EBP Extravaganza 2009 Too many cooks in the kitchen? Tracheostomy & Critical Care EBP group

EBP Extravaganza 2009

Too many cooks in the kitchen?

Tracheostomy & Critical Care EBP group


Our group

Sputum, suction, swallow, cough, cuff, PMSV, ventilation,

ICU


History of question• Multidisciplinary

management as best practice in healthcare – what does this mean for tracheostomy management?

• Challenges reported by group members advocating and implementing multidisciplinary management of tracheostomy weaning


Question

In patients with a tracheostomy, does management by an identified multidisciplinary

team improve patient outcome?


CAP 1

• Frank U, Mäder M, Sticher H. (2007) Dysphagic patients with tracheostomies: a multidisciplinary approach to treatment and decannulation management. Dysphagia. Jan;22(1):20-29

– Level IV evidence

– Retrospective descriptive study comparing length of cannulation and functional rehabilitation progress

Clinical Bottom line:

MDTT reduces cannulation time in TBI & vascular Pts within a rehabilitation setting


CAP 2

• Tobin, A. E. & Santamaria, J. D. (2008) An intensivist-led tracheostomy review team is associated with shorter decannulation time and length of stay: a prospective cohort study, Crit Care,12(2): R48.

– Level IV evidence

– Prospective cohort study comparing cannulation time, mortality and length of hospital stay post ICU


Trend that MDTT reduces cannulation time, mortality and length of stay in TBI & vascular Pts within a rehabilitation

setting


CAP 3

• Cameron TS, McKinstry A, Burt SK, Howard ME, Bellomo R, Brown DJ, Ross JM, Sweeney JM, O’Donoghue FJ (2009) Outcomes of patients with spinal cord injury before and after an introduction of an interdisciplinary tracheostomy team. Critical Care and Resuscitation 11 (1) 14-19

– Level III (3) evidence

– Matched pairs design w 2 cohorts comparing cannulation time, length of stay, cost, use and time to use of speaking valves before and after the introduction of TRAMS.


MDTT reduces cannulation time, length of stay, and cost in spinal cord injury Pts. MDTT also increased use and time to

use of speaking valves in this population


Strengths/Weaknesses

• Systematic reviews – Date of review– Source of review

• Research design:– RCT strong evidence– Pre/post test: weak, unable to establish

treatment effectiveness


Validity

• From Speech Bite/Psych bite/PEDRO– Recruitment of participants– Statistically similar at baseline– Blinding– Reporting on outcomes statistically– Intention to treat– 85% participants had post treatment data

collected


Our Papers

• Assessment tools used in research not sensitive to measure outcomes

• Groups not equal at baseline• Non-matched groups being compared• Nil significant stats reported• Poor outline of methodology• No blinding• Historic controls ?change of practice?


Bottom line

Based on the 3 articles critiqued it is evident that management by a multidisciplinary team improves

patient outcomes in specific populations including SCI, TBI & vascular in terms of their length of cannulation,

length of stay, and use and time to SV use.

Although unable to generate these findings to all trachechostomised populations the preliminary data and trends suggest that management by an MDT is safe and effective however further research is indicated to more

objectively evaluate and generalise the outcomes.


Clinical application

• Tool for presentation to Spinal and TBI units

• Tool to advocate for MDT

• Ensure policies in SP cater for MDT management

• Allows for improved knowledge overall of health professionals roles and boundaries


Clinical example

• POWH:patient on respiratory ward after a lengthy stay in ICU.

• Pt had a tracheostomy inserted secondary to respiratory failure and unable to be successfully extubated.

• Referred to speech path and H&N CNC 7 days after transfer to respiratory ward and 1 day prior to family conference: – Focus of family conference was on “discharge planning of

this patient with a tracheostomy”– Respiratory Medics felt this patient was not going to be

effectively decannulated and would have a long term tracheostomy tube in the community - ?NH


Case Study (ctd)• Speech Path and H&N CNC

involved ENT Registrar, and as a team with the Physio, RNs and Respiratory CNC, a weaning plan was determined and implemented

• Patient’s tracheostomy was effectively decannulated one week later.

• Pt will be discharged without a tracheostomy and this will mean he will be able to be d/c home vs being placed with nursing care.


Quick group update

• Hot topics– H1N1

• Peer review

• Planning for future


Questions?

Documents

EBP Extravaganza 2009 Too many cooks in the kitchen? Tracheostomy & Critical Care EBP group