Carol Smith – Advanced Practice Physiotherapist in Surgical and Critical Care. University Hospital Hairmyres (UHH), NHS Lanarkshire.
How can we keep tracheostomy patients safe and improve their journey and outcomes? I am one of the NHS Education for Scotland (NES) Allied Health Professional (AHP) Career Fellows for 2021/22 and that question is the focus of my Fellowship project this year. I feel very lucky to have been awarded the NES AHP Career Fellowship but I do wonder about my timing as a Critical Care Physiotherapist in Lanarkshire – am I crazy embarking on this just now? However, as challenging as the pandemic has been it has opened some doors around extended roles and professional boundaries, so perhaps now is the best time to be exploring the role of AHPS, and specifically Physiotherapy, in the management of tracheostomies.
My Fellowship is based around coordinating and standardising acute tracheostomy management to keep patients safer with improved outcomes within UHH. This vulnerable patient group straddles multiples specialties and often lacks standardised care and accountability, particularly after leaving Critical Care. This international issue has been brought to the forefront and championed by a number of initiatives including the Global Tracheostomy Collaborative and the National Tracheostomy Safety Project (NTSP).
The evidence is startling regarding risk and harm with 30% of tracheostomy patients experiencing an incident and for 60-70% of patients this can be measureable harm (McGrath et al, 2020). The good news is that the evidence to remedy this risk is strong and definitive.
Tracheostomy Multidisciplinary Teams (MDTs) reduce adverse events in patients as well as reducing length of stay and tracheostomy days (Bonvento et al, 2017; McGrath & Wilkinson, 2015). McGrath et al (2020) also demonstrated reduced time to first vocalisation and first diet through implementation of standardised care including weekly ward rounds, champion roles and accessible education. Very importantly significant reductions in patient anxiety and depression were also seen alongside large financial savings for organisations.
The NTSP produced the Guidance for Tracheostomy Care (2020) alongside the Intensive Care Society and the Faculty of Intensive Care Medicine, to define the standards for tracheostomy management. In essence, the standards formulate the core of my Fellowship change ideas.
The vision for University Hospital Hairmyres (UHH) is by March 2022:
- All UHH in-patients will be seen weekly by a tracheostomy MDT
- A tracheostomy champion will be appointed for UHH
- A MDT tracheostomy working group will be established at UHH
- A UHH tracheostomy policy will be created, including a clear pathway defining tracheostomy appropriate wards
- Education recommendations will be in place for UHH staff who treat tracheostomy patients
Accessible and standardised education for all staff treating tracheostomy patients is a huge priority but C-19 challenges, mainly very high clinical activity, may hamper achievement of that change idea. I intend to pilot education sessions and offer recommendations moving forward.
It has been refreshing during engagement conversations to be met with ‘it’s a no brainer, isn’t it?’ but also worrying as what many consider to be a ‘no brainer’ is not standardised care throughout Scotland. NHS Lanarkshire is extremely lucky to have a Tracheostomy Nurse Specialist in ENT but there is a limit to what our ‘Tracheostomy Queen’ can achieve. The structure of three University Hospitals in Lanarkshire is a huge barrier from a time and workforce perspective. We need to find a way for tracheostomy trained clinicians to routinely ‘have eyes’ on these patients to improve safety, journey and outcome.
I am tracheostomy champion for UHH over the Fellowship period. This is ultimately a coordinator role and this will develop further in the coming months. Having worked in large neurosciences units previously, I had thought my post in Lanarkshire would not utilise my passion and experience for tracheostomy management as much. In fact, I now feel that smaller hospitals are more in need of these roles. How do staff maintain competency and confidence when tracheostomy patients are less frequent than in larger hospitals? Nursing staff confidence questionnaires have demonstrated significant concerns around these issues. This is a strong driver for cohorting tracheostomy patients as much as possible so we are not diluting experience and confidence. I will discuss this in my next blog.
The most important ‘why’ for me is around the patients and families who live the tracheostomy journey. Interviews with them has shown the vulnerability and isolation these patients experience. As staff, our words and actions guide the patient journey clinically and emotionally. We must empower, educate and support all members of the MDT who treat tracheostomy patients for their sake and for the sake of our patients. Standardising and coordinating care by meeting the national standards will be beneficial for all.
My personal reflection on the first portion of my Fellowship is just wow! What a positive, empowering experience and I give a lot of credit for that to my mentor Claire and my manager Abi. I would encourage any AHP with a larger project in mind to consider the Fellowship and to think strategically around mentor selection if successful. Think of where you may lack experience and what you might need from a mentor. I am an experienced clinician but have never managed such a big piece of service improvement. My mentors have guided and nurtured skills around quality improvement, strategic thinking, change management and networking.
I would love to hear from any clinicians who have examples of excellent MDT working around tracheostomy management. What have you achieved and what are your tips for an evolving service?
- B. A. McGrath et al (2020) Improving Tracheostomy Care in the United Kingdom: Results of a Guided Quality Improvement Programme in 20 Diverse Hospitals, British Journal of Anaesthesia, Volume 125, Issue 1, Pages 119-129
- B. A. McGrath, K. Wilkinson (2015) The NCEPOD Study: on the right trach? Lessons for the Anaesthetist, British Journal of Anaesthesia, Volume 115, Issue 2 Pages 155–158
- Bonvento, B et al (2017) Role of the Multidisciplinary Team in the Care of the Tracheostomy Patient Journal of Multidisciplinary Healthcare 10; Pages 391-398
- Faculty of Intensive Care Medicine, Intensive Care Society National Tracheostomy Safety Project (2020) Guidance for Tracheostomy Care