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Management of patients with a tracheostomy tube includes many components of care provided by clinicians from various health care disciplines.
In recent years, clinicians worldwide have demonstrated a renewed interest in the management of patients with tracheostomy due to the recognition that more effective and efficient management of this patient population is necessary to decrease morbidity and mortality and to optimize the value of the procedure.
Commensurate with the goal of enhancing the care of patients with tracheostomy, we conducted a systematic review to facilitate the development of recommendations relevant to the care of adult patients with tracheostomy in the acute care setting. From our systematic review, clinical practice guidelines were developed to address questions regarding the impact of tracheostomy bundles, tracheostomy teams, and protocol-directed care on time to decannulation, length of stay, tracheostomy-related cost, tracheostomy-related adverse events, and other tracheostomy-related outcomes in tracheostomized adult patients in the acute care setting.
A tracheostomy is commonly performed in critically ill patients because it potentially confers several benefits over prolonged endotracheal intubation, including airway stability, facilitation of oral intake, increased comfort, and, possibly, facilitation of weaning.
Between and , 9. The care of patients with tracheostomy is costlier because of their longer hospital stay and because they are commonly discharged to a long-term facility. Halum and colleagues 11 investigated the long-term outcomes of critically ill patients with ages ranging from 15 to 93 y and reported that subjects with tracheostomy had higher mortality Adult patients with tracheostomy consume a disproportionate amount of health care resources.
Effective and efficient management of patients with tracheostomy is necessary to prevent morbidity and mortality and to reduce the cost of care in this patient population.
We conducted a systematic review of peer-reviewed literature to develop recommendations that could enhance the care of adult patients in the acute care setting with tracheostomy tubes in situ. The clinical practice guidelines that were developed from this systematic review are centered around the following questions relevant to the management of adult patients in the acute care setting:. Does the use of a tracheostomy bundle impact time to decannulation, length of stay LOS , tracheostomy-related cost, and tracheostomy-related adverse events in tracheostomized adult patients in the acute care setting?
Does the use of tracheostomy teams impact time to decannulation, LOS, tracheostomy-related cost, and tracheostomy-related adverse events in tracheostomized adult patients in the acute care setting? Does protocol-directed care impact time to decannulation, LOS, tracheostomy-related cost, and tracheostomy-related adverse events in tracheostomized adult patients in the acute care setting?
A committee was selected by American Association for Respiratory Care AARC leadership based on their known experience related to the topic, interest in participating in the project, and commitment to the process details. The committee first met face-to-face, where they were introduced to the process of developing clinical practice guidelines. At that time, the committee selected a chair and wrote a first draft of questions in a format that directly related to the patient, intervention, comparison, and outcome PICO.
Subsequent meetings occurred as needed by conference call and included AARC staff as needed. Frequent email communications occurred among committee members and AARC staff. The committee members received no remuneration for their participation in the process, though their expenses for the face-to-face meeting were covered by the AARC.
The search strategies used a combination of relevant controlled vocabulary ie, Medical Subject Headings and CINAHL Headings and keyword variations that related to tracheostomy care and techniques, hospitalization, and outcomes. The searches were limited to English-language studies about human populations. The searches were also designed to filter out citations indexed as commentaries, editorials, interviews, news, or reviews.
No date restrictions were applied to the searches. Duplicate citations were identified and removed using EndNote X7 citation management software Clarivate Analytics, Philadelphia, Pennsylvania. Two reviewers independently assessed study eligibility in the Covidence systematic review software Melbourne, Australia. Inclusion criteria used to assess eligibility were: 1 tracheostomy and 2 adult population. The exclusion criteria used were: 1 not tracheostomy care, 2 non-clinical topic, 3 pediatric population, 4 endotracheal tube, 5 intubated patients, 6 laryngectomy, 7 case study, and 8 not empirical research eg, theory or opinion articles.
The search strategies retrieved 1, articles. After the removal of duplicates, 1, articles remained for screening, of which 1, were excluded at the title and abstract level. Of the remaining articles, 96 were excluded following full text review against the inclusion and exclusion criteria. During the extraction phase, 4 additional articles were excluded.
A total of 17 articles were included in this systematic review Fig. Risk of bias for most of the studies no. The most common limitations to the quality of the studies were small sample size, retrospective study design, inadequate description of study subjects and procedures, and weakness in statistical methodology.
It is recognized that a process is necessary to combine the best available evidence with the collective experience of committee members. The literature was collapsed into evidence tables according to PICO question. Individual panel members were assigned the task of writing a systematic review of the topic, drafting 1 or more recommendations, and suggesting the level of evidence supporting the recommendation: A convincing scientific evidence based on randomized controlled trials of sufficient rigor; B weaker scientific evidence based on lower levels of evidence such as cohort studies, retrospective studies, case-control studies, and cross-sectional studies; C based on the collective experience of the committee.
Committee members reviewed the first draft of evidence tables, systematic reviews, recommendations, and evidence levels. Each committee member rated each recommendation using a Likert scale of 1—9, with 1 meaning expected harms greatly outweigh the expected benefits and 9 meaning expected benefits greatly outweigh the expected harms. The ratings were returned to the committee chair. The first ratings were done with no interaction among committee members.
A conference call was convened, during which the individual committee ratings were discussed. Particular attention was given to any outlier scores and the justification. Recommendations and evidence levels were revised with input from the committee members. After discussing each PICO question, committee members re-rated each recommendation. The final median and range of committee members’ scores are reported. Strong agreement required that all committee members rank the recommendation 7 or higher, whereas weak agreement meant that one or more committee members ranked the recommendation below 7, but the median vote was at least 7.
For recommendations with weak agreement, the percentage of committee members who rated 7 or above was calculated and reported after each weak recommendation. Figure 2 illustrates the process flow the panel used to rate the appropriateness and quality of the literature selected through the search process. Drafts were distributed among committee members in several iterations.
When all committee members were satisfied, the document was submitted for publication. The clinical practice guidelines were subjected to peer review before final publication. Patients with tracheostomies are medically complex and require integrated care from several different health care professionals. To streamline the care of multiple providers, care bundles have been introduced. Care bundles have become commonplace because their use has demonstrated improvement in both care processes and outcomes.
For example, discharge care bundles for patients with COPD result in fewer hospital readmissions, 32 and specific ventilator bundle components are associated with improved outcomes. Despite this evidence, a review of the relevant literature yielded only 1 observational study of a tracheostomy care bundle, which consisted of 4 structured approaches to providing care for patients with tracheostomies.
Tracheostomy-related outcomes are important consequences of having a tracheostomy tube in situ and include time to decannulation, tracheostomy-related adverse events, tracheostomy-related health care cost, hospital LOS, tracheostomy-related pressure injury, time to oral intake, and time to communication. Only 2 studies, which were observational in nature, have addressed this question Table 1.
The researchers noted that the decannulation rate before discharge Additionally, the proportion of subjects in the post-tracheostomy bundle group that tolerated an oral diet before discharge There was no significant difference in the median hospital LOS between the 3 groups of subjects.
Because this observational study of subjects was conducted in a single institution and the severity of illness and duration of mechanical ventilation was different between groups, it is unclear whether these results can be generalized.
Over the past decade, the awareness of medical device-related pressure injury has increased, as have recommendations for preventive measures for reducing pressure injury caused by respiratory care devices, such as noninvasive positive pressure device interfaces and endotracheal tubes. The bundle used in the study consisted of 4 components: 1 placement of a hydrocolloid dressing underneath the tracheostomy flange in the postoperative period, 2 removal of plate sutures within 7 d of the tracheostomy procedure, 3 placement of a polyurethane foam dressing after suture removal, and 4 neutral positioning of the head.
The researchers reported a significant reduction in the rate of hospital-acquired tracheostomy-related pressure ulcers in the post-TRAPU care bundle group 1. Given the benefits of using a structured approach to provide unique care to each patient, evidence supports the use of tracheostomy bundles that have been evaluated and approved by a team of individuals experienced in tracheostomy management for tracheostomized adult patients in the acute care setting Evidence level B; median appropriateness score 7, range 6—8.
This approach has been shown to decrease time to decannulation, decrease tracheostomy-related adverse events, and improve other tracheostomy-related outcomes, namely, tolerance of oral diet. The most rigorous assessment of the evidence regarding the use of tracheostomy teams in the management of patients with tracheostomy tubes was performed by Speed and Harding 36 via a systematic review and meta-analysis. After the publication of this meta-analysis, 2 observational studies 21 , 23 that focused on the use of a tracheostomy team were published.
The study by Arora and colleagues 14 was not included in the meta-analysis. These 3 additional observational studies were determined to be of low to moderate quality. The outcomes on which the meta-analysis by Speed and Harding 36 focused were limited to time to decannulation and hospital LOS. However, other clinically important tracheostomy-related outcomes were reported in the meta-analysis. The results of the meta-analysis indicated that tracheostomy teams were associated with reductions in total tracheostomy time and increased speaking valve use.
Of the 10 studies 14 — 23 all observational that focused on the use of tracheostomy teams, 8 reported time to decannulation as an outcome, 14 — 19 , 22 , 23 and 3 of these 8 studies 14 , 16 , 22 reported a significant decrease in time to decannulation in subjects managed by a tracheostomy team.
Six studies 15 — 17 , 19 — 21 reported tracheostomy-related complications or adverse clinical events as an outcome, and all 6 studies reported significantly less adverse clinical outcomes in subjects managed by a tracheostomy team. One study reported tracheostomy-related cost, 15 and 1 study reported tracheostomy tube downsizing time 17 Table 2. The composition of the multidisciplinary tracheostomy team, role of team members, and team responsibilities varied for each study. In the 2 North American studies by de Mestral et al 17 and Welton et al, 23 a respiratory therapist was a member of the multidisciplinary team that included a physician and a speech-language pathologist.
However, in other countries such as Australia and England, where respiratory therapists are unavailable, the multidisciplinary teams may consist of a combination of one or more physicians from different specialties eg, otolaryngology, pulmonary, critical care , one or more nurses, a speech-language pathologist, a respiratory physiotherapist, a dietitian, and a social worker.
Sodhi and colleagues 21 used specially trained staff nurses for the specialized tracheostomy team. Evidence supports the addition of a multidisciplinary tracheostomy team to the management strategy of tracheostomized adult patients in the acute care setting Evidence level B; median score 7, range 5—8.
A multidisciplinary tracheostomy team can decrease time to decannulation, LOS, and tracheostomy-related adverse events; this approach can also improve other tracheostomy-related outcomes, namely, increase in speaking valve use. The composition of the tracheostomy team should follow local custom. The use of evidence-based protocols in health care has become widely accepted, and respiratory therapists are expected to be highly proficient in the application of protocols to improve the quality of the care they provide.
With regard to patients with tracheostomies, the inherent complexity of providing safe, efficacious care for them merits the use of evidence-based protocols. A review of the literature yielded a total of 5 studies 24 — 28 that focused on the use of protocols in the management of tracheostomized adult patients in the acute care setting.
All 5 studies were observational and were judged to be of low to moderate quality. Most of the studies that investigated the effectiveness of protocols in the care of subjects with tracheostomies used time to decannulation as the primary outcome Table 3. Frank and colleagues 25 performed a retrospective chart review 3 y after the implementation of a multidisciplinary swallowing and weaning protocol for dysphagic patients with tracheostomies.
Data for 35 subjects who had tracheostomy tubes in situ after the protocol was implemented and data for 12 subjects with tracheostomy tubes in situ before the protocol was implemented were analyzed. The mean time to decannulation prior to protocol implementation was The researchers concluded that the multidisciplinary protocol was associated with earlier decannulation. The mean total time to decannulation in the baseline cohort was After pathway implementation in the pilot cohort, total time to decannulation decreased to 5.
In the follow-up cohort, total time to decannulation was 8.
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