Abstract
Dear Editor,
We would like to share our local audit experience with your readers.
The National Audit Project (NAP4) “Major complications of airway management in the UK” highlighted that in 50% of all airway-related deaths and cases of brain damage in critical care the airway problems were attributed to tracheostomy complications. 1 A large number of tracheostomies are performed each year. The presence of a tracheostomy places the patient at a high risk of mortality and morbidity, and patients experiencing one complication are at higher risk of developing further complications.
We recently completed a full audit cycle to assess the knowledge of emergency tracheostomy management amongst multidisciplinary team (MDT) members involved in caring for patients with tracheostomies; this included intensive care unit (ICU) trainees, ICU nurses and ward nurses. We compared our practice against the national recommendations set out by the recently published report “On the right trach” from the National Confidential Enquiry into Patient Outcome (NCEPOD). 2
Very striking results were found on the first evaluation cycle. For instance, only 55% of our trainees were aware of an existing emergency tracheostomy management algorithm 3 as opposed to the 90% of ICU and ward nurses. Likewise only 55% of ICU trainees stated they had received training in tracheostomy management, compared with 90% of ICU and ward nurses. Knowledge of how to administer high-flow oxygen to a tracheostomised patient in an emergency was suboptimal amongst all the groups (50–70%).
Our audit identified a clear need for further training throughout the MDT. A multi-modal educational programme has been implemented, achieving improved outcomes as shown by the follow-up/repeat audit.
“On the right trach” found that staff in a quarter of hospitals studied had not received training in the management of blocked and displaced tubes. It summarised by saying that “The only way in which hospitals can maintain safe teams is to recognise training as a continuous process, an intrinsic part of the routine work.” Although lack of competency and the need for training in managing these patients have been recognised in multiple publications and national audits, we still continue to have significant knowledge gaps as has been acknowledged by our audit. We would like to use our experience to suggest that emergency tracheostomy management should be defined as an independent practical procedure by the Royal College of Anaesthetists curriculum requiring specific evaluation within the emergency airway management competences section. Training sessions at local inductions and/or in the numerous local, regional and national simulation training courses may be a useful option of ensuring the further safeguarding of this group of patients. This could be valid ways of ensuring that our trainee’s skills are maintained and monitored on a regular basis.
Anaesthetists in their various capacities are most likely to face and deal with the complications of tracheostomy and are uniquely placed to provide leadership and direction in managing this common and serious issue.