1. Critical Care and Tracheostomy EBP Network 2012

2. PRESENTATION OUTLINE
Year in review
2012 CAT topic
E3BP project

3. YEAR IN REVIEW
Change in leaders (thank you to Eva and Klint for their hard work)
50% increase in membership
6 meetings this year
Critical care and tracheostomy discussion list serve remains active with just under 200 members.
Included clinical case discussion to each meeting following member survey
Interstate collaboration and pending SPA poster presentation in 2013
Reviewed CAPs on “in critical care patients does intubation effect laryngeal health ? ”, with aim to complete CAT early 2013

4. CAT TOPIC – 2012 – FEES IN CRITICAL CARE
Background to CAT – there are differences between sites utilising FEES for management in critical care. Some sites are keen to introduce the use of FEES in critical care and it would be ideal to have evidence to justify service establishment.
Clinical question was formed to assist in examining the documented evidence supporting the use of FEES to identify dysphagia.
Is FEES an effective diagnostic tool in critical care for identifying dysphagia?

5. Support for clinical question?
Article
Level
Participants
Method
Diagnostic tool
Outcome measure
Results
Support for clinical question?
Hafner et al (2008) 4
553 critical care pts (incl tracheostomised pts)
Prospective interventional study
Screening risk for dysphagia in ICU post extubation
Self generated FEES protocol
Detection of silent aspiration in 69.3%, 22.9% decannulated.
Yes
Hales et al (2008)
25 critical care tracheostomised pts
Prospective observational study
Clinical bedside swallow Ax
FEES Ax (Rosenbeck Scale)
Detecting penetration and aspiration- FEES more reliable
Ajemian et al (2001)
48 critical care (non-trache) pts
Prospective observatonal study
FEES within 48 hrs of extubation
Dysphagia detected in 56% pts
25% pts silently aspirated
McGowan
4 ventilated , tracheostomised pt’s with cuff inflated
Case series pilot study
¼ had normal swallow, ¼ aspirated, 2/4 had laryngeal penetration
Noordally et al (2011) 3
21 critical care pts
(non-tracheostomised)
Prospective comparison study
Attempted to compare parameters of swallow between FEES, MBS and clincial ax
Clinical Ax and FEES within 24hrs of extubation
Above evaluations repeated at 48hrs and 10/21 stable patients also recieved a MBS
? Each swallow component rated on scale of 1-3 and then rating compared between tools.
?Statistical correlations of ratings
Methodological limitations.
Disregard study
Barquist et.al 2001
70 critical care patients
Prospective comparison study with concurrent controls
FEES
Clinical assessment of swallowing
Incidence of post extubation pneumonia between patients with clinical and FEES in patients intubated > 48 hrs
Limted study with many methodological limitations.

6. COMMENTS Discrepancy in data recorded in some articles
Limited uniformity between the patient populations in these studies (some tracheostomised, some ventilated, post extubation etc)
Speech Pathologist was not consistently part of the investigating teams
Inter-rater reliability was an issue

7. CAT bottom line
“In the critical care population, limited, low level evidence suggests that FEES may be useful in identifying dysphagia. In some studies, FEES has been shown to be more sensitive than bedside Ax in detecting silent aspiration.”
Further robust research is required in order to support the use of FEES in preference to clinical bedside ax or MBS in the critical care setting

8. CAT bottom line : application to clinical practice
Confirms what we know about FEES ie :
FEES may be useful for detection of silent aspiration
Useful for both tracheostomised and non tracheostomised patients
Suggests that FEES can be useful for non-mobile and medically unstable patients
Consistent with results of NSW Health Draft Tracheostomy Clinical Practice guideline (2012) recommendation: “Where objective assessment of swallowing is required a FEES may be considered as alternative objective assessment to a VFSS. A FEES has been demonstrated to have greater sensitivity than clinical assessment alone to detect aspiration and is particularly useful in critical care environments. FEES may allow earlier commencement of oral intake.”

9. 2012 E3BP PROJECT E3BP review Background
Collection in the clinical setting
Themes from collation
Future directions in the clinical setting &beyond

10. E3BP TRIANGLE Best external evidence Clinical expertise
Best internal evidence
(from clinical practice)
Best internal evidence
(from client factors & preferences)

11. BACKGROUND TO E3BP PROJECT
2011 CAT involved review of the literature on the effect of tracheostomy on swallow function
CAT bottom line - “low level evidence to suggest that a tracheostomy tube does not cause dysphagia; rather, the dysphagia is attributed to the underlying diagnoses and co morbidities”
The group identified a significant gap in evidence versus clinician opinion/practice
Decided to use E3BP to enable holistic decision making around trache care
Group then circulated and analysed an online survey to NSW speechies to gauge level of knowledge and ideas on current practice
Survey was also distributed to Vic tracheostomy interest group

12. E3BP collection in the clinical setting
Group brainstorming session and development of preliminary data collection table → some concerns from the group regarding the sensitivity and robustness of the tool.
Group members and their departments started data collection
Some members of group attended Beyond Basics EBP workshop. Some discussion with Elise Baker. → its not research ! Include “the mess” and keep collecting!
Refined table online during data collection. Easy to use, not time intensive, aim to make it a part of clinical assessment.

13. Swallow Ax (A) Swallow Ax (B)
Trache
Trache Insitu
(Last swallow Ax pre-decannulation)
Post-Decannulation
(First swallow Ax post-decannulation)
Time
Summary
Reason for Trache insertion
Trache type insitu at time of Ax
Swallow Ax (A)
Diet + Fluids recommendation
Swallow Ax (B)
□Airway patency
□ Respiratory/ pulmonary toileting
□ Prolonged ventilator wean
□ GCS
Size
□ 6
□ 7
□ 8
□ 9
Other:
□ Portex
□ Shiley
□ Other brand:
□ Fenestrated
□Non-fenestrated
□Cuffed
□Uncuffed
□Cuff up
□ Cuff down
□Speaking Valve
□ Capped
Respiratory support:
□ Trache mask + vent
□ Trache mask only
Assessment type:
□ Bed-side
□ FEES
□ MBS
□Posture:
Upright; Semi-upright; supine
□ Delayed onset of pharyngeal initiation
□ >1 swallow per bolus
□ Reduced hyolaryngeal excursion
□ Other:
Signs of aspiration:
□ Cough
□ Throat clearing
□ Wet vocal quality
□ Increased SOB
□ Reduced oxygen saturation
□ Stained secretions (food/fluid)
□ NBM
□ NGT/TPN
□ NGT/TPN + oral intake
□ Oral intake only
□ Thin Fluids
□ Nectar/mildly thick
□ Honey/moderately thick
□ Pudding/extremely thick
□ Puree
□ Minced
□Soft
□Full
□ Small amounts (specify):
□ Swallowing strategies:
□ >1 swallow/bolus
No. of days trache insitu :
No. of days between Swallow Ax (A) and Swallow Ax (B):
Has there been a change in swallow function?
□ No change
□ Improvement
□ Decline
If swallow function has improved, what may have contributed to this?
□ Trache decannulation
□ Improved general medical status

14. E3BP data trends to date PRELIMINARY TRENDS IN DATA – see table N = 36
6 sites completed (other sites interested but not included at this stage)
5 tertiary sites, 1 metro site
Data collected over last 6 months (May-Nov)
35 clinical Axs (only 1 MBS, no FEES)
Last ax with trache insitu and first ax post decannulation
Average of days between ax’s
Reason for trachy insertion : 30/36 prolonged vent weans, 4/36 low GCS, 1/36 airway patency, 1/36 respiratory toilet
PRELIMINARY TRENDS IN DATA – see table

15. Cohort = 36
Was there a change in swallow between last Ax with trache insitu and first assessment with trache removed? (Eg. Change to diet recommendations, less repeat swallows, reduced aspiration/penetration signs?)
YES = 22
No = 14
What caused the improvement? 15
medical
improvement 5
trache
decannulation 2
Combination
other factors?
Anxiety, upper airway
irritation

16. WHERE TO FROM HERE ?
Continuation of E3BP data collection to increase our body of internal evidence with future trend analysis
Continued liaison with Victorian tracheostomy interest group. Joint submission of poster abstract for 2013 SPA conference re member survey
Finalise the CAT on the effect of intubation on laryngeal health
Hosting tracheostomy education day 2013