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ADC Online First, published on September 1, 2016 as 10.1136/archdischild-2015-309661
Great Ormond Street Hospital,
London, UK
Correspondence to
Andrew Hall, Great Ormond
Street Hospital, Great Ormond
Street, London WC1N 3JH, UK;
andyhall07@googlemail.com
Received 15 November 2015
Revised 11 August 2016
Accepted 12 August 2016
To cite: Hall A, Bates J,
Ifeacho S, et al. Arch Dis
Child Published Online First:
[please include Day Month
Year] doi:10.1136/
archdischild-2015-309661
Copyright Article author (or their employer) 2016. Produced by BMJ Publishing Group Ltd (& RCPCH) under licence.
Quality reports
Implementation of the TRACHE care bundle:
improving safety in paediatric tracheostomy
management
Andrew Hall, James Bates, Sonna Ifeacho, Benjamin Hartley, David Albert,
Christopher Jephson, Richard J Hewitt, Lesley Cochrane, Michelle Wyatt,
Joanne Cooke
INTRODUCTION
Tracheostomy management has been the focus of a
number of reviews in the UK over the last decade;
however, paediatric patients have thus far been
excluded from the analysis.1 2 Currently, there are
no formally accepted national standards in the UK
for paediatric tracheostomy management.
Paediatric tracheostomies are associated with risks
and complications in the order of two to three
times higher than morbidity and mortality rates
reported in adults. The mortality rate for a compli-
cation directly related to a paediatric tracheostomy
is 0.7%.3 The majority of reported adverse inci-
dents do not occur in the immediate postoperative
period; late complications over a week from inser-
tion are four times more common.4 Our aim was
formalising standards of optimal paediatric tracheo-
stomy management to minimise future morbidity.
METHODS
Assessments of paediatric tracheostomy care were
collected from 40 consecutive patients at a tertiary
specialist paediatric institution in 2007. An initial
multidisciplinary root cause analysis of morbidity
associated with paediatric tracheostomy was carried
out by the senior authors. Main areas of concern
relating to tracheostomy care were identified, and
from these, proposed minimum standards of best
practice were developed. The recommendations
were neatly encompassed in the mnemonic
‘TRACHE’ promoted as the recommended paediat-
ric tracheostomy ‘care bundle’ (figure 1).
This ‘TRACHE’ care bundle was communicated
widely within our hospital using the following
means:
▸ Standardised ‘TRACHE’ approach teaching on
the Trust Paediatric Immediate Life Support
course and reoccurring biannual 1-day course
on tracheostomy care.
▸ Monthly tracheostomy simulation training pro-
gramme, designed to teach competence through
the TRACHE approach.
▸ Clinical guidelines published on the hospital
intranet.
Further assessments were performed at regular
intervals by the tracheostomy nurse specialist and
senior authors on ward nursing staff caring for
paediatric inpatients with a tracheostomy (figure 2).
All paediatric patients under the age of 16 with a
paediatric tracheostomy were included with no
further exclusion criteria. Areas assessed included
Hall A, et al. Arch Dis Child 2016;0:1–3. doi:10.1136/archdischild-2015-309661
paediatric intensive care, respiratory, oncology and
otolaryngology wards. A designated ‘care bundle’
proforma with pass/fail outcomes in each of the
TRACHE domains was used to record results for
analysis. Subsequent feedback was given to the
ward team as to their performance and areas of
potential improvement. All statistical analyses were
performed in GraphPad Prism (V.6).
RESULTS
The baseline assessment for each outcome measure
in 2007 demonstrated deficiencies in ward trache-
ostomy care: incorrect tension of tracheostomy
ties in 35% of patients, incorrect humidity in 7%
of cases, incorrect suctioning technique in 15%,
evidence of neck skin or stoma breakdown in
20% of patients, incomplete or incorrect emer-
gency box use in 35% of patients and incomplete
understanding of tracheostomy resuscitation in
27% of cases.
In total, 359 paediatric tracheostomies have been
assessed at multiple intervals from 2007 to 2013
with consistent improvements shown across all
domains. The results from 2013 show a 92%–
100% compliance with the six aspects of the care
bundle (figure 2). χ2 test of independence was per-
formed demonstrating statistically significant
increases in compliance with the TRACHE care
bundle guideline in 2013 in comparison with that
in 2007, as shown.
Since the implementation of the TRACHE proto-
col, there has been no tracheostomy-related morta-
lity at our institution. Risks of decannulation events
have been minimised through ongoing dedication
to achieving correct tape tension. Documented
neck trauma and excoriation reduced from 20% to
8% of the 50 cases assessed in 2013, showing a
reduction in tracheostomy-related morbidity,
although this did not attain statistical significance in
our analysis.
DISCUSSION
The role of the TRACHE ‘care bundle’ was to
create a simple, memorable and effective tool used
across all hospital wards and departments to
enhance patient safety. The ‘care bundle’ approach
has previously been used to standardise ward man-
agement in adult tracheostomy care.5
T=Tapes: keeping the tracheostomy tube secure
Security of the tracheostomy tube is a key prin-
ciple in maintaining airway safety with accidental
1
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Quality reports

Figure 1 Promotional poster

summarising ‘TRACHE’ care bundle
approach.

Figure 2 Compliance with ‘TRACHE’ care bundle guidelines 2007–2013.

2 Hall A, et al. Arch Dis Child 2016;0:1–3. doi:10.1136/archdischild-2015-309661
 Downloaded from http://adc.bmj.com/ on March 26, 2017 - Published by group.bmj.com
decannulation occurring in around 5% of paediatric tracheosto-
mies.1 It had been noted that Velcro neck tapes were more
easily undone by the patient and were associated with a higher
rate of accidental decannulation. A departmental policy for the
exclusive use of hand-tied cotton tapes to secure tracheostomy
tubes was implemented. Tape tension is an essential factor; the
tapes need to be tight enough to secure the tube appropriately,
but not too tight that the skin is excoriated. The ideal tape
tension should allow one finger to fit underneath the tapes at
the back of the neck.
R=Resus: know the resuscitation process
The mandatory Paediatric Intermediate Life Support course
for all clinical staff includes resuscitation in a child with a
tracheostomy.
In addition, parental resuscitation training is completed prior
to discharge for all children with a new tracheostomy. The aim
of parental education and training is to impart both the confi-
dence and skills to deal with an airway emergency.
A=Airway: demonstrate the correct suction technique
Precise suctioning is important in paediatric tracheostomy
care. If the suction length is too short, the patient is at risk of
tube occlusion; yet, if the suction length is too long, it may lead
to tracheal trauma with distal soft tissue trauma and subsequent
formation of granulation tissue. Optimal tracheostomy tube care
involves measuring the tracheostomy tube length (to the nearest
millimetre) with a suction catheter prior to tube insertion and
using this measurement for future suctioning. This information
is documented on the operation note and communicated ver-
bally and in writing to all staff and parents caring for the
patient.
C=Care of the site: stoma and neck
It is important to review the stoma, assess the skin of the
neck and clean the local area around a tracheostomy thoroughly
each day. Cases of trauma and excoriation to the skin surround-
ing the child’s neck and stoma were carefully documented.
Neonates and those with increased susceptibility to skin trauma,
for example, vascular and lymphatic malformations are most at
risk.
We found that stay sutures, placed intraoperatively to aid the
postoperative management of the stoma and facilitate reinser-
tion of a dislodged or displaced tube, could ‘cheese wire’ the
stomal skin edges if pulled too tightly. Damage to the skin
around the neck was usually related to tape tension, usually
overtightening, and not cleaning the skin regularly.
H=Humidity: essential to keep the tube clear
In the first week after a new tracheostomy, warm humidifica-
tion should be used to counter thick secretions that can occlude
the tracheostomy tube. This is a potential cause of an emergency
first tracheostomy tube change before the stoma has matured.
After the first tube change, it is recommended that an appro-
priately sized heat moisture exchange device is used. The size is
calculated from the estimated tidal volume for the patient.
E=Emergency box
Hall A, et al. Arch Dis Child 2016;0:1–3. doi:10.1136/archdischild-2015-309661
Quality reports
The contents of the emergency tracheostomy box are
designed to be the essential equipment required in case of an
accidental decannulation or for an emergency tube change. This
includes one tube of the same type and size, one tube a size
smaller, scissors, lubricating jelly, spare pair of tracheostomy
ties, a suction catheter and 10 mL syringe (if cuffed tube). This
emergency box accompanies the child at all times.
Implementing sustained change
A challenge to the introduction of any new policy is the uptake
by the professionals required to implement it long term. A key
concept in the successful sustained use of the TRACHE
approach was widespread multidisciplinary senior engagement
throughout paediatric intensive care, otolaryngology and
respiratory teams. This was further supported through enthusi-
asm in teaching and regular training of nursing and medical
staff.
CONCLUSION
Delivering and maintaining consistently safe, high-quality
tracheostomy care are essential in both the hospital and commu-
nity environments. The results reported here demonstrate the
benefits gained from the structured ‘TRACHE’ paediatric care
bundle approach used in this institution over a 6-year period.
This represents an embedded change within practice for the
improvement of patient care.
A key factor in its success is in its simplicity and repeatability,
ensuring day-to-day tracheostomy management is standardised.
This demonstrates that the core principles of the paediatric
TRACHE care bundle appear applicable within the hospital
setting and could be replicated by other centres and settings
worldwide where experience in dealing with paediatric tracheos-
tomy may vary.
Contributors AH, JB, SI, LC, DA, BH and CJ were involved in the conception,
drafting and review of the article. RJH, LC and MW were involved in the revision/
analysis and approval of the article.
Competing interests The Great Ormond Street department developed with
Marpac (a medical company specialising in medical device securement) modified
tracheostomy ties to offer increased comfort and safety. These were implemented
across the hospital from 2012.
Provenance and peer review Not commissioned; externally peer reviewed.
REFERENCES
1 Thomas AN, McGrath BA. Patient safety incidents associated with airway devices in
critical care: a review of reports to the UK National Patient Safety Agency.
Anaesthesia 2009;64:358–65.
2 NCEPOD (On the Right Trach) 2014 Royal College of Nursing, London.
3 Alladi A, Rao S, Das K, et al. Pediatric tracheostomy: a 13-year experience. Pediatr
Surg Int 2004;20:695–8.
4 Corbett HJ, Mann KS, Mitra I, et al. Tracheostomy—A 10-year experience from a UK
pediatric surgical center. J Pediatr Surg 2007;42:1251–4.
5 Cetto R, Arora A, Hettige R, et al. Improving tracheostomy care: a prospective study
of the multidisciplinary approach. Clin Otolaryngol 2011;36:482–8.
3
 Downloaded from http://adc.bmj.com/ on March 26, 2017 - Published by group.bmj.com

Implementation of the TRACHE care bundle:

improving safety in paediatric tracheostomy
management
Andrew Hall, James Bates, Sonna Ifeacho, Benjamin Hartley, David
Albert, Christopher Jephson, Richard J Hewitt, Lesley Cochrane, Michelle
Wyatt and Joanne Cooke

Arch Dis Child published online September 1, 2016

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