Give patients what they want: impact of tracheostomy quality improvement program on patients’ psychological wellbeing

Abstract

Tracheostomy placement is often a life-saving airway procedure, and to most patients, it is a new and unpleasant experience which can lead to anxiety and distress.1 Psychological distress may be compounded by a lack of communication, inconsistent or fragmented care, or care from poorly trained or prepared staff.2 Improving Tracheostomy Care (ITC), a 20-site UK quality improvement (QI) program, was set up to implement Global Tracheostomy Collaborative's resources into the UK NHS.3 We aimed to investigate the ITC's impact on patients' psychological wellbeing. Following ethical approval, diverse NHS Trusts were guided through three-phases of the QI program: baseline (0 months), implementation (12) and evaluation (24). Specific program elements addressed communication, vocalisation and staff training, hypothesized to reduce anxiety. The Hospital Anxiety and Depression Scale (HADS) was used to evaluate patients' psychological experiences. HADS consists of 14 questions, each scored 0-3, with seven questions each focussing separately on anxiety and depression. Total scores = 11 are 'cases'. The internal consistency (reliability) of HADS was evaluated by Cronbach's alpha. Summary scores and categorical cases were examined using Microsoft Excel and IBM SPSS 22.0, with group comparisons made using Fisher's exact test. Eleven sites contributed HADS questionnaires (142 at Baseline, 128 at implementation and 144 at evaluation phases). At baseline, 54.2% of patients were classified as anxious (35.9%) or borderline anxious (18.3%), with a significant drop to 37.4% by the end of the program (20.0% anxious, 17.4% borderline, p<0.01). This represents a 44.3% reduction in the number of patients reporting anxiety over the 2-year program. A similar pattern was observed for depression, falling significantly from 38.7% categorised as depressed at baseline to 18.3% at 24-months (52.7% reduction, p<0.01). Cronbach's alpha of 0.86 was generated for anxiety construct (373 complete cases), 0.83 for depression construct (363 complete cases) and 0.90 for all questions combined (358 complete cases). This represents good to excellent reliability for the HADS questionnaire in our setting. Our study demonstrated that following the ITC QI program, the prevalence of both anxiety and depression among tracheostomised patients reduced significantly. Anxieties around communication, vocalisation, information provision, consistency of care and staff education previously highlighted 2 were addressed by the ITC QI program which seem to have plausibly led to a reduction in psychological distress amongst tracheostomised patients. Funder: The Health Foundation, an independent charity committed to bringing about better health and health care for people in the UK References [1] McGrath BA, Wilkinson KA. BJA 2015; 115: 155-8. [2] McGrath BA, Lynch J, Bonvento B, et al. BMA QI Reports 2017; 6. [3] McGrath BA, Lynch J, Coe B, et al. Med Res Arch 2018; 6.Copyright © 2020