1. MULTIDISCIPLINARY TRACHEOSTOMY TEAM DEVELOPMENT
Fleurette K. Davis, SLP.D., CCC-SLP

2. DISCLOSURES Dr. Fleurette K. Davis
Financial relationships:
- I am receiving a speaking fee from Passy-Muir, Inc.
Nonfinancial relationships:
- Full-time employee of Amedisys Home Health
- ASHA member

3. Course Objectives Identify key roles and members of the team.
MULTIDISCIPLINARY TRACHEOSTOMY TEAM DEVELOPMENT
Course Objectives
Identify key roles and members of the team.
Identify three key roles of an SLP as a member of the interdisciplinary tracheostomy management team
List three goals of an interdisciplinary tracheostomy management team.
Discuss how the team can impact outcomes of the tracheostomized and/or ventilator dependent patient.
Describe how the use of the Passy-Muir® Valve may be integrated into a weaning/decannulation protocol.

4. Course Outline Importance of an airway management team
MULTIDISCIPLINARY TRACHEOSTOMY TEAM DEVELOPMENT
Course Outline
Importance of an airway management team
Facts, Figures, Complications of Tracheostomy Tubes & Cuffs
Benefits of a Team Approach
Who is on the Team? What is the Process?
Collaborative Protocols
Documentation and Goals
Review Team Process
Resources, Web links, Decannulation Protocol

5. MULTIDISCIPLINARY TRACHEOSTOMY TEAM DEVELOPMENT
David Muir

6. The Practice of Medicine Has Changed
MULTIDISCIPLINARY TRACHEOSTOMY TEAM DEVELOPMENT
The Practice of Medicine Has Changed
In the 70’s
Doctor
Nurse
Everyone else
patient
21st Century
Patient centered care
Teamwork
Evidenced Based Practice
Patient Safety
Best Practice
Multidisciplinary Care
Protocols
-The tracheotomy procedure was first documented on Egyptian tablets 3600 BC, and has remained virtually unchanged.
More than 100,000 tracheotomy procedures were performed in 2007 according to the Health Cost Utilization Project 2007 (HCUP) and are among the most frequently performed procedures in the Intensive Care Unit (ICU) today
There are benefits to artificial airway but complications also
Health care providers main goals should be to reduce complications and hospital length of stay
-patient centered care in this century
- We already use “teams” in most facilities (rapid response teams as example)
(Dean Hess 2010)

7. MULTIDISCIPLINARY TRACHEOSTOMY TEAM DEVELOPMENT
Institution of a tracheostomy care team contributed to: increased speaking valve use
Speaking-valve use increased from 35% to 82%
Median time to a valve trial decreased from 22 days to 6 days after TT
Insertion
(TRAMS Cameron article reference)

8. Tracheostomy Team and Speaking Valve Use Improves Outcomes
MULTIDISCIPLINARY TRACHEOSTOMY TEAM DEVELOPMENT
Tracheostomy Team and Speaking Valve Use Improves Outcomes
Faster decannulation time (from 22.5 to 16.5 days)
Decreased Length of Stay (from 60 to 41.5 days)
Improved outcomes
Decreased cost of care (annual savings of $402,465)
Fewer tracheostomy-related complications
Standardized care provided by a specialized multidisciplinary team was associated with fewer tracheostomy-related complications and an increase in the use of a speaking valve.
- Timely decision making by the team
De Mestral (2011). Canadian Journal of Surgery. Jun;54(3): Cameron (2009). Critical Care and Resuscitation. 11(1):14-19 Cetto (2011). Clinical Otolaryngology. 35(5): Speed (2012). Journal of Critical Care.

9. Benefits of a Multidisciplinary Team
MULTIDISCIPLINARY TRACHEOSTOMY TEAM DEVELOPMENT
Benefits of a Multidisciplinary Team
Le Blanc, et al. 2009
Level I Tertiary Trauma Center
Time to decannulation decreased by 6.49 days
Length of stay decreased by 37.8 days
Earlier discharge to rehabilitation facility
Collaboration and decision making
Earlier intervention by SLP
Earlier use of Passy-Muir® Valve
ANOTHER STUDY:
In 2009, Simpson et al reported a 49% decrease in mortality rate and a 14.3% reduction in mean length of stay four years after the implementation of a multidisciplinary tracheostomy team at the Medical University of South Carolina. (8)

10. Are Tracheostomized Patients Safe on the Regular Hospital Wards ?
MULTIDISCIPLINARY TRACHEOSTOMY TEAM DEVELOPMENT
Are Tracheostomized Patients Safe on the Regular Hospital Wards ?
……”tracheostomized patients should be followed by a dedicated multidisciplinary team that continues to evaluate for decannulation, provides continuity of tracheostomy care and manages emergency situations.”
- How often are these patients being monitored?
Wilcox, et al. RESPIRATORY CARE • DECEMBER 2009 VOL 54 NO 12

11. Indications for Tracheotomy
MULTIDISCIPLINARY TRACHEOSTOMY TEAM DEVELOPMENT
Indications for Tracheotomy
Prolonged intubation
Need for long-term mechanical ventilation
Need for permanent tracheostomy tube
Inability to intubate - trauma
Airway protection/secretion removal
Airway anomaly
Patient comfort
Facilitates weaning
Options for oral feeding and communication
A tracheostomy alone is not the treatment for aspiration

12. Complications of Tracheostomy
MULTIDISCIPLINARY TRACHEOSTOMY TEAM DEVELOPMENT
Complications of Tracheostomy
Inflated Cuff
Trauma
Laryngeal anchoring
Reduced airway closure
No Airflow to upper airway
reduced sensation
reduced taste/smell
loss of voice
Loss of positive airway pressures
peep
cough
swallow
trunk stability, postural control
Anatomical Complications/Risk
- List anatomic and physiologic changes

13. MULTIDISCIPLINARY TRACHEOSTOMY TEAM DEVELOPMENT
To Improve Outcomes
First, we need to recognize the nature of the problem.
Second, most hospitals have the experts available to develop teams, just not (working together) at the bedside.
Third, we need to take what we know-scientific knowledge- along with what we think we know-expert consensus-to develop team based protocols.
Hefner, J. Tracheostomy Decannulation: Marathons and Finish Lines. Crit Care 2008; 12(2) 128
- Trach patients can have numerous co-morbidities prior to having trach
- Make timelier decisions regarding patients by developing an airway management team
Hefner, J. Tracheostomy Decannulation: Marathons and Finish Lines. Crit Care 2008; 12(2) 128

14. MULTIDISCIPLINARY TRACHEOSTOMY TEAM DEVELOPMENT
Team Work
Develop a facility-wide program for all tracheostomy and mechanically ventilated patients to be evaluated for candidacy for the Passy-Muir® Valve within 24 hours of admission, and at appropriate times throughout their stay.
“A big job ain’t nothin’ but a whole lot of little jobs laid end to end”

15. What’s In A Name? MULTIDISCIPLINARY TRACHEOSTOMY TEAM DEVELOPMENT
TRAMS- by Gail Sudderth, Licensed RT and Clinical Consultant (Trach Review and Management Service)- take care of trach patients in community/hospital in Australia

16. Why You Need a Trach Team
MULTIDISCIPLINARY TRACHEOSTOMY TEAM DEVELOPMENT
Why You Need a Trach Team
Communication
Patient Safety
Risk of Aspiration
Risk Associated with Trach Tube
Infection Control
Mechanical Ventilation
Long-Term Trach Placement
Education
Staff Confidence/Knowledge
Plan of Care
Continuity of Care
Quality of Care
Quality of Life
CONTINUITY OF CARE
DON’T WANT decisions made by individual physicians’ preference and habit but by evidence based practice.
doesn’t matter if its 2-3 yearly or monthly
- trach patients use lots of “resources” (more than just trach)
- $10K daily for trach care patient
- COMMUNICATION IS VERY IMPORTANT

17. Benefits of an Interdisciplinary Team
MULTIDISCIPLINARY TRACHEOSTOMY TEAM DEVELOPMENT
Benefits of an Interdisciplinary Team
Trach team can benefit facility because more than 1 professional is taking care of patient
-improved patient comfort
Improved safety
Improved oral hygiene and oral intake
Lower mortality
Reduced ICU and length of stay
Earlier ability to communicate

18. “Study the past if you would define the future”
MULTIDISCIPLINARY TRACHEOSTOMY TEAM DEVELOPMENT
WHERE DO I START?
“Study the past if you would define the future”
- Confucius -

19. Identify the Needs of Your Facility
MULTIDISCIPLINARY TRACHEOSTOMY TEAM DEVELOPMENT
Identify the Needs of Your Facility
Survey: -Staff knowledge and comfort levels -Patient satisfaction Review: -Present protocols -Statistics -Events related to tracheostomy tube
STRATEGY
-How many tracheostomized patients are in the facility?
-Are bounce-backs to the ICU a common or expected occurrence?
-Interview patients and family members to determine their perception of care and allow them to share their experiences while in the facility.
-Survey the staff; what is the reported knowledge, experience and confidence levels in the care of the tracheostomized patient?

20. Team Members “Strength lies in differences, not in similarities”
MULTIDISCIPLINARY TRACHEOSTOMY TEAM DEVELOPMENT
Team Members
“Strength lies in differences, not in similarities”
Obj 1-Identify key roles and members of the team.

21. MULTIDISCIPLINARY TRACHEOSTOMY TEAM DEVELOPMENT
Team Members
Nursing – at bedside, activities of daily living (ADL), medication
RCP – mechanical ventilation, weaning & BPH
SLP – swallow evaluation and treatment, speech
OT/PT – Range of Motion (ROM), rehabilitation & strength, ADL
Case Manager – discharge planning
Wound Specialist – stoma care
Family – emotional support
Physician – orders, consults
Ancillary Staff – anyone who cares for the patient
Co-treat & cross train
Educate
RCP- resp care practitioner
BPH- broncho pulmonary hygiene

22. Team: Initial Plan Identify a Champion Organize the Team
MULTIDISCIPLINARY TRACHEOSTOMY TEAM DEVELOPMENT
Team: Initial Plan
Identify a Champion
Organize the Team
Develop Collaborative Protocols & Competencies
Educate Staff
Start! GO TEAM!
Who will lead the team?
Members’ Roles/Responsibilities
Meeting Plans
Goals and Target Dates
Plans for Daily Rounds
- Establish team goals upfront

23. Role of an SLP on the Team
MULTIDISCIPLINARY TRACHEOSTOMY TEAM DEVELOPMENT
Role of an SLP on the Team
EVALUATE FOR SPEECH
EVALUATE FOR SWALLOWING
TRIAL WITH PASSY-MUIR VALVE
ORAL TRIALS/DIAGNOSITIC TESTING TO ASSESS SAFE DIET
VOICE ACTIVITIES FOR VERBAL SPEECH
RESPIRATORY STRENGTHENING EXERCISES FOR VOICING AND AIRWAY CLEARANCE,
OBJ 2-Identify three key roles of an SLP as a member of the interdisciplinary tracheostomy management team
- Treatment for voice, swallowing, and respiration

24. Team Goals How will it function? Who will lead the team?
MULTIDISCIPLINARY TRACHEOSTOMY TEAM DEVELOPMENT
Team Goals
How will it function?
Who will lead the team?
How will it evolve?
Get help organizing and resolving conflicts
There is no “I” in team!
OBJ 3- List three goals of an interdisciplinary tracheostomy management team

25. Team: Ongoing 1. Daily Rounds Who will perform?
MULTIDISCIPLINARY TRACHEOSTOMY TEAM DEVELOPMENT
Team: Ongoing
1. Daily Rounds
Who will perform?
Documentation in medical record
Recording for quality improvement
2. Monitor Compliance
Encourage Reporting
Identify Barriers
3. Education
Patients & Families
Staff
COLLAB PROTOCOLS ON NEXT SLIDE

26. Collaborative Protocols
MULTIDISCIPLINARY TRACHEOSTOMY TEAM DEVELOPMENT
Collaborative Protocols
Suggested
Protocols
Timing of tracheotomy
Types of tubes/cuffs used
Communication Method
Decannulation Pathway
SLP Consults
RT Consults
OT/PT Consults
Nutrition Consults
Wound/Stoma Management
Trach changes/downsizing
Cuff maintenance
Oral care
13. Bed Control/patient placement
14. Suctioning/BPH
Oxygen and humidity
Discharge Planning
17. Patient/Family Education
18. Aspiration/VAP prevention
19. Patient Transport Standards
20. Passy-Muir® Valve Use
21. MD Responsibilities
22. Staff Competencies
23. Standard/standing Orders
24. Emergency Procedures
TEAM APPROACH….WHO WILL DO WHAT?

27. Team Outcomes Improved patient comfort Lower mortality rate
MULTIDISCIPLINARY TRACHEOSTOMY TEAM DEVELOPMENT
Team Outcomes
Improved patient comfort
Lower mortality rate
Reduced ICU and LOS
Improved patient safety
Improved oral hygiene and oral intake
Earlier ability to communicate
OBJ 4- Discuss how the team can impact outcomes of the tracheostomized and/or ventilator dependent patient
-improved patient comfort
Improved safety
Improved oral hygiene and oral intake
Lower mortality
Reduced ICU and length of stay
Earlier ability to communicate

28. Team: Follow-up Review and maintain Stats
MULTIDISCIPLINARY TRACHEOSTOMY TEAM DEVELOPMENT
Team: Follow-up
Review and maintain Stats
Who, What, Why ?
Continuing Education and Competencies
Review and Revise Processes as Necessary
Team Meetings: ongoing
Monthly/Quarterly
Continuing education, compliance and competencies
-Team members and healthcare practitioners caring for the tracheostomized patient are expected to keep skills current with documented competencies.
-Non-compliance issues and adverse events are documented and reported in a timely manner. Such events are used as teaching tools and to improve patient care, patient safety and outcomes.
-Only those clinicians that have adequate knowledge, skills and confidence are assigned to care for the tracheostomized patient. Clinicians are encouraged to report their lack of knowledge or confidence in caring for this patient population and are provided with support and education to improve clinical skills.
Maintain and review statistics for quality improvement
-Pre and post team development statistics are compared. For example, unplanned decannulation, ICU bounce-backs, overall length of stay, etc.
-Interview patients and family members and compare subjective reports before and after the team implementation.
-Survey the staff to assess post team implementation knowledge and confidence level of caring for the tracheostomized patient and use this information to revise how education is disseminated and competency is maintained.

29. Team Process: Review MULTIDISCIPLINARY TRACHEOSTOMY TEAM DEVELOPMENT
- Everyone needs to do what to do in an emergency (who to call, how to proceed, etc)

30. MULTIDISCIPLINARY TRACHEOSTOMY TEAM DEVELOPMENT
Sample Documents

31. Tracheostomy Algorithm
MULTIDISCIPLINARY TRACHEOSTOMY TEAM DEVELOPMENT
Tracheostomy Algorithm

32. Decannulation Algorithm: Phase I
MULTIDISCIPLINARY TRACHEOSTOMY TEAM DEVELOPMENT
Decannulation Algorithm: Phase I
Decannulation planning starts at intubation!!
wwwwh- WHO WHAT WHEN WHY WHERE HOW
-medically stable?
-patent upper airway?
Tolerates PMV?
-manages oral secretions?
- Would be great to discuss prior to procedure (not always the case)
SLP important here

33. Decannulation Algorithm: Phase II
MULTIDISCIPLINARY TRACHEOSTOMY TEAM DEVELOPMENT
Decannulation Algorithm: Phase II
Where will they end up
Can they tolerate cuff deflation….yes---advance to trials of PMV…..no re-inflate cuff and reassess patient at later time….at re-assessment (once tolerate cuff deflation) may have to downsize trach before being able to tolerate PMV

34. Decannulation Algorithm: Phase III
MULTIDISCIPLINARY TRACHEOSTOMY TEAM DEVELOPMENT
Decannulation Algorithm: Phase III
- After trials of PMV can patient be capped??....YES..recommendations for decannulation at least within hrs….NO reassess to determine barriers

35. MULTIDISCIPLINARY TRACHEOSTOMY TEAM DEVELOPMENT
Standard Order Set
Tracheostomy Protocol (for emergency items at bedside, Trach Team Consult and general plan of care)
Tracheostomy tube
Size/type
Cuff (up/down)
Cuff pressure
Tracheostomy tube secured
If sutures, when and who will remove
Tracheostomy tube plans for initial tube change (when and who will perform)
Oxygen and humidity
Suctioning and BPH
Trach/Stoma Care
Oral Care
Consults - #1 SLP for swallow and communication
Physician responsible for emergencies/second call
Who is responsible for trach? Which MD?- pulmonologist?
- As team we are only “Advisory” because we need a physicians order

36. Emergency Trach Box (At Bedside/Easy Access)
MULTIDISCIPLINARY TRACHEOSTOMY TEAM DEVELOPMENT
Emergency Trach Box (At Bedside/Easy Access)
Tracheostomy Tubes – assorted sizes
Spare Inner Cannulae – assorted sizes
Sterile Suction Catheters – assorted sizes
Sterile Gloves – assorted sizes
Tracheostomy tube securing device
Saline Bullets/Sterile H2O
10 cc syringe
Scissors/Kelly clamps/Dilator
Cricoid Hook
Oral suction
Water soluble lubricant
Not to be used for routine tracheostomy changes
- At least have on the nursing hall or patient room

37. Bedside Checklist (Laminated/On Clipboard)
MULTIDISCIPLINARY TRACHEOSTOMY TEAM DEVELOPMENT
Bedside Checklist (Laminated/On Clipboard)
Resuscitation bag and mask
with filter and cap
Suction source
Suction catheters
Saline bullets/Bottle of Sterile H20
Spare tracheostomy tube(custom)
Spare inner cannulae
Obturator
10cc syringe
Suture removal kit
Instructions for transport/O2 set-up
Emergency Trach Box at bedside
- Place where appropriate in your facility

38. Daily Rounds (not part of the medical record)
MULTIDISCIPLINARY TRACHEOSTOMY TEAM DEVELOPMENT
Daily Rounds (not part of the medical record)
Date of initial and present tracheostomy
Tracheostomy tube size and type
Sutures present/plan for removal
Decannulation (per order or self)
Cuff pressure or cuff deflated
Trach security method
Condition of tube/stoma/mouth/
lips/other tissue
Ventilator/respiratory status
Nutritional status
Method of communication
Cough/secretion management
Emergency equipment at bedside
Subjective reports
Findings/recommendations/care plan
Documentation in medical record

39. MULTIDISCIPLINARY TRACHEOSTOMY TEAM DEVELOPMENT
Daily Rounds Record

40. Team Process: Review12 Steps
MULTIDISCIPLINARY TRACHEOSTOMY TEAM DEVELOPMENT
Team Process: Review12 Steps
1. Identify needs
2. Champion/Members
3. Organize Team
4. Present to Administration
5. Identify Barriers
6. Develop Protocols
7. Educate Staff
8. Cross-train
9. Team Rounds
10. Documentation
11. Monitor Compliance
12. Reach Goal

41. MULTIDISCIPLINARY TRACHEOSTOMY TEAM DEVELOPMENT
Key Points
The management of tracheostomy patients is multi-disciplinary and requires active collaboration by all health care professionals
Assessment and reassessment by the team is crucial for ensuring safe, effective weaning and decannulation
The strength of the team lies in the differences of the members, not the similarities
A team approach can significantly impact weaning, rehab, decannulation time, length of stay (LOS), cost and quality of life of the tracheostomized/ventilator dependent patient

42. Keys to Success: Develop an Education Program
MULTIDISCIPLINARY TRACHEOSTOMY TEAM DEVELOPMENT
Keys to Success: Develop an Education Program
Complete Online Self-Study Courses
Review Research & Address Questions
Schedule In-service for Facility

43. Keys to Success: Establish Policies & Procedures
MULTIDISCIPLINARY TRACHEOSTOMY TEAM DEVELOPMENT
Keys to Success: Establish Policies & Procedures
Incorporate the Passy-Muir Valve into ventilator weaning and decannulation policies and procedures.
Samples of policy and procedures available:
Implement competencies for all clinical staff.
COE-

44. Additional Educational Opportunities
MULTIDISCIPLINARY TRACHEOSTOMY TEAM DEVELOPMENT
Additional Educational Opportunities
Self-study webinars available on demand
Getting Started
Ventilator Application
Swallowing
Pediatric
Special Populations
Live group webinars
Passy-Muir Inc. is an approved provider of continuing education through ASHA , AARC and California Board of Nursing Credit