McMaster Children’s Hospital’s Pediatric Complex Care Inpatient Unit opened in July 2016. Children with medical complexity, when admitted to hospital, are now cohorted in effort to improve patient experience, optimize care and enhance skill set of nurses/health care team. Tracheostomy patient’s rooms were quickly identified to be set-up inconsistently and therefore became an A3 on our Continuous Quality Improvement (CQI) board as an opportunity to develop a standard room set up to improve patient safety.

Current policies and alternative room set-ups, were explored and tested through Rapid Cycle Deliberate Practice simulation with healthcare providers caring for these children. Parents of children with tracheostomies were also invited to participate, in order to gain perspective through their lens.

Using 3 emergency tracheostomy care scenarios, factors were identified in access to emergency equipment causing delays in patient care. This was flagged as a significant safety issue. Historically emergency equipment was stored in a clear draw string bag. One parent designed a storage kit using a clear case with multiple compartments’ and provided the team a proto type to be tested in scenarios.

In simulations 41 issues were identified, 13 classified as impacting patient safety requiring immediate correction. As a result changes were made resulting in a positive impact on patient care and safety. Specifically a decrease in time to first responder locating and using of equipment was observed. This process led to a change in practice, standardization in tracheostomy room set-ups and ultimately an improvement in care and safety for children with tracheostomy.

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