DR KAREN ORR, ST7 ICM/ANAESTHETICS, UHD

DR CONN RUSSELL, CONSULTANT INTENSIVE CARE/ANAESTHETICS, UHD

DR CHARLES PHILPOTT, CONSULTANT ANAESTHETICS, UHD

Intensive Care Medicine Trainees’

experience of Percutaneous Dilatational

Tracheostomy Insertion:

A UK wide survey

• Background

• Outline of survey design

• Results

•All trainees, ST7+ trainees, NI trainees

• Discussion

BACKGROUND

NCEPOD “On the right Trach?” (2014)

• Estimated 8000 PDT insertions annually in the UK

http://www.ncepod.org.uk/2014report1/downloads/On%20the%20Right%20Trach_FullReport.pdf

• Lethal cases btwn 1985 and 2003

• 71 cases: 0.17% of all pts. or 1 in 600 pts.

• 31% during procedure

• Haemorrhage (38%), airway complications (29.6%),

tracheal perforation (15.5%), PTX (5.6%),

bronchospasm (4.4%), arrhythmia/cardiac arrest

(4.4%) and sepsis (1.5%)

• Bronchoscopic guidance only in 46.5%

Competency Level Descriptors

Domain 5: Practical procedures

ACCS CAT CMT ST Stage 2 Stage 3

5.6 Performs percutaneous tracheostomy

0 0 0 1 3 4

SURVEY DESIGN

Survey Content

• Demographics

• Experience of PDT insertion

•Direct/ indirect supervision

• Self perceived level of competency

DEMOGRAPHICS

• Approximately 400 UK ICM trainees

• 116 complete responses (29%)

• 6 Northern Ireland responses (75%)

• 39 trainees at ST7 level and above

• All training grades, deaneries and base

specialities represented

Number of PDTs performed in career so far - Direct supervision

All trainees, completed responses only

43%

4%9%4%

9%

9%

4%3% 7%

0%8% Zero

One

Two

Three

Four

Five

Six

Seven

Eight

Nine

Ten

Number of PDTs performed in career so far- Indirect Supervision

All trainees, completed responses only

71%

9%

4% 5%

2% 2%2%

1% 1%1% 2%

Zero

One

Two

Three

Four

Five

Six

Seven

Eight

Nine

Ten

PERCEIVED COMPETENCY

Do you feel competent to perform a PDT with direct supervision?

All trainees, completed responses only

86%

14%

Yes

No

Do you feel competent to perform a PDT with indirect supervision?

All trainees, completed responses only

44%

56% Yes

No

TRAINEES ST7 AND ABOVE

Number of PDTs performed in career so far- Direct supervision

59%

0%2%

5%

3%

8%

3%0%

10%

0% 10% Zero

One

Two

Three

Four

Five

Six

Seven

Eight

Nine

Ten

Trainees ST7+, completed responses only

Number of PDTs performed in career so far- Indirect Supervision

51%

15%

5%

8%

2%0% 5%

3%3% 3%

5% Zero

One

Two

Three

Four

Five

Six

Seven

Eight

Nine

Ten

Trainees ST7+, completed responses only

Do you feel competent to perform a PDT with direct supervision?

Trainees ST7+, completed responses only

95%

5%

Yes

No

Do you feel competent to perform a PDT with indirect supervision?

Trainees ST7+, completed responses only

69%

31%

Yes

No

NORTHERN IRELAND TRAINEES

Number of PDTs performed in career so far- Direct supervision

NI trainees, completed responses only

33%

0%33%

17%

0%17%

0% 0% 0% 0% 0%

Zero

One

Two

Three

Four

Five

Six

Seven

Eight

Nine

Ten

Number of PDTs performed in career so far- Indirect Supervision

NI trainees, completed responses only

83%

17%

0%0%0%0%0%0%0%0%0%Zero

One

Two

Three

Four

Five

Six

Seven

Eight

Nine

Ten

Do you feel competent to perform a PDT with direct supervision?

NI trainees, completed responses only

50%50%

Yes

No

Do you feel competent to perform a PDT with indirect supervision?

NI trainees, completed responses only

17%

83%

Yes

No

COMPARISONALL TRAINEES V ST7+ V NI

All TraineesST7+

TraineesNI Trainees

Career, >2 PDT- Direct

61/11652.6%

16/3941.0%

4/666.7%

Career, >2 PDT- Indirect

23/11619.8%

13/3933.3%

1/616.7%

% Self perceived

competency-Direct

100/11686.2%

37/3994.9%

3/650%

% Self perceived

competency-Indirect

51/11644.0%

27/3969.2%

1/616.7%

COMMENTS

Additional Trainee Comments

• Generally inadequate exposure and training opportunities

lacking- many responses from trainees

• Wide variety in training opportunities

• Seldinger technique is a generic skill and PDT should only

require a small number of supervised observations

• Number of PDTs inserted is falling and with it, exposure for

training

• Some consultants struggling to maintain their own skills with

falling numbers , before training junior staff

• Should a small number of consultants in each unit

maintain PDT insertion skills- a specialist rather than

generic skill?

• Skills in managing complications e.g. bleeding are lacking

• Variation between units on focus on training ICM trainees

specifically (above anaesthetic trainees or speciality

doctors for example)

• Uncommon to perform without a consultant present

undertaking bronchoscopy

CONCLUSION

• 86% of all, 95% of ST7+ and 50% of NI trainees feel

competent to perform PDT insertion with direct

supervision

• 44%, 69% and 17% respectively with indirect supervision

• Some inaccuracies with reported numbers, particularly

ST7+ trainees

• Perceived inadequacy of training opportunities (falling

numbers, consultant skill maintenance, training of non

ICM trainee doctors)

• Should it remain a core skill for all Intensivists?

Thanks

• Dr Conn Russell (Consultant Intensive Care,

UHD)

• Dr Charles Philpott (Consultant Anaesthetist,

UHD)