Multidisciplinary tracheostomy decannulation programme to improve outcomes in patients with temporary tracheostomy in an extended care setting

Abstract

Background: With advances in critical care medicine, more patients receive temporary tracheostomy. Most of them were taken care of in an extended care setting after stabilisation. Patients on prolonged tracheostomy were at risk of complications and difficult to be managed in the community. Most had to wait for limited quota of hospitalbased infirmaries as the discharge destination resulting in a long-stay problem in an extended care setting. Indeed, many of these stabilised patients had resolved indications for tracheostomy, and decannulation (weaning) should be considered. As a quality improvement project, a multidisciplinary tracheostomy workgroup was formed in Rehabilitation Block (Medicine and Geriatrics), Tuen Mun Hospital in September 2015. In 2016, a tracheostomy decannulation programme was implemented, including (1) a decannulation protocol to triage patient readiness for weaning after multidisciplinary assessment, (2) tracheostomy care coordinators to provide consultative advice, and (3) education talks to staff. Objective: To evaluate the effectiveness of a multidisciplinary tracheostomy decannulation programme on the outcomes of tracheostomised patients in an extended care setting. Methods: This was a retrospective cohort study of adult patients with newly inserted temporary tracheostomy staying in the Rehabilitation Block for >30 days. The postprogramme group admitted in 2016 was compared with the pre-programme group admitted in 2014. Baseline characteristics were recorded at the time of admission, and 1-year outcomes in terms of decannulation rate, length of stay (LOS), and discharge outcomes were compared between groups. Results: 48 tracheostomised patients (mean age, 64.3±12.1 years) were included: 27 in the post-programme group and 21 in the preprogramme group. The two groups were comparable in terms of baseline characteristics including age, gender, premorbid comorbidities, function, admission diagnoses, and intensive care unit / cardiac care unit admission. The post-programme group was more likely to attempt weaning (96.3% vs 71.4%, p=0.03) and be successfully decannulated (74.1% vs 42.9%, p=0.03), compared with the pre-programme group. There was no significant difference in the number of safety concerns during the weaning process. For LOS and discharge outcomes, there were trends for fewer patients to have prolonged (>6 months) LOS (18.5% vs 33.3%, p=0.24) and more patients to be discharged alive (70.4% vs 42.9%, p=0.06) in the postprogramme group. Conclusion: Our multidisciplinary tracheostomy decannulation programme standardised care and safely facilitated weaning, allowing more longstay tracheostomised patients to be discharged and reintegrated to the community.

Background: With advances in critical care medicine, more patients receive temporary tracheostomy. Most of them were taken care of in an extended care setting after stabilisation. Patients on prolonged tracheostomy were at risk of complications and difficult to be managed in the community. Most had to wait for limited quota of hospitalbased infirmaries as the discharge destination resulting in a long-stay problem in an extended care setting. Indeed, many of these stabilised patients had resolved indications for tracheostomy, and decannulation (weaning) should be considered. As a quality improvement project, a multidisciplinary tracheostomy workgroup was formed in Rehabilitation Block (Medicine and Geriatrics), Tuen Mun Hospital in September 2015. In 2016, a tracheostomy decannulation programme was implemented, including (1) a decannulation protocol to triage patient readiness for weaning after multidisciplinary assessment, (2) tracheostomy care coordinators to provide consultative advice, and (3) education talks to staff. Objective: To evaluate the effectiveness of a multidisciplinary tracheostomy decannulation programme on the outcomes of tracheostomised patients in an extended care setting. Methods: This was a retrospective cohort study of adult patients with newly inserted temporary tracheostomy staying in the Rehabilitation Block for >30 days. The postprogramme group admitted in 2016 was compared with the pre-programme group admitted in 2014. Baseline characteristics were recorded at the time of admission, and 1-year outcomes in terms of decannulation rate, length of stay (LOS), and discharge outcomes were compared between groups. Results: 48 tracheostomised patients (mean age, 64.3±12.1 years) were included: 27 in the post-programme group and 21 in the preprogramme group. The two groups were comparable in terms of baseline characteristics including age, gender, premorbid comorbidities, function, admission diagnoses, and intensive care unit / cardiac care unit admission. The post-programme group was more likely to attempt weaning (96.3% vs 71.4%, p=0.03) and be successfully decannulated (74.1% vs 42.9%, p=0.03), compared with the pre-programme group. There was no significant difference in the number of safety concerns during the weaning process. For LOS and discharge outcomes, there were trends for fewer patients to have prolonged (>6 months) LOS (18.5% vs 33.3%, p=0.24) and more patients to be discharged alive (70.4% vs 42.9%, p=0.06) in the postprogramme group. Conclusion: Our multidisciplinary tracheostomy decannulation programme standardised care and safely facilitated weaning, allowing more longstay tracheostomised patients to be discharged and reintegrated to the community.