1. 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

2. 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

3. 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.

4. 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.

5. 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

6. 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!!!

7. 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.

8. 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)

9. 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

10. 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

11. 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

12. 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.

13. 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.

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

15. 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.

16. 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

17. 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