A Tracheostomy Care Journey …. Tanis Cameron, Director TRAMS

Vice Preseident Glbal Tracheostomy Collaborative

US Roll Out GTC Boston 26 April 2014

Outline

Tracheostomy Review and Management Service

TRAMS Journey

System improvements based on our experiences

Success Stories

Reflecting on change

The TRAMS Journey

2002 TRAMS Pilot Study

2003- 2006 Project funding

2007 TRAMS becomes core business

2009 Outcomes published

2011 International Tracheostomy Symposium

2012 Invited to participate in creation of GTC

2014 Roll Out USA - Excellent !

All Team Members Involved In:

Acute care rounds

Decannulation decision making

Documentation

Community patient care

Policy and procedures

Education, research

Staff meetings & communication

TRAMS Outcomes

Outcomes of patients with spinal cord injury before and after the introduction of an

interdisciplinary tracheostomy team Critical Care and Resuscitation, 2009 11

(1), 14-19

1. All Decannulated Patients Group 514 patients 3 years

Heterogeneous group

Multiple co-morbidities

2. Subgroup of Spinal Cord Injured Patients

Largest subgroup, more homogenous

Tracheostomy is one of the primary diagnosis

Matched pairs 34 pre TRAMS 58 Post TRAMS

Outcomes, Spinal Cord Injury Patients

DOC decreased by 5.5 days ( 23.5 to 18 days) p=0.02

LOS decreased by 27 days (73 to 46) p=0.098

Time to talking decreased by 11 days (20 days to 11 days)

p=0.001

Patient reports lack of voice as torture –anxiety, stress,

withdrawal, depression Freedman-Sanderson 2011

Effective communication is fundamental to quality healthcare

Cost savings with team in place described

System Improvements?

We have become better at:

Asking the right questions

Communicating and collaborating

Patients involvement at all stages increasing

Educating

Should A Tracheostomy Tube Be Inserted in this Patient ?

Frail 90 year old woman, hearing and vision impairment, admitted

post fall for hip surgery. Sepsis, respiratory failure then

tracheostomy. On ward copious secretions, no communication. Died

on ward 2 months later

54 year old man, PSP, poor bulbar function, nil cough admitted for

tracheostomy. TRAMS meets with patient, asks what he values at

this stage of life, discusses realities of long term tracheostomy and

other options. Patient chose to go to nursing home close to family,

Died peacefully 3 months later

Asking the Right Questions

In the event of a failed decannulation what does this

patient and family want? Should the tube to go back in?

65 year old man massive stroke, family made courageous

decision that if things did not go well upon decannulation the

tube would not go back in. Post decannulation the Medical

Emergency Team was called. Tube went back in. How difficult

for the family.

We now document and use a structured decannulation form

audit – 94 % completed correctly over 2 years

Decannulation and documentation procedure created

At the Time of Decannulation

Communicate, Collaborate, Consult

TRAMS is a consultative service

We do not tell other ward-based teams what to do

Initially resented (we were instituting change)

We performed many staff / patient surveys and

implemented suggestions- provided feedback

It takes time to grow, establish trust

You cannot over communicate

Key Supporting Programs

ICU Team

ENT service

Victorian Respiratory Support

Service (VRSS)

Victorian Spinal Cord Injury

Service (VSCS)

Clinical Nurse Educators

Community programs

Medical Emergency Team (MET)

Respecting Patient Choices (RPC)

Patient Journey

In the ideal the same team follows patient across their

hospital journey and then into the community

Tracheostomy Care and National Standards

2013 Handover and rounds streamlined, audited

2013 Decannulation Documentation standardized M79.30 created

2013 Patient advocates participate in workshops, websites and act as advisors

Admissions: Unplanned vs Planned

VB - Admission days

0

10

20

30

40

50

60

70

80

90

100

2003 2004 2005 2006

Da

ys

Planned

Unplanned

Highly Structured Education Program

Patient brochure

Consumer participation and engagement

Community Patients

2 week intensive training program prior to discharge and ongoing

Patient, , Family and carers

Nursing Homes

Respite

Carer agencies

Interdisciplinary Staff Education Intranet, e learning series critical

Simulation and emergency management training

Bedside trianing

25 staff in services annually

2-3 full day workshops annually

2011 Inaugural International Tracheostomy Symposium

Interdisciplinary Tracheostomy Education Model

From Random Chaos To Competence

TRAMS and National Standards

2013 TRAMS handover and rounds streamlined, audited

2013 Decannulation documentation standardized M79.30

2013 Patient advocates participate in workshops, websites and act as advisors

Changes to Practice

Routine endoscopic examination

New decannulation documentation form

used across the centre

Interdepartmental tracheostomy forum

Quality and safety issues shared

Bleeding at the stoma site policy created

Colin Gray

BACKGROUND

Late 2011 – C6 Quadriplegia following farming accident

Limited arm movement ,Absent trunk and leg movement

Diaphragm intact

Decreased lung volumes and poor cough/clearance

T/F to rehabilitation centre

D/C home August 2012 (no tracheostomy)

Readmitted with aspirate pneumonia and tracheostomy reinserted

Worsening dysphagia (movement of cervical fixation now impacting on

epiglottic movement, laryngeal elevation and pharyngeal contraction)

Ongoing weak cough

Col and Jenny decide to keep tracheostomy for discharge and plan for

the future

Colin Gray and Family

Col’s  100th blood bank donation

Colin in the Community

100 Blood Donations

In Colins Words In  C

o

l ’s  words…

Colin’s Goals My  Goals…

Discharge Planning

Insured through workplace

Occupational Therapy, Physiotherapy, Nurses, Doctors,

Dietician Social Worker Speech Pathologist

Carer agency

TRAMS

Discharge and Care plan formulated with Colin and

Jenny

Training of Jenny and carers

Trial periods of leave

Success – Back to the farm !

Success - Home for the wedding !

Col gives away his daughter Robyn

Closing Thoughts

Patient centered systems change lives

Tracheostomy care is improving around the world

We still have a long way to go

Interdisciplinary teams are effective, creative, fun

The best is yet to be –Join Us!

The Global Tracheostomy Collaborative is the way

to move forward together

Reflecting on Change

The voyage of discovery lies not

in finding new landscapes but in

having new eyes M Proust