Critical Care and Tracheostomy EBP

Network 2012

PRESENTATION OUTLINE

• Year in review• 2012 CAT topic • E3BP project

YEAR IN REVIEW

Change in leaders (thank you to Eva and Klint for their hard work)

50% increase in membership

6 meetings this year

Critical care and tracheostomy discussion list serve remains active with just under 200 members.

Included clinical case discussion to each meeting following member survey

Interstate collaboration and pending SPA poster presentation in 2013

Reviewed CAPs on “in critical care patients does intubation effect laryngeal health ? ”, with aim to complete CAT early 2013

CAT TOPIC – 2012 – FEES IN CRITICAL CARE

Background to CAT – there are differences between sites utilising FEES for management in critical care. Some sites are keen to introduce the use of FEES in critical care and it would be ideal to have evidence to justify service establishment.

Clinical question was formed to assist in examining the documented evidence supporting the use of FEES to identify dysphagia.

Is FEES an effective diagnostic tool in critical care for identifying dysphagia?

Article Level Participants Method Diagnostic tool Outcome measure

Results Support for clinical question?

Hafner et al (2008)

4 553 critical care pts (incl tracheostomised pts)

Prospective interventional study

Screening risk for dysphagia in ICU post extubationSelf generated FEES protocol

Detection of silent aspiration in 69.3%, 22.9% decannulated.

Yes

Hales et al (2008)

4 25 critical care tracheostomised pts

Prospective observational study

Clinical bedside swallow Ax

FEES Ax (Rosenbeck Scale)

Detecting penetration and aspiration- FEES more reliable

Yes

Ajemian et al (2001)

4 48 critical care (non-trache) pts

Prospective observatonal study

FEES within 48 hrs of extubation

Dysphagia detected in 56% pts

25% pts silently aspirated

Yes

McGowan 4 4 ventilated , tracheostomised pt’s with cuff inflated

Case series pilot study

FEES Ax (Rosenbeck Scale)

¼ had normal swallow, ¼ aspirated, 2/4 had laryngeal penetration

Yes

Noordally et al (2011)

3 21 critical care pts

(non-tracheostomised)

Prospective comparison study

Attempted to compare parameters of swallow between FEES, MBS and clincial ax

Clinical Ax and FEES within 24hrs of extubation

Above evaluations repeated at 48hrs and 10/21 stable patients also recieved a MBS

? Each swallow component rated on scale of 1-3 and then rating compared between tools.

?Statistical correlations of ratings

Methodological limitations.

Disregard study

Barquist et.al 2001

3 70 critical care patients

Prospective comparison study with concurrent controls

FEESClinical assessment of swallowing

Incidence of post extubation pneumonia between patients with clinical and FEES in patients intubated > 48 hrs

Limted study with many methodological limitations.

Disregard study

COMMENTS

Discrepancy in data recorded in some articles

Limited uniformity between the patient populations in these studies (some tracheostomised, some ventilated, post extubation etc)

Speech Pathologist was not consistently part of the investigating teams

Inter-rater reliability was an issue

CAT bottom line

“In the critical care population, limited, low level evidence suggests that FEES may be useful in identifying dysphagia. In some studies, FEES has been shown to be more sensitive than bedside Ax in detecting silent aspiration.”

Further robust research is required in order to support the use of FEES in preference to clinical bedside ax or MBS in the critical care setting

CAT bottom line : application to clinical practice

Confirms what we know about FEES ie :

FEES may be useful for detection of silent aspiration

Useful for both tracheostomised and non tracheostomised patients

Suggests that FEES can be useful for non-mobile and medically unstable patients

Consistent with results of NSW Health Draft Tracheostomy Clinical Practice guideline (2012) recommendation: “Where objective assessment of swallowing is required a FEES may be considered as alternative objective assessment to a VFSS. A FEES has been demonstrated to have greater sensitivity than clinical assessment alone to detect aspiration and is particularly useful in critical care environments. FEES may allow earlier commencement of oral intake.”

2012 E3BP PROJECT

• E3BP review• Background • Collection in the clinical setting• Themes from collation • Future directions in the clinical setting &beyond

E3BP TRIANGLE

Best external evidence

Best internal evidence(from clinical practice)

Best internal evidence(from client factors & preferences)

Clinical expertise

BACKGROUND TO E3BP PROJECT• 2011 CAT involved review of the literature on the effect of

tracheostomy on swallow function• CAT bottom line - “low level evidence to suggest that a

tracheostomy tube does not cause dysphagia; rather, the dysphagia is attributed to the underlying diagnoses and co morbidities”

• The group identified a significant gap in evidence versus clinician opinion/practice

• Decided to use E3BP to enable holistic decision making around trache care

• Group then circulated and analysed an online survey to NSW speechies to gauge level of knowledge and ideas on current practice

• Survey was also distributed to Vic tracheostomy interest group

E3BP collection in the clinical setting

Group brainstorming session and development of preliminary data collection table → some concerns from the group regarding the sensitivity and robustness of the tool.

Group members and their departments started data collection

Some members of group attended Beyond Basics EBP workshop. Some discussion with Elise Baker. → its not research ! Include “the mess” and keep collecting!

Refined table online during data collection. Easy to use, not time intensive, aim to make it a part of clinical assessment.

Trache Trache Insitu(Last swallow Ax pre-decannulation)

Post-Decannulation(First swallow Ax post-decannulation)

Time Summary

Reason for Trache insertion Trache type insitu at time of

Ax

Swallow Ax (A) Diet + Fluids recommendation

Swallow Ax (B) Diet + Fluids recommendation

□Airway patency□ Respiratory/ pulmonary toileting□ Prolonged ventilator wean□ GCS

Size□ 6□ 7□ 8□ 9Other: □ Portex□ Shiley□ Other brand:□ Fenestrated□Non-fenestrated□Cuffed□Uncuffed□Cuff up□ Cuff down□Speaking Valve□ CappedRespiratory support:□ Trache mask + vent□ Trache mask only

Assessment type:□ Bed-side□ FEES□ MBS□Posture:Upright; Semi-upright; supine□ Delayed onset of pharyngeal initiation□ >1 swallow per bolus□ Reduced hyolaryngeal excursion□ Other:Signs of aspiration:□ Cough□ Throat clearing□ Wet vocal quality□ Increased SOB□ Reduced oxygen saturation□ Stained secretions (food/fluid)

□ NBM□ NGT/TPN□ NGT/TPN + oral intake□ Oral intake only□ Thin Fluids□ Nectar/mildly thick□ Honey/moderately thick□ Pudding/extremely thick□ Puree□ Minced□Soft□Full□ Small amounts (specify):□ Other: □ Swallowing strategies:

Assessment type:□ Bed-side□ FEES□ MBS□Posture:Upright; Semi-upright; supine□ Delayed onset of pharyngeal initiation□ >1 swallow/bolus□ Reduced hyolaryngeal excursion□ Other:Signs of aspiration:□ Cough□ Throat clearing□ Wet vocal quality□ Increased SOB□ Reduced oxygen saturation□ Stained secretions (food/fluid)

□ NBM□ NGT/TPN□ NGT/TPN + oral intake□ Oral intake only□ Thin Fluids□ Nectar/mildly thick□ Honey/moderately thick□ Pudding/extremely thick□ Puree□ Minced□Soft□Full□ Small amounts (specify):□ Other: □ Swallowing strategies:

No. of days trache insitu :No. of days between Swallow Ax (A) and Swallow Ax (B):

Has there been a change in swallow function?□ No change□ Improvement□ Decline If swallow function has improved, what may have contributed to this?□ Trache decannulation□ Improved general medical status

E3BP data trends to date • N = 36

• 6 sites completed (other sites interested but not included at this stage)

• 5 tertiary sites, 1 metro site

• Data collected over last 6 months (May-Nov)

• 35 clinical Axs (only 1 MBS, no FEES)

• Last ax with trache insitu and first ax post decannulation

• Average of 12.86 days between ax’s

• Reason for trachy insertion : 30/36 prolonged vent weans, 4/36 low GCS, 1/36 airway patency, 1/36 respiratory toilet

PRELIMINARY TRENDS IN DATA – see table

Cohort = 36

Was there a change in swallow between last Ax with trache insitu and first assessment with trache removed? (Eg. Change to diet recommendations, less repeat swallows, reduced aspiration/penetration signs?)

YES = 22 No = 14

15 medical

improvement

What caused the improvement?

5 trache

decannulation

2Combination

Anxiety, upper airway irritation

other factors?

WHERE TO FROM HERE ?

• Continuation of E3BP data collection to increase our body of internal evidence with future trend analysis

• Continued liaison with Victorian tracheostomy interest group. Joint submission of poster abstract for 2013 SPA conference re member survey

• Finalise the CAT on the effect of intubation on laryngeal health

• Hosting tracheostomy education day 2013