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Implementation of the TRACHE care bundle: improving safety in paediatric tracheostomy management
  1. Andrew Hall,
  2. James Bates,
  3. Sonna Ifeacho,
  4. Benjamin Hartley,
  5. David Albert,
  6. Christopher Jephson,
  7. Richard J Hewitt,
  8. Lesley Cochrane,
  9. Michelle Wyatt,
  10. Joanne Cooke
  1. Great Ormond Street Hospital, London, UK
  1. Correspondence to Andrew Hall, Great Ormond Street Hospital, Great Ormond Street, London WC1N 3JH, UK; andyhall07{at}

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Tracheostomy management has been the focus of a number of reviews in the UK over the last decade; however, paediatric patients have thus far been excluded from the analysis.1 ,2 Currently, there are no formally accepted national standards in the UK for paediatric tracheostomy management. Paediatric tracheostomies are associated with risks and complications in the order of two to three times higher than morbidity and mortality rates reported in adults. The mortality rate for a complication directly related to a paediatric tracheostomy is 0.7%.3 The majority of reported adverse incidents do not occur in the immediate postoperative period; late complications over a week from insertion are four times more common.4 Our aim was formalising standards of optimal paediatric tracheostomy management to minimise future morbidity.


Assessments of paediatric tracheostomy care were collected from 40 consecutive patients at a tertiary specialist paediatric institution in 2007. An initial multidisciplinary root cause analysis of morbidity associated with paediatric tracheostomy was carried out by the senior authors. Main areas of concern relating to tracheostomy care were identified, and from these, proposed minimum standards of best practice were developed. The recommendations were neatly encompassed in the mnemonic ‘TRACHE’ promoted as the recommended paediatric tracheostomy ‘care bundle’ (figure 1).

Figure 1

Promotional poster summarising ‘TRACHE’ care bundle approach.

This ‘TRACHE’ care bundle was communicated widely within our hospital using the following means:

  • Standardised ‘TRACHE’ approach teaching on the Trust Paediatric Immediate Life Support course and reoccurring biannual 1-day course on tracheostomy care.

  • Monthly tracheostomy simulation training programme, designed to teach competence through the TRACHE approach.

  • Clinical guidelines published on the hospital intranet.

Further assessments were performed at regular intervals by the tracheostomy nurse specialist and senior authors on ward nursing staff caring for …

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  • Contributors AH, JB, SI, LC, DA, BH and CJ were involved in the conception, drafting and review of the article. RJH, LC and MW were involved in the revision/analysis and approval of the article.

  • Competing interests The Great Ormond Street department developed with Marpac (a medical company specialising in medical device securement) modified tracheostomy ties to offer increased comfort and safety. These were implemented across the hospital from 2012.

  • Provenance and peer review Not commissioned; externally peer reviewed.