Lessons learned from safe tracheostomy aftercare taskforce implemented during COVID-19 pandemic.

PURPOSE: At the height of the COVID-19 pandemic, our institution instituted a Safe Tracheostomy Aftercare Taskforce (STAT) team to care for the influx of patients undergoing tracheostomies. This review was undertaken to understand this team's impact on outcomes of tracheostomy care. METHODS: We compared retrospective data collected from patients undergoing tracheostomies at our institution from February to June 2019, prior to creation of the STAT team, to prospectively collected data from tracheostomies performed from February to June 2020, while the STAT team was in place and performed statistical analysis on outcomes of care such as decannulation prior to discharge, timely tube change, and post-discharge follow-up. RESULTS: We found that the STAT team significantly increased rate of decannulation prior to discharge (P < 0.0005), performance of timely trach tube change when indicated (P < 0.05), and rates of follow-up for tracheostomy patients after discharge from the hospital (P < 0.0005). CONCLUSION: The positive impact of the STAT team on outcomes of patient care such as decannulation prior to discharge, timely tube change, and post-discharge follow-up makes a strong case for its continuation even in non-pandemic times.

Tracheostomy in children: Recommendations for a safer technique.

Over the last few decades, tracheostomy has been increasingly performed in children with various complex and chronic conditions. We have seen a dramatic change in indications for tracheostomy in pediatric patients due to better survival of premature infants and those suffering from severe congenital anomalies. There is no consensus about the timing of tracheostomy in pediatric patients. Although percutaneous tracheostomy has become the standard of care for adults, there is not sufficient evidence to start performing it routinely in pediatric patients. The indications, preoperative considerations, and different procedures for tracheostomy in children are reviewed. Surgical tracheostomy is described step by step placing an emphasis on safety measures to minimize complications. There is also a great variability in tracheostomy care protocols in the literature. Post-operative tracheostomy care is discussed for the early and late post-operative periods. There is no general consensus on decannulation protocols, but prevailing expert opinion is presented. There is growing evidence in support for an interdisciplinary approach to pediatric tracheostomized patients. The focus of this paper is the review of the literature regarding safety improvement strategies from the surgical and post-operative point of view.

Pragmatic Recommendations for Tracheostomy, Discharge, and Rehabilitation Measures in Hospitalized Patients Recovering From Severe COVID-19 in Low- and Middle-Income Countries.

New studies of COVID-19 are constantly updating best practices in clinical care. However, research mainly originates in resource-rich settings in high-income countries. Often, it is impractical to apply recommendations based on these investigations to resource-constrained settings in low- and middle-income countries (LMICs). We report on a set of pragmatic recommendations for tracheostomy, discharge, and rehabilitation measures in hospitalized patients recovering from severe COVID-19 in LMICs. We recommend that tracheostomy be performed in a negative pressure room or negative pressure operating room, if possible, and otherwise in a single room with a closed door. We recommend using the technique that is most familiar to the institution and that can be conducted most safely. We recommend using fit-tested enhanced personal protection equipment, with the fewest people required, and incorporating strategies to minimize aerosolization of the virus. For recovering patients, we suggest following local, regional, or national hospital discharge guidelines. If these are lacking, we suggest deisolation and hospital discharge using symptom-based criteria, rather than with testing. We likewise suggest taking into consideration the capability of primary caregivers to provide the necessary care to meet the psychological, physical, and neurocognitive needs of the patient.

Evidence-Based Care of Children With Tracheostomies: Hospitalization to Home Care.

ABSTRACT: Routine tracheostomy care in children maintains airway patency, minimizes infection, and ensures skin integrity around the tracheostomy stoma to prevent complications. Using evidence-based recommendations for care of the mature tracheostomy limits variation in practice and leads to better patient outcomes in all care settings. Incorporating evidence-based care into practice is especially important because children with tracheostomies are at high risk for morbidity and mortality. The purpose of this review is to summarize the most current, evidence-based literature for pediatric tracheostomy care, including stoma care and tracheostomy suctioning. Rehabilitation nurses can then include these best practices when caring for children with tracheostomies and when educating caregivers who provide tracheostomy care to children at home.

Tracheostomy trends in paediatric intensive care.

Paediatric tracheostomy is most commonly performed in children on the paediatric intensive care unit (PICU) to facilitate long-term ventilation. We sought to identify trends in UK tracheostomy practice in PICUs. Data were analysed from 250 261 admissions, including 4409 children tracheostomised between 2003 and 2017. The incidence of tracheostomy in 2017 was approximately half that in 2003 (incidence rate ratio=0.48, 95% CI 0.40 to 0.57). The percentage of patients tracheostomised during a PICU admission, as a proportion of all admissions, was 2.44% (n=319) in 2003 and reduced to 0.97% (n=180) in 2017. Nevertheless, we identified great variability in practice between different PICUs with tracheostomy rates between 0.0% and 4.0% of all admissions. Risk-adjusted PICU mortality was comparable between tracheostomised children and all admissions to PICU.

Short-term Outcomes for Patients and Providers After Elective Tracheostomy in COVID-19-Positive Patients.

BACKGROUND: Urgent guidance is needed on the safety for providers of percutaneous tracheostomy in patients diagnosed with COVID-19. The objective of the study was to demonstrate that percutaneous dilational tracheostomy (PDT) with a period of apnea in patients requiring prolonged mechanical ventilation due to COVID-19 is safe and can be performed for the usual indications in the intensive care unit. METHODS: This study involves an observational case series at a single-center medical intensive care unit at a level-1 trauma center in patients diagnosed with COVID-19 who were assessed for tracheostomy. Success of a modified technique included direct visualization of tracheal access by bronchoscopy and a blind dilation and tracheostomy insertion during a period of patient apnea to reduce aerosolization. Secondary outcomes include transmission rate of COVID-19 to providers and patient complications. RESULTS: From April 6th, 2020 to July 21st, 2020, 2030 patients were admitted to the hospital with COVID-19, 615 required intensive care unit care (30.3%), and 254 patients required mechanical ventilation (12.5%). The mortality rate for patients requiring mechanical ventilation was 29%. Eighteen patients were assessed for PDT, and 11 (61%) underwent the procedure. The majority had failed extubation at least once (72.7%), and the median duration of intubation before tracheostomy was 15 d (interquartile range 13-24). The median positive end-expiratory pressure at time of tracheostomy was 10.8. The median partial pressure of oxygen (PaO2)/FiO2 ratio on the day of tracheostomy was 142.8 (interquartile range 104.5-224.4). Two patients had bleeding complications. At 1-week follow-up, eight patients still required ventilator support (73%). At the most recent follow-up, eight patients (73%) have been liberated from the ventilator, one patient (9%) died as a result of respiratory/multiorgan failure, and two were discharged on the ventilator (18%). Average follow-up was 20 d. None of the surgeons performing PDT have symptoms of or have tested positive for COVID-19. CONCLUSIONS: and relevance: PDT for patients with COVID-19 is safe for health care workers and patients despite higher positive end-expiratory pressure requirements and should be performed for the same indications as other causes of respiratory failure.

Tracheostomy to Noninvasive Ventilation: From Acute Care to Home.

The number of patients experiencing prolonged mechanical ventilation is increasing over time. Patients who have a tracheostomy placed in a critical care setting have been described as having an average of 4 separate transitions between the acute care setting, long-term acute care (LTAC), and home. Transition points can be problematic if not addressed adequately; however, proactive planning can optimize patient care. Individual patient factors will determine if the patient will require long-term tracheostomy, transitioned to noninvasive positive pressure ventilation, or able to be decannulated. Patients and caregivers should be included in transition planning to optimize outcomes.

Controversies in Tracheostomy for Patients With COVID-19: The When, Where, and How.

COVID-19 has impacted how we deliver care to patients, and much remains unknown regarding optimal management of respiratory failure in this patient population. There are significant controversies regarding tracheostomy in patients with COVID-19 related to timing, location of procedure, and technique. In this narrative review, we explore the recent literature, publicly available guidelines, protocols from different institutions, and clinical reports to provide critical insights on how to deliver the most benefit to our patients while safeguarding the health care force. Consensus can be reached that patients with COVID-19 should be managed in a negative-pressure environment with proper personal protective equipment, and that performing tracheostomy is a complex decision that should be made through multidisciplinary discussions considering patient prognosis, institutional resources, staff experience, and risks to essential health care workers. A broad range of practices exist because there is no conclusive guidance regarding the optimal timing or technique for tracheostomy.

Society of swallowing and dysphagia of Japan: Position statement on dysphagia management during the COVID-19 outbreak.

On April 14, the Society of Swallowing and Dysphagia of Japan (SSDJ) proposed its position statement on dysphagia treatment considering the ongoing spread of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). The main routes of transmission of SARS-CoV-2 are physical contact with infected persons and exposure to respiratory droplets. In cases of infection, the nasal cavity and nasopharynx have the highest viral load in the body. Swallowing occurs in the oral cavity and pharynx, which correspond to the sites of viral proliferation. In addition, the possibility of infection by aerosol transmission is also concerning. Dysphagia treatment includes a broad range of clinical assessments and examinations, dysphagia rehabilitation, oral care, nursing care, and surgical treatments. Any of these can lead to the production of droplets and aerosols, as well as contact with viral particles. In terms of proper infection control measures, all healthcare professionals involved in dysphagia treatment must be fully briefed and must appropriately implement all measures. In addition, most patients with dysphagia should be considered to be at a higher risk for severe illness from COVID-19 because they are elderly and have complications including heart diseases, diabetes, respiratory diseases, and cerebrovascular diseases. This statement establishes three regional categories according to the status of SARS-CoV-2 infection. Accordingly, the SSDJ proposes specific infection countermeasures that should be implemented considering 1) the current status of SARS-CoV-2 infection in the region, 2) the patient status of SARS-CoV-2 infection, and 3) whether the examinations or procedures conducted correspond to aerosol-generating procedures, depending on the status of dysphagia treatment. This statement is arranged into separate sections providing information and advice in consideration of the COVID-19 outbreak, including "terminology", "clinical swallowing assessment and examination", "swallowing therapy", "oral care", "surgical procedure for dysphagia", "tracheotomy care", and "nursing care". In areas where SARS-CoV-2 infection is widespread, sufficient personal protective equipment should be used when performing aerosol generation procedures. The current set of statements on dysphagia management in the COVID-19 outbreak is not an evidence-based clinical practice guideline, but a guide for all healthcare workers involved in the treatment of dysphagia during the COVID-19 epidemic to prevent SARS-CoV-2 infection.

Speech-Language Pathology Guidance for Tracheostomy During the COVID-19 Pandemic: An International Multidisciplinary Perspective.

Purpose As the COVID-19 pandemic has unfolded, there has been growing recognition of risks to frontline health care workers. When caring for patients with tracheostomy, speech-language pathologists have significant exposure to mucosal surfaces, secretions, and aerosols that may harbor the SARS-CoV-2 virus. This tutorial provides guidance on practices for safely performing patient evaluation and procedures, thereby reducing risk of infection. Method Data were collated through review of literature, guidelines, and consensus statements relating to COVID-19 and similar high-consequent infections, with a focus on mitigating risk of transmission to health care workers. Particular emphasis was placed on speech-language pathologists, nurses, and other allied health professionals. A multinational interdisciplinary team then analyzed findings, arriving at recommendations through consensus via electronic communications and video conference. Results Reports of transmission of infection to health care workers in the current COVID-19 pandemic and previous outbreaks substantiate the need for safe practices. Many procedures routinely performed by speech-language pathologists have a significant risk of infection due to aerosol generation. COVID-19 testing can inform level of protective equipment, and meticulous hygiene can stem spread of nosocomial infection. Modifications to standard clinical practice in tracheostomy are often required. Personal protective equipment, including either powered air-purifying respirator or N95 mask, gloves, goggles, and gown, are needed when performing aerosol-generating procedures in patients with known or suspected COVID-19 infection. Conclusions Speech-language pathologists are often called on to assist in the care of patients with tracheostomy and known or suspected COVID-19 infection. Appropriate care of these patients is predicated on maintaining the health and safety of the health care team. Careful adherence to best practices can significantly reduce risk of infectious transmission.

Standardization of elective tracheostomies at the Central Institute of the Hospital das Clínicas in São Paulo during the COVID-19 pandemic.

The COVID-19 Pandemic has resulted in a high number of hospital admissions and some of those patients need ventilatory support in intensive care units. The viral pneumonia secondary to Sars-cov-2 infection may lead to acute respiratory distress syndrome (ARDS) and longer mechanical ventilation needs, resulting in a higher demand for tracheostomies. Due to the high aerosolization potential of such procedure, and the associated risks of staff and envoirenment contamination, it is necesseray to develop a specific standardization of the of the whole process involving tracheostomies. This manuscript aims to demonstrate the main steps of the standardization created by a tracheostomy team in a tertiary hospital dedicated to providing care for patients with COVID-19.

Alternatives for establishing a surgical airway during the COVID-19 pandemic. / Alternativas para o estabelecimento de via aérea cirúrgica durante a pandemia de COVID-19.

Currently doctors and health professionals are facing a challenging pandemic caused by a new strain called 2019 Novel Coronavirus (COVID-19). Human infection with COVID-19 does not yet have the clinical spectrum fully described, and the pattern of lethality, mortality, infectivity and transmissibility is not known with precision. There is no specific vaccine or medication available. Treatment is supportive and nonspecific. In Brazil, as in the rest of the world, the number of COVID-19 cases has grown alarmingly, leading to an increase in the number of hospitalizations as well as in mortality from the disease. Currently, the states with the highest number of cases are, respectively, São Paulo, Rio de Janeiro, Distrito Federal and Ceará. The objective of this work is to offer alternatives in order to guide surgeons regarding the surgical management of the airways in patients with suspicion and / or confirmation for COVID-19 infection.

Atualmente médicos e profissionais da saúde encontram-se frente a uma pandemia desafiadora causada por uma nova cepa denominada 2019 Novel Coronavírus (COVID-19). A infecção humana pelo COVID-19 ainda não tem o espectro clínico completamente descrito, bem como não se sabe com precisão o padrão de letalidade, mortalidade, infectividade e transmissibilidade. Não há vacina ou medicamento específico disponível. O tratamento é de suporte e inespecífico. No Brasil, assim como no restante do mundo o número de casos de COVID-19 tem crescido de maneira alarmante levando a um aumento do número de internações assim como da mortalidade pela doença. Atualmente os estados com maior número de casos são, respectivamente, São Paulo, Rio de Janeiro, Distrito Federal e Ceará. O objetivo deste trabalho é oferecer alternativas a fim de orientar cirurgiões quanto ao manejo cirúrgico das vias aéreas em pacientes com suspeita e/ou confirmação para infecção pelo COVID-19.

Improving tracheostomy care in the United Kingdom: results of a guided quality improvement programme in 20 diverse hospitals.

BACKGROUND: Inconsistent and poorly coordinated systems of tracheostomy care commonly result in frustrations, delays, and harm. Quality improvement strategies described by exemplar hospitals of the Global Tracheostomy Collaborative have potential to mitigate such problems. This 3 yr guided implementation programme investigated interventions designed to improve the quality and safety of tracheostomy care. METHODS: The programme management team guided the implementation of 18 interventions over three phases (baseline/implementation/evaluation). Mixed-methods interviews, focus groups, and Hospital Anxiety and Depression Scale questionnaires defined outcome measures, with patient-level databases tracking and benchmarking process metrics. Appreciative inquiry, interviews, and Normalisation Measure Development questionnaires explored change barriers and enablers. RESULTS: All sites implemented at least 16/18 interventions, with the magnitude of some improvements linked to staff engagement (1536 questionnaires from 1019 staff), and 2405 admissions (1868 ICU/high-dependency unit; 7.3% children) were prospectively captured. Median stay was 50 hospital days, 23 ICU days, and 28 tracheostomy days. Incident severity score reduced significantly (n=606; P<0.01). There were significant reductions in ICU (-;0.25 days month-1), ventilator (-;0.11 days month-1), tracheostomy (-;0.35 days month-1), and hospital (-;0.78 days month-1) days (all P<0.01). Time to first vocalisation and first oral intake both decreased by 7 days (n=733; P<0.01). Anxiety decreased by 44% (from 35.9% to 20.0%), and depression decreased by 55% (from 38.7% to 18.3%) (n=385; both P<0.01). Independent economic analysis demonstrated £33 251 savings per patient, with projected annual UK National Health Service savings of £275 million. CONCLUSIONS: This guided improvement programme for tracheostomy patients significantly improved the quality and safety of care, contributing rich qualitative improvement data. Patient-centred outcomes were improved along with significant efficiency and cost savings across diverse UK hospitals. CLINICAL TRIAL REGISTRATION: IRAS-ID-206955; REC-Ref-16/LO/1196; NIHR Portfolio CPMS ID 31544.

Consensus Document of the Spanish Society of Intensive and Critical Care Medicine and Coronary Units (SEMICYUC), the Spanish Society of Otorhinolaryngology and Head and Neck Surgery (SEORL-CCC) and the Spanish Society of Anesthesiology and Resuscitation (SEDAR) on Tracheotomy in Patients with COVID-19 Infection. / Documento de consenso de la Sociedad Española de Medicina Intensiva, Crítica, y Unidades Coronarias (SEMICYUC), la Sociedad Española de Otorrinolaringología y Cirugía de Cabeza y Cuello (SEORL-CCC) y la Sociedad Española de Anestesiología y Reanimación (SEDAR) sobre la traqueotomía en pacientes con COVID-19.

The current COVID-19 pandemic has rendered up to 15% of patients under mechanical ventilation. Because the subsequent tracheotomy is a frequent procedure, the three societies mostly involved (SEMICYUC, SEDAR and SEORL-CCC) have setup a consensus paper that offers an overview about indications and contraindications of tracheotomy, be it by puncture or open, clarifying its respective advantages and enumerating the ideal conditions under which they should be performed, as well as the necessary steps. Regular and emergency situations are displayed together with the postoperative measures.

[Consensus document of the Spanish Society of Intensive and Critical Care Medicine and Coronary Units (SEMICYUC), the Spanish Society of Otorhinolaryngology and Head and Neck Surgery (SEORL-CCC) and the Spanish Society of Anesthesiology and Resuscitation (SEDAR) on tracheotomy in patients with COVID-19 infection]. / Documento de consenso de la Sociedad Española de Medicina Intensiva, Crítica, y Unidades Coronarias (SEMICYUC), la Sociedad Española de Otorrinolaringología y Cirugía de Cabeza y Cuello (SEORL-CCC) y la Sociedad Española de Anestesiología y Reanimación (SEDAR) sobre la traqueotomía en pacientes con COVID-19.

The current COVID-19 pandemic has rendered up to 15% of patients under mechanical ventilation. Because the subsequent tracheotomy is a frequent procedure, the three societies mostly involved (SEMICYUC, SEDAR and SEORL-CCC) have setup a consensus paper that offers an overview about indications and contraindications of tracheotomy, be it by puncture or open, clarifying its respective advantages and enumerating the ideal conditions under which they should be performed, as well as the necessary steps. Regular and emergency situations are displayed together with the postoperative measures.