Improving the Decannulation Rate in Trauma Patients

General Information 

Institution Name: Christiana Care Health System 

Submitter Name: Michael Farrell, MD, MS, General Surgery Resident 

Name of the Case Study: Improving the Decannulation Rate in Trauma Patients 

What Was Done? 

Global Problem Addressed 

Tracheostomy is one of the most commonly performed procedures in critically ill patients. There are multiple studies and guidelines addressing the timing and techniques for placement of a tracheostomy. In 2013 the TracMan trial provided updated insight into the timing of a tracheostomy by demonstrating that a tracheostomy within four days of intubation was not associated with improvement in mortality or time on the ventilator compared with at 10 days.¹ Prolonged tracheostomy placement does carry risks, including, but not limited to, tracheal stenosis, bleeding, site infection, and dehiscence. Despite the known risks there is very limited data and no guidelines to help determine the timing or steps to take toward decannulation.^2,3 Other institutions have attempted to address this need, with mixed results, by developing tracheostomy teams and bundle packages.^4-7 In spite of these efforts, a need still exists for a reliable protocol that can work in a variety of settings and maintain patient safety. 

Identification of Local Problem 

The decision to decannulate a patient must be considered on a case-by-case basis, and this makes it difficult to compare multiple institutions. Additionally, there are no set criteria to use as a comparison for decannulation rates. Instead, it was recognized that some of our patients had prolonged discharge planning due to their tracheostomy. Some patients had limited rehabilitation options due to still having a tracheostomy in place that was no longer required from a safety perspective. Other patients were being decannulated just prior to discharge, and it was felt that this step could have been completed earlier. 

How Was the Quality Improvement (QI) Activity Put in Place? 

Context of the QI Activity 

Christiana Care Health System is a large community hospital system providing care for Northern Delaware. It consists of approximately 1,000 beds and is an American College of Surgeons-designated Level I trauma center and a JCAHO stroke center. It serves approximately 4,000 trauma activations annually. 

The decannulation initiative was driven primarily through cooperation between the trauma department and respiratory therapy department. 

Planning and Development Process 

Initial planning developed after the recognition of the opportunity for improvement. A task force was created with the goal of developing a protocol. Participants in the group consisted of surgical intensivists, pulmonary intensivists, respiratory therapists, speech therapists, and critical care administration. 

Patient safety, due to the potential for an urgent airway emergency, was of primary concern. The protocol was developed to allow for clinical judgment and use of a skill set within the training and daily routines of team members. For added safety, a physician order was required to initiate the protocol and prior to decannulation. 

There is no standard guideline for decannulation, therefore the protocol was developed based on consensus among practitioners. After an agreed 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. 

Description of the Quality Improvement Activity 

A tracheostomy decannulation protocol was developed (Figure 1). The population of interest consisted of trauma patients with new tracheostomies. The surgical intensivists are required to identify the patient as appropriate for the protocol based on clinical judgment. Additional inclusion criteria included: 

• Not being ventilator dependent 

• Not have planned procedures requiring an advanced airway 
• Have an intact airway with a cough reflex 
• Maintain adequate oxygenation with FiO2 less than 40 percent demonstrated by pulse oximetry or blood gas 
• If patient has sleep apnea, must be addressed 

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, intensive care unit (ICU) nurses, respiratory therapists, and speech therapists all received education on the steps of the protocol and the selection criteria.

The surgical intensivists were responsible for patient selection. 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 assisted with speaking valves, if needed. ICU nurses were made aware of the protocol, but it did not impact their daily role.

Resources Used and Skills Needed

1. The initial protocol development consisted of a small group of one to two representatives from each involved department. Specifically, this included the director or associate director for the departments of trauma, pulmonology, respiratory therapy, and speech therapy. 
2. There was no additional cost beyond the normal hospital operations to implement and maintain this program. This protocol empowered individuals to advance patient care, within their skill set and within agreed upon standards. 

What Were the Results?

Overall Results 

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. We compared patients treated by the protocol with those not treated by the protocol. We also wanted to assess for any cultural changes within the hospital system since the initiation of the protocol, so we compared patients treated before with those treated after the protocol was made available. To be considered for the analyses, all patients had to meet the inclusion criteria, as outlined above. 

We have cared for 134 patients since the initiation of the protocol with 62 (46%) of patients being treated by the protocol. In this assessment, patients treated by the protocol were 50 percent more likely to be decannulated (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). 

By initiating a protocol, we did see a cultural change that impacted patient care. By comparing the 134 patients treated since the protocol was made available with 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 were decannulated 5.2 days sooner (p=0.07) and were discharged 7.3 days sooner (p=0.04) if treated since the protocol was made available. 

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 patients who are decannulated may require a reintubation, and this was still less than 2 percent. 

Setbacks

There were no true setbacks during this improvement project. There were three limiting steps that were addressed within the protocol design that helped limit any setbacks. First, the initial initiation of the protocol and final approval for the decannulation required a provider order. This step served as a safety net that allowed for patient selection. Second, the actual order was incorporated into an order set already commonly used by the trauma team. This step helped limit any extra work to the provider placing the order. Third, our ICU trauma team incorporates respiratory therapist into rounding. Due to this relationship, the empowerment of the respiratory therapists to advance care in a patient was easily accepted.

Cost Savings

The focus of this project was patient care. We did not calculate the cost savings; however, we believe there are areas that would undoubtedly have had cost savings to both the patient and the hospital system. Through empowerment of the respiratory therapists, they were able to expedite patient care while continuing their daily assessments. By decannulating patients earlier we were able to decrease the number of patients who were being followed by the respiratory therapists. Similarly, with more patients being decannulated, we were able to shorten the average hospitalization by over a week. We believe this is likely secondary to an increased number of available rehabilitation centers, which would otherwise not evaluate or accept patients with tracheostomies. 

Tips for Others 

• The key factor that we felt made our decannulation protocol successful was that we simply empowered the respiratory therapists to advance patient care within a structured system. We did not require additional funding or staff since the protocol 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 utilization. Additionally, the wide-spread and in-person education on the protocol and the steps required by each team member allowed for easy incorporation. All of these steps do require 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.

References

1. 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. 
2. Christopher K. Tracheostomy TD. Respir Care. 2005;50:538-541. 
3. Singh RK, Saran S, Baronia AK. The practice of tracheostomy TD–A systematic review. Journal of Intensive Care. 2017;5:38. 
4. De Lima Zanata I, Santos RS, Hirata GC. Tracheal TD protocol in patients affected by traumatic brain injury. Int Arch Otorhinolaryngol. 2014;18:108-114. 
5. Pasqua F, Nardi I, Provenzano A, et al. Weaning from tracheostomy in subjects undergoing pulmonary rehabilitation. Multidisciplinary Respiratory Medicine. 2015;10:35. 
6. Mah JW, Staff II, Fisher SR, et al. Improving TD and swallowing function: A comprehensive, multidisciplinary approach to post-tracheostomy care. Respiratory Care. 2017; 62:137-143. 
7. 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; 54:167-172.