Matlary RED1, Thomas A2
1University College London, GOS Institute of Child Health, London, United Kingdom, 2The Royal London Hospital, Critical Care Outreach Team, London, United Kingdom
Background: Tracheostomies are artificial airways where an opening (stoma) is created in the trachea to establish an airway through the neck and a tracheostomy tube is inserted to maintain the opening. Tracheostomies can be performed by surgical or percutaneous dilatational techniques. Approximately 17,000 patients are tracheostomised in the United Kingdom annually. Knowledge regarding what constitutes good tracheostomy practice is growing, but longitudinal studies of tracheostomy care are limited.
Purpose: The aim of the case note review was to explore changes to tracheostomy-related outcomes over time, and identify associations between patient/tracheostomy-related characteristics and outcomes.
Methods: A retrospective, longitudinal case note review was undertaken for the period 2007-2017. Adult patients with temporary tracheostomies at one tertiary centre were included.
Results: Records from 1,758 patients were successfully analysed. In-hospital mortality decreased by an average of 1.4 percentage pointsper year (95% confidence interval -2.52 to -0.29, p=0.02). This equates to approximately 0.4 fewer patients dying during hospital admission per year over the study period. Mortality was significantly greater for patients who; were older (mean difference 10.2 years, 95% confidence interval 7.10 to 12.34 years, p 0.001), underwent percutaneous tracheostomy insertion (odds ratio 1.27, 95% CI 1.03 to 1.57, p=0.025), and received tracheostomy due to prolonged ventilation/difficult weaning (odds ratio 3.17, 95% confidence interval 1.87 to 5.37, p 0.0001). These three variables explained between 7.7 and 12.9% of the in-hospital mortality rate. The strongest predictor of in-hospital mortality was reason for tracheostomy (being prolonged mechanical ventilation or difficulties with weaning).
Negative clinical tracheostomy events, as defined by emergency tracheostomy changes and unsuccessful decannulations were relatively low throughout the period, with an overall rate of 7.8% and 3.8% respectively. There were no significant changes in these outcomes over the study period (p=0.97 and p=0.89 respectively). Emergency tracheostomy changes were significantly greater for patients who; were older (mean difference 5.0 years, 95% confidence interval, 1.69 to 7.83, p=0.002) and underwent surgical tracheostomy insertion (odds ratio 1.63, 95% confidence interval 1.18 to 2.46, p=0.003). Failed decannulations were also significantly greater for patients who; were older (mean difference 7.5 years, 95% confidence interval 1.82 to 13.07, p=0.009) and underwent surgical tracheostomy insertion (odds ratio 2.35, 95% confidence interval 1.19 to 4.70, p=0.012).
Conclusion(s): Reduction in mortality and stable, low incidences of emergency tracheostomy changes and failed decannulations were identified. Although generalisation of the findings is not possible, this study provides a starting point for further research into relationships between patient/tracheostomy-related variables and outcomes.
Implications: The findings indicate that the quality of tracheostomy care at this tertiary centre has been high over the last eleven years. It suggests a rationale for continuing current practice including continuous quality improvement measures, as enhanced practice has the potential to improve patients' quality of life and save resources. Detailed data on patient and tracheostomy-related characteristics, and tracheostomy-related outcomes should be collected at all institutions where tracheostomies are performed in order to enable audit, identify needs for improvement and share best practice.
Keywords: Tracheostomy, tracheostomy-related outcomes
Funding acknowledgements: N/A.
Purpose: The aim of the case note review was to explore changes to tracheostomy-related outcomes over time, and identify associations between patient/tracheostomy-related characteristics and outcomes.
Methods: A retrospective, longitudinal case note review was undertaken for the period 2007-2017. Adult patients with temporary tracheostomies at one tertiary centre were included.
Results: Records from 1,758 patients were successfully analysed. In-hospital mortality decreased by an average of 1.4 percentage pointsper year (95% confidence interval -2.52 to -0.29, p=0.02). This equates to approximately 0.4 fewer patients dying during hospital admission per year over the study period. Mortality was significantly greater for patients who; were older (mean difference 10.2 years, 95% confidence interval 7.10 to 12.34 years, p 0.001), underwent percutaneous tracheostomy insertion (odds ratio 1.27, 95% CI 1.03 to 1.57, p=0.025), and received tracheostomy due to prolonged ventilation/difficult weaning (odds ratio 3.17, 95% confidence interval 1.87 to 5.37, p 0.0001). These three variables explained between 7.7 and 12.9% of the in-hospital mortality rate. The strongest predictor of in-hospital mortality was reason for tracheostomy (being prolonged mechanical ventilation or difficulties with weaning).
Negative clinical tracheostomy events, as defined by emergency tracheostomy changes and unsuccessful decannulations were relatively low throughout the period, with an overall rate of 7.8% and 3.8% respectively. There were no significant changes in these outcomes over the study period (p=0.97 and p=0.89 respectively). Emergency tracheostomy changes were significantly greater for patients who; were older (mean difference 5.0 years, 95% confidence interval, 1.69 to 7.83, p=0.002) and underwent surgical tracheostomy insertion (odds ratio 1.63, 95% confidence interval 1.18 to 2.46, p=0.003). Failed decannulations were also significantly greater for patients who; were older (mean difference 7.5 years, 95% confidence interval 1.82 to 13.07, p=0.009) and underwent surgical tracheostomy insertion (odds ratio 2.35, 95% confidence interval 1.19 to 4.70, p=0.012).
Conclusion(s): Reduction in mortality and stable, low incidences of emergency tracheostomy changes and failed decannulations were identified. Although generalisation of the findings is not possible, this study provides a starting point for further research into relationships between patient/tracheostomy-related variables and outcomes.
Implications: The findings indicate that the quality of tracheostomy care at this tertiary centre has been high over the last eleven years. It suggests a rationale for continuing current practice including continuous quality improvement measures, as enhanced practice has the potential to improve patients' quality of life and save resources. Detailed data on patient and tracheostomy-related characteristics, and tracheostomy-related outcomes should be collected at all institutions where tracheostomies are performed in order to enable audit, identify needs for improvement and share best practice.
Keywords: Tracheostomy, tracheostomy-related outcomes
Funding acknowledgements: N/A.
Topic: Cardiorespiratory
Ethics approval required: No
Institution: N/A
Ethics committee: N/A
Reason not required: The project was deemed a service evaluation by the Joint Research Office at University College London and the Royal London Hospital Clinical Effectiveness Unit.
All authors, affiliations and abstracts have been published as submitted.
