Paediatric tracheostomy emergencies: simulation found three hidden safety threats per scenario

Design

Multi-institutional in-situ simulation quality-improvement study

Population

67 simulations across 11 children's hospitals

Primary outcome

Time to critical actions and latent safety threats

Effect

77% replaced tube within 5 min (median 188 s); median 3.2 safety threats per scenario

PEAK-II Trach, published 29 June in Otolaryngology–Head and Neck Surgery, ran 67 in-situ simulations of blocked or partially dislodged paediatric tracheostomy tubes on wards, intensive care units and emergency departments across 11 children's hospitals.

Seventy-seven per cent of teams replaced the tube with an identical one within five minutes (median 188 seconds). Teams identified a median of 3.2 latent safety threats per simulation, including attempts to ventilate through an occluded tube, unclear leadership, ambiguous roles and non-standard equipment locations. Teams with a respiratory therapist, and hospitals with a dedicated tracheostomy team, completed time-critical actions faster.

These threats are not visible until an emergency happens. Simulation in the actual ward, with the actual equipment, finds them first.

• Keep a spare tube of the same size and one size smaller at every tracheostomised child's bedside.
• Teach staff to suction and change a blocked tube rather than ventilate through it.
• Standardise the location of tracheostomy emergency equipment across units.
• Run in-situ simulations on wards that care for children with tracheostomies.

Why it matters

Nearly one team in four took more than five minutes to replace a tube in a child who cannot breathe.

Don't overread it

Simulation performance; it does not measure real patient outcomes.

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