On the right trach Consultant Editor James Watts reviews the NCEPOD tracheostomy survey
The first record of tracheostomy procedures is allegedly recorded on ancient Egyptian tablets dating from about 3600BC [1]. It is also described in the Hindu text the Rigveda, dating from 2000BC [2]. The prominent Greek physician, surgeon and philosopher Galen described the mechanism of ventilation via a reed placed in an animal’s trachea [3]; while legend has it that Alexander the Great saved the life of one of his soldiers by opening his throat with the tip of a sword.
Despite this, the presentation of a tracheostomised patient to a 21st-century physician or nurse can still induce anxiety and concern, even though there are an undefined number of patients who manage to survive perfectly well in the community with a permanent tracheostomy in situ, looking after it by themselves, or in conjunction with non-professional carers.
In 2014, NCEPOD (National Confidential Enquiry into Patient Outcome and Death) published the results of its nationwide survey into tracheostomy care across the UK [4]. The aim of the exercise was to capture data on every tracheostomy performed during the specified time period, from performance in theatre or critical care, to discharge. Following an initial scoping survey, which aimed to identify which hospitals performed tracheostomy, and which wards within their environment were designated as ‘tracheostomy wards’, the survey collected data on 2546 patients who had tracheostomies performed for whatever indication. The purpose was to determine what standards of care were in place at that time, and to make recommendations about future care.
In brief, the report recommended that no tracheostomy should be performed without the indications being recorded in the notes or without being properly coded, in order to fully identify these patients. They also recommended that, irrespective of whatever counselling was recorded in the notes prior to the procedure, and whatever detailed discussions may have occurred with relatives, a proper standard consent Form 1 or Form 4 document should be completed. This point was clarified to the author verbally by the panel during the report launch conference. This will in fact be an audit standard for quality of care, and 100 per cent compliance will be expected. NCEPOD also recommended that a World Health Organisation (WHO)-type checklist should be incorporated into the procedure, prior to performance, as standard, even on ITU; and that capnography should always be used to monitor insertion and function of tracheostomies.
Graph 1. Percutaneous tracheostomies by day/week — Graph 2. Tracheostomies by time/day — Graph 3. Timing of tracheostomy decannulation by day/week
The report also considered the standards of post-tracheostomy care. It should be clear, for example, to all staff caring for such a patient whether the patient has undergone a laryngectomy or not, as this is vital in management of any respiratory complications. The nursing care of a tracheostomy should be crystallised in local guidelines, based on national recommendations. In particular, the management of blocked, or displaced, tracheostomy tubes should be in accordance with management suggested by the National Tracheostomy Safety Project [5]. The use of tracheostomy tubes with inner cannulae was promoted in order to prevent blockages.
The report’s findings bear detailed scrutiny. Most tracheostomies were performed percutaneously on the ITU, and 30 per cent of patients who underwent tracheostomy were morbidly obese. Of the 41 patients who experienced unplanned tracheostomy removal within seven days of performance, 21 had a BMI greater than 30, indicating that obese patients were particularly high risk for this complication.
Despite this, only 19 per cent of patients had an adjustable flanged tube inserted. Discussion at the launch meeting suggested that this was because there was not yet an adjustable flanged tube with an inner cannula available.
Surprisingly, it was found that many tracheostomised patients leaving ITU for the wards were discharged with an inflated cuff; yet many wards could not supply care to the standard recommended. Discharge of tracheostomised patients should therefore be subject to a multidisciplinary team (MDT) process, so that the correct equipment, support and resources could follow them to their final location. This would involve better communication between nurses, doctors, physiotherapists and speech therapists. Referral to speech and language therapy (SALT) should occur whenever dysphagia is suspected, and the patient should be reviewed by SALT within 48 hours of the referral being made. However, the incidence of swallowing difficulties in patients with tracheostomies requires further research.
Overall, 24 per cent patients experienced complications on ITU, and 31 per cent experienced problems on the ward. The most common complications were accidental decannulation, obstruction, pneumothorax and haemorrhage. Incredibly, 28 per cent of hospitals did not seem to have a formal training programme in place for staff to deal with these kinds of difficulties.
Participation in this exercise allowed the performance and care of tracheostomies to be examined at my own Trust in detail for the first time. The initial scoping survey confirmed that patients with tracheostomies were cared for in the two critical care units (CCUs), the post-operative care unit, two respiratory medical wards and one surgical ward. There was already a designated Trust tracheostomy lead nurse, and training which was co-ordinated through the outreach service. Guidelines for tracheostomy care were available, and it could be evidenced that tracheostomy care was performed to an appropriate standard in all areas; however, SALT support was not routinely available to patients who were resident on ITU, despite the fact that all newly tracheostomised patients passed through the CCU. It could be shown that appropriate information about the tracheostomy and the care provided followed the patient on his/her journey through the hospital and out into the community if required.
The scoping exercise also found that the coding of tracheostomy was inconsistent. Between 2011 and 2012, a coding search suggested that only 34 tracheostomies had been performed in a year, whereas 39 were captured in the study period in 2013 alone. The majority were performed percutaneously on ITU.
Participation in the NCEPOD study allowed us to determine that the ITU provided a seven-day-a-week percutaneous tracheostomy service (see Graph 1). No tracheostomies that were performed on CCU were subject to a WHO checklist, or had a Form 1 or Form 4 consent document, although all had full discussions about the procedure recorded in the notes. Most tracheostomies were performed in the early afternoon (Graph 2).
Weaning from tracheostomy is equally as important as insertion, and is a matter of timing and judgement. Most patients were decannulated between the middle and end of the week (Graph 3). Unsurprisingly, as it would normally be the end of a planned process, most decannulations occurred in the late morning and early afternoon.
Very few complications were recorded during the study in our facility, and none were major or had any effect on patient wellbeing.
Following the study, processes were changed to include a WHO checklist for the performance of percutaneous tracheostomy on ITU, which would ensure that a consent form was completed for all patients to comply with the recommended audit standard. Compliance with the NCEPOD recommendations will be subject to repeated audits in the future.
Conclusion
The NCEPOD audit provided a national snapshot of the care provided to patients undergoing tracheostomy procedures, and resulted in recommendations targeted at improving care. Participation in the NCEPOD study allowed our hospital to examine our own practice and make changes to processes to allow us to better monitor our compliance with these standards
References
Pahor, A.L. (1992) Ear, nose and throat in Ancient Egypt. J. Laryngol. Otol. 106, 677–687
Stock, C.R. (1987) What is past is prologue: a short history of the development of the tracheostomy. ENT Journal 66(4), 166–169
Stoller, J.K. (1999) The history of intubation, tracheotomy and airway appliances. Respiratory Care 44(6), 595–603
NCEPOD. On the Right Trach. A review of the care received by patients who underwent a tracheostomy. www.ncepod.org.uk/2014report1/downloads/On%20the%20Right%20Trach_Summary.pdf (accessed May 2015)
National Tracheostomy Safety Project. www.tracheostomy.org.uk (accessed May 2015)
