Abstract & Commentary
Multidisciplinary Tracheostomy Teams Shorten Time to Decannulation and Increase Speaking Valve Use
By Eric C. Walter, MD, MSc, Pulmonary and Critical Care Medicine, Northwest Permanente and Kaiser Sunnyside Medical Center, Portland, is Associate Editor for Critical Care Alert.
Dr. Walter reports no financial relationships relevant to this field of study.
Synopsis: This systematic review and meta-analysis finds that the implementation of multidisciplinary tracheostomy teams leads to significant improvements in time to decannulation and in speaking valve use but not in ICU or hospital length of stay. The quality of the evidence was low.
Source: Speed L, Harding K. Tracheostomy teams reduce total tracheostomy time and increase speaking valve use: A systematic review and meta-analysis. J Crit Care 2012; Aug 27. [Epub ahead of print.]
This systematic review and meta-analysis reviewed studies evaluating the implementation of multidisciplinary tracheostomy teams in acute care hospitals. Potential studies identified and independently reviewed for inclusion criteria related to population studied, intervention, outcomes, and methodology. The population studied included patients with a temporary tracheostomy or undergoing tracheostomy weaning. Studies of patients with tracheostomies related to structural abnormalities of the trachea or with permanent tracheostomy were excluded. The intervention team must have been multidisciplinary and have included at least two health professionals, including one allied health professional (i.e., speech pathologist, physical therapist, or respiratory therapist). Teams comprised of only medicine, or medicine and nursing, were excluded. Seven studies met inclusion criteria. Study quality was judged to be medium to low as all were observational, with a pre-post design, and there were no randomized controlled trials.
The most common outcome measured was time to decannulation, reported in six of seven studies. Sufficient data were reported from four of these studies to perform a meta-analysis. Tracheostomy teams were associated with a reduction in time to decannulation (mean difference 8 days; 95% confidence interval, -6 to -11; P < 0.01). Three of the seven studies reported on speaking valve use and all reported increased use from about one-third or less to two-thirds or more of patients using speaking valves. Because a measure of variability was not available for this outcome, meta-analysis could not be performed. Meta-analysis of three studies that reported hospital length of stay (LOS)revealed a decrease in hospital LOS although the result was not statistically significant. A non-significant reduction in ICU LOS was reported in three studies. Insufficient data were available to perform meta-analysis.
The quality of any meta-analysis is directly related to the quality of included studies. Unfortunately, it has been historically difficult to obtain high-quality data with respect to tracheostomy in critically ill patients. Tracheotomies are performed on only a minority of critically ill patients making it difficult for any single institution to report outcomes on large numbers of patients, and strong differences of opinion have made multicenter studies challenging. Therefore, despite low-quality studies available for inclusion, meta-analyses such as this study provide useful information for practicing clinicians.
Strengths of this study include careful selection criteria and clinically relevant outcome measures. The authors showed that the introduction of multidisciplinary tracheostomy teams was associated with a statistically significant reduction in time to decannulation. This had been reported in five of the six studies, but small sample sizes limited the ability to report statistically significant outcomes. Tracheostomy teams also appeared to be associated with a greater percentage of patients using a speaking valve. It is not surprising that tracheostomy teams were not associated with a significant reduction in ICU or hospital LOS. LOS is affected by a host of variables, including illness type and severity, a hospital's ability to care for patients with tracheostomies outside of the ICU, and disposition options for these patients. Nevertheless, a shorter time to decannulation and greater use of speaking valves should be highly valued outcomes to both patients and clinicians and argue in support of tracheostomy teams.
However, limitations of this meta-analysis and of the primary studies must be considered. Pre-post intervention studies are considered low grade for valid reasons. A number of changes may occur following an intervention, such as the implementation of a tracheostomy team that may explain the observed outcome. For example, over time improved adherence to low tidal volume ventilation recommendations may decrease lung injury leading to decreased need for long-term tracheostomies.
In summary, the implementation of a multidisciplinary tracheostomy team was associated with a reduction in time to decannulation and an improvement in speaking valve use among critically ill patients with a tracheostomy. While the quality of included studies was low, the findings were generally consistent across studies. The importance of tracheostomy teams may become even more apparent in the future with the growth of percutaneous tracheostomy. As more practitioners perform this procedure, deciding who will follow, and how patients will be followed, will become more important. It makes sense that a dedicated tracheostomy team may help standardize this care and improve outcomes.