<Tracheostomy ? patient flow.
Where patients come from.
In this study of 142 tracheostomy patients the admitting services were as follows:
PDT OT
Medical ? 38.2% 24.5%
Surgical ? 22.4% 22.6%
Trauma ? 38.2% 5.6%
Burn ? 1.2% 47%
Source: Lehigh Valley Hospital
http://www.facs.org/spring_meeting/2005/gs04heyrosa.pdf
--------------------------------------------------
Where they are treated (also see who performs the procedure).
In this study 43 tracheostomies were performed.
Operating room ? 25
Bedside ? 18
Source: Comparative analysis of bedside and operating room
tracheostomies in critically ill patients with burns. Lujan HJ, Dries
DJ, Gamelli RL
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=7673305&dopt=Abstract
In this study, 74% were performed at the bedside and 26% in the operating theatre.
Source: Percutaneous dilatative tracheostomy versus conventional
surgical tracheostomy: a retrospective trial. Stripf T et al.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=12717604&dopt=Abstract
------------------------------------------------
Where they go after treatment.
The tracheotomized patient undergoing mechanical ventilation presents
numerous challenges to the intensive care team. During the initial
phase of respiratory failure, patient instability and risks of
multiorgan failure focus efforts on an array of critical care
management techniques designed to reverse the underlying process and
prevent complications. During the stabilization phase, issues of
tracheostomy care become equally important in improving patient
outcome. These topics include the proper assistance in patient
communication, initiation of enteral nutrition, weaning from airway
cannulation, and anticipation of adverse reactions after airway
decannulation. Failure in promoting a logically conceived and
carefully applied treatment plan in any of these areas frequently
delays patient recovery and risks serious complications of airway
compromise.
Source: Special critical care considerations in tracheostomy
management. Godwin JE, Heffner JE.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=1934957&dopt=Abstract
Hospital discharge destinations.
All locations ? 972
No post-acute care - 60.29%
Rehab only - 4.12%
SNF only -17.59%
HHA only 9.77%
More than one PAC 8.23%
Discharge destination of post-acute care users.
All locations ? 386
Rehab only ? 10.36%
SNF only ?44.3%
HHA only 24.61%
More than one PAC 20.73%
SNF ? skilled nursing facilities.
HHA ? home health agencies.
PAC ? post acute care.
Source: U.S. Department of Health and Human Services.
http://aspe.os.dhhs.gov/daltcp/reports/mpacqmA1.htm#A1-table1
http://aspe.os.dhhs.gov/daltcp/reports/mpacqmA1.htm#A1-table3
In long-term care hospitals (LTCH) 3% of patients are tracheostomy cases.
Among patients who live in areas with LTCHs, 5 percent used IRFs. In
areas without LTCHs, 7% of patients with tracheostomies used IRFs.
Discharge destinations for tracheostomy patients, 2001. (Source: MedPac)
Areas with long-term care hospitals.
Long term care hospital 23%
Freestanding skilled nursing facility 11%
Hospital based skilled nursing facility 4%
Inpatient rehabilitation facility 5%
Home healthcare 4%
No post-acute care 21%
Died 32%
Areas without long-term care hospitals
Long-term care hospital 6%
Freestanding skilled nursing facility 17%
Hospital based skilled nursing facility 5%
Inpatient rehabilitation facility 7%
Home healthcare 6%
No post-acute care 20%
Died 39%
http://64.233.183.104/search?q=cache:cejvXt4edD0J:www.medpac.gov/publications%255Ccongressional_reports%255CJune04_ch5.pdf+%22tracheostomy+patients%22+%22transferred+to%22&hl=nl&ct=clnk&cd=9
This study reviews 44 cases. Each child was maintained at home with a
tracheostomy for an average of 19 months for a total of 635 months of
home tracheostomy care. Indications for tracheostomy were
tracheomalacia (32%), obstructive airway lesions (23%), central
nervous system lesions (16%), vocal cord paralysis (9%), Pierre Robin
syndrome (9%), and a list of miscellaneous conditions (11%). Our
tracheostomy care regimen begins with intensive parental training in
tracheostomy management for a minimum of 10 days prior to discharge.
Home nursing was arranged for 77% of these children for an average of
11 hours per day at the time of discharge. Eighty-three percent had
home apnea monitors. Discharge of these children was delayed or
transfer to a secondary hospital was made when parents failed to show
adequate proficiency in tracheostomy management with existing home
nursing. Eight percent were ventilator dependent at discharge. As of
January 1, 1989, 34% of these children have been decannulated. There
were six deaths, all due to underlying disease. There were no
tracheostomy-related deaths in hospital or after discharge home.
Source: Tracheostomy in children with emphasis on home care. J Pediatr
Surg. 1992;27(4):432-5 Duncan BW et al.
http://www.medscape.com/medline/abstract/1522451?src=emed_ckb_ref_0
Cause of respiratory failure.
Neuromuscular weakness ? 22%
COPD ? 16%
Encephalopathy ? 12%
Aspiration ? 10%
ARDS ? 10%
Empyema ? 4%
Other ? 22% (Includes three cases of congestive heart failure, three
of pneumonia, and one each of BOOP, flail chest, lung cancer,
endobronchial mucormycosis, and intra-abdominal sepsis.)
Immediate disposition
Expired 28%
LTACH 15% (Long-term acute care hospital for ventilator-dependent patients).
Rehabilitation 10%
Acute care hospital 26%
Skilled nursing 2%
Home 2%
Failed PDT 2%
Longterm disposition
Home 14%
Expired later than 30 days 10%
LTACH 10%
Nursing/rehabilitation 18%
Lost to follow-up 16%
Complications 8%
Source: Outcome of bedside percutaneous tracheostomy with
bronchoscopic analysis. R. Hinerman, F. Alvarez and C.A. Keller.
http://www.springerlink.com/media/n97gyvtuwn2gjxhpyddj/contributions/a/u/p/r/auprn65pyp2kv88u_html/fulltext.html
This report describes the tracheostomy weaning and decannulation
protocol for Stanford Hospital.
Who may perform: Interdisciplinary; with Respiratory Care Services,
Nursing and Speech Pathology, in conjunction with physician
participation and a protocol guided order set.
Source: Stanford Hospital
http://scalpel.stanford.edu/ICU/Trach%20Weaning%20Protocol%208-3.pdf
---------------------------------------
Number of procedures.
Number of discharges ? 112,472
Mean length of stay ? 37 days.
In hospital mortality ? 20.6%
Source: Procedures in US Hospitals 2003. Agency for Healthcare Research
http://www.ahrq.gov/data/hcup/factbk7/factbk7.pdf
Number of discharges
Tracheostomy w/ mouth, larynx or pharynx disorder ? 17,540
Tracheostomy except for mouth, larynx or pharynx disorder ? 73,118
Source: 1994 statistics. Agency for Healthcare Research
http://www.ahrq.gov/data/hcup/94drgb.htm#478
Hospital cases under Medicare?s inpatient transfer payment policy.
DRG483 tracheostomy except for face, mouth and neck diagnoses.
Number of cases ? 40,954
Cases discharged to post-acute care ? 52.5%
Transfer cases with short stays ? 47.5%
All cases in DRG that are short-stay transfers ? 24.9%
Cases in DRG 483, tend to have very long lengths of stay (the
geometric mean is 35 days).
Hospitals located in areas with facilities that can provide ventilator
support for these patients are potentially able to transfer patients
relatively early in a stay (after as few as three days).
Source: Medpac.
http://www.medpac.gov/publications/congressional_reports/Mar03_Entire_report.pdf
Pediatric tracheostomies
Data from 22 states in 1997.
2065 procedures.
The incidence is 6.6 children per 100,000 and it is associated with
less than 1 percent of all pediatric discharges nationally.
The means length for each of these children of hospital stay was 50
days with a mean total hospitalization cost per patient of
approximately $200,000. Infants had longer stays and higher hospital
charges relative to other age groups.
http://www.bcm.edu/oto/grand/01202005.htm
Discharge data
Decanulated during hospital stay.
http://www.pulmonetic.com/distributables/pdfs/Pediatric_Trach_Patients.pdf
------------------------------------
Length of stay.
Average length of stay ? 37 days.
Source: Mednet
http://www.mednetliban.com/mednet/Bulletin19.pdf
Median time to decannulation ? 14 days.
Source: The effect of tracheostomy on outcome in intensive care unit
patients. H. Flaaten et al.
http://www.blackwell-synergy.com/doi/abs/10.1111/j.1399-6576.2005.00898.x
-----------------------------------
Who performs the procedures?
Otolaryngologist-head and neck surgeons perform two of every three
tracheotomies done in the United States. In most medical schools, a
member of this specialty will teach the physician-in-training how to
carry out this emergency procedure.
Source: American Academy of Otolaryngology Head and Neck Surgery (AAOHNS)
http://www.medicalnewstoday.com/medicalnews.php?newsid=20423
Tracheostomy continues to be a standard procedure for the management
of long-term ventilator-dependent patients. Traditionally the
procedure has been performed by surgeons in the operating theater
using an open technique. This routine practice has recently been
challenged by the introduction of bedside percutaneous dilatational
tracheostomy (PDT), which has been reported to be a cost-effective
alternative.
This study reviewed 213 tracheostomy patients.
Of the 74 percutaneous tracheostomies, 73 were performed by general
surgeons, pulmonary physicians or anesthesiologists in the intensive
care unit. All open procedures were performed by surgeons in the
operating room and one pecutaneous procedure was performed in the
operating room.
Perioperative complications occurred in five of 74 patients (6.76%)
during PDT; of these, three patients (4.1%) experienced major
complications requiring emergent operative exploration of the neck.
Three patients (2.2%) experienced perioperative complications during
surgical tracheostomy.
Source: Comparison of safety and cost of percutaneous versus surgical
tracheostomy. Bowen CP et al.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=11206898&dopt=Abstract
In this study 100 procedures were carried out in the operating room by
a head and neck surgeon and 50 procedures were carried out by critical
care physicians at the bedside.
Source: Experience with percutaneous dilational tracheostomy.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=11007078&dopt=Abstract
In this study trained pulmonologists and surgeons performed the
procedure at the bedside.
Source: Repeat bedside percutaneous dilational tracheostomy. Meyer, Marianne et al.
http://www.ccmjournal.com/pt/re/ccm/abstract.00003246-200205000-00006.htm;jsessionid=GKVQKHR1HnMmzk8h2T0f2C5psLng3y5TkcLY7nBGwkL02wyplyPF!-1082563917!-949856145!8091!-1
-----------------------------------
Medical conditions needing a tracheostomy.
To relieve upper airway obstruction:
Foreign bocy
Trauma
Acute infection ? acute epiglottitis, diptheria
Glottic oedema
Bilateral abductor paralysis of the vocal cords
Tumours of the larynx
Congenital web or atresia
To improve respiratory function:
Fulminating bronchopneumonia
Chronic bronchitis and emphysema
Chest injury and flail chest
Respiratory paralysis:
Unconscious head injury
Bulbar poliomylitis
Tetanus.
Source: Surgical Tutor.
http://www.surgical-tutor.org.uk/default-home.htm?system/hnep/tracheostomy.htm~right
-----------------------------------
Complications.
Duration of tracheostomy.
Male 17.6 +- 23.5 days
Complications ? 9.7%
Subcutaneous emphysema ? 2.2%
Pneumothorax ? 0.7%
Cuff rupture ? 0.5%
False passage ? 0.7%
Premature extubation ? 0.7%
Bleeding ? 0.7%
Peristomal infection ? 1.5%
Tracheosophageal fistula ? 0.2%
Tracheal Stenosis ? 1.5%
Stomal fistula ? 0.2%
Granulation at stomal site ? 0.7%
Source: Percutaneous Dilational Tracheostomy : safety and ease of
performance at the bedside in the ICU. N. Cakar et al.
http://www.springerlink.com/media/3dufumurxh1vb8xh8r4h/contributions/u/5/7/5/u5758h703q306078.pdf
Complications
Bleeding ?10%
Tracheostomy management problems 17.5 %
Asymptomatic stomal site tracheal narrowing - 16%
Required tracheal resection for symptomatic stomal site tracheal stenosis ? 8%
Asymptomatic tracheal defects at the cuff site ? 16%
Source: A prospective study of complications after tracheotomy for
assisted ventilation.. Dane TE, King EG.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=1122767&dopt=Abstract
Forty-three percent had serious complications involving loss of the
tracheostomy airway (tube occlusion or accidental decannulation) or
requiring a separate surgical procedure. Deaths directly attributable
to tracheostomy complications occurred in 0.7%.
Source:Complications in Pediatric Trachestomies.
Carr, Michele et al.
http://www.laryngoscope.com/pt/re/laryngoscope/abstract.00005537-200111000-00010.htm;jsessionid=GLkKCxGcKChfh3GwbTmfpf5QlV4bsQbQwpTWLpvQTmJMTpyQnBft!-251499885!-949856144!8091!-1
Emergency room visits for Home health patients with tracheostomy for
face, mouth and neck.
1997 ? 28.9%
1999 ? 32.3%
Difference +3.4%
Source: National claims history file.
http://64.233.183.104/search?q=cache:KNpKcfjoR4IJ:oig.hhs.gov/oei/reports/oei-02-99-00531.pdf+%22tracheostomy%22+%22emergency+room%22+percent&hl=nl&ct=clnk&cd=6
Late complications of Tracheostomy.
A review of the literature.
http://www.rcjournal.com/contents/04.05/04.05.0542.pdf
Complications burn patients.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=10716364&dopt=Abstract
http://www.ijohns.com/article.asp?issn=0019-5421;year=2005;volume=57;issue=3;spage=202;epage=206;aulast=Ravi
-------------------------------------------------
Is there a speciality?
Otolaryngologist-head and neck surgeons perform two of every three
tracheotomies done in the United States. In most medical schools, a
member of this specialty will teach the physician-in-training how to
carry out this emergency procedure.
Source: American Academy of Otolaryngology Head and Neck Surgery (AAOHNS)
http://www.medicalnewstoday.com/medicalnews.php?newsid=20423
----------------------------------------
Additional sources:
Tracheostomy except for face, mouth and neck diagnoses ? clinical
financial & Statistical data. This report from Solucient costs $35.00.
http://solucient.ecnext.com/coms2/drgdesc_483
This French study reviews 2,738 patients.
Source: Indications, timing and techniques of tracheostomy in 152
French ICUs. Francois Blot, Christian Melot.
http://www.findarticles.com/p/articles/mi_m0984/is_4_127/ai_n13662801/pg_4
Long-term care of the patient with tracheostomy. Joseph S Lewarski.
http://64.233.183.104/search?q=cache:mAoFXHOoGr4J:www.rcjournal.com/contents/04.05/04.05.0534.pdf+%22tracheostomy+patients+in+the%22&hl=nl&ct=clnk&cd=2
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<Hope this helps.> |
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