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Mills CS, Michou E, Bellamy MC, Siddle HJ, Brennan CA, Bojke C. Worth a try or a last resort: Healthcare professionals' experiences and opinions of above cuff vocalisation. INTERNATIONAL JOURNAL OF LANGUAGE & COMMUNICATION DISORDERS 2024; 59:932-946. [PMID: 37902100 DOI: 10.1111/1460-6984.12970] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/10/2023] [Accepted: 10/02/2023] [Indexed: 10/31/2023]
Abstract
BACKGROUND Above cuff vocalisation (ACV) involves the application of an external flow of air via the subglottic port of a tracheostomy. ACV can facilitate vocalisation and may improve swallowing and quality of life for patients with a tracheostomy. A recent systematic review highlighted the limited evidence available for the acceptability, effectiveness, safety or optimal implementation of ACV. AIMS To explore the experience of healthcare professionals (HCPs) using ACV and their perceptions of best practice. METHODS AND PROCEDURES Semi-structured interviews were conducted with a range of HCPs with experience using ACV. Topics included: experiences with ACV, management of ACV, opinions about ACV, impact of COVID-19, future directions for ACV and impact on length of stay. Interviews were conducted online from December 2020 to March 2022. Data were analysed using reflexive thematic analysis. OUTCOMES AND RESULTS Twenty-four HCPs were interviewed from seven countries and five professional groups. Four interconnected themes were developed: (1) moral distress amplifying the need to fix patients; (2) subjectivity and uncertainty leading to variations in practice and purpose; (3) knowledge and experience leading to control and caution; and (4) worth a try or a last resort. Theme four contained three sub-themes: (a) part of the toolbox; (b) useful but limited tool; and (c) following the patient's lead. The moral distress experienced by HCPs and their essential 'need to fix' patients seems to underpin the varied opinions of ACV. These opinions appear to be formed primarily on the basis of experience, because of the underlying subjectivities and uncertainties. As knowledge and experience with ACV increased, and adverse events were experienced, most HCPs became more cautious in their approach to ACV. CONCLUSIONS AND IMPLICATIONS More research is needed to reduce the subjectivities and uncertainties surrounding ACV. The implementation of standardised procedures, processes, and competencies may help to reduce the frequency of adverse events and support a more controlled approach. Widening the focus of the purpose of ACV to include swallowing may help to maximise the potential benefits. WHAT THIS PAPER ADDS What is already known on the subject There is limited and low-quality evidence for above cuff vocalisation (ACV) and clinical application and practice varies substantially. However, the reasons for this variation in practice and healthcare professionals' (HCPs') opinions of ACV were unclear. What this study adds HCPs' experiences and opinions of ACV vary as a result of the uncertainty and subjectivity surrounding ACV compounded by their personal experiences with it. A need for caution also appears to emerge as HCPs become more familiar and experienced with using ACV. What are the clinical implications of this work? Implementing standardised procedures, safety processes and competencies may help to compensate for the uncertainty and subjectivity surrounding ACV and may reduce the frequency of adverse events. Widening the focus of purpose of ACV, including swallowing in addition to communication, may increase the number of potential candidates and increase the potential benefits of ACV. Using multidisciplinary team (MDT) simulation training for ACV competency development might help to improve MDT working and ACV implementation.
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Affiliation(s)
- Claire S Mills
- Speech & Language Therapy Department, Leeds Teaching Hospitals NHS Trust, Leeds, UK
- Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
| | - Emilia Michou
- Centre for Gastrointestinal Sciences, The University of Manchester, Manchester, UK
- Speech Language Therapy Department, University of Patras, Patras, Greece
| | - Mark C Bellamy
- Leeds Institute of Medical Research at St James's, University of Leeds, Leeds, UK
| | - Heidi J Siddle
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, UK
| | - Cathy A Brennan
- Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
| | - Chris Bojke
- Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
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Kadri W, Halfpenny R, Whiten B, Mulkerrin S, Smith C. Dysphagia therapy in adults with a tracheostomy: A scoping review protocol. INTERNATIONAL JOURNAL OF LANGUAGE & COMMUNICATION DISORDERS 2024. [PMID: 38533839 DOI: 10.1111/1460-6984.13029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/31/2023] [Accepted: 03/09/2024] [Indexed: 03/28/2024]
Abstract
BACKGROUND Swallowing impairment (dysphagia) and tracheostomy coexist. Research in this area has often provided an overview of dysphagia management as a whole, but there is limited information pertaining to specific dysphagia therapy in the tracheostomy population. The aim of this scoping review is to provide a detailed exploration of the literature with regard to dysphagia therapeutic interventions in adults with a tracheostomy. The scoping review will describe current evidence and thus facilitate future discussions to guide clinical practice. METHODS A scoping review using the Joanna Briggs Institute and Preferred Reporting Items for Systematic Reviews guideline will be used. Ten electronic databases from inception to December 2023 and grey literature will be searched. From identified texts forward and backward citation chasing will be completed. Data extraction will compose of population demographics, aetiology and dysphagia therapy (type, design, dose and intensity). A number of citations and papers included in the scoping review will be presented visually. DISCUSSION The scoping review aims to expand upon the existing literature in this field. A detailed description of the evidence is required to facilitate clinical discussions and develop therapeutic protocols in a tracheostomised population. The results of this scoping review will support future research in dysphagia therapy and provide the basis for the development of best practice guidelines. WHAT THIS PAPER ADDS What is already known on this subject There is an abundance of evidence available regarding dysphagia therapy targeting impairments of the swallowing sequence in a variety of populations including stroke, head and neck cancer, progressive neurological conditions and critical illness. However, there is a paucity in the literature with regard to identifying dysphagia therapy for adults with a tracheostomy. What this study adds The study protocol aims to describe the methodological features that need to be extracted from existing studies to outline dysphagia therapy for adults with a tracheostomy. To the researchers' knowledge, this is the first study protocol to describe the methodological features of dysphagia therapy for people with a tracheostomy from the literature using a standardised approach (Joanna Briggs Institute and Preferred Reporting Items for Systematic Reviews and Meta-Analyses [PRISMA] guideline). This will ensure that the protocol is replicable for other researchers to use and demonstrates transparency in research methods. What are the clinical implications of this work? The development of a robust protocol is necessary in order to facilitate the scoping review to describe the current evidence and thus facilitate future discussions to guide clinical practice for speech and language therapists working with adults who have a tracheostomy and dysphagia. The publication of the scoping review protocol allows future clinical researchers in the area of tracheostomy and dysphagia management a blueprint with which to narrow their own research questions and it also enables replicability as the principles of good research practice dictate.
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Affiliation(s)
- Waiza Kadri
- Northwick Park Hospital, London North West University Healthcare NHS Trust, Harrow, England
- University College London (UCL), Division of Psychology and Language Sciences, London, England
| | - Rhiannon Halfpenny
- University College London (UCL), Division of Psychology and Language Sciences, London, England
- Great Ormond Street Hospital, London, England
| | - Breege Whiten
- University College London (UCL), Division of Psychology and Language Sciences, London, England
| | - Siofra Mulkerrin
- Addenbrookes Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, England
| | - Christina Smith
- University College London (UCL), Division of Psychology and Language Sciences, London, England
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Bjerrum K, Grove LMD, Mortensen SS, Fabricius J. Development and Effect Evaluation of an Action-Oriented Interdisciplinary Weaning Protocol for Cuffed Tracheostomy Tubes in Patients with Acquired Brain Injury. Healthcare (Basel) 2024; 12:480. [PMID: 38391855 PMCID: PMC10887695 DOI: 10.3390/healthcare12040480] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2023] [Revised: 02/08/2024] [Accepted: 02/09/2024] [Indexed: 02/24/2024] Open
Abstract
The objective was to develop an interdisciplinary weaning protocol (IWP) for patients with tracheostomy tubes due to acquired brain injury, and to effect evaluate implementation of the IWP on decannulation rates and weaning duration. An expert panel completed a literature review in 2018 to identify essential criteria in the weaning process. Based on consensus and availability in clinical practice, criteria for guiding the weaning process were included in the protocol. Using the IWP, dysphagia is graded as either severe, moderate, or mild. The weaning process is guided through a protocol which specified the daily duration of cuff deflation until decannulation, along with recommendations for treatment and rehabilitation interventions. Data from 337 patient records (161 before and 176 after implementation) were included for effect evaluation. Decannulation rate during hospitalization was unchanged at 91% vs. 90% before and after implementation (decannulation rate at 60 days was 68% vs. 74%). After implementation, the weaning duration had decreased compared to before implementation, hazard ratio 1.309 (95%CI: 1.013; 1.693), without any increased risk of tube-reinsertion or pneumonia. Furthermore, a tendency toward decreased length of stay was seen with median 102 days (IQR: 73-138) and median 90 days (IQR: 58-119) (p = 0.061) before and after implementation, respectively. Scientific debate on weaning protocols for tracheostomy tubes are encouraged.
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Affiliation(s)
- Katje Bjerrum
- Hammel Neurorehabilitation Centre and University Research Clinic, Department of Clinical Medicine, Aarhus University, 8450 Hammel, Denmark
| | - Linda-Maria Delgado Grove
- Hammel Neurorehabilitation Centre and University Research Clinic, Department of Clinical Medicine, Aarhus University, 8450 Hammel, Denmark
| | - Sine Secher Mortensen
- Hammel Neurorehabilitation Centre and University Research Clinic, Department of Clinical Medicine, Aarhus University, 8450 Hammel, Denmark
| | - Jesper Fabricius
- Hammel Neurorehabilitation Centre and University Research Clinic, Department of Clinical Medicine, Aarhus University, 8450 Hammel, Denmark
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Gajic S, Jacobs L, Gellentien C, Dubin RM, Ma K. Implementation of Above-Cuff Vocalization After Tracheostomy Is Feasible and Associated With Earlier Speech. AMERICAN JOURNAL OF SPEECH-LANGUAGE PATHOLOGY 2024; 33:51-56. [PMID: 38056485 DOI: 10.1044/2023_ajslp-23-00184] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/08/2023]
Abstract
PURPOSE The purpose of this study was to assess the feasibility of hospital-wide implementation of an above-cuff vocalization (ACV) protocol using ACV-capable tracheostomy tubes and its impact on patient speech in four intensive care unit (ICU) patient populations. METHOD This research was an observational pre-post study that was conducted over a 26-month period and included 323 critically ill adult ICU patients who underwent tracheostomy in a 365-bed academic tertiary care hospital. ACV was assessed using a protocol developed by a multidisciplinary team. Presence of speech was defined as at least one comprehensible word spoken during a speech-language pathologist evaluation. RESULTS Median time-to-speech was 13 days (interquartile range [IQR]: 8-20 days) before the intervention, compared to 9 days (IQR: 6-16 days) after the intervention (p = .0017). In the pre-intervention group, 101 out of 167 (60.5%) patients achieved speech within 60 days, compared to 83 out of 133 (62.4%) patients in the post-intervention group (p = .12). Of the 83 patients who achieved speech in the post-intervention group, 24 (28.9%) did so via ACV, with the remainder using a speaking valve or digital occlusion. Of those 24 patients, seven did not progress to using a speaking valve within the follow-up period. The median number of speech days gained by using ACV was 8 (IQR: 5-18 days). ACV was successful in facilitating speech in 24 out of 29 (82.8%) patients trialed, with no major complications. CONCLUSIONS Routine implementation of ACV after tracheostomy is feasible, safe, and associated with earlier speech in a diverse population of critically ill patients. ACV is an important method to facilitate communication in patients requiring mechanical ventilation with tracheostomy cuff inflation.
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Affiliation(s)
- Srdjan Gajic
- Division of Pulmonary, Allergy and Critical Care, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Lauren Jacobs
- Division of Speech Language Pathology, University of Pennsylvania Health System, Philadelphia
| | - Catherine Gellentien
- Division of Speech Language Pathology, University of Pennsylvania Health System, Philadelphia
| | - Randy M Dubin
- Division of Speech Language Pathology, University of Pennsylvania Health System, Philadelphia
| | - Kevin Ma
- Division of Pulmonary, Allergy and Critical Care, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia
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Freeman-Sanderson A, Hemsley B, Thompson K, Rogers KD, Knowles S, Hammond NE. Communication functions of adult patients admitted to intensive care: A multicentre, binational point prevalence study. Aust Crit Care 2023; 36:1084-1089. [PMID: 37198003 DOI: 10.1016/j.aucc.2023.01.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2023] [Accepted: 01/30/2023] [Indexed: 05/19/2023] Open
Abstract
BACKGROUND Patient communication is profoundly impacted during the intensive care unit (ICU) stay. While the impacts of altered communication are recognised, there is a paucity of data on the prevalence of communication attempts as well as modes utilised by patients and unit practices to manage communication function. OBJECTIVE The objectives of this study were to describe the prevalence and characteristics of observed communication attempts (nonverbal, verbal, and use of the staff call bell) in adult ICU patients and report on unit-level practices on communication management. METHODS A prospective, binational, cross-sectional point-prevalence study was conducted across 44 Australia and New Zealand adult ICUs. Data on communication attempts, modes, ICU-level guidelines, training, and resources were collected in June 2019. RESULTS Across 44 ICUs, 470 of 623 (75%) participants, including ventilated and nonventilated patients, were attempting to communicate on the study day. Of those invasively ventilated via an endotracheal tube for the entire study day, 42 of 172 (24%) were attempting to communicate and 39 of 45 (87%) patients with a tracheostomy were attempting to communicate. Across the cohort, the primary mode of communication was verbal communication, with 395 of 470 (84%) patients using speech; of those 371 of 395 (94%) spoke English and 24 of 395 (6%) spoke a language other than English. Participants attempting to communicate on the study day had a shorter length of stay (LOS), a mean difference of 3.8 days (95% confidence interval: 0.2; 5.1) shorter LOS in the ICU than those not attempting to communicate, and a mean difference 7.9 days (95% confidence interval: 3.1; 12.6) shorter LOS in hospital overall. Unit-level practices and supports were collected. Six of 44 (14%) ICUs had a protocol for communication management, training was available in 11 of 44 (25%) ICUs, and communication resources were available in 37 of 44 (84%) ICUs. CONCLUSION Three-quarters of patients admitted to the ICU were attempting to communicate on the study day, with multiple methods used to support verbal and nonverbal communication regardless of ventilation status. Guidance and training were absent from the majority of ICUs, indicating a need for development and implementation of policies, training, and resources.
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Affiliation(s)
- Amy Freeman-Sanderson
- Graduate School of Health, University of Technology, Sydney, NSW, Australia; Royal Prince Alfred Hospital, Sydney, NSW, Australia; Critical Care Division, The George Institute for Global Health, Faculty of Medicine, UNSW Sydney, Sydney, Australia; Australian and New Zealand Intensive Care Research Centre (ANZIC-RC), School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia.
| | - Bronwyn Hemsley
- Graduate School of Health, University of Technology, Sydney, NSW, Australia; The University of Newcastle, NSW, Australia
| | - Kelly Thompson
- Critical Care Division, The George Institute for Global Health, Faculty of Medicine, UNSW Sydney, Sydney, Australia; Nepean Blue Mountains Local Health District, Sydney, NSW, Australia
| | - Kris D Rogers
- Graduate School of Health, University of Technology, Sydney, NSW, Australia; Statistics Division, The George Institute for Global Health, Faculty of Medicine, UNSW Sydney, Sydney, Australia
| | - Serena Knowles
- Critical Care Division, The George Institute for Global Health, Faculty of Medicine, UNSW Sydney, Sydney, Australia
| | - Naomi E Hammond
- Critical Care Division, The George Institute for Global Health, Faculty of Medicine, UNSW Sydney, Sydney, Australia; Australian and New Zealand Intensive Care Research Centre (ANZIC-RC), School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia; Malcolm Fisher Department of Intensive Care, Royal North Shore Hospital, Sydney, Australia
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Zaga CJ, Chao C, Cameron T, Ross J, Rautela L, Rollinson TC, Marchingo E, Gregson PA, Warrillow S, Atkins NE, Howard ME. A Multidisciplinary Approach to Verbal Communication Interventions for Mechanically Ventilated Adults With a Tracheostomy. Respir Care 2023; 68:680-691. [PMID: 37076435 PMCID: PMC10171346 DOI: 10.4187/respcare.10511] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/21/2023]
Abstract
There is developing evidence with regard to the feasibility, utility, and safety of verbal communication interventions with patients with tracheostomy who are invasively ventilated. In the past 2 decades, research efforts have focused on establishing evidence for communication interventions, including introducing an intentional leak into the ventilatory circuit such as with a fenestrated tube, leak speech or ventilator-adjusted leak speech, the use of a one-way valve in-line with the ventilator, and above cuff vocalization. This narrative review describes the benefits of a multi-disciplinary approach, summarizes verbal communication interventions, and provides guidance on the indications, contraindications and considerations for patient selection. Our clinical procedures based on collective clinical experience are shared. A multidisciplinary team approach enables holistic management across acuity, ventilation, airway, communication, and swallowing parameters. This collaborative approach is recommended to maximize the chance of successful opportunities for patients to communicate safely and effectively.
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Affiliation(s)
- Charissa J Zaga
- Division of Allied Health, Department of Speech Pathology, Austin Health, Melbourne, Australia.
- Department of Audiology and Speech Pathology, University of Melbourne, Melbourne, Australia
- Institute for Breathing and Sleep, Austin Health, Melbourne, Australia
| | - Caroline Chao
- Institute for Breathing and Sleep, Austin Health, Melbourne, Australia
- Tracheostomy Review and Management Service, Austin Health, Melbourne, Australia
- Department of Respiratory and Sleep Medicine, Austin Health, Melbourne, Australia
- Division of Allied Health, Department of Physiotherapy, Austin Health, Melbourne, Australia
| | - Tanis Cameron
- Tracheostomy Review and Management Service, Austin Health, Melbourne, Australia
| | - Jacqueline Ross
- Division of Allied Health, Department of Physiotherapy, Austin Health, Melbourne, Australia
- Victorian Spinal Cord Service, Austin Health, Melbourne, Australia
| | - Linda Rautela
- Institute for Breathing and Sleep, Austin Health, Melbourne, Australia
- Department of Respiratory and Sleep Medicine, Austin Health, Melbourne, Australia
- Division of Allied Health, Department of Physiotherapy, Austin Health, Melbourne, Australia
| | - Thomas C Rollinson
- Institute for Breathing and Sleep, Austin Health, Melbourne, Australia
- Division of Allied Health, Department of Physiotherapy, Austin Health, Melbourne, Australia
- Department of Physiotherapy, University of Melbourne, Melbourne, Australia
| | - Emma Marchingo
- Clinical Nursing Education, Austin Health, Melbourne Australia
| | - Prudence A Gregson
- Tracheostomy Review and Management Service, Austin Health, Melbourne, Australia
| | - Stephen Warrillow
- Department of Intensive Care, Austin Health, Melbourne, Australia
- Department of Critical Care, Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne, Parkville, Victoria, Australia
| | - Naomi E Atkins
- Institute for Breathing and Sleep, Austin Health, Melbourne, Australia
- Tracheostomy Review and Management Service, Austin Health, Melbourne, Australia
- Department of Respiratory and Sleep Medicine, Austin Health, Melbourne, Australia
| | - Mark E Howard
- Institute for Breathing and Sleep, Austin Health, Melbourne, Australia
- Department of Respiratory and Sleep Medicine, Austin Health, Melbourne, Australia
- Department of Medicine, Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne, Parkville, Victoria, Australia
- School of Psychological Sciences and Turner Institute for Brain and Mental Health, Monash University, Clayton, Victoria, Australia
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Wallace S, McGowan S, Sutt AL. Benefits and options for voice restoration in mechanically ventilated intensive care unit patients with a tracheostomy. J Intensive Care Soc 2023; 24:104-111. [PMID: 36874291 PMCID: PMC9975806 DOI: 10.1177/17511437221113162] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Communication difficulties and their effects on patients who are mechanically ventilated are commonly reported and well described. The possibility of restoring speech for patients has obvious benefits, not only for meeting patient's immediate needs, but for helping them to re-engage in relationships and participate meaningfully in their recovery and rehabilitation. This opinion piece by a group of United Kingdom (UK) based Speech and Language Therapy experts working in critical care describes the various ways by which a patient's own voice can be restored. Common barriers to using different techniques and potential solutions are explored. We therefore hope that this will encourage intensive care unit (ICU) multi-disciplinary teams to advocate and facilitate early verbal communication in these patients.
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Affiliation(s)
- Sarah Wallace
- Department of Speech Voice and Swallowing, Wythenshawe Hospital, Manchester University NHS Foundation Trust, UK.,Manchester Academic Critical Care, Division of Infection, Immunity and Respiratory Medicine, School of Biological Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, UK
| | - Sue McGowan
- Therapy Services, National Hospital for Neurology and Neurosurgery, UK
| | - Anna-Liisa Sutt
- Critical Care Research Group, The Prince Charles Hospital, Brisbane, Australia.,Faculty of Medicine, University of Queensland, Brisbane, Australia.,Speech and Language Therapy, The Royal London Hospital, UK
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Karlsen MMW, Holm A, Kvande ME, Dreyer P, Tate JA, Heyn LG, Happ MB. Communication with mechanically ventilated patients in intensive care units: A concept analysis. J Adv Nurs 2023; 79:563-580. [PMID: 36443915 PMCID: PMC10099624 DOI: 10.1111/jan.15501] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2022] [Revised: 10/05/2022] [Accepted: 10/30/2022] [Indexed: 11/30/2022]
Abstract
AIMS The aim of this study was to perform a concept analysis of communication with mechanically ventilated patients in intensive care units and present a preliminary model for communication practice with these patients. DESIGN The Im & Meleis approach for concept analysis guided the study. SEARCH METHODS A literature search was performed in January 2022 in MEDLINE, Embase, CINAHL, psycINFO and Scopus, limited to 1998-2022. The main medical subject headings search terms used were artificial respiration, communication and critical care. The search resulted in 10,698 unique references. REVIEW METHODS After a blinded review by two authors, 108 references were included. Core concepts and terminology related to communication with mechanically ventilated patients were defined by content analytic methods. The concepts were then grouped into main categories after proposing relationships between them. As a final step, a preliminary model for communication with mechanically ventilated patients was developed. RESULTS We identified 39 different phrases to describe the mechanically ventilated patient. A total of 60 relevant concepts describing the communication with mechanically ventilated patients in intensive care were identified. The concepts were categorized into five main categories in a conceptual map. The preliminary model encompasses the unique communication practice when interacting with mechanically ventilated patients in intensive care units. CONCLUSION Highlighting different perspectives of the communication between mechanically ventilated patients and providers through concept analysis has contributed to a deeper understanding of the phenomena and the complexity of communication when the patients have limited possibilities to express themselves. IMPACT A clear definition of concepts is needed in the further development of guidelines and recommendations for patient care in intensive care, as well as in future research. The preliminary model will be tested further. PATIENT OR PUBLIC CONTRIBUTION No patient or public contribution, as this is a concept analysis of previous research.
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Affiliation(s)
| | - Anna Holm
- Department of Public Health, Aarhus University, Aarhus C, Denmark.,Department of Intensive Care, Aarhus University Hospital, Aarhus, Denmark
| | - Monica Evelyn Kvande
- Department for postgraduate studies, Lovisenberg Diaconal University College, Oslo, Norway
| | - Pia Dreyer
- Department of Public Health, Aarhus University, Aarhus C, Denmark.,Department of Intensive Care, Aarhus University Hospital, Aarhus, Denmark
| | - Judith Ann Tate
- Center of Healthy Aging, Self-Management and Complex Care, The Ohio State University College of Nursing, Columbus, Ohio, USA
| | - Lena Günterberg Heyn
- Center for Health and Technology, Faculty of Health and Social Sciences, University of South-Eastern Norway, Drammen, Norway
| | - Mary Beth Happ
- Center of Healthy Aging, Self-Management and Complex Care, The Ohio State University College of Nursing, Columbus, Ohio, USA
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Zaga CJ, Freeman-Sanderson A, Happ MB, Hoit JD, McGrath BA, Pandian V, Quraishi-Akhtar T, Rose L, Sutt AL, Tuinman PR, Wallace S, Bellomo R, Berney S, Vogel AP. Defining effective communication for critically ill patients with an artificial airway: An international multi-professional consensus. Intensive Crit Care Nurs 2023; 76:103393. [PMID: 36706499 DOI: 10.1016/j.iccn.2023.103393] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2022] [Revised: 01/10/2023] [Accepted: 01/16/2023] [Indexed: 01/27/2023]
Abstract
OBJECTIVES To define effective communication and identify its key elements specific to critically ill patients with an artificial airway. DESIGN A modified Consensus Development Panel methodology. SETTING International video-conferences. MAIN OUTCOME MEASURES Definition of effective communication and it's key elements. RESULTS Eight experts across four international regions and three professions agreed to form the Consensus Development Panel together with a Chair and one person with lived experience who reviewed the outputs prior to finalisation. "Communication for critically ill adult patients with an artificial airway (endotracheal or tracheostomy tube) is defined as the degree in which a patient can initiate, impart, receive, and understand information, and can range from an ineffective to effective exchange of basic to complex information between the patient and the communication partner(s). Effective communication encompasses seven key elements including: comprehension, quantity, rate, effort, duration, independence, and satisfaction. In critically ill adults, communication is impacted by factors including medical, physical and cognitive status, delirium, fatigue, emotional status, the communication partner and the nature of the ICU environment (e.g., staff wearing personal protective equipment, noisy equipment, bright lights)." The panel agreed that communication occurs on a continuum from ineffective to effective for basic and complex communication. CONCLUSION We developed a definition and list of key elements which constitute effective communication for critically ill patients with an artificial airway. These can be used as the basis of standard terminology to support future research on the development of communication-related outcome measurement tools in this population. IMPLICATIONS FOR CLINICAL PRACTICE This study provides international multi-professional consensus terminology and a definition of effective communication which can be used in clinical practice. This standard definition and key elements of effective communication can be included in our clinical impressions of patient communication, and be used in discussion with the patient themselves, their families and the multi-professional team, to guide care, goal development and intervention.
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Affiliation(s)
- Charissa J Zaga
- Department of Speech Pathology, Division of Allied Health, Austin Health, Melbourne, Australia; Audiology and Speech Pathology, The University of Melbourne, Melbourne, Australia; Centre for Neuroscience of Speech, The University of Melbourne, Melbourne, Australia; Institute of Breathing and Sleep, Austin Health, Melbourne, Australia.
| | - Amy Freeman-Sanderson
- Graduate School of Health, University of Technology, Sydney, Australia; Royal Prince Alfred Hospital, Sydney, NSW, Australia; Critical Care Division, The George Institute for Global Health, Faculty of Medicine, UNSW Sydney, Sydney, Australia; Australian and New Zealand Intensive Care Research Centre (ANZIC-RC), School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Mary Beth Happ
- Center for Healthy Aging, Self-Management & Complex Care, The Ohio State University College of Nursing, United States of America
| | - Jeannette D Hoit
- Department of Speech, Language, and Hearing Sciences, University of Arizona, Tucson, AZ, United States of America
| | - Brendan A McGrath
- Manchester Academic Critical Care, Division of Infection, Immunity and Respiratory Medicine, School of Biological Sciences, Faculty of Biology, Medicine and Health, the University of Manchester, Manchester Academic Health Science Centre, United Kingdom; Department of Anaesthesia, Manchester University NHS Foundation Trust, Manchester, United Kingdom
| | - Vinciya Pandian
- Department of Nursing Faculty, Johns Hopkins University, Baltimore, MD, United States of America; Department of Physical Medicine and Rehabilitation, Johns Hopkins University, Baltimore, MD, United States of America
| | | | - Louise Rose
- Florence Nightingale Faculty of Nursing, Midwifery and Palliative Care, King's College London, London, United Kingdom
| | - Anna-Liisa Sutt
- Critical Care Research Group, The Prince Charles Hospital, Brisbane, Australia; Faculty of Medicine, University of Queensland, Brisbane, Australia
| | - Pieter R Tuinman
- Department of Intensive Care Medicine, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, Cardiovascular Sciences, The Netherlands
| | - Sarah Wallace
- Manchester Academic Critical Care, Division of Infection, Immunity and Respiratory Medicine, School of Biological Sciences, Faculty of Biology, Medicine and Health, the University of Manchester, Manchester Academic Health Science Centre, United Kingdom; Department of Speech Voice and Swallowing, Wythenshawe Hospital, Manchester University NHS Foundation Trust, United Kingdom
| | - Rinaldo Bellomo
- Department of Intensive Care, Austin Health, Melbourne, Australia; Department of Critical Care, University of Melbourne, Melbourne, Australia; Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, Australia; Department of Intensive Care, Royal Melbourne Hospital, Melbourne, Australia
| | - Sue Berney
- Department of Physiotherapy, Division of Allied Health, Austin Health, Melbourne, Australia; Physiotherapy, The University of Melbourne, Melbourne, Australia
| | - Adam P Vogel
- Audiology and Speech Pathology, The University of Melbourne, Melbourne, Australia; Centre for Neuroscience of Speech, The University of Melbourne, Melbourne, Australia; Department of Neurodegeneration, Hertie Institute for Clinical Brain Research, Tübingen, Germany; Redenlab, Melbourne, Australia
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Waydhas C, Deffner T, Gaschler R, Häske D, Hamsen U, Herbstreit F, Hierundar A, Kumpf O, Rohe G, Spiekermann A, Vonderhagen S, Waeschle RM, Riessen R. Sedation, sleep-promotion, and non-verbal and verbal communication techniques in critically ill intubated or tracheostomized patients: results of a survey. BMC Anesthesiol 2022; 22:384. [PMID: 36503427 PMCID: PMC9743767 DOI: 10.1186/s12871-022-01887-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2022] [Accepted: 10/25/2022] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND The aim of this survey was to describe, on a patient basis, the current practice of sedation, pharmacologic and non-pharmacologic measures to promote sleep and facilitation of communication in critically ill patients oro-tracheally intubated or tracheostomized. METHODS Cross-sectional online-survey evaluating sedation, sleep management and communication in oro-tracheally intubated (IP) or tracheostomized (TP) patients in intensive care units on a single point. RESULTS Eighty-one intensive care units including 447 patients (IP: n = 320, TP: n = 127) participated. A score of ≤ -2 on the Richmond Agitation Sedation Scale (RASS) was prevalent in 58.2% (IP 70.7% vs. TP 26.8%). RASS -1/0 was present in 32.2% (IP 25.9% vs. TP 55.1%) of subjects. Propofol and alpha-2-agonist were the predominant sedatives used while benzodiazepines were applied in only 12.1% of patients. For sleep management, ear plugs and sleeping masks were rarely used (< 7%). In half of the participating intensive care units a technique for phonation was used in the tracheostomized patients. CONCLUSIONS The overall rate of moderate and deep sedation appears high, particularly in oro-tracheally intubated patients. There is no uniform sleep management and ear plugs and sleeping masks are only rarely applied. The application of phonation techniques in tracheostomized patients during assisted breathing is low. More efforts should be directed towards improved guideline implementation. The enhancement of sleep promotion and communication techniques in non-verbal critically ill patients may be a focus of future guideline development.
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Affiliation(s)
- Christian Waydhas
- grid.5570.70000 0004 0490 981XRuhr-Universität-Bochum, Universitätsstrasse 150, 44801 Bochum, Germany ,grid.412471.50000 0004 0551 2937Klinik Und Poliklinik Für Chirurgie, Berufsgenossenschaftliches Universitätsklinikum Bergmannsheil Bochum, Bürkle-de-La-Camp-Platz 1, 44789 Bochum, Germany ,Present Address: Klinik Für Unfallchirurgie, Universitätsklinikum, Universitätsmedizin Essen, Hufelandstr. 55, 45147 Essen, Germany
| | - Teresa Deffner
- grid.275559.90000 0000 8517 6224Klinik Für Anästhesiologie Und Intensivmedizin, Universitätsklinikum Jena, Bachstrasse 18, 07743 Jena, Germany
| | - Robert Gaschler
- Fakultät Für Psychologie, Lehrgebiet Allgemeine Psychologie: Lernen, Motivation, Emotion, FernUniversität in Hagen, Universitätsstrasse 33, 58084 Hagen, Germany
| | - David Häske
- grid.411544.10000 0001 0196 8249Center for Public Health and Health Services Research, University Hospital Tübingen, Osianderstraße 5, 72076 Tübingen, Germany
| | - Uwe Hamsen
- grid.5570.70000 0004 0490 981XRuhr-Universität-Bochum, Universitätsstrasse 150, 44801 Bochum, Germany ,grid.412471.50000 0004 0551 2937Klinik Und Poliklinik Für Chirurgie, Berufsgenossenschaftliches Universitätsklinikum Bergmannsheil Bochum, Bürkle-de-La-Camp-Platz 1, 44789 Bochum, Germany
| | - Frank Herbstreit
- Klinik Für Anästhesiologie Und Intensivmedizin, Universitätsklinikum, Universitätsmedizin Essen, Hufelandstr. 55, 45147 Essen, Germany
| | - Anke Hierundar
- grid.413108.f0000 0000 9737 0454Klinik Für Anästhesiologie Und Intensivtherapie, Universitätsmedizin Rostock, Schillingallee 35, 18057 Rostock, Germany
| | - Oliver Kumpf
- grid.7468.d0000 0001 2248 7639Klinik Für Anästhesiologie Mit Schwerpunkt Operative Intensivmedizin, Campus Charité Mitte Und Campus Virchow-Klinikum, Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität Zu Berlin, and Berlin Institute of Health, Charitéplatz 1, 10117 Berlin, Germany
| | - Georg Rohe
- grid.5560.60000 0001 1009 3608University Clinic for Anaesthesiology / Intensive Care Medicine / Emergency Medicine / Pain Medicine, Klinikum Oldenburg, Medical Campus of the University Oldenburg), Rahel Straus - Str. 10, 26133 Oldenburg, Germany
| | - Aileen Spiekermann
- grid.5570.70000 0004 0490 981XRuhr-Universität-Bochum, Universitätsstrasse 150, 44801 Bochum, Germany ,grid.412471.50000 0004 0551 2937Klinik Und Poliklinik Für Chirurgie, Berufsgenossenschaftliches Universitätsklinikum Bergmannsheil Bochum, Bürkle-de-La-Camp-Platz 1, 44789 Bochum, Germany
| | - Sonja Vonderhagen
- Present Address: Klinik Für Unfallchirurgie, Universitätsklinikum, Universitätsmedizin Essen, Hufelandstr. 55, 45147 Essen, Germany
| | - Reiner M. Waeschle
- grid.411984.10000 0001 0482 5331Klinik Für Anästhesiologie, Universitätsmedizin Göttingen, Robert-Koch-Str. 40, 37099 Göttingen, Germany
| | - Reimer Riessen
- grid.411544.10000 0001 0196 8249Department Für Innere Medizin, Universitätsklinikum Tübingen, Otfried-Müller-Str. 10, 72076 Tübingen, Germany
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11
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Zaga CJ, Cigognini B, Vogel AP, Berney S. Outcome measurement tools for communication, voice and speech intelligibility in the ICU and their clinimetric properties: A systematic review. J Intensive Care Soc 2022; 23:459-472. [PMID: 36751341 PMCID: PMC9679912 DOI: 10.1177/1751143720963757] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Purpose To identify outcome measurement tools used to evaluate communication, voice and speech intelligibility in the mechanically ventilated ICU population. Secondly, to evaluate, synthesise and compare the clinimetric properties of the tools identified. Materials and methods A systematic review of articles was undertaken via electronic databases in two parts. Eligibility criteria for selection: part one - quantitative or mixed methods studies which assessed communication, voice or speech intelligibility; part two - studies which evaluated a clinimetric property for one of the tools identified in part one. Two independent reviewers assessed articles for inclusion and used the consensus-based standards for health status measurement instruments (COSMIN) risk of bias checklist. Results The part one search yielded five included studies comprised of eight outcome measurement tools. The part two search yielded 22 included studies comprised of nine tools. Few studies had adequate reliability and measurement error properties. No studies established responsiveness. A notable proportion of studies utilised tools that have no clinimetric properties. Conclusions There is a relatively small number of studies which have established clinimetric properties for outcome measurement tools that evaluate communication, voice and/or speech intelligibility, and a fewer number which have done so in the mechanically ventilated ICU population.
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Affiliation(s)
- Charissa J Zaga
- Department of Speech Pathology, Austin Health,
Melbourne, Australia,Centre for Neuroscience of Speech, University
of Melbourne, Melbourne, Australia,Charissa J Zaga, Austin Health, 145 Studley Road,
Heidelberg, Melbourne, Australia.
| | - Bridie Cigognini
- Department of Speech Pathology, Austin Health,
Melbourne, Australia
| | - Adam P Vogel
- Centre for Neuroscience of Speech, University
of Melbourne, Melbourne, Australia,Department of Neurodegeneration, Hertie
Institute for Clinical Brain Research, Tübingen, Germany,Redenlab, Melbourne, Australia
| | - Sue Berney
- Department of Physiotherapy, Austin Health,
Melbourne, Australia,Department of Physiotherapy, School of Health
Sciences, University of Melbourne, Melbourne, Australia
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12
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Mills CS, Michou E, Bellamy MC, Siddle HJ, Brennan CA, Bojke C. Determining the Prevalence, Implementation Approaches, and Opinions of Above Cuff Vocalization: A Survey of Health Care Professionals. Arch Phys Med Rehabil 2021; 103:394-401. [PMID: 34562433 PMCID: PMC8890002 DOI: 10.1016/j.apmr.2021.08.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2021] [Revised: 08/05/2021] [Accepted: 08/20/2021] [Indexed: 11/17/2022]
Abstract
Objective To conduct an international survey to investigate the use of above cuff vocalization (ACV) and how practice and opinion differs. Design Observational, cross-sectional online survey. Setting Critical care, acute, rehabilitation, long-term care, and community. Participants Health care professionals involved in tracheostomy care or weaning (N=243). Interventions Not applicable. Main Outcome Measures Tracheostomy management, prevalence, personal experiences and opinions, and barriers to use. Quantitative data were reported descriptively, and content analysis was conducted with qualitative data. Results The survey was completed by 243 health care professionals from 9 professional groups and 25 countries, with most responses from the United Kingdom (54%) and speech and language therapists (55%). ACV was used in 39% of services (n=93). Sixty percent (n=50/83) of health care professionals with direct experience of ACV had used it with <10 people. Implementation of ACV varied widely concerning procedures, contraindications, safety processes, professionals involved, competencies, staff training, delivery, and outcome measures. The top benefits were communication (n=76/93; 82%), mood (n=62/93; 67%), and laryngeal sensation (n=49/93; 53%). Complications included discomfort (n=54/93; 58%) and strained vocal quality (n=39/93; 42%). Barriers to ACV implementation included lack of knowledgeable staff (n=92/238; 39%) and lack of access to training (n=73/238; 31%). Conclusions ACV uptake varies internationally with no standardized approach to ACV delivery. Diversity of opinions on approaches and benefits exist. Serious complications are infrequent, but minor complications are common. Future research is needed to establish optimal ACV implementation to maximize benefits and minimize risks.
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Affiliation(s)
- Claire S Mills
- Speech and Language Therapy Department, Leeds Teaching Hospitals National Health Service Trust, Leeds, United Kingdom; Leeds Institute of Health Sciences, University of Leeds, Leeds, United Kingdom.
| | - Emilia Michou
- Centre for Gastrointestinal Sciences, University of Manchester, Manchester, United Kingdom; Speech Language Therapy Department, University of Patras, Patras, Greece
| | - Mark C Bellamy
- Leeds Institute of Medical Research at St James's, University of Leeds, Leeds, United Kingdom
| | - Heidi J Siddle
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, United Kingdom; Department of Podiatry, Leeds Teaching Hospitals National Health Service Trust, Leeds, United Kingdom
| | - Cathy A Brennan
- Leeds Institute of Health Sciences, University of Leeds, Leeds, United Kingdom
| | - Chris Bojke
- Leeds Institute of Health Sciences, University of Leeds, Leeds, United Kingdom
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13
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Senior A, Chan J, Brookes K, Jolly K, Darr A, Ameen R. Emergency management of neck stoma patients during the coronavirus pandemic: a national nurse survey. ACTA ACUST UNITED AC 2021; 30:742-746. [PMID: 34170732 DOI: 10.12968/bjon.2021.30.12.742] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND Neck stoma patient care involves significant clinical complexity. Inadequate staff training, equipment provision and infrastructure have all been highlighted as causes for avoidable patient harm. AIMS To establish the perception of knowledge and confidence levels relating to the emergency management of neck stomas among UK nurses during the COVID-19 pandemic. METHOD A nationwide prospective electronic survey of both primary and secondary care nurses via the Royal College of Nursing and social media. FINDINGS 402 responses were collated: 81 primary care and 321 secondary care; the majority (n=130) were band 5. Forty-nine per cent could differentiate between a laryngectomy and a tracheostomy; ENT nurses scored highest (1.56; range 0-2) on knowledge. Fifty-seven per cent could oxygenate a tracheostomy stoma correctly and 54% could oxygenate a laryngectomy stoma correctly. Sixty-five per cent cited inadequate neck stoma training and 91% felt inclusion of neck stoma training was essential within the nursing curriculum. CONCLUSION Clinical deficiencies of management identified by nurses can be attributed to a lack of confidence secondary to reduced clinical exposure and education.
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Affiliation(s)
- Andrew Senior
- ENT Registrar, Birmingham Women's and Children's NHS Foundation Trust
| | | | - Kim Brookes
- Head and Neck Clinical Nurse Specialist, Royal Wolverhampton New Cross Hospital, Wolverhampton
| | - Karan Jolly
- ENT Registrar, Princess Royal Hospital, Telford
| | - Adnan Darr
- ENT Registrar, Princess Royal Hospital, Telford
| | - Rohan Ameen
- ENT Senior House Officer, Princess Royal Hospital, Telford
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14
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Mills CS, Michou E, King N, Bellamy MC, Siddle HJ, Brennan CA, Bojke C. Evidence for Above Cuff Vocalization in Patients With a Tracheostomy: A Systematic Review. Laryngoscope 2021; 132:600-611. [PMID: 33932229 DOI: 10.1002/lary.29591] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2020] [Revised: 04/13/2021] [Accepted: 04/17/2021] [Indexed: 12/21/2022]
Abstract
OBJECTIVES/HYPOTHESIS To determine how above cuff vocalization (ACV) is implemented in clinical practice, to identify what evidence exists on the effectiveness and safety of ACV, and to evaluate the acceptability of ACV. STUDY DESIGN Systematic review. METHODS A literature search was conducted in eight databases (MEDLINE, Embase, AMED, CINAHL, Cochrane Library, PsycINFO, Scopus, and Web of Science) in May 2019 and updated in June 2020. Two reviewers independently screened, selected, and extracted data. Study quality was appraised using the Joanna Briggs Institute Critical Appraisal Tools and a narrative synthesis was conducted. Systematic review registration number: CRD42019133942. RESULTS The searches identified 1327 records. The 13 eligible studies included four case studies, three case series, four observational studies without a control group, one quasi-experimental study, and one randomized controlled trial. Study quality was low, with most studies having high risk of bias. There was a high level of heterogeneity in study design and outcome measures used. Detailed information on ACV application and dose-delivered was lacking in 12 studies. Positive effects were reported for communication (n = 7), swallowing (n = 4), cough response (n = 2), and quality-of-life (n = 2), but with inconsistent use of objective outcome measures. There is limited quantitative or qualitative evidence for acceptability. Adverse events and complications were reported in nine studies, and four highlighted the importance of involving an experienced speech and language therapist. CONCLUSIONS There is limited evidence for the acceptability, effectiveness, safety, or optimal implementation of ACV. The evidence is insufficient to provide recommendations regarding optimal intervention delivery. Future research should ensure detailed recording of ACV delivery and utilize a core outcome set. Laryngoscope, 2021.
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Affiliation(s)
- Claire S Mills
- Speech and Language Therapy Department, Leeds Teaching Hospitals NHS Trust, Leeds, United Kingdom.,Leeds Institute of Health Sciences, University of Leeds, Leeds, United Kingdom
| | - Emilia Michou
- Centre for Gastrointestinal Sciences, The University of Manchester, Manchester, United Kingdom.,Speech and Language Therapy Department, University of Patras, Patras, Greece
| | - Natalie King
- Leeds Institute of Health Sciences, University of Leeds, Leeds, United Kingdom
| | - Mark C Bellamy
- Leeds Institute of Medical Research at St James's, University of Leeds, Leeds, United Kingdom
| | - Heidi J Siddle
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, United Kingdom.,Department of Podiatry, Leeds Teaching Hospitals NHS Trust, Leeds, United Kingdom
| | - Cathy A Brennan
- Leeds Institute of Health Sciences, University of Leeds, Leeds, United Kingdom
| | - Chris Bojke
- Leeds Institute of Health Sciences, University of Leeds, Leeds, United Kingdom
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15
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Wallace S, McGrath BA. Laryngeal complications after tracheal intubation and tracheostomy. BJA Educ 2021; 21:250-257. [PMID: 34178381 DOI: 10.1016/j.bjae.2021.02.005] [Citation(s) in RCA: 30] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/19/2021] [Indexed: 12/20/2022] Open
Affiliation(s)
- S Wallace
- Wythenshawe Hospital, Manchester University NHS Foundation Trust, Manchester, UK
| | - B A McGrath
- Wythenshawe Hospital, Manchester University NHS Foundation Trust, Manchester, UK.,University of Manchester Academic Critical Care, Wythenshawe Hospital, Manchester, UK
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16
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Johnson E, Heyns T, Nilsson S. Nurses' perspectives on alternative communication strategies use in critical care units. Nurs Crit Care 2021; 27:120-129. [PMID: 33624908 DOI: 10.1111/nicc.12612] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Revised: 02/11/2021] [Accepted: 02/12/2021] [Indexed: 12/11/2022]
Abstract
BACKGROUND Critically ill patients have the right to communicate and participate in their treatment to avoid adverse medical outcomes due to the severity of their illness, their responsiveness, and level of consciousness. This human right has often been neglected by health care professionals, as a result of limited alternative communication support provided to patients who are unable to speak due to, for example, endotracheal intubation. Despite the successful use of alternative communication strategies in critical care units (CCUs) in other countries, limited implementation in South African hospitals has been reported. AIMS AND OBJECTIVES This study aimed to determine the perspectives of South African nurses working in CCUs on the frequency of use of alternative communication strategies to support patient-centred communication with critically ill adult patients. DESIGN The study followed a quantitative non-experimental survey research design. METHODS A total of 210 nurses working in both private and public hospitals completed a survey on their perspectives on the use of alternative communication strategies in CCUs. RESULTS Nurse participants reported experience working with critically ill and communication-vulnerable patients. Nurse-patient communication mainly involved the use of pen and paper, facial expressions and gestures to obtain information relating to patients' needs and their health history. Limited use of speech-generating communication devices was reported. CONCLUSION Nurse training on the use and implementation of alternative communication strategies, such as communication boards or electronic speech-generating devices, should be investigated to improve nurses' communication with communication-vulnerable patients in South Africa. RELEVANCE TO CLINICAL PRACTICE The results are applicable in clinical practice due to patients' need for alternative communication. The nurses mainly used low-tech solutions, which are cheap and easy to access. However, there exists an opportunity to increase the use of available digital solutions.
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Affiliation(s)
- Ensa Johnson
- Centre for Augmentative and Alternative Communication, University of Pretoria, Pretoria, South Africa
| | - Tanya Heyns
- Department of Nursing Science, University of Pretoria, Pretoria, South Africa
| | - Stefan Nilsson
- Institute of Health and Care Sciences, University of Gothenburg Centre for Person-Centred Care, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
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17
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Petosic A, Viravong MF, Martin AM, Nilsen CB, Olafsen K, Berntzen H. Above cuff vocalisation (ACV): A scoping review. Acta Anaesthesiol Scand 2021; 65:15-25. [PMID: 32920849 PMCID: PMC7756796 DOI: 10.1111/aas.13706] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2020] [Revised: 09/02/2020] [Accepted: 09/04/2020] [Indexed: 12/21/2022]
Abstract
Introduction Patients in intensive care frequently suffer from not being able to communicate verbally. The aim of this scoping review was to study the safety and effectiveness of the above cuff vocalisation (ACV) on speech and quality of life (QOL) in patients dependent on a cuffed tracheostomy. Methods A scoping review was conducted. The databases Ovid Medline, Cochrane Library, and Embase were systematically searched in May 2020. We included clinical studies with patients exposed to ACV where speech, QOL or safety issues were assessed. Results Overall, 17 studies were included, of which 15 were observational and 2 were randomised controlled trials. Totally, 231 patients were included. ACV enabled most of the included patients (115/131; 88%) to speak with an audible voice or whisper (moderate quality of evidence). Voice related QOL (V‐RQOL) and QOL in mechanically ventilated patients (QOL‐MV) improved from pre‐ to post‐ ACV compared to a control group not tolerating a one‐way speaking valve (P = .01 and P = .04, respectively) (very low quality of evidence). Several minor complications or problems were reported in 20/75 (27%) cases in addition to two serious adverse events: subcutaneous emphysema in one patient where the tracheostomy was dislodged and a distended trachea in another due to the misconnection of continuous gas to the cuff (low/ very low quality of evidence). Conclusion ACV facilitated communication in patients dependent on a cuffed tracheostomy and attempting to communicate. Quality of evidence in improved V‐RQOL and QOL‐MV was very low. Several minor complications and two serious adverse events were reported.
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Affiliation(s)
- Antonija Petosic
- Division of Emergencies and Critical care Department of Postoperative and Intensive care Oslo University Hospital Oslo Norway
- Faculty of Medicine Institute of Health and Society University of Oslo Oslo Norway
| | - Marit F. Viravong
- Medical Division Department of Clinical Services, Physiotherapy Service Oslo University Hospital Oslo Norway
| | - Anna M. Martin
- Medical Division Department for Clinical Services, Speech and Language Therapy Service Oslo University Hospital Oslo Norway
| | - Cecilie B. Nilsen
- Division of Emergencies and Critical care Department of Postoperative and Intensive care Oslo University Hospital Oslo Norway
| | - Kjell Olafsen
- Division of Emergencies and Critical care Department of Anesthesiology Oslo University Hospital Oslo Norway
| | - Helene Berntzen
- Division of Emergencies and Critical care Department of Postoperative and Intensive care Oslo University Hospital Oslo Norway
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18
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Wiberg S, Whitling S, Bergström L. Tracheostomy management by speech-language pathologists in Sweden. LOGOP PHONIATR VOCO 2020; 47:146-156. [PMID: 33356717 DOI: 10.1080/14015439.2020.1847320] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
Purpose: Speech-language pathologists' (SLPs) role in tracheostomy management is well described internationally. Surveys from Australia and the United Kingdom show high clinical consistency in SLP tracheostomy management, and that practice follows guidelines, research evidence and protocols. Swedish SLPs work with tracheostomised patients, however, the content and extent of this practice, and how it compares to international research is unknown. This study reports how SLPs in Sweden work with tracheostomised patients, investigating (a) the differences and similarities in SLPs tracheostomy management and (b) the facilitators and barriers to tracheostomy management, as reported by SLPs.Methods: A study-specific, online questionnaire was completed by 28 SLPs who had managed tracheostomised patients during the previous year. This study was conducted in 2018, pre Covid-19 pandemic. The answers were analysed for exploratory descriptive comparison of data. Content analyses were made on answers from open-ended questions.Results: Swedish SLPs manage tracheostomised patients, both for dysphagia and communication. During this study, the use of protocols and guidelines were limited and SLPs were often not part of a tracheostomy team. Speech-language pathologists reported that the biggest challenges in tracheostomy management were in (a) collaboration with other professionals, (b) unclear roles and (c) self-perceived inexperience. Improved collaboration with other professionals and clearer roles was suggested to facilitate team tracheostomy management.Conclusions: This study provides insight into SLP tracheostomy management in Sweden, previously uncharted. Results suggest improved collaboration, further education and clinical training as beneficial for a clearer and more involved SLP role in tracheostomy management.
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Affiliation(s)
- Sara Wiberg
- Department of Speech and Language Therapy, Helsingborg Hospital, Helsingborg, Sweden.,Department of Logopedics, Phoniatrics and Audiology, Faculty of Medicine, Lund University, Lund, Sweden
| | - Susanna Whitling
- Department of Logopedics, Phoniatrics and Audiology, Faculty of Medicine, Lund University, Lund, Sweden
| | - Liza Bergström
- Division of Speech and Language Pathology, Department of Clinical Neuroscience and Rehabilitation, Institute of Neuroscience and Physiology, University of Gothenburg, Gothenburg, Sweden.,REMEO Stockholm, Sköndal, Sweden
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19
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Brenner MJ, Pandian V, Milliren CE, Graham DA, Zaga C, Morris LL, Bedwell JR, Das P, Zhu H, Lee Y. Allen J, Peltz A, Chin K, Schiff BA, Randall DM, Swords C, French D, Ward E, Sweeney JM, Warrillow SJ, Arora A, Narula A, McGrath BA, Cameron TS, Roberson DW. Global Tracheostomy Collaborative: data-driven improvements in patient safety through multidisciplinary teamwork, standardisation, education, and patient partnership. Br J Anaesth 2020; 125:e104-e118. [DOI: 10.1016/j.bja.2020.04.054] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2019] [Revised: 03/17/2020] [Accepted: 04/17/2020] [Indexed: 01/15/2023] Open
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20
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Tracheostomy in the COVID-19 era: global and multidisciplinary guidance. THE LANCET. RESPIRATORY MEDICINE 2020; 8:717-725. [PMID: 32422180 PMCID: PMC7228735 DOI: 10.1016/s2213-2600(20)30230-7] [Citation(s) in RCA: 265] [Impact Index Per Article: 66.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/18/2020] [Revised: 04/27/2020] [Accepted: 05/10/2020] [Indexed: 01/08/2023]
Abstract
Global health care is experiencing an unprecedented surge in the number of critically ill patients who require mechanical ventilation due to the COVID-19 pandemic. The requirement for relatively long periods of ventilation in those who survive means that many are considered for tracheostomy to free patients from ventilatory support and maximise scarce resources. COVID-19 provides unique challenges for tracheostomy care: health-care workers need to safely undertake tracheostomy procedures and manage patients afterwards, minimising risks of nosocomial transmission and compromises in the quality of care. Conflicting recommendations exist about case selection, the timing and performance of tracheostomy, and the subsequent management of patients. In response, we convened an international working group of individuals with relevant expertise in tracheostomy. We did a literature and internet search for reports of research pertaining to tracheostomy during the COVID-19 pandemic, supplemented by sources comprising statements and guidance on tracheostomy care. By synthesising early experiences from countries that have managed a surge in patient numbers, emerging virological data, and international, multidisciplinary expert opinion, we aim to provide consensus guidelines and recommendations on the conduct and management of tracheostomy during the COVID-19 pandemic.
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21
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McGrath BA. Above cuff vocalization (ACV): an additional benefit of subglottic suction tracheostomy tubes. Minerva Anestesiol 2020; 87:113-114. [PMID: 32549550 DOI: 10.23736/s0375-9393.20.14878-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Affiliation(s)
- Brendan A McGrath
- Wythenshawe Hospital, Manchester University NHS Foundation Trust, Manchester, UK -
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22
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McGrath BA, Ashby N, Birchall M, Dean P, Doherty C, Ferguson K, Gimblett J, Grocott M, Jacob T, Kerawala C, Macnaughton P, Magennis P, Moonesinghe R, Twose P, Wallace S, Higgs A. Multidisciplinary guidance for safe tracheostomy care during the COVID-19 pandemic: the NHS National Patient Safety Improvement Programme (NatPatSIP). Anaesthesia 2020; 75:1659-1670. [PMID: 32396986 PMCID: PMC7272992 DOI: 10.1111/anae.15120] [Citation(s) in RCA: 54] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/10/2020] [Indexed: 12/18/2022]
Abstract
The COVID-19 pandemic is causing a significant increase in the number of patients requiring relatively prolonged invasive mechanical ventilation and an associated surge in patients who need a tracheostomy to facilitate weaning from respiratory support. In parallel, there has been a global increase in guidance from professional bodies representing staff who care for patients with tracheostomies at different points in their acute hospital journey, rehabilitation and recovery. Of concern are the risks to healthcare staff of infection arising from tracheostomy insertion and caring for patients with a tracheostomy. Hospitals are also facing extraordinary demands on critical care services such that many patients who require a tracheostomy will be managed outside established intensive care or head and neck units and cared for by staff with little tracheostomy experience. These concerns led NHS England and NHS Improvement to expedite the National Patient Safety Improvement Programme's 'Safe Tracheostomy Care' workstream as part of the NHS COVID-19 response. Supporting this workstream, UK stakeholder organisations involved in tracheostomy care were invited to develop consensus guidance based on: expert opinion; the best available published literature; and existing multidisciplinary guidelines. Topics with direct relevance for frontline staff were identified. This consensus guidance includes: infectivity of patients with respect to tracheostomy indications and timing; aerosol-generating procedures and risks to staff; insertion procedures; and management following tracheostomy.
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Affiliation(s)
- B A McGrath
- Department of Intensive Care Medicine, Wythenshawe Hospital, Manchester University Hospital NHS Foundation Trust, National Tracheostomy Safety Project, Manchester, UK
| | - N Ashby
- Royal College of Nursing, University of Nottingham, Nottingham, UK
| | - M Birchall
- British Laryngological Association, University College London, London, UK
| | - P Dean
- Intensive Care Society, Royal Blackburn Teaching Hospital, Lancashire, UK
| | - C Doherty
- Royal Manchester Children's Hospital, National Tracheostomy Safety Project Paediatric Lead, Manchester University NHS Foundation Trust, Manchester, UK
| | - K Ferguson
- Aberdeen Royal Infirmary, Association of Anaesthetists, Aberdeen, UK
| | | | - M Grocott
- Anaesthesia and Critical Care, Royal College of Anaesthetists, University of Southampton, Southampton, UK
| | - T Jacob
- ENT & Head and Neck surgeon, Lewisham & Greenwich NHS Trust, ENT-UKt, London, UK
| | - C Kerawala
- Maxillofacial & Head and Neck Surgeon, The Royal Marsden Hospital, British Association of Head & Neck Oncologists, London, UK
| | - P Macnaughton
- Intensive Care Medicine at Derriford Hospital, Faculty of Intensive Care Medicine, Plymouth, UK
| | - P Magennis
- Oral and Maxillofacial Surgeon, Aintree University Hospital, NHS Foundation Trust, British Association of Oral and Maxillofacial Surgeons, Liverpool, UK
| | - R Moonesinghe
- Anaesthetics and Critical Care Medicine, NHS England & NHS Improvement, University College London Hospitals, London, UK
| | - P Twose
- Association of Chartered Physiotherapists in Respiratory Care, Cardiff and Vale University Health Board, Cardiff, UK
| | - S Wallace
- Speech & Language Therapist, Royal College of Speech & Language Therapists, Manchester University NHS Foundation Trust, Manchester, UK
| | - A Higgs
- Anaesthesia & Intensive Care Medicine, Warrington & Halton Teaching Hospitals NHS Foundation Trust, Difficult Airway Society, Warrington, UK
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Lewith H, Athanassoglou V. Update on management of tracheostomy. BJA Educ 2019; 19:370-376. [PMID: 33456860 DOI: 10.1016/j.bjae.2019.08.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/09/2019] [Indexed: 11/28/2022] Open
Affiliation(s)
- H Lewith
- Nuffield Department of Anaesthetics, John Radcliffe Hospital, Oxford, UK
| | - V Athanassoglou
- Nuffield Department of Anaesthetics, John Radcliffe Hospital, Oxford, UK
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Pandian V, Boisen S, Mathews S, Brenner MJ. Speech and Safety in Tracheostomy Patients Receiving Mechanical Ventilation: A Systematic Review. Am J Crit Care 2019; 28:441-450. [PMID: 31676519 DOI: 10.4037/ajcc2019892] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
OBJECTIVE To synthesize evidence of the safety and effectiveness of phonation in patients with fenestrated tracheostomy tubes. METHODS PubMed, CINAHL, Scopus, Cochrane, and Web of Science databases were searched. The research question was, "Are fenestrated tracheostomy tubes a safe and effective option to facilitate early phonation in patients undergoing tracheostomy?" Studies of fenestrated tracheostomy tubes were assessed for risk of bias and quality of evidence. Data were abstracted, cross-checked for accuracy, and synthesized. RESULTS Of the 160 studies identified, 13 met inclusion criteria, including 6 clinical studies (104 patients), 6 case reports (13 patients), and 1 nationwide clinician survey. The primary indications for a tracheostomy were chronic ventilator dependence (83%) and airway protection (17%). Indications for fenestrated tracheostomy included inaudible phonation and poor voice intelligibility. Patients with fenestrated tubes achieved robust voice outcomes. Complications included granulation tissue (6 patients [5%]), malpositioning (1 patient [0.9%]), decreased oxygen saturation (3 patients [2.6%]), increased blood pressure (1 patient [0.9%]), increased peak pressures (2 patients [1.7%]), and air leakage (1 patient [0.9%]); subcutaneous emphysema also occurred frequently. Patient-reported symptoms included shortness of breath (4 patients [3.4%]), anxiety (3 patients [2.6%]), and chest discomfort (1 patient [0.9%]). CONCLUSIONS Fenestrated devices afford benefits for speech and decannulation but carry risks of granulation, aberrant airflow, and acclimation challenges. Findings highlight the need for continued innovation, education, and quality improvement around the use of fenestrated devices.
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Affiliation(s)
- Vinciya Pandian
- Vinciya Pandian is an associate professor, Johns Hopkins School of Nursing, Baltimore, Maryland. Sarah Boisen is an intensive care unit nurse, The Johns Hopkins Hospital, Baltimore, Maryland. Shifali Mathews is a BS student and research assistant, Johns Hopkins School of Nursing. Michael J. Brenner is an associate professor, Department of Otolaryngology–Head & Neck Surgery, Michigan Medicine–University of Michigan, Ann Arbor, Michigan
| | - Sarah Boisen
- Vinciya Pandian is an associate professor, Johns Hopkins School of Nursing, Baltimore, Maryland. Sarah Boisen is an intensive care unit nurse, The Johns Hopkins Hospital, Baltimore, Maryland. Shifali Mathews is a BS student and research assistant, Johns Hopkins School of Nursing. Michael J. Brenner is an associate professor, Department of Otolaryngology–Head & Neck Surgery, Michigan Medicine–University of Michigan, Ann Arbor, Michigan
| | - Shifali Mathews
- Vinciya Pandian is an associate professor, Johns Hopkins School of Nursing, Baltimore, Maryland. Sarah Boisen is an intensive care unit nurse, The Johns Hopkins Hospital, Baltimore, Maryland. Shifali Mathews is a BS student and research assistant, Johns Hopkins School of Nursing. Michael J. Brenner is an associate professor, Department of Otolaryngology–Head & Neck Surgery, Michigan Medicine–University of Michigan, Ann Arbor, Michigan
| | - Michael J. Brenner
- Vinciya Pandian is an associate professor, Johns Hopkins School of Nursing, Baltimore, Maryland. Sarah Boisen is an intensive care unit nurse, The Johns Hopkins Hospital, Baltimore, Maryland. Shifali Mathews is a BS student and research assistant, Johns Hopkins School of Nursing. Michael J. Brenner is an associate professor, Department of Otolaryngology–Head & Neck Surgery, Michigan Medicine–University of Michigan, Ann Arbor, Michigan
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McRae J, Montgomery E, Garstang Z, Cleary E. The role of speech and language therapists in the intensive care unit. J Intensive Care Soc 2019; 21:344-348. [PMID: 34093737 DOI: 10.1177/1751143719875687] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
National guidance recommends the involvement of speech and language therapists in intensive care particularly for those requiring tracheostomy and ventilation. However, the role of speech and language therapists is poorly understood especially in the context of critical care. This article aims to increase awareness of the background training and skills development of speech and language therapists working in this context to demonstrate their range of specialist abilities. Speech and language therapists support and enhance the process of laryngeal weaning alongside the rehabilitation of speech and swallowing as part of the multidisciplinary team. Examples are provided of the types of interventions that are used and technological innovations that may enhance rehabilitation of oropharyngeal impairments.
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Affiliation(s)
- Jackie McRae
- Speech and Language Therapy Department, St George's University Hospitals NHS Foundation Trust, London, UK.,School of Allied Health, Midwifery and Social Care, Faculty of Health, Social Care and Education, Kingston University and St George's, University of London, London, UK
| | - Elizabeth Montgomery
- Speech and Language Therapy Department, St George's University Hospitals NHS Foundation Trust, London, UK
| | - Zoë Garstang
- Speech and Language Therapy Department, St George's University Hospitals NHS Foundation Trust, London, UK
| | - Eibhlin Cleary
- Speech and Language Therapy Department, St George's University Hospitals NHS Foundation Trust, London, UK
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Zaga CJ, Berney S, Vogel AP. The Feasibility, Utility, and Safety of Communication Interventions With Mechanically Ventilated Intensive Care Unit Patients: A Systematic Review. AMERICAN JOURNAL OF SPEECH-LANGUAGE PATHOLOGY 2019; 28:1335-1355. [PMID: 31296037 DOI: 10.1044/2019_ajslp-19-0001] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
Purpose The aim of this study was to conduct a systematic review of the literature relating to the feasibility, utility, and safety of augmentative and alternative communication (AAC) interventions and tracheostomy-related communication interventions with mechanically ventilated adult patients in the intensive care unit (ICU). Method MEDLINE, Embase, and PsycINFO databases were searched for relevant articles. Studies were included if (a) they were performed in the ICU, (b) they involved participants > 18 years of age, (c) > 85% of participants were mechanically ventilated, and (d) they reported on content that related to the feasibility and/or utility and/or safety of AAC intervention and/or tracheostomy-related communication intervention. Studies were extracted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The levels of evidence for included studies were assessed using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) guidelines. Results Forty-eight studies met the inclusion criteria. Different communication interventions relating to intubated and tracheostomized mechanically ventilated patients were reviewed, including (a) communication boards, (b) electrolarynx, (c) high-technology AAC devices, (d) tracheostomy tubes with communication-enabling features, (e) one-way valve in line with the ventilator, (f) ventilator-adjusted leak speech, (g) ventilator adjustments and one-way valve, and (h) multiple interventions. Forty-seven of 48 studies examined the feasibility and utility of the interventions. Sixteen studies examined the safety of the interventions. The included studies were composed of randomized controlled trials (n = 2), quasi-experimental studies (n = 7), cohort studies (n = 8), case-control (n = 1), case series (n = 23), and case reports (n = 7). The levels of evidence varied and ranged from high (n = 2), moderate (n = 7), low (n = 9), and very low (n = 30). Conclusions There is developing evidence that communication interventions with mechanically ventilated ICU patients are feasible, have utility, and are safe. Further research is warranted to guide speech pathologist-directed intervention to improve patient outcomes and the patient experience in the ICU.
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Affiliation(s)
- Charissa J Zaga
- Speech Pathology Department, Austin Health, Melbourne, Australia
- Centre for Neuroscience of Speech, The University of Melbourne, Australia
- Tracheostomy Review and Management Service, Austin Health, Melbourne, Australia
| | - Sue Berney
- Department of Physiotherapy, Austin Health, Melbourne, Australia
- Department of Physiotherapy, School of Health Sciences, The University of Melbourne, Australia
| | - Adam P Vogel
- Centre for Neuroscience of Speech, The University of Melbourne, Australia
- Department of Neurodegeneration, Hertie Institute for Clinical Brain Research, Tübingen Germany
- Redenlab, Melbourne, Australia
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Pandian V, Boisen SE, Mathews S, Cole T. Are Fenestrated Tracheostomy Tubes Still Valuable? AMERICAN JOURNAL OF SPEECH-LANGUAGE PATHOLOGY 2019; 28:1019-1028. [PMID: 31318610 PMCID: PMC6802915 DOI: 10.1044/2019_ajslp-18-0187] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/27/2018] [Revised: 01/31/2019] [Accepted: 03/29/2019] [Indexed: 06/10/2023]
Abstract
Purpose The purpose of this clinical focus article is to describe the frequency, indications, and outcomes of fenestrated tracheostomy tube use in a large academic institution. Method A retrospective chart review was conducted to evaluate the use of fenestrated tracheostomy tubes between 2007 and 2017. Patients were included in the study if they were ≥ 18 years of age and received a fenestrated tracheostomy tube in the recent 10-year period. Results Of 2,000 patients who received a tracheostomy, 15 patients had a fenestrated tracheostomy tube; however, only 5 patients received a fenestrated tracheostomy tube at the study institution. The primary reason why the 15 patients received a tracheostomy was chronic respiratory failure (73%); other reasons included airway obstruction (20%) and airway protection (7%). Thirteen (87%) patients received a fenestrated tracheostomy tube for phonation purposes. The remaining 2 patients received it as a step to weaning. Of the 13 patients who received a fenestrated tracheostomy tube for phonation, only 1 patient was not able to phonate. Nine (60%) patients developed some type of complications: granulation only, 2 (13.3%); granulation and tracheomalacia, 2 (13.3%); granulation and stenosis, 4 (26.7%); and granulation, tracheomalacia, and stenosis, 1 (6.7%). Conclusions Fenestrated tracheostomy tubes may assist with phonation in patients who cannot tolerate a 1-way speaking valve; however, the risk of developing granulation tissue, tracheomalacia, and tracheal stenosis exists. Health care providers should be educated on the safe use of a fenestrated tracheostomy tube and other options available to improve phonation while ensuring patient safety.
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28
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Pandian V, Cole T, Kilonsky D, Holden K, Feller-Kopman DJ, Brower R, Mirski M. Voice-Related Quality of Life Increases With a Talking Tracheostomy Tube: A Randomized Controlled Trial. Laryngoscope 2019; 130:1249-1255. [PMID: 31385620 DOI: 10.1002/lary.28211] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2019] [Revised: 07/01/2019] [Accepted: 07/10/2019] [Indexed: 12/12/2022]
Abstract
OBJECTIVE The primary objective of our study was to determine the quality of life (QOL) using a talking tracheostomy tube. METHODS Randomized clinical trial (NCT2018562). Adult intensive care unit patients who were mechanically ventilated, awake, alert, attempting to communicate, English-speaking, and could not tolerate one-way speaking valve were included. Intervention comprised a Blue Line Ultra Suctionaid (BLUSA) talking tracheostomy tube (Smiths Medical, Dublin, OH, US). Outcome measures included QOL scores measured using Quality of Life in Mechanically Ventilated Patients (QOL-MV) and Voice-Related Quality of Life (V-RQOL), Speech Intelligibility Test (SIT) scores, independence, and satisfaction. RESULTS The change in V-RQOL scores from pre- to postintervention was higher among patients using a BLUSA (Smiths Medical) compared to those who did not (P = 0.001). The QOL-MV scores from pre- to postintervention were significantly higher among patients who used a BLUSA (Smiths Medical) compared to patients who did not use BLUSA (Smiths Medical) or a one-way speaking valve (P = 0.04). SIT scores decreased by 6.4 points for each 1-point increase in their Sequential Organ Failure Assessment scores (P = 0.04). The overall QOL-MV scores correlated moderately with the overall V-RQOL scores (correlation coefficient = 0.59). Cronbach alpha score for overall QOL-MV was 0.71. Seventy-three percent of the 22 intervention patients reported the ability to use the BLUSA (Smiths Medical) with some level of independence, whereas 41% reported some level of satisfaction with the use of BLUSA (Smiths Medical). The lengths of stay was longer in the intervention group. CONCLUSION Our study suggests that BLUSA (Smiths Medical) talking tracheostomy tube improves patient-reported QOL in mechanically ventilated patients with a tracheostomy who cannot tolerate cuff deflation. LEVEL OF EVIDENCE I Laryngoscope, 130:1249-1255, 2020.
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Affiliation(s)
| | - Therese Cole
- The Johns Hopkins Hospital, Baltimore, Maryland, U.S.A
| | - Dana Kilonsky
- The Johns Hopkins Hospital, Baltimore, Maryland, U.S.A
| | - Kate Holden
- The Johns Hopkins Hospital, Baltimore, Maryland, U.S.A
| | | | - Roy Brower
- The Johns Hopkins Hospital, Baltimore, Maryland, U.S.A
| | - Marek Mirski
- The Johns Hopkins Hospital, Baltimore, Maryland, U.S.A
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29
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Gropp M, Johnson E, Bornman J, Koul R. Nurses' perspectives about communication with patients in an intensive care setting using a communication board: A pilot study. Health SA 2019; 24:1162. [PMID: 31934427 PMCID: PMC6917450 DOI: 10.4102/hsag.v24i0.1162] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2018] [Accepted: 02/27/2019] [Indexed: 01/10/2023] Open
Abstract
Background Communication in the intensive care setting (ICS) is critical for both the patient and the medical staff to provide efficient care and thus alleviate possible patient adverse effects. Persons with complex communication needs are particularly vulnerable in ICSs and therefore require additional communication support. Aim This study focused on the perspectives of nurses about communication with patients with communication needs in ICSs using paper-based communication boards, namely the translated Vidatak EZ Board, before and after a training session. Setting A 1650-bed public hospital with a 26-bed ICS in a semi-urban, low socio-economic area in South Africa served as the research setting. Methods A quasi-experimental pre-test post-test group design with withdrawal and a control group was used. Data were gathered using a custom-designed questionnaire completed by ICS nurse participants recruited from a public hospital. Results Responses of some nurses did not change in post-test 1, but their responses did change in post-test 2. Some of the nurses’ perspectives changed, as expected from the pre-test to post-test 1. Nurses recommended specific adaptations to the communication board. Conclusions Most nurses agreed that communication is crucial in ICSs and that a communication board can be implemented; however, limited success was observed implementing the board following a short training. The inter-professional collaboration between nurses and speech-language therapists to provide optimal health care to patients in ICS is emphasised.
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Affiliation(s)
- Martelize Gropp
- Centre for Augmentative and Alternative Communication, University of Pretoria, Pretoria, South Africa
| | - Ensa Johnson
- Centre for Augmentative and Alternative Communication, University of Pretoria, Pretoria, South Africa
| | - Juan Bornman
- Centre for Augmentative and Alternative Communication, University of Pretoria, Pretoria, South Africa
| | - Rajinder Koul
- Centre for Augmentative and Alternative Communication, University of Pretoria, Pretoria, South Africa.,Department of Communication Sciences and Disorders, Moody College of Communication, The University of Texas at Austin, Austin, United States
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30
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Seligman KL, Liming BJ, Smith RJH. Pediatric Tracheostomy Decannulation: 11-Year Experience. Otolaryngol Head Neck Surg 2019; 161:499-506. [PMID: 30987524 DOI: 10.1177/0194599819842164] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE To determine the successful decannulation rate with a published pediatric tracheostomy decannulation protocol. STUDY DESIGN Case series with chart review. SETTING A single tertiary care institution. SUBJECTS AND METHODS A chart review was performed for patients aged ≤5 years who underwent tracheostomy. Extracted data included demographic data, indication for tracheostomy, age at tracheostomy and decannulation, comorbidities, and surgical complications. Records were searched for documentation of early decannulation failure (within 1 month of decannulation) or late failure (within 1 year). RESULTS Forty patients with a tracheostomy aged ≤5 years underwent attempted decannulation during the 11-year study period. Seventeen patients were excluded from the study for documentation of nonprotocol decannulation. The final study population of 23 patients underwent a total of 27 decannulations, 26 of which were performed by protocol. Of the 26 protocol decannulations, 22 were successful, for a failure rate of 15%. CONCLUSION Twenty-six protocol decannulations were attempted among 23 patients, 4 of which were unsuccessful for an overall failure rate of 15%. This result is consistent with rates reported in other published decannulation protocols. We believe that our protocol minimizes resource utilization in its use of pulse oximetry over polysomnography, while maximizing patient safety and success through the use of capping trials for very young and very small pediatric patients.
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Affiliation(s)
- Kristen L Seligman
- 1 Department of Otolaryngology-Head and Neck Surgery, University of Iowa, Iowa City, Iowa, USA
| | - Bryan J Liming
- 2 Department of Otolaryngology-Head and Neck Surgery, Tripler Army Medical Center, Honolulu, Hawaii, USA
| | - Richard J H Smith
- 1 Department of Otolaryngology-Head and Neck Surgery, University of Iowa, Iowa City, Iowa, USA
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31
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McGrath BA, Wallace S, Wilson M, Nicholson L, Felton T, Bowyer C, Bentley AM. Safety and feasibility of above cuff vocalisation for ventilator-dependant patients with tracheostomies. J Intensive Care Soc 2018; 20:59-65. [PMID: 30792764 DOI: 10.1177/1751143718767055] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
Introduction Temporary tracheostomy is commonly used in patients admitted to intensive care units. Cuffed tubes prevent laryngeal airflow, preventing vocalisation. Sub-glottic suction tubes such as the 'Blue Line Ultra Suctionaid™' are used primarily to remove sub-glottic secretions, but retrograde gas flows via the suction port can facilitate above cuff vocalisation. The aims were to assess whether patients could achieve an audible voice using above cuff vocalisation, to demonstrate the safe use of the Blue Line Ultra Suctionaid™ tracheostomy tube for above cuff vocalisation, and to assess potential benefits of above cuff vocalisation for communication, secretion management and swallowing. Methods Our study (Reference 15/NW/0464, IRAS 178997) recruited adult intensive care unit patients who were alert, able to participate in an above cuff vocalisation trial and dependent on an inflated Blue Line Ultra Suctionaid™ cuff for ventilatory support. Consenting participants underwent fibreoptic endoscopic assessment of swallow by experienced Speech & Language Therapy staff with and without above cuff vocalisation. Clinical and fibreoptic endoscopic assessment of swallow, assessment of voice quality, swallowing and secretion management were recorded and scored. Median differences between paired observations and scores were analysed with and without above cuff vocalisation. Adverse events were identified by follow up fibreoptic endoscopic assessment of swallow and patient accounts. Results Ten patients completed the study. Above cuff vocalisation was used for a median of 15 min, during a median of nine episodes, over a median of three days. Above cuff vocalisation resulted in an audible voice in eight of the 10 patients, during 66 out of 91 above cuff vocalisation attempts. There improvements in unstimulated dry cough and swallow frequency and aspiration ratings measured by fibreoptic endoscopic assessment of swallow. No complications were reported or observed in 66 attempts with only one episode terminated prematurely. Conclusions Above cuff vocalisation can achieve effective, safe, well-tolerated vocalisation in ventilator-dependant intensive care unit patients. Above cuff vocalisation has the potential to aid earlier, more effective communication and may improve laryngeal function and rehabilitation.
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Affiliation(s)
- Brendan A McGrath
- Acute Intensive Care Unit, University Hospital South Manchester, Manchester, UK
| | - Sarah Wallace
- Department of Speech Voice & Swallowing, University Hospital South Manchester, Manchester, UK
| | - Mark Wilson
- Department of Speech Voice & Swallowing, University Hospital South Manchester, Manchester, UK
| | - Leanne Nicholson
- Department of Speech Voice & Swallowing, University Hospital South Manchester, Manchester, UK
| | - Tim Felton
- Acute Intensive Care Unit, University Hospital South Manchester, Manchester, UK
| | - Christine Bowyer
- Acute Intensive Care Unit, University Hospital South Manchester, Manchester, UK
| | - Andrew M Bentley
- Acute Intensive Care Unit, University Hospital South Manchester, Manchester, UK
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Abstract
PURPOSE OF REVIEW Understanding the mechanisms and abnormalities of respiratory function in neuromuscular disease is critical to supporting the patient and maintaining ventilation in the face of acute or chronic progressive impairment. RECENT FINDINGS Retrospective clinical studies reviewing the care of patients with Guillain-Barré syndrome and myasthenia have shown a disturbingly high mortality following step-down from intensive care. This implies high dependency and rehabilitation management is failing despite evidence that delayed improvement can occur with long-term care. A variety of mechanisms of phrenic nerve impairment have been recognized with newer investigation techniques, including EMG and ultrasound. Specific treatment for progressive neuromuscular and muscle disease has been increasingly possible particularly for the treatment of myasthenia, metabolic myopathies, and Duchenne muscular dystrophy. For those conditions without specific treatment, it has been increasingly possible to support ventilation in the domiciliary setting with newer techniques of noninvasive ventilation and better airway clearance. There remained several areas of vigorous debates, including the role for tracheostomy care and the place of respiratory muscle training and phrenic nerve/diaphragm pacing. SUMMARY Recent studies and systematic reviews have defined criteria for anticipating, recognizing, and managing ventilatory failure because of acute neuromuscular disease. The care of patients requiring long-term noninvasive ventilatory support for chronic disorders has also evolved. This has resulted in significantly improved survival for patients requiring domiciliary ventilatory support.
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Bonvento B, Wallace S, Lynch J, Coe B, McGrath BA. Role of the multidisciplinary team in the care of the tracheostomy patient. J Multidiscip Healthc 2017; 10:391-398. [PMID: 29066907 PMCID: PMC5644554 DOI: 10.2147/jmdh.s118419] [Citation(s) in RCA: 47] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
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.
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Affiliation(s)
- Barbara Bonvento
- Acute Intensive Care Unit, University Hospital South Manchester, Manchester
| | - Sarah Wallace
- Acute Intensive Care Unit, University Hospital South Manchester, Manchester.,Royal College of Speech and Language Therapists, London, UK
| | - James Lynch
- Acute Intensive Care Unit, University Hospital South Manchester, Manchester
| | - Barry Coe
- Acute Intensive Care Unit, University Hospital South Manchester, Manchester
| | - Brendan A McGrath
- Acute Intensive Care Unit, University Hospital South Manchester, Manchester
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McGrath BA, Lynch J, Bonvento B, Wallace S, Poole V, Farrell A, Diaz C, Khwaja S, Roberson DW. Evaluating the quality improvement impact of the Global Tracheostomy Collaborative in four diverse NHS hospitals. BMJ QUALITY IMPROVEMENT REPORTS 2017; 6:bmjqir.u220636.w7996. [PMID: 28607676 PMCID: PMC5457966 DOI: 10.1136/bmjquality.u220636.w7996] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Tracheostomies are predominantly used in Head & Neck Surgery and the critically ill. The needs of these complex patients frequently cross traditional speciality working boundaries and locations and any resulting airway problems can rapidly lead to significant harm. The Global Tracheostomy Collaborative (GTC) was formed in 2012 with the aim of bringing together international expertise in tracheostomy care in order to bring about rapid adoption of best practices and to improve the quality and safety of care to this vulnerable group. The primary aim of this project was to improve the safety and quality of care delivered to adult patients with new or existing tracheostomies. We implemented changes guided by the GTC using multiple PDSA cycles over a 12-month period. Interventions were across three themes: educational, patient-centred (earlier vocalisation and enteral intake) and organisational. We hypothesised that systematic healthcare improvements would reduce the severity of harm resulting from tracheostomy-related safety incidents and improve surrogate markers of the quality of patient-centred care. Furthermore, we hypothesised that raising the quality and safety of healthcare services would lead to more efficient care, measured by earlier tracheostomy decannulation times and reduced hospital lengths of stay. This Quality Improvement project implemented the GTC into four diverse NHS Trusts in Greater Manchester. Key drivers implemented included multidisciplinary tracheostomy steering groups, ward rounds and bedside teams, standardisation of tracheostomy protocols, staff education and meaningful involvement of patient and family. Surrogates for the quality and safety of care were captured for all patients using a bespoke database. Implementing the GTC into four NHS Trusts rapidly and positively impacted on patient safety metrics and surrogates for the quality of care delivered. It is likely that the comprehensive resources of the GTC will be of benefit to other NHS hospitals and indeed other healthcare systems around the world.
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Affiliation(s)
| | | | | | | | - Val Poole
- University Hospital South Manchester, UK
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