Brendan McGrath

Multidisciplinary guidelines for the management of tracheostomy and laryngectomy airway emergencies

Adult tracheostomy and laryngectomy airway emergencies are uncommon, but do lead to significant morbidity and mortality. The National Tracheostomy Safety Project incorporates key stakeholder groups with multi‐disciplinary expertise in airway management. , the Intensive Care Society, the Royal College of Anaesthetists, ENT UK, the British Association of Oral and Maxillofacial Surgeons, the College of Emergency Medicine, the Resuscitation Council (UK) the Royal College of Nursing, the Royal College of Speech and Language Therapists, the Association of Chartered Physiotherapists in Respiratory Care and the National Patient Safety Agency. Resources and emergency algorithms were developed by consensus, taking into account existing guidelines, evidence and experiences. The stakeholder groups reviewed draft emergency algorithms and feedback was also received from open peer review. The final algorithms describe a universal approach to managing such emergencies and are designed to be followed by first responders. The project aims to improve the management of tracheostomy and laryngectomy critical incidents.

Patient safety incidents associated with tracheostomies occurring in hospital wards: a review of reports to the UK National Patient Safety Agency

Background Tracheostomies are increasingly common in hospital wards due to the rising use of percutaneous and surgical tracheostomies in critical care and bed pressures in these units. Hospital wards may lack appropriate infrastructure to care for this vulnerable group and significant patient harm may result. Objectives To identify and analyse tracheostomy related incident reports from hospital wards between 1 October 2005 and 30 September 2007, and to make recommendations to improve patient safety based on the recurrent themes identified. The study was performed between August 2008 and August 2009. Methods 968 tracheostomy related critical incidents reported to the National Patient Safety Agency over the 2 year period, identified by key letter searches, were analysed. Incidents were categorised to identify common themes, and root cause analysis attempted where possible. Results In the 453 incidents where patients were directly affected, 338 (75%) were associated with some identifiable patient harm, of which 83 (18%) were associated with more than temporary harm. In 29 incidents (6%) some intervention was required to maintain life, and in 15 cases the incident may have contributed to the patients death. Equipment was involved in 176 incidents and 276 incidents involved tracheostomies becoming blocked or displaced. Conclusions By identifying and analysing themes in incident reports associated with tracheostomies, recommendations can be made to improve safety for this group of patients. These recommendations include improvements in infrastructure, competency and training, equipment provision, and in communication.

Guidelines for the management of tracheal intubation in critically ill adults

These guidelines describe a comprehensive strategy to optimize oxygenation, airway management, and tracheal intubation in critically ill patients, in all hospital locations. They are a direct response to the 4th National Audit Project of the Royal College of Anaesthetists and Difficult Airway Society, which highlighted deficient management of these extremely vulnerable patients leading to major complications and avoidable deaths. They are founded on robust evidence where available, supplemented by expert consensus opinion where it is not. These guidelines recognize that improved outcomes of emergency airway management require closer attention to human factors, rather than simply introduction of new devices or improved technical proficiency. They stress the role of the airway team, a shared mental model, planning, and communication throughout airway management. The primacy of oxygenation including pre- and peroxygenation is emphasized. A modified rapid sequence approach is recommended. Optimal management is presented in an algorithm that combines Plans B and C, incorporating elements of the Vortex approach. To avoid delays and task fixation, the importance of limiting procedural attempts, promptly recognizing failure, and transitioning to the next algorithm step are emphasized. The guidelines recommend early use of a videolaryngoscope, with a screen visible to all, and second generation supraglottic airways for airway rescue. Recommendations for emergency front of neck airway are for a scalpel-bougie-tube technique while acknowledging the value of other techniques performed by trained experts. As most critical care airway catastrophes occur after intubation, from dislodged or blocked tubes, essential methods to avoid these complications are also emphasized.

Reduction in harm from tracheostomy-related patient safety incidents following introduction of the National Tracheostomy Safety Project: our experience from two hundred and eighty-seven incidents.

following introduction of the National Tracheostomy Safety Project: Our experience from two hundred and eighty-seven incidents McGrath, B.A.,* Calder, N., Laha, S., Perks, A., Chaudry, I., Bates, L., Moore, J.A.** & Atkinson, D.** *Acute Intensive Care Unit, University Hospital South Manchester, Manchester, ENT, Monklands Hospital, Glasgow, Intensive Care, Lancashire Teaching Hospitals NHS Trust, Preston, Anaesthesia, Salford Royal Hospitals NHS Trust, Salford, Intensive Care, Royal Bolton Hospital, Bolton, and **Intensive Care, Central Manchester NHS Foundation Trust, Manchester, UK

Airway management in the critically ill: the same, but different

A. Higgs1, T. M. Cook2 and B. A. McGrath3,* Department of Anaesthesia and Intensive Care Medicine, Warrington & Halton Hospitals NHS Foundation Trust, Lovely Lane, Warrington, Cheshire WA5 1QG, UK, Department of Anaesthesia, Royal United Hospitals Bath Foundation Trust, Combe Park, Bath BA1 3NG, UK, and Department of Anaesthesia and Intensive Care Medicine, University Hospital South Manchester, Southmoor Road, Wythenshawe, Manchester M23 9LT, UK

The Uk National Tracheostomy Safety Project and the role of speech and language therapists

Purpose of reviewTracheostomy care is evolving, with the majority of procedures now performed percutaneously to facilitate weaning from mechanical ventilation in the critically ill. Traditional surgical indications remain, but surgical tracheostomies are increasingly performed in more complex patients and procedures. This brings unique challenges for the multidisciplinary professional team in which speech and language therapists (SLTs) have a key role. Recent findingsReviews of tracheostomy-related critical incidents have identified recurrent themes associated with adverse outcomes for this high-risk population. Recent research has highlighted the impact of tracheostomy on communication and swallowing, along with the contribution of SLTs to the multidisciplinary professional team, prompting new guidance for SLTs. The UK National Tracheostomy Safety Project has developed educational and practical resources that have been shown to improve care. Similar approaches from around the world led to the newly formed Global Tracheostomy Collaborative. SummaryPatients with tracheostomies can benefit from a co-ordinated, truly multidisciplinary approach to care. SLT-specific expertise in assessing and managing communication and swallowing needs is a vital part of this process.

The NCEPOD study: on the right trach? lessons for the anaesthetist

Patients managed in our hospitals with temporary or permanent tracheostomies are exposed to awide range of healthcare professionals and specialities, with the anaesthetist often pivotal in their inpatient journey. Since the widespread adoption of percutaneous procedures in the critically ill, the population of hospitalised patients with tracheostomy has changed. It is surprisingly difficult to find national data on the number of patientsmanaged with tracheostomy. What detailed data there are suggests that 7–19% of all patients admitted to an Intensive Care Unit (ICU) will be managed with a tracheostomy, and that up to 90% of these tracheostomies are currently performed by percutaneous routes. 3 This figure varies with the admission diagnosis, individual units, and to some extent, the country. The spotlight has turned onto tracheostomy care, after reports from around the world highlighting measurable harm in up to 30% of all acute hospital admissions involving temporary or permanent tracheostomy. 8–12 The requirement for tracheostomy marks the patient out as one with high risk for morbidity and mortality. This is borne out by studies which demonstrate mortality rates during the index hospital admission ranging from 17–20%, rising to 40% in groups with significant comorbidities. 11 Harm may occur that can be directly associated with the management of the airway device. 9 Analysis of severe incidents has revealed common underlying themes, which include a lack of staff training, of basic bedside equipment, and inadequate environments and support mechanisms, compounded by poorly thought out care pathways and response to incidents. These findings were reinforced by the 2011 4th National Audit Project of the UK Royal College of Anaesthetists (NAP4), which reported similar problems in a subset of major tracheostomy incidents, that occurred in the UK’s critical care units. Eleven out of the 14 dislodged ICU tracheostomies reported to NAP4 led to death or severe hypoxic brain injury. Competency deficiencies and a lack of capnography were consistent factors in these patients. Anaesthetists will usually have first hand experience of dealing with routine and emergency care of neck breathing patients. They are also the professional group most likely to be involved acutely when care does not go well, as airway specialists, resuscitation experts and intensivists. These varied experiences alongside increasing awareness of avoidable harm, prompted the Association of Anaesthetists of Great Britain & Ireland (AAGBI) to propose a study specifically on tracheostomy care. The survey-based study was undertaken by the National Confidential Enquiry into Patient Outcome and Death (NCEPOD) and is the largest study of its type to date.

A comparison of ventilator-associated pneumonia rates determined by different scoring systems in four intensive care units in the North West of England†

Ventilator‐associated pneumonia is a common healthcare‐associated infection with significant mortality, morbidity and healthcare cost, and rates have been proposed as a potential quality indicator. We examined ventilator‐associated pneumonia rates as determined by different diagnostic scoring systems across four adult intensive care units in the North West of England. We also collected clinical opinions as to whether patients had ventilator‐associated pneumonia, and whether patients were receiving antibiotics as treatment. Pooled ventilator‐associated pneumonia rates were 36.3, 22.2, 15.2 and 1.1 per 1000 ventilator‐bed days depending on the scoring system used. There was significant within‐unit heterogeneity for ventilator‐associated pneumonia rates calculated by the various scoring systems (all p < 0.001). Clinical opinion and antibiotic use did not correlate well with the scoring systems (k = 0.23 and k = 0.17, respectively). We therefore question whether the ventilator‐associated pneumonia rate as measured by existing tools is either useful or desirable as a quality indicator.

Necrotising Pneumonia, Staphylococcus Aureus and Panton-Valentine Leukocidin

The Panton-Valentin leukocidin (PVL) strain of meticillin-resistant Staphylococcus aureus (MRSA) is producing a new pattern of MRSA-related disease in the UK and world-wide. PVL is one of several extracellular cytotoxins produced by Staphylococcus aureus, and is usually associated with skin and soft tissue infections. PVL MRSA is uncommon in hospitals, but in the US, and now in the UK, there have been reports of severe, rapidly progressive, community-acquired haemorrhagic, necrotising pneumonia occurring in previously healthy young adults, and associated with a mortality rate of up to 75%. We review features of the pathophysiology, diagnosis and treatment of this condition, whose incidence appears to be increasing in the UK.

Observational Study of the Effect of Heparin-Containing Flush Solutions on the Incidence of Arterial Catheter Occlusion

The National Patient Safety Agency (NPSA) highlighted potential dangers associated with arterial lines in 2008, recommending the use of saline-only flush solutions. The incidence of catheter thrombosis appeared to increase following the implementation of this guidance in some units. The objective of the current study was to observe local practice regarding the use of heparin in arterial catheter flush solutions, and subsequent arterial catheter occlusion rates. This was an observational study in which data were collected prospectively from 445 catheter insertions in unselected intensive care patients in eight member hospitals of the Association of North Western Intensive Care Units (ANWICU). Catheters flushed with heparinised solutions had a significantly increased median lifespan of 102 hours versus 72 hours for saline-flushed catheters (p<0.01). The likelihood of line blockage was significantly decreased in the heparin group (7.9%) compared with the saline group (41.2%, p<0.0001). Our results suggest that routine use of heparinised flush solutions is associated with increased catheter lifespan and reduced catheter thrombosis. We believe that there is justification for an adequately powered, randomised controlled trial. Current NPSA guidance may need to be reviewed.