title: Accidental decannulation following placement of a tracheostomy tube.
abstract: BACKGROUND
  Accidental decannulation is a cause of substantial morbidity and mortality in patients in long-term acute care hospitals who require a tracheostomy tube.
  
  
  OBJECTIVE
  To analyze features of accidental decannulation (AD) following placement of a tracheostomy tube, and to implement strategies to reduce the problem.
  
  
  METHODS
  An analysis of data collected prospectively for quality management in a long-term acute care hospital was performed.
  
  
  RESULTS
  AD occurred at a rate of 4.2 ± 0.9/1,000 tracheostomy days over a 7 month period. Factors associated with AD included mental status changes, increased secretions, and change of shift. Following the implementation of a series of interventions (staff education on risk factors for AD and best tracheostomy care practice; increased availability of telemetry and oximetry; and signage to identify patients at high risk of AD), the incidence of AD over a subsequent 7 month period was significantly reduced, to 2.7 ± 1.9/1,000 tracheostomy days. In addition the numbers of multiple, unmonitored, unreported, and night shift ADs were all significantly reduced.
  
  
  CONCLUSIONS
  Targeted interventions can significantly reduce both the incidence of AD following tracheostomy and associated morbidity. Best practice guidelines to help minimize AD in patients with tracheostomy tubes are proposed.
authors.affiliation: Department of Pulmonary and Sleep Medicine, Rose Kalman Research Center, Stoughton, MA, USA. awhite@nesinai.org
authors.forename: Alexander C
authors.initials: AC
authors.lastname: White
authors.forename: Elaine
authors.initials: E
authors.lastname: Purcell
authors.forename: Mary Beth
authors.initials: MB
authors.lastname: Urquhart
authors.forename: Bernard
authors.initials: B
authors.lastname: Joseph
authors.forename: Heidi H
authors.initials: HH
authors.lastname: O'Connor
mesh_terms: D003221:Confusion; D020878:Device Removal; D006801:Humans; D007318:Inservice Training; D008134:Long-Term Care; D061214:Patient Safety; D010561:Personnel Staffing and Scheduling; D011595:Psychomotor Agitation; D019984:Quality Indicators, Health Care; D012149:Restraint, Physical; D012307:Risk Factors; D014139:Tracheostomy / Q000009:adverse effects*