I spent last Thursday and Friday at The Alfred Hospital in Melbourne. This was my last stop in Melbourne before moving to Sydney for my last 4 visits.
My trip to The Alfred was coordinated by Jacqui Laurenson. Jacqui is a Neurotrauma physiotherapist at Alfred. J.firstname.lastname@example.org
Jacqui coordinated my visit in conjunction with Dr Scott Bradley (senior physiotherapist on ICU) and Sharon Hade (nurse manager on ICU).
The Alfreds tracheostomy care began to formalise 2 years ago. Like at NUH they focused on their neurological patient population, as this was the main area identified with multiple tracheostomies and a need for improvements in there care.
They set about implementing evidence based tracheostomy care guidelines, as well as starting an MDT ward round once a week.
This MDT round consists of the Neuro physio and speech, as well as an ICU consultant and ICU nurse liaison.
They round only on the neuro wards, every Tuesday.
The Alfred is however different to all of the hospitals I have visited so far in that they have an ICU ward round, off of ICU, every morning at 09:30.
A consultant is rota’d on a 2 weekly basis to provided continued support to the wards.
A team consisting of a, consultant intensivist, registrar and ICU nurse liaison, review all the patients that stepped down to the wards off of ICU within the last 24hours, as well as all the tracheostomy patients. It is this team that meets to do a formal round for the neuro-tracheostomies once a week (described above).
But they will also review these patients daily.
Therefore the tracheostomy management is always overseen by intensive care.
I was able to attend this ward round and ask the team questions about their tracheostomy care and the decisions they make towards decanulation.
It is important to note that when a patient leaves ICU they are then under the care of their admitting specialty e.g. neuro, orthopaedics etc. This ICU service is to provide support to those teams. If the patients still require a ICU consult after the initial review post ‘step down’ then they will review the patient again as required.
When looking just from the perspective of the trache patients, this team acts as the safety and progression review. Providing support to the ward staff along with the ICU liaison nurses.
The ICU rounding team often make decisions regarding the tracheostomy weaning without the therapists present, although it is often the therapists that carry out this plan. E.g. cuff deflation. Also it appears that a lot of the time it’s the therapist that initiate these discussions. However this appears to be consultant dependent also.
An example of one of my observations was regarding a patient who had not yet had any ‘formal weaning’ but had progressed to managing well on minimal oxygen, cuff inflated and coughing out of the tube. The plan was made to trail cuff deflation for 4 hours and if the patient was managing well then decanulate after the 4 hours.
Discussing the rational behind this with the consultant, showed a large emphasis on the cough strength, as well as the patients tracheostomy charts showing suction rates, quantity etc. I asked about discussions with physio and speech in this case, and I was informed that the ward physios and speech would be informed as would the parent unit, for any concerns they might have regarding the plan (this is in their care guidelines). There is no mention of minimum cuff deflation time prior to decanulation within these guidelines.
Most of the ward physios and speech therapists will attempt to see the patient with the ICU team on their ward rounds, to update them and discuss further management. However as this round is in the morning and it is not certain when the round will visit each patient, sometimes this is not possible, (due to meeting and seeing other patients).
I was informed that they have had a lot of success with these patients that are weaned so quickly. They have had very few patients that they have weaned this quick requiring recanulation. They feel that, with the assessment they provide and rational per patient, this weaning process is not unreasonable. It allows for less trauma from processes such as serial downsizing, it reduces length of stay and therefore has great economic outcomes. As well as great psychological benefits for the patient.
The Alfred’s policy on decanulation also states that the patient needs to be starved for at least 4 hours prior to decanulation.
I can’t recall any of the other sites I have visited doing this. The rational is two fold, if for any reason the patient vomits after decanulation the stomach will not be full (reduced risks of aspiration etc), but also if the patient fails decanulation and is not able to be easily reintubated/recanulated then they are ready for any anaesthesia and emergency surgery they might require.
I discussed the need for data around decantation processes, discussing how this particular case is vastly different to the management that would be received at John Hopkins Hospital Baltimore. However they both seem to have the same outcomes. They do have their data recorded, regarding insertion, decanulation, adverse events etc. however like many of the institutions do not have the time to interpret it. Or publish it.
It was agreed that indeed we need much more data around many things within tracheostomy care, and rarely can one institute provide the quantity, let alone the diversity of care needed, to formulate best practices and rational around processes such as weaning and decanulation.
The above again shows the need for a larger database and how the GTC’s database would benefit tracheostomy care on so many levels.
However I do feel that it depends on what the institution is trying to combat (at their current stage) as their trache concerns, and this is one of the reasons why there is such great diversity.
E.g. is your hospital trying to achieve: quicker decanulation, quicker introduction of speaking valve, 0% recanulations, improved patient satisfaction, all the above. As well as your specific hospital pressures hospital pressures.
Summery of trache guidelines, in relation to weaning and decanulation:
Guidelines state that the decision to remove the tracheostomy is made by the medical unit managing the tube, in consultation with the rest of the MDT. (parent unit, nursing, PT, SLT).
The format of how this is done at The Alfred does seem to change, depending on the patient and the ICU team rounding.
There are guidelines based on the indications and practicalities of weaning e.g. cuff deflation, but these do not discuss any MDT discussions or which profession leads / initates cuff deflation.
All safety procedures and equipment are very similar to the rest of the institutions I have visited.