Abstract
Objective
To systematically assess safety risks pertaining to tracheostomy care in the long-term
care (LTC) setting using a human factors engineering approach.
Design
We utilized a 5-part approach to complete our proactive risk assessment: (1) performed
a hierarchical task analysis of the processes of tracheostomy stoma and suctioning;
(2) identified failure modes where a subtask may be completed inappropriately; (3)
prioritized each failure mode based on a risk priority scale; (4) identified contributing
factors to and consequences for each of the prioritized failure modes; and (5) identified
potential solutions to eliminate or mitigate risks.
Setting
Three high-acuity LTC facilities with ventilator units across Maryland.
Methods
The hierarchical task analysis was conducted jointly by 2 human-factors experts and
an infectious disease physician based on respiratory care policies from the Centers
for Disease Control and Prevention and existing policies at each LTC facility. The
findings were used to guide direct observations with contextual inquiry and focus
group sessions to assess safety risks for residents receiving tracheostomy care.
Results
Direct observations of tracheostomy care and suctioning in the LTC setting revealed
significant variations in practice. Respiratory therapists working in LTC reported
lack of training and ambiguity concerning recommended procedures to reduce infection
transmission in daily care. Highest risk steps identified in tracheostomy care and
suctioning included hand hygiene, donning gloves, and providing intermittent suctioning
as the suction catheter was withdrawn. Participants identified risk mitigation strategies
targeting these high-risk failure modes that addressed contributing factors related
to 5 work system components: person (knowledge and competency), task (eg, urgency
or time constraints), tools and technology (eg, availability of hand sanitizer), environment
(eg, communal rooms), and organization (eg, patient safety culture).
Conclusions and implications
Human factors analysis of the highest-risk steps in respiratory care activities in
the LTC setting suggest several potential mitigation strategies to decrease the risk
of infection transmission. Clear procedure guidelines with training are needed to
reduce ambiguity and improve care in this setting. Involving frontline staff in patient
safety issues using human factors principles and risk analysis may encourage participation
and improve the infection prevention culture in LTC.
Keywords
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Article info
Publication history
Published online: November 30, 2019
Footnotes
This work was funded by the Centers for Disease Control and Prevention (Grant 128249).
The authors declare no conflicts of interest.
Identification
Copyright
© 2019 AMDA - The Society for Post-Acute and Long-Term Care Medicine.
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