Adult Outpatient Tracheostomy Care
Content
Otolaryngology–Head and Neck Surgery (2007) 136, 301-306
ORIGINAL RESEARCH
Adult outpatient tracheostomy care: Practices and perspectives
Justin M. Garner, MD, Michael Shoemaker-Moyle, MD, and Christine B. Franzese, MD, Jackson, MI
OBJECTIVES: To determine the attitudes, opinions, and current practice of adult outpatient tracheostomy care from the surgeon and primary care physician’s perspective. STUDY DESIGN: Multidisciplinary physician survey. RESULTS: Found 53.4% (667 of 1250) and 28.9% (404 of 1400) of otolaryngologists and internists responded, respectively; 47% of otolaryngologists lack standardized tracheostomy discharge protocols. General ward nurses most commonly (33%) provide discharge education. A total of 64% of otolaryngologists felt primarily responsible for tracheostomy care and follow-up; 48% expect the primary physician to provide some or all tracheostomy care. Ninety-seven percent of internists received little or no residency training in tracheostomy care, which was significantly associated with decreased comfort (P Ͻ 0.0001) and willingness (P Ͻ 0.0001) to care for these patients. CONCLUSIONS: Tracheostomy care is a concerted effort between the patient, surgeon, primary physician, and interdisciplinary team. Otolaryngologists should strive to standardize tracheostomy discharge, education, and follow-up practices. SIGNIFICANCE: Disparities are highlighted between disciplines in their comfort, willingness, and knowledge of outpatient tracheostomy care. © 2007 American Academy of Otolaryngology–Head and Neck Surgery Foundation. All rights reserved.
T
he tracheotomy has a long and storied history in the practice of medicine and the field of otolaryngology. Before the nineteenth century only a very limited number of successful tracheotomies had been reported. It was not until the early twentieth century, that Chevalier Q. Jackson helped standardize and refine the procedure. The resultant decrease in mortality brought the procedure into the mainstream and
broadened its use. Today, the tracheotomy is a common procedure performed by the otolaryngologist; in 1999, there were over 83,000 tracheostomies placed in the United States.1 Tracheostomies are most commonly placed for purposes of mechanical ventilation in chronically ill patients.2 These patients often require long-term use of their tracheostomy either at home or in long-term care facilities where specialty care by the otolaryngologist is often not available. Consequently, these patients are often lost to follow-up by the operating surgeon. This raises the question of who provides the medical care and maintenance of these adult outpatient tracheostomies. It is presumed that much of this care falls to the primary care physician. Tracheostomies can require relatively intensive outpatient care and maintenance including routine care, tube changes, and troubleshooting. Much has been written in the literature, including physician surveys, with respect to the care, management, and education of pediatric tracheostomies,3-6 and to a lesser extent adult outpatient tracheostomies.7-15 Unfortunately, there is a relative paucity of literature with respect to the current practices of outpatient care of the adult tracheostomy from the physician’s perspective. The purpose of this study is to determine the attitudes, opinions, and current practice of adult outpatient tracheostomy care from both the surgeon and primary care physician’s perspective.
MATERIALS AND METHODS
A short, 10-question, discipline-specific survey approved by the University of Mississippi Medical Center InstituReprint requests: Justin M. Garner, MD, Department of Otolaryngology and Communicative Sciences, The University of Mississippi Medical Center, 2500 North State St, Jackson, MS 39216. E-mail address: [email protected].
From the Departments of Otolaryngology and Communicative Sciences (Drs Garner and Franzese) and Internal Medicine (Dr Shoemaker-Moyle), The University of Mississippi Medical Center, Jackson, Mississippi. Presented at the Southern Section Meeting of the Triological Society, Naples, FL, January 12-14, 2006.
0194-5998/$32.00 © 2007 American Academy of Otolaryngology–Head and Neck Surgery Foundation. All rights reserved. doi:10.1016/j.otohns.2006.08.023
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Otolaryngology–Head and Neck Surgery, Vol 136, No 2, February 2007 tively, were currently practicing. Otolaryngology and internist survey instruments and responses are seen in Appendix 1 and Appendix 2 (www.http://journal.entnet.org), respectively.
tional Review Board was sent to 1250 randomly selected general otolaryngologists and to 1400 randomly selected general internists in the United States. Surveys were sent to general internists and otolaryngologists in all 50 states, Puerto Rico, and the District of Columbia. The general otolaryngologist participant list was obtained from a randomly generated list drawn from the general otolaryngology subgroup of the American Academy of Otolaryngology and the Mississippi State Medical Association directories. The general internist participant list was obtained from the member directories of the Society of General Internal Medicine and the internal medicine subgroup of the Mississippi State Medical Association. Where available, email addresses were used preferentially over postal addresses to distribute an electronic version of the survey in order to increase efficiency and reduce survey costs. Only one survey response was allowed per survey participant. Surveys that were returned partially completed had their completed responses included in the results. Those surveys that were returned with multiple responses to a single response question had those questions excluded, with the correctly completed questions included. Given the categorical nature of the survey responses, we used the 2-test for the significance test of proportions to obtain P-values and to determine statistically significant differences (P Յ 0.05) between responses among different groups. SPSS version 13.0 (SPSS, Inc, Chicago, Ill) was used for statistical analyses. The surveys were created to determine the attitudes, experience, and current practices of these 2 different disciplines with respect to adult outpatient tracheostomy care. The general otolaryngology survey (Appendix 1, www.http://journal. entnet.org) focused on current practice type, types of tracheotomy performed, as well as their current protocol of tracheostomy patient discharge, education, and follow-up. The remainder of the survey focused on opinions of which medical professionals are qualified, and who should primarily provide outpatient tracheostomy follow-up. The general internist survey (Appendix 2, www.http://journal. entnet.org) focused on current practice type, practice experience with tracheostomy patients, amount of residency training that involved tracheostomy care, and tracheostomy knowledge. Other questions sought to ascertain their comfort level and likely management strategy for adult outpatient tracheostomy patients. The remainder of the survey focused on the internist’s opinion of which medical professionals are qualified and who should primarily provide outpatient tracheostomy follow-up.
Otolaryngologists
Single-specialty group practice (48.8%, 321 of 658) was the most commonly reported practice type among otolaryngologists, followed by solo practice (28%, 184 of 658), multispecialty group practice (12.9%, 85 of 658), and academics (10.3%, 68 of 658). All but one otolaryngologist reported performing tracheotomies either currently or in the past. All of these otolaryngologists reported using an open technique; 7.1% (47 of 665) also reported the routine use of the percutaneous technique with bronchoscopic guidance, whereas 3.6% (24 of 665) reported the routine use of the percutaneous technique without bronchoscopic guidance; 9.4% (63 of 667) of otolaryngologists reported using at least one form of percutaneous tracheotomy technique. Academic otolaryngologists (22.4%, 15 of 67) were significantly more likely (P ϭ 0.0002) to use percutaneous techniques than nonacademics (8.1%, 48 of 589). When questioned if they had a standardized protocol for discharge planning and education in new adult tracheostomy patients, just over half (52.9%, 350 of 662) responded yes, whereas the remaining 47.1% (312 of 662) had no standardized protocol. One-third (32.7%, 203 of 621) of respondents reported that general ward or floor nurses were primarily responsible for patient tracheostomy education before discharge, followed by the surgeon (24.8%, 154 of 621), respiratory therapist (18.8%, 117 of 621), specialty (tracheostomy) nurse (13%, 81 of 621), home health nurse (8.4%, 52 of 621), physician extenders (1.8%, 11 of 621), and other (0.5%, 3 of 621) (Fig 1). Academic otolaryngologists (20.6%, 14 of 68) were significantly more likely (P ϭ 0.025) to use the services of a tracheostomy nurse than other practice types (11.2%, 66 of 590).
RESULTS
Of the 1250 otolaryngology surveys, 667 responses were obtained for a 53.4% response rate. Of the 1400 general internist surveys, 404 were returned for a 28.9% response rate. Of the responding otolaryngologists and general internists, 97.1% (647 of 666) and 95% (384 of 404), respec-
Figure 1 Chart shows who primarily provides discharge tracheostomy education.
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When asked to characterize their outpatient care practices for adult tracheostomy patients after the initial tracheostomy change, 51.8% (340 of 656) of otolaryngologists reported performing all routine tracheostomy care and follow-up themselves. Another 39.9% (262 of 656) expected to jointly follow their patients with the primary care provider or pulmonologist; 5.8% (38 of 656) referred all tracheostomy care and follow-up to the pulmonologist, whereas 2.4% (16 of 656) referred this care to the primary care physician. When asked if they felt that primary care physicians in general were qualified or competent to provide routine tracheostomy care and follow-up, over three-quarters (75.9%, 503 of 663) responded no. Otolaryngologists were then asked their opinion of whether five different health care providers were qualified to provide routine tracheostomy follow-up (Fig 2). Most (97.3%, 644 of 662) respondents felt surgeons (general surgeons and otolaryngologists) were qualified, followed by pulmonologists (69.9%, 463 of 662), respiratory therapists (66.2%, 438 of 662), home health nurses (55.6%, 368 of 662), primary care providers (26.6%, 176 of 662), with 4.8% (32 of 662) responding other. When asked who should primarily provide routine tracheostomy follow-up (Fig 3), nearly two thirds (64%, 357 of 558) responded the surgeon, followed by the home health nurse (19%, 106 of 558), respiratory therapist (5.7%, 32 of 558), primary care provider (5.6%, 31 of 558), pulmonologist (4.8%, 27 of 558), and other (0.9%, 5 of 558). Otolaryngologists were significantly more likely than internists (P Ͻ 0.0001) to believe the surgeon is primarily responsible.
Figure 3 Chart shows which provider should primarily provide routine tracheostomy care and follow-up.
Internists
General internist respondents differed in their practice type compared with otolaryngology respondents. The majority (77.7%, 310 of 399) characterized their current practice as academic, with single-specialty group practice (9%, 36 of 399), multi-specialty group practice (8.3%, 33 of 399), and solo practice (5%, 20 of 399) less common. Nearly two thirds (64.7%, 260 of 402) reported caring for adult patients
Figure 2 Chart shows which providers are felt to be qualified to perform routine tracheostomy care and follow-up.
with a tracheostomy in their outpatient practices either currently or in the past. With respect to their residency training and current knowledge of routine tracheostomy care and follow-up, the majority (62.1%, 251 of 404) reported receiving no training in tracheostomy care and follow-up during their residency, whereas 35.1% (142 of 404) received a small amount, 2.7% (11 of 404) a moderate amount; none of them reported receiving a large amount. Academic internists (34.8%, 108 of 310) were significantly less likely (P ϭ 0.021) to have received residency training in tracheostomy care than their nonacademic counterparts (48.3%, 43 of 89). The vast majority of internists as a whole (84.7%, 342 of 404) reported that they did not know how to perform a routine tracheostomy change. Academic internists (11.9%, 37 of 310) were significantly less likely (P ϭ 0.0002) than nonacademics (28.1%, 25 of 89) to know how to do this. Even a larger majority of internists (92%, 370 of 402) did not know how often a tracheostomy tube should be changed. When asked about their comfort level for providing routine tracheostomy care and follow-up for adult tracheostomy patients, the majority of internists (59.6%, 236 of 396) felt very uncomfortable and would refer all their patients to a surgeon for routine tracheostomy care. Another 30.8% (122 of 396) felt somewhat uncomfortable and frequently referred these patients to the surgeon for care, whereas even fewer (8.3%, 33 of 396) felt somewhat comfortable and would perform some tracheostomy care but would often refer the care to the surgeon. Only 1.3% (5 of 396) felt very comfortable and performed all routine tracheostomy care with minimal to no referrals to the surgeon. Among internists who had received at least a small amount of residency training in tracheostomy care, there was significantly more comfort (22.0%, 33 of 150 vs 2.0%, 5 of 246, P Ͻ 0.0001) with caring for tracheostomies than those who had not received any tracheostomy education during residency (Fig 4). When given the scenario of seeing a new adult in their practice who was recently discharged from the hospital with a newly placed tracheostomy, 47.5% (187 of 394) stated
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Otolaryngology–Head and Neck Surgery, Vol 136, No 2, February 2007 agement of historically inpatient illnesses and treatments. This has resulted in more adult tracheostomy patients being managed on an outpatient basis or in subacute and longterm facilities rather than the traditional acute care facility. With this trend comes the need for outpatient tracheostomy care and follow-up. The multidisciplinary approach to the outpatient tracheostomy patient has been discussed widely.12-14 Although the use of percutaneous techniques has increased over the last decade, with a correspondingly broader range of practitioners performing the procedure,12 the otolaryngologist is often regarded as the tracheostomy and airway expert. For this reason, the otolaryngologist is often called on to provide routine tracheostomy care and follow-up for these patients. However, given the multiple comorbidities and medical issues that many of these patients entail, the general internist is often the most intimately involved in their care. The current survey aimed to determine the current attitudes, opinions, and practices of adult outpatient tracheostomy care from both the surgeon’s and physician’s perspective. It is evident from the survey results that otolaryngologists as a whole have been slow to adopt forms of percutaneous tracheotomy technique. Academic otolaryngologists are significantly more likely (P ϭ 0.0002) to use percutaneous techniques than nonacademics. Some progress seems to have been made in the standardization of discharge protocols and education for tracheostomy patients, but nearly half of otolaryngologists reported that they did not have this system in place. General ward nurses were most commonly responsible for tracheostomy education before discharge for these patients; this implies that these nurses are competent with tracheostomies themselves, and if not, discharge education for these patients is inadequate. Interestingly, only 13% have the services of a specialty tracheostomy nurse (Fig 1). Academic otolaryngologists were significantly more likely (P ϭ 0.025) to use the services of a tracheostomy nurse than other practice types, which is not surprising given that they likely are more frequently available in this setting. Internist respondents tended to have more academic practices compared with otolaryngologists, and interesting significant differences between academic and their nonacademic counterparts are noted. Although nearly two thirds of internists reported having cared for adult tracheostomy patients in the outpatient setting, 97% had little to no tracheostomy care training during their residency. Few reported knowing how and how often to change the tracheostomy tube. Nearly 90% of internists felt uncomfortable providing tracheostomy care and follow-up, with only 2% willing to provide all routine tracheostomy care for their patients. Interestingly, among internists who had received at least a small amount of residency training in tracheostomy care, there was significantly more comfort (P Ͻ 0.0001) and willingness (P Ͻ 0.0001) to care for tracheostomies than those who had not received any tracheostomy education during residency (Fig 4). Sentiment among otolaryngolo-
Figure 4 Chart shows internist tracheostomy care comfort level vs amount of residency training.
they would refer all tracheostomy care and follow-up to the surgeon. Another 38.6% (152 of 394) would refer to a surgeon and perform tracheostomy care only if the patient was unable to see the surgeon in a timely fashion, whereas 11.7% (46 of 394) would perform some tracheostomy care and follow-up but refer to the surgeon for recommendations and care for any minor or major problems. Only 2.3% (9 of 394) would perform all routine tracheostomy care and follow-up and refer to the surgeon only for emergencies or complicated problems. Internists who had received at least a small amount of residency training in tracheostomy care were significantly more willing (24.3%, 36 of 148 vs 7.7%, 19 of 246, P Ͻ 0.0001) to care for tracheostomies than those who had not received any tracheostomy education during residency. Internists were then asked their opinion of whether five different health care providers were qualified to provide routine tracheostomy follow-up (Fig 2). Most (96.8%, 382 of 396) felt surgeons were qualified, followed by respiratory therapists (88.9%, 352 of 396), pulmonologists (84.8%, 336 of 396), home health nurses (60.4%, 239 of 396), primary care providers (43.4%, 172 of 396), and 5.3% (21 of 396) responding other. Internists were significantly more likely (P Ͻ 0.0001) than otolaryngologists to feel primary care physicians are qualified. When asked who should primarily provide tracheostomy follow-up (Fig 3), 35.4% (109 of 308) responded the surgeon, followed by the respiratory therapist (24.4%, 75 of 308), home health nurse (16.9%, 52 of 308), primary care provider (13.3%, 41 of 308), pulmonologist (7.1%, 22 of 308), and other (2.9%, 9 of 308).
DISCUSSION
The placement of a tracheostomy is a very important event in the doctor-patient relationship that requires long-term care and management by both the patient and the broader health care system. With the increase in the number of tracheostomy patients and the advent of home and longterm ventilation, more patients are being discharged with tracheostomies because of the push toward outpatient man-
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gists was similar with less than one fourth of respondents believing primary care physicians were qualified and competent to perform routine tracheostomy care and follow-up. Even so, only about half of otolaryngologists report they perform all tracheostomy care and follow-up on their patients. Another 40% expect to jointly provide this care; nearly one tenth refer all tracheostomy care to either the primary care physician or pulmonologist. Both internists and otolaryngologists most frequently felt that the surgeon was qualified to perform outpatient tracheostomy care and follow-up. Pulmonologists and respiratory therapists were the next most commonly reported qualified professionals. For any given care professional, internists were more likely than otolaryngologists to feel they were qualified to provide outpatient tracheostomy care and follow-up (Fig 2). In fact, internists were significantly more likely (P Ͻ 0.0001) than otolaryngologists to feel primary care physicians are qualified. Both internists and otolaryngologists were most likely to list the surgeon as primarily responsible for this care (Fig 3), with otolaryngologists significantly more likely (P Ͻ 0.0001) to believe this. Interestingly, only about one third of internists felt the surgeon was primarily responsible for this care. Internists were significantly more likely than otolaryngologists (P Ͻ 0.0001) to list respiratory therapists as primarily responsible for outpatient tracheostomy care and follow-up, which is likely due to their exposure to this function of the respiratory therapist in the acute inpatient setting. Interestingly, otolaryngologists listed pulmonologists least frequently as being primarily responsible for tracheostomy care, even though they listed them most frequently, second only to the surgeon, as being qualified to perform this care. Although academic internists were just as likely as nonacademics to have cared for patients with tracheostomies, interestingly, they were significantly less likely (P ϭ 0.021) to have received residency training in tracheostomy care than their nonacademic counterparts. Academic internists were also less likely (P ϭ 0.0002) than nonacademics to know how to change a tracheostomy. This raises the question of academic internists’ ability to educate trainees in tracheostomy care and follow-up, and even more importantly, whether there is an obligation of the otolaryngologist to provide this education. Surveys have both sampling and nonsampling error potential. Potential sampling error in our study could be from our responders not representing the intended population. Although our response rates for otolaryngologists and internists were relatively good at 53% and 29%, respectively, these responders could potentially not represent otolaryngologists and internists as a whole. This is particularly true of our internist respondents who were primarily academics, although this allowed us to make interesting comparisons between academic and nonacademic internists. Nonsampling error may have been introduced into the study due to questionnaire definitions or instructions that were inadequate or ambiguous and resulted in questions being inappropriately or incompletely answered. Recall bias can affect
survey responses; however, we feel that this was minimized in our survey given that 97% and 95% of the responding otolaryngologists and internists, respectively, were currently practicing. Although survey error can be introduced by respondents reporting one thing but doing another, we feel this was minimized due to the confidentiality, anonymity, and straightforward nature of the survey.
CONCLUSION
In conclusion, adult patients with tracheostomies can often be complex patients who require the expertise of not only the surgeon and internist, but many other health care professionals. The routine care and maintenance of tracheostomies should be a concerted effort between the patient, surgeon, primary physician, and interdisciplinary team. In particular, those physicians and surgeons who are performing tracheotomies should be adept not only with the procedure, but also with their outpatient care, maintenance, and troubleshooting.12 One pitfall to avoid in the care of these patients is the lack of communication among team members about the patient’s status, goals, and types of care provided by different care team members.13 Communication and planning is paramount, and tracheostomy knowledge, care, and follow-up should not be assumed of any health professional. A more concerted effort should be undertaken by the specialty of otolaryngology to standardize tracheostomy patient discharge and education. Tracheostomy care manuals such as the one by Levine and Miller15 can be very helpful for the education of these patients, their caregivers, as well as other physicians and health care professionals. As primary care physicians, general internists should be familiar with the routine care and maintenance of tracheostomies as evidenced by the majority of respondents who have cared for outpatient tracheostomy patients. As echoed by many internists’ survey comments, tracheostomy education should be considered for inclusion in the curriculum of a medical residency, and this education will inevitably fall on the shoulders of the specialty of otolaryngology as the tracheostomy and airway experts.
REFERENCES
1. Popovic JR. 1999 National Hospital Discharge Summary: annual summary with detailed diagnosis and procedure data. National Center for Health Statistics. Vital Health Stat 2001;13(151):168. (Grade C). 2. Yaremchuk K. Regular tracheostomy tube changes to prevent formation of granulation tissue. Laryngoscope 2003;113(1):1–10. (Grade B). 3. Turnage CS, Engleman S. Discharge education for parents of infants with tracheostomies. J Pediatr Nurs 1994;9(6):425– 6. (Grade D). 4. Hotaling AJ, Zablocki H, Madgy DN. Pediatric tracheotomy discharge teaching: a comprehensive checklist format. Int J Pediatr Otorhinolaryngol 1995;33(2):113–26. (Grade D). 5. Senders CW, Muntz HR, Schweiss D. Physician survey on the care of children with tracheotomy. Am J Otolaryngol 1991;12(1):48 –50. (Grade C).
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11. Minsley MA, Wrenn S. Long-term care of the tracheostomy patient from an outpatient nursing perspective. ORL Head Neck Nurs 1996; 14(4):18 –22. (Grade D). 12. Wright SE, VanDahm K. Long-term care of the tracheostomy patient. Clin Chest Med 2003;24:473– 87. (Grade D). 13. Nace DA, Fox A. Long-term care of tracheostomy patients. In: Myers EN, Johnson J, Murry T, eds. Tracheotomy: airway management, communication, and swallowing. San Diego, CA: Singular Publishing Group; 1998. p. 67–74. (Grade D). 14. Diehl BC, Dorsey LK, Koller C. Transitioning the client with a tracheostomy from acute care to alternative settings. In: Tippet DC, ed. Tracheostomy and ventilator dependency: management of breathing, speaking, and swallowing. New York, NY: Thieme; 2000. p. 237-66. (Grade D). 15. Levine H, Miller C. Tracheostomy care manual, 2nd ed. New York, NY: Thieme; 1988. (Grade D).
6. Woolley AL, Muntz HR, Prater D. Physician survey on the care of children with tracheotomies. Am J Otolaryngol 1996;17(1):50 –3. (Grade C). 7. Kopacz MA, Moriarty-Wright R. Multidisciplinary approach for the patient on a home ventilator. Heart Lung 1984;13(3):255– 62. (Grade D). 8. Votava KM, Cleveland T, Hiltunen K. Home care of the patient dependent on mechanical ventilation: home care policy development and goal setting using outcome criteria for quality assurance. Home Healthc Nurse 1985;3(2):18 –25. (Grade D). 9. Wilson EB, Malley N. Discharge planning for the patient with a new tracheostomy. Crit Care Nurse 1990;10(7):73–9. (Grade D). 10. Sevick MA, Erlen JA, van Muiswinkel J, et al. Health care professionals’ characterizations of the system of care for long-term ventilator-dependent patients: a preliminary study. J Health Soc Policy 1994; 6(2):51–70. (Grade D).
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APPENDIX 1
Adult outpatient tracheostomy care survey: Surgeon
Otolaryngology Survey 1. Do you currently practice otolaryngology? (select one) 97.1% (647 of 666) Yes 2.9% (19 of 666) No 2. What best describes your current practice type? (select one) 48.8% (321 of 658) Group practice (single-specialty) 28.0% (184 of 658) Solo practice 12.9% (85 of 658) Group practice (multi-specialty) 10.3% (68 of 658) Academic 3. Do you currently or have you ever performed tracheotomies on adult patients? (select one) 99.99% (665 of 666) Yes 0.01% (1 of 666) No 4. What type of tracheotomy do you routinely perform, or have you ever routinely performed? (select all that apply) 100% (665 of 665) Standard open tracheotomy 7.1% (47 of 665) Percutaneous tracheotomy with bronchoscopic guidance 3.6% (24 of 665) Percutaneous tracheotomy without bronchoscopic guidance 5. Do you have a standardized protocol for discharge planning and education in new adult tracheostomy patients? (select one) 52.9% (350 of 662) Yes 47.1% (312 of 662) No 6. In your practice, who is primarily responsible for tracheostomy education for adult patients with a new tracheostomy at the time of their discharge? (select one) 32.7% (203 of 621) General ward or floor nurse 24.8% (154 of 621) Physician or surgeon 18.8% (117 of 621) Respiratory therapist 13.0% (81 of 621) Specialty nurse (ie, tracheostomy nurse) 8.4% (52 of 621) Home health nurse 1.8% (11 of 621) Physician extender (ie, physician assistant or nurse practitioner) 0.5% (3 of 621) Other 7. Which of the following best describes your outpatient care practices for adult tracheostomy patients following initial inpatient discharge and after the initial tracheostomy change? (select one) 51.8% (340 of 656) I perform all routine tracheostomy care and follow-up for my adult tracheostomy patients. 39.9% (262 of 656) I follow my adult tracheostomy patients and expect to jointly perform routine outpatient tracheostomy care and follow-up with their primary care provider of internist or pulmonologist. 5.8% (38 of 656) I refer all my adult tracheostomy patients to a pulmonologist for their routine tracheostomy care and follow-up. 2.4% (16 of 656) I refer all my adult tracheostomy patients to their primary care provider of internist for all routine tracheostomy care and follow-up. 8. In your general opinion, is a primary care physician qualified or competent to perform routine tracheostomy care and follow-up for adult outpatients? (select one) 24.1% (160 of 663) Yes 75.9% (503 of 663) No 9. Who do you feel is qualified to provide routine tracheostomy follow-up? (select all that apply) 97.3% (644 of 662) Surgeon (general surgeon, otolaryngologist) 69.9% (463 of 662) Pulmonologist 66.2% (438 of 662) Respiratory therapist 55.6% (368 of 662) Home health nurse 26.6% (176 of 662) Primary care provider (general internist, family practitioner) 4.8% (32 of 662) Other 10. Who do you feel should primarily provide routine tracheostomy follow-up? (select one) 64.0% (357 of 558) Surgeon (general surgeon, otolaryngologist) 19.0% (106 of 558) Home health nurse
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Appendix 1 (Continued)
Otolaryngology Survey 5.7% 5.6% 4.8% 0.9% (32 of 558) Respiratory therapist (31 of 558) Primary care provider (general internist, family practitioner) (27 of 558) Pulmonologist (5 of 558) Other
APPENDIX 2
Adult outpatient tracheostomy care survery: Internist
Internist Survey 1. Do you currently practice general internal medicine? (select one) 95.0% (384 of 404) Yes 5.0% (20 of 404) No 2. What best describes your current practice type? (select one) 77.7% (310 of 399) Academic 9.0% (36 of 399) Group practice (single-specialty) 8.3% (33 of 399) Group practice (multi-specialty) 5.0% (20 of 399) Solo practice 3. Do you currently or have you ever cared for adult patients with tracheostomies in your outpatient practice? (select one) 64.7% (260 of 402) Yes 35.3% (142 of 402) No 4. Did you receive any training during your residency in internal medicine regarding routine tracheostomy care and follow-up for adult tracheostomy patients? (select one) 62.1% (251 of 404) None at all 35.1% (142 of 404) Yes, a small amount 2.7% (11 of 404) Yes, a moderate amount 0.0% (0 of 404) Yes, a large amount 5. Do you know how to perform a routine tracheostomy change in an adult patient? (select one) 15.3% (62 of 404) Yes 84.7% (342 of 404) No 6. Do you know how often to perform a routine tracheostomy change in an adult patient? (select one) 8.0% (32 of 402) Yes 92.0% (370 of 402) No 7. Do you feel comfortable performing routine tracheostomy care and following adult tracheostomy patients? (select one choice that best describes your practice) 59.6% (236 of 396) I feel very uncomfortable and perform no tracheostomy care. I refer all my tracheostomy patients to a surgeon for evaluation and follow-up of routine tracheostomy care. 30.8% (122 of 396) I feel somewhat uncomfortable and perform very little routine tracheostomy care of follow up. I frequently refer these patients to a surgeon for their tracheostomy care of follow-up. 8.3% (33 of 396) I feel somewhat comfortable and will perform some routine tracheostomy care of followup, but often refer these patients to a surgeon who performs tracheotomy. 1.3% (5 of 396) I feel very comfortable and perform all routine tracheostomy care with minimal or no referrals to a surgeon who performs tracheotomy. 8. If you were to see a new adult outpatient in your practice who was recently discharged from the hospital with a newly placed tracheostomy, which of the following best describes your management strategy? (select one) 47.5% (187 of 394) I would refer to a surgeon, and refer all tracheostomy care and follow-up to that surgeon. 38.6% (152 of 394) I would refer to a surgeon for most tracheostomy care of follow-up, and perform tracheostomy care only if the patient was unable to see the surgeon in a timely fashion. 11.7% (46 of 394) I would perform some tracheostomy care of follow-up, but would refer to a surgeon for recommendations and follow-up care for minor or major problems. 2.3% (9 of 394) I would perform all routine tracheostomy care of follow-up and refer to a surgeon only in emergencies or complicated problems. 9. Who do you feel is qualified to provide routine tracheostomy follow-up? (select all that apply)
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Appendix 2 (Continued)
Internist Survey 96.8% (382 of 396) Surgeon (general surgeon, otolaryngologist) 88.9% (352 of 396) Respiratory therapist 84.8% (336 of 396) Pulmonologist 60.4% (239 of 396) Home health nurse 43.4% (172 of 396) Primary care provider (general internist, family practitioner) 5.3% (21 of 396) Other 10. Who do you feel should primarily provide routine tracheostomy follow-up? (select one) 35.4% (109 of 308) Surgeon (general surgeon, otolaryngologist) 24.4% (75 of 308) Respiratory therapist 16.9% (52 of 308) Home health nurse 13.3% (41 of 308) Primary care provider (general internist, family practitioner) 7.1% (22 of 308) Pulmonologist 2.9% (9 of 308) Other
ORIGINAL RESEARCH
Adult outpatient tracheostomy care: Practices and perspectives
Justin M. Garner, MD, Michael Shoemaker-Moyle, MD, and Christine B. Franzese, MD, Jackson, MI
OBJECTIVES: To determine the attitudes, opinions, and current practice of adult outpatient tracheostomy care from the surgeon and primary care physician’s perspective. STUDY DESIGN: Multidisciplinary physician survey. RESULTS: Found 53.4% (667 of 1250) and 28.9% (404 of 1400) of otolaryngologists and internists responded, respectively; 47% of otolaryngologists lack standardized tracheostomy discharge protocols. General ward nurses most commonly (33%) provide discharge education. A total of 64% of otolaryngologists felt primarily responsible for tracheostomy care and follow-up; 48% expect the primary physician to provide some or all tracheostomy care. Ninety-seven percent of internists received little or no residency training in tracheostomy care, which was significantly associated with decreased comfort (P Ͻ 0.0001) and willingness (P Ͻ 0.0001) to care for these patients. CONCLUSIONS: Tracheostomy care is a concerted effort between the patient, surgeon, primary physician, and interdisciplinary team. Otolaryngologists should strive to standardize tracheostomy discharge, education, and follow-up practices. SIGNIFICANCE: Disparities are highlighted between disciplines in their comfort, willingness, and knowledge of outpatient tracheostomy care. © 2007 American Academy of Otolaryngology–Head and Neck Surgery Foundation. All rights reserved.
T
he tracheotomy has a long and storied history in the practice of medicine and the field of otolaryngology. Before the nineteenth century only a very limited number of successful tracheotomies had been reported. It was not until the early twentieth century, that Chevalier Q. Jackson helped standardize and refine the procedure. The resultant decrease in mortality brought the procedure into the mainstream and
broadened its use. Today, the tracheotomy is a common procedure performed by the otolaryngologist; in 1999, there were over 83,000 tracheostomies placed in the United States.1 Tracheostomies are most commonly placed for purposes of mechanical ventilation in chronically ill patients.2 These patients often require long-term use of their tracheostomy either at home or in long-term care facilities where specialty care by the otolaryngologist is often not available. Consequently, these patients are often lost to follow-up by the operating surgeon. This raises the question of who provides the medical care and maintenance of these adult outpatient tracheostomies. It is presumed that much of this care falls to the primary care physician. Tracheostomies can require relatively intensive outpatient care and maintenance including routine care, tube changes, and troubleshooting. Much has been written in the literature, including physician surveys, with respect to the care, management, and education of pediatric tracheostomies,3-6 and to a lesser extent adult outpatient tracheostomies.7-15 Unfortunately, there is a relative paucity of literature with respect to the current practices of outpatient care of the adult tracheostomy from the physician’s perspective. The purpose of this study is to determine the attitudes, opinions, and current practice of adult outpatient tracheostomy care from both the surgeon and primary care physician’s perspective.
MATERIALS AND METHODS
A short, 10-question, discipline-specific survey approved by the University of Mississippi Medical Center InstituReprint requests: Justin M. Garner, MD, Department of Otolaryngology and Communicative Sciences, The University of Mississippi Medical Center, 2500 North State St, Jackson, MS 39216. E-mail address: [email protected].
From the Departments of Otolaryngology and Communicative Sciences (Drs Garner and Franzese) and Internal Medicine (Dr Shoemaker-Moyle), The University of Mississippi Medical Center, Jackson, Mississippi. Presented at the Southern Section Meeting of the Triological Society, Naples, FL, January 12-14, 2006.
0194-5998/$32.00 © 2007 American Academy of Otolaryngology–Head and Neck Surgery Foundation. All rights reserved. doi:10.1016/j.otohns.2006.08.023
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Otolaryngology–Head and Neck Surgery, Vol 136, No 2, February 2007 tively, were currently practicing. Otolaryngology and internist survey instruments and responses are seen in Appendix 1 and Appendix 2 (www.http://journal.entnet.org), respectively.
tional Review Board was sent to 1250 randomly selected general otolaryngologists and to 1400 randomly selected general internists in the United States. Surveys were sent to general internists and otolaryngologists in all 50 states, Puerto Rico, and the District of Columbia. The general otolaryngologist participant list was obtained from a randomly generated list drawn from the general otolaryngology subgroup of the American Academy of Otolaryngology and the Mississippi State Medical Association directories. The general internist participant list was obtained from the member directories of the Society of General Internal Medicine and the internal medicine subgroup of the Mississippi State Medical Association. Where available, email addresses were used preferentially over postal addresses to distribute an electronic version of the survey in order to increase efficiency and reduce survey costs. Only one survey response was allowed per survey participant. Surveys that were returned partially completed had their completed responses included in the results. Those surveys that were returned with multiple responses to a single response question had those questions excluded, with the correctly completed questions included. Given the categorical nature of the survey responses, we used the 2-test for the significance test of proportions to obtain P-values and to determine statistically significant differences (P Յ 0.05) between responses among different groups. SPSS version 13.0 (SPSS, Inc, Chicago, Ill) was used for statistical analyses. The surveys were created to determine the attitudes, experience, and current practices of these 2 different disciplines with respect to adult outpatient tracheostomy care. The general otolaryngology survey (Appendix 1, www.http://journal. entnet.org) focused on current practice type, types of tracheotomy performed, as well as their current protocol of tracheostomy patient discharge, education, and follow-up. The remainder of the survey focused on opinions of which medical professionals are qualified, and who should primarily provide outpatient tracheostomy follow-up. The general internist survey (Appendix 2, www.http://journal. entnet.org) focused on current practice type, practice experience with tracheostomy patients, amount of residency training that involved tracheostomy care, and tracheostomy knowledge. Other questions sought to ascertain their comfort level and likely management strategy for adult outpatient tracheostomy patients. The remainder of the survey focused on the internist’s opinion of which medical professionals are qualified and who should primarily provide outpatient tracheostomy follow-up.
Otolaryngologists
Single-specialty group practice (48.8%, 321 of 658) was the most commonly reported practice type among otolaryngologists, followed by solo practice (28%, 184 of 658), multispecialty group practice (12.9%, 85 of 658), and academics (10.3%, 68 of 658). All but one otolaryngologist reported performing tracheotomies either currently or in the past. All of these otolaryngologists reported using an open technique; 7.1% (47 of 665) also reported the routine use of the percutaneous technique with bronchoscopic guidance, whereas 3.6% (24 of 665) reported the routine use of the percutaneous technique without bronchoscopic guidance; 9.4% (63 of 667) of otolaryngologists reported using at least one form of percutaneous tracheotomy technique. Academic otolaryngologists (22.4%, 15 of 67) were significantly more likely (P ϭ 0.0002) to use percutaneous techniques than nonacademics (8.1%, 48 of 589). When questioned if they had a standardized protocol for discharge planning and education in new adult tracheostomy patients, just over half (52.9%, 350 of 662) responded yes, whereas the remaining 47.1% (312 of 662) had no standardized protocol. One-third (32.7%, 203 of 621) of respondents reported that general ward or floor nurses were primarily responsible for patient tracheostomy education before discharge, followed by the surgeon (24.8%, 154 of 621), respiratory therapist (18.8%, 117 of 621), specialty (tracheostomy) nurse (13%, 81 of 621), home health nurse (8.4%, 52 of 621), physician extenders (1.8%, 11 of 621), and other (0.5%, 3 of 621) (Fig 1). Academic otolaryngologists (20.6%, 14 of 68) were significantly more likely (P ϭ 0.025) to use the services of a tracheostomy nurse than other practice types (11.2%, 66 of 590).
RESULTS
Of the 1250 otolaryngology surveys, 667 responses were obtained for a 53.4% response rate. Of the 1400 general internist surveys, 404 were returned for a 28.9% response rate. Of the responding otolaryngologists and general internists, 97.1% (647 of 666) and 95% (384 of 404), respec-
Figure 1 Chart shows who primarily provides discharge tracheostomy education.
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When asked to characterize their outpatient care practices for adult tracheostomy patients after the initial tracheostomy change, 51.8% (340 of 656) of otolaryngologists reported performing all routine tracheostomy care and follow-up themselves. Another 39.9% (262 of 656) expected to jointly follow their patients with the primary care provider or pulmonologist; 5.8% (38 of 656) referred all tracheostomy care and follow-up to the pulmonologist, whereas 2.4% (16 of 656) referred this care to the primary care physician. When asked if they felt that primary care physicians in general were qualified or competent to provide routine tracheostomy care and follow-up, over three-quarters (75.9%, 503 of 663) responded no. Otolaryngologists were then asked their opinion of whether five different health care providers were qualified to provide routine tracheostomy follow-up (Fig 2). Most (97.3%, 644 of 662) respondents felt surgeons (general surgeons and otolaryngologists) were qualified, followed by pulmonologists (69.9%, 463 of 662), respiratory therapists (66.2%, 438 of 662), home health nurses (55.6%, 368 of 662), primary care providers (26.6%, 176 of 662), with 4.8% (32 of 662) responding other. When asked who should primarily provide routine tracheostomy follow-up (Fig 3), nearly two thirds (64%, 357 of 558) responded the surgeon, followed by the home health nurse (19%, 106 of 558), respiratory therapist (5.7%, 32 of 558), primary care provider (5.6%, 31 of 558), pulmonologist (4.8%, 27 of 558), and other (0.9%, 5 of 558). Otolaryngologists were significantly more likely than internists (P Ͻ 0.0001) to believe the surgeon is primarily responsible.
Figure 3 Chart shows which provider should primarily provide routine tracheostomy care and follow-up.
Internists
General internist respondents differed in their practice type compared with otolaryngology respondents. The majority (77.7%, 310 of 399) characterized their current practice as academic, with single-specialty group practice (9%, 36 of 399), multi-specialty group practice (8.3%, 33 of 399), and solo practice (5%, 20 of 399) less common. Nearly two thirds (64.7%, 260 of 402) reported caring for adult patients
Figure 2 Chart shows which providers are felt to be qualified to perform routine tracheostomy care and follow-up.
with a tracheostomy in their outpatient practices either currently or in the past. With respect to their residency training and current knowledge of routine tracheostomy care and follow-up, the majority (62.1%, 251 of 404) reported receiving no training in tracheostomy care and follow-up during their residency, whereas 35.1% (142 of 404) received a small amount, 2.7% (11 of 404) a moderate amount; none of them reported receiving a large amount. Academic internists (34.8%, 108 of 310) were significantly less likely (P ϭ 0.021) to have received residency training in tracheostomy care than their nonacademic counterparts (48.3%, 43 of 89). The vast majority of internists as a whole (84.7%, 342 of 404) reported that they did not know how to perform a routine tracheostomy change. Academic internists (11.9%, 37 of 310) were significantly less likely (P ϭ 0.0002) than nonacademics (28.1%, 25 of 89) to know how to do this. Even a larger majority of internists (92%, 370 of 402) did not know how often a tracheostomy tube should be changed. When asked about their comfort level for providing routine tracheostomy care and follow-up for adult tracheostomy patients, the majority of internists (59.6%, 236 of 396) felt very uncomfortable and would refer all their patients to a surgeon for routine tracheostomy care. Another 30.8% (122 of 396) felt somewhat uncomfortable and frequently referred these patients to the surgeon for care, whereas even fewer (8.3%, 33 of 396) felt somewhat comfortable and would perform some tracheostomy care but would often refer the care to the surgeon. Only 1.3% (5 of 396) felt very comfortable and performed all routine tracheostomy care with minimal to no referrals to the surgeon. Among internists who had received at least a small amount of residency training in tracheostomy care, there was significantly more comfort (22.0%, 33 of 150 vs 2.0%, 5 of 246, P Ͻ 0.0001) with caring for tracheostomies than those who had not received any tracheostomy education during residency (Fig 4). When given the scenario of seeing a new adult in their practice who was recently discharged from the hospital with a newly placed tracheostomy, 47.5% (187 of 394) stated
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Otolaryngology–Head and Neck Surgery, Vol 136, No 2, February 2007 agement of historically inpatient illnesses and treatments. This has resulted in more adult tracheostomy patients being managed on an outpatient basis or in subacute and longterm facilities rather than the traditional acute care facility. With this trend comes the need for outpatient tracheostomy care and follow-up. The multidisciplinary approach to the outpatient tracheostomy patient has been discussed widely.12-14 Although the use of percutaneous techniques has increased over the last decade, with a correspondingly broader range of practitioners performing the procedure,12 the otolaryngologist is often regarded as the tracheostomy and airway expert. For this reason, the otolaryngologist is often called on to provide routine tracheostomy care and follow-up for these patients. However, given the multiple comorbidities and medical issues that many of these patients entail, the general internist is often the most intimately involved in their care. The current survey aimed to determine the current attitudes, opinions, and practices of adult outpatient tracheostomy care from both the surgeon’s and physician’s perspective. It is evident from the survey results that otolaryngologists as a whole have been slow to adopt forms of percutaneous tracheotomy technique. Academic otolaryngologists are significantly more likely (P ϭ 0.0002) to use percutaneous techniques than nonacademics. Some progress seems to have been made in the standardization of discharge protocols and education for tracheostomy patients, but nearly half of otolaryngologists reported that they did not have this system in place. General ward nurses were most commonly responsible for tracheostomy education before discharge for these patients; this implies that these nurses are competent with tracheostomies themselves, and if not, discharge education for these patients is inadequate. Interestingly, only 13% have the services of a specialty tracheostomy nurse (Fig 1). Academic otolaryngologists were significantly more likely (P ϭ 0.025) to use the services of a tracheostomy nurse than other practice types, which is not surprising given that they likely are more frequently available in this setting. Internist respondents tended to have more academic practices compared with otolaryngologists, and interesting significant differences between academic and their nonacademic counterparts are noted. Although nearly two thirds of internists reported having cared for adult tracheostomy patients in the outpatient setting, 97% had little to no tracheostomy care training during their residency. Few reported knowing how and how often to change the tracheostomy tube. Nearly 90% of internists felt uncomfortable providing tracheostomy care and follow-up, with only 2% willing to provide all routine tracheostomy care for their patients. Interestingly, among internists who had received at least a small amount of residency training in tracheostomy care, there was significantly more comfort (P Ͻ 0.0001) and willingness (P Ͻ 0.0001) to care for tracheostomies than those who had not received any tracheostomy education during residency (Fig 4). Sentiment among otolaryngolo-
Figure 4 Chart shows internist tracheostomy care comfort level vs amount of residency training.
they would refer all tracheostomy care and follow-up to the surgeon. Another 38.6% (152 of 394) would refer to a surgeon and perform tracheostomy care only if the patient was unable to see the surgeon in a timely fashion, whereas 11.7% (46 of 394) would perform some tracheostomy care and follow-up but refer to the surgeon for recommendations and care for any minor or major problems. Only 2.3% (9 of 394) would perform all routine tracheostomy care and follow-up and refer to the surgeon only for emergencies or complicated problems. Internists who had received at least a small amount of residency training in tracheostomy care were significantly more willing (24.3%, 36 of 148 vs 7.7%, 19 of 246, P Ͻ 0.0001) to care for tracheostomies than those who had not received any tracheostomy education during residency. Internists were then asked their opinion of whether five different health care providers were qualified to provide routine tracheostomy follow-up (Fig 2). Most (96.8%, 382 of 396) felt surgeons were qualified, followed by respiratory therapists (88.9%, 352 of 396), pulmonologists (84.8%, 336 of 396), home health nurses (60.4%, 239 of 396), primary care providers (43.4%, 172 of 396), and 5.3% (21 of 396) responding other. Internists were significantly more likely (P Ͻ 0.0001) than otolaryngologists to feel primary care physicians are qualified. When asked who should primarily provide tracheostomy follow-up (Fig 3), 35.4% (109 of 308) responded the surgeon, followed by the respiratory therapist (24.4%, 75 of 308), home health nurse (16.9%, 52 of 308), primary care provider (13.3%, 41 of 308), pulmonologist (7.1%, 22 of 308), and other (2.9%, 9 of 308).
DISCUSSION
The placement of a tracheostomy is a very important event in the doctor-patient relationship that requires long-term care and management by both the patient and the broader health care system. With the increase in the number of tracheostomy patients and the advent of home and longterm ventilation, more patients are being discharged with tracheostomies because of the push toward outpatient man-
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gists was similar with less than one fourth of respondents believing primary care physicians were qualified and competent to perform routine tracheostomy care and follow-up. Even so, only about half of otolaryngologists report they perform all tracheostomy care and follow-up on their patients. Another 40% expect to jointly provide this care; nearly one tenth refer all tracheostomy care to either the primary care physician or pulmonologist. Both internists and otolaryngologists most frequently felt that the surgeon was qualified to perform outpatient tracheostomy care and follow-up. Pulmonologists and respiratory therapists were the next most commonly reported qualified professionals. For any given care professional, internists were more likely than otolaryngologists to feel they were qualified to provide outpatient tracheostomy care and follow-up (Fig 2). In fact, internists were significantly more likely (P Ͻ 0.0001) than otolaryngologists to feel primary care physicians are qualified. Both internists and otolaryngologists were most likely to list the surgeon as primarily responsible for this care (Fig 3), with otolaryngologists significantly more likely (P Ͻ 0.0001) to believe this. Interestingly, only about one third of internists felt the surgeon was primarily responsible for this care. Internists were significantly more likely than otolaryngologists (P Ͻ 0.0001) to list respiratory therapists as primarily responsible for outpatient tracheostomy care and follow-up, which is likely due to their exposure to this function of the respiratory therapist in the acute inpatient setting. Interestingly, otolaryngologists listed pulmonologists least frequently as being primarily responsible for tracheostomy care, even though they listed them most frequently, second only to the surgeon, as being qualified to perform this care. Although academic internists were just as likely as nonacademics to have cared for patients with tracheostomies, interestingly, they were significantly less likely (P ϭ 0.021) to have received residency training in tracheostomy care than their nonacademic counterparts. Academic internists were also less likely (P ϭ 0.0002) than nonacademics to know how to change a tracheostomy. This raises the question of academic internists’ ability to educate trainees in tracheostomy care and follow-up, and even more importantly, whether there is an obligation of the otolaryngologist to provide this education. Surveys have both sampling and nonsampling error potential. Potential sampling error in our study could be from our responders not representing the intended population. Although our response rates for otolaryngologists and internists were relatively good at 53% and 29%, respectively, these responders could potentially not represent otolaryngologists and internists as a whole. This is particularly true of our internist respondents who were primarily academics, although this allowed us to make interesting comparisons between academic and nonacademic internists. Nonsampling error may have been introduced into the study due to questionnaire definitions or instructions that were inadequate or ambiguous and resulted in questions being inappropriately or incompletely answered. Recall bias can affect
survey responses; however, we feel that this was minimized in our survey given that 97% and 95% of the responding otolaryngologists and internists, respectively, were currently practicing. Although survey error can be introduced by respondents reporting one thing but doing another, we feel this was minimized due to the confidentiality, anonymity, and straightforward nature of the survey.
CONCLUSION
In conclusion, adult patients with tracheostomies can often be complex patients who require the expertise of not only the surgeon and internist, but many other health care professionals. The routine care and maintenance of tracheostomies should be a concerted effort between the patient, surgeon, primary physician, and interdisciplinary team. In particular, those physicians and surgeons who are performing tracheotomies should be adept not only with the procedure, but also with their outpatient care, maintenance, and troubleshooting.12 One pitfall to avoid in the care of these patients is the lack of communication among team members about the patient’s status, goals, and types of care provided by different care team members.13 Communication and planning is paramount, and tracheostomy knowledge, care, and follow-up should not be assumed of any health professional. A more concerted effort should be undertaken by the specialty of otolaryngology to standardize tracheostomy patient discharge and education. Tracheostomy care manuals such as the one by Levine and Miller15 can be very helpful for the education of these patients, their caregivers, as well as other physicians and health care professionals. As primary care physicians, general internists should be familiar with the routine care and maintenance of tracheostomies as evidenced by the majority of respondents who have cared for outpatient tracheostomy patients. As echoed by many internists’ survey comments, tracheostomy education should be considered for inclusion in the curriculum of a medical residency, and this education will inevitably fall on the shoulders of the specialty of otolaryngology as the tracheostomy and airway experts.
REFERENCES
1. Popovic JR. 1999 National Hospital Discharge Summary: annual summary with detailed diagnosis and procedure data. National Center for Health Statistics. Vital Health Stat 2001;13(151):168. (Grade C). 2. Yaremchuk K. Regular tracheostomy tube changes to prevent formation of granulation tissue. Laryngoscope 2003;113(1):1–10. (Grade B). 3. Turnage CS, Engleman S. Discharge education for parents of infants with tracheostomies. J Pediatr Nurs 1994;9(6):425– 6. (Grade D). 4. Hotaling AJ, Zablocki H, Madgy DN. Pediatric tracheotomy discharge teaching: a comprehensive checklist format. Int J Pediatr Otorhinolaryngol 1995;33(2):113–26. (Grade D). 5. Senders CW, Muntz HR, Schweiss D. Physician survey on the care of children with tracheotomy. Am J Otolaryngol 1991;12(1):48 –50. (Grade C).
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11. Minsley MA, Wrenn S. Long-term care of the tracheostomy patient from an outpatient nursing perspective. ORL Head Neck Nurs 1996; 14(4):18 –22. (Grade D). 12. Wright SE, VanDahm K. Long-term care of the tracheostomy patient. Clin Chest Med 2003;24:473– 87. (Grade D). 13. Nace DA, Fox A. Long-term care of tracheostomy patients. In: Myers EN, Johnson J, Murry T, eds. Tracheotomy: airway management, communication, and swallowing. San Diego, CA: Singular Publishing Group; 1998. p. 67–74. (Grade D). 14. Diehl BC, Dorsey LK, Koller C. Transitioning the client with a tracheostomy from acute care to alternative settings. In: Tippet DC, ed. Tracheostomy and ventilator dependency: management of breathing, speaking, and swallowing. New York, NY: Thieme; 2000. p. 237-66. (Grade D). 15. Levine H, Miller C. Tracheostomy care manual, 2nd ed. New York, NY: Thieme; 1988. (Grade D).
6. Woolley AL, Muntz HR, Prater D. Physician survey on the care of children with tracheotomies. Am J Otolaryngol 1996;17(1):50 –3. (Grade C). 7. Kopacz MA, Moriarty-Wright R. Multidisciplinary approach for the patient on a home ventilator. Heart Lung 1984;13(3):255– 62. (Grade D). 8. Votava KM, Cleveland T, Hiltunen K. Home care of the patient dependent on mechanical ventilation: home care policy development and goal setting using outcome criteria for quality assurance. Home Healthc Nurse 1985;3(2):18 –25. (Grade D). 9. Wilson EB, Malley N. Discharge planning for the patient with a new tracheostomy. Crit Care Nurse 1990;10(7):73–9. (Grade D). 10. Sevick MA, Erlen JA, van Muiswinkel J, et al. Health care professionals’ characterizations of the system of care for long-term ventilator-dependent patients: a preliminary study. J Health Soc Policy 1994; 6(2):51–70. (Grade D).
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APPENDIX 1
Adult outpatient tracheostomy care survey: Surgeon
Otolaryngology Survey 1. Do you currently practice otolaryngology? (select one) 97.1% (647 of 666) Yes 2.9% (19 of 666) No 2. What best describes your current practice type? (select one) 48.8% (321 of 658) Group practice (single-specialty) 28.0% (184 of 658) Solo practice 12.9% (85 of 658) Group practice (multi-specialty) 10.3% (68 of 658) Academic 3. Do you currently or have you ever performed tracheotomies on adult patients? (select one) 99.99% (665 of 666) Yes 0.01% (1 of 666) No 4. What type of tracheotomy do you routinely perform, or have you ever routinely performed? (select all that apply) 100% (665 of 665) Standard open tracheotomy 7.1% (47 of 665) Percutaneous tracheotomy with bronchoscopic guidance 3.6% (24 of 665) Percutaneous tracheotomy without bronchoscopic guidance 5. Do you have a standardized protocol for discharge planning and education in new adult tracheostomy patients? (select one) 52.9% (350 of 662) Yes 47.1% (312 of 662) No 6. In your practice, who is primarily responsible for tracheostomy education for adult patients with a new tracheostomy at the time of their discharge? (select one) 32.7% (203 of 621) General ward or floor nurse 24.8% (154 of 621) Physician or surgeon 18.8% (117 of 621) Respiratory therapist 13.0% (81 of 621) Specialty nurse (ie, tracheostomy nurse) 8.4% (52 of 621) Home health nurse 1.8% (11 of 621) Physician extender (ie, physician assistant or nurse practitioner) 0.5% (3 of 621) Other 7. Which of the following best describes your outpatient care practices for adult tracheostomy patients following initial inpatient discharge and after the initial tracheostomy change? (select one) 51.8% (340 of 656) I perform all routine tracheostomy care and follow-up for my adult tracheostomy patients. 39.9% (262 of 656) I follow my adult tracheostomy patients and expect to jointly perform routine outpatient tracheostomy care and follow-up with their primary care provider of internist or pulmonologist. 5.8% (38 of 656) I refer all my adult tracheostomy patients to a pulmonologist for their routine tracheostomy care and follow-up. 2.4% (16 of 656) I refer all my adult tracheostomy patients to their primary care provider of internist for all routine tracheostomy care and follow-up. 8. In your general opinion, is a primary care physician qualified or competent to perform routine tracheostomy care and follow-up for adult outpatients? (select one) 24.1% (160 of 663) Yes 75.9% (503 of 663) No 9. Who do you feel is qualified to provide routine tracheostomy follow-up? (select all that apply) 97.3% (644 of 662) Surgeon (general surgeon, otolaryngologist) 69.9% (463 of 662) Pulmonologist 66.2% (438 of 662) Respiratory therapist 55.6% (368 of 662) Home health nurse 26.6% (176 of 662) Primary care provider (general internist, family practitioner) 4.8% (32 of 662) Other 10. Who do you feel should primarily provide routine tracheostomy follow-up? (select one) 64.0% (357 of 558) Surgeon (general surgeon, otolaryngologist) 19.0% (106 of 558) Home health nurse
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Appendix 1 (Continued)
Otolaryngology Survey 5.7% 5.6% 4.8% 0.9% (32 of 558) Respiratory therapist (31 of 558) Primary care provider (general internist, family practitioner) (27 of 558) Pulmonologist (5 of 558) Other
APPENDIX 2
Adult outpatient tracheostomy care survery: Internist
Internist Survey 1. Do you currently practice general internal medicine? (select one) 95.0% (384 of 404) Yes 5.0% (20 of 404) No 2. What best describes your current practice type? (select one) 77.7% (310 of 399) Academic 9.0% (36 of 399) Group practice (single-specialty) 8.3% (33 of 399) Group practice (multi-specialty) 5.0% (20 of 399) Solo practice 3. Do you currently or have you ever cared for adult patients with tracheostomies in your outpatient practice? (select one) 64.7% (260 of 402) Yes 35.3% (142 of 402) No 4. Did you receive any training during your residency in internal medicine regarding routine tracheostomy care and follow-up for adult tracheostomy patients? (select one) 62.1% (251 of 404) None at all 35.1% (142 of 404) Yes, a small amount 2.7% (11 of 404) Yes, a moderate amount 0.0% (0 of 404) Yes, a large amount 5. Do you know how to perform a routine tracheostomy change in an adult patient? (select one) 15.3% (62 of 404) Yes 84.7% (342 of 404) No 6. Do you know how often to perform a routine tracheostomy change in an adult patient? (select one) 8.0% (32 of 402) Yes 92.0% (370 of 402) No 7. Do you feel comfortable performing routine tracheostomy care and following adult tracheostomy patients? (select one choice that best describes your practice) 59.6% (236 of 396) I feel very uncomfortable and perform no tracheostomy care. I refer all my tracheostomy patients to a surgeon for evaluation and follow-up of routine tracheostomy care. 30.8% (122 of 396) I feel somewhat uncomfortable and perform very little routine tracheostomy care of follow up. I frequently refer these patients to a surgeon for their tracheostomy care of follow-up. 8.3% (33 of 396) I feel somewhat comfortable and will perform some routine tracheostomy care of followup, but often refer these patients to a surgeon who performs tracheotomy. 1.3% (5 of 396) I feel very comfortable and perform all routine tracheostomy care with minimal or no referrals to a surgeon who performs tracheotomy. 8. If you were to see a new adult outpatient in your practice who was recently discharged from the hospital with a newly placed tracheostomy, which of the following best describes your management strategy? (select one) 47.5% (187 of 394) I would refer to a surgeon, and refer all tracheostomy care and follow-up to that surgeon. 38.6% (152 of 394) I would refer to a surgeon for most tracheostomy care of follow-up, and perform tracheostomy care only if the patient was unable to see the surgeon in a timely fashion. 11.7% (46 of 394) I would perform some tracheostomy care of follow-up, but would refer to a surgeon for recommendations and follow-up care for minor or major problems. 2.3% (9 of 394) I would perform all routine tracheostomy care of follow-up and refer to a surgeon only in emergencies or complicated problems. 9. Who do you feel is qualified to provide routine tracheostomy follow-up? (select all that apply)
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Appendix 2 (Continued)
Internist Survey 96.8% (382 of 396) Surgeon (general surgeon, otolaryngologist) 88.9% (352 of 396) Respiratory therapist 84.8% (336 of 396) Pulmonologist 60.4% (239 of 396) Home health nurse 43.4% (172 of 396) Primary care provider (general internist, family practitioner) 5.3% (21 of 396) Other 10. Who do you feel should primarily provide routine tracheostomy follow-up? (select one) 35.4% (109 of 308) Surgeon (general surgeon, otolaryngologist) 24.4% (75 of 308) Respiratory therapist 16.9% (52 of 308) Home health nurse 13.3% (41 of 308) Primary care provider (general internist, family practitioner) 7.1% (22 of 308) Pulmonologist 2.9% (9 of 308) Other
