What are the strategies to reduce tracheostomy incidents in acute care, adult patients?

 

 

Introduction:

The objective of this report is to scrutinize the strategies that can reduce tracheostomy incidents that occur in a hospital acute setting, in adult patients.

 The background will provide information on what tracheostomy is, its history throughout the centuries and its importance in maintaining life. Emphasis is given on the National Tracheostomy Safety Project (2020) and its guidelines by McGrath, Bates, Atkinson and Moore (2012).

The rationale behind this report will be justified through evidence nursing research. Using the Population, Intervention, Comparison and Outcome framework (Richardson, Wilson, Nishikawa & Hayward, 1995) , in the Aim section of the report, the research question will be addressed and each part of it will be thoroughly explained, analyzing the topic accordingly.

The search strategy includes information on how and where the evidence was obtained to support the guideline, along with an example of database research, key search terms, and inclusion and exclusion criteria.

In the summary of evidence, a table comprising all key findings to the research question, will be discussed regarding quality and relevance to the topic.

The critical appraisal of the evidence base section will identify the barriers and challenges to the implementation of the tracheostomy guidelines, along with critical appraisal of the key findings of the research.

A dissemination plan will be presented for the key stakeholders and finally a conclusion section, summarizing all key findings in this report.

 

Background:

Tracheostomy goes four thousand years back into history, as one of the oldest surgical procedures known to mankind. Proof of its implementation can be found in the ancient Indian, Egyptian and Greek civilizations. Over the centuries tracheostomy has been a procedure of conflict and controversy, especially for its safety, necessity and chosen technique.

Tracheotomy derives from the Greek words trachea and tomy and it means, opening to the tracheal wall. It is a procedure that is not always a permanent solution for the patient , and it is a valuable tool of dealing with upper and lower respiratory conditions and effective long term ventilation, especially in ICUs, (Choby & Goldenberg, 2011,p.34 38).

According to the NTSP Manual (2013, p.15), it is estimated that more than 10 15,000 tracheostomies are implemented every year in England’s Critical Care Units. The actual numbers rise each year, due to the benefits of a temporary tracheostomy.  

Patients with tracheostomy, are commonly treated in many general wards, due to the increased demand in Intensive Care Unit (ICU) beds and to an effort to defuse care as soon as possible. This has a direct impact on the Nursing staff, which is expected to provide care without having adequate knowledge and basic competencies, increasing tracheostomy related incidents and raising concerns on patient safety (NTSP Manual, 2013, p.15).

More than 1,700 incidents were recorded and reported to the National Patient Safety Agency (2012) ,in the period between 1^st January 2005 and 31^st December 2008, involving more than 30 deaths. From research conducted by the NPSA, it was confirmed that when a tracheostomy incident takes place, the rate of harm to the patient goes up to 60% even 70% according to McGrath & Thomas (2010).

By the term ‘incident’ we identify various early and late complications like airway loss, bleeding, stenosis, infection of the stoma, overgranulation, blockage or displacement. Also, equipment, competency and infrastructure incidents are a major part of tracheotomy complications (NTSP Manual, 2013, p.16).  

The 4^th National Audit Project Report (2011), was a major prospective study across the United Kingdom in order to record the incidents of airway management in all four countries.

 The findings of this report were devastating since poor airway assessment and management in emergency situations were identified, and Nurses’ respond in most of the cases was unstructured, with poor judgement causing harm to patients and even death. Deaths which according to the NAP4 (2011, p 4 9) report could have possibly been avoided.

The breadth of this report for a whole year gave a succinct list of things that needed to be addressed, in order to minimize tracheostomy incidents in acute care, adult patients and generally in patients with tracheostomy in place (NAP4,2011, p10).

The National Confidential Enquiry into Patient Outcome and Death (2018) and its report ‘On the right trach?’(2014), three years after the NAP4 (2011) report ,just confirmed the findings on tracheostomy incidents rate, lack of nursing skills, competence and equipment. Inadequate documentation and training of the staff regarding tracheostomy care and management was also recorded. The possibility of a patient experiencing a patient safety incident was estimated to a socking 30% , staff not provided appropriate training 27.9% and hospitals with policies in place for blocked tracheostomy or displaced tubes 80.6% (On the right track, 2014, p. 113)

The National Tracheostomy Safety Project (2020), was created in order to increase safety and quality of care for patients with tracheostomies and laryngectomies nationally and globally via crucial collaborations with the department of health (2015) and the Global Tracheostomy Collaborative (2012). The NTSP issued the first Multidisciplinary emergency management tracheostomy guidelines for adults (McGrath et al., 2012) along with other valuable educational resources like the NTSP Manual (2013) for comprehensive tracheostomy care. Most of the NHS Trusts guidelines, refer to NTSP for emergency tracheostomy management and care like St Georges Healthcare NHS Trust guidelines (2002).

From basic care to emergency management, vocalisation and swallowing, emergency algorithms, bedhead signs, documentation and many other resources, the NTSP provides not only to Nurses but to all Healthcare professionals and families, excellent and up to date information, standards, guidelines and training. In that way, Red flags can be identified in early stage and tracheostomy incidents reduced (NTSP Manual, 2013, p.107 113).

Aim:

Research is vital for improving and implementing Evidence Based Practice (EBP), so that the best outcomes for the patients can be achieved (The Code, 2015). That is the reason why it is part of every Nursing program and included in pre registration requirements by the Nursing and Midwifery Council (2010).

EBP would not exist without clinical questions. The biggest challenge is to formulate and identify an answerable research question. A well structured question can help towards proper research targeted literature. If the research question has no structure or it is generic and broad, it can be a significant waste of time, which for Nurses is a scarce element and can lead to irrelevant information retrieval (Davies, 2011).

Adopting a standardised framework to ask a research question, also helps targeting on key elements and enables reflection on how, why and if ,there is another way of approach according to Davies (2011, p.75). The review of the literature presented aims to answer:

What are the causes of tracheostomy incidents in acute care, adult patients?

A very popular framework for clinical research questions, is the Population Intervention Comparison and Outcome known as PICO, by Richardson et.al. (1995). PICO, and its derivatives like PEO (Bettany & Saltikov,2012), were created to address quantitative and qualitative research questions respectively.

In a review study by Huang, Lin and Demner Fushman (2006) where 59 clinical question were analysed, it was discovered that only two of the research questions contained all four elements of PICO and 37%, both Intervention and Outcome. The result indicated that, this framework is considered to work better for clinical questions that involve therapeutic interventions and less for other clinical issues and needs (Huang,Lin & Demner Fushman, 2006, p.359).

Despite criticism, research questions that adopt this framework, get higher citation rates (Siny, Colin F. & Abdullah Sulieman, 2017) and there is not enough studies to prove the efficiency of the PICO framework comparing to other models or use of no models at all (Brandt Eriksen and Faber Frandsen, 2018) . PICO is used to address the research question in this report.

P Patient or problem: Which is the patient group or populations, its characteristics, the primary problem or co existing condition? In this research question the group is tracheostomy adult patients, in acute care. That means that the age is >18 in any acute care hospital setting. There is no gender, ethnicity or co morbidity demarcation.   

 I Intervention: what is the intervention or alternative implemented? The intervention is the Strategies that can be adopted to achieve that.

C Comparison: what is the primary intervention compared to? In this research question there is no comparing intervention.

O Outcome: what are the expected outcomes, improvements or affects? It is the reduction in tracheostomy incidents.

Table 1:

 

Application of PICO framework:

 

PICO

POPULATION	INTERVENTION	COMPARISON	OUTCOME
Tracheostomy adult patients in acute care	Strategies Implementation	n/a	Reduction in tracheostomy incidents

        

Search strategy:

In order to do an effective ,systematic literature search ,keywords from the research question is used, aiming to collect relevant articles to support the chosen topic (Melnyk et al., 2010). When researching for evidence, Healthcare professionals should be aware that accessing a database, can only provide research that is published. There is continuous research on emergency tracheostomy care and strategies and also grey literature like government projects and reports that may not be traceable in databases but can expand significantly the scope of literature found according to Mahood, Van Eerd and Irvin (2014).

Researchers should be careful of biased publications since authors/researchers, tend not to publish results that oppose their research question or theory. That means that there is a plethora of articles that counter significant findings, but they are not available to be used in critical appraisal and ratification of the research articles (Matosin, Frank, Engel, Lum, J. S., & Newell, 2014).

After formulating the research question there was a scoping search to evaluate adequacy of literature to support and justify the topic chosen. Grey literature was identified, like National projects (NAP4, 2011) and reports related to tracheostomy incidents (Shine, 2015). Guidelines were also retrieved and from different Trusts on Tracheostomy care and management. Findings were recorded for evaluation and comparison purposes.

For the research articles required for this report MEDLINE and CINAHL databases were used. MEDLINE database includes published literature since 1966 and held in 2016 more than 23 million articles, (U.S. National Library of Medicine 2016) presenting a vast literature search. CINAHL (Cumulative Index to Nursing and Allied Health Literature) is the most comprehensive and broadly used database for nursing journal articles (EBSCO Nursing Resources 2017).

Table two, shows an example of keywords that were used to retrieve the articles required. Keywords from the research question but also from relevant articles were used in multiple and various researches. Alternative spelling, acronyms, synonyms and terminology were broadly used to expand the search. Truncation symbol was used (*) to acquire all possible suffixes like nurs*, polic* and care plan*, that retrieved articles including nurse, nursing, policy,policies and care plan, care plans and care planning respectively. Boolean operators ‘OR’ AND ‘END’ were used in the search. The Boolean operator ‘OR’, was used to conjoin the synonyms and the ‘END’ to retrieve citations incorporating a combination of keywords provided (Aveyard and Sharp 2013).

Table 2:

keywords

Reduce	Tracheostomy	incident	Hospital	Strategies
Lessen*	tracheotomy	Accident*	Acute care/setting	Ways
Minimis*	Tracheal stoma	Adverse effects	Wards	Methods
Reduc*	Airway device*	Side effects	ICU/Intensive Care	Care plan*
Prevent*		episode	Clinical area	tactics
decrease		occurrence	Critical care	process
curtail		Adverse events	A&E/ Emergency care/Urgent care	Polic*

 

A data extraction table can be very useful in concentrating and assessing the key points of the study and identifying the articles and their validity in the research. The CINAHL database in the initial search retrieved 122,042 results based on keywords, Boolean operators and the Asterix truncation symbol. An example of the above mentioned search strategy retrieval is included in the report appendix section.

The results were filtered according to whether there were full text available articles that decreased the number to 14,367 papers. Evidence based, peer reviewed and containing abstracts and references were a few more limitation agents. Others applied were, date of issuance, major concept and findings concerning only adult patients. See table three. There were no limitations in gender and language since many hospitals around the world share the same guidelines and tools and face the same issue that it is addressed in this research question about tracheostomy incidents in the acute setting according to The Global Tracheostomy Collaborative (2018). After narrowing down the search, the identified articles were reduced to 20. Abstracts were read and most suitable articles were studied, recorded and used in this report.

Table 3:

Inclusion/exclusion

Inclusion	Exclusion
Papers from>2010	Papers<2010
Papers in all languages
Nursing related tracheostomy incidents papers	other healthcare professionals related tracheostomy incidents
Full text papers	Abstracts only
Evidence based papers	Non evidence based papers
Peer reviewed papers	Non peer reviewed papers
References included	References not included
Abstract included	No abstract included
Adult patient group papers	All other age groups
All genders

 

Summary of the evidence:

Ten articles were identified and used in this review. Two used mix qualitative quantitative methods and were conducted in Brazil. The rest of the studies used quantitative methods and were conducted, three in India, one in France, one in Sudan, one in Canada, one in United Kingdom and one in Iran setting the number of the countries participated to seven. All the articles revolve around tracheostomy and provides a consistent knowledge about every perspective related to this. The ten articles include the researches from the researchers De Pinto et al., (2015), Rocio de Faria Gaspar et al., (2015), Dhaliwal, Choudhary and Sharma, (2018), Qadir, M. B. (2018), Beuret et al., (2013), Abdelazeem, Fashafsheh and Fadllalah, (2019), Leddy and Wilkinson, 2015, Sodhi, Shrivastava and Singla, (2014), Mcgrath et al., (2013), Hoseini et al., (2018). The articles analyse the nursing care practices to promote consistent health in prevention of tracheostomy. One articles identifies the importance of communication in tracheostomized patients care and other than this the knowledge and skills about the working of the nurses and tracheostomy care. Risk of complications and several guidelines regarding the suctioning in mechanical ventilated patients is also searched out. Endo Tracheal Tube care and mechanical ventilated patients has also been studied in Sudan. While the suctioning practices and impact of a dedicated specialized tracheostomy care and related complications are also in the findings of these researches. In the last, nature and severity and the determination of complications in ICU were also under research findings.

 

Quality appraisal and discussion:

Evidence based practice:

Evidence based practice is a problem solving approach that incorporates the best possible evidence that comes from well formulated and conducted research questions from healthcare professionals coming from patient assessments, preferences, values and data from clinical practice (Melnyk & Fineout Overholt 2011). EBP allows Nurses in every clinical setting to have a voice, make a difference in their practice and be able to achieve holistic person centred care (Pangarakis & Graner, 2010).

According to Aveyard & Sharp (2013), the hierarchy of evidence (Figure 1) ranks the ranks the strength of the research based on the rigor of their methodology that was used. Systematic literature reviews are concidered as the strongest type of evidence. However the the golden standard of evIdence to answer a clinical question are Randomised Control Trials (RCTs). A RCT is a type of study using cetain resources of bias in order to test the effectiveness of new interventions. It s accomplished by allocating subjects to two or more groups, treating them differently and then compare the data based on the response (Aveyard & Sharp, 2013). For this research question no findings of such research were retrieved and maybe that is because the variables that cannot be controlled are numerous and it would take big samples for statistically significant findings (

here I  have started talking about evidence based practice. I will do this bit and mention Caldwell and his list . do not do anything here.I am on it!

Appraisal of the evidence: (1500 words)

Strengths: you are suppose to write the strengths of every article mentioning the two mixed method articles together and the rest together. They are based on Caldwell as I will mention above so you do not have to do keep mentioning him. I am sending you the framework so that you know the questions that need to be answered.

Weaknesses:

Research articles have different weaknesses as well, and most of the weaknesses lies under the type of the conducted research. De Pinto’s research does not have an appropriate type of study and the observations are only based on the night shifts. Rocio has the same weaknesses and also his research does not have appropriate time of communication. In the research of Dhaliwal, Choudhary and Sharma, 2018, there were no strategies discussed or there was no precentage of the staff participation. While most of the biases occur due to the type of the study or the relative size and sample of the partcipants. One of the resaerch by Mcgrath has weaker evidence in the type of the study. Adir in his research studies has the limitation of having the limited midwifery candidates, and the type of the study is pre experimental.

Discussion:

Most of the selected researches was based on quantitative analysis that is considered to be the most authentic one. The quantitative analysis provides detailed statistical data about any of the practiced approach. But qualitative data has also its place in research and it incorporates in dealing with more of the descriptive analysis of the research. Research in Brazil was conducted to see the knowledge skills of nursing and various interventions related to that. this study has both quantitative and quantitative types of analysis. The researchers find out that acute care of a tracheostomy requires proper analysis and effective use of the instruments. The main instruments to treat the patient with tracheostomy include the endotracheal tube, mechanical ventilator, and the other instruments that provide more care and assistance to the patients. Also, these instruments and the primary healthcare of nurses provide patients with acute care. For nursing interventions it is highly necessary for nurses to provide the patients with care without providing any harm to the patient to minimize the chances of harm, there is a need to provide the patients with effective treatment The main purpose of the research is to collect the quantitative data about accessing the knowledge of the nurses. The study selected to proceed with the research is Quasi experiment. The entire study has different domains of selection and different sorts of observational studies are also present here. The research is peer reviewed and is highly authentic to deal with the main requirements of the research. For example, according to the findings of the research, most of the nurses do not know the mechanical ventilation that is used in nursing, it is all about dealing with the clinical practices that are required to deal with the complications of tracheostomy. (Abdelazeem, Fashafsheh, and Fadllalah, 2019). The data can be generalized as about 50 ICUs were selected and analyzed as per the requirements of the research. Other than this, about 50% of the participants fall in the criteria that do not have any knowledge about the mechanical ventilators. This was a major challenge to deal with patients who were suffering from tracheostomy. The quantitative results of the study fall in the favor that about 46% of one of the interventions to deal with a tracheostomy was not that much effective. The mechanical ventilator was one of the most efficient techniques used in the system. Other than this, 44% of the participants have only a few knowledge regarding this, which means that the knowledge about dealing with the tracheostomy patients was not efficiently present in nurses. There was also a quantitative relationship between nursing care and nurses performance to deal with the patients suffering from tracheostomy with oral care. The p value of this relationship came out to be 0.106. without any kind of errors. The qualitative study takes place in Brazil to highlight all the major points related to tracheostomy. The qualitative research proceeds with interviewing the nurses to see the relative knowledge and skills about the tracheostomy. The nurses were specified to provide practical knowledge about the orotracheal tube, and according to this only 83% of the nurses were able to do so, while the rest were not that efficient. Another tested intervention of the research was about tracheostomy care in which about 97% of the nurses were efficient. So, this study proves that providing nursing to patients of tracheostomy requires a greater level of assistance and care. This will be highly assisting to prevent the possibility of injury. OT cuff care was also part of the research in which 40% of the professionals were efficient.

Barriers to implementation:

Due to the decrease of the knowledge, nurses faced many complications in providing care to the patients of tracheostomy. The nurses have to face many problems in the appropriate management that can also impact on the health of the patients. According to a research based study by Hayat and Imad decrease in knowledge of the acute care proves out to be very challenging for the nurses as well as for the health of the patients. (Abdelazeem, Fashafsheh, and Fadllalah, 2019). Different strategies are need to be implemented to deal with the proper care and incidents faced in providing the patient with care. Tracheostomy is a condition that can also lead to the injury of the lungs and it is due to the poor acute care to the patients. Lung infections and diaphragm damage problems are common to provide the patient with proper care. This is all due to the limited availability of the equipment used for the treatment of tracheostomy. (Abdelazeem, Fashafsheh, and Fadllalah, 2019). So there is a need to provide the patients with effective care and management, otherwise, the damage to the endotracheal tube might also occur. Dealing with mechanical ventilation is also a major challenge that might be faced by the working staff. Mechanical Coping up with health demands is highly necessary to provide the patients with efficient treatment. Airways complications require a vast amount of knowledge to deal with the conditions of the patients. Both upper and lower respiratory problems cause a lot of damages to provide patients with healthcare facilities. As per the research, if the condition of tracheostomy lasts for a longer time, it might lead to permanent damage to the airways. This permanent damage leads to prolonged the problem to ETT, which is again an appropriate strategy to get over the issue of tracheostomy. The condition can also get dislocation, nasopharyngeal injury, web formation, paralysis, or fixation. So, the nurses must be having the proper knowledge to provide the patients with mechanical ventilator care. (Abdelazeem, Fashafsheh, and Fadllalah, 2019). Otherwise, the condition can get worsen as well. Every evidence based research has its implementations across the professional field. The need is to provide patients with efficient care and consistent acute care. Hoseini et al., 2018 in his analytical study describe every aspect of the complications faced by the patients who are suffering from tracheostomy. (Hoseini et al., 2018). The study analyzes an in depth overview of the complications faced by the patients. (Hoseini et al., 2018).

 

Dissemination plan

The dissemination plan provides a detailed overview of each perspective and detailed information about the possible medications. The key stakeholders that are linked to this report provide a detailed overview of multidisciplinary staff that is involved in the clinical practices.

The following dissemination plan provides a detailed overview about the detailed overview to the stakeholders. Dissemination plan helps in dealing with the detailed information about the clinical leads used by the stakeholders. The dissemination plan produced a detailed perspectives about the strategies used. Different proposed researches have different dissemination plans that defines the strategies about nursing and relative care strategy to treat tracheostomy. Different strategies are used to provide information about the clinical care to the stakeholders. The clinical trial strategies for stakeholders includes Ward meetings, Local trust seminar, conference, oral presentation, conference, poster presentation, publication, and mechanical ventilator. Different dissemination plans have different perspectives to provide clinical trials and information to the clinical stakeholders. Such as in the case of publications and poster presentation. Poster presentation provides a more advantageous view of every aspect in a creative and enhanced way but it has lack of clinical experience and there might be mismanagement in intuitions. While in the case of publications, they provides a detailed perspective of each view with a complete understanding of everything. But knowledge is limited to books despite considering the conditions of patients. Mechanical ventilator is another strategy which is highly efficient for the stakeholders to have a clinical trial. Mechanical ventilator is also a dissemination strategy to provide to the stakeholders, this strategy is highly efficient to provide care to the patients. The knowledge of ETT and mechanically ventilated patients is highly efficient to provide care to the ones facing tracheostomy. Different findings have different set of clinical leads that paly an efficient role to provide care and assistance to the patients. Suctioning practices is also an highly efficient strategy to provide information to the stakeholders. Local trust critical incidents and the reporting system along with the implementation of NTSP is also highly efficient technique to implement and dissemination can be provided in the form of clinical leads to stakeholders regarding this. Following is the range of strategies that provides a detailed view of every possible aspect of information required for the treatment of tracheostomy:

 

 

Strategy	Advantage	Disadvantage
Ward meetings	It provides a detailed and practical knowledge about providing care to the tracheostomy adults.	It does not involve practicing.
Local trust seminar	The increased number of seminars helps in providing the nurses with theoretical as well as practical knowledge about every phenomenon.	Local seminars do not allow every nursing person globally to have a piece of complete knowledge about these strategies.
Conference: oral presentation	It makes the nurses aware of every possible situation that they might face about providing the patients with acute care.	There is no practical knowledge of this strategy.
Conference: poster presentation	This provides a more advantageous view of every aspect in a creative and enhanced way.	Lack of clinical experience and there might be mismanagement in intuitions.
Publication	A detailed perspective of each view with a complete understanding of everything.	The knowledge is limited to books despite considering the conditions of patients.
Mechanical ventilator	The approach is highly successful in dealing with the lower and upper respiratory problems.	There is a lack of knowledge as explained by the researches.

Conclusion

All the selected researches are evidence based and are registered in the Nursing and Midwifey Council (2010). All the researches are evidence based and provides a complete overview about the tracheostomy and every research based study revolves around it. However, research can be further improved by using different rationale based practices to have a complete generalization about the research topic. However, the selected studies have limitations on the type of the study and the percentage of population. Despite some of the ethical considerations also have limitations regarding this are also considered. Further research questions can be addressed using other research papers. All the researches are addressed with proper clinical appraisal, and provides literature of detailed discussion. The PICO technique is used to devised the research questions and to proceed with the evidence based practices. This technique adds more strength to the report as it highlights the discussion, appraisal, and limitations of every research. There is aa need to implement all the above evidence based practices practically in nursing care to provide care and assistance to the patients. Nurses must be aware about all the research based evidences regarding tracheostomy to provide the patients with on time care and assistance. Also these discussed strategies and interventions play a vital role in promoting innovation in the nursing practices.

 

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 Appendix:

Author, Year and Location	Aim of Study	Methodology	Key findings
De Pinto et al., (2015) Brazil	Analyse the care provided by the nursing team to promote the safety of adult patients and prevention of skin and mucosal lesions associated with the presence of lower airways invasive devices.	Mixed descriptive and exploratory qualitative and quantitative method	For Orotracheal tube: 83% nursing professionals new how to perfume (OT) preventive care. The rest stated that did not know how to. 72% were changing the collar/lace around the neck once a shift or whenever necessary. 40% of the nurses were changing (OT) position and 37% of the nursing technicians considered to use a protective gauze against friction. Only 80% believed that accidental extubation is part of nursing care. 34% related (AE)  with proper collar/lace fixation. For tracheostomy care: 97% reported care for injury prevention. 72% assessed the patients for need of dressing. 80% of the staff was changing the collar/lace once a shift and when necessary. Percentage of Nursing technicians reported they did not know hoe to perform tracheostomy care. Cuff Care: Regarding OT care 40% of the checked the cuff pressure and only once a shift. (p=0.756) Lack of knowledge was stated and that doctors were responsible for this. Cuff pressure monitor was not available in many clinical areas. Suctioning: 98% assessed patients before suctioning. The rest followed the clinic’s routine. 40% chose as criterion the frequency and breathing pattern. 39.1% chose secretion view. Auscultation was performed only by 22.7% of the nurses and 3.3% of the nursing technicians. (p=0.051) Superficiality in direct care was identified by nursing professionals. The role of the nurse was distant from the clinical evaluation process and interventions. Care differed according to unit and profession category.
Do Rocio de Faria Gaspar et al., (2015) Brazil	Identify nursing team perceptions on the importance of communication in tracheostomized patients care	Qualitative, quantitative method	Participants’ answers evidenced the importance of communication with tracheostomy patients, developing strategies and recovery up to 100% in each question respectively. 93.1% of nursing assistants, 83.3% of nursing technicians and 57.1% of nurses pointed out that they had guidance during their education process. 60% of nursing assistants, 61.5% nursing technicians and 28.6% of nurses claimed communication practices during nursing exercise. On education to care performance 73.3% of nursing assistants, 75% of nursing technicians and 57.1% of nurses felt well prepared. To the question if the incapability of oral communication by patients interferes in their relationship to the nursing team, 63.3% of nursing assistants, 50% of nursing technicians and 57.1% of nurses answered affirmatively. 93.5% of nursing assistants, 100% nursing technicians and 71.4% nurses had ever guided a tracheostomized patient to communicate with them.
(Dhaliwal, Choudhary and Sharma, 2018)  India	Assess the knowledge and skills on tracheostomy care amongst staff nurses working in selected hospitals of district Mohali, Punjab	Quantitative descriptive method	The majority of the the staff nurses 57% fell into the category of average knowledge regarding tracheostomy care and 43% into the good knowledge. None of them fell into the category of poor or excellent knowledge.  Most of the nurses 56% fell into the category of good skills, regarding tracheostomy care and 44% into the fair category. None of them into the poor category. There was a weak positive correlation between knowledge and skills of tracheostomy suctioning. There was a significant association of knowledge with age, total work experience in years, present area of work, experience/duration of work in the present area in years and educational program attended on tracheostomy care. There was no significant association of knowledge with gender and educational qualification.  There was no significant association of skills of tracheostomy care with age, gender, educational qualification, total work experience/duration of work in the present area and educational program attended on tracheostomy care.
Qadir, M. B. (2018) India	Assess the impact of structured teaching programme n knowledge regarding tracheostomy care among staff nurses working in selected hospital of Kashmir in order to reduce the risk of complications associated with the procedure.	Quantitative, pre experimental research method. ‘’one group pre test post test research design’’	100% of the the sample had never attended any in service education programme related to tracheostomy care. The pre test knowledge levels od staff nurses showed that majority 81.67% had inadequate knowledge level and 18.33% of the subjects has adequate knowledge level regarding tracheostomy care. In most of the subjects 53.33% had adequate knowledge level and none had fallen in the category of inadequate knowledge level. The mean post test knowledge score (39.47) was significantly higher than the mean pre test knowledge score (24.10) with the mean difference (15.37). there was a significant difference between pre test and post test knowledge score at p<0.05. the results proved that the planned teaching program was significantly effective in improving the knowledge of the staff nurses.
Beuret et al., (2013) France	To identify discrepancies between guidelines and practice of tracheal suctioning in mechanically ventilated patients	1 day point prevalence observational study.	there was no routine use of saline instillation prior to suctioning, to a 96.3%.  82.3% of the staff  suctioned without disconnecting the patient from the ventilator, 79.5%  of the suctioning duration was <15 s, 57.7%  performed shallow suctioning, 57.6% monitored the negative pressure of the level of suction, 55.6% performed suctioning only when secretions were present and only 5.3% used diameter of suction catheter, not exceeding one half the diameter of the artificial airway.
Abdelazeem, Fashafsheh and Fadllalah, (2019) Sudan	Assess the effectiveness of the training program on nurses’ knowledge and performance regarding the care of Endo Tracheal Tube (ETT) and tracheostomy in mechanically ventilated patients.	Quasi experimental method	Before the training program nurses’ knowledge was 55% good,68% good in post test I and 80% good in post test II. The result was also statistically significant as a 95% confidence interval of the difference was not containing zero and P value <0.005.  Infection control went from 57% in pre test to 78% in post test I and 88% in post test II. Patient and ventilator assessment was 30% in pre, 63% in post I and 67.7% in post II. Suctioning an ETT was 54% in pre, 70.9% in post I and 80% in post II. Suctioning tracheostomy was 61% in pre test , 71.5% in post I and 80% in post II.
(Leddy and Wilkinson, 2015) Canada	Examine suctioning practices or registered nurses and registered respiratory therapists in six hospital ICUs in Ontario with special attention to use of nasal irrigation (NSI)	25 question self administered survey	There were similarities between both groups with both reporting high use of NSI. Both groups observed side effects following NSI with suctioning including decreased oxygen saturation, patient agitation and increased volume of secretions. A significant number of both groups were unaware of the existence of suctioning and/or NSI protocols in ICU. Some reported suctioning routinely rather as required.
(Sodhi, Shrivastava and Singla, 2014)	Assess the impact of a dedicated specialized tracheostomy care nurse program on tracheostomy care outcomes and incidence of tracheostomy related complications.	Correlational Cohort Study	During the pre intervention period, of 82% tracheostomized patient, 34.15% had complications including 24.39% readmissions to the ICU. During the post intervention period, 107 patients had a tracheostomy of which 6.54% had complications with only 1.87% readmissions which was significant (p< 0.05). Decannulations non significantly increased during the post intervention period (25 vs 16%, p>0.05). the average length of hospital stay (ALOS) decreased from 36 to 27 days (p<0.05).
(Mcgrath et al., 2013) United Kingdom	Use local trust’s critical incident reporting systems to ascertain whether the implementation of the NTSP influenced the nature and severity of harm in tracheostomy related incidents.	Retrospective uncontrolled case method	Hospitals continue to report airway related critical incidents, reflecting the high risk nature of this cohort of patients. 287 retrospective uncontrolled case series were analysed before and after introduction. Incidents in which patient harm occurred were reduced from to 82%  to 57% (p<0.0001) with a relative risk reduction of 0.65 in the monthly rates of such incidents.
(Hoseini et al., 2018)	Determine the complications and their underlying causes in patients admitted to the intensive care unit. (ICU)	Descriptive analytical study	the highest percentage of units (21.5%) experienced one complication, 19.6% two complications and 5.6% had no complication and 0.9% of the units showed most complications (11). The most common complications were infections and redness (46.7%), swelling (43.9%) and bleeding and air leakage from tracheostomy (33.6%) respectively. Patients with diabetes and high blood pressure, patients with surgical tracheostomy and patients with ischemic heart disease, experienced the most complications respectively. The quality of nursing care was determined 66.4% in average grade.

 

no	Strengths	Limitations
1 De Pinto et al., (2015)	·         Type of study adult quantitative qualitative ·         duration ·         Gained consent ethics committee ·         Effective number of participants ·         Relevant to report	·         Type of  study ·         Observations on night shifts ·         Lack of evidence in using 0.9% saline solution in endotracheal suctioning ·         No staff per patient ratio
2 Rocio de Faria Gaspar et al., (2015)	·         type of study ·         gained consent ethics committee ·         duration ·         relevant to report	·         type of study ·         population (51) %? ·         No staff per patient ratio to assess time for communication
3(Dhaliwal, Choudhary and Sharma, 2018)  India	·         Gained consent ethics committee ·         Related to subject	·         No dissemination plan ·         No strategies or application to practice ·         Don’t know if adult nurses or children as well. ·         Questionnaire and checklist not included ·         No limitations or strengths ·         No duration ? ·         No percentage of staff participation
4 Qadir, M. B. (2018) India	·         type of study ·         gained consent ethics committee ·         duration relevant to report	·         Type of study (pre experimental) ·         Doesn’t say adult? Included midwifery candidates
5 Beuret et al., (2013) France	·         type of study ·         gained consent ethics committee ·         duration ·         relevant to report	·         Not approved by ethical committee or gained consent mentioned ·         Size of sample
6 Abdelazeem, Fashafsheh and Fadllalah, (2019) Sudan	·         No ethical consideration. Voluntary /approval by authorities ·         Type o study quasi experimental	·         small number of participants (n=50) ·         it investigates ETT as well.
7 (Leddy and Wilkinson, 2015) Canada	·         research ethics board approval	·         Only 180 participants 80 RNs and 80 RRTs.
8 (Sodhi, Shrivastava and Singla, 2014)
9 (Mcgrath et al., 2013)	·         Approval was sought from the trust’s clinical governance leads. ethical approval was not required. ·         Large sample	·         Weak evidence due to type of study
10 (Hoseini et al., 2018)

       

 Appendix  1:                 

#	Query	Limiters/expanders	Last run via	Results
S1	tracheostomy care OR management AND complications OR incidents OR accidents AND strategies OR ways AND nurs* AND acute care	Expanders  Apply equivalent subjects Search modes  Boolean/Phrase	Interface  EBSCOhost Research Databases Search Screen  Advanced Search Database  CINAHL	122,042
S2	tracheostomy care OR management AND complications OR incidents OR accidents AND strategies OR ways AND nurs* AND acute care	Limiters  Linked Full Text Expanders  Apply equivalent subjects Search modes  Boolean/Phrase	Interface  EBSCOhost Research Databases Search Screen  Advanced Search Database  CINAHL	14,367
S3	tracheostomy care OR management AND complications OR incidents OR accidents AND strategies OR ways AND nurs* AND acute care	Limiters  Linked Full Text; Abstract Available Expanders  Apply equivalent subjects Search modes  Boolean/Phrase	Interface  EBSCOhost Research Databases Search Screen  Advanced Search Database  CINAHL	12,723
S4	tracheostomy care OR management AND complications OR incidents OR accidents AND strategies OR ways AND nurs* AND acute care	Limiters  Linked Full Text; Abstract Available; Published Date: 20100101 20201231 Expanders  Apply equivalent subjects Search modes  Boolean/Phrase	Interface  EBSCOhost Research Databases Search Screen  Advanced Search Database  CINAHL	10,698
S5	tracheostomy care OR management AND complications OR incidents OR accidents AND strategies OR ways AND nurs* AND acute care	Limiters  Linked Full Text; References Available; Abstract Available; Published Date: 20100101 20201231 Expanders  Apply equivalent subjects Search modes  Boolean/Phrase	Interface  EBSCOhost Research Databases Search Screen  Advanced Search Database  CINAHL	61
S6	tracheostomy care OR management AND complications OR incidents OR accidents AND strategies OR ways AND nurs* AND acute care	Limiters  Linked Full Text; References Available; Abstract Available; Published Date: 20100101 20201231 Expanders  Apply equivalent subjects Narrow by Subject Age:  all adult Search modes  Boolean/Phrase	Interface  EBSCOhost Research Databases Search Screen  Advanced Search Database  CINAHL	20