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Role of the multidisciplinary team in the care of the tracheostomy patient

Role of the multidisciplinary team in the care of the tracheostomy patient Journal name: Journal of Multidisciplinary Healthcare Article Designation: Review Year: 2017 Volume: 10 Running head verso: Bonvento et al Journal of Multidisciplinary Healthcare Dovepress Running head recto: MDT tracheostomy care open access to scientific and medical research DOI: http://dx.doi.org/10.2147/JMDH.S118419 Open Access Full Text Article Review Role of the multidisciplinary team in the care of the tracheostomy patient Abstract: Tracheostomies are used to provide artificial airways for increasingly complex patients Barbara Bonvento 1,2 for a variety of indications. Patients and their families are dependent on knowledgeable multidis- Sarah w allace ciplinary staff, including medical, nursing, respiratory physiotherapy and speech and language James Lynch 1 therapy staff, dieticians and psychologists, from a wide range of specialty backgrounds. There Barry Coe is increasing evidence that coordinated tracheostomy multidisciplinary teams can influence the Brendan A McGrath safety and quality of care for patients and their families. This article reviews the roles of these Acute intensive Care Unit, University team members and highlights the potential for improvements in care. Hospital South Manchester, Keywords: tracheotomy, physiotherapist, Speech & Language, Nursing Manchester, Royal College of Speech and Language Therapists, London, UK Introduction Tracheostomy is one of the first recorded surgical procedures and refers to an artificial communication between the trachea and the anterior neck. It can be confused with Video abstract laryngectomy, which refers to complete excision of the larynx, usually as treatment for laryngeal cancer, with the trachea terminating on the anterior neck. Patients with a laryngectomy therefore have no connection from their upper airways (nose and mouth) to their lungs. Whilst tracheostomies were classically performed by surgeons to relieve airway obstruction, the majority of tracheostomies are now performed in critically ill patients in order to facilitate weaning from prolonged mechanical ventilatory support. Other indications include offering a degree of protection against pulmonary aspira- tion, to aid clearance of respiratory secretions and to facilitate long-term invasive ventilation. Between 5,000 and 6,000 surgical tracheostomies are performed annually in adults Point your SmartPhone at the code above. If you have a QR code reader the video abstract will appear. Or use: in the UK. Although some surgical tracheostomies are performed for emergency airway http://youtu.be/1_PTrrrMTMY obstruction, the majority of surgical procedures are elective, associated with extensive head and neck surgery and inserted to maintain perioperative airway patency. Approxi- mately 12,000–14,000 (almost exclusively) percutaneous tracheostomies are performed 2,3 in the UK’s intensive care units (ICUs) annually. The main indication for tracheostomy Correspondence: Brendan A McGrath in ICU is to facilitate weaning from prolonged mechanical ventilation. Tracheostomies Acute intensive Care Unit, University Hospital South Manchester, Southmoor are well tolerated and allow patients to be managed without sedation whilst still receiv- Road, wythenshawe, Manchester M23 ing invasive mechanical ventilatory support. This has clear advantages over prolonged 9LT, UK Tel +44 161 291 6420 endotracheal intubation, although the best timing for tracheostomy in different patient Fax +44 161 291 6421 populations remains unclear. Data from across Europe tell us that 7%–16% of critical email brendan.mcgrath@manchester. 5–7 ac.uk care admissions will be managed with a tracheostomy at some point in their care, with submit your manuscript | www.dovepress.com Journal of Multidisciplinary Healthcare 2017:10 391–398 Dovepress © 2017 Bonvento et al. This work is published and licensed by Dove Medical Press Limited. The full terms of this license are available at https://www.dovepress.com/terms. php and incorporate the Creative Commons Attribution – Non Commercial (unported, v3.0) License (http://creativecommons.org/licenses/by-nc/3.0/). By accessing the work http://dx.doi.org/10.2147/JMDH.S118419 you hereby accept the Terms. Non-commercial uses of the work are permitted without any further permission from Dove Medical Press Limited, provided the work is properly attributed. For permission for commercial use of this work, please see paragraphs 4.2 and 5 of our Terms (https://www.dovepress.com/terms.php). Bonvento et al Dovepress similar proportions in the USA contributing to their 100,000 What is the problem with 8–10 or so annual tracheostomy procedures. tracheostomies? The landscape has therefore evolved such that around In adult practice, the requirement for tracheostomy usually two-thirds of hospital inpatients with tracheostomy are pri- indicates important underlying pathology that can have a marily managed by nonsurgical teams, usually from intensive significant impact on morbidity and mortality. A review of 3,11 care medicine or respiratory backgrounds. This evolution more than 23,000 North American inpatient records where has coincided with developments in the delivery of health a tracheostomy was performed demonstrated that only 80% care in general whereby the increasingly complex needs of survived to hospital discharge, with as few as 60% surviving patients and their families call for multidisciplinary teams if there were significant comorbidities. Similar figures exist 12,13 (MDTs) to achieve optimal patient outcomes. Fortunately, 3,11 for the UK and Europe. the roles of medical, nursing and allied health staff in safely Whilst tracheostomies are increasingly commonplace, managing and rehabilitating all patients with tracheostomies patient safety incidents associated directly with their use have also advanced significantly, both individually and col- are unfortunately also increasing. A number of high-profile laboratively. It is worth noting that multidisciplinary care reports from registries of reported patient safety incidents of the ventilated ICU patients has also evolved such that have helped to identify key themes around failings with patients are increasingly offered opportunities to wean from 23–26 tracheostomy care. Such themes include inadequacies mechanical ventilation with tracheostomy often delayed to in staff education, equipment provision, monitoring and the facilitate trials of extubation. response to clinical incidents. When a clinical incident occurs Tracheostomy care can be one of the best examples of relating to a tracheostomy, the chance of some harm occur- multidisciplinary care, with many different medical, nursing 27,28 ring is between 60% and 70%, depending on location. and allied health teams being required to deliver coordinated The UK National Confidential Enquiry into Patient and effective care. There have been calls in the literature for Outcome and Death (NCEPOD) conducted a national study better coordinated management of tracheostomy patients into tracheotomy care, the lessons of which are applicable since the early 1990s, followed by published examples and to multidisciplinary health care professionals working with 14–21 accounts of successful MDTs. These teams typically tracheostomy patients. The report identified variability in included speech and language therapists (SLTs), physio- the composition and performance of tracheostomy MDTs, therapists and nurse specialists, with early teams usually noting that multidisciplinary care was fragmented, with long led by medical staff from head and neck surgical, neurology, delays in referrals to SLTs and other allied health professional pulmonology or critical care backgrounds. The role of such (AHP) groups. The report made a number of significant teams typically included the following: recommendations aimed at increasing the safety and quality of care, recognizing the key role that that the MDT can play. • Setting, reviewing and monitoring a weaning regime Better coordination and collaboration between specialties and (from mechanical ventilation) including decannulation professions could significantly increase the accessibility of • Setting goals for cuff deflation, use of speaking valve and relevant expertise for tracheostomy patients and significantly capping off the tubes affect the quality of care delivered to this vulnerable group. • Identifying patients for tracheostomy tube changes; The goal of tracheostomy care is to provide a safe environ- either routine changes or downsizing/changing the type ment for management of the patients, whether they are adults of tracheostomy tube in line with the weaning process or children or cared for in hospitals or our communities. Each • Identifying patients who need further investigation by member of the MDT has unique skills around tracheostomy other specialties care that he/she can bring to the bedside. AHPs can provide • Providing education specialist skills and expertise in assessment and treatment • Monitoring and auditing tracheostomy care of swallowing and communication needs, tracheostomy tube • Maintaining a safe environment with appropriate emer- choice, decannulation decisions, nutrition, psychological gency equipment for this vulnerable patient group well-being and maintenance of a patent airway. Specialist multidisciplinary staff help to provide the consistency and This article reviews the roles of the MDT in the care of continuity that is associated with improvements in care. the tracheostomy patients and outlines the potential benefits The principle roles of different health care professionals are of a coordinated multidisciplinary approach for the patients, outlined in the following section. their family and our health care systems. submit your manuscript | www.dovepress.com Journal of Multidisciplinary Healthcare 2017:10 Dovepress Dovepress MDT tracheostomy care Physiotherapists may consider the use of pharmacologi- Roles of the multidisciplinary cal therapies in mobilizing secretions to aid expectoration. tracheostomy team Therapies include simple nebulized drugs such as isotonic Respiratory (physio)therapists 0.9% saline solution through to higher concentration hyper- Although the role can vary with institution or country, respi- tonic 9% saline, or mucolytics. A simple spirometer can be ratory physiotherapists are independent practitioners with used to monitor the effects on the airways. skills in assessment and treatment of respiratory problems, Suctioning secretions through artificial airway devices including the management of those dependent on mechanical can remove or retrieve pulmonary secretions from the proxi- ventilatory support. Chest clearance has always been a core mal airways. Suctioning can provoke transient hypoxemia function of physiotherapists. The first description of chest and cardiac arrhythmias, especially in the critically ill, and clearance exercises appeared as early as 1915 and remains a experienced practitioner will know how frequently to perform key part of the management of tracheostomy patients whose suction on a given patient. However, there are no absolute ability to humidify, cough and swallow chest secretions may contraindications, as problems are usually short-lived and be significantly impaired or absent. related to the baseline stability of the patient. Active cycle of breathing techniques (ACBTs) is a rela- Physiotherapists also have a key role to play in reducing tively basic form of chest clearance employed to aid sputum the incidence and impact of ventilator-associated pneumonia expectoration. It is accessible to most physiotherapists and (VAP), which affects between 9% and 27% of all ventilated applicable to a wide variety of patient groups. This tech- patients with associated mortality estimates between 33% and nique combines a cycle of relaxed breaths with thoracic 50%. Chest physiotherapy treatments in conjunction with expansions and breath hold, followed by forced expira- diagnostic interventions such as nondirected bronchoalveolar tion. This technique is effective and safe in spontaneously lavage have been shown to reduce the incidence of VAP. breathing patients and also easily applied to those with a The role of the typical respiratory physiotherapist in tracheostomy. Europe also includes managing of the physical rehabilita- In tracheotomized patients, chest clearance can also be tion of the patients. This may be especially pertinent in ICU aided with the use of manual hyperinflation, administering where the consequences of mechanical ventilation, with passive positive pressure breaths by inflating the lungs of prolonged bed rest or inactivity, muscle wasting, weakness the patients, holding and then releasing the applied pres- and general deconditioning, are more marked. The UK sure. In addition to clearance of sputum, dependent areas National Institute for Health and Clinical Excellence (NICE) of pulmonary collapse can be re-recruited with consequent guidelines have emphasized the importance of this aspect improved lung compliance and gas exchange. An extension of treatment. Early mobilization is an effective and safe of this mechanism is to apply a negative pressure in expira- strategy in this situation, often overseen by physiotherapists tion, thus mimicking a cough effort. This change in pressure once cardiorespiratory stability has been achieved. Not helps to replicate a cough effort, aiding sputum clearance. only this can improve functional mobility outcomes, but This insufflation/exsufflation device, commonly referred to also it is beneficial for cognitive and respiratory well-being. as a “cough assist”, can be used with a facemask but also Mobilization can be safely achieved whilst the patient is still on tracheotomized patients, using an adaptor attached to the attached to a ventilator. Various scoring systems have been tracheostomy tube. described that track progress and function, and may predict Intermittent positive pressure breathing (IPPB) devices 44,45 future functionality and hospital discharge destination. can assist the physiotherapist by timing a mechanical pres- Whilst some are applicable only in the critically ill, univer- sure-supported inspiration with the patient’s own respiratory sally adopted systems to describe progress promote the same effort. IPPB can improve lung volumes and decrease the dialog between health care professionals and can facilitate work of breathing, especially in the postsurgical setting. The 46,47 effective handover between care locations. American Association for Respiratory Care (AARC) recom- Assessing the suitability of a particular patient for decan- mends the use only for patients with atelectasis and suggests nulation can be complex, and the role of the physiotherapist the effects of IPPB are short term; however, IPPB is still here is vital. Simple measures such as peak expiratory or widely used elsewhere. As with the cough assist devices, cough flow alone are not reliable predictors of decannulation IPPB can be used through a facemask or used attached to a success. The need for ventilatory support, oral and pulmonary tracheostomy tube. submit your manuscript | www.dovepress.com Journal of Multidisciplinary Healthcare 2017:10 Dovepress Bonvento et al Dovepress secretion management, swallowing adequacy, airway patency Assessment and management of oropharyngeal secretions and the course of underlying medical conditions are notori- can promote successful cuff deflation and may be predictive ously difficult to predict and will require the input of the of the ability to tolerate oral intake or play a role in reducing 48 30,60 MDT. Whilst various scoring systems have been proposed respiratory infections. Oral secretion management may be and various decannulation strategies described, there is no helped by tracheostomy tubes with subglottic suction ports consensus on best practice. (which aspirate material from above the cuff space), patient positioning, mobilization, humidification, changes in ventila- Speech and language therapists tion, sputum management (physiotherapy, suction, medical (pathologists) treatment) or the use of anticholinergic medications. Evalu- Assessment, diagnosis and management of communication ation of ability to manage oral secretions is a frequent inter- and swallowing difficulties are key parts of the SLT role in vention for SLT with therapeutic swallowing exercises often the care of tracheostomy patients. However, expertise is not aimed at increasing patient awareness and clearance of saliva. confined to this area alone, and a series of national reports Bedside clinical assessment of swallowing can be augmented have highlighted the potential for SLT services to further by instrumental assessment, including videofluoroscopy and 3,50,51 enhance the care of tracheostomy patients. fiberoptic endoscopic evaluation of swallow (FEES). These Communication difficulties can be expected and pre- specialist assessments can quantify secretion management, dicted in between 16% and 24% patients requiring trache- swallow safety and aspiration risk in tracheostomized patients ostomies and laryngectomies, especially those who require and influence decannulation decisions. Bedside FEES per - prolonged mechanical ventilation. Careful selection and formed by SLT is ideal for tracheostomized patients in ICU use of tracheostomy tubes, fenestrations, cuff management and is essential for detecting silent aspiration. FEES is a safe and novel communication techniques can have a signifi- assessment for those presenting with high aspiration risks. It cant effect on speech facilitation and a positive impact on can also detect occult laryngeal injury, which may impact on 52,53 patient anxiety levels. An inflated tracheostomy tube airway patency or airway protection capability, contributing cuff excludes the larynx and upper airway from normal to MDT tracheostomy weaning decisions. airflow patterns, and one of the best methods of facilitating Ventilated patients or those unable to tolerate cuff defla- communication is to deflate the cuff as soon as possible. tion can still be assessed using FEES facilitating earlier rec- Cuff deflation can add a significant work of breathing to ognition of dysphagia that may have a potentially detrimental the patient however, especially if upper airway gas flow impact on respiratory function and weaning. Head and neck 54,55 is augmented by the use of one-way speaking valves. surgical patients and those with underlying neurological The potential impact of therapies has a clear overlap with diseases are at higher risk of aspiration, and the effects of historical roles of the multidisciplinary care team, but spe- mechanical ventilation, dysphagia and tracheostomy are cialist SLTs are well placed to understand these interactions. associated with increased risk of pneumonia, length of stay, 30,61 Early identification of suitable patients for cuff deflation morbidity and mortality. Although occult aspiration rates and facilitating vocalization may have additional positive may be as high as 60%, some patients will be able to com- effects in promoting laryngeal function and resensitization of mence safe oral intake following FEES that simple clinical 56 60,62–64 laryngopharyngeal mucosa and reflexes. A team approach assessment would not have predicted. FEES also can result in the earlier introduction of speaking valves and facilitates targeted rehabilitation of swallowing early on with 19,57 substantial increase in their use. SLT evaluation of voice implementation of individualized exercise programs and can quality can also assist in the detection of dysphonia and more accurately predict the prognosis for recovery of swallow vocal fold immobility, for example, as a result of intubation function. This is of particular importance for patients such trauma or cardiothoracic surgery and facilitate involvement as those with critical illness polyneuromyopathy who have of ENT opinion as needed. Early identification of vocal a reported incidence of significant protracted dysphagia of fold palsy is important given the associated increased risk 91%. FEES enables SLTs to adopt a proactive, individual- of aspiration in dysphagia patients. Differential diagnosis ized approach without deferring swallowing assessment and treatment of communication difficulties associated with until cuff deflation expediting feeding decisions and reha- specific tracheostomized patient groups, such as those with bilitation. SLTs can also provide much-needed support to neurogenic or head and neck cancer etiology, also requires tracheostomized patients to minimize the negative impact of 51,59 specialist SLT intervention. communication and swallowing difficulties within the MDT. submit your manuscript | www.dovepress.com Journal of Multidisciplinary Healthcare 2017:10 Dovepress Dovepress MDT tracheostomy care Many patients who require tracheostomy present with, Specialist nursing staff or are subsequently found to have, swallowing difficulties. Historical roles of specialist tracheostomy nursing staff have This may mean that a degree of malnutrition is present which centered on head and neck surgical patients, but there has requires careful assessment and management by the dietetic been recognition that these core skills are applicable and 71,72 team. translatable to nonsurgical tracheostomy patients for some Occupational therapists may also have a role to play in years. The first reports of specialist nursing teams manag- improving functional performance or satisfaction with cur- ing increasing numbers of patients on nonsurgical wards rent performance, and whilst there is likely overlap with the described Critical Care “Outreach” teams which comprised 67,68 management of related chronic conditions, this area remains mostly ICU nursing staff. Such teams were managing the largely unstudied for specific populations of tracheostomy transition from intensive nursing environments into more patients. general ward care and were often called upon to educate Finally, there are many roles for the MDT to play in safely ward staff around tracheostomy care. It has been widely transitioning the care of an adult or child from the hospital recognized that nurses working outside of critical care or to the community. These roles are often not well established, head and neck surgical environments can lack the experi- but there are reports of successful programs that educate ence, knowledge and confidence to provide safe and effective staff, patients, parents and carers in the safe management of tracheostomy care. a tracheostomy, and there may be a reduction in hospital (re) So whilst the hospital-wide specialist nursing roles may admission following the implementation of such packages. have had origins in education, with increasing numbers of non-head and neck surgical patients with tracheostomies Medical staff in our hospitals, the role of specialist tracheostomy nurse Medical staff have a key role in planning, performing and is evolving. The support of a specialist tracheostomy nurse managing patient care at key points in their tracheostomy has been shown to decrease complication rates and, by sup- journey. Whilst medical staff have historically taken a leader- porting other nurses in more general ward environments, ship role in day-to-day patient management, there are pub- reduce readmissions to the ICUs, and even have an impact lished examples of successful tracheostomy MDTs that adopt on overall length of stay. a non-medical leadership model. The skills of experienced As with the other multidisciplinary positions, there are and highly trained medical and surgical staff remain essen- clear overlaps with other roles. This however is an advantage tial, but with the increasing complexity of patients and the to the wider team, and specialist nursing roles can develop investigation and treatment options available, the expanded without impacting on learning opportunities or exposure role of other members of the MDT must be welcomed. There for those working in other disciplines. Indeed, specialist are clear benefits in developing multispecialty care models nurse-led clinics may actually enhance opportunities for for complex patients with tracheostomies, and engagement other health care professionals and medical staff to learn the of medical and surgical teams within each other’s historical best practice for management of the tracheostomy patients. practice has been described, with positive effects. Medical Specialist nursing programs have been shown to be a cost- staff often retain overall responsibility and accountability for effective method of improving hospital-wide tracheostomy patient care, and so local agreement about the roles of MDT care, even when overlapping with other roles from the MDT. care and management must be agreed. Other allied health care professionals The addition of a dietician into the tracheostomy MDT has Psychologists been shown to be of benefit. Dieticians are not only expert Critical illness is known to cause delirium and may lead to in the amount and constituents of nutritional intake, but the posttraumatic stress disorders. In addition, the inability to best route of delivery. This can be difficult to predict and speak and communicate is a well-recognized cause of anxiety requires discussion with medical and surgical colleagues and can lead to reduced compliance with care and prolonged 30,75 and SLTs in order to gauge likely recovery times from the inpatient episodes. Altered body image can affect the current condition and safest and most effective routes for well-being and psychological status of a tracheostomized nutrition. Routes of administration may include intravenous patient, which may be influenced by offering professional, means, percutaneous endoscopic gastrostomy or nasogastric/ targeted psychological support. It is likely that a combined nasojejunal routes, as well as oral intake. approach from SLTs and psychologists will address some of submit your manuscript | www.dovepress.com Journal of Multidisciplinary Healthcare 2017:10 Dovepress Bonvento et al Dovepress the psychological consequences of tracheostomy, although individual patients, nonspecialist teams and our wider institu- research in this area is currently limited. tions and communities. The impact of multidisciplinary care has been judged largely by cohort comparisons care from a dedicated MDT versus standard or historical care, using end Family and friends points such as reductions in time to decannulation, length Whilst not strictly part of the MDT, support from friends and of stay and adverse events. These metrics probably reflect families can be as important as professional care. Supportive better coordination and more effective care, but the impacts family members may become primary carers, especially if the on quality of care are not generally reported. Initiatives patient is discharged into the community with a tracheostomy. such as the Global Tracheostomy (Quality Improvement) Successful, integrated predischarge tracheostomy education Collaborative (www.globaltrach.org) have the potential to programs have been described for pediatric patients, com- collect meaningful patient-level data around the quality of prising hands-on training, emergency management training, 77–79 care delivered. Quality improvement programs such as resources and support links from the hospital. One survey this can deliver data that are relevant to patients and their of such carers found that less than half of respondents felt families, multidisciplinary health care professionals and also adequately prepared at the time of discharge, highlighting hospital administrators that can comprehensively benchmark future challenges for the tracheostomy MDT. the effectiveness of multidisciplinary tracheostomy care in the future. Coordinating the MDT Thus far, we have highlighted the roles of individuals within Acknowledgment the multidisciplinary tracheostomy team and the skills that This paper was supported by the Health Foundation. these team members can offer. However, there is increasing evidence of the collective effectiveness of this team approach Disclosure to tracheostomy care. Dr McGrath is chair of the UK National Tracheostomy Safety MDTs have been shown to be effective throughout the Project and European Lead of the Global Tracheostomy Col- patient journey, from patient selection and counseling around laborative. The other authors report no conflicts of interest insertion of the tracheostomy, within the ICU to reduce in this work. weaning time and weaning failure, through to ward-based educational programs to improve patient safety and reduce References 21,81–84 complications and readmissions. Better coordination 1. NHS. Hospital Episode Statistics. 2013. Available from: http://www. of care can improve the efficiency of the interdisciplinary hesonline.nhs.uk/Ease/servlet/ContentServer?siteID=1937. Accessed February 26, 2017. team and ensure appropriate therapies, and interventions are 2. McGrath BA, Ramsaran R, Columb MO. 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Nutritional management tracheostomy capping and decannulation protocol to improve patient in head and neck cancer: United Kingdom National Multidisciplinary safety. Laryngoscope. 2014;124(8):1794–1800. Guidelines. J Laryngol Otol. 2016;130(S2):S32–S40. 87. Pandian V , Miller CR, Mirski MA, et al. Multidisciplinary team approach 72. Wong S, Derry F, Jamous A, Hirani SP, Forbes A. Is undernutrition in the management of tracheostomy patients. Otolaryngol Head Neck risk associated with an adverse clinical outcome in spinal cord-injured Surg. 2012;147(4):684–691. patients admitted to a spinal centre? Eur J Clin Nutr. 2014;68(1): 88. Garrubba M, Turner T, Grieveson C. Multidisciplinary care for trache- 125–130. ostomy patients: a systematic review. Crit Care. 2009;13(6):R177. 73. Martinsen U, Bentzen H, Holter MK, et al. The effect of occupational 89. McGrath BA, Lynch J, Bonvento B, et al. Evaluating the quality improve- therapy in patients with chronic obstructive pulmonary disease: a ran- ment impact of the Global Tracheostomy Collaborative in four diverse domized controlled trial. Scand J Occup Ther. 2017;24(2):89–97. NHS hospitals. BMJ Qual Improv Rep. 2017;6(1):u220636.w7996. Journal of Multidisciplinary Healthcare Dovepress Publish your work in this journal The Journal of Multidisciplinary Healthcare is an international, peer- care processes in general. The journal covers a very wide range of areas and reviewed open-access journal that aims to represent and publish research welcomes submissions from practitioners at all levels, from all over the world. in healthcare areas delivered by practitioners of different disciplines. This The manuscript management system is completely online and includes a includes studies and reviews conducted by multidisciplinary teams as well very quick and fair peer-review system. 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Role of the multidisciplinary team in the care of the tracheostomy patient

Journal of Multidisciplinary Healthcare , Volume 10 – Oct 11, 2017

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Journal name: Journal of Multidisciplinary Healthcare Article Designation: Review Year: 2017 Volume: 10 Running head verso: Bonvento et al Journal of Multidisciplinary Healthcare Dovepress Running head recto: MDT tracheostomy care open access to scientific and medical research DOI: http://dx.doi.org/10.2147/JMDH.S118419 Open Access Full Text Article Review Role of the multidisciplinary team in the care of the tracheostomy patient Abstract: Tracheostomies are used to provide artificial airways for increasingly complex patients Barbara Bonvento 1,2 for a variety of indications. Patients and their families are dependent on knowledgeable multidis- Sarah w allace ciplinary staff, including medical, nursing, respiratory physiotherapy and speech and language James Lynch 1 therapy staff, dieticians and psychologists, from a wide range of specialty backgrounds. There Barry Coe is increasing evidence that coordinated tracheostomy multidisciplinary teams can influence the Brendan A McGrath safety and quality of care for patients and their families. This article reviews the roles of these Acute intensive Care Unit, University team members and highlights the potential for improvements in care. Hospital South Manchester, Keywords: tracheotomy, physiotherapist, Speech & Language, Nursing Manchester, Royal College of Speech and Language Therapists, London, UK Introduction Tracheostomy is one of the first recorded surgical procedures and refers to an artificial communication between the trachea and the anterior neck. It can be confused with Video abstract laryngectomy, which refers to complete excision of the larynx, usually as treatment for laryngeal cancer, with the trachea terminating on the anterior neck. Patients with a laryngectomy therefore have no connection from their upper airways (nose and mouth) to their lungs. Whilst tracheostomies were classically performed by surgeons to relieve airway obstruction, the majority of tracheostomies are now performed in critically ill patients in order to facilitate weaning from prolonged mechanical ventilatory support. Other indications include offering a degree of protection against pulmonary aspira- tion, to aid clearance of respiratory secretions and to facilitate long-term invasive ventilation. Between 5,000 and 6,000 surgical tracheostomies are performed annually in adults Point your SmartPhone at the code above. If you have a QR code reader the video abstract will appear. Or use: in the UK. Although some surgical tracheostomies are performed for emergency airway http://youtu.be/1_PTrrrMTMY obstruction, the majority of surgical procedures are elective, associated with extensive head and neck surgery and inserted to maintain perioperative airway patency. Approxi- mately 12,000–14,000 (almost exclusively) percutaneous tracheostomies are performed 2,3 in the UK’s intensive care units (ICUs) annually. The main indication for tracheostomy Correspondence: Brendan A McGrath in ICU is to facilitate weaning from prolonged mechanical ventilation. Tracheostomies Acute intensive Care Unit, University Hospital South Manchester, Southmoor are well tolerated and allow patients to be managed without sedation whilst still receiv- Road, wythenshawe, Manchester M23 ing invasive mechanical ventilatory support. This has clear advantages over prolonged 9LT, UK Tel +44 161 291 6420 endotracheal intubation, although the best timing for tracheostomy in different patient Fax +44 161 291 6421 populations remains unclear. Data from across Europe tell us that 7%–16% of critical email brendan.mcgrath@manchester. 5–7 ac.uk care admissions will be managed with a tracheostomy at some point in their care, with submit your manuscript | www.dovepress.com Journal of Multidisciplinary Healthcare 2017:10 391–398 Dovepress © 2017 Bonvento et al. This work is published and licensed by Dove Medical Press Limited. The full terms of this license are available at https://www.dovepress.com/terms. php and incorporate the Creative Commons Attribution – Non Commercial (unported, v3.0) License (http://creativecommons.org/licenses/by-nc/3.0/). By accessing the work http://dx.doi.org/10.2147/JMDH.S118419 you hereby accept the Terms. Non-commercial uses of the work are permitted without any further permission from Dove Medical Press Limited, provided the work is properly attributed. For permission for commercial use of this work, please see paragraphs 4.2 and 5 of our Terms (https://www.dovepress.com/terms.php). Bonvento et al Dovepress similar proportions in the USA contributing to their 100,000 What is the problem with 8–10 or so annual tracheostomy procedures. tracheostomies? The landscape has therefore evolved such that around In adult practice, the requirement for tracheostomy usually two-thirds of hospital inpatients with tracheostomy are pri- indicates important underlying pathology that can have a marily managed by nonsurgical teams, usually from intensive significant impact on morbidity and mortality. A review of 3,11 care medicine or respiratory backgrounds. This evolution more than 23,000 North American inpatient records where has coincided with developments in the delivery of health a tracheostomy was performed demonstrated that only 80% care in general whereby the increasingly complex needs of survived to hospital discharge, with as few as 60% surviving patients and their families call for multidisciplinary teams if there were significant comorbidities. Similar figures exist 12,13 (MDTs) to achieve optimal patient outcomes. Fortunately, 3,11 for the UK and Europe. the roles of medical, nursing and allied health staff in safely Whilst tracheostomies are increasingly commonplace, managing and rehabilitating all patients with tracheostomies patient safety incidents associated directly with their use have also advanced significantly, both individually and col- are unfortunately also increasing. A number of high-profile laboratively. It is worth noting that multidisciplinary care reports from registries of reported patient safety incidents of the ventilated ICU patients has also evolved such that have helped to identify key themes around failings with patients are increasingly offered opportunities to wean from 23–26 tracheostomy care. Such themes include inadequacies mechanical ventilation with tracheostomy often delayed to in staff education, equipment provision, monitoring and the facilitate trials of extubation. response to clinical incidents. When a clinical incident occurs Tracheostomy care can be one of the best examples of relating to a tracheostomy, the chance of some harm occur- multidisciplinary care, with many different medical, nursing 27,28 ring is between 60% and 70%, depending on location. and allied health teams being required to deliver coordinated The UK National Confidential Enquiry into Patient and effective care. There have been calls in the literature for Outcome and Death (NCEPOD) conducted a national study better coordinated management of tracheostomy patients into tracheotomy care, the lessons of which are applicable since the early 1990s, followed by published examples and to multidisciplinary health care professionals working with 14–21 accounts of successful MDTs. These teams typically tracheostomy patients. The report identified variability in included speech and language therapists (SLTs), physio- the composition and performance of tracheostomy MDTs, therapists and nurse specialists, with early teams usually noting that multidisciplinary care was fragmented, with long led by medical staff from head and neck surgical, neurology, delays in referrals to SLTs and other allied health professional pulmonology or critical care backgrounds. The role of such (AHP) groups. The report made a number of significant teams typically included the following: recommendations aimed at increasing the safety and quality of care, recognizing the key role that that the MDT can play. • Setting, reviewing and monitoring a weaning regime Better coordination and collaboration between specialties and (from mechanical ventilation) including decannulation professions could significantly increase the accessibility of • Setting goals for cuff deflation, use of speaking valve and relevant expertise for tracheostomy patients and significantly capping off the tubes affect the quality of care delivered to this vulnerable group. • Identifying patients for tracheostomy tube changes; The goal of tracheostomy care is to provide a safe environ- either routine changes or downsizing/changing the type ment for management of the patients, whether they are adults of tracheostomy tube in line with the weaning process or children or cared for in hospitals or our communities. Each • Identifying patients who need further investigation by member of the MDT has unique skills around tracheostomy other specialties care that he/she can bring to the bedside. AHPs can provide • Providing education specialist skills and expertise in assessment and treatment • Monitoring and auditing tracheostomy care of swallowing and communication needs, tracheostomy tube • Maintaining a safe environment with appropriate emer- choice, decannulation decisions, nutrition, psychological gency equipment for this vulnerable patient group well-being and maintenance of a patent airway. Specialist multidisciplinary staff help to provide the consistency and This article reviews the roles of the MDT in the care of continuity that is associated with improvements in care. the tracheostomy patients and outlines the potential benefits The principle roles of different health care professionals are of a coordinated multidisciplinary approach for the patients, outlined in the following section. their family and our health care systems. submit your manuscript | www.dovepress.com Journal of Multidisciplinary Healthcare 2017:10 Dovepress Dovepress MDT tracheostomy care Physiotherapists may consider the use of pharmacologi- Roles of the multidisciplinary cal therapies in mobilizing secretions to aid expectoration. tracheostomy team Therapies include simple nebulized drugs such as isotonic Respiratory (physio)therapists 0.9% saline solution through to higher concentration hyper- Although the role can vary with institution or country, respi- tonic 9% saline, or mucolytics. A simple spirometer can be ratory physiotherapists are independent practitioners with used to monitor the effects on the airways. skills in assessment and treatment of respiratory problems, Suctioning secretions through artificial airway devices including the management of those dependent on mechanical can remove or retrieve pulmonary secretions from the proxi- ventilatory support. Chest clearance has always been a core mal airways. Suctioning can provoke transient hypoxemia function of physiotherapists. The first description of chest and cardiac arrhythmias, especially in the critically ill, and clearance exercises appeared as early as 1915 and remains a experienced practitioner will know how frequently to perform key part of the management of tracheostomy patients whose suction on a given patient. However, there are no absolute ability to humidify, cough and swallow chest secretions may contraindications, as problems are usually short-lived and be significantly impaired or absent. related to the baseline stability of the patient. Active cycle of breathing techniques (ACBTs) is a rela- Physiotherapists also have a key role to play in reducing tively basic form of chest clearance employed to aid sputum the incidence and impact of ventilator-associated pneumonia expectoration. It is accessible to most physiotherapists and (VAP), which affects between 9% and 27% of all ventilated applicable to a wide variety of patient groups. This tech- patients with associated mortality estimates between 33% and nique combines a cycle of relaxed breaths with thoracic 50%. Chest physiotherapy treatments in conjunction with expansions and breath hold, followed by forced expira- diagnostic interventions such as nondirected bronchoalveolar tion. This technique is effective and safe in spontaneously lavage have been shown to reduce the incidence of VAP. breathing patients and also easily applied to those with a The role of the typical respiratory physiotherapist in tracheostomy. Europe also includes managing of the physical rehabilita- In tracheotomized patients, chest clearance can also be tion of the patients. This may be especially pertinent in ICU aided with the use of manual hyperinflation, administering where the consequences of mechanical ventilation, with passive positive pressure breaths by inflating the lungs of prolonged bed rest or inactivity, muscle wasting, weakness the patients, holding and then releasing the applied pres- and general deconditioning, are more marked. The UK sure. In addition to clearance of sputum, dependent areas National Institute for Health and Clinical Excellence (NICE) of pulmonary collapse can be re-recruited with consequent guidelines have emphasized the importance of this aspect improved lung compliance and gas exchange. An extension of treatment. Early mobilization is an effective and safe of this mechanism is to apply a negative pressure in expira- strategy in this situation, often overseen by physiotherapists tion, thus mimicking a cough effort. This change in pressure once cardiorespiratory stability has been achieved. Not helps to replicate a cough effort, aiding sputum clearance. only this can improve functional mobility outcomes, but This insufflation/exsufflation device, commonly referred to also it is beneficial for cognitive and respiratory well-being. as a “cough assist”, can be used with a facemask but also Mobilization can be safely achieved whilst the patient is still on tracheotomized patients, using an adaptor attached to the attached to a ventilator. Various scoring systems have been tracheostomy tube. described that track progress and function, and may predict Intermittent positive pressure breathing (IPPB) devices 44,45 future functionality and hospital discharge destination. can assist the physiotherapist by timing a mechanical pres- Whilst some are applicable only in the critically ill, univer- sure-supported inspiration with the patient’s own respiratory sally adopted systems to describe progress promote the same effort. IPPB can improve lung volumes and decrease the dialog between health care professionals and can facilitate work of breathing, especially in the postsurgical setting. The 46,47 effective handover between care locations. American Association for Respiratory Care (AARC) recom- Assessing the suitability of a particular patient for decan- mends the use only for patients with atelectasis and suggests nulation can be complex, and the role of the physiotherapist the effects of IPPB are short term; however, IPPB is still here is vital. Simple measures such as peak expiratory or widely used elsewhere. As with the cough assist devices, cough flow alone are not reliable predictors of decannulation IPPB can be used through a facemask or used attached to a success. The need for ventilatory support, oral and pulmonary tracheostomy tube. submit your manuscript | www.dovepress.com Journal of Multidisciplinary Healthcare 2017:10 Dovepress Bonvento et al Dovepress secretion management, swallowing adequacy, airway patency Assessment and management of oropharyngeal secretions and the course of underlying medical conditions are notori- can promote successful cuff deflation and may be predictive ously difficult to predict and will require the input of the of the ability to tolerate oral intake or play a role in reducing 48 30,60 MDT. Whilst various scoring systems have been proposed respiratory infections. Oral secretion management may be and various decannulation strategies described, there is no helped by tracheostomy tubes with subglottic suction ports consensus on best practice. (which aspirate material from above the cuff space), patient positioning, mobilization, humidification, changes in ventila- Speech and language therapists tion, sputum management (physiotherapy, suction, medical (pathologists) treatment) or the use of anticholinergic medications. Evalu- Assessment, diagnosis and management of communication ation of ability to manage oral secretions is a frequent inter- and swallowing difficulties are key parts of the SLT role in vention for SLT with therapeutic swallowing exercises often the care of tracheostomy patients. However, expertise is not aimed at increasing patient awareness and clearance of saliva. confined to this area alone, and a series of national reports Bedside clinical assessment of swallowing can be augmented have highlighted the potential for SLT services to further by instrumental assessment, including videofluoroscopy and 3,50,51 enhance the care of tracheostomy patients. fiberoptic endoscopic evaluation of swallow (FEES). These Communication difficulties can be expected and pre- specialist assessments can quantify secretion management, dicted in between 16% and 24% patients requiring trache- swallow safety and aspiration risk in tracheostomized patients ostomies and laryngectomies, especially those who require and influence decannulation decisions. Bedside FEES per - prolonged mechanical ventilation. Careful selection and formed by SLT is ideal for tracheostomized patients in ICU use of tracheostomy tubes, fenestrations, cuff management and is essential for detecting silent aspiration. FEES is a safe and novel communication techniques can have a signifi- assessment for those presenting with high aspiration risks. It cant effect on speech facilitation and a positive impact on can also detect occult laryngeal injury, which may impact on 52,53 patient anxiety levels. An inflated tracheostomy tube airway patency or airway protection capability, contributing cuff excludes the larynx and upper airway from normal to MDT tracheostomy weaning decisions. airflow patterns, and one of the best methods of facilitating Ventilated patients or those unable to tolerate cuff defla- communication is to deflate the cuff as soon as possible. tion can still be assessed using FEES facilitating earlier rec- Cuff deflation can add a significant work of breathing to ognition of dysphagia that may have a potentially detrimental the patient however, especially if upper airway gas flow impact on respiratory function and weaning. Head and neck 54,55 is augmented by the use of one-way speaking valves. surgical patients and those with underlying neurological The potential impact of therapies has a clear overlap with diseases are at higher risk of aspiration, and the effects of historical roles of the multidisciplinary care team, but spe- mechanical ventilation, dysphagia and tracheostomy are cialist SLTs are well placed to understand these interactions. associated with increased risk of pneumonia, length of stay, 30,61 Early identification of suitable patients for cuff deflation morbidity and mortality. Although occult aspiration rates and facilitating vocalization may have additional positive may be as high as 60%, some patients will be able to com- effects in promoting laryngeal function and resensitization of mence safe oral intake following FEES that simple clinical 56 60,62–64 laryngopharyngeal mucosa and reflexes. A team approach assessment would not have predicted. FEES also can result in the earlier introduction of speaking valves and facilitates targeted rehabilitation of swallowing early on with 19,57 substantial increase in their use. SLT evaluation of voice implementation of individualized exercise programs and can quality can also assist in the detection of dysphonia and more accurately predict the prognosis for recovery of swallow vocal fold immobility, for example, as a result of intubation function. This is of particular importance for patients such trauma or cardiothoracic surgery and facilitate involvement as those with critical illness polyneuromyopathy who have of ENT opinion as needed. Early identification of vocal a reported incidence of significant protracted dysphagia of fold palsy is important given the associated increased risk 91%. FEES enables SLTs to adopt a proactive, individual- of aspiration in dysphagia patients. Differential diagnosis ized approach without deferring swallowing assessment and treatment of communication difficulties associated with until cuff deflation expediting feeding decisions and reha- specific tracheostomized patient groups, such as those with bilitation. SLTs can also provide much-needed support to neurogenic or head and neck cancer etiology, also requires tracheostomized patients to minimize the negative impact of 51,59 specialist SLT intervention. communication and swallowing difficulties within the MDT. submit your manuscript | www.dovepress.com Journal of Multidisciplinary Healthcare 2017:10 Dovepress Dovepress MDT tracheostomy care Many patients who require tracheostomy present with, Specialist nursing staff or are subsequently found to have, swallowing difficulties. Historical roles of specialist tracheostomy nursing staff have This may mean that a degree of malnutrition is present which centered on head and neck surgical patients, but there has requires careful assessment and management by the dietetic been recognition that these core skills are applicable and 71,72 team. translatable to nonsurgical tracheostomy patients for some Occupational therapists may also have a role to play in years. The first reports of specialist nursing teams manag- improving functional performance or satisfaction with cur- ing increasing numbers of patients on nonsurgical wards rent performance, and whilst there is likely overlap with the described Critical Care “Outreach” teams which comprised 67,68 management of related chronic conditions, this area remains mostly ICU nursing staff. Such teams were managing the largely unstudied for specific populations of tracheostomy transition from intensive nursing environments into more patients. general ward care and were often called upon to educate Finally, there are many roles for the MDT to play in safely ward staff around tracheostomy care. It has been widely transitioning the care of an adult or child from the hospital recognized that nurses working outside of critical care or to the community. These roles are often not well established, head and neck surgical environments can lack the experi- but there are reports of successful programs that educate ence, knowledge and confidence to provide safe and effective staff, patients, parents and carers in the safe management of tracheostomy care. a tracheostomy, and there may be a reduction in hospital (re) So whilst the hospital-wide specialist nursing roles may admission following the implementation of such packages. have had origins in education, with increasing numbers of non-head and neck surgical patients with tracheostomies Medical staff in our hospitals, the role of specialist tracheostomy nurse Medical staff have a key role in planning, performing and is evolving. The support of a specialist tracheostomy nurse managing patient care at key points in their tracheostomy has been shown to decrease complication rates and, by sup- journey. Whilst medical staff have historically taken a leader- porting other nurses in more general ward environments, ship role in day-to-day patient management, there are pub- reduce readmissions to the ICUs, and even have an impact lished examples of successful tracheostomy MDTs that adopt on overall length of stay. a non-medical leadership model. The skills of experienced As with the other multidisciplinary positions, there are and highly trained medical and surgical staff remain essen- clear overlaps with other roles. This however is an advantage tial, but with the increasing complexity of patients and the to the wider team, and specialist nursing roles can develop investigation and treatment options available, the expanded without impacting on learning opportunities or exposure role of other members of the MDT must be welcomed. There for those working in other disciplines. Indeed, specialist are clear benefits in developing multispecialty care models nurse-led clinics may actually enhance opportunities for for complex patients with tracheostomies, and engagement other health care professionals and medical staff to learn the of medical and surgical teams within each other’s historical best practice for management of the tracheostomy patients. practice has been described, with positive effects. Medical Specialist nursing programs have been shown to be a cost- staff often retain overall responsibility and accountability for effective method of improving hospital-wide tracheostomy patient care, and so local agreement about the roles of MDT care, even when overlapping with other roles from the MDT. care and management must be agreed. Other allied health care professionals The addition of a dietician into the tracheostomy MDT has Psychologists been shown to be of benefit. Dieticians are not only expert Critical illness is known to cause delirium and may lead to in the amount and constituents of nutritional intake, but the posttraumatic stress disorders. In addition, the inability to best route of delivery. This can be difficult to predict and speak and communicate is a well-recognized cause of anxiety requires discussion with medical and surgical colleagues and can lead to reduced compliance with care and prolonged 30,75 and SLTs in order to gauge likely recovery times from the inpatient episodes. Altered body image can affect the current condition and safest and most effective routes for well-being and psychological status of a tracheostomized nutrition. Routes of administration may include intravenous patient, which may be influenced by offering professional, means, percutaneous endoscopic gastrostomy or nasogastric/ targeted psychological support. It is likely that a combined nasojejunal routes, as well as oral intake. approach from SLTs and psychologists will address some of submit your manuscript | www.dovepress.com Journal of Multidisciplinary Healthcare 2017:10 Dovepress Bonvento et al Dovepress the psychological consequences of tracheostomy, although individual patients, nonspecialist teams and our wider institu- research in this area is currently limited. tions and communities. The impact of multidisciplinary care has been judged largely by cohort comparisons care from a dedicated MDT versus standard or historical care, using end Family and friends points such as reductions in time to decannulation, length Whilst not strictly part of the MDT, support from friends and of stay and adverse events. These metrics probably reflect families can be as important as professional care. Supportive better coordination and more effective care, but the impacts family members may become primary carers, especially if the on quality of care are not generally reported. Initiatives patient is discharged into the community with a tracheostomy. such as the Global Tracheostomy (Quality Improvement) Successful, integrated predischarge tracheostomy education Collaborative (www.globaltrach.org) have the potential to programs have been described for pediatric patients, com- collect meaningful patient-level data around the quality of prising hands-on training, emergency management training, 77–79 care delivered. Quality improvement programs such as resources and support links from the hospital. One survey this can deliver data that are relevant to patients and their of such carers found that less than half of respondents felt families, multidisciplinary health care professionals and also adequately prepared at the time of discharge, highlighting hospital administrators that can comprehensively benchmark future challenges for the tracheostomy MDT. the effectiveness of multidisciplinary tracheostomy care in the future. Coordinating the MDT Thus far, we have highlighted the roles of individuals within Acknowledgment the multidisciplinary tracheostomy team and the skills that This paper was supported by the Health Foundation. these team members can offer. However, there is increasing evidence of the collective effectiveness of this team approach Disclosure to tracheostomy care. Dr McGrath is chair of the UK National Tracheostomy Safety MDTs have been shown to be effective throughout the Project and European Lead of the Global Tracheostomy Col- patient journey, from patient selection and counseling around laborative. The other authors report no conflicts of interest insertion of the tracheostomy, within the ICU to reduce in this work. weaning time and weaning failure, through to ward-based educational programs to improve patient safety and reduce References 21,81–84 complications and readmissions. Better coordination 1. NHS. Hospital Episode Statistics. 2013. Available from: http://www. of care can improve the efficiency of the interdisciplinary hesonline.nhs.uk/Ease/servlet/ContentServer?siteID=1937. Accessed February 26, 2017. team and ensure appropriate therapies, and interventions are 2. McGrath BA, Ramsaran R, Columb MO. 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Evaluating the quality improve- therapy in patients with chronic obstructive pulmonary disease: a ran- ment impact of the Global Tracheostomy Collaborative in four diverse domized controlled trial. Scand J Occup Ther. 2017;24(2):89–97. NHS hospitals. BMJ Qual Improv Rep. 2017;6(1):u220636.w7996. Journal of Multidisciplinary Healthcare Dovepress Publish your work in this journal The Journal of Multidisciplinary Healthcare is an international, peer- care processes in general. The journal covers a very wide range of areas and reviewed open-access journal that aims to represent and publish research welcomes submissions from practitioners at all levels, from all over the world. in healthcare areas delivered by practitioners of different disciplines. This The manuscript management system is completely online and includes a includes studies and reviews conducted by multidisciplinary teams as well very quick and fair peer-review system. 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