Tracheostomy and Laryngectomies are high-risk procedures in increasingly complex patients, meaning that it is not always clear how they should be managed in emergency scenarios – ear nose and throat (ENT) specialists, anaesthetists or the intensive care team? An early experience of the chaos that ensued during an emergency tracheostomy caused Dr Brendan McGrath to reflect on how better to manage the situation.

“I remember asking for some relevant equipment that took 10 or 15 minutes to find. Fortunately, the patient was okay in the end. But there could be Head & Neck surgeons trying to do one thing, anaesthetists trying to do something else. Or a patient may be on the ward and under the care of neither ICU nor ENT, and if a problem arose, we could spend 10 minutes trying to find the person in charge, by which time it may be too late. Talking with colleagues, I realised that there were actually no guidelines on what to do, even though about 10% of all patients in ICU ended up having tracheostomies.”

Galvanised by the support of like-minded colleagues in the North West of England, Dr McGrath searched for existing guidance on managing emergency tracheostomies, looking both nationally and internationally. Although some helpful instructions were available, they were aimed at very specific patient groups or problems. Dr McGrath recognised a clear need to create overarching guidance to cover everyone.

“We started off by drafting a universal guideline for the emergency management of all patients with tracheostomy problems. It was just a single side of A4 and we invited representations from other disciplines involved in tracheostomy care to help too.”

To formulate these guidelines, Dr McGrath and co-workers needed to understand the problems that tracheostomy patients encounter, so working alongside the National Patient Safety Agency (NPSA) they analysed tracheostomy-related critical incidents that were reported nationally. Sifting through two years of data, certain themes emerged that mirrored what Dr McGrath and his colleagues had experienced locally, largely reflecting the weighty burden of tracheostomy management, often without sufficient expertise, training and infrastructure to safely manage patients (1).

“When we started looking with the NPSA, the themes that came out were a lack of training and a lack of familiarity with equipment, a lack of immediately available equipment at the bedside and deficiencies in the infrastructure supporting the management these patients.”

These multidisciplinary guidelines were developed for all of the stakeholders involved in emergency tracheostomy: medical, nursing and allied health staff from ICU, Anaesthesia, Head & Neck Surgery and Emergency Medicine. These guidelines were then taken to various different medical colleges and speciality groups for formal consideration, and subsequently shared on various different websites for consultation to make them as universal and accessible as possible.

The National Tracheostomy Safety Project incorporates the following key stakeholder groups with multi-disciplinary expertise in airway management:

• The Difficult Airway Society
• The Intensive Care Society
• The Royal College of Anaesthetists
• ENT UK
• The British Association of Oral and Maxillofacial Surgeons
• The College of Emergency Medicine
• The Resuscitation Council (UK)
• The Royal College of Nursing
• The Royal College of Speech and Language Therapists
• The Association of Chartered Physiotherapists in Respiratory Care
• The National Patient Safety Agency

With the support of these organisations, the groups developed into the National Tracheostomy Safety Project (NTSP), tasked with improving the care of patients.

The guidelines were simplified into a single A4 algorithm and so resources were needed to support them. (2) The aim of the NTSP was to create a comprehensive one-stop-shop for tracheostomy care. They began making videos detailing complicated procedures, which were hosted on their website with involvement from e-Learning for Healthcare (eLFH). This lead to collaborations with the Advanced Life Support Group (ALSG) and the Resuscitation council to develop international tracheostomy courses, and the publication of multidisciplinary guidelines in ‘Comprehensive Tracheostomy Care,’ effectively the NTSP manual

Being a quality improvement project in hospitals, the NTSP attempts to put the training in place to prevent emergencies. “We’ve been running courses ourselves now since 2008, about 80 courses so far. In fact, demand was so high, we were having so many requests to run courses that we went to the ALSG and set up a course with them, which effectively runs itself. Hospitals can either go to our website and find the majority of the material to create a training course themselves or they can go to the ALSG and sign up to their training packages and learn how to train their staff with resources from ALSG”.

Discussing paediatric guidelines that they also developed Dr McGrath said: “The initial focus was on adult tracheostomies because the emergencies mainly involved adults. Tracheostomies in children are more commonly performed because of breathing problems caused by anatomical abnormalities. Furthermore, because paediatrics tracheas are a lot smaller, inner tubes, which are a key safety feature of adult tracheostomies, tend not to be used in paediatric tracheostomies. Although the cause and treatment of adult and paediatric tracheostomies can be quite different, the same approach was taken to create the tracheostomy algorithms.

Concluding, Dr McGrath described the promising results from collaborations with hospitals around the world that have come together to form the Global Tracheostomy Collaborative (www.globaltrach.org). “With the help of significant funding from the Health Foundation, we’ve shown reductions in severity or harm with the implemented guidelines, with data showing reduced length of stay, reductions in the number, nature and severity of incidents (3) as well as improvements in the quality of care using surrogate markers (for example, patients talking and eating earlier following their tracheostomy).” In identifying and stressing the issues in tracheostomy management, the NTSP guidelines, together with the requisite training, aim towards decisive and cohesive management of all tracheostomy patients. We hope that the NTSP will grow and continue to disseminate this essential information internationally (4).

If you would like to comment on any of the issues raised by this article, particularly from your own experience or insight, Healthcare-Arena would welcome your views.

References

1. McGrath BA, Thomas AN. Patient safety incidents associated with tracheostomies occurring in hospital wards: a review of reports to the UK National Patient Safety Agency. Postgraduate medical journal. 2010;86(1019):522-5. Epub 2010/08/17.
2. McGrath BA, Bates L, Atkinson D, Moore JA. Multidisciplinary guidelines for the management of tracheostomy and laryngectomy airway emergencies. Anaesthesia. 2012;67(9):1025-41. Epub 2012/06/27.
3. McGrath BA, Calder N, Laha S, Perks A, Chaudry I, Bates L, et al. Reduction in harm from tracheostomy-related patient safety incidents following introduction of the National Tracheostomy Safety Project: our experience from two hundred and eighty-seven incidents. Clinical otolaryngology : official journal of ENT-UK ; official journal of Netherlands Society for Oto-Rhino-Laryngology & Cervico-Facial Surgery. 2013;38(6):541-5. Epub 2013/10/10.
4. McGrath B, Wilkinson K, Shah RK. Notes from a Small Island: Lessons from the UK NCEPOD Tracheotomy Report. Otolaryngology–head and neck surgery : official journal of American Academy of Otolaryngology-Head and Neck Surgery. 2015;153(2):167-9. Epub 2015/06/07.