Interdisciplinary Tracheostomy Management

Tracheostomized patients require the expertise of a team of healthcare professionals from different fields, making it difficult to get an integrated perspective of their needs.

However, there is growing evidence that interdisciplinary teams can significantly impact the safety and quality of tracheostomy care. This article examines the roles played by these multidisciplinary groups and shows how they can help provide optimal care for patients with tracheostomies.

Medical Errors

Medical errors are a serious problem in hospitals, where at least 44,000 people die annually due to preventable errors. These may include medication errors, surgical injuries and wrong-site surgeries, restraint-related deaths or injuries, falls, burns, and pressure ulcers as well as mistakes during communication or documentation processes.

Many of these issues can be linked to a lack of consistency in how care is delivered, particularly for tracheostomy patients. The Global Tracheostomy Collaborative (GTC) has identified quality improvement strategies that may address some of these issues.

To assess these interventions, the GTC ran a 3-year guided implementation program in 20 UK hospitals that represented both socioeconomic diversity within the National Health Service as well as geographical and operational variation. This included management-team-guided implementation of 18 interventions over three phases: baseline, implementation, and evaluation. Utilizing mixed methods interviewing, focus groups, Hospital Anxiety & Depression Scale questionnaires, patient-level databases, and appreciative inquiry techniques - we investigated process metrics, change barriers/enablers, and outcomes.

All sites implemented interventions at various rates, with varying implementation times. On average, it took 12 months to begin implementing substantial numbers of interventions across all sites. All sites made significant progress with an average of nine new interventions per site. At 6-monthly intervals, site representatives evaluated which interventions had been fully implemented based on their opinion of how well-implemented they appeared at that point; this information was aggregated to create an aggregate implementation score by site, intervention, and time.

The program was associated with significant reductions in ICU and hospital length of stay, time to first vocalization, first oral intake, anxiety and depression levels as well as the cost of care for all patients. These findings underscore the value of a dedicated, guided Quality Improvement initiative to enhance tracheostomy training care quality.

Length of Stay

The length of stay for patients with tracheostomy can be extensive and is determined by several factors, such as patient acuity and complexity, staffing levels, equipment accessibility and the ward environment. All these elements contribute to making tracheostomy management a challenging and frustrating experience for both patients and their families.

One major challenge is ensuring all bedside staff are knowledgeable about tracheostomy care basics and can identify common airway complications like tube obstruction or displacement. Despite these obstacles, research has demonstrated that collaboration among medical specialties can safely and effectively improve tracheostomy management.

Trach Trail, a standardized tracheostomy pathway, has been created with the goal of reducing patient length of stay through education and coordinated care protocols. Trach Trail includes a monthly training program for tracheostomy champions as well as written materials and experiential learning opportunities.

To assess Trach Trail’s effectiveness, we compared demographics, length of stay and care outcomes between patients enrolled in Trach Trail and a synchronous control group during tracheostomy surgery. Results revealed that patients in the Trach Trail group experienced more comprehensive tracheostomy care and fewer length-of-stay complications.

This study revealed that patient characteristics were strong predictors of mortality and length of hospital stay. Mortality rates were higher among those with cardiovascular disease, hematological/immunological co-morbidities, as well as musculoskeletal issues.

The GTC global database collected prospective data on over 5000 patients with tracheostomy, providing predictors of adverse events, mortality, and length of stay. These indicators were tied to patient characteristics, coexisting conditions, risk factors, and context.

This data is an invaluable asset for evaluating and improving patient care. It lays the foundation for future risk-adjusted benchmarking as well as creating a learning community that drives continuous quality improvement efforts around the world.

The Trach Trail Project demonstrates how tracheostomy care can be improved safely and effectively through collaboration among all members of the management team. This includes tracheostomy nurses, respiratory therapists, as well as other nursing and support personnel. Together they form a unique fingerprint that can be used to implement effective tracheostomy care and improve patient outcomes.

Patient Outcomes

Studies have demonstrated that patient outcomes improve when tracheostomy management teams are coordinated. These teams typically consist of members from multiple specialties, such as otolaryngology, pulmonary medicine, intensive care medicine and respiratory therapy. Studies have reported improvements in time to decannulation, length of stay and frequency of adverse events among those with tracheostomies.

The Global Tracheostomy Collaborative (GTC) has created a learning community to disseminate information, foster best practices and connect teams caring for tracheostomized patients. After collecting prospective data on over 6500 patients, GTC has identified predictors of adverse events and mortality based on patient characteristics, comorbidities, risk factors and context.

Hettige et al reported that an interdisciplinary tracheostomy team could reduce critical events related to tracheostomy and increase the success rate of successful decannulation after ICU discharge. Furthermore, time to decannulation was significantly shorter among this group, while patients experienced less respiratory failure or hypoxemia compared with those receiving standard care alone.

Another study examined the effects of a monthly tracheostomy outpatient clinic on decannulation, ventilator weaning and communication among adult tracheostomy patients with recurrent admissions. Staffed by 3 otolaryngologists, 2 speech and language pathologists and a clinical nurse specialist, this clinic provided ongoing education about tracheostomy care protocols as well as tracking patient outcomes such as decannulation rates, oral intake rate and length of stay.

Tobin and Santamaria6 emphasize the necessity for a sustained commitment from members of a multidisciplinary tracheostomy team, as they must attend weekly rounds, provide care, and educate other hospital personnel. Each member should commit 4 hours per week towards this endeavor; however, this number may vary depending on the size and complexity of the practice.

Despite these difficulties, the GTC has successfully implemented a tracheostomy team-based model of care that significantly reduces tracheostomy-related critical events. Furthermore, it has reduced hospital and ICU stays, leading to improved patient outcomes.

Education

Education can be broadly defined as the process of imparting knowledge that people engage in. This could take place at various levels such as elementary schools, high schools, colleges or even medical or law schools.

Throughout history, societies have devised various methods for imparting knowledge to future generations. Early forms of education relied on observation and imitation in the real world - this approach is commonly referred to as “practical education.” With time, however, more formalized institutionalized methods replaced this approach and were now known simply as “schooling.”

Schools today strive to impart essential information and skills that are vital for society at large. It can also serve as a vital resource in teaching people how to solve complex problems encountered daily.

Doctors must know how to diagnose and treat patients with certain diseases, while nurses need an understanding of the anatomy and physiology of human organs.

Interdisciplinary teams across all clinical specialties that care for tracheostomized patients can play an invaluable role in improving outcomes for this population. Many hospitals have had success with setting up such teams, though it requires a significant amount of time and resources. Team members should commit to meeting regularly with their patients, educating other physicians and staff about the advantages of tracheostomy management, as well as creating standardized protocols of care.

Multidisciplinary teams can improve tracheostomy care quality by incorporating evidence-based interventions into daily clinical practice. Studies have demonstrated that these programs reduce pressure ulcers, pneumonia and other adverse events associated with tracheostomy while decreasing the length of stay and hospitalization rates. They also reduce the overall cost associated with tracheostomy care.