The number of patients requiring relatively prolonged ventilatory support in intensive care due to coronavirus (COVID-19) led to increased numbers of patients requiring tracheostomies, which are used to help wean some patients from respiratory support.
We published, in collaboration with the National Tracheostomy Safety Project (NTSP), and the National Patient Safety Improvement Programmes, a toolkit for healthcare staff to support them to safely care for patients with tracheostomies.
In a five-month period, PSCs helped increase the percentage of trusts implementing all three key interventions in the project’s care bundle from 71% to 92%. A two-year study of 2,400 patients with tracheostomies in 20 trusts, found a 55% reduction in serious incident severity and a 20% reduction in length of stay, where key tracheostomy safety interventions were followed.
Access the safe tracheostomy care toolkit and resources, and read more in the AHSN Network report, Safer care during COVID-19.
If you think about what was done in the space of 12 weeks, with people under incredible pressure – and targeting the most pressurised part of the system, the ICU and stepped-down teams – we have achieved a lot.
Jay Hamilton, Associate Director of Health & Implementation and Patient Safety Collaborative Lead at Health Innovation Manchester
Human factors improvements
In partnership with Health Education England (HEE) we have raised awareness of the importance of human factors in both understanding how harm occurs, but also how harm can be prevented when attention is focused on human factors.
During the first wave of COVID-19, the Chartered Institute of Ergonomics & Human Factors (CIEHF) worked with the AHSN Network and others to provide rapid responses to key safety issues. The ventilator challenge was the first project with CIEHF members volunteering from many sectors, such as rail, oil and gas, and nuclear energy.
They went on to develop bedside action cards for the care of ventilated patients, and tracheostomy guidance for use by healthcare staff who have been assigned to care for patients with tracheostomies. These help to make processes simpler and clearer for staff to understand and to follow.