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http://oto.sagepub.com/content/147/4/684The online version of this article can be found at:

 DOI: 10.1177/0194599812449995

2012 147: 684 originally published online 5 June 2012Otolaryngology -- Head and Neck SurgeryKalmar, David J. Feller-Kopman, Elliott R. Haut, Lonny B. Yarmus and Nasir I. Bhatti

Vinciya Pandian, Christina R. Miller, Marek A. Mirski, Adam J. Schiavi, Athir H. Morad, Ravi S. Vaswani, Christopher L.Multidisciplinary Team Approach in the Management of Tracheostomy Patients

  

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Original Research—General Otolaryngology

Multidisciplinary Team Approach in theManagement of Tracheostomy Patients

Otolaryngology–Head and Neck Surgery147(4) 684–691� American Academy ofOtolaryngology—Head and NeckSurgery Foundation 2012Reprints and permission:sagepub.com/journalsPermissions.navDOI: 10.1177/0194599812449995http://otojournal.org

Vinciya Pandian, PhDc, CRNP1, Christina R. Miller, MD2,Marek A. Mirski, MD, PhD2, Adam J. Schiavi, MD, PhD2,Athir H. Morad, MD2, Ravi S. Vaswani1, Christopher L. Kalmar1,David J. Feller-Kopman, MD3, Elliott R. Haut, MD2,4,Lonny B. Yarmus, DO3, and Nasir I. Bhatti , MD, MHS5

Sponsorships or competing interests that may be relevant to content are dis-

closed at the end of this article.

Abstract

Objective. To examine whether the implementation of a mul-tidisciplinary percutaneous tracheostomy team decreasescomplications, improves efficiency in patient care, andreduces length of stay and cost in patients undergoing per-cutaneous tracheostomy.

Study Design. Case series with planned data collection.

Setting. Urban, academic, tertiary care medical center.

Subjects and Methods. Patients who underwent a percuta-neous tracheostomy in 2004 and 2008, before and after theformation of a multidisciplinary percutaneous tracheostomyteam, were included in the study. Data for the study wereretrieved from a tracheostomy database. Measured outcomesinclude complications, efficiency, length of stay, and cost.

Results. Complications such as airway bleeding and physiolo-gical disturbances decreased significantly in 2008 as com-pared with 2004. The percentage of patients who received atracheostomy within 2 days increased from 42.3% to 92%(2004 vs 2008), showing improvement in efficiency of care.There was no significant difference between the groups interms of infection rate, length of stay, or mortality.However, in a subanalysis, the length of stay was found tobe decreased in patients whose primary diagnosis was aneurological disorder. Finally, despite the necessity of ahospital-based subsidy, the team approach yielded substantialfinancial benefit to the medical center.

Conclusions. Airway bleeding, physiological disturbances, andefficiency of care improved after the institution of a multidis-ciplinary percutaneous tracheostomy team approach andmay have a favorable impact on health care costs.

Keywords

percutaneous tracheostomy, multidisciplinary team, criticallyill patients, mechanical ventilation

Received January 6, 2012; revised April 11, 2012; accepted May 8,

2012.

Chronic ventilator dependence is a significant prob-

lem in health care. According to the United States

Healthcare Cost and Utilization Project, mechanical

ventilation is the inpatient procedure that consumes the

most health care dollars annually; costs that are related to

the prolonged length of stay (LOS), morbidity, and mortal-

ity associated with mechanical ventilation.1 The number of

critically ill patients requiring chronic mechanical ventila-

tion is rising by as much as 5.5% each year.2 Most patients

with chronic ventilator dependence require a tracheostomy;

hence, the number of tracheostomies is also rising. In recent

years, percutaneous tracheostomy has gained favorability as

the standard technique used to perform tracheostomies.

Open tracheostomy is now reserved for anatomically diffi-

cult or medically challenging patients. Since the introduc-

tion of the percutaneous tracheostomy by Sheldon et al in

1955, there has been ongoing debate regarding the relative

merits of various approaches such as the Griggs, Seldinger,

Fantoni, and Ciaglia techniques.3-6

Despite the refinement of these techniques and reports of

potentially decreasing complications with percutaneous tra-

cheostomy, questions remain as to why morbidity persists

1Percutaneous Tracheostomy Service, The Johns Hopkins Medical

Institutions, Baltimore, Maryland, USA2Department of Anesthesiology and Critical Care Medicine, The Johns

Hopkins Medical Institutions, Baltimore, Maryland, USA3Department of Pulmonary and Critical Care Medicine, The Johns Hopkins

Medical Institutions, Baltimore, Maryland, USA4Department of Surgery, The Johns Hopkins Medical Institutions, Baltimore,

Maryland, USA5Department of Otolaryngology Head and Neck Surgery, The Johns

Hopkins Medical Institutions, Baltimore, Maryland, USA

Corresponding Author:

Vinciya Pandian, PhDc, CRNP, Percutaneous Tracheostomy Service, The

Johns Hopkins Hospital, 600 N Wolfe Street, Meyer 8-140, Baltimore, MD

21287, USA

Email: vpandia1@jhmi.edu

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and how to improve practice. Clinicians caring for patients

receiving coronary artery bypass graft and arthroplasty have

noted a significant improvement in patient outcomes after

dedicating structured multidisciplinary teams for the provi-

sion of standardized patient care.7,8 Multidisciplinary teams

have also been established in a few institutions to manage

tracheostomy patients.9-17 They often include physicians,

nurses, physiotherapists, speech-language pathologists, and

respiratory therapists, but the role of these teams begins

postoperatively and is limited to tracheostomy care and

education.

A unique multidisciplinary percutaneous tracheostomy

team (MPTT) was established in 2006 at the Johns Hopkins

Hospital with the goal of improving patient care by promot-

ing safety, decreasing complication rates, and decreasing

intensive care unit (ICU) and hospital LOS in patients

undergoing percutaneous tracheostomy in the ICU. The pur-

pose of this study was to examine whether the newly estab-

lished MPTT was effective in accomplishing these goals

and reducing costs. We hypothesized that each of these fac-

tors would be improved in patients who received a percuta-

neous tracheostomy in 2008 by the MPTT compared with

patients in 2004 prior to the formation of the team.

Methods

After obtaining approval from the Johns Hopkins Medicine

Office of Human Subjects Research Institutional Review

Boards (Committee: JHM-IRB X), data were retrieved from

a tracheostomy database that was created after the establish-

ment of tracheostomy program in 2006 and stored on a

secure hospital server. Patients who were 18 years or older,

underwent mechanical ventilation, and received a bedside

percutaneous tracheostomy in an ICU at the Johns Hopkins

Hospital during the calendar years of 2004 and 2008 were

included in the study. Patients who received an open tra-

cheostomy or cricothyroidotomy within our institution or a

percutaneous or open tracheostomy at an outside hospital

were excluded. The data for patients who received a percu-

taneous tracheostomy in 2004 were retrospectively collected

from patient health records and entered into the database;

data for patients in 2008 were prospectively collected and

entered.

Our MPTT is composed of a credentialed operator (from

the disciplines of otolaryngology head and neck surgery,

trauma surgery, or interventional pulmonology [IP]), an

anesthesiologist, a dedicated tracheostomy coordinator

(nurse practitioner), registered nurses, respiratory therapists,

speech-language pathologists, an administrative assistant,

and equipment specialists (Figure 1).18,19 Our tracheostomy

coordinator screened patients who were intubated for greater

than 96 hours to establish eligibility for percutaneous tra-

cheostomy. Once the patient met the criteria for a percuta-

neous tracheostomy, a formal consult was initiated to

manage perioperative issues.18 The team provided standar-

dized preoperative evaluation and optimization, performed

the percutaneous tracheostomy at the bedside, and provided

postoperative care and education until the patient was dis-

charged from the hospital (Figure 2). The team used a Blue

Rhino Cook Percutaneous Tracheostomy Kit and video-

bronchoscopy for all tracheostomies. The MPTT was avail-

able for procedures 3 days per week. The MPTT

coordinator performed screening, follow-up, and education

5 days per week and was available for consultation by

pager. Patients requiring follow-up care were also seen as

outpatients in otolaryngology, interventional pulmonary, or

general surgery clinics.

The effectiveness of the MPTT was evaluated using out-

come variables including complications, efficiency, and

LOS. Complications included airway injury, physiological

disturbances, development of infection, and mortality.

Airway injury was defined as an injury to the posterior wall

of the trachea or any adjacent blood vessels that resulted in

hemorrhage.20 Minor hemorrhage was defined as presence

of less than 50 mL of blood loss that required an additional

Director

Tracheostomy Coordinator(Nurse Practitioner)

Administrative Roles

AdministrativeAssistant

EquipmentSpecialist

Clinical Roles

CredentialedOperators

Anesthesiologist RegisteredNurses

RespiratoryTherapists

Speech-Language

Pathologists

Figure 1. Organizational structure of the members within the multidisciplinary percutaneous tracheostomy team.

Pandian et al 685

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suture during or soon after procedure but not additional nur-

sing interventions such as recurrent packing of the wound or

administration of blood products.21 Intermediate hemorrhage

was defined as hemorrhage greater than 50 mL requiring

recurrent packing or suturing but not the administration of

blood products.21 Major hemorrhage was defined as hemor-

rhage greater than 50 mL requiring recurrent packing and

administration of blood products.21 Hypoxia and loss of

airway were important physiological disturbances identified

on review of electronic data. Hypoxia was defined as

oxygen saturation less than 90% perioperatively, from the

initial procedure time out to 1 hour after the procedure.

Loss of airway was the unplanned extubation of the endotra-

cheal tube during the procedure. Development of infection

was assessed in terms of local peristomal infection and

ventilator-associated pneumonia (VAP). Mortality rates

were assessed at 48 hours posttracheostomy, at discharge

from the hospital, and at 1 year posttracheostomy.

Efficiency of care provided by the MPTT was defined by

the number of days from the time of request for a tracheost-

omy to the time the procedure was performed and the opera-

tive time. Time to tracheostomy was dichotomized into less

than or equal to 2 days and greater than 2 days after the

request time. The MPTT was considered efficient if this

time was less than or equal to 2 days. Efficiency was also

measured by calculating the operative time (from skin loca-

lization to final securement of tracheostomy tube) and

anesthesia time (total time spent at bedside by the anesthe-

siologist) for tracheostomy placement. LOS was measured

in ICU posttracheostomy days, overall ICU days, and over-

all hospital days.

The MPTT was created with an institutional contribu-

tion for MPTT staff support to supplement the discounted

professional reimbursement and capital equipment costs.

The subsidy for salary support was apportioned between

anesthesiology, general surgery, interventional pulmonol-

ogy, and otolaryngology in accordance with percentage

effort contributed to the clinical activity. Cost-benefits

analysis was performed by assessing the increased revenue

or savings incurred and then subtracting any hospital-

required subsidy. Overall, the financial impact was deter-

mined by subtracting the running cost of care to the facil-

ity from the assumed usual discounted cost of admission

and additional admissions to the ICU for the common

diagnosis and procedure codes at our facility. These diag-

noses and procedure codes were in accordance with the

Maryland Health Care Commission. ICU cost efficiency

was determined by estimating calculated LOS reduction

using a 75% backfill rate of open ICU beds made available

based on the reduction in patient LOS from 2004. These

estimations are consistent with our daily ICU average

census of 75% to 100%.

STATA 11.0 (StataCorp, College Station, Texas) was

used to analyze the data. Means and standard deviations

Screening and Identificationof the Patient

Education and ConsentObtainmentEvaluation of the Patient

Scheduling and Notification

Tracheostomy Placement

Documentation and DataManagementEducationFollow-up

Work Flow

Preoperative

Postoperative

Intraoperative

Improved Patient OutcomesDecreased Health Care Costs

Figure 2. Workflow of the multidisciplinary percutaneous tracheostomy team.

686 Otolaryngology–Head and Neck Surgery 147(4)

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were calculated for continuous data. Percentages were cal-

culated for categorical data. T tests were performed to com-

pare continuous data, and x2 or the Fisher exact test was

used to compare categorical data. All patient-refined diag-

nosis-related groups (APR-DRGs), a classification that is

composed of scores for severity of illness, risk of mortality,

and resource intensity of patient care, were also retrieved

from the electronic data to account for variations in

acuity.22 Regression analyses were performed to explore the

relationship between LOS and the year the trachestomy was

done, controlling for factors such as age, sex, reason for the

tracheostomy, and APR-DRGs.

Results

A total of 242 patients met inclusion criteria, and all were

included in the final analysis. A total of 59 patients from

2004 and 183 from 2008 had received a percutaneous tra-

cheostomy. There was no significant difference in patient

characteristics between percutaneous tracheostomy patients

in 2004 and 2008 (Table 1). The average age of all the

patients in our study was 56.9 6 16.7 years, and 45.87% of

them were women.

The indication for tracheostomy was classified into 1 of

4 categories: chronic ventilator dependence, severe hypoxia,

aspiration (prior aspiration event), and airway protection (at

risk for aspiration). Chronic ventilator dependence was the

leading indication for tracheostomy in 2004 (n = 52; 88.1%)

and 2008 (n = 166; 90.7%).

The predominant disease category of patients in this

study was neurological disease in both 2004 (n = 14;

23.73%) and 2008 (n = 46; 25.14%). However, the second

most common disease category was pulmonary in 2004 (n =

11; 18.64%) and trauma in 2008 (n = 25; 13.66%). The dif-

ference in acuity of illness defined by APR-DRGs between

the 2 groups in 2004 and 2008 was not statistically signifi-

cant (P = .33).

Table 1. Patient Characteristics

Pre-MPTT Post-MPTT

Patient Characteristic 2004 (n = 59) 2008 (n = 183) P Value

Age, y, mean 6 SD 57.1 6 19.1 59.9 6 15.9 .92

Female, % 49.1 44.8 .56

Indication for tracheostomy, n (%)

Chronic ventilator dependence 52 (88.1) 166 (90.7) .65

Aspiration 2 (3.4) 6 (3.3)

Airway protection 5 (8.5) 9 (4.9)

Severe hypoxia 0 2 (1.1)

Disease categories, n (%)

Cardiac 4 (6.8) 15 (8.2) .38

Cardiothoracic surgery 3 (5.1) 21 (11.5)

Head and neck surgery 0 1 (0.5)

Head and neck oncology 2 (3.4) 0

Hematologic oncology 0 4 (2.2)

Other oncology 5 (8.5) 16 (8.7)

Hepatic 1 (1.7) 2 (1.1)

Neurology 14 (23.7) 46 (25.1)

Pulmonary 11 (18.6) 19 (10.4)

General surgery 5 (8.5) 10 (5.5)

Thoracic surgery 0 1 (0.5)

Transplant 2 (3.4) 9 (4.9)

Trauma 6 (10.2) 25 (13.7)

Urology 4 (6.8) 7 (3.8)

Vascular surgery 2 (3.4) 7 (3.8)

Acuity of illness, n (%)

APR-DRG

1 0 1 (0.5) .33

2 0 4 (2.2)

3 0 0

4 44 (74.6) 116 (63.4)

5 15 (25.4) 62 (33.9)

Abbreviations: APR-DRG, all patient-refined diagnosis-related groups; MPTT, multidisciplinary percutaneous tracheostomy team.

Pandian et al 687

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When complications were assessed, we found that the

number of patients with airway bleeding decreased by

84.3% (P = .002), and physiological disturbances decreased

by 76.2% (P = .001) in 2008 as compared with 2004. There

was no significant difference in infection and mortality rates

between the 2 groups (Table 2).

All measurements of efficiency significantly improved

from 2004 to 2008. Compared with 2004, the mean number

of days from time the tracheostomy was requested to the

procedure was significantly shorter by about 1.5 days in

2008 (2.7 6 3.02 vs 1.3 6 2.0; P = .0006; Table 2). The

percentage of patients who received a tracheostomy within

2 days of the request significantly increased from 42.4% in

2004 to 92% in 2008 (P \ .001). Both the time needed to

perform percutaneous tracheostomy and the time spent by

anesthesiologists with the patient at the bedside significantly

decreased by 22.7 minutes (P = .013) and 28.3 minutes (P =

.006), respectively (Table 2).

The LOSs (posttracheostomy ICU, overall ICU, and over-

all hospital stay) were not significantly different between the

2 groups of patients receiving percutaneous tracheostomy

after controlling for age, sex, reason for the tracheostomy,

and APR-DRGs. However, on a subanalysis of patients in

various disease categories, patients with neurological diseases

were found to have a decreased posttracheostomy ICU and

overall ICU LOS. Posttracheostomy ICU LOS was reduced

by 39.47% (P = .04) and overall ICU LOS by 25% (P = .01;

Table 2). Because of an ICU LOS reduction, especially in

patients with primary neurological disorders, incremental

growth of admissions and surgeries was realized. Table 3

Table 2. Outcomes

Pre-MPTT Post-MPTT

2004 (n = 59) 2008 (n = 183) P Value

Complications, n (%)

Airway bleeding 6 (10.5) 3 (1.6) .002

Minor 2 (3.4) 1 (0.5) .03

Intermediate 2 (3.4) 1 (0.5)

Major 2 (3.4) 1 (0.5)

Physiological disturbances

Hypoxia 8 (13.8) 6 (3.3) .001

Loss of airway 3 (5.1) 1 (0.5)

Infection

Stoma infection 18 (30.5) 61 (33.3) .69

Ventilator-associated pneumonia 3 (5.1) 24 (13.1) .09

Mortality

Death within 48 h 0 0

Death before discharge 17 (28.8) 50 (27.5) .47

Death after discharge 2 (3.4) 3 (1.6)

Efficiency

Number of days to tracheostomy, days 6 SD 2.7 6 3.0 1.3 6 2.0 .0006

Tracheostomy performed within 2 days, n (%)

�2 days 25 (42.4) 167 (91.8) \.001

.2 days 34 (57.6) 15 (8.2)

Clinical time, min, mean 6 SD

Operating time 59.7 6 67.1 37.0 6 20.2 .02

Anesthesiologist time 78.3 6 79.6 50.0 6 22.3 .0061

Length of stay, days, mean 6 SD

Overall ICU 35.1 6 25.5 37.1 6 27.0 .61

Posttracheostomy ICU 15.8 6 12.8 15.7 6 10.6 .96

Overall hospital 48.7 6 40.0 52.8 6 35.7 .46

Length of stay of patients with neurological disorders (subanalysis) 2004 (n = 14) 2008 (n = 46) P value

Overall ICU 24.82 6 12.37 18.6 6 4.33 .01

Posttracheostomy ICU 12.06 6 11.63 7.30 6 3.41 .04

Overall hospital 30.18 6 14.16 28.80 6 9.85 .70

Abbreviations: ICU, intensive care unit; MPTT, multidisciplinary percutaneous tracheostomy team.

688 Otolaryngology–Head and Neck Surgery 147(4)

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illustrates the overall positive net revenue benefit to the med-

ical center as a result of the MPTT, despite a hospital contri-

bution of approximately $500,000 per year to the program.

Discussion

We implemented an MPTT that improved efficiency of

care, promoted safer practice by decreasing complications,

and decreased LOS for an important subcategory of patients

who need tracheostomy. These factors are increasingly

important in the current environment of rising health care

costs and the resultant need for cost containment.

Multidisciplinary tracheostomy teams have been attempted

in a few institutions.9-17 Norwood et al17 implemented a ser-

vice led by respiratory therapists to follow patients who

received a tracheostomy in the ICU with emphasis on suc-

tioning, cleaning, tube changing, and early decannulation of

tracheostomies as well as an educational component for the

nursing staff on the wards, but the service was limited to

posttracheostomy care.17 The study showed a decrease in

complication rates of patients with tracheostomies on the

wards; however, tracheostomy complications in the ICU

actually increased. Our MPTT provides a more comprehen-

sive approach by screening for and recruiting patients who

have been intubated for more than 96 hours. Our small

group of dedicated percutaneous tracheostomy clinicians

performs tracheostomies at the bedside. In addition, our

team consists of physicians, nurses, respiratory therapists,

and speech-language pathologists who provide continuous

care from initial screening to postdecannulation evaluation.

We demonstrated that the addition of an MPTT decreases

complications such as airway bleeding and physiological

disturbances. We believe that this is because we have a

select number of clinicians who are part of the team and

have become experts because of the high volume of percuta-

neous tracheostomies they perform. The team gained exper-

tise and formed a strong team dynamic by frequently

performing these procedures and working in small familiar

groups. Evidence suggests that teams that work together on

a regular basis communicate more effectively during high-

stress situations, thereby reducing complications.23 In addi-

tion, we used standardized equipment, screening criteria,

surgical procedure protocol, and postoperative management

to minimize variations in outcome. The use of video

bronchoscopy is standard in all procedures and likely mini-

mizes the risk of trauma to adjacent structures and inadver-

tent loss of airway. We believe that the presence of a

dedicated anesthesiologist for every case is also crucial for

physiologic stability and airway management.

The definition of ‘‘efficiency’’ varies in the literature,

where it pertains to multidisciplinary tracheostomy teams.

Some studies have focused on the time to decannulation as

a measure of efficiency.10,11,12,15,16 Arora et al10 found that

time to decannulation decreased significantly from 21.1

days to 5.4 days after implementing a tracheostomy team.10

Tobin and Santamaria15 had similar findings with a signifi-

cant decrease from 14 to 7 days. Norwood et al17 demon-

strated an increase in the number of patients decannulated

in the ICU prior to discharge to the wards, suggesting more

efficient management with a team approach. Our study

defined efficiency as the number of days it took for our

MPTT to perform a percutaneous tracheostomy from the

time of request to the operative time. We noted a significant

decrease in the number of days to tracheostomy from 2.7 6

3.02 in 2004 to 1.32 6 2 in 2008. This decrease is predomi-

nantly due to the presence of a dedicated tracheostomy

coordinator within the team who identifies eligible patients

and schedules the procedure in a timely manner and the reli-

able availability of the MPTT team to perform the proce-

dure.19 In the control group (2004), the main reasons for the

delay in tracheostomy placement were the lack of availabil-

ity of a surgical team, operating room, or bronchoscope

cart. The operative and anesthesia times were also signifi-

cantly lower in 2008 than in 2004 (Table 2). The MPTT

has dedicated credentialed operators and anesthesiologists

who have significant experience in performing the proce-

dure and follow a standardized protocol.24-26

When the complication rates in 2004 and 2008 were

compared, there were no differences in terms of infection

and mortality. This apparent lack of improvement may be

due to a change in the standardization of billing codes that

were used to identify infection. VAPs were identified in the

charts based on International Statistical Classification of

Diseases and Related Health Problems (ICD)–9 codes in

2008, whereas in 2004, the ICD-9 codes for VAP varied. In

addition, greater awareness of VAPs has led to an increase

in diagnosis and treatment, which has likely skewed our

data. The 2004 data probably represents an underdiagnosis

of this increasingly frequent complication. Since its estab-

lishment, the MPTT has meticulously investigated the possi-

bility of local peristomal infection in every patient. We

believe that many such infections were underreported prior

to our intervention, and it is possible that the data from

2004 reflects this bias. In 2008, the number of peristomal

Table 3. Cost-Benefit Summary

Benefit in Dollars

Comparing 2008

versus 2004

ICU length of stay reduction benefit ($)a 235,922

Back-fill incremental profit ($)b 374,932

Overall hospital cost benefitc 610,854

MPTT professional fee revenue 224,000

Cost of MPTT, hospital yearly contribution (581,348)

Overall net medical center cost benefit 235,506

Abbreviations: ICU, intensive care unit; MPTT, multidisciplinary percuta-

neous tracheostomy team.aICU length of stay decrement from 2004 data.bBased on 75% back-fill estimate of .85% weekday ICU bed utilization. All

primary ICU domains were included: surgical, neurosciences, and medicine.cData based on incremental tracheostomy cases of 124 cases between 2004

and 2008 and change in ICU length of stay reduction and backfill benefit.

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infections was captured more accurately, and as a result, we

are unable to demonstrate any significant decrease in the

number of peristomal infections.

LOS has been used as an indicator of quality of care of

tracheostomy teams.13-15 Tobin and Santamaria15 found a

significant decrease in both hospital LOS (42-34.5 days)

and LOS after ICU (30-19 days) but not in ICU LOS.

However, Arora et al10 did not find a significant decrease in

the ICU or hospital LOS. In our study, the mean LOS days

for our sample did not vary before and after the creation of

the MPTT. However, on subgroup analysis, the posttra-

cheostomy ICU and overall ICU LOSs were reduced for

patients whose primary diagnosis was neurological disease,

which was the most common indication for a tracheostomy

in both 2004 and 2008. Nonneurological patients tend to

remain in the hospital for other procedures or treatment,

while neurological patients frequently require tracheos-

tomies to meet discharge requirements. These patients’

underlying neurological issues are often cared for in a reha-

bilitation setting rather than in the hospital.

Financially, the MPTT required the medical center to

supplement operational costs as well as provide a subsidy

to offset the discounted surgical and anesthesia profes-

sional fees. Because of positive financial projections and

the potential safety enhancement to patients, the faculty-

derived business plan was rapidly endorsed. Improvements

in ICU efficiency and a reduction of LOS in an important

subgroup ICU population were in fact realized, permitting

effective back filling of available operating room time.

The direct financial benefit, added to the elimination of

serious adverse events associated with elective tracheost-

omy, collectively yielded a compelling financial assess-

ment of the MPTT.

This study has some limitations. The study is a retro-

spective analysis of prospectively collected data from a

single institution. More prospective and multicenter stud-

ies are necessary to further explore the patient outcomes

of standardized multidisciplinary teams. There were

fewer patients in the 2004 group than in 2008, an imbal-

ance due to the increased number of percutaneous tra-

cheostomies that are being performed at the bedside. This

may reflect increasing acceptance of percutaneous tra-

cheostomy as the standard technique, increased capture of

eligible patients with our team screening process, and

increased availability of clinicians to perform the proce-

dure by a dedicated team.

Conclusion

A multidisciplinary percutaneous tracheostomy team was

developed to improve efficiency, promote safety, and

decrease LOS and costs. The team is unique in its composi-

tion and provides comprehensive care from the time patients

are eligible for percutaneous tracheostomy throughout the

duration of their hospital stay and beyond to outpatient

clinic follow-up. Our study demonstrated that safety and

efficiency improved after the development of the MPTT. It

is our belief that small groups of dedicated professionals

and an emphasis on continuity of care are responsible for

our findings.

Acknowledgments

Members of the Percutaneous Tracheostomy Service at the Johns

Hopkins Hospital, Baltimore, Maryland. David T. Efron, MD,

FACS; Adil H. Haider, MD, MPH, FACS; Kent A. Stevens, MD,

MPH, FACS; Amy P. Rushing, MD; Albert Chi, MD; Sylvia

Mack; Victor Roberts, BBA. Paul Intihar, MS, assistant director,

Department of Financial Analysis, The Johns Hopkins Hospital.

Author Contributions

Vinciya Pandian, conception and design, data collection, analysis

and interpretation of data, drafting the article and revising it criti-

cally for important intellectual content, and final approval of the

version to be published; Christina R. Miller, data analysis and

interpretation, critical revision, and final approval of the version to

be published; Marek A. Mirski, conception and design, critical

revision, and final approval of the version to be published; Adam J.

Schiavi, analysis and interpretation of data, critical review, and final

approval of the version to be published; Athir H. Morad, analysis

and interpretation of the data, critical review, and final approval of

the version to be published; Ravi S. Vaswani, data collection and

analysis, critical revision, and final approval of the version to be

published; Christopher L. Kalmar, data collection and analysis,

drafting the article, and final approval of the version to be published;

David J. Feller-Kopman, conception and design of the study, criti-

cal review, and final approval of the version to be published; Elliott

R. Haut, conception and design, critical review, and final approval

of the version to be published; Lonny B. Yarmus, conception and

design, critical review, and final approval of the version to be pub-

lished; Nasir I. Bhatti, conception and design, data interpretation,

drafting the article and critical review, and final approval of the ver-

sion to be published.

Disclosures

Competing interests: Elliott Haut received royalties for his book

Avoiding Common ICU Errors from Lippincott Williams &

Wilkins.

Sponsorships: None.

Funding source: None.

References

1. Nationwide Inpatient Sample. Healthcare Cost and Utilization

Project. 2009. Agency for Healthcare Research and Quality.

http://hcupnetahrqgov. Accessed November 23, 2011.

2. Nelson JE, Cox CE, Hope AA, Carson SS. Chronic critical ill-

ness. Am J Respir Crit Care Med. 2010;182:446-454.

3. Fantoni A, Ripamonti D. A non-derivative, non-surgical tra-

cheostomy: the translaryngeal method. Intensive Care Med.

1997;23:386-392.

4. Griggs WM, Worthley LI, Gilligan JE, Thomas PD, Myburg

JA. A simple percutaneous tracheostomy technique. Surg

Gynecol Obstet. 1990;170:543-545.

5. Rao BK, Pande R, Sharma SC, et al. Percutaneous tracheost-

omy. Ann Card Anaesth. 2003;6:19-26.

6. Sheldon CH, Pudenz RH, Freshwater DB, Cure BL. A new

method for tracheostomy. J Neurosurg. 1955;12:428-431.

690 Otolaryngology–Head and Neck Surgery 147(4)

at OhioLink on June 24, 2014oto.sagepub.comDownloaded from

7. Berry SA, Doll MC, McKinley KE, Casale AS, Bothe A Jr.

ProvenCare: quality improvement model for designing highly

reliable care in cardiac surgery. Qual Saf Health Care. 2009;

18:360-368.

8. Grotle M, Garratt AM, Klokkerud M, Lochting I, Uhlig T, Hagen

KB. What’s in team rehabilitation care after arthroplasty for

osteoarthritis? Results from a multicenter, longitudinal study asses-

sing structure, process, and outcome. Phys Ther. 2010;90:121-131.

9. Cetto R, Arora A, Hettige R, et al. Improving tracheostomy

care: aprospective study of the multi-disciplinary approach.

Clin Otolaryngol. 2011;36:482-488.

10. Arora A, Hettige R, Ifeacho S, Narula A. Driving standards in

tracheostomy care: a preliminary communication of the St

Mary’s ENT-led multi disciplinary team approach. Clin

Otolaryngol. 2008;33:596-599.

11. de Mestral C, Iqbal S, Fong N, et al. Impact of a specialized

multidisciplinary tracheostomy team on tracheostomy care in

critically ill patients. Can J Surg. 2011;54:167-172.

12. LeBlanc J, Shultz JR, Seresova A, et al. Outcome in tracheos-

tomized patients with severe traumatic brain injury following

implementation of a specialized multidisciplinary tracheost-

omy team. J Head Trauma Rehabil. 2010;25:362-365.

13. Parker V, Shylan G, Archer W, McMullen P, Morrison J,

Austin N. Trends and challenges in the management of tra-

cheostomy in older people: the need for a multidisciplinary

team approach. Contemp Nurse. 2007;26:177-183.

14. Parker V, Giles M, Shylan G, et al. Tracheostomy manage-

ment in acute care facilities—a matter of teamwork. J Clin

Nurs. 2010;19:1275-1283.

15. Tobin AE, Santamaria JD. An intensivist-led tracheostomy

review team is associated with shorter decannulation time and

length of stay: a prospective cohort study. Crit Care. 2008;12:

R48.

16. Frank U, Mader M, Sticher H. Dysphagic patients with tra-

cheotomies: a multidisciplinary approach to treatment and

decannulation management. Dysphagia. 2007;22:20-29.

17. Norwood MG, Spiers P, Bailiss J, Sayers RD. Evaluation of

the role of a specialist tracheostomy service: from critical care

to outreach and beyond. Postgrad Med J. 2004;80:478-480.

18. Pandian V, Nguyen TT, Mirski M, Bhatti NI. Percutaneous

tracheostomy: a multidisciplinary approach. Perspect Voice

Voice Disord. 2008;18:87-98.

19. Pandian V, Maragos C, Turner L, Mirski M, Bhatti N, Joyner K.

Model for best practice: nurse practitioner facilitated percutaneous

tracheostomy service. ORL Head Neck Nurs. 2011;29:8-15.

20. Blankenship DR, Kulbersh BD, Gourin CG, Blanchard AR,

Terris DJ. High-risk tracheostomy: exploring the limits of the

percutaneous tracheostomy. Laryngoscope. 2005;115:987-989.

21. Pandian V, Vaswani RS, Mirski MA, Haut E, Gupta S, Bhatti

NI. Safety of percutaneous dilational tracheostomy in coagulo-

pathic patients. Ear Nose Throat J. 2010;89:387-395.

22. Averill R, Goldfield N, Steinbeck B, Grant T. All Patient

Refined Diagnosis Related Groups Version 15.0 Definittions

Manual. 3, 21-261998. Wallingford, CT: 3M Health

Informations Systems; 1998.

23. Reader TW, Flin R, Mearns K, Cuthbertson BH. Developing a

team performance framework for the intensive care unit. Crit

Care Med. 2009;37:1787-1793.

24. Bhatti N, Tatlipinar A, Mirski M, Koch WM, Goldenberg D.

Percutaneous dilation tracheotomy in intensive care unit

patients. Otolaryngol Head Neck Surg. 2007;136:938-941.

25. Bhatti N, Mirski M, Tatlipinar A, Koch WM, Goldenberg D.

Reduction of complication rate in percutaneous dilation tra-

cheostomies. Laryngoscope. 2007;117:172-175.

26. Bhatti NI. Percutaneous dilatational tracheostomy. Oper Techn

Otolaryngol Head Neck Surg. 2007;18:90-94.

Pandian et al 691

at OhioLink on June 24, 2014oto.sagepub.comDownloaded from