Sedatives, analgesics and antipsychotics in tracheostomised ICU patients - Is less more?

Tracheostomy clinical practices and patient outcomes in three tertiary metropolitan hospitals in Australia

BACKGROUND

There is a paucity of literature in Australia on patient-focused tracheostomy outcomes and process outcomes. Exploration of processes of care enables teams to identify and address existing barriers that may prevent earlier therapeutic interventions that could improve patient outcomes following critical care survival.

OBJECTIVES

The objectives of this study were to examine and provide baseline data and associations between tracheostomy clinical practices and patient outcomes across three large metropolitan hospitals.

METHODS

We performed a retrospective multisite observational study in three tertiary metropolitan Australian health services who are members of the Global Tracheostomy Collaborative. Deidentified data were entered into the Global Tracheostomy Collaborative database from Jan 2016 to Dec 2019. Descriptive statistics were used for the reported outcomes of length of stay, mortality, tracheostomy-related adverse events and complications, tracheostomy insertion, airway, mechanical ventilation, communication, swallowing, nutrition, length of cannulation, and decannulation. Pearson's correlation coefficient and one-way analyses of variance were performed to examine associations between variables.

RESULTS

The total cohort was 380 patients. The in-hospital mortality of the study cohort was 13%. Overall median hospital length of stay was 46 days (interquartile range: 31-74). Length of cannulation was shorter in patients who did not experience any tracheostomy-related adverse events (p= 0.036) and who utilised nonverbal communication methods (p = 0.041). Few patients (8%) utilised verbal communication methods while mechanically ventilated, compared with 80% who utilised a one-way speaking valve while off the ventilator. Oral intake was commenced in 20% of patients prior to decannulation. Patient nutritional intake varied prior to and at the time of decannulation. Decannulation occurred in 83% of patients.

CONCLUSIONS

This study provides baseline data for tracheostomy outcomes across three large metropolitan Australian hospitals. Most outcomes were comparable with previous international and local studies. Future research is warranted to explore the impact of earlier nonverbal communication and interventions targeting the reduction in tracheostomy-related adverse events.

Communication Success and Speaking Valve Use in Intensive Care Patients Receiving Mechanical Ventilation

BACKGROUND

Communication with patients receiving mechanical ventilation in an intensive care unit can be challenging. Once a patient is tracheostomized, a speaking valve may enable restoration of verbal communication. To date, no data are available on the effect of speaking valves on communication success in intensive care units.

OBJECTIVE

The aim of this prospective cohort study was to measure communication success before and during speaking valve use for intensive care patients being weaned from mechanical ventilation, from both the nurses' and the patients' perspectives.

METHODS

In a prospective cohort study, consecutive eligible patients and their nurses were asked to complete newly developed questionnaires on communication success before and while patients used a speaking valve (6 questions for patients, 5 questions for nurses, answers on a 10-point scale with 10 the best score). The Wilcoxon signed rank test was used to analyze score differences.

RESULTS

For all questionnaire items, both patients (n = 25) and nursing staff (n = 52) reported significantly higher communication success during speaking valve use. Nurses understood moderately well that their patients were in pain (median [IQR], 5.8 [4.7-7.4]) even before speaking valve use. Most patients found it challenging to say something quickly even while using a speaking valve (6.9 [5.7-10.0]). Overall, speaking valve use markedly increased communication success.

CONCLUSION

A speaking valve should be considered for patients with a tracheostomy as soon as possible to improve their communication success.