My first stop in Australia is Austin Health in Melbourne and the renowned TRAMS project.
The TRAMS project is the Tracheostomy Review and Management Service and is one of the longest running specific MDT tracheostomy services in the world. http://tracheostomyteam.org/
I am fortunate enough to be spending a week observing and understanding their practice and role.
Tanis Cameron: tanis.CAMERON@austin.org.au
Tanis is the Director of TRAMS. She is a Senior Speech Pathologist within Austin Health.
She is also a vice president of the Global Tracheostomy Collaborative.
Jack Ross: jack.ROSS@austin.org.au
Is a Specialist Physiotherapist within the spinal unit at Austin Health. She is also one of the lead physiotherapists on the TRAMS project.
Both Tanis and Jack, helped coordinate my visit and have been instrumental in my education of their programme. The support from the rest of the team has also been fantastic! And as I have found everywhere, people are very willing to help me and educate me at every avenue.
As will all of my visit, my first blog will be an overview of their service and care pathway.
Tracheostomy Management at Austin Health (with TRAMS) Overview:
Initial decision for a tracheostomy and insertion:
This decision is made by the team on ICU and ultimately the consultant intensivist. Where able the patient is consulted and consent gained. If not the NOK takes this role.
As in most of the adult settings I have seen, tracheostomies are generally considered for anyone requiring invasive ventilation for longer than 7 days. However with the nature of medical care there is no set protocol, ‘one rule rarely fits all’.
In most cases, the nursing staff and physiotherapists on ICU are briefly consulted about tracheostomy insertions. The physiotherapists are consulted further for more complex patient’s e.g. high spinal cord patients.
After the insertion the patient continues with their ICU care until fit to be stepped down off the ICU. Whilst on the ICU the TRAMS team do not see the patient (unless consulted).
There tracheostomy continues to be managed by the ICU team inc. physio’s, Dr’s and nursing staff. Most often the Speech and Language Team are contacted whilst the patient is on ICU to review from a communication perspective. They work in conjunction with the physio’s on this.
At the point of discharge from ICU, the physio’s complete a ‘tracheostomy-ICU discharge’ form. And the nursing/medical team contact TRAMS to inform them that the patient is moving off of ICU.
This allows the opportunity for the TRAMS team to support the ward receiving the patient, as required, and set up the bedside safety equipment, in conjunction with the ward staff.
As an aside:
Austin Health is unique in that it has a respiratory support service within the ward setting. VRSS: The Victorian Respiratory Support Service (VRSS) is a statewide specialist program providing a range of services to adults with a chronic respiratory failure.
See online for the services they provide: http://www.austin.org.au/vrss
This enables the longer term ventilated patients to step down off of the ICU, to a specialised area in managing long term ventilated patients as well as patients who require a prolonged weaning plan.
The TRAMS team:
Aims of the TRAMS Team
- To improve the quality and safety of tracheostomy management
- To support unit staff in managing patients with tracheostomy tubes
- To reduce the number of adverse events surrounding tracheostomy care
- To facilitate safe and timely removal of tracheostomy tubes
- To facilitate the institution of center wide multidisciplinary tracheostomy clinical standards and procedures
- To offer multidisciplinary tracheostomy education on current best practices
- To provide discharge planning, case management and equipment for tracheostomised, non-ventilated, patients in the community
NB: the VRSS team manage the ventilated patients when D/C to the community.
Tracheostomy care at Austin Health is structured and coordinated in order to improve patient safety. TRAMS is a multidisciplinary tracheostomy team in place to coordinate tracheostomy care across all disciplines. The team conducts tracheostomy ward rounds, provides and coordinates tracheostomy training and education and develops centre wide tracheostomy policy. Patients are followed from outside of ICU through to the community. TRAMS works closely with ICU, ENT, VRSS staff and many other specialists.
The team consists of Respiratory Registrars and Consultants, ICU Consultants, Clinical Nurse Consultants, Physiotherapists, Speech Pathologists and Manager
TRAMS is a consultative service. TRAMS makes recommendations and assists with practical management of tracheostomies but ultimate decision making rests with the treating team
TRAMS In Patient Service manages ward based patients across 3 campuses (in patient ENT patients seen only upon referral)
TRAMS Community manages patients who have permanent tracheostomy (no ventilation) and live in the community. Discharge planning, education, consumables, equipment and follow up care are provided for patients with long term tracheostomy. Tube changes are usually performed in the Ambulatory Care Centre (ACC). This is a unique service in Australia. NOTE: Most nursing homes do not take patients with tracheostomy, TRAMS Community enables discharge, prevents bed blocking and hospital readmissions
A Tracheostomy ICU discharge summary must be completed before discharge from ICU. NB When a patient leaves ICU, medical staff must contact TRAMS (excluding ENT patients).
Patients with tracheostomy who are admitted directly to wards : nurse in charge contacts TRAMS on pager to notify staff that this patient is in the hospital
Assessment and Review of Patients
All new patients with tracheostomy are seen by TRAMS within 24 hours of arriving on the ward excluding weekends. Patients with long term or permanent tracheostomy on other campuses are reviewed by a TRAMS member once a fortnight or as requested by the treating unit
TRAMS in patient rounds are conducted on Mon and Thurs PM. Patients are seen on a priority basis or as requested by the unit. TRAMS team members review patients on other days as needed
TRAMS entry in the medical history is made at each review. Each entry will identify the TRAMS Respiratory Consultant. TRAMS contacts the treating unit medical staff directly when there are issues to clarify or recommended changes in management
TRAMS team is always involved in decannulation assessment of patients. Formalised documentation of readiness to decannulate (pre decannulation entry) and a post decannulation entry are mandatory.
Readiness for decannulation is discussed with parent unit, nursing, allied health and medical staff
Follow up TRAMS sees the patient within 24 hours of decannulation or as requested by treating team
All of the TRAMS: policy, procedures and clinical instruction sheets can be accessed on their public webpage, http://tracheostomyteam.org/policies-procedures-1/