Managing patients with tracheostomies: Demonstrating our value and striving for high quality care.

Ioan Morgan – Highly Specialist PhysiotherapistClaire Cahoon – Highly Specialist Speech and Language Therapist.

The Service

Based on the Regional Hyper-Acute and Rehabilitation Unit, Northwick Park Hospital, Harrow

Level 1 complex specialised rehabilitation service commissioned by NHS England

24 beds primarily for patients with severe complex physical, cognitive, and communication disability, including those in prolonged disorders of consciousness → highly dependent

Increasing numbers of patients with tracheostomies over past 12 months

National Context

Increased prominence of tracheostomy care - NCEPOD report ‘On The Right Trach’ (2014) and National Tracheostomy Safety Project

Published guidelines / care information about tracheostomy management are typically orientated towards patients in acute care. However, our population presents a different set of challenges.

There is also little/no published data regarding outcomes in this population.

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Current Practice on RHRU

• Weaning is current led by SLT / PT

• Nursing staff implement weaning guidelines and make on-line decisions on a daily basis but do not take an active role in decision making process / overall management planning.

• Decreased confidence among the junior therapy team when working with this population

• Use of standard documentation – used for all tracheostomy patients throughout the hospital.

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Striving for high quality care and measuring our outcomes

The evidence gap in the literature, together with observations made at “ground level” led us to:

a) Implement a service improvement projectb) Develop a system to measure our outcomes

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Service improvement project

• Established tracheostomy working party with key stakeholders

• Created a weaning guideline for the RHRU patient group

• Qualitative data collection via learning needs questionnaires to all therapy and nursing staff

• Review of current documentation used on unit – new documentation developed.

• Audit of the service against national guidelines (NCEPOD)

Measuring our outcomes

• Data collected using excel spreadsheet over 11 month period (n = 34)

• The vast majority of our patients are admitted to the unit with either no history of previous weaning or weaning trials conducted in SLT/PT sessions only.

• We have achieved decannulation in 65% of patients.

• Statistical analysis completed by Zi-Wei Liu, Specialist Registrar ENT

Pre-admission weaning history

None (13)SLT/PT trial (12)One-way valve (6)Cuff deflation (4)

Outcomes

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Weaning outcomes

Decannulation (22)poor secretion management (6)continued weaning (3)subglottic stenosis (1)Tracheal granulations (1)medical deterioration/death (1)

Outcomes

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Outcomes

Sign off copy goes hereImpairment Activity Participation Distress0

0.5

1

1.5

2

2.5

3

Changes in tracheostomy outcome scores (TOMs) from ad-mission to discharge

(higher score indicates improvement)

ImpairmentActivityParticipationDistress

TOM

Sco

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Outcomes

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Effective model of AHP leadership working resulting in:

• Successful, timely decannulation of complex, long term tracheostomy patients

• Cost savings in ongoing care• Improved inter-professional collaboration (immediate and

wider MDT)

Our work is in line with key recommendations from NCEPOD report demonstrating safe and effective practice

Where next?

• Outcome data to be presented at British Academic Conference of Otolaryngology on 9.7.15 – recognition that our work is recognised as being innovative in its field.

• Gain feedback re: weaning protocol – qualitative and quantitative.

• Implement the use of the new working forms to the department and review.

• Collaboration with other units.• On-going data collection and publication.