Oral Themed Presentation
Background: : High-risk low-volume technology-dependent patients such as those with tracheostomies are infrequently cared for in many pediatric inpatient and intensive care settings. Inconsistencies in care exists because management of tracheostomies depend directly on the experience of the bedside registered nurses (RNs). These inconsistencies may result in suboptimal care and an increased risk of complications, leading to prolonged hospital stays, unnecessary ED presentations, or readmissions.
The Simulation-based Nursing Education Program was developed as part of the Simulation-based Discharge Program (SDP) at the NewYork-Presbyterian Weill Cornell Medical Center Komansky Children's Hospital to address variations in the bedside nursing care of tracheostomies.
Research Question: : Using simulation-based education (SBE), the primary objective was to improve RN’s comfort level with performing tracheostomy care. Our secondary objective was to improve tracheostomy care-related knowledge and skills.
Methodology: : Our study utilized a pre and post quasi-experimental design with SBE based on our tracheostomy education guide as the intervention on a representative sample of RNs at a tertiary children’s hospital over six months. An 18-items survey assessed RNs’ self-reported comfort and knowledge on a 5-level Likert scale. Demographics data and nursing experience were also part of the survey. A simulation-based skills assessment based on a 27-items checklist objectively assessed RNs’ skills according to the standard of care. Wilcoxon signed-rank test was used to analyse survey data and t-paired samples test for checklist results.
Results: : Our study collected baseline data on 68 RNs with a subgroup of 30 participating in the SBE session. Of the 68 RNs, 43% were aged 21-30 years and 24% were aged 31-40 years. Half (50%) reported working as an RN for only 1-5 years and 28% for 20+ years. A similar number of RNs from each of our inpatient units participated. In terms of experience, 22% reported they had not performed any tracheostomy skin care in the past year, compared to 26% for any tie change and 65% for any tube change. Most RNs “strongly agreed” with feeling comfortable (68%) and confident (68%) in performing suctioning, but less felt similarly comfortable (15%) or confident (24%) in performing a tracheostomy tube change. Only 25% and 27% of RNs were able meet all the suctioning and tube change checklist items respectively.
For the subgroup of 30 RNs who participated in an SBE session, there were significant improvement in self-reported comfort (p=0.046) and confidence (p=0.004) in performing suctioning pre- and post-SBE. The effect was stronger for self-reported comfort (p<0.001) and confidence (p<0.001) on performing a tracheostomy tube change after SBE. The skills assessment using a checklist found a significant improvement in total score post-SBE compared to pre-SBE (t=3.88, p<0.01). Before SBE, RNs were observed to meet the standard, on average, on only 67% of the checklist items. After SBE, they were able to perform, on average, 89% of the items.
Discussion/Conclusions: : This study demonstrated that simulation-based education is associated with a significant improvement in RNs’ comfort, confidence and skills in performing routine bedside tracheostomy care. From our baseline observation, while RNs reported feeling comfortable and confident in their skills, in practice, many do not meet the institutional standard of care. Incorporating SBE into nursing training may help standardize care for high-risk low-volume patients.