Utilizing Simulation to Enhance Knowledge and Skill in Management of

Tracheostomy and Laryngectomy

Tracheostomy and laryngectomy are specific surgical techniques that create an

airway which communicate with the anterior neck to allow respiration in

patients with upper airway obstructions among other indications. While these

may have similar superficial appearance; the upper airway can never be used in

total laryngectomy, but may possibly be used in tracheostomy patients.

Physicians not trained in performing these surgical procedures often have

inadequate knowledge to properly manage the airways of these patient

populations.1 Individuals with surgically constructed upper airways often have

additional co-morbid medical conditions and require care from a variety of

physician specialists, increasing the chances that they could receive care from

providers with little to no training in management of their airway. This

prospective study is an educational research and quality improvement project

aimed to determine if high fidelity simulation combined with didactics is an

effective strategy in educating physicians in tracheostomy and laryngectomy

care. A similar educational intervention has been used in tracheostomy

education in other studies with encouraging results.2,3,4

INTRODUCTION METHODS

Pre- and post- intervention assessment of self-perceived comfort showed astatistically significant improvement in median Likert score from 2.21 to 4.40(p < 0.001).

DISCUSSION

REFERENCES

Patients with laryngectomy and tracheostomy are commonly cared forby many physician specialties, some of which have had minimal trainingon the unique features of tracheostomy and laryngectomy care. Thisstudy has shown that comprehensive tracheostomy and laryngectomyeducation, which combines enhancement of knowledge with simulationof both routine and emergent aspects of care, was effective in improvingconfidence, knowledge, and procedural proficiency. This should result inimproved outcomes for these patient populations. Similar educationcourses would be a useful addition to the curriculum of physiciantrainees likely to manage patients with tracheostomy or laryngectomy.

1. Casserly P, Lang E, Fenton JE, Walsh M. Assessment of healthcare professionals’ knowledge of managing emergency complications in patients with a tracheostomy. Br J Anaesth 2007;99:380-3

2. Dorton LH, Lintzenich CR, Evans AK. Simulation model for tracheotomy education for primary health-care providers. Ann Otol Rhinol Laryngol 2014;123:11–18

3. Khademi A, Cuccurullo SJ, Cerillo LM, Dibling J, Wade C, Liang J, Martin ML, PetagnaAM, Strax TE. Tracheostomy management skills competency in physical medicine and rehabilitation residents: a method for development and assessment. Am J Phys Med Rehabil 2012;91:65–74.

4. Agarwal A, Marks N, Wessel V, Willis D, Bai S, Tang X, Ward WL, Schellhase DE, Carroll JL. Improving knowledge, technical skills, and confidence among pediatric health care providers in the management of chronic tracheostomy using a simulation model. Pediatr Pulmonol. 2015 doi: 10.1002/ppul.23355

RESULTS

Figure 1. Anatomy of Tracheostomy and Laryngectomy Source: McGrath, Brendan. Comprehensive Tracheostomy Care: The National

Tracheostomy Safety Project Manual. Vol. 1. N.p.: Wiley-Blackwell, n.d. Print.

Kevin A. Davis, M.D.1; Courtney Edgar-Zarate, M.D.1; Julianna Bonilla-Velez, M.D.2; Timothy N Atkinson, Ed.D.1

Ozlem Tulunay Ugur, M.D.3*; Amit Agarwal, M.D.4*1Department of Internal Medicine, University of Arkansas for Medical Sciences, Little Rock, Arkansas, 2Department of Otolaryngology-Head and Neck Surgery, University of Arkansas for Medical Sciences, Little Rock, Arkansas, 3Division of Laryngology, Department of Otolaryngology-Head and Neck Surgery, University of Arkansas for Medical sciences, Little Rock, Arkansas, 4Division of Pediatric Pulmonary and Sleep Medicine, Department of Pediatrics, University of Arkansas for Medical Sciences, Little Rock, Arkansas, *Co-senior authorship

Tracheostomy Laryngectomy

Tracheostomy Laryngectomy

Figure 2. External Appearance of Tracheostomy and Laryngectomy Source: UK National Tracheostomy Safety Project <tracheostomy.org.uk>; basic knowledge learning module

Sixty-four physician trainees from internal medicine, internal

medicine-pediatrics, emergency medicine, and pediatric

emergency medicine training programs participated in this

educational study and comprehensive, simulation-based

curriculum. The curriculum included a tracheostomy and

laryngectomy didactic session, hands on experience performing a

tracheostomy change, and practicing emergency scenarios on

interactive, high fidelity simulation mannequins. Pre- and post-

intervention assessments were performed which included a

Likert scale based assessment of self-perceived comfort, an

objective multiple choice assessment of knowledge, and a check-

list assessment of routine tracheostomy change proficiency

performed by staff experienced in tracheostomy care. Pre- and

post- assessments were individually matched using anonymous

identifiers and results compared.

Didactics Content

• Anatomy of Tracheostomy and Laryngectomy

• Physiologic changes

• Tracheostomy maturity

• Tracheostomy tube introduction

• Accessory equipment

• Speech in Laryngectomy

• Tracheostomy/Laryngectomy Emergencies

• Bleeding from Tracheostomy

• Unplanned Decannulation

• Tracheostomy obstruction

• ACLS neck breathers

Emergency Scenarios

• Plugged Tracheostomy Tube in Mature Tracheostomy

• False Passage in Fresh Tracheostomy

• ACLS in Laryngectomy

Figure 4. (right) ACLS in Laryngectomy Scenario

Figure 3. (left) False Passage Scenario in ICU setting

Proctor assessment of learners’ ability to perform routine tracheostomychange showed a statistically significant improvement (p < 0.001) from42.5% of individual proficiencies completed to 83.9%.

Assessment of objective knowledge showed a statistically significantimprovement in mean multiple choice score from 58.8% to 84.6% (p < 0.001).

Curriculum evaluation by participants was overwhelmingly positive with meanLikert scores of greater than 4.9 out of 5 in every category evaluated.

Of the 47 participants that completed the pre- and post-test, 46 reportedan improvement in average comfort score after the training.

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