(0259) Uncovering Real-World Latent Safety Threats in Pediatric and Adult Tracheostomy Care Using In Situ Simulation

Introduction: Tracheostomy-associated complications and adverse events are prevalent in pediatric and adult patient populations. In situ simulation is a powerful quality improvement tool to identify latent safety threats (LSTs) that contribute to errors in tracheostomy care. By employing in situ simulation of a tracheostomy emergency scenario, our objective was to compare LSTs present in pediatric and adult patient care, and to explore potential areas for collaborative opportunities in quality improvement within both settings.

Methods: Multidisciplinary in situ tracheostomy emergency simulations were conducted in pediatric and adult intensive care and inpatient units within a single, tertiary academic center from November 2018 to December 2023. The simulation scenario consisted of either an obstructed or dislodged tracheostomy tube. LSTs were collected through systems-based structured debriefs, post-hoc video review, and real time scoring. Pediatric and adult LSTs were organized into knowledge gaps, equipment, communication, and infection control categories.

Results: 73 pediatric and 36 adult simulations were conducted. The most common category of LST in both pediatric and adult simulations was knowledge. Within this category, adult teams had an average of 3.6 LSTs per simulation (SD 1.6) while pediatric teams had an average of 1.2 LSTs per simulation (SD 1.1). The most prevalent knowledge gap among all teams was failure to maintain adequate ventilation throughout the scenario. Additionally, in the equipment LST category, lack of awareness of spare tracheostomy tube locations on the unit was observed in more pediatric teams (21%) compared to adult teams (6%).

Conclusions: The frequency of tracheostomy care-associated LSTs in both pediatric and adult patient care settings demonstrates the importance of systematic education and the potential opportunity for knowledge sharing and collaboration between our pediatric and adult airway committees. Future steps include an implementation science approach to understanding contextual variability and mitigating LSTs in both pediatric and adult settings.