Is the post-critical care environment safe for tracheostomy patients?

Introduction

Over 5,000 tracheostomies are performed in the UK per year [1]. The 4th National Audit Project identified significant morbidity and mortality associated with tracheostomy care [1]. The National Tracheostomy Safety Project (NTSP) 2013 manual highlighted the need for: local policy; an appropriate care environment; immediate availability of emergency equipment; trained staff and local training programmes; and bed-head sign and emergency algorithms for tracheostomy patients [2]. Following these guidelines, we asked: how are adult tracheostomy patients managed post discharge from the intensive care/high dependence unit (ICU/HDU) throughout the UK?

Methods

In November 2013, 200 adult ICU/HDUs throughout the UK were contacted to take part in a telephone survey. Data were collected on tracheostomy weaning, post-ICU/HDU care, safety guidelines, emergency protocols and training for clinicians and nurses.

Results

Out of the 200 adult ICU/HDUs contacted, 134 took part in the survey. Out of these, 44% have a tracheostomy weaning protocol, 69% initiate weaning whilst the patient is mechanically ventilated, and 92% use a speaking valve in their weaning process. Also, 87% allow tracheostomy patients to have oral nutritional intake and in 59% of these the decision involves speech and language therapy. Post ICU/ HDU, 67% of units discharge to specialised wards, 22% to nonspecialised wards, 4% to dedicated step-down units and 6% do not step down their tracheostomy patients. A critical care outreach team reviews the patients in 73% of the hospitals surveyed. Furthermore, only 11% of the hospitals have a consultant lead tracheostomy ward round and 17% have a tracheostomy multidisciplinary team (MDT). Also within these hospitals, 57% have their own tracheostomy safety guidelines and 70% have emergency tracheostomy management protocols. On the wards: 34% have tracheostomy bed-head information signs, 93% have emergency bed-side tracheostomy equipment, 89% have a tracheostomy training programme, and 50% have a MDT approach to decannulation.

Conclusion

There is a wide variation in post-ICU/HDU management of tracheostomy patients throughout the UK. Although there are well established UK national guidelines for the management of tracheostomy patients, outside the ICU/HDU environment there is a lack of full implementation of the NTSP recommendations, increasing the risk of tracheostomy-related morbidity and mortality.