Editor’s note: The authors published a similar article in the July 2019 issue of Critical Care Explorations. This column is published with the permission of Wolters Kluwer Health, Inc. and Copyright Clearance Center, New York, NY.
Tracheostomy is one of the most commonly performed procedures in critical care. Multiple studies and guidelines address the timing and techniques for placement of a tracheostomy.1 Prolonged tracheostomy placement is associated with certain risks, including tracheal stenosis, bleeding, site infection, dehiscence, and others. Despite these risks, very limited data and no official guidelines are available to assist with decannulation.2,3 Other institutions have attempted to address this need with mixed results by developing tracheostomy teams and bundle packages.4-7 The trauma team at Christiana Care Health System, Newark, DE, sought to develop a reliable protocol that can work in a variety of settings and maintain patient safety.
The local problem
Christiana Hospital is a large community hospital within a health system that serves patients in northern Delaware. It has approximately 1,000 beds and is an American College of Surgeons (ACS) Level I trauma center, and a Joint Commission-accredited stroke center. It serves approximately 4,000 trauma patient annually.
Because the decision to decannulate a patient must be considered on a case-by-case basis, it can be difficult to compare decannulation rates at various institutions. Rather than compare Christiana Hospital with national guidelines, we identified our local problem through a series of individual patient encounters. Specifically, we noticed that some patients were being decannulated just prior to discharge, and the trauma team agreed that it could have been completed earlier. Furthermore, we identified instances when discharge planning was limited due to tracheostomies that may no longer have been required.
Putting the quality improvement (QI) activity in place
The decannulation initiative was driven primarily through collaboration between the trauma department and the respiratory therapy department. Initial planning developed after the recognition of the opportunity for improvement. A task force was created in the summer of 2015 with the goal of developing a protocol, which was finalized in March 2016. There were six primary participants in the group, including two surgical intensivists, one pulmonary intensivist, two respiratory therapists, and one speech therapist.
Because the decision to decannulate a patient must be considered on a case-by-case basis, it can be difficult to compare decannulation rates at various institutions.
The protocol was developed to incorporate the daily routines of team members and to allow for clinical judgment based on the skills and knowledge of team members. Patient safety, because of the potential for an airway emergency, was of primary concern. For added safety, a provider order was required to initiate the protocol and before decannulation.
Because no standard guideline for decannulation is available, the protocol was developed based on consensus among trauma and respiratory therapy health care professionals. After an agreed upon protocol was created, an order option for the protocol was added to the order set used for tracheostomy. All team members were educated on the topic in small groups at regularly scheduled meetings. Protected time and financial incentives were not offered for this project. We obtained team support through early engagement.
Implementation of the QI activity
The team developed a tracheostomy decannulation protocol (see Figure 1). The population of interest consisted of trauma patients with new tracheostomies. Under the protocol, critical care providers and respiratory therapists identified patients as appropriate for the protocol based on clinical judgment. Additional inclusion criteria included:
- Patients who were not ventilator dependent
- Patients without planned procedures requiring an advanced airway
- Patients with an intact airway and with a cough reflex
- Maintaining adequate oxygenation with FiO2 (fixation of inspired oxygen) <40 percent demonstrated by pulse oximetry or blood gas
- Addressing sleep apnea, if applicable
Figure 1. Outline of the tracheostomy decannulation protocol
The protocol was initiated in March 2016. The respiratory therapy department was primarily responsible for education. The surgical intensivists, as well as the residents, physician assistants, nurse practitioners, respiratory therapists, and speech therapists, all received education on the steps of the protocol and the selection criteria.
The respiratory therapists primarily were responsible for patient identification. The order for initiation or final decannulation could be placed by the surgical intensivists, residents, physician assistants, or nurse practitioners. Respiratory therapists proceeded through the protocol on daily rounding. Speech therapy would assist with speaking valves, if needed. Intensive care unit (ICU) nurses were informed of the protocol, but it did not affect their daily role.
The initial protocol development consisted of one to two representatives from each involved department. Specifically, the director or associate director for the departments of trauma, pulmonology, respiratory therapy, and speech therapy department were involved.
No additional costs were involved beyond the normal hospital operations to implement and maintain this program. This protocol empowered individuals to progress patient care within their skill set and within agreed upon standards.
We conducted a full assessment approximately 18 months after initiation. Propensity matching was used to account for patient age, gender, injury severity score, and duration on a ventilator. We assessed for decannulation rates, time to decannulation after a patient was liberated from the ventilator, and time to discharge after ventilator liberation. Patients treated with the protocol were compared with patients not treated per the protocol. To be considered for the analyses, all patients had to meet the inclusion criteria outlined previously.
A total of 134 patients received care subsequent to the initiation of the protocol; 62 (46 percent) of these patients received treatment that complied with the protocol. In this assessment, patients treated by the protocol were 50 percent more likely to be decannulated (odds ratio [OR] 9.2 [4.0, 21.4], p<0.001). If they were decannulated, it was 1.1 days sooner (p = 0.54). There was no difference in the time to discharge (p = 0.96).
The decannulation initiative was driven primarily through collaboration between the trauma department and the respiratory therapy department. Initial planning developed after the recognition of the opportunity for improvement.
Initiation of the protocol led to a cultural change that affected patient care. By comparing the 134 patients treated since the protocol was made available to 118 patients treated before the protocol was available, we saw similar results. Even if a patient was not treated by the protocol, patients were more likely to be decannulated after the protocol was available (OR 2.1 [1.5, 3], p<0.001). Patients treated since the protocol was implemented were decannulated 5.2 days sooner (p = 0.07) and were discharged 7.3 days sooner (p = 0.04).
One patient did require a reintubation. This patient was treated within the protocol. Nationally, the standard of care is that 2 to 5 percent of decannulated patients may require a reintubation, and our rate was still less than 2 percent.
There were no true setbacks during this improvement project. Three limiting steps that were addressed within the protocol design helped to reduce this possibility. First, the initiation of the protocol and final approval for the decannulation required a provider order. This specification served as a safety net that allowed for patient selection. Second, the actual order was incorporated into an order set that the trauma team already used, so the provider didn’t need to do extra work to place the order. Third, our ICU trauma team incorporated respiratory therapists into rounding. Consequently, the empowerment of the respiratory therapists to advance care in a patient was readily accepted.
The focus of this project was patient care. Although we did not calculate the cost savings, we believe that the protocol has had cost benefits to both the patient and the hospital system. Empowerment of the respiratory therapists allowed them to expedite patient care while continuing their daily assessments. Decannulating patients earlier meant fewer patients needed to be monitored by the respiratory therapists. Similarly, we feel that this expedited care contributed to the greater than one week decrease in mean hospital length of stay.
The key factor that made our decannulation protocol successful was the decision to empower the respiratory therapists to advance patient care within a structured system.
The key factor that made our decannulation protocol successful was the decision to empower the respiratory therapists to advance patient care within a structured system. We did not require additional funding or staff because it incorporated established daily routines.
We had early buy-in from a multidisciplinary standpoint, which was likely secondary to involving members from each department and incorporating their concerns for both patient safety and ease of use. In addition, widespread, in-person education on the protocol and the steps required by each team member allowed for easy adoption. All of these factors were dependent on a strong and trusting relationship between the trauma providers and the respiratory therapists. At our institution, this relationship was well established, but increased communication on patient updates and outcomes could help during the transition period.
For additional details on our methods and results, read our article in Critical Care Explorations.
- Young D, Harrison DA, Cuthbertson BH, et al. Effect of early vs late tracheostomy placement on survival in patients receiving mechanical ventilation: The TracMan randomized trial. JAMA. 2013;309(20):2121-2129.
- Christopher KL. Tracheostomy decannulation. Respir Care. 2005;50(4):538-541.
- Singh RK, Saran S, Baronia AK. The practice of tracheostomy decannulation—a systematic review. J Intensive Care. 2017;5:38.
- Zanata Ide L, Santos RS, Hirata GC. Tracheal decannulation protocol in patients affected by traumatic brain injury. Int Arch Otorhinolaryngol. 2014;18(2):108-114.
- Pasqua F, Nardi I, Provenzano A, Mari A. Weaning from tracheostomy in subjects undergoing pulmonary rehabilitation. Multidiscip Respir Med. 2015;10:35.
- Mah JW, Staff II, Fisher SR, et al. Improving decannulation and swallowing function: A comprehensive, multidisciplinary approach to post-tracheostomy care. Respir Care. 2017;62(2):137-143.
- De Mestral C, Iqbal S, Fong N, et al. Impact of a specialized multidisciplinary tracheostomy team on tracheostomy care in critically ill patients. Can J Surg. 2011;54(3):167-172.