Royal Melbourne Hospital (RMH)

  

Firstly I met with Leonie,  

We had a full discussion of the trache team and hospital pathway.

Leonie Shaw is a Senior Cardiothoracic Physiotherapist on the Specialty Surgery Units, mainly ENT. Leonie.Shaw@mh.org.au  

Overview:  

Tracheostomies are inserted on ICU lead by the consultant intensivists. ICU is very medically lead at RMH, there are physios but no OT’s and only SALT for 4 hours a week.

ICU medical staff will wean the patient off all ventilatory support before stepping them down to HDU or Ward level.

On step down the ICU physio will page the receiving PT to notify them that the patient has moved down to the ward. They will also direct them to look at the handover on the computer. This is a simple electronic form which has sections for each discipline. On the physio section it will discuss the trache and any progress that has been made.

The tracheostomy team are informed of the movement of patients through the ICU nurse consultants. There are 5 of them in this role and they will continue to follow up all tracheostomy patients from ICU daily, as well as being part of the tracheostomy team.

Tracheostomy Team:

RMH ‘team’ approach to tracheostomy care started in 2001.

The team consists of ICU nurse specialists and clinical nurse consultants, speech pathologists and physiotherapists.

The team is always changing personal due to the nursing shifts and the physios and SLP’s rotating through from different areas.

A positive of this approach however is the great education opportunity for multiple staff members, and a developing team with greater longevity.

There is not a physician on the team, but the team have good links with their ENT doctors who assist as required.

They did an analysis in 2011 (10 year review) of their programme. Within that time their sample size was 693 Patients. Their main statistically significant finding was that they had managed to reduce the mean days to decannulaiton from 23 to 11.

During this time they also showed improvements in their overall care of this patient group by: implementing a 7 day service for weaning (increased access to SLP), development of a weaning policy, bedside management sheets and guidelines, greater use of speaking valves and developments of PT and SLP competency packages.

The ward team will manage the weaning of the tracheostomy, mainly lead by the ward PT and SALT. On top of this the tracheostomy team will review the patient and assist as required.  

The tracheostomy team review all tracheostomy patients, off of ICU that are not ENT patients, on Tuesdays and Fridays.

On each trache ward round day the ward physio will fill in a tracheostomy review sheet detailing: the patients current therapist, treatment and weaning progress. The tracheostomy team will then add any feedback and comments to the bottom of this sheet. Again the team is able (due to their skill set) to fully assess the patient and provide appropriate investigations and management as required. These are all discussed with the patient’s host team.

Unfortunately there were no tracheostomies on the day I visited and therefore ward round did not occur. But I was able to see some weening on ENT by speech and physio.  

This is very similar to lots of other practices I have seen. The patient had had very complex and extensive max-fax and plastic surgery requiring the need for a tracheostomy to maintain their airway. The patient was sat out of bed upright in a chair, the physio did a respiratory assessment, after which speech deflated the cuff and physio suctioned simultaneously, watching the patients observations. With the patient stable, speech manually and visually assessed the patients swallow, and trialed some finger occlusion. Between the patient, PT, SLP and the nurse a plan was then made regarding progression of the wean. Deciding that they would attempt to keep the cuff down for 12 hours, without the use of a speaking valve. The patient would be monitored by the ward nursing staff as well as the ward physios during treatment or if called upon.

Education:  

The education structure at RMH is very similar to the UK hospitals I have worked in. The critical care nurses provide support and education to the the wards, and each other profession provides inter-departmental education and competencies. Leonie did state that they have a multi-disciplinary training programme which is currently not running due to staff time constraints and logistics.

Very few of their tracheotomies are permanent and rarely does a patient leave the hospital with a tracheostomy. If they do however, this is co-ordinated by the critical care nurses and the follow up are done predominantly by nurses and SALT in clinic, as well as a medical review.

ICU visit:

I was lucky enough to be shown around the RMH ICU with one of the lead ICU physios.

I was keen to find out more about the lack of AHP’s on their ICU and what role physios are allowed to take in that setting.

As Leonie had said, the ward is very under represented by AHP’s with only 2 ½ PT posts and a 4hour SLP post, there is no OT representative on ICU. From an SLP perspective, their limited presents means that they have been able to provide communication charts and eye gaze boards for the staff to use, and can educate staff and patients in some management strategies, but they don’t have the time to provide consistent treatment or continuity of care in this setting.

When discussing the role of the physios on ICU, I was informed that they are allowed to do very little in terms of respiratory treatment, and the ICU’s main focus is for them to provide early mobility rehab.

When asking if they will still do a respiratory assessment, the answer was yes, but they are not allowed to provide any manual techniques, alter ventilation settings, MHI, IPPB etc. The doctors will work on recruitment on the ventilator and undertake a greater amount of bronchoscopies, from what I have been informed. The reasoning behind this was unclear, and despite great efforts from allied health to promote themselves in this setting, little change has occurred at RMH.

Presentations:  

Leonie and I both presented to a group of CNC, SLP and PT colleagues.

Leonie discussed trache care at RMH, some of the successes they have had (reducing average LOS from 22days-11) as well as some of the challenges they face, summarising with the global stand point of trache care.

As with many of my visits, I was asked to do a small presentation about my fellowship and observations so far.  

With a group of over 20 of us we were able to stimulate some positive discussions regarding tracheostomy care practices and improvements at RMH.

With such a good AHP turn out it was great to see the enthusiasm they have for trache care and their role within it. Many agreeing that physios do have a role in tracheostomy ‘team’ care.

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