Over the last few days I have been shown the exciting work being done at JDCH by Diane Randall as well as discussing their current practice with Dr Ostrower.
Diane Randall, RRT-NPS. Respiratory therapist and tracheostomy education lead. (DRandall@mhs.net)
Dr Samuel Ostrower, MD. Paediatric Otolaryngologist.
Both Diane and Dr Ostrower have great enthusiasm and passion when it comes to tracheostomy care. This drive and determination, as well as great support from their administration has allowed them to implement their ideas and practice, improving patient care and wellbeing.
As always to help give this structure I will give a brief overview. The way their programme ‘ideally’ works is as follows:
Within the NICU or the PICU the attending teams will discuss the need for a patient to have a trache. They will then discuss this with the family and come to a decision. If the family elect for their child to have a tracheostomy the teams should then call Diane so she can meet them and begin some simple education as well as answer any further questions. In the NICU the patients will be seen by Dr Ostrower or another ORL attending prior to the operation also. This is because of the BPD (bronchopulmonary dysplasia) programme they are running in the NICU, which requires an ORL review.
By referring patients to the education team (Diane) as soon as the decision has been made for a tracheostomy, the family receive quicker help, reassurance and guidance.
I will discuss the eduction format and safety procedures in depth in another blog.
Diane will then follow the patient and family until discharge from the hospital. If the family decide they want to take their child home and care for them with the support of community nursing staff, then Diane and the social work team facilitate this. If not the child would potentially go to ventilation rehab or anther care facility depending on their circumstances.
Currently there is no specific follow-up from a tracheostomy point of view but the child will be reviewed by their speciality team.
However Dr Ostrower has begun seeing more and more patients in his clinic, and is reviewing tracheostomy patients more regularly.
Dr Jason Adler, chief of the department of medicine, has also just started a clinic for complex chronic paediatric patients. I was lucky enough to get the chance to speak with him about his clinic. Again this is not a tracheostomy specific clinic.
He is reviewing complex chronic paediatric patients in his clinic. Many of these patients have not seen a health care professional for a while or have come from other health care settings without the knowledge to help look after their child. Some of these patients have been tracheostomy patients. Because the teaching required for families is not always given at other hospitals, Dr Adler has asked Diane if she will work with some of the families visiting his clinic. This will give the patients better care for a start, as well as educating families on what to do in emergencies and day to day care. Reducing adverse events and improving the prognosis for that child.
Due to Dr Adler’s position I also asked him what he felt about a formalised tracheostomy MDT with regards to an outpatient clinic.
Although he agrees it would be very beneficial, providing many positive benefits and gold standard of care. He concedes that currently this is a long way off at JDCH. This is mainly due to the changes in the health care system in the U.S.A as well as the changes that would need to be made within the hospital e.g. staffing, compliance with all departments.
Dr Adler is very supportive of the work being done so far at JDCH, with regards to their trache work, and from my point of view it is great to see that kind of investment and support from a senior figure within the hospital.
In discussion with Dr Ostrower about his clinic he describes his review of trache patients:
As well as his general assessment and history taking, he will most often scope both down the trache and nasal pharyngeal to view above the trache. This way he can assess the placement of the tube within the trachea as well as tracheal stenosis, granulation or damage, and look at the local cords.
This is a great overall assessment of these patients by a specialist in this area, but currently not all off JDCH patients will have this service. Tracheostomies placed by other surgical specialities will not be this comprehensively reviewed.
Although good Dr Ostrower agrees that an MDT approach in these clinics for a proportion of the patients would be valuable in their progression. As shown by my visit to Boston Childrens Hospital (see trache clinic BCH blog).
During dinner one evening and a meeting the following day I was able to ask Diane and Dr Ostrower about their journey to get to their current practice, their plans moving forwards, as well as tracheostomy care as a whole.
It wont surprise many of you that this has been a tough undertaking. Wether that is from personal experience or from reading my blogs.
This is a running theme when developing tracheostomy care changes within hospitals, that there is a lot to resistance and it takes time to develop procedures and relationships to make change.
Diane and Dr Ostrower both attribute their current success not only to the drive each of them have but to the fantastic support they have received from their administration team. I will discuss some of the impacts they have had in the educational section.
Left Middle: Diane Randel, Respiratory therapist and tracheostomy education lead
Far Right: Bella Cabrera, Chief Nursing Officer
Dr Ostrower is very keen to make their next step a tracheostomy ward round. Initially just the two of them (himself and Diane) but expanding the MDT as able. They are in discussion about the frequency and role of this round currently. As well as this, continuing to educate the entire health care staff at the Memorial Health Trust, improving tracheostomy awareness and safety is their priority.
Long term (as is most facilities goal) is to aid a full tracheostomy pathway and protocol within JDCH, expanding this to the adult side as able.