in Patient Safety: From Research to Implementation Volume 3. Implementation Issues

A New Model of Tracheostomy Care: Closing the ResearchPractice Gap

Joel St. Clair

Abstract

Performance improvements have brought about fundamental changes in the past year at Walter Reed Army Medical Center (WRAMC), where a concerted effort is underway to put current research into clinical practice. Tracheostomy care and suctioning became the pilot procedure for these changes in November 2002. What began as a unit-level initiative quickly developed into a Department of Nursing project. The focus of the project is adapting the hospital's existing performance improvement model to better facilitate evidence-based practice. Initial surveys on tracheostomy care conducted throughout the hospital showed an inconsistent level of knowledge and a variation in clinical practice. These inconsistencies represented a patient safety threat in the form of nosocomial infections, prolonged hospitalizations, airway complications, and even death. To address these issues, the Nursing Performance Improvement and Nursing Research Departments entered into a research collaboration. Representatives from these departments worked with clinical experts to develop a plan and timeline for conducting a tracheostomy care project with the goal of implementing evidence into practice and thereby improving patient safety at the hospital. The group completed initial data collection in April 2003 and then began work on the evidence-based procedure. A literature review was completed using online search engines such as MEDLINE, the Cumulative Index to Nursing and Allied Health Literature (CINAHL), the Cochrane Collaboration, Medscape, the American Association of Critical-Care Nurses (AACN) practice guidelines, and the Joanna Briggs Institute. Pertinent articles were identified and evaluated by two independent reviewers. The Agency for Healthcare Research and Quality (AHRQ) levels of evidence were used to grade more than 30 articles. The results of this search were used to develop a WRAMC Department of Nursing Procedure for tracheostomy care, which was completed in September 2003. This new model of evidence-based nursing performance improvement has been in use at WRAMC for 2 years at the time of this writing, and it continues to close the research-practice gap. The WRAMC Department of Nursing is presently developing similar evidence-based procedures for pressure ulcer prevention, deep vein thrombosis prophylaxis, and for enteral feeding.

Introduction

Performance improvement has evolved over the past two decades from quality assurance, to quality improvement, to performance improvement. While different in their subtleties, the common thread running through each of them is the improvement of safety for patients. As the process of performance improvement has changed, the amount of research relevant to nursing procedures has grown. The application of this scholarly research by clinical staff nurses has become a priority, due to its anticipated positive effects on patient safety. During the past 5 years, systemic change with an emphasis on evidence-based practice has been encouraged. ¹ At the same time, studies and papers documenting the discrepancy of available research as it relates to the practice of clinical nursing continue to be published. ^{2 4} This discrepancy has been labeled the "researchpractice gap." The Department of Nursing at Walter Reed Army Medical Center (WRAMC) has made systematic changes during the past 2 years and has adapted the process of performance improvement to help narrow the researchpractice gap. The Nursing Performance Improvement Department has been the impetus for this change and the pilot project chosen to demonstrate the effectiveness of this new approach to nursing at WRAMC is tracheostomy care and suctioning.

Methods

In the years leading up to this change, performance improvement strategies were put into practice on each individual patient care unit. The head nurse for each unit would designate a staff nurse as the performance improvement facilitator. This individual would attend 3 days of lectures on performance improvement processes before returning to work on the floor. Staff nurses regarded performance improvement as an additional duty carried out in an isolated environment. Performance improvement meetings were held each month for the Department of Nursing staff, where each facilitator would present the details of his or her current project, describe the progress made, and seek help if needed. The primary focus of the unit-level projects was data collection and chart audits. Changes to this system were needed before a departmentwide implementation of evidence-based care could be undertaken.

In November 2002, the newly appointed director of performance improvement began laying the groundwork for a fundamental change in the performance improvement process at WRAMC. This change involved a refocusing of the resources available to the Department of Nursing. Involvement increased, beginning with the upper echelons of the leadership structure. Research utilization became the cornerstone of all nursing performance improvement projects. Within the first few months, these changes began shifting the paradigm of performance improvement and invoked a new outlook and attitude among staff nurses. The clinical topic of tracheostomy care and suctioning was chosen for the pilot project on the basis of its significant patient safety implications. An informal clinical survey of this procedure found widespread disparities and variations in technique. Far from being a benign procedure, tracheostomy, suctioning done incorrectly, can lead to nosocomial infections, hypoxia, bradycardia, and dysrythmias. ^{5 7} An interdisciplinary team was formed at WRAMC to develop and introduce the hospital's first evidence-based nursing procedure.

The interdisciplinary team included clinical staff nurses from different areas of the hospital, members of the nursing performance improvement office, nurse researchers, and physicians. This team met on a regular basis to accomplish three objectives: outline the current practice of tracheostomy care, gather the available evidence on this nursing procedure, and develop an evidence-based nursing procedure.

The tracheostomy team was divided into two groups to accomplish these objectives. One group focused on collecting the available tracheostomy care and suctioning research. A literature search of online databases, such as Cumulative Index to Nursing and Allied Health Literature (CINAHL), MEDLINE, American Association of Critical-Care Nurses (AACN) practice guidelines, the Joanna Briggs Institute, and the Cochrane Collaboration, was organized and conducted. Once all the available literature had been collected, two nurses read and graded the research using the Agency for Healthcare Research and Quality (AHRQ) recommendations (Table 1).

AHRQ scale of research grades and levels

Table 1.

Grade of research
A	Strongly recommend; Good evidence
B	Recommend; At least fair evidence
C	No recommendation for or against; Balance of benefits and harms too close to justify a recommendation
D	Recommend against; Fair evidence is ineffective or harm outweighs the benefit
E	Evidence is insufficient to recommend for or against routinely; Evidence is lacking or of poor quality; Benefits and harms cannot be determined.
Level of evidence
Level I	Meta-analysis of multiple studies
Level II	Experimental studies
Level III	Well-designed, quasi-experimental studies
Level IV	Well-designed, non-experimental studies
Level V	Case reports and clinical examples

Each study was graded by at least one doctoral nurse researcher. The group then organized all of the graded data to serve as a guide as the procedure was being written (Table 2). The second group gathered clinical data related to the environment of care, nursing documentation, and a staff knowledge assessment. The environment of care was assessed with the use of an inventory of the tracheostomy supplies available at each patient's bedside.

Tracheostomy care literature review

Table 2.

Author	Subject	Grade
Elpern, et al. (1994)	Aspiration	IV A
Young, et al. (2000)	Aspiration with cuffed tube	II E
Peruzzi, et al. (2001)	Aspiration with dye	III A
Henrich, et al. (1997)	Bedside procedure	IV B
Burns, et al. (1998)	Cannula changes	III B
Crimlisk, et al. (1996)	Cuff management	IV E
Davis, et al. (2002)	Cuff management	III B
Ackerstaff, et al. (1995)	Humidification	IV B
Shelley, et al. (1986)	Humidification	IV E
Cowan, et al. (2001)	Inner cannula	II E
Johnson, Wagner, Sigler (1987)	Inner cannula	IV C
Clarke (1995)	Literature review	V E
Schwenker, et al. (1998)	Professional knowledge	IV E
Ackerman, Mick (1998)	Saline instillation	II B
Ackerman (1993)	Saline instillation	III B
Akgul, Akyolcu (2002)	Saline instillation	II E
Blackwood (1999)	Saline instillation	V D
Bostick, Wendelgass (1987)	Saline instillation	II E
Hudak, Bond-Domb (1996)	Saline instillation	III E
Ji, Kim, Park (2002)	Saline instillation	II B
Kinloch (1999)	Saline instillation	III B
O'Neal, et al. (2001)	Saline instillation	III C/D
Harris, Hyman (1983)	Sterile vs. clean	IV B
Celik, Elbas (2000)	Suctioning	II B/E
Day, et al. (2001)	Suctioning	III A
Hess (2001)	Suctioning	IV B
Isea, et al. (1993)	Suctioning	II B
Odell, et al. (1993)	Suctioning	IV E
Raymond (1995)	Suctioning	IV B
Ridling, Martin, Bratton (2003)	Suctioning	II A
Sole, et al. (2003)	Suctioning	IV B
Swartz, et al. (1996)	Suctioning	IV E
Wood (1998)	Suctioning	V E

The group reviewed the charts of any inpatient who had received a tracheostomy. Finally, staff nurses at WRAMC were given a knowledge assessment test on tracheostomy care and suctioning. After completing a thorough literature review and collecting the staff knowledge data, work commenced on the written procedure. Using an algorithm (Figure 1) to draft the procedure helped to delineate specific clinical decisions that a nurse would need to make during tracheostomy care. Full explanations and available research were included for five major sections of the algorithm, including: emergency procedures, dressing changes, suctioning, tracheostomy tie changes, and special considerations.

Figure 1. Tracheostomy care and suctioning algorithm

Once the procedure had been written, we involved the Nursing Education and Staff Development (NESD) Department in an effort to incorporate the new model into our nursing orientation program. The NESD staff also made the evidence-based procedure part of the annual nursing competencies required by the Department of Nursing. After the approved procedure had been finalized, three units were selected to pilot test the implementation phase. Each unit was contacted and its staff members received education on tracheostomy care and suctioning. This implementation phase was used to adapt the ongoing projects in nursing performance improvement.

Tracheostomy care and suctioning was the first procedure used to demonstrate our model of performance improvement. Ongoing and future projects funded through the TriService Nursing Research Program (TSNRP) include pressure ulcer prevention, deep vein thrombosis prophylaxis, and enteral feeding precautions to reduce aspiration. The selection criterion for a nursing procedure focuses on its ability to improve patient safety and outcomes.

Discussion

The development of an interdisciplinary team for the purpose of implementing the procedural changes added depth and diversity to the performance improvement process. Each member of the team contributed their professional expertise and helped to sustain the process momentum.

A traditional outline method was used initially to write the procedure. They found that tracheostomy care was not a linear process; rather, the process more closely resembled an algorithm model in the way each health care provider exercised their clinical judgment. After numerous failed attempts to clearly convey the process, the group adapted the style. We incorporated the major parts of the procedure into an algorithm with detailed descriptions and supporting research attached to each point.

As we near the end of this pilot project, we have learned many lessons from the adaptation process, some of which were learned thanks to the strong resources available to us at WRAMC. We now see the value of completing future performance improvement projects in a shorter length of time. As we repeat the process with various patient safety topics, we will strive to implement the procedural changes more quickly, while using the available resources more efficiently. Moreover, we will organize assessment tools for use before and after each implementation, to better evaluate the effect of any changes.

Conclusion

Patient safety is expected to be the highest priority for health care providers. Using an existing performance improvement model, in conjunction with redesigned department-level performance improvement efforts, we have refocused our patient safety efforts at Walter Reed Army Medical Center. Together in partnership, the nursing performance-improvement team, nurse researchers, and clinical staff nurses worked to align existing nursing procedures with the best evidence-based practices, and to reduce variance. Tracheostomy care and suctioning was chosen as the pilot procedure and the target for change. Using the lessons that we have learned we hope to adapt more nursing procedures, in a more efficient manner, thereby serving to narrow the researchpractice gap while further improving patient safety.

Acknowledgments

I am indebted to COL Patricia Patrician for her counsel and support, to LTC Deborah Kenny for her contributions, and to Dr. Suzie Miltner for her courage to make positive change.

Author affiliations

Walter Reed Army Medical Center, Washington, DC (JS).

Address correspondence to: Joel St. Clair, 1LT, AN, Walter Reed Army Medical Center, 6900 Georgia Ave. NW, Washington, D.C. 20307-5001; phone: 301-980-1540; e-mail: joel.stclair@us.army.mil.

References

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2. Brett JL. Use of nursing practice research findings. Nurs Res 1987. 36:344-9. (PubMed)

3. Carroll DL, Greenwood R, Lynch KE, et al. Barriers and facilitators to the utilization of nursing research. Clin Nurs Spec 1997. 11(5):207-12.

4. McKenna HP, Ashton S, Keeney S. Barriers to evidence-based practice in primary care. J Adv Nurs 2004. 45(2):178-9. (PubMed)

5. Ackerman MH. The effect of saline lavage prior to suctioning. Am J Crit Care 1993. 2:326-30. (PubMed)

6. Ackerman MH, Mick DJ. Instillation of normal saline before suctioning in patients with pulmonary infections: a prospective randomized controlled trial. Am J Crit Care 1998. 7(4):261-6. (PubMed)

7. Thompson L. Suctioning adults with an artificial airway. Systematic Review #9. Adelaide (AUS): The Joanna Briggs Institute for Evidence Based Nursing and Midwifery; 2000.