Simple but effective changes to how breathing tubes are inserted and maintained in the throats of very sick patients is helping AU Medical Center avoid a common and costly complication, doctors said.
Dr. Daniel Carroll and Dr. Christopher Leto, residents in the Department of Otolaryngology, took on the task of eliminating pressure injuries from tracheotomy tubes. Those tubes are often inserted in patients who are on a ventilator for a week or more to try and prevent injury from another breathing tube that crosses their vocal cords and can cause scarring. But those trach tubes, as they are called, can also cause injury themselves to the tissue in the neck over time.
In 2009, the Centers for Medicare and Medicaid Services included those injuries among the hospital-acquired conditions that it would no longer pay for, what are called the “never events” because the federal government maintains they are entirely preventable with good care. Other examples are surgery on the wrong body part or seriously harming a patient by giving them the wrong blood or medication.
Carroll and Leto looked at a year’s worth of data and found that 79 percent of those injuries were from the hard plastic lip of the tube pressing against the patient’s neck and 21 percent were from the twill tie used to secure it to the neck. Leto demonstrated on Carroll how that could happen.
“We would tie it as tight as possible so it would be squeezing (the neck),” he said as he cranked the tie down on Carroll’s neck.
“That was just traditional dogma because the thing you worry about is if this (tube) came out, the patient loses their airway,” Carroll said. The demonstration proved to be a little too effective and Leto ends up using scissors to get the tie off Carroll’s neck.
Instead, the doctors suggested using a softer, more cushioned tie. The flange, the plastic part that sticks out of the neck, is traditionally sutured into place at the four corners.
“We used to really crank those sutures down but really sutures don’t need to be that tight,” he said. Instead of removing those sutures on day 5, they are now typically removed on day 3, Carroll said. The surgeons are working closely with the nursing staff and respiratory therapists, who will also be managing the patient’s airway, to see that the patient is positioned correctly and equipment is adjusted to relieve straining or pulling on the neck, Leto said.
“It’s little things like that can make a big difference,” he said. “Everybody has to be on board.”
Their department performs about 180 of these procedures a year and was averaging about an 8 percent pressure injury rate prior to the change, which was better than the 10-30 percent rate of peer institutions, Carroll said. Since the new procedures were implemented, however, those injuries have been eliminated, he said.
“We were at 8 percent and with our protocol we went to zero,” Carroll said. Not getting paid for a patient’s extended stay because of a injury has serious cost consequences in the intensive care unit, Leto said.
“Those are ICU stays, which are extremely expensive,” he said.
“They are already hundreds of thousands of dollars,” Carroll said.
The federal government is increasingly basing payments on quality measures and it is becoming an important thing for hospitals to monitor and track, he said. It is also an increasing focus of research in surgery and the residents are hoping to present their results at a major meeting next year, Carroll said.
“Quality is a metric that you can get some real results that impact patients positively,” he said. “And it doesn’t have to be expensive and it doesn’t have to be that much of a time investment for the faculty involved and can make a big difference.”
Reach Tom Corwin at (706) 823-3213