The tracheotomy procedure was first documented on Egyptian tablets in 3600 BC and has remained virtually unchanged. In 1909, Chevalier Jackson, MD, improved the surgical process, and the percutaneous dilatation procedure followed in the mid 20th century.1 At one time, tracheostomy tubes were made of either stainless steel or sterling silver; the tubes are now available in a variety of materials, diameters, shapes, lengths, and styles.
More than 100,000 tracheotomy procedures were performed in 2007, according to the Health Cost Utilization Project 2007 (HCUP), and they are among the most frequently performed procedures in the intensive care unit (ICU) today. The tracheostomized patient population ranks among the top three diagnostic related groups for cost and length of stay.2 Most tracheostomized patients will also require mechanical ventilation and are among the highest acuity levels. There are many reputed benefits of performing a tracheotomy, but the placement of an artificial airway is not without secondary complications caused by the alteration of normal upper airway physiology. Complications may include the inability to communicate, dysphagia or difficulty swallowing, and increased risk for aspiration and pulmonary infections. The focus of respiratory care practitioners (RCPs) is on maintaining adequate ventilation and weaning, although their responsibilities should not end there. Once the patient begins to wean from mechanical ventilation, the care plan should focus on reducing complications and length of stay. Respiratory care practitioners should broaden their scope and look forward to understand their place in a multidisciplinary team. Each member of the team should understand their role in:
- Providing an optimal means of communication
- Ensuring patient safety
- Providing the least restrictive means of nutrition and hydration and preventing aspiration
- Preventing infection
- Assisting in discharge planning
- Assuring continuity and quality care
- Addressing end of life issues
Heffner writes, “Defining best clinical practices for tracheostomy care presents a highly complex and nonlinear challenge.”3 Predicting outcomes of tracheostomized patients who are discharged from the ICU remains difficult, but studies by both Gerber et al and Martinez et al agree there is an increased risk of adverse events for all tracheostomized patients discharged to non-ICU floors.4,5 Studies have shown that care planning by multidisciplinary tracheostomy teams has reduced overall length of stay and has decreased decannulation time. Tobin and Santamaria reported that after the initiation of an intensivist-led tracheostomy team, there was a reduction in length of stay and decannulation time following ICU discharge.6 LeBlanc et al7 also reported reduced time to decannulation by 6.49 days and decreased overall length of stay by over 35 days in traumatic brain injury patients following the institution of a multidisciplinary team. Among the reasons cited for this change were better coordination of care and timely decision-making by the team. In addition to the team management, early intervention by a speech-language pathologist who can address cognition, communication (including initial evaluation for placement of speaking valves), and swallowing issues may also explain these outcomes.7 In 2009, Simpson et al reported a 49% decrease in mortality rate and a 14.3% reduction in mean length of stay 4 years after the implementation of a multidisciplinary tracheostomy team at the Medical University of South Carolina.8
Do we need more studies? In the words of John Heffner, “I am confident that tracheostomy teams that monitor their experiences and share their outcomes and process of care would outpace any controlled randomized trials … it is time now to Plan-Do-Study-Act.”9 The focus of this paper will therefore not be on if multidisciplinary teams improve outcomes, rather it will be on how to organize the team and how the team will function on a daily basis.
The Care Team
As previously mentioned, tracheotomies have been performed for thousands of years. Unfortunately, a core curriculum rarely covers tracheostomy care or caring for the tracheostomized patient population in medical, nursing, respiratory therapy, or speech-language pathology programs. Clinical knowledge must be obtained by making an effort to study the literature and/or mentoring with an experienced clinician. It is common to find a wide range of knowledge, skills, experiences, and confidence levels in clinicians across disciplines in a given department or facility caring for tracheostomized patients. The need for an organized group such as a tracheostomy management team is paramount to patient safety and continuity of care. Spremulli10 writes, “Standard processes and protocols can ensure that every patient receives the best possible most appropriate care every time. Without such processes and protocols in place, decisions are made by individual physicians’ preferences and habits rather than by evidence based practice. This can result in wide variations and discrepancies in care for which no one is accountable. Unfortunately, patients and families pay the price for this inconsistency.”
The importance and need for teams is well established. Most facilities have weaning teams, rapid response teams, and operating room teams, just to name a few. Such teams are composed of knowledgeable, well-trained, experienced clinicians who work together following established protocols. These teams are called upon to make quick decisions based on their knowledge and experience. To be effective, team members must be willing to cooperate toward a shared goal of improved patient care, which will improve outcomes and ultimately decrease costs. The success of the team depends on effective communication, and the team must be supported by the facility in which it will function. Each member should understand their role and responsibilities within the team, as well as those of the other team members. It is not necessary for each to be able to function in multiple roles; however, it is essential for each to understand how their roles are interdependent and, to that end, should hold each other accountable.
The Initial Plan
The multidisciplinary tracheostomy management team is a group of knowledgeable and experienced clinicians who follow tracheostomized patients throughout the hospital—from ICU to discharge. The team also serves a critical role in establishing protocols and serves as a resource for less experienced clinicians. Tobin and Santamaria6 noted that an additional 4 hours per week were required for members to participate in team rounds. Obviously, the time commitment will vary depending on the facility size, number of tracheostomized patients, and acuity level. A greater time commitment should be expected during the initial stages of team development and formation. Education and protocol standardization will be critical. Administration at the facility and department level must be supportive of these imperative investments in the team. The tracheostomized patient population is very costly and at high risk for adverse events. The investment of human resources to form and organize the team will be considerably less than the high cost of adverse outcomes that will arise with the tracheostomized population without the expertise of such a team.
Team members. In the beginning stages of team development, the following disciplines should be involved in the establishment of facility-wide protocols, education, and competencies: physician (likely an intensivist, pulmonologist, and/or otolaryngologist), speech-language pathologist, RCP, ICU nurse, occupational therapist, physical therapist, wound nurse, and case manager. The registered dietician and nursing assistant/technician may also be included in the planning stages and protocol development.
Establish the needs in the facility.
- How many tracheostomized patients are in the facility?
- Are bounce-backs to the ICU a common or expected occurrence?
- Interview patients and family members to determine their perception of care and allow them to share their experiences.
- Survey the staff: What is the reported knowledge, experience, and confidence levels in the care of the tracheostomized patient?
Review, revise, or develop protocols and policies. The protocols should include who is responsible for specific tasks and documentation standards. All staff should receive education on new processes, and their competency in the following components should be documented.
- When and how is the tracheotomy performed?
- How is the tracheostomy tube size and type determined?
- When are downsizing and tracheostomy tube changes performed?
- Decannulation algorithm
- Post-decannulation care
- Emergency procedures
- Emergency and routine equipment stocked in the patient’s room and/or in proximity including checklists posted
- Initiate consults for speech-language pathology to assess communication, cognition, and swallowing when clinically appropriate
- Cuff maintenance and cuff deflation
- Tracheostomy and oral care
- Patient transport throughout the facility
- Discharge planning
- Patient and family education
- Wound and stoma management
- Suctioning, oxygen, and humidity
- Staff competencies
- Documentation of team rounds
New Processes, Daily Team Rounds
The respiratory care practitioner, speech-language pathologist, and attending nurse comprise the daily core team. Other disciplines are consulted as needed. Team rounds should be performed daily to assess each tracheostomized patient, including those who require mechanical ventilation. A tool should be used to provide a methodical checklist with ample space for documentation and recommendations. The tool should be separate from the medical record and used by the team for continuous quality improvement. Pertinent information and recommendations are documented in the medical record as appropriate. The core team will report findings and recommendations to the attending physician. The daily rounds should include:
- Date of initial tracheostomy placement and date of present tracheostomy tube
- Tracheostomy tube size and type
- Presence of sutures and plan for removal
- Decannulation (planned or self)
- Cuff status (cuffless, inflated, deflated)
- Cuff pressure for inflated cuffs
- Trach security method
- Condition of tube, stoma, mouth, lips, and other tissue
- Ventilation, respiratory status, weaning plan, and progress
- Nutritional status
- Method of communication
- Cough and secretion management
- Occupational and physical therapy, speech-language pathology, wound care, and psychiatry liaison consults
- Presence of emergency equipment
- Subjective reports
- Findings and recommendations
- Issues of noncompliance or deficiencies noted
- Goals and plan
Continuing education, compliance, and competencies.
- Team members and health care practitioners caring for the tracheostomized patient are expected to keep skills current with documented competencies.
- Noncompliance issues and adverse events are documented and reported in a timely manner. Such events are used as teaching tools and to improve patient care, patient safety, and outcomes.
- Only those clinicians who have adequate knowledge, skills, and confidence are assigned to care for the tracheostomized patient. Clinicians are encouraged to report their lack of knowledge or confidence in caring for this patient population and are provided with support and education to improve clinical skills.
Maintain and review statistics for quality improvement.
- Pre- and post-team development statistics are compared. For example, unplanned decannulation, ICU bounce-backs, overall length of stay, etc.
- Interview patients and family members and compare subjective reports before and after the team implementation.
- Survey the staff to assess post-team implementation knowledge and confidence level of caring for the tracheostomized patient and use this information to revise how education is disseminated and competency is maintained.
Initiating and implementing a multidisciplinary tracheostomy team may seem like a daunting, labor-intensive task. This may be true in the beginning, but the time and effort invested in the development of the team will likely result in one of the most important quality assurance tools implemented within a facility. Reducing length of stay, decannulation time, and adverse events will have a significant impact on the cost of care. Moreover, a dedicated tracheostomy management team will ensure consistent quality care is provided and prevent tracheostomized patients from “falling through the cracks.”
The team can provide education and be the “go to” place when questions arise or practitioners need assistance or clarification of policies and procedures. Most important, the patient will ultimately benefit from consistent, proactive care. Timely interventions regarding communication, swallowing, decannulation, and rehabilitation while maintaining a safe environment will translate into an immeasurable impact on the quality of life of the tracheostomized patient.
Gail M. Sudderth, RRT, is a clinician and educator. Currently a full-time clinical specialist for Passy-Muir Inc, she shares her expertise and experience on the team management of tracheostomized patients and in-line ventilator use of the Passy-Muir® Valve with health care practitioners from all disciplines. For further information, contact [email protected]
- History of tracheal intubation. Available at: en.wikipedia.org/w/index.php?title=History_of_tracheal_intubation&oldid=442263963. Accessed September 1, 2011.
- HCUP Facts and Figures 2007. Table of Contents. Healthcare Cost and Utilization Project (HCUP). Available at: www.hcup-us.ahrq.gov/reports/factsandfigures/2007/TOC_2007.jsp. Accessed September 1, 2011
- Heffner JE. Toward leaner tracheostomy care: first observe, then improve. Respir Care. 2009;54:1635-7.
- Gerber DR, Chaaya A, Schorr CA, Markely D, Abourzgheib W. Can outcomes of ICU patients undergoing tracheostomy be predicted? Respir Care. 2009;54:1653-7.
- Martinez GH, Fernandez R, Casado MS. Tracheostomy tube in place at ICU discharge is associated with increased ward mortality. Respir Care. 2009;54:1644-52.
- Tobin AE, Santamaria JD. An intensivist-led tracheostomy review team is associated with shorter decannulation time and length of stay: a prospective cohort study. Crit Care. 2008;12:R48.
- LeBlanc J, Shultz JR, Seresova A, et al. Outcomes in tracheostomy patients with severe traumatic brain injury following implementation of a specialized multidisciplinary tracheostomy management team. J Head Trauma Rehabil. 2010;25:362-5.
- Simpson E, Gill D, Dickson A, Hays L, Ellis C. Benefits of a Tracheostomy Team: 4 Year Pre and Post Statistics. Presented at: 2008 ASHA Convention; November 20-22; Chicago.
- Heffner JE. Tracheostomy decannulation: marathons and finish lines. Crit Care. 2008;12:128.
- Spremulli M. Safer Care for Patients with Tracheostomy. Joint Commission Perspectives on Patient Safety. Available at: www.ingentaconnect.com/content/jcaho/jcpps/2010/00000010/00000004/art00001. Accessed September 23, 2011.