Authors (including presenting author) :
Ng SW (1), Wong MN (1), Fung WM (1), Tsang WL (2), Leung KW (1) Tsang LF (1), Chu KL (3), Ip V (4)
Affiliation :
(1) Nursing Services Division, United Christian Hospital (2) Department of Surgery, United Christian Hospital (3) Department of Anaesthesiology, Pain Medicine and Operating Services, United Christian Hospital (4) KEC Quality & Safety Office
Keyword 1: :
Tracheostomy
Keyword 4: :
documentation
Keyword 5: :
communication
Introduction :
Tracheostomy patients represent a high-risk, low-volume population requiring specialized care. Historical serious adverse events in Hong Kong related to tracheostomy cases have been linked to inadequate handover, particularly during inter-departmental and inter-hospital transfers.
Objectives :
This project aimed to review the tracheostomy patient journey and compliance with a newly introduced structured handover document to improve communication and safety.
Methodology :
A quality improvement review was conducted by nurse specialists under the Quality & Safety Office workgroup of Kowloon East Cluster from July 1 to September 15, 2025. Using a standardized checklist, 23 tracheostomy cases at UCH were reviewed. The review focused on epidemiology, compliance with handover documentation across three sections (Part A: insertion; Part B: established tracheostomy; Part C: upon transfer), and the complexity of the patient journey.
Result & Outcome :
The cohort (mean age: 65 years, 70% male) tracheostomized primarily for vocal cord paralysis (13%), prolonged intubation (35%), or upper airway pathology (52%). The care pathway was complex, involving multiple handover points: an average of 1.7 transfers (range 0–6), 2.8 clinical units (1–6) across 2.4 departments (1–5), 1.7 hospitals (1–3), and 1.2 clusters (1–2). Compliance with the structured handover form varied: Part A (physician-completed record of tracheostomy insertion) was 72-83%. Part B (nurse-completed record on established tracheostomy) was 75%. Part C (nurse-completed record upon transfer) achieved 100%. The recommended emergency equipment and cognitive aids were universally accessible. The average total length of stay within the Hospital Authority was 97 days (UCH: 68 days). Discharge destinations were home (52%), other institutions (26%), or death (22%).
