A multi-faceted tracheostomy decannulation pathway facilitates successful decannulation

Abstract

Introduction: The Tracheostomy Review and Management Service (TRAMS) at Austin Health, Melbourne Australia is a consultative multi-disciplinary team comprised of respiratory physicians, clinical nurse consultants, speech pathologists and physiotherapists. The TRAMS review and manage adult tracheostomy patients from the Intensive Care Unit to the community. Earlier outcomes of the TRAMS have been published elsewhere. Austin Health is a tertiary institution with a complex case-mix, associated with several state-wide specialty services, including the Victorian Respiratory Support Service and Victorian Spinal Cord Service. Objectives: The objectives of this study were to 1) describe the TRAMS decannulation pathway reflecting routine and complex tracheostomy management for acute inpatients 2) retrospectively analyse successful decannulation between September 2015 and April 2019. Methods: The TRAMS utilise the standard decannulation pathway (SDP) which reflects the standard steps and clinical domains of tracheostomy management towards decannulation. For patients who deviate from the SDP due to high acuity or individual diagnostic complexities, TRAMS utilise additional decannulation steps (ADS) that reflect special considerations for tracheostomy decannulation. Patients who were successfully decannulated over the study period were included in this study. Results: During the study period there were 383 tracheostomy-patient admissions, of which 271 (71%) survived hospital admission and were successfully decannulated. 139 patients followed the SDP and for 132 patients, the ADS were utilised. The four categories of ADS which facilitated decannulation were 1) changed and/or downsized tracheostomy tube (n=42), 2) decannulation to mini-tracheostomy (n=27), 3) decannulation to non-invasive ventilation (n=35) and 4) decannulation to stoma stent (n=28). Conclusion: TRAMS have described a multifaceted decannulation pathway that has facilitated successful decannulation for our standard and complex patients. Retrospective analysis of our patient cohort has demonstrated that approximately half of our patients require ADS in order to achieve decannulation. This reinforces the importance of an expert multidisciplinary team approach.