Authors: (including presenting author): :
Wong MN(1), Ng SW(1), Tsang LF(1), Leung KW(1), Yau J(2), Chu KL(2), Ip V(3)
Affiliation: :
(1)Nursing Services Division, United Christian Hospital, (2)Department of Anaesthesiology, Pain Medicine and Operating Services, United Christian Hospital, (3) KEC Quality & Safety Office
Keyword 1: :
Tracheostomy Emergency Management
Keyword 2: :
Cognitive Aids
Keyword 3: :
Documentation
Introduction: :
Tracheostomy emergencies, including life-threatening events such as bleeding, tube displacement, dislodgement, and occlusion, demand swift, coordinated, and error-free intervention. Cognitive aids serve as critical implementation tools, designed to safeguard against cognitive fixation and procedural omission by providing immediate, step-by-step guidance aligned with evidence-based practice algorithms. This project aimed to proactively enhance clinical safety by developing and embedding of real-time cognitive aids for emergency management, alongside a standardized patient-specific recording form, to support multidisciplinary teams in high-acuity situations.
Objectives: :
To design, implement, and evaluate a suite of cognitive aids for tracheostomy emergency management and a companion recording form, with the overarching goal of improving patient safety, team performance, and communication.
Methodology: :
Two primary cognitive aids were created for “Tracheostomy” and “End Tracheostomy” emergencies by multidisciplinary collaboration. Each aid features a structured algorithm guiding the clinician through logical crisis management: initial assessment of signs/symptoms, escalating calls for help, patient positioning, airway protection, oxygen/IV setup, specific interventions (addressing bleeding, dislodgement, displacement, occlusion), and urgent contacts. Designed for real-time use, the aids employ a clear visual layout, color-coded sections, and imperative language to facilitate rapid comprehension and decisive action under pressure. A corresponding at-a-glance recording form was developed to consolidate critical patient-specific tracheostomy details, promoting continuity of care and facilitating team communication. Implementation was supported by a comprehensive education programme across relevant clinical departments in November 2024.
Result & Outcome: :
A post-implementation evaluation in September 2025 surveyed 100 multidisciplinary clinicians (77 nurses, 23 doctors) from nine specialty areas. Quantitative survey data revealed strong endorsement: •Cognitive Aids: Over 88% of nurses and doctors agreed the aids were useful, easy to understand, and strengthened knowledge. Crucially, more than 87% affirmed they directly supported decision-making, procedural execution, enhanced confidence during actual emergencies, and fostered a cohesive, patient-centric team approach. •Recording Form: Over 82% found the form useful, with 87% of nurses and 91% of doctors agreeing it facilitated superior interdisciplinary communication. The overwhelmingly positive multidisciplinary validation demonstrates that this proactive safety system directly enhances patient safety and team performance. Constructive user feedback has been instrumental in outlining the next phase of development, focusing on enhanced usability during high-stakes scenarios through intuitive design refinements, bolded visual cues, and strategic reinforcement of training and access. This iterative approach, coupled with the initiative's standardized design and high user acceptance, solidifies its suitability for adoption as a corporate product, ensuring it will remain a scalable, frontline-trusted solution to standardize tracheostomy care across cluster hospitals and improve outcomes system-wide.
