Abstract
Tracheostomy insertion is one of the oldest surgical procedures dating back 4000 years. Ciaglia et al. 1 introduced percutaneous tracheostomy (PCT) 1 and since then its use has become widespread on the intensive care unit (ICU). Several studies have compared PCT with surgical tracheostomy with most revealing no significant difference between the two and lower complication rates with the former. 2
There are, however, significant complications with PCT insertion. Also, in recent years, there is a trend towards delaying the insertion of tracheostomy on ICU. This is partly due to the body of evidence suggesting early tracheostomy has no mortality benefit over late insertion 3 and also because, by waiting longer, a considerable number of patients will be extubated and not require a tracheostomy.
As a consequence of this, intensivists may have less exposure and therefore obtain less experience with PCT insertion. This may present significant patient safety issues, as surely such an invasive procedure will need an operator who has performed a minimum number of these procedures per year. This has been highlighted in the “Getting It Right First Time” Program (GIRFT) 4 which has demonstrated better patient outcomes in orthopaedic surgery in those centres performing higher volumes of cases.
Several ICUs are now leaning towards direct surgical tracheostomy insertion in theatre rather than PCT insertion by an intensivist on the ICU. This will also result in limited training opportunities for Intensive Care Medicine (ICM) trainees and subsequently for the ICU Consultants of the future.
We feel PCT is a core skill on the ICM curriculum and is a procedure that should be performed by the intensivist unless, of course, this is not feasible (e.g. difficult anatomy) in which case surgical tracheostomy is a useful alternative strategy.
As with the case of percutaneous chest drain insertion, the British Thoracic Society recommends “all operators should be appropriately trained and have been initially supervised by an experienced trainer.” 5 The same should apply to PCT, with a compulsory log book for ICM trainees and ICM Consultants to log the number of procedures they do per year. This will not only improve patient safety but also act as evidence for yearly appraisal and for revalidation in this procedure.
One step further would be the creation of “Trache Teams” in each ICU or region. These teams could comprise of a selection of ICM Consultants in each local area that are able to maintain high volume experience in PCT insertion. These teams could then either perform the tracheostomies in units or act to train and teach fellow ICM Consultants and trainees and act as tracheostomy supervisors. This would surely result in better safer care for patients, and an improved training pathway for this procedure. Overall, we feel this may be a solution to ensure the insertion of PCT remains a fundamental skill for intensivists in the future.