Getting on the right trach: Our experience with setting up a tracheostomy service

Dear Editor

We read with interest the recent editorial ‘Tracheostomy care in 2015; Are we on the right trach?’ ¹ We are in full agreement with the authors that the key improvements in tracheostomy care relate to the management and ongoing care of ‘Neck Breathers’ rather than the traditional focus on the time frame surrounding insertion. Our figures indicate that in addition to approximately 60 tracheostomies performed in our critical care unit every year, there are 2–3 patients with permanent tracheostomies or laryngectomies admitted every month, and these relatively unknown patients are potentially at an even greater risk. In order to provide the best care possible for this patient group, our trust has adopted a number of strategies.

In response to the Cheshire & Merseyside Critical Care Network Guidelines, ² a multidisciplinary tracheostomy steering group (MTSG) was formed. The clinical lead role is of paramount importance, and we have an anaesthetic intensivist in this pivotal role. Our aims are to train medical, nursing and allied health professionals in all areas where a neck breathing patient may be located. The training is run as a one day course six times a year and is recognised by the RCoA for five CPD points. The MTSG has introduced cohort wards, where both patients discharged from critical care and patients admitted from the community are cared for.

The importance of ownership of this patient group was identified by the authors, and we feel that we have gone some way towards addressing that by highlighting the need for early identification and referral of the neck breathing patient to the ‘tracheostomy and laryngectomy team’. This utilises the hospital computer referral system. By using this technology, we are able to record and audit the number of neck breathing patients admitted and ensure all patients are reviewed by a comprehensive multidisciplinary team where applicable.

We utilise the bed head signs and algorithms developed by the National Tracheostomy Safety Project (NTSP). ³ Emergency tracheostomy ‘blue boxes’ are available in the hospital which allows staff caring for the patient to access the correct equipment at the bed space. Specific simulation training for intensive care doctors is provided 3–4 times per year. A ‘neck breathers’ care plan has been constructed and is currently undergoing editing prior to a hospital wide launch.

We remain ‘on trach’ to improve care and are seeking to employ a tracheostomy nurse, integral to the continued work of the tracheostomy team. This role would continue to develop training, support for cohort wards, communication across different departments and discharge planning.