New interprofessional team puts patients first

After years of discussion on ways to improve the care provided to patients living with a , St. Joseph’s Health Centre Toronto (St. Joe’s) created a new Tracheostomy Team on November 23, 2010.

The core group in this new interprofessional tracheostomy team includes a Registered Respiratory Therapist (RRT), Speech Language Pathologist (SLP), and Intensivist.

Unique to this team when compared to other Tracheostomy Team models is that the most responsible physician hands over care of the tracheostomy to the Intensivist who also helps facilitate dialogue with specialty services where required.

Four Respiratory Therapists directly support the team on its scheduled Tuesday rounds, rearranging their schedule in order to ensure coverage. The plan of care set by the team is then carried out by the front-line SLP where the patients reside and by the ward designated RRT. In those circumstances when the plan of care needs alteration in between team meeting dates, then the front-line RRT and SLP are able to obtain new orders in a timely manner from the Intensivist so that care related to the tracheostomy is not delayed.

Together the team is building on St. Joe’s commitment to Put Patients First by providing the safest care by minimizing time with a tracheostomy tube through expeditious weaning, improving communication, facilitating eating, and assisting with discharge planning coordination of patients with tracheostomies.

“This new initiative is part of the emergency department and critical care program’s quality improvement strategy,” says Silvana Biscaro, Administrative Program Director and project sponsor. “The overall goal is to improve patient outcomes and satisfaction and reduce length of stay for these high risk and medically complex patients.”

A tracheostomy is an opening from the trachea, or windpipe, to the outside of the body -thus creating an airway to breath. Over the last 10 years, there has been an increased use of tracheostomy tubes in order to decrease mechanical ventilation time, pneumonia, unit (ICU) length of stay, and hospital mortality. With the advent of percutaneous tracheotomy in the Adult ICU, the ability to deliver on early tracheostomy has been facilitated. As a result, the number of tracheotomized patients in the ICU and subsequently on the general patient units has increased considerably.

At any given time at St. Joe’s, there are between three and 10 inpatients living with a tracheostomy, who often have an extended length of stay plus an additional three to five patients in the intensive care unit.

Sometimes the length of stay and/or length of time for a patient with a tracheostomy can be unnecessarily prolonged due to the many complications that can arise. So the more expeditiously we work to wean patients from a tracheostomy, the quicker their ability to regain verbal communication, and return to natural oral intake of food and the better quality of life they will have. For those that cannot be liberated and will require discharge home with a tracheostomy, the team helps ensure timely patient and caregiver tracheostomy care education and works closely with hospital staff, the social worker and Community Care Access Centre (CCAC) hospital co-ordinator, to better customize a community care plan to ensure appropriate community supports and resources are organized prior to going home.

“Through earlier education about the tracheostomy and care required we can help build patient and caregiver comfort and confidence on returning home safely when discharged from the hospital,” says Helen Papakyriacou, Speech Language Pathologist/PPL and colead.

“Involvement of the CCAC in the development of the Tracheostomy Team has provided the opportunity for collaboration and feedback about how to best initiate community care services while providing a positive experience for patients with tracheotomies leaving St. Joseph’s Health Centre who require ongoing support,” adds Karey Kosatschenko, CCAC Hospital Care Co-ordinator for St. Joe’s.

To obtain a clear picture of the patient’s current tracheostomy status, the team meets on a weekly basis to review the patient’s history and condition, and discusses patient cases together. Each professional brings their expertise to the decision-making process so the team can design a care plan specific for the patient’s unique needs. Front-line speech language pathologists and respiratory therapists will carry out the established care plan throughout the week, ensuring that the patient gets the right level of care at the right time. Care for patients with a tracheostomy is available 24 hours a day, seven days a week.

“I think the care for these patients has not been as coordinated as it should be and those looking after them directly have been doing it in isolation. Now, with the team we come together, discuss each patients (needs) and develop a care plan (with everyone involved) – which is so important in supporting continuity of care for our patients,” explains Dr. Joanne Meyer, Physician lead for the team.

Key successes since the team’s launch:

Since the team was created last November, it has assessed and facilitated a tracheostomy plan of care for 16 patients.

• Of those 16, nine patients have been decannulated successfully.

• One patient has been liberated from the tracheostomy within two days of team involvement.

• Resolution of a medical problem that had delayed the decision to remove the tracheostomy was expedited.

• Two patients that would not be candidates for decannulation were identified immediately post-tracheotomy. This resulted in timely discharge planning processes including tracheostomy care teaching for patient and care-givers and equipment organization for home.

• There has been immediate consideration for and performance of swallowing assessments when appropriate to identify opportunities for re-introduction of food.

• Two individuals not appropriate for corking were identified as good candidates for a Speaking Valve which enhanced verbal communication.

Moving forward, St. Joe’s Tracheostomy Team strives to keep up the momentum to continue this interprofessional collaboration and provide consistent patient care with a team of experts. This team has helped alleviate some of the fears among patients and their families of a tracheostomy.

With files from Michelle Tadique.