Tracheostomy & Critical Care Discussion and EBP group Health crews & tracheostomy anchors? Navigation to improved patient management Tracheostomy & Critical Care Discussion and EBP group Extravaganza 2010

2010 Review Held Trache Ed day – April 2010 Developed Trache Handover Form – awaiting ratification 2009 CAT – Trache MDT – clinical application Completed 2010 CAT Held Trache Ed day – April 2010 – at Liverpool Hospital. Postiive feedback identified Developed Trache Handover Form – awaiting ratification 2009 CAT – MDT – clinical application 2010 CAT – Trache & Swallow discuss in detail

Taking you back to 2009 CAT 3 articles critiqued MDT = Pt outcome Population specific evidence Preliminary data In patients with a tracheostomy, does management by an identified multidisciplinary team improve patient outcome? Based on the 3 articles critiqued it is evident that management by a multidisciplinary team improves patient outcomes in specific populations including SCI, TBI & vascular in terms of their length of cannulation, length of stay, and use and time to SV use. Although unable to generate these findings to all tracheostomised populations the preliminary data and trends suggest that management by an MDT is safe and effective however further research is indicated to more objectively evaluate and generalise the outcomes.

Clinical application in 2010 Using the evidence Thinking about MDT and trache Mx Engaging in service delivery change Shift towards MDT management All professions getting on board Group members t/o 2010 have brought examples to our meetings as to how the CAT from last year on Trache MDT has been used in clinical practice both as a resource as well as to affect change. The critical appraisal of evidence has been used across sites in presentations, and submissions in advocating for MDT management and there has been a positive response. What has been great is the feedback from group members of the growing number of other medical, AH and nursing professionals that are showing interest in trache MDT and we are starting to see a shift towards a MDT approach with the beginning stages of service delivery change happening so we will watch this space with regards to service delivery for Pts with trache.

Does the presence of a tracheostomy tube impact on swallow function? CAT 2010 Does the presence of a tracheostomy tube impact on swallow function? Hx of getting to this Q Other questions/ideas

Researching the evidence 20 articles - 7 appropriate Interesting facts/ideas along the way Articles of interest Research design & methodology Statistical significance Animal testing!!! 20 articles - 7 appropriate Interesting facts/ideas on the way Research design & methodology (trache out) Statistical signifigance Animal testing!!!

CAP 1 – Leader & Ross 2000 Prospective consecutive case series N = 23 (20 experimental and 3 controls) Range of diagnoses FEES conducted pre & post tracheostomy Outcome = presence of aspiration Clinical bottom line: Presence of a trache tube does not impact on presence or absence of aspiration.

CAP 2 – Leader & Ross 2005 N = 22 Head & Neck cancer patients FEES conducted under 3 conditions Outcome = presence of aspiration Clinical bottom line: Presence of a trache tube (including occlusion status) does not impact on aspiration status in post op H&N patients. Oral or pharyngeal cancer FEES conditions Trache tube present Trache tube removed and stoma covered Trache removed and stoma opened 3 x 5ml puree and 3 x 5ml milk (if not aspirated puree)

CAP 3 – Terk et al. 2007 Prospective crossover study N = 7 Range of diagnoses MBS conducted under 3 conditions Outcome = larynx-to-hyoid bone approximation and maximum hyoid bone displacement Clinical bottom line: Presence of a trache tube (including occlusion status) does not prevent normal hyoid bone and laryngeal movement when swallowing a liquid bolus

CAP 4 – Brady et al. 2009 Prospective case series N = 6 Range of diagnoses FEES conducted under 4 conditions Outcome = penetration-aspiration scale, durational measure of swallow initiation time and complete “whiteout” time Clinical bottom line: Presence of a trache tube (including occlusion status) does not impact on penetration-aspiration status and durational measures of swallow initiation and laryngeal closure

CAP 5 – Leader & Ross 2010 Direct replication study (2000) N = 25 FEES pre and post-tracheostomy Series of food and fluid trialled Outcome = presence of aspiration Clinical bottom line: No causal relationship between aspiration and presence of a tracheostomy with 90% of patients exhibiting the same aspiration status

CAP 6 – McMahon 2003 Critical appraisal of literature (1960-1996) 19 articles discussed Clinical evidence suggests tracheostomy influences swallowing Swallow co-ordination, laryngeal elevation and glottic closure likely to be impacted Clinical bottom line: Limited scientific evidence (low to moderate) exists to support the documented clinical evidence of impact of a tracheostomy on swallow.

CAP 7 – Donzelli et al. 2005 Prospective repeated-measure design study FEES pre and post tracheostomy Puree bolus Outcomes = aspiration and laryngeal penetration Clinical bottom line: No cause-and-effect relationship between the presence of a tracheostomy tube and aspiration. Aspiration status in agreement with and without trache in 95% of participants.

Group Discussion More research needed Population specific research Sample size Other swallow parameters need to be researched E.g. sensation, swallow pressures etc…

Clinical Bottom Line - CAT The current literature does not support that the presence of a tracheostomy tube impacts on swallow function. Due to large range of diagnoses within small participant numbers as well as that not all measures of swallow function were looked at we still cannot rule out a causal relationship between tracheostomy presence and swallow function. Further research is required.

Clinical implications Heavier consideration of diagnosis and co-morbidities rather than the presence of trache Adjust our rationales to doctors & patients E3BP – Collect anecdotal data on patients Cohort of patients

Future Directions Ideas for CAT 2011 Group direction Stoma suturing Intubation Suctioning and impact on secretions and sensation Sensitivity of bedside assessment in critical care Group direction Opportunities for PD Successful video teleconferencing and active participation of rural members Updates on current trache equipment trache education day 2011