Otolaryngologists Reach Consensus on Standardized Care for Tracheostomy Patients

Wide variation in the way tracheostomy care is delivered in the United States has led to efforts to standardize care to reduce complications. These efforts are happening both at the local level, among an increasing number of institutions developing and implementing their own standardized approach to tracheostomy care, and on the national level, as demonstrated by the recently published clinical consensus statement by the American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS) (Otolaryngol Head Neck Surg. 2013;148:620).

Published in September 2012, the clinical consensus statement provides a list of statements on tracheostomy care. A multidisciplinary panel of experts achieved consensus on these statements by using the modified Delphi method, which offers a way to refine expert opinion and facilitate consensus. The panel included representatives from pediatric and adult otolaryngology, laryngology, head and neck oncologic surgery, advanced nursing practice, respiratory therapy and emergency medicine.

According to the lead author of the study, Ron Mitchell, MD, the William Beckner MD Distinguished Chair in Otolaryngology at UT Southwestern Medical Center, Children’s Medical Center Dallas in Dallas, the consensus statement should be viewed as a road map for the care of a patient with a tracheostomy starting from the time the patient is prepared for the procedure and lasting through the education of patients and caregivers on tracheostomy care after discharge.

He emphasized that the areas of concensus achieved by the panel on tracheostomy care are based on opinion and practice and not on high quality published evidence, qualities that distinguish a consensus statement from a clinical guideline. “A guideline is a document that is based on the best available evidence,” he said. “A consensus document recognizes that there is not enough evidence to come up with a guideline and is basically an opinion-based document of a group of experts in the field.”

Key Areas of Consensus

Overall, the panel achieved consensus on 77 items that they believe influence tracheostomy care and are essential to improving care among patients with a tracheostomy tube. Areas covered include tracheostomy tube selection, care and maintenance; tracheostomy tube cuffs; complications; patient/caregiver education; pediatric tracheostomy care; and adult tracheostomy care. Although the statement does address issues specific to pediatric and adult tracheostomy care, as indicated by the last two areas, the conscensus statement overall provided guidance on tracheostomy care that pertains to both adult and pediatric patients.

Among the 77 items, the panel identified 13 key statements:

1. The purpose of the consensus statement is to improve care among pediatric and adult patients with a tracheostomy.
2. Patient and caregiver education should be provided prior to performing an elective tracheostomy.
3. A communication assessment should begin prior to the procedure when nonemergent tracheostomy is planned.
4. All supplies to replace a tracheostomy tube should be at bedside or within reach.
5. An initial tracheostomy tube change should normally be performed by an experienced physician, with the assistance of nursing staff, a respiratory therapist, medical assistant or assistance of another physician.
6. In the absence of aspiration, tracheostomy tube cuffs should be deflated when a patient no longer requires mechanical ventilation.
7. In children, prior to decannulation, a discussion with family regarding care needs and preparation for decannulation should take place.
8. Utilization of a defined tracheostomy care protocol for patient and caregiver education prior to discharge will improve patient outcomes and decrease complications related to their tracheostomy tube.
9. Patients and their caregivers should receive a checklist of emergency supplies prior to discharge that should remain with the patient at all times.
10. All patients and their caregivers should be evaluated prior to discharge to assess competancy of tracheostomy care procedures.
11. Patients and their caregivers should be informed of what to do in an emergency situation prior to discharge.
12. In an emergency, a dislodged, mature tracheostomy should be replaced with the same size or a size smaller tube or an endotracheal tube through the tracheostomy wound.
13. In an emergency, patients with a dislodged tracheostomy that cannot be reinserted should be intubated (when able to intubate orally) if the patient is failing to oxygenate, ventilate or there is fear the airway will be lost without intubation.

Dr. Mitchell emphasized that one key message of the consensus statement is the importance of educating the patient and family about tracheostomy care to reduce the complication rate. For example, he said that the consensus statement emphasizes involving a communication assessment before the tracheostomy is put in and making sure that patients and caregivers know how to change the tracheostomy upon discharge from the hospital. Further emphasis is placed on familiarizing caregivers and patients with emergency procedures and safety.

Pros and Cons

Although Kevin D. Pereira, MD, MS, professor of otorhinolaryngology-head and neck surgery and director of pediatric otolaryngology at Baltimore’s University of Maryland School of Medicine, agrees with most of the document’s points, he believes that several of the statements actually leave the door open for continued ambiguity instead of achieving the purported aim of the consensus statement to reduce variability in tracheostomy care.

For example, he said that statement five is too ambiguous and fails to offer any real strength of direction on who should normally change an initial tracheostomy tube. “The statement says that an experienced physician should be present at the first change, but one problem with this statement is defining who an experienced physician is,” he said. “Is it the attending otolaryngologist, an otolaryngology chief resident or fellow or an intensivist who routinely manages tracheostomies?”

Ideally, he said, he thinks this physician should be a member of the surgical team who is familiar with how that particular procedure was performed and aware of any variations in technique or complications that occurred during the procedure. “Outside of that,” he said, “I think the next best possible person would be another otolaryngologist.”

Although Dr. Pereira thinks the consensus statement is helpful in providing an overall general standard of care for both adult and pediatric tracheostomy care, he thinks there will be areas that people will not agree on. He also emphasized that the real success in standardizing tracheostomy care will come at the institutional level. “Right now, many hospitals have multidisciplinary teams to perform tracheostomies and have standardized care and technique within their hospitals,” he said, adding that this hospital-specific approach to standardizing care is better than a national effort because it allows institutions to evaluate their approach against outcomes.

Need for Local-Level Standardization

The Johns Hopkins University School of Medicine in Baltimore is one such institution. The hospital has developed and implemented a standardized approach to tracheostomy care over the past four or five years. According to Nasir Bhatti, MD, director of the university’s Johns Hopkins Adult Tracheostomy and Airway Service in the department of otolaryngology-head and neck surgery, the inclusion and participation of all stakeholders in its development and implementation has been critical to the success of the approach. Stakeholders include representatives from otolaryngology, head and neck surgery, general surgery, pulmonology, internal medicine and emergency medicine, as well as nurses, respiratory therapists and speech therapists.

“Everyone participates in developing the policy on things like electronic medical records, tracheostomy care orders, tracheostomy change policy and tracheostomy troubleshooting scenarios,” he said, adding that they used a modified Delphi technique to ensure that the process was truly collaborative and not top down.

Another critical factor was ensuring that everyone’s role on the tracheostomy team was clearly defined, as well as performing ongoing assessments of what works and what doesn’t. Of key importance, he said, is appointing one person to act as coordinator, spokesperson and advocate for the tracheostomy care policy. “In our case, we hired a nurse practitioner to take on that role to educate ancillary staff on an ongoing basis,” he added. This addition, he said, has led to a significant improvement in the standard and efficiency of tracheostomy care, particularly percutaneous tracheostomy, at their institution (see “The Tracheostomy Nurse Practitioner,” p. 9). Since the standardized approach has been in place, the institution’s major complication rate is approaching zero, said Dr. Bhatti, and the minor complication rate has been reduced by one-fourth of what it was prior to implementation of the policy.

Dr. Bhatti said the consensus statement may provide some direction to institutions trying to develop and implement their own standard tracheostomy care approaches. According to Dr. Bhatti, the consensus statement can be useful if institutions ask, “What is our culture and how can we meld our policy with those recommended in the consensus statement so that it is feasible to implement on an ongoing basis?”

According to Dr. Mitchell, the statement highly encourages this approach. “The consensus statement is not institution specific, and having teams that take care of patients with tracheostomy is highly encouraged,” he said, adding that the statement makes suggestions to the team regarding the agreed requirements for looking after a patient with a tracheostomy. The goal of the consensus statement, he emphasized, is not to restrict or dictate care.