ACI trache guideline SPA - PowerPoint Presentation

Slide1

ACI

trache

guideline

SPA

trache

guideline

Tracheostomy and Critical Care Discussion and EBP Group

Bubble

Bubble

Trache and Trouble

What has been bubbling

in the critical care cauldron?Slide2

CAT’S and CAP’sSlide3

CAT TOPIC 2013

Intubation and Implications on Laryngeal Health

Aim:

To explore the relationship between intubation and the impact it may have upon laryngeal health. Multiple database searches completed and key articles related to intubation, laryngeal trauma, laryngeal health, and critical care were sourced.

Clinical Question: In critical care does laryngeal intubation affect laryngeal health?Slide4

ARTICLE

LEVEL PARTICIPANTSMETHOD

DIAGNOSTIC TOOL OUTCOME MEASURE

RESULTS

SUPPORT FOR CLINICAL Q?Colice et al (1989) IV84All maleMean age: 64.3Prospective studyLaryngoscopeWithin 24 hrsof extubation Laryngeal Injury graded scale (Mild – Severe)

>97% pts with laryngeal damage at initial scope>63% had normal larynx 4 weeks post extubation YesColice et al

(1992) IV54All maleMean age: 63.1Prospective studyDirect laryngoscope within 24 hrs of extubationLaryngeal injury graded scale (Mild – Severe)>92% of pts had normal laryngeal exam 8wks post extubation>Median resolution time = 4 weeks Yes

Thomas et al (1995) IV150 Male & FemaleMean age: 28.2

Prospective studyFibre optic bronchoscopy at time of extubation

13 Parameters analysed to determine predictive factors of laryngeal trauma >87% pts acute laryngeal changes >9% chronic laryngeal changes>Nil correlation between sex, ethnicity, duration of ETT or number of ETT changes YesRashkin et al (1986) IV61 Male & FemaleProspective studyBronchoscope evaluationNil significant relationship between variables

(reintubation, duration etc..) and acute laryngeal injuries

Yes

Kastanos et al (1983)

III

19

Male & Female

Prospective

study

Fibre endoscopic

bronchoscopy

Examination

During 2 week period post extubation

>63%

pts with early laryngeal lesions

3 months post extubation lesions resolved

Variables nil significance to injury

Yes

Heidegger et al (2007)

II

270

Male & Female

Prospective

randomised

trial

Laryngoscopy day 1 post extubation

? Statistical

analysis of data

>8.5%

with vocal cord sequelae.

>Erythema most common laryngeal injury

Nil persistent injuries In either group

YesSlide5

Key Findings….

Acute/short-term changes were commonly reported including vocal cord/tracheal oedema, granulomas, paresis and vocal changes

Chronic/long-term changes were reported with lesser frequency in one key studyA number of papers detail examinations of laryngeal health via laryngoscope within

24 hours post extubationNo significant relationship was found between laryngeal health outcomes and duration of intubation or the number of intubations.Data is not without its flaws:Sample sizes, methodology and subjective data analysis Some of the data is dated

Further research is required! Slide6

Clinical bottom line and implications for practice….

‘ In critical care patients current literature indicates that intubation can cause acute changes to laryngeal health. There is little evidence to support chronic changes.

Currently no significant relationship exits between the duration of intubation or number of intubations on laryngeal health based on the available literature’.Implications on clinical practice:

All SP’s to be aware of the implications of intubation on laryngeal health in acute bedside assessment and long term management.Note difference between acute vs. chronic changes Slide7

Developing a PICI indicatorSlide8

The group has decided that we will develop a Performance Indicator (PI) / Clinical Indicator (CI), based around tracheostomy management in 2014

We have enlisted the assistance of Sarah Whitney (PICI Committee) who has presented to the groupWhere are we up to?Refining the definition of our PICI indicator

Looking at how we can use current E3BP data collection to assist in development of baseline data for PICI indicatorLiaison with Sarah Whitney and Hans Bogaardt (academic mentor)Slide9

RepresentationSlide10

Academic MentorWelcome (and thank you) to Hans

Bogaardt (Sydney University) who is keen to participate in the NSW Tracheostomy and Critical Care EBP GroupHans is a Speech Pathologist, who has extensive international experience in acute clinical care (

dysphagia, tracheostomy and laryngectomy), clinical outcome design, lecturing and epidemiology

Hans’ research experience will be an invaluable addition to our group!Slide11

SPA conference: Interstate poster presentation

Poster

presented at 2013 SPA conference summarising our groups 2.5 year involvement in EBP and E3BP regarding whether a

tracheostomy ‘causes’ dysphagia. Joint project

with Victorian Tracheostomy Discussion Group focusing on:Clinicians ideas about whether the tracheostomy causes dysphagia

Differences in knowledge and clinical practice between NSW and Victoria.

Poster was jointly presented by Klint Goers (NSW) and Anna Ryan (Vic). A HETI scholarship was received to support attendance/travel.The poster has been circulated via the tracheostomy and critical care list serviceSlide12

What we learnt from the SPA experience…The up side

Poster was received wellPresenters were able to speak to other researchers about methods and outcomes

Provides a wider audience for dissemination of evidenceGood for networking and relationships

For the futureSPA may not have been best forum to capture critical care speech pathologists. Suggestions raised in our group that we could consider other critical care conferences in the future Slide13

Agency for Clinical Innovation Best Practice Working Group

The NSW ACI has recently established a multidisciplinary Intensive Care Unit (ICU) working partyThe aim of the group – to look at state-wide clinical practice variation and patient outcomes

First meeting held in early DecemberGroup Representatives: 28 total 2 ACI reps8 ICU staff specialists

14 nursing reps2 physiotherapist1 pharmacist1 Speech Pathologist – Rebecca Black (ICU/Transplant Speech Pathologist- St Vincent's Hospital Darlinghurst). Slide14

EducationSlide15

Tracheostomy Education day 201340 Speech Pathologist attendees from across NSW, including clinicians learning about

tracheostomy management and those wanting a ‘refresher’The day included:Presentations on anatomy and physiology (ENT), tracheostomy and dysphagia (SP)

Patient perspective story (previous trache patient)Expert panel (ENT, trache CNC, ICU CNC, PT plus SP!)

Half day site visits attended by rural attendees for observation on the wards at Westmead Hospital (with great feedback!)Slide16

Tracheostomy education day feedback20 respondents (approx. 50% response rate)

60% respondents worked in adult acute care42% had no experience in tracheostomy management; 31% 1 year or less

93% see 1-5 tracheostomised patients per yearMajority of respondents rated the presentations as “above average” or “excellent”

Slide17

Trache education day feedback (cont)100% said the day met their learning goalsMost positive aspects: patient perspective, panel (case studies), Q and A session, site visit

Some constructive feedback around requests for more case discussion/more time for case studies“I certainly feel less isolated and more confident in developing my skills in this area”Slide18
Slide19

Clinical GuidelinesSlide20

Tracheostomy Clinical Guideline Updates 2013

Both

Speech Pathology Australia and

ACI (NSW Agency for Clinical Innovation) released Clinical Guidelines for Tracheostomy Management in 2013ACI guideline- new; provides recommendations for all areas of

tracheostomy management including multidisciplinary rolesSPA guideline- revised; specific to Speech pathology scope of practice only

Both documents acknowledge the advanced practice for Speech Pathologists in

tracheostomy management. Each hospital/site and LHD responsible for review and considerationSlide21

SPA Tracheostomy Management Clinical Guideline

Updated from the former ‘Tracheostomy Management Position Paper

’ (originally developed in 1996, and revised in 2005)

The new guideline incorporates more critical evidence and provides recommendations for tracheostomy management based on the latest evidence in the literature. The evidence to support these guidelines has been graded according to the National Health and Medical Research Council (NHMRC) This change encourages clinicians to keep up to date with current best clinical practice. A ‘dedicated tracheostomy team’ is highlighted as an ideal model for tracheostomy care. Slide22

Agency for Clinical Innovation – Tracheostomy Clinical Practice Guideline

 Klint Goers (Nepean Hospital) and Julia McLean (St George Hospital) were the Speech Pathologists involved in the Multidisciplinary Clinical Guideline working party

A consumer rep was also a part of this party.

The Clinical Guideline was developed as a result of multiple incidents involving tracheostomised patients across NSW Health. Common themes between SPA and ACI:Recommendations are supported by evidence and NHRMC ratings

 highlights the need for Evidence Based Practice!Tracheostomy teams are strongly encouraged in major hospitals