Training for tracheostomy

Abstract

Editor'The 4th National Audit Project (NAP4) has highlighted several important areas for improvement in airway management. Some of its inspirational closing words read ‘Airway management is a fundamental anaesthetic responsibility and skill; anaesthetic departments should provide leadership in developing strategies to deal with difficult airways throughout the entire organisation’.14th National Audit Project (NAP4), Major complications of airway management in the United Kingdom: report and findings'March 2011. http://www.rcoa.ac.uk/document-store/nap4-executive-summary (accessed 5 July 2013).Google Scholar One of the key findings was the significant morbidity and mortality from displaced tracheostomies in intensive care unit patients. This has quite rightly led to a focus on teaching and training to optimize management of these rare but potentially devastating emergency situations. Aside from these critical incidents, anaesthetists routinely encounter tracheostomies in the theatre and critical care environment. In addition, adverse events not only present as acute emergencies from blocked or displaced tubes, but also more insidiously, because of inappropriate weaning strategies. It is therefore essential that anaesthetists of all grades possess a basic level of knowledge and familiarity with the day-to-day care of tracheostomies. Indeed, one would imagine that it is this core experience that would lead to increased confidence in managing emergencies when they arise. The 2010 intermediate level training curriculum of the Royal College of Anaesthetists (RCoA) recommends that learning objectives include indications, anaesthetic principles, and management of the obstructed/misplaced tracheostomy.2CCT in anaesthetics'intermediate level training (Annex C). http://www.rcoa.ac.uk/node/1434 accessed 5 July 2013).Google Scholar In addition, the 2010 RCoA Higher Intensive Care Medicine curriculum identifies percutaneous tracheostomy insertion as a core competency and lists elective changing of tracheostomy tubes as an objective.3CCT in anaesthetics'intensive care medicine (Annex F). http://www.rcoa.ac.uk/CCT/AnnexF (accessed 5 July 2013).Google Scholar However, there are no formal learning objectives for other important aspects such as the process of weaning in tracheostomy patients and the equipment involved in daily management. We believe this to be a vital but often overlooked area of training. We undertook a survey of our trainees investigating their perceived level of knowledge, training, and confidence with tracheostomy patients. The second part of the survey consisted of 17 true–false questions regarding tracheostomy equipment and weaning, based on the Trust Tracheostomy Policy. The results that we obtained were surprising to us and we imagine are not unique to our School of Anaesthesia. Of the 49 responding trainees, 39 out of 49 stated that they had received no formal tracheostomy training. Fifteen out of 49 felt ‘not at all confident’ in caring for patients with tracheostomies and 21 out of 49 felt ‘not at all confident’ in making decisions regarding tracheostomy weaning. As expected, the level of confidence did vary appropriately with grade of trainee (Fig. 1). However, there were still a significant proportion of senior trainees with low confidence in these situations. The anaesthetic registrars who were also training in intensive care medicine (ICM) (five trainees) were far more likely to have received formal training (4/5 vs 6/44). This was reflected in their increased levels confidence in both caring for tracheostomy patients and making weaning decisions (none of the dual ICM trainees felt ‘not at all confident’ in either of these situations). There was an average overall score of 10/17 for the true/false questions regarding tracheostomy equipment and weaning. This average incremented appropriately with grade and experience. However, these answers revealed some striking deficiencies in the knowledge and understanding of the details of tracheostomy care. Alarmingly, 29 out of 49 trainees believed a trial of speaking valve could be considered before a trial of cuff down. Thirteen out of 49 trainees did not realize that fenestrated tubes were no longer used within the Trust, and 12 out of 49 trainees did not know that humidification was an essential component of tracheostomy care. Our findings would suggest that training in tracheostomy care remains a worrying deficiency in the current curriculum, particularly for those trainees who are not on the ICM training programme. This is apparent in the levels of confidence among the trainees. It may contribute, if left unaddressed, to further adverse incidents. Our strategy to deal with this lack of confidence and training has been to develop and run a comprehensive training day. In addition to rehearsing emergency algorithms, there was a focus on general tracheostomy care and equipment. There was input from the physiotherapists and speech therapists, to ensure that communication, weaning, and swallowing were also adequately covered. The inaugural pilot day was very well received by the trainees and we hope this will improve their practice in the future. None declared. Download .zip (.0 MB) Help with zip files