Best practice statement : caring for the patient with a tracheostomy
Tracheostomy Program 21-final - Passy-MuirPercutaneous Tracheostomy Program and Patient Outcomes...
Transcript of Tracheostomy Program 21-final - Passy-MuirPercutaneous Tracheostomy Program and Patient Outcomes...
Percutaneous Tracheostomy Program and Patient Outcomes
10/26/2010
Passy-Muir Inc. 1
Percutaneous Tracheostomy Program and Patient Outcomes
Vinciya Pandian PhDc, MSN, CRNP
Percutaneous Tracheostomy Service
The Johns Hopkins Hospital
Baltimore, MD
Outline
• The Johns Hopkins Experience
• Participants
• Functions
• Percutaneous Tracheostomy
• Role of Respiratory Therapistsp y p
• Role of Speech - Language Pathologists
• The Johns Hopkins Standards, Policies, and Protocols
• Education of team
• Outcomes of Tracheostomy Program
The Johns Hopkins Experience
• Initiation of bedside tracheostomy in 1999
• Building of team and experience with anesthesiologists
• Continued use of videobronchoscopy
• Switch to single-dilator technique in 2002
• Submission of a business plan to hospital administration in 2005
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The Johns Hopkins Experience
• Participants– Hospital Administration
– Anesthesia/Critical Care Medicine
– Otolaryngology Head and Neck Surgery
– General Surgery
Nursing– Nursing
– Respiratory Therapy
– Speech-Language Pathology (SLP)
The Johns Hopkins Experience
• Clearly defined indications and contraindications
• Hospital-wide standardized consultation, procedural and perioperative care protocols available on the intranet
• Tracheostomy coordinator - central clearing house
• Tracheostomy nurse practitioner as the key resource
Percutaneous Tracheostomy Program
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Functions
Obtain consent from the patient
or family
Evaluation of the patient
Scheduling and Notification
Identification of the patient
Preoperative
Functions
Obtain consent from the patient
or family
Evaluation of the patient
Scheduling and Notification
Identification of the patient
Preoperative
Tracheostomy PlacementPerioperative
Percutaneous Tracheostomy Program and Patient Outcomes
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Percutaneous Tracheostomy Program and Patient Outcomes
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Percutaneous Tracheostomy Program and Patient Outcomes
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Functions
Obtain consent from the patient
or family
Evaluation of the patient
Scheduling and Notification
Identification of the patient
Preoperative
Tracheostomy Placement
EducationFollow-UpDocumentation
and Data management
Perioperative
Postoperative
Respiratory Therapists’ Role
• Preoperative Role– Management of intubated patient
• Perioperative Role– Preparation of the patient
• Oxygenationyg• Suctioning
– Collection of equipment– Ventilator modifications
• Postoperative Role– Suctioning– Tracheostomy tube changes after initial change– Managing ventilator– In-line speaking valve trials with SLP
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Passy-Muir Valve request????
Speech-Language Pathologist’s Role
Predominantly postoperative care• Initial evaluation performed 48 hours after
tracheostomy placement
• Passy Muir Speaking Valve (PMSV) evaluation performed on initial evaluationperformed on initial evaluation
• If patient is able to tolerate: SLP makes recommendations for wear time, posts signs, informs team
• If patient is unable to tolerate: SLP makes recommendations for tracheostomy tube changes if applicable.
In-line Passy Muir Speaking Valve Evaluation
• Assess the candidacy of the patient– Vent settings, alertness, lung compliance
• Co-evaluation with Respiratory Therapy– Vent modifications made for optimal phonation
• After initial recommendations made, PMSV may be placed by SLP with RT present, or RT alone.
• 1:1 supervision required when wearing PMSV
• SLP makes recommendations for appropriateness of formal swallowing evaluation
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Swallowing Considerations
• Ideally, patient will demonstrate tolerance of PMSV for >3 hours prior to initiation of formal swallowing evaluation
• All patients with tracheostomy receive formal t d di d ll i t (VFSSstandardized swallowing assessment (VFSS or
FEES)
• Critical Care Transport team able to bring ICU & ventilated patients to radiology
The Johns Hopkins Standards
• ICU tracheostomy screening forms
• Consent forms
• Time outs
• Operative techniques
• Documentation– Electronic Patient Record
– Physician Order Entry• Postoperative orderset
– Clinical Documentation• Procedure note
• Tracheostomy tube change
The Johns Hopkins Policies and Protocols
• Tracheostomy protocol (last revised in 2009)– Care of different types of tracheostomy tubes
– Sterile and Clean Tracheostomy Care
– Tracheostomy care Procedure for reusable inner cannula
– Percutaneous Dilatational Tracheostomy Procedure– Percutaneous Dilatational Tracheostomy Procedure
– Tracheostomy Tube Changes
– Decannulation Guidelines
– Swallow study
– Laryngectomy Tubes
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The Johns Hopkins Education
• Competencies of staff caring for these patients– Quarterly morbidity and mortality meeting
– Quarterly staff meeting
– RNs – Annual skills day
– SLPs – Competency evaluation on hiring
• Continuing education– RNs - Biannual workshop
– RTs – Biennial workshop
– Yearly physician training
• Compliance
Tracheostomy Statistics
FY 2006 FY 2007 FY 2008 FY 2009Received tracheostomy 226 253 248 214
Performed at bedside
131 (57 96%)
173 (70 36%)
178 (71 77%)
172 (80 37%)(57.96%) (70.36%) (71.77%) (80.37%)
Performed in operating room 95 75 70 42
Pre and Post Tracheostomy Program
Patient Characteristics 2004 (N = 132) 2008 (N = 251)P
value
Age in years (Mean) 55.98±16.96 57.45±15.90 0.40
Sex (Females) % 61 (46.21) 115 (45.82) 0.005
Reasons for Tracheostomy n (%)
Chronic Ventilator Dependence 86 (65.15) 193 (76.89)
A i ti 6 (4 55) 7 (2 79)0.081
Aspiration 6 (4.55) 7 (2.79)
Airway Protection 39 (29.55) 48 (19.12)
Severe Hypoxia 1 (0.76) 3 (1.20)
Type of Tracheostomy n (%)
Percutaneous Tracheostomy 59 (44.70) 183 (72.91)
<0.001
Open Tracheostomy 67 (50.76) 54 (21.51)
Awake Tracheostomy 3 (2.27) 10 (3.98)
Cricothyroidotomy 3 (2.27) 0 (0.00)
Cricothyroidotomy Revision to Tracheostomy
0 4 (1.59)
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Pre and Post Tracheostomy Program
Patient Characteristics 2004 (N = 132) 2008 (N = 251)P
value
Underlying Problems
Cardiac 9 (6.82) 16 (6.37)
Cardiothoracic 8 (6.06) 27 (10.76)
Head and Neck 2 (1.52) 4 (1.59)
Head and Neck Oncology 2 (1.52) 26 (10.36)
0.37
Hematology Oncology 28 (21.21) 26 (10.36)
Oncology 10 (7.58) 20 (7.97)
Hepatic 2 (1.52) 2 (0.80)
Neurology 23 (17.42) 54 (21.51)
Pulmonary 17 (12.88) 26 (10.36)
Surgery 9 (6.82) 14 (5.58)
Thoracic 0 2 (1.20)
Transplant 3 (2.27) 10 (3.98)
Urology 5 (3.79) 7 (2.79)
Vascular Surgery 3 (2.27) 9 (3.59)
Pre and Post Tracheostomy Program (Outcomes)
Complications 2004 (N = 101) 2008 (N = 215)P
value
Airway Injury n (%) 6 (5.88) 3 (1.36) 0.022
Minor 2 (1.96) 1 (0.45)
0.153Intermediate 2 (1.96) 1 (0.45)
Major 2 (1.96) 1 (0.45)
Physiologic Disturbances
0 005Hypoxia 9 (8 91) 7 (3 17) 0.005Hypoxia 9 (8.91) 7 (3.17)
Loss of airway 4 (3.96) 1 (0.45)
Infection 31 (30.39) 75 (33.94) 0.528
No stoma infection 74 (72.55) 159 (71.95)
0.796Stoma infection within 1 week 16 (15.69) 40 (18.10)
Stoma infection after 1 week 12 (11.76) 22 (9.95)
Ventilator-associated pneumonia 4 (3.92) 27 (12.22) 0.019
Mortality
Death secondary to tracheostomy 0 0
Death before discharge 29 (28.43) 57 (25.79) 0.618
Death after discharge 3 (2.94) 6 (2.71) 0.909
Outcomes excluding patients who underwent head and neck surgery, cricothyroidotomy, cricothyroidotomyrevision to tracheostomy, and awake tracheostomy
Pre and Post Tracheostomy Program (Outcomes)
Percutaneous2008
(n = 182)
Open 2008
(n = 33)
P value
1.32 ± 1.99 5.21 ± 5.34 <0.001
167 (91.76) 14 (42.42)<0.001
15 (8.24) 19 (57.58)
Complications2004
(n = 57)2008
(n = 182)P
value
Efficiency in Days 2.61 ± 3.04 1.32 ± 1.99 0.001
Efficiency n (%)
Less than 48 hours 25 (43.86) 167 (91.76)<0.001
Greater than 48 hours 32 (56.14) 15 (8.24)
Time (Mean minutes)
37.02 ± 20.16 168.96 ± 190.92 <0.001
50.02 ± 22.29 210.21 ± 188.86 <0.001
37.32 ± 26.96 30.30 ± 26.65 0.169
53.11 ± 35.57 48.73 ± 36.65 0.518
Operating Time 59.71 ± 67.13 37.02 ± 20.16 0.01
Anesthesiologist’s Time
78.29 ± 79.62 50.02 ± 22.29 0.006
Length of Stay (Mean number of days)
ICU 35.26 ± 25.75 37.32 ± 26.96 0.61
Hospital 48.64 ± 40.74 53.11 ± 35.57 0.43
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Tracheostomy Support
• www.hopkinsmedicine.org/tracheostomy
• Educational Videos
• [email protected] pp @j
The End