Safety, efficiency, and cost-effectiveness of a multidisciplinary percutaneous tracheostomy program

A 5-Year Review of a Tracheostomy Quality Improvement Initiative: Reducing Adverse Event Frequency and Severity

OBJECTIVE

The number of tracheostomies performed annually in resource-rich countries is estimated at 250,000. While an essential procedure, approximately 20% to 30% of patients will experience at least 1 tracheostomy-related adverse event. Within tracheostomy care and across wider health care environments, quality improvement (QI) programs have been shown to reduce patient harm and improve outcomes. Herein we report on a 5-year long, tracheostomy QI initiative aimed at improving patient experience and reducing the frequency and severity of adverse events.

METHODS

A 5-year (ongoing) QI initiative led by the Cardiff and Vale University Health Board tracheostomy team, within a tertiary, 1000-bedded hospital in South Wales, United Kingdom. The QI initiative has focused on 3 main themes: (1) Education and training; (2) Clinical oversight and decision making; and (3) improved data collection. Data were collected from existing tracheostomy databases.

RESULTS

Over the past 5 years, we have observed a sustained reduction in both the frequency and severity of adverse events, with less than 1 patient per 100 experiencing a moderate or severe adverse event. This has resulted in improvements in patient experience and a cost reduction of £GBP364,726 per annum.

DISCUSSION

Our 5-year ongoing tracheostomy QI initiative has resulted in improved outcomes with increased achievement of tracheostomy weaning markers and sustained reductions in both the frequency and severity of adverse events.

IMPLICATIONS FOR PRACTICE

A continuous focus on QI is associated with improved patient and service outcomes. These improvements can be spread and scaled to benefit more patients and organizations.

Improving Operating Room Efficiency in Otolaryngology-Head and Neck Surgery: A Scoping Review

OBJECTIVE

One minute of operating room (OR) time costs $36 to 37. However, ORs are notoriously inefficient. There is growing literature on improving OR efficiency, but no formal review of this topic within otolaryngology has been performed. This study reviews and synthesizes the current literature on improving OR efficiency within otolaryngology.

DATA SOURCES

MEDLINE, EMBASE, Web of Science, CINAHL, Cochrane Library, preprints.org, and medRxiv were searched on November 4, 2022.

REVIEW METHODS

Published English studies were included if they reported on metrics for improving OR efficiency within otolaryngology. There were no publication date restrictions. Articles were screened by 2 reviewers. Preferred Reporting Items for Systematic Reviews and Meta-analysis reporting for scoping reviews was followed.

RESULTS

The search yielded 9316 no-duplicate articles; 129 articles were included. Most of the studies reported on head and neck procedures (n = 52/129). The main tactics included surgical considerations: hemostatic devices, techniques, and team/simultaneous approaches; anesthetic considerations: local anesthetic and laryngeal mask airways; procedure location considerations: procedures outside of the OR and remote technologies; standardization: equipment, checklists, and personnel; scheduling considerations: use of machine learning for booking, considering patient/surgeon factors, and utilizing dedicated OR time/multidisciplinary teams for on-call cases.

CONCLUSION

The current literature brings to attention numerous strategies for improving OR efficiency within otolaryngology. Applying these strategies and implementing novel techniques to manage surgical cases may assist in offloading overloaded health care systems and improving access to care while facilitating patient safety and outcomes. Anticipated barriers to implementation include resistance to change, funding, and the current strain on health care systems and providers.

Pro-Con Debate: Should Critically Ill Patients Undergo Procedures at Bedside or in the Operating Room?

Nonoperating room anesthesia (NORA) is a fast-growing field in anesthesiology, wherein anesthesia care is provided for surgical procedures performed outside the main operating room (OR) pavilion. Advances in medical science and technology have led to an increasing number of procedures being moved out of the operating room to procedural suites. One such NORA location is the intensive care unit (ICU), where a growing number of urgent and emergent procedures are being performed on medically unstable patients. ICU-NORA allows medical care to be provided to patients who are too sick to tolerate transport between the ICU and the OR. However, offering the same, high-quality, and safe care in this setting may be challenging. It requires special planning and a thorough consideration of the presence of life-threatening comorbidities and location-specific and ergonomic barriers. In this Pro-Con commentary article, we discuss these special considerations and argue in favor of and against routinely performing procedures at the bedside in the ICU versus in the OR.

Does Cuff Design Impact Insertion and Removal Force of Tracheostomy Tubes? A Bench Model

INTRODUCTION

Percutaneous dilatational tracheostomy is a commonly performed procedure in intensive care units. Unrecognized tracheal ring fracture has been suggested as a possible factor for tracheal stenosis. The degree of tracheal compression relates to the amount of force required to cannulate the trachea. The objective of this study was to determine the force required to insert two types of tracheostomy tubes with different cuff designs.

MATERIALS AND METHODS

This bench model measured the insertion and removal force of two tracheostomy tubes; one with a barrel-shaped, high-volume, low-pressure cuff (traditional Shiley tracheostomy tube) and another with a taper-shaped, low-volume, low-pressure cuff (Shiley flexible tracheostomy tube). Three sizes of tracheostomy tubes either with a barrel- or taper-shaped cuff were tested (Jackson sizes 4, 6, and 10, corresponding to 6.5-, 7.5-, and 10-mm ISO sizes, respectively). A model representing the tissue that the tube traverses to enter the tracheal lumen was designed, and the tracheostomy tube was mounted on a universal testing machine to measure the force necessary to insert and remove the tube.

RESULTS

Across all tracheostomy tubes' sizes tested, significantly less force was required to insert the Shiley flexible tracheostomy tube compared to the traditional Shiley tracheostomy tube. Significantly less force was also required to remove the flexible tracheostomy tube compared to the traditional tracheostomy tube.

CONCLUSIONS

This model suggests that less force is required to insert the Shiley flexible tracheostomy tube, which could result in less tracheal compression. This may be because of the smaller taper-shaped cuff that, when deflated, occupies less volume compared to the barrel-shaped cuff. As a result, less tracheal injury may occur when using the Shiley flexible tracheostomy tube during percutaneous tracheostomy procedures.

Effectiveness of interprofessional tracheostomy teams: A systematic review

AIM(S)

To systematically locate, evaluate and synthesize evidence regarding effectiveness of interprofessional tracheostomy teams in increasing speaking valve use and decreasing time to speech and decannulation, adverse events, lengths of stay (intensive care unit (ICU) and hospital) and mortality. In addition, to evaluate facilitators and barriers to implementing an interprofessional tracheostomy team in hospital settings.

DESIGN

Systematic review using Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) and Johns Hopkins Nursing Evidence-Based Practice Model's guidance.

METHODS

Our clinical question: Do interprofessional tracheostomy teams increase speaking valve use and decrease time to speech and decannulation, adverse events, lengths of stay and mortality? Primary studies involving adult patients with a tracheostomy were included. Eligible studies were systematically reviewed by two reviewers and verified by another two reviewers.

DATA SOURCES

MEDLINE, CINAHL and EMBASE.

RESULTS

Fourteen studies met eligibility criteria; primarily pre-post intervention cohort studies. Percent increase in speaking valve use ranged 14%-275%; percent reduction in median days to speech ranged 33%-73% and median days to decannulation ranged 26%-32%; percent reduction in rate of adverse events ranged 32%-88%; percent reduction in median hospital length of stay days ranged 18-40 days; no significant change in overall ICU length of stay and mortality rates. Facilitators include team education, coverage, rounds, standardization, communication, lead personnel and automation, patient tracking; barrier is financial.

CONCLUSION

Patients with tracheostomy who received care from a dedicated interprofessional team showed improvements in several clinical outcomes.

IMPLICATIONS FOR PATIENT CARE

Additional high-quality evidence from rigorous, well-controlled and adequately powered studies are necessary, as are implementation strategies to promote broader adoption of interprofessional tracheostomy team strategies. Interprofessional tracheostomy teams are associated with improved safety and quality of care.

IMPACT

Evidence from review provides rationale for broader implementation of interprofessional tracheostomy teams.

REPORTING METHOD

PRISMA and Synthesis Without Meta-analysis (SWiM).

PATIENT/PUBLIC CONTRIBUTION

None.

Early tracheostomy after cardiac surgery improves intermediate- and long-term survival

OBJECTIVE

Complicated post-cardiac surgery course, can lead to both prolonged ICU stay and ventilation, and may require a tracheostomy. This study represents the single-center experience with post-cardiac surgery tracheostomy. The aim of this study was to assess the timing of tracheostomy as a risk factor for early, intermediate, and late mortality. The study's second aim was to assess the incidence of both superficial and deep sternal wound infections.

DESIGN

Retrospective study of prospectively collected data.

SETTING

Tertiary hospital.

PATIENTS

Patients were divided into 3 groups, according to the timing of tracheostomy; early (4-10 days); intermediate (11-20 days) and late (≥21 days).

INTERVENTIONS

None.

MAIN VARIABLES OF INTEREST

The primary outcomes were early, intermediate, and long-term mortality. The secondary outcome was the incidence of sternal wound infection.

RESULTS

During the 17-year study period, 12,782 patients underwent cardiac surgery, of whom 407 (3.18%) required postoperative tracheostomy. 147 (36.1%) had early, 195 (47.9%) intermediate, and 65 (16%) had a late tracheostomy. Early, 30-day, and in-hospital mortality was similar for all groups. However, patients, who underwent early- and intermediate tracheostomy, demonstrated statistically significant lower mortality after 1- and 5-year (42.8%; 57.4%; 64.6%; and 55.8%; 68.7%; 75.4%, respectively; P < .001). Cox model demonstrated age [1.025 (1.014-1.036)] and timing of tracheostomy [0.315 (0.159-0.757)] had significant impacts on mortality.

CONCLUSIONS

This study demonstrates a relationship between the timing of tracheostomy after cardiac surgery and mortality: early tracheostomy (within 4-10 days of mechanical ventilation) is associated with better intermediate- and long-term survival.

Updates in percutaneous tracheostomy and gastrostomy: should we strive for combined placement during one procedure?

PURPOSE OF REVIEW

Percutaneous tracheostomy and gastrostomy are minimally invasive procedures among the most common performed in intensive care units. Practices across centres vary considerably, and questions remain about the optimal timing, performance and postoperative care related to these procedures.

RECENT FINDINGS

The COVID-19 pandemic has triggered a reevaluation of the practice of percutaneous tracheostomy and gastrostomy in the ICU. Combined percutaneous tracheostomy and gastrostomy at the bedside has potential benefits, including improved nutrition, decreased exposure to anaesthetics, decreased patient transport and decreased hospital costs. Percutaneous ultrasound gastrostomy is a novel technique that eliminates the need for an endoscope that may allow intensivists to perform gastrostomy at the bedside.

SUMMARY

Multidisciplinary care is essential to the follow up of critically ill patients receiving tracheostomy and gastrostomy. Combined tracheostomy and gastrostomy has numerous potential benefits to patients and hospital systems. Interventional pulmonologists are uniquely qualified to perform both procedures and serve on a tracheostomy and gastrostomy team.

Pediatric Tracheostomy Outcomes After Development of a Multidisciplinary Airway Team: A Quality Improvement Initiative

Objectives

To analyze a multidisciplinary tracheostomy team's effect on length of stay and cost.

Methods

An airway management program using a balanced scorecard was created to track key performance measures. Interventions included weekly rounding, standardized placement, postoperative care, and caregiver education. Process measures included time to first education, speech-language pathology consultation rates, and pretracheostomy consultations. Outcome measures focused on the total length of stay, 30-day revisit rates after discharge, accidental decannulation rate, and standardized cost. Regression analysis was used to predict the program's effect on length of stay and total cost.

Results

In total, 239 children met inclusion. The mean time to first education class was reduced from 13.7 to 1.9 days (P < .001). The speech-language pathology consultation rate increased from 68% to 95% (P < .001), and the presurgical consultation rate with the tracheostomy team increased from 14% to 93% (P < .001). The length of stay decreased from 133 to 96 days (P = .006). Total costs were lower for short admissions but higher for prolonged admissions. Revisits within 30 days remained stable over time (18%).

Discussion

Establishing a multidisciplinary tracheostomy team results in improvements in quality metrics when caring for children with tracheostomies. Controlling for associated factors showed the mean length of stay decreased significantly in the first full year of program implementation. Cost analysis estimated significant reductions for tracheostomy patients spending less time in the hospital.

Implications for Practice

A airway management program can positively affect tracheostomy processes and outcomes.

Multidisciplinary care in surgery: Are team-based interventions cost-effective?

BACKGROUND

Multidisciplinary care has been shown to improve outcomes for patients, and interprofessional collaboration has been demonstrated to be beneficial for providers. In the field of surgery, although a large number of multidisciplinary care teams have been described, no study to date has examined whether or not these team-based interventions are generally cost-effective. This is the first systematic review to examine cost savings attributable to multidisciplinary care across all surgical fields.

METHODS

A comprehensive literature review of articles published on cost outcomes associated with multidisciplinary surgical teams was performed. Selected articles reported on cost outcomes directly attributable to a collaborative intervention. Cost savings were totaled on a per-patient basis. Each article was also reviewed to determine whether the authors ultimately recommended the team-based intervention described.

RESULTS

A total of 1421 articles were identified in the initial query, of which 43 met inclusion criteria. Thirty-nine studies (91%) reported multidisciplinary care to be cost effective, with an average cost savings among all studies of $5815 per patient. No significant differences in the amount of savings achieved were found between different intervention subtypes. All studies ultimately recommended (40) or gave mixed reviews (3) of multidisciplinary care, regardless of whether cost savings were achieved.

CONCLUSION

Multidisciplinary surgical care is beneficial not only in terms of patient and provider outcomes, but also in reference to its cost-effectiveness. Well-designed multidisciplinary teams tend to optimize perioperative care for all involved parties. Efforts to improve surgical care should employ multidisciplinary teams to promote both quality and cost-effective care.

Intensive Care Admission and Early Neuro-Rehabilitation. Lessons for COVID-19?

Coronavirus disease 2019 (COVID-19) requires admission to intensive care (ICU) for the management of acute respiratory distress syndrome in about 5% of cases. Although our understanding of COVID-19 is still incomplete, a growing body of evidence is indicating potential direct deleterious effects on the central and peripheral nervous systems. Indeed, complex and long-lasting physical, cognitive, and functional impairments have often been observed after COVID-19. Early (defined as during and immediately after ICU discharge) rehabilitative interventions are fundamental for reducing the neurological burden of a disease that already heavily affects lung function with pulmonary fibrosis as a possible long-term consequence. In addition, ameliorating neuromuscular weakness with early rehabilitation would improve the efficiency of respiratory function as respiratory muscle atrophy worsens lung capacity. This review briefly summarizes the polymorphic burden of COVID-19 and addresses possible early interventions that could minimize the neurological and systemic impact. In fact, the benefits of early multidisciplinary rehabilitation after an ICU stay have been shown to be advantageous in several clinical conditions making an early rehabilitative approach generalizable and desirable to physicians from a wide range of different specialties.

Use of Tracheostomy During the COVID-19 Pandemic: American College of Chest Physicians/American Association for Bronchology and Interventional Pulmonology/Association of Interventional Pulmonology Program Directors Expert Panel Report

Background

The role of tracheostomy during the coronavirus disease 2019 (COVID-19) pandemic remains unknown. The goal of this consensus statement is to examine the current evidence for performing tracheostomy in patients with respiratory failure from COVID-19 and offer guidance to physicians on the preparation, timing, and technique while minimizing the risk of infection to health care workers (HCWs).

Methods

A panel including intensivists and interventional pulmonologists from three professional societies representing 13 institutions with experience in managing patients with COVID-19 across a spectrum of health-care environments developed key clinical questions addressing specific topics on tracheostomy in COVID-19. A systematic review of the literature and an established modified Delphi consensus methodology were applied to provide a reliable evidence-based consensus statement and expert panel report.

Results

Eight key questions, corresponding to 14 decision points, were rated by the panel. The results were aggregated, resulting in eight main recommendations and five additional remarks intended to guide health-care providers in the decision-making process pertinent to tracheostomy in patients with COVID-19-related respiratory failure.

Conclusion

This panel suggests performing tracheostomy in patients expected to require prolonged mechanical ventilation. A specific timing of tracheostomy cannot be recommended. There is no evidence for routine repeat reverse transcription polymerase chain reaction testing in patients with confirmed COVID-19 evaluated for tracheostomy. To reduce the risk of infection in HCWs, we recommend performing the procedure using techniques that minimize aerosolization while wearing enhanced personal protective equipment. The recommendations presented in this statement may change as more experience is gained during this pandemic.

State of the Art: Interventional Pulmonology

Interventional pulmonology (IP) has evolved over the past decade from an obscure subspecialty in pulmonary medicine to a recognized discipline offering advanced consultative and procedural services to patients with thoracic malignancy, anatomic airway disease, and pleural disease. Innovative interventions are now also available for diseases not traditionally treated procedurally, such as asthma and emphysema. The IP field has established certification examinations and training standards for IP training programs in an effort to enhance training quality and ensure competency. Validating new technology and proving its cost-effectiveness and effect on patient outcomes present the biggest challenge to IP as the health-care environment marches toward value-based health care. High-quality research is now thriving in IP and promises to elevate its practice into patient-centric evidence-based care.

Outcomes of prolonged mechanical ventilation in patients who underwent bedside percutaneous dilatation tracheostomy in intermediate care units - A single center study

BACKGROUND

The number of chronic critical illness (CCI) patients requiring prolonged mechanical ventilation (PMV) is increasing worldwide, mandating health professionals to discuss interventions while considering disease trajectory. The aim of this study was to analyze the survival of CCI patients who underwent percutaneous dilatational tracheostomy (PDT) within intermediate care units.

METHODS

We carried out a retrospective study of all patients who underwent PDT in our intermediate care units from 2009 to 2015. Based on their survival statuses at different time points, patients were categorized into groups of survival at one week, one month, and one year following the procedure.

RESULTS

This study included 254 patients. The mean age was 77.7 (±11.8) years. Out of the 254 patients included, 213 patients (84.2%) were defined as nursing care dependent. In-hospital mortality was 38.2% (97 patients). Seven patients (2.7%) were discharged to their homes. Overall survival rates at one week, one month, and one year following PDT were 88.6%, 66.1%, and 29.5%, respectively. Upon multivariate analyses, higher creatinine levels and resuscitation prior to the procedure were associated with increased mortality rates at one week and one month following tracheostomy. Higher creatinine and low albumin levels were associated with increased mortality at one year following tracheostomy.

CONCLUSION

The prognosis of CCI patients in intermediate care units is generally poor. Identified risk factors for complications and survival should be presented to patients and their surrogates when discussing courses of action and future treatments.

Analyzing ICU Patient Room Environmental Quality Through Unoccupied, Normal, and Emergency Procedure Modes: An EQI Evaluation

BACKGROUND

There is increasing need to perform invasive surgical procedures in intensive care units (ICUs). Traditional ICUs differ from operating rooms (ORs) in several ways including air changes per hour (ACH) and pressurization. Increased ACH and positive pressurization of ORs intend to provide more aseptic environments for surgery. Development of procedure ready ICUs that transition through unoccupied, occupied, and procedure modes is one solution to improve environmental quality when performing surgery in ICUs. This study assessed the efficacy of two airflow control systems, variable air volume (VAV) and Venturi control, in preventing contaminants from entering ICU from adjacent corridors.

STUDY DESIGN

Controlled contaminants, sulfur hexafluoride (SF6) and baker's yeast (CFU/m³), were released in the corridor adjacent to the ICU. SF6 and CFU/m³ were detected inside the ICU at the patient bed during a dynamic simulation of code blue event. VAV and Venturi were compared as they cycled the room through unoccupied, occupied, and procedure modes.

RESULTS

VAV and Venturi showed significantly fewer CFU/m³ at the patient bed than corridor point of release (p < .05). Although not significant, Venturi cultured 14% fewer CFU/m³ than VAV at the patient bed. There was less SF6 detected at the patient bed with VAV and Venturi (p < .05). There was less SF6 detected at the patient bed with Venturi compared to VAV (p < .05). Venturi transitioned between modes faster than VAV (p < .05).

CONCLUSION

Using efficient mode transitioning systems in ICUs may be effective in creating a more aseptic environment that mimics that of the OR.

Outcome and survival following tracheostomy in patients ≥ 85 years old

PURPOSE

To evaluate percutaneous dilatational tracheostomy in patients ≥ 85 years old: its complication rate and possible risk factors. In addition, to assess prognostic factors for short, intermediate and long term survival following the procedure.

METHODS

A retrospective case-control study of 72 patients ≥ 85 years who received percutaneous dilatation tracheotomy (PTD), compared to a control group of younger patients (n = 182). Demographics, clinical and laboratory data were collected. Survival and risk for complications were analyzed.

RESULTS

The study group's mean age was 89 ± 4. Twelve patients had complications, three (4.2%) were major. No significant difference was found in overall complication rates between the groups. Cerebrovascular disease with neurologic deficits and pre-procedure albumin levels were significantly associated with complications. Survival rates did not differ in 1 week and 1 month following procedure between study and control group. There was a significant difference in the 1-year survival rates between the patients ≥ 85 years and the control groups (18.1% vs. 34.4%, p = 0.01, respectively). Congestive heart failure, a frailty score > 0.27 and failure to wean from a cannula were associated with reduced 1-year survival.

CONCLUSION

PTD is safe for patients ≥ 85 years. Complication risk factors and reduced survival should be discussed with patients and families before conducting tracheostomies.

LEVEL OF EVIDENCE

3b.

Multidisciplinary Tracheotomy Teams: An Analysis of Patient Outcomes and Resource Allocation

We sought to establish the effect of introducing a multidisciplinary tracheotomy management team (MDT). Tracheotomies are high-cost interventions with potentially devastating complications. Multidisciplinary teams have been introduced in many hospitals with the aim of reducing complications, however, data supporting them are lacking. There is currently insufficient evidence to conclude MDTs reduce length of hospital or intensive care unit (ICU) stay, and there is little information on cost analysis. A chart review identified patients who had a tracheotomy inserted at a major metropolitan teaching hospital with an acute spinal medicine service 2 years before and after the MDT was implemented. The primary outcome was time to decannulation. Other outcomes included tracheotomy complications, the proportion of patients decannulated, length of ICU and hospital stay, and admission cost. Our search identified 174 (78 prior and 96 post-MDT) patients. Baseline demographics were similar between groups. There was no difference in time to decannulation, the decannulation rate, or the length of hospital or ICU stay. Complication rates were low in both groups. There was an increase in the proportion of patients who received speaking valves and a reduction in cost of admission in a subgroup of patients who did not undergo head and neck surgery. There is insufficient evidence to support the widespread introduction of tracheotomy MDTs. Institutions considering introducing a tracheotomy team should carefully consider their case-mix, volume, and available resources as well as the structure and responsibilities of the team, and the timing of its activities within the working week. The potential benefits of MDTs including teaching of staff, and collaboration of teams should be acknowledged. Given the potentially significant implications for cost to the health system, a randomized trial is needed to guide policy in this area.

Percutaneous Dilational Tracheostomy

Tracheostomy tubes can be inserted surgically or percutaneously via percutaneous dilational tracheostomy (PDT). Tracheostomy is performed for upper airway obstruction, though more often to allow prolonged mechanical ventilation in place of endotracheal tubes. Preparation, performance, and postoperative management for PDT are best provided by a multidisciplinary team. Although PDT is a safe procedure in the hands of experienced operators, both early and late complications can arise. Caution must also be taken during early tracheostomy tube exchange given that immaturity of the stomal tract can risk loss of the airway.

Percutaneous Ultrasound Gastrostomy: A Novel Device and Bedside Procedure for Gastrostomy Tube Insertion Using Magnetic and Ultrasound Guidance

This paper describes a novel percutaneous ultrasound gastrostomy (PUG) procedure and the CoapTech point-of-care ultrasound magnet-aligned gastrostomy (PUMA-G) device, which were developed to allow the placement of gastrostomy tubes by physicians across a variety of specialties, using ultrasound equipment found in many nonspecialized medical locations while consuming fewer resources. The current practice for the placement of gastrostomy tubes requires highly specialized equipment and trained physicians, which can delay the performance of the procedure or make it inaccessible in some locations. The PUMA-G device consists of an orogastric catheter with a balloon that encloses a magnetic bar at its distal end and an external, handheld magnet. The orogastric tube is passed through the mouth or the nose and into the stomach. The external magnet is then used to maneuver the balloon to the desired location in the stomach, with feedback and guidance from real-time ultrasound visualization. The novelty of this approach is the use of magnets to create the static compressive force needed for coaptation, in which the stomach is pushed flush against the abdominal wall, allowing ultrasound visualization of the entire gastrostomy tract (skin to stomach), safe cutaneous puncture, and guidewire-assisted placement of the gastrostomy tube. The development of the PUMA-G device has been aided by benchtop and simulation testing in addition to canine and human cadaver studies. The PUMA-G device was used successfully in 29 of 30 cadaver tests, with the one failure attributed to operator error and not the device. Further testing in live patients will assess the safety of the procedure, the speed with which it can be completed, the cost savings, and other benefits the device might offer over the existing gastrostomy procedures.

Bedside percutaneous dilatational tracheostomy in patients outside the ICU: a single-center experience

PURPOSE

To assess the safety of medical-ward bedside percutaneous dilatational tracheostomy (GWB-PDT).

MATERIALS AND METHODS

A retrospective study of all patients who underwent elective GWB-PDT between 2009 and 2015. A joint otolaryngology-ICU team performed all GWB-PDTs. The patients were followed until decannulation, discharge or death. Complications were divided into early (within 24 h) and late, and into minor and major.

RESULTS

Two hundred and fifty six patients were included in the study. The mean age was 77.7 ± 11.8 Medical history included cardiac comorbidities (42.6%) and cerebrovascular accidents (34.4%). Overall, 48 patients (18.9%) had 60 complications, of which 70% (42/60) were minor (13 early; 29 late complications). Fifteen patients (5.9%) had major complications. Eight patients had early major complications (loss of airway - two patients [0.8%], pneumothorax - two patients [0.8%], resuscitation - one patient [0.4%], and a single patient (0.4%) died within 24 h following PDT). Two additional patients (0.8%) underwent conversion to an open tracheostomy. Seven patients had late complications (airway complications in six patients [2.3%] and major bleeding in a single patient [0.4%]). Of the seven patients with late major complications, three had two major complications. Half of the complications occurred by POD 3.

CONCLUSION

GWB-PDT is a feasible and safe solution for tracheostomies in general-ward ventilated patients.

Timing and Outcomes of Tracheostomy Performed by Pulmonary and/or Critical Care Physicians

BACKGROUND

Although pulmonary and/or critical care (P/CC) physicians perform percutaneous tracheostomy in mechanically ventilated patients, the trends, timing, and outcomes of this procedure have not been well described. This study aims to describe the trends, timing, and outcomes of this procedure.

METHODS

Using 5% medicare data, we retrospectively examined a cohort who had tracheostomy performed after initiation of mechanical ventilation during acute hospitalization to describe the timing of tracheostomy placement by pulmonary and/or critical care (P/CC) physicians and associated outcomes.

RESULTS

There were 4864 participants in the study cohort from 2007 to 2014. We examined the timing of tracheostomy (in days from initiation of mechanical ventilation), length of hospital stay, in-hospital death, and death within 30 days after hospital discharge. The percentage of tracheostomies performed by P/CC physicians increased significantly, from 7.2% in 2007 to 14.1% in 2014 (Cochran-Armitage test for trend, P = .001). Tracheostomies performed by P/CC physicians were more common in larger hospitals and major academic medical centers. After adjustment for baseline characteristics, the following parameters did not differ by provider: time to tracheostomy, length of hospital stay (days), in-hospital death, and death within 30 days after discharge. A tracheostomy was more likely to be performed by a P/CC physician at a larger (≥500 beds) hospital (adjusted odds ratio: 1.85, 95% confidence interval: 1.47-2.34).

CONCLUSIONS

Tracheostomies are increasingly performed by P/CC physicians with similar outcomes, likely related to patient selection.

Role of the multidisciplinary team in the care of the tracheostomy patient

Tracheostomies are used to provide artificial airways for increasingly complex patients for a variety of indications. Patients and their families are dependent on knowledgeable multidisciplinary staff, including medical, nursing, respiratory physiotherapy and speech and language therapy staff, dieticians and psychologists, from a wide range of specialty backgrounds. There is increasing evidence that coordinated tracheostomy multidisciplinary teams can influence the safety and quality of care for patients and their families. This article reviews the roles of these team members and highlights the potential for improvements in care.

Outcomes of Tracheostomy With Concomitant and Delayed Percutaneous Endoscopic Gastrostomy in the Neuroscience Critical Care Unit

BACKGROUND

In patients with severe neurologic conditions, percutaneous endoscopic gastrostomy (PEG) is typically performed either alone or with a tracheostomy. The characteristics and outcomes of patients receiving PEG concomitantly with a tracheostomy (CTPEG) and those receiving delayed PEG (DPEG) after a tracheostomy were compared.

METHODS

Retrospective cohort study in a 24-bed neuroscience critical care unit (NCCU) at a tertiary care hospital. Consecutive patients admitted to the NCCU from April 2007 to July 2013 who underwent percutaneous tracheostomy and gastrostomy by the percutaneous tracheostomy team were included and grouped according to the timing of PEG placement: CTPEG versus DPEG.

RESULTS

Of the 290 patients, 234 (81%) received CTPEG. Demographic and clinical characteristics were similar among the 2 groups except for a lower median (interquartile range [IQR]) body mass index (BMI; 27 [22.67-31.60] versus 30.8 [24.55-40.06], P = .017) and lower rate of acute respiratory distress syndrome (3.85% vs 10.71%, P = .048) in the CTPEG cohort. Furthermore, 59% of CTPEG cohort were neurology patients while 63% of DPEG were neurosurgery patients, P = .004. Primary outcomes showed shorter mean NCCU length of stay (LOS; 25 [12] vs 33 [17] days, P < .001) and median hospital LOS (32 [25-43] vs 37 [31-56] days, P = .002) for the CTPEG cohort. Secondary outcomes showed higher predischarge prealbumin levels (15.6 [7.75] vs 11.58 [5.41], P = .021) and lower median overall hospital cost (US$123 860.20 [US$99 024-US$168 713.40] vs US$159 633.50 [US$121 312-US$240 213.10], P = .0003) in the CTPEG group. Anatomic contraindications were the most common reason for DPEG (30%).

CONCLUSIONS

Among institutions with a tracheostomy team, the practice of tracheostomy with concomitant PEG placement may be considered as feasible as delayed PEG in carefully selected neurocritically ill patients with possible advantages of overall shorter NCCU and hospital LOS, higher predischarge prealbumin, and lower hospital costs. These findings may aid in decisions regarding the timing of PEG placement in the NCCU. Further prospective studies are warranted.

Evidence-based guides in tracheostomy use in critical patients

OBJECTIVES

Provide evidence based guidelines for tracheostomy in critically ill adult patients and identify areas needing further research.

METHODS

A task force composed of representatives of 10 member countries of the Pan-American and Iberic Federation of Societies of Critical and Intensive Therapy Medicine and of the Latin American Critical Care Trial Investigators Network developed recommendations based on the Grading of Recommendations Assessment, Development and Evaluation system.

RESULTS

The group identified 23 relevant questions among 87 issues that were initially identified. In the initial search, 333 relevant publications were identified of which 226 publications were chosen. The task force generated a total of 19 recommendations: 10 positive (1B=3, 2C=3, 2D=4) and 9 negative (1B=8, 2C=1). A recommendation was not possible in six questions.

CONCLUSION

Percutaneous techniques are associated with a lower risk of infections compared to surgical tracheostomy. Early tracheostomy only seems to reduce the duration of ventilator use but not the incidence of pneumonia, the length of stay, or the long-term mortality rate. The evidence does not support the use of routine bronchoscopy guidance or laryngeal masks during the procedure. Finally, proper prior training is as important or even a more significant factor in reducing complications than the technique used.

Fiber optic bronchoscopy-assisted percutaneous tracheostomy: a decade of experience at a university hospital

Objective

To evaluate the efficacy and safety of percutaneous tracheostomy by means of single-step dilation with fiber optic bronchoscopy assistance in critical care patients under mechanical ventilation.

Methods

Between the years 2004 and 2014, 512 patients with indication of tracheostomy according to clinical criteria, were prospectively and consecutively included in our study. One-third of them were high-risk patients. Demographic variables, APACHE II score, and days on mechanical ventilation prior to percutaneous tracheostomy were recorded. The efficacy of the procedure was evaluated according to an execution success rate and based on the necessity of switching to an open surgical technique. Safety was evaluated according to post-operative and operative complication rates.

Results

The mean age of the group was 64 ± 18 years (203 women and 309 males). The mean APACHE II score was 21 ± 3. Patients remained an average of 11 ± 3 days on mechanical ventilation before percutaneous tracheostomy was performed. All procedures were successfully completed without the need to switch to an open surgical technique. Eighteen patients (3.5%) presented procedure complications. Five patients experienced transient desaturation, 4 presented low blood pressure related to sedation, and 9 presented minor bleeding, but none required a transfusion. No serious complications or deaths associated with the procedure were recorded. Eleven patients (2.1%) presented post-operative complications. Seven presented minor and transitory bleeding of the percutaneous tracheostomy stoma, 2 suffered displacement of the tracheostomy cannula, and 2 developed a superficial infection of the stoma.

Conclusion

Percutaneous tracheostomy using the single-step dilation technique with fiber optic bronchoscopy assistance seems to be effective and safe in critically ill patients under mechanical ventilation when performed by experienced intensive care specialists using a standardized procedure.

Evidence-based guidelines for the use of tracheostomy in critically ill patients

OBJECTIVES

To provide evidence-based guidelines for tracheostomy in critically ill adult patients and identify areas needing further research.

METHODS

A taskforce composed of representatives of 10 member countries of the Pan-American and Iberic Federation of Societies of Critical and Intensive Therapy Medicine and of the Latin American Critical Care Trial Investigators Network developed recommendations based on the Grading of Recommendations Assessment, Development and Evaluation system.

RESULTS

The group identified 23 relevant questions among 87 issues that were initially identified. In the initial search, 333 relevant publications were identified, of which 226 publications were chosen. The taskforce generated a total of 19 recommendations, 10 positive (1B, 3; 2C, 3; 2D, 4) and 9 negative (1B, 8; 2C, 1). A recommendation was not possible in 6 questions.

CONCLUSIONS

Percutaneous techniques are associated with a lower risk of infections compared with surgical tracheostomy. Early tracheostomy only seems to reduce the duration of ventilator use but not the incidence of pneumonia, the length of stay, or the long-term mortality rate. The evidence does not support the use of routine bronchoscopy guidance or laryngeal masks during the procedure. Finally, proper prior training is as important or even a more significant factor in reducing complications than the technique used.

The Changing Role for Tracheostomy in Patients Requiring Mechanical Ventilation

Tracheostomy is performed in patients who require prolonged mechanical ventilation or have upper airway instability. Percutaneous tracheostomy with Ciaglia technique is commonly used and rivals the surgical approach. Percutaneous technique is associated with decreased risk of stomal inflammation, infection, and bleeding along with reduction in health resource utilization when performed at bedside. Bronchoscopy and ultrasound guidance improve the safety of percutaneous tracheostomy. Early tracheostomy decreases the need for sedation and intensive care unit stay but may be unnecessary in some patients who can be extubated later successfully. A multidisciplinary approach to tracheostomy care leads to improved outcomes.

Predicting the need for nonstandard tracheostomy tubes in critically ill patients

PURPOSE

Few guidelines exist regarding the selection of a particular type or size of tracheostomy tube. Although nonstandard tubes can be placed over the percutaneous kit dilator, clinicians often place standard tracheostomy tubes and change to nonstandard tubes only after problems arise. This practice risks early tracheostomy tube change, possible bleeding, or loss of the airway. We sought to identify predictors of nonstandard tracheostomy tubes.

MATERIALS AND METHODS

In this matched case-control study at an urban, academic, tertiary care medical center, we reviewed 1220 records of patients who received a tracheostomy. Seventy-seven patients received nonstandard tracheostomy tubes (cases), and 154 received standard tracheostomy tubes (controls).

RESULTS

Sex, endotracheal tube size, severity of illness, and computed tomography scan measurement of the distance from the trachea to the skin at the level of the superior aspect of the anterior clavicle were significant predictors of nonstandard tracheostomy tubes. Specifically, trachea-to-skin distance >4.4 cm and endotracheal tube sizes ≥8.0 were associated with nonstandard tracheostomy.

CONCLUSIONS

The findings suggest that clinicians should consider using nonstandard tracheostomy tubes as the first choice if the patient is male with an endotracheal tube size ≥8.0 and has a trachea-to-skin distance >4.4 cm on the computed tomography scan.

Medical economic impact of tracheotomy patients on a hospital system

BACKGROUND

Tracheotomy patients are a small portion of hospitalizations, but account for disproportionately high risk and costs. There are many complex decisions that go into the care of these patients, and practice variation is expected to be compounded in a health system. This study sought to characterize the medical economic impact of tracheotomy patients on the hospital system.

METHODS

A retrospective review of the health system's hospital billing software was performed for 2013, and pertinent outcomes measures were tabulated.

RESULTS

There were 829 tracheotomies performed in the health system of seven hospitals, with total costs of $128,883,865. Average length of stay was 36.74 days for principal procedures, and 43.36 days for tracheotomy as secondary procedures. Mortality was ∼ 18% overall, and re-admissions were 10.93% for primary, and 14.36% for secondary procedures. A fairly wide variation in each category among the different hospitals was observed.

CONCLUSIONS

There are potentially many factors that impact variations of care and outcomes in patients with tracheotomy. Due to their large economic impact and risks for morbidity and mortality, a formalized care pathway is warranted. Goals of the pathway should include understanding medical decisions surrounding these complex patients, monitoring pertinent outcomes, reducing practice variation, and improving the efficiency of compassionate care.

Developing a percutaneous dilatational tracheostomy service by medical intensivists: experience at one academic institution

PURPOSE

Percutaneous dilatational tracheostomy (PDT) is increasingly becoming the preferred method, compared with open surgical tracheostomy, for patients requiring chronic ventilatory assistance. Little is known regarding the process involved to incorporate PDT as a standard service in the medical intensive care unit. In this report, we describe our experience developing a "PDT service" led by medical intensivists.

MATERIALS AND METHODS

With support from our leadership and surgical colleagues, we developed a credentialing and training process for medical intensivists, formulated a bedside team to perform PDT, refined our technique, and maintained a patient data registry for quality improvement.

RESULTS

To date, our service includes 4 medical intensivists with PDT privileges. Over a 4-year period, we performed 171 PDTs for patients in the medical intensive care unit after 12.1 ± 8.2 days of mechanical ventilation. Our procedure-related complication rates are similar to other reports. No patient required emergent open surgical tracheostomy, and there were no deaths related to PDT. We required minimal to no backup support from our surgical colleagues in performing PDT.

CONCLUSIONS

We successfully developed a medical intensivist-driven PDT service, sharing our unique successes and challenges, to facilitate the care of our patients requiring prolonged ventilator support.

Indications, Hospital Course, and Complexity of Patients Undergoing Tracheostomy at a Tertiary Care Pediatric Hospital

OBJECTIVE

The purpose of this study was to review inpatients undergoing tracheostomies at a tertiary care pediatric hospital in a 24-month period and to identify the indications, comorbidities, hospital course, patient complexity, and predischarge planning for tracheostomy care. The goal was to analyze these factors to highlight potential areas for improvement.

STUDY DESIGN

Case series with chart review.

SETTING

Tertiary care pediatric hospital.

SUBJECTS

Ninety-five inpatients at Boston Children's Hospital requiring a primary or revision tracheostomy during the 24-month period encompassing 2010 to 2011.

METHODS

Inpatients undergoing tracheostomy during the study period were identified using 2 different databases: the Boston Children's Hospital Department of Otolaryngology and Communication Enhancement database and institution-specific information from the Child Health Corporation of America's Pediatric Health Information System (PHIS). We extracted the specified metrics from the inpatient charts.

RESULTS

Patients undergoing tracheostomy are complex, with an average of 3.4 comorbidities and 13.6 services involved in their care. The tracheostomy was mentioned in 97.9% of physician and 69.5% of nurse discharge notes, and 42.5% of physician discharge notes contained a plan or appointment for follow-up. Of the patients, 33.7% were discharged home (27.3% of the nonanatomic group and 52.4% of the anatomic group). Overall, 8.4% of tracheostomy patients died before discharge.

CONCLUSION

The complexity of pediatric tracheostomy patients presents challenges and opportunities for optimizing quality of care for these children. Future directions include the introduction and assessment of multidisciplinary tracheostomy care teams, tracheostomy nurse specialists, and tracheostomy care plans in the pediatric setting.

Utilization of a standardized tracheostomy capping and decannulation protocol to improve patient safety

OBJECTIVES/HYPOTHESIS

To develop and assess the feasibility of a new standardized protocol to guide tracheostomy decannulation.

STUDY DESIGN

Descriptive review of quality improvement project.

METHODS

A quality improvement project was conducted in the inpatient setting of a tertiary urban academic hospital. Adult patients who had received a tracheostomy and for whom the indication for tracheostomy had resolved were included. A multidisciplinary task force reviewed input from clinicians caring for tracheostomy patients and developed a protocol for screening, capping, and decannulation. The primary outcome measured was successful decannulation.

RESULTS

Fifty-seven patients were screened for a capping trial over a 12-month period; 54 were capped. Six patients were lost to follow-up. Fifty patients passed the capping trial, and all 50 were decannulated successfully. When decannulation was pursued in one patient who had twice failed the screening criteria and subsequent capping trials, the patient failed decannulation and ultimately required reintubation for the management of secretions. The screening tool had high sensitivity (90%) and positive predictive value (100%) for successful decannulation. Additionally, the number of reported patient safety concerns decreased from seven in the 6 months preceding implementation of the program to one report in the 6 months after implementation.

CONCLUSION

The new tracheostomy capping and decannulation protocol assisted in predicting both successful and failed decannulation. Although several patients failed certain capping criteria initially, the protocol stipulated modifications of care that enabled successful decannulation. The screening tool had high sensitivity and promoted communication, standardization of practice, and patient safety.

Early tracheostomy improves outcomes in severely injured children and adolescents

BACKGROUND

Early tracheostomy has been advocated for adult trauma patients to improve outcomes and resource utilization. We hypothesized that timing of tracheostomy for severely injured children would similarly impact outcomes.

METHODS

Injured children undergoing tracheostomy over a 10-year period (2002-2012) were reviewed. Early tracheostomy was defined as post-injury day ≤ 7. Data were compared using Student's t test, Pearson chi-squared test and Fisher exact test. Statistical significance was set at p<0.05 with 95% confidence intervals.

RESULTS

During the 10-year study period, 91 patients underwent tracheostomy following injury. Twenty-nine (32%) patients were < 12 years old; of these, 38% received early tracheostomy. Sixty-two (68%) patients were age 13 to 18; of these, 52% underwent early tracheostomy. Patients undergoing early tracheostomy had fewer ventilator days (p=0.003), ICU days (p=0.003), hospital days (p=0.046), and tracheal complications (p=0.03) compared to late tracheostomy. There was no difference in pneumonia (p=0.48) between early and late tracheostomy.

CONCLUSION

Children undergoing early tracheostomy had improved outcomes compared to those who underwent late tracheostomy. Early tracheostomy should be considered for the severely injured child.

SUMMARY

Early tracheostomy is advocated for adult trauma patients to improve patient comfort and resource utilization. In a review of 91 pediatric trauma patients undergoing tracheostomy, those undergoing tracheostomy on post-injury day ≤ 7 had fewer ventilator days, ICU days, hospital days, and tracheal complications compared to those undergoing tracheostomy after post-injury day 7.

Simulation Model for Tracheotomy Education for Primary Health-Care Providers

Objectives:

We performed this study to evaluate the competency of health-care providers managing patients with tracheotomies, and assess the need for, and efficacy of, a multidisciplinary educational program incorporating patient simulation.

Methods:

The prospective observational study included 87 subjects who manage patients with tracheotomies within a tertiary-care hospital. The subjects completed self-assessment questionnaires and objective multiple-choice tests before and after attending a comprehensive educational course using patient simulation. The outcome measurements included pre-course and post-course questionnaire and test scores, as well as observational data collected during recorded patient simulation sessions.

Results:

Before the education and simulation, the subjects reported an average comfort level of 3.3 on a 5-point Likert scale across 10 categories in the questionnaire, which improved to 4.4 after the training (p < 0.0001). The subjects’ mean scores improved from 56% on the pre-course test to 91% on the post-course test (p < 0.0001). The specific deficiencies observed during patient simulation scenarios included unfamiliarity with different tracheotomy tube types, misunderstanding of speaking valve physiology, and delayed recognition and treatment of a plugged or dislodged tracheotomy tube.

Conclusions:

There is a significant need for improved tracheotomy education among primary health-care providers. Incorporating patient simulation into a comprehensive tracheotomy educational program was effective in improving provider confidence, increasing provider knowledge, and teaching the skills necessary for managing patients with a tracheotomy.

New cost-effective treatment strategies for acute emergency situations

In an era of ever-increasing healthcare costs, new treatments must not only improve outcomes and quality of care but also be cost-effective. This is most challenging for emergency and critical care. Bigger and better has been the mantra of Western medical care for decades, leading to costlier but not necessarily better care. Recent advances focused on new implementation processes for evidence-based best practices such as checklists and bundles have transformed medical care. We outline recent advances in medical practice that have positively affected both the quality of care and its cost-effectiveness. Future medical care must be smarter and more effective if we are to meet the increasing demands of an aging patient population in the context of ever more limited resources.

The business of interventional pulmonology

Interventional pulmonologists are regularly asked to perform more complicated and advanced procedures, but reimbursement for the time, effort and skill involved in these procedures has not kept up with other procedural specialties. Further changes in funding and reimbursement are likely under the Affordable Care Act. Understanding and effectively using the current system of funding for interventional pulmonology practices are imperative as we adapt to changing medical needs, legislative mandates, and reimbursement policy. This article reviews the current landscape of insurance and reimbursement in health care and anticipates some changes that might be expected from implementation of the Affordable Care Act.