الفهرس 
IntroductionOnly 14 pages are availabe for public view
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Abstract
One of the most frequent surgical procedures is tracheostomy. There are many reasons to perform a tracheotomy, including airway obstruction, prolonged intubation, airway cancer, and excessive secretions. For patients who need to be intubated for an extended period of time and receive mechanical ventilation, a tracheostomy is necessary. The safety and cost-effectiveness of care for patients with tracheostomies are impacted by a variety of surgical alternatives and post-operative care choices, with complication for intraoperative, early, and late problems, respectively. To prevent major problems such infection, bleeding, unintentional decannulation, and obstruction from granulation tissue formation or secretions, proper tube care and maintenance are essential. Anoxic brain injury or death are the most severe tracheostomy-related problems that can occur.
With multiple specialties and surgeons performing and caring for tracheostomies, there is wide variation in clinical practice. There have been a limited number of clinical guidelines published which describe the standard of care for management of patients with tracheostomy tubes. It is also challenging to manage these complex tracheostomy patients without a multidisciplinary approach.a multidisciplinary team that consists of healthcare professionals participating in every aspect of the patient’s care. These interdisciplinary teams have shown shortened time to decannulation, lower frequency of unfavorable events, shorter stays in the ICU, and decreased lengths of hospital stays.Therefore, the aim of this study is to determine the effect of implementing tracheostomy tube care bundle on outcomes of critically ill patients.
Materials &Method
A quasi-experimental research design was used todetermine the effect of implementing tracheostomy tube care bundle on outcomes of critically ill patients.This study was performed in theGeneral ICUs at AMUH namely; Casualty unit(unit I), General ICU (unit II, III). The general ICUs: unit IV, V. Beds capacity of these units are 12, 9,16,8, and 12 beds respectively.
A convenience sample of 70 newly admitted critically ill adult patients with tracheostomy tube who were admitted to the previously mentioned units constituted the subjects for this study (35 for each group). The subjects were randomly assigned into two groups: group I, the intervention group and group II, the control group.Data were collected by the researcher over a period of seven consecutive months (from January to July 2022).
- Data were collected as follows:
Phase I: Assessment phase
For both groups:
- The demographic data such as patient’s age and sex were obtained and recorded using part I of tool I.
- The clinical data such as admission diagnosis, APACHE II score and comorbidities were assessed and documented using part I of tool I.
- The length of ICU stay was calculated during the study time.
- The tube-related data including sizes and types of tracheostomy tube such as cuffed, uncuffedwere assessed and documented using part I of tool I.
- The tracheostomy tube was assessed for the risk of dislodgment through observing the tube for loose ties and excessive patients’ movement and recorded using part II of tool I.
- Patients were assessed for signs of tube dislodgment such as low airway pressure alarms, low expiratory volume alarms on the mechanical ventilator, resistance with passage of suction catheter, were also assessed at the baseline and daily for 7 consecutive days using part II of tool I.
Implementation phase
TRACHECOMS care bundle was implemented daily by the researcher for 7 consecutive days as follows:
• Tube care was performed as follows:
- Tube tie was inspected every 8 hours using gauze ties as per hospital policy.
- Cuff pressure was measured by the researcher every 8 hours using cuff pressure manometer
• Resuscitation measures were implemented through placing bedhead signs by the researcher in patient’s chart
- The unit staff were informed and oriented to the bedhead signs by the researcher.
• Airway patency was maintained through tracheal suctioning which was performed according to patient’s needs following aseptic technique.
• Care of stoma was performed through inspecting the stoma site daily for signs of infection
- The stoma site was disinfected daily using distilled (sterile) water in circular motion
• Humidification of the airway was maintained through ensuring that the patient was receiving humidified oxygen either through the wall oxygen or ventilator humidifier
- Chest physiotherapy in the form of percussion was performed daily before tracheal suctioning if not contraindicated.
• Emergency equipment was placed at patients’ bedside to use it in emergency situations and ensured their presence every shift by the researcher.
• Communication with conscious patients was maintained daily using communication board
• Mouth care was performed by the researcher every shift including suctioning oral secretion according to patients’ needs.
• Swallowing ability of conscious patients attached to tracheostomy tube was assessed daily using small amount of water to drink to check if patient able to swallow or cough due to impaired swallowing.
• Patients’ were assessed to ensure that they received the prescribed nutrition.
• For the control group: patients were subjected to the routine care provided by the staff member of the unit
Outcome assessment
For both groups:
- Stoma site was assessed at the baseline before implementation of intervention and daily for 7 consecutive days for signs of infection, in addition to daily assessment for signs of bleeding. The findings were recorded using part I of tool II.
• Tube related outcomes was assessed as follows:
- Cuff pressure was assessed and recorded using part II of tool II as mentioned before in the implementation phase.
- Tracheal secretions was assessed either large, moderate or small, color include bloody white, yellow, green and consistency include sticky, thick, foamy.
- Tracheostomy tube was assessed for the need to change
• patient’s related outcomes were assessed as follows:
- Physiological parameters such as respiratory rate, temperature, mean arterial pressure were assessed and recorded using part III of tool II
- Signs of respiratory distress including intercostal retractions, use of accessory muscles
- Signs of respiratory tract infections were assessed every shift and recorded at the baseline and daily for 7 consecutive days using part II of tool III.
Results
Regarding redness around stoma there was statistical significance differences between the two groups from 3rd day to 7th day (p=0.031,p=0.017,p=0.008, p=0.006,p=0.011.) , as regard signs of stoma site bleeding there was significant difference between the study and control group regarding bloody secretions from 4th day to 7th day (p=0.015 ,p=0.022,p=0.034 ,p=0.034)
As regard cuff pressure, amount of tracheal secretions and signs of tube obstruction there was highly statistical significance between two groups from 3rd day to 7th day
In relation to physiological parameters, there was a significant difference from 4th day between the study and control groups regarding heart rate, respiratory rate, Spo2, Sao2 andmean arterial pressure, in relation to signs of respiratory tract infection, there was significant difference between study and control groups regarding increase in WBC count (white blood cells), positive sputum culture for microorganism, increase need for suctioning and x-ray changes.
Conclusion
from the present study it could be concluded that:
• Implementation of tracheostomy tube care bundle interventions significantly decreased the complications such as: stoma site infection, bleeding signs and need for suctioning
• Implementation of tracheostomy tube care bundle interventions significantly maintained normal physiological parameters as RR, oxygen saturation, breath sounds, HR of critically ill patients.
Recommendations
The following recommendations are suggested:
- Critical care nurses should assess the stoma site and around it for signs of infection and bleeding.
- Critical care nurses should be aware of physiological parameters of critically ill patients and assess for signs of respiratory distress and respiratory tract infection.
- Undergraduate critical care nursing courses should handle the concept of tracheostomy tube care bundle focusing on its positive outcomes.
- Implementing an educational program for health care providers as regard tracheostomy tube care bundle emphasizing that tracheostomy tube care bundle interventions are feasible, cost effective and applicable by critically care nurses.
- Policies should be developed to simplify the charting and documentation system as regard implementation using protocol and pathway of intervention of tracheostomy tube care bundle.
- Evaluation of the effect of tracheostomy tube care bundle interventions on long term outcomes.