tracheostomy program 21-final - passy-muirpercutaneous tracheostomy program and patient outcomes...

Percutaneous Tracheostomy Program and Patient Outcomes

10/26/2010

Passy-Muir Inc. 1


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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• Participants– Hospital Administration

– Anesthesia/Critical Care Medicine

– Otolaryngology Head and Neck Surgery

– General Surgery

Nursing– Nursing

– Respiratory Therapy

– Speech-Language Pathology (SLP)


• 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


or family




Preoperative

Tracheostomy PlacementPerioperative


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Functions


or family




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

tracheostomy program 21-final - passy-muirpercutaneous tracheostomy program and patient outcomes...

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