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A Tracheostomy Care Journey …. Tanis Cameron, Director TRAMS
Vice Preseident Glbal Tracheostomy Collaborative
US Roll Out GTC Boston 26 April 2014
Outline
Tracheostomy Review and Management Service
TRAMS Journey
System improvements based on our experiences
Success Stories
Reflecting on change
The TRAMS Journey
2002 TRAMS Pilot Study
2003- 2006 Project funding
2007 TRAMS becomes core business
2009 Outcomes published
2011 International Tracheostomy Symposium
2012 Invited to participate in creation of GTC
2014 Roll Out USA - Excellent !
All Team Members Involved In:
Acute care rounds
Decannulation decision making
Documentation
Community patient care
Policy and procedures
Education, research
Staff meetings & communication
TRAMS Outcomes
Outcomes of patients with spinal cord injury before and after the introduction of an
interdisciplinary tracheostomy team Critical Care and Resuscitation, 2009 11
(1), 14-19
1. All Decannulated Patients Group 514 patients 3 years
Heterogeneous group
Multiple co-morbidities
2. Subgroup of Spinal Cord Injured Patients
Largest subgroup, more homogenous
Tracheostomy is one of the primary diagnosis
Matched pairs 34 pre TRAMS 58 Post TRAMS
Outcomes, Spinal Cord Injury Patients
DOC decreased by 5.5 days ( 23.5 to 18 days) p=0.02
LOS decreased by 27 days (73 to 46) p=0.098
Time to talking decreased by 11 days (20 days to 11 days)
p=0.001
Patient reports lack of voice as torture –anxiety, stress,
withdrawal, depression Freedman-Sanderson 2011
Effective communication is fundamental to quality healthcare
Cost savings with team in place described
System Improvements?
We have become better at:
Asking the right questions
Communicating and collaborating
Patients involvement at all stages increasing
Educating
Should A Tracheostomy Tube Be Inserted in this Patient ?
Frail 90 year old woman, hearing and vision impairment, admitted
post fall for hip surgery. Sepsis, respiratory failure then
tracheostomy. On ward copious secretions, no communication. Died
on ward 2 months later
54 year old man, PSP, poor bulbar function, nil cough admitted for
tracheostomy. TRAMS meets with patient, asks what he values at
this stage of life, discusses realities of long term tracheostomy and
other options. Patient chose to go to nursing home close to family,
Died peacefully 3 months later
Asking the Right Questions
In the event of a failed decannulation what does this
patient and family want? Should the tube to go back in?
65 year old man massive stroke, family made courageous
decision that if things did not go well upon decannulation the
tube would not go back in. Post decannulation the Medical
Emergency Team was called. Tube went back in. How difficult
for the family.
We now document and use a structured decannulation form
audit – 94 % completed correctly over 2 years
Decannulation and documentation procedure created
At the Time of Decannulation
Communicate, Collaborate, Consult
TRAMS is a consultative service
We do not tell other ward-based teams what to do
Initially resented (we were instituting change)
We performed many staff / patient surveys and
implemented suggestions- provided feedback
It takes time to grow, establish trust
You cannot over communicate
Key Supporting Programs
ICU Team
ENT service
Victorian Respiratory Support
Service (VRSS)
Victorian Spinal Cord Injury
Service (VSCS)
Clinical Nurse Educators
Community programs
Medical Emergency Team (MET)
Respecting Patient Choices (RPC)
Patient Journey
In the ideal the same team follows patient across their
hospital journey and then into the community
Tracheostomy Care and National Standards
2013 Handover and rounds streamlined, audited
2013 Decannulation Documentation standardized M79.30 created
2013 Patient advocates participate in workshops, websites and act as advisors
Admissions: Unplanned vs Planned
VB - Admission days
0
10
20
30
40
50
60
70
80
90
100
2003 2004 2005 2006
Da
ys
Planned
Unplanned
Highly Structured Education Program
Patient brochure
Consumer participation and engagement
Community Patients
2 week intensive training program prior to discharge and ongoing
Patient, , Family and carers
Nursing Homes
Respite
Carer agencies
Interdisciplinary Staff Education Intranet, e learning series critical
Simulation and emergency management training
Bedside trianing
25 staff in services annually
2-3 full day workshops annually
2011 Inaugural International Tracheostomy Symposium
Interdisciplinary Tracheostomy Education Model
From Random Chaos To Competence
TRAMS and National Standards
2013 TRAMS handover and rounds streamlined, audited
2013 Decannulation documentation standardized M79.30
2013 Patient advocates participate in workshops, websites and act as advisors
Changes to Practice
Routine endoscopic examination
New decannulation documentation form
used across the centre
Interdepartmental tracheostomy forum
Quality and safety issues shared
Bleeding at the stoma site policy created
Colin Gray
BACKGROUND
Late 2011 – C6 Quadriplegia following farming accident
Limited arm movement ,Absent trunk and leg movement
Diaphragm intact
Decreased lung volumes and poor cough/clearance
T/F to rehabilitation centre
D/C home August 2012 (no tracheostomy)
Readmitted with aspirate pneumonia and tracheostomy reinserted
Worsening dysphagia (movement of cervical fixation now impacting on
epiglottic movement, laryngeal elevation and pharyngeal contraction)
Ongoing weak cough
Col and Jenny decide to keep tracheostomy for discharge and plan for
the future
Colin Gray and Family
Col’s 100th blood bank donation
Colin in the Community
100 Blood Donations
In Colins Words In C
o
l ’s words…
Colin’s Goals My Goals…
Discharge Planning
Insured through workplace
Occupational Therapy, Physiotherapy, Nurses, Doctors,
Dietician Social Worker Speech Pathologist
Carer agency
TRAMS
Discharge and Care plan formulated with Colin and
Jenny
Training of Jenny and carers
Trial periods of leave
Success – Back to the farm !
Success - Home for the wedding !
Col gives away his daughter Robyn
Closing Thoughts
Patient centered systems change lives
Tracheostomy care is improving around the world
We still have a long way to go
Interdisciplinary teams are effective, creative, fun
The best is yet to be –Join Us!
The Global Tracheostomy Collaborative is the way
to move forward together
Reflecting on Change
The voyage of discovery lies not
in finding new landscapes but in
having new eyes M Proust