An interprofessional team approach to tracheostomy care: A mixed-method investigation into the mechanisms explaining tracheostomy team effectiveness

Optimizing infection control and antimicrobial stewardship bedside discussion: a scoping review of existing evidence on effective healthcare communication in hospitals

BACKGROUND

The link between healthcare worker (HCW) communication, teamwork and patient safety is well-established. Infection prevention and control (IPC) and antimicrobial stewardship (AMS) require multidisciplinary teamwork and communication.

OBJECTIVES

We conducted a scoping review of published evidence on effective mechanisms of HCW team communication in hospitals with the intention of transferring and tailoring learning to IPC and AMS team communication.

METHODS

PubMed, Scopus, Web of Science, and CINAHL were searched for studies that investigated HCW team communication across in-hospital patient pathways. Studies published between 2000 and 2021 that provided evidence on/or described the effect of communication on team and patient outcomes in hospital were included. Through a process of inductive qualitative content analysis, key themes in the included studies were identified.

RESULTS

Of 537 studies identified, 53 (from high-income countries) were included in the data extraction. Fifty one percent (27/53) of studies were conducted in high acuity settings e.g., intensive care units. Standardizing or structuring the content and/or process of team communication was the most common goal of interventions (34/53, 64%). The key outcome measures were either team communication focused (25/34,74%) or patient and process outcome focused (8/34, 24%), such as reduced length of mechanical ventilation days, length of hospital stay, and shorter empiric antibiotic duration. Four studies (4/53, 8%) associated improved communication with positive IPC and AMS outcome measures. Mixed method intervention studies primarily facilitated collaborative input from HCWs and applied structures to standardize the content of patient care discussions, whereas observational studies describe component of team communication.

CONCLUSIONS

A communication strategy that formalizes input from multidisciplinary team members can lead to optimized and consistent clinical discussion including in IPC and AMS-related care. Although we were unable to assess the effectiveness of interventions, the existing evidence suggests that optimizing team communication can have a positive effect on infection-related patient outcomes.

Interprofessional clinical decision-making process in health: A scoping review

AIMS

To describe the key elements of the interprofessional decision-making process in health, based on published scientific studies. To describe the authors, reviews and subject matter of those publications.

DESIGN

Scoping review of the literature.

DATA SOURCES

MEDLINE, APA Psycinfo OpenGrey, Lissa and Cochrane databases were searched in December 2019 and January 2023.

REVIEW METHODS

References were considered eligible if they (i) were written in French or English, (ii) concerned health, (iii) studied a clinical decision-making process, (iv) were performed in an interprofessional context. 'PRISMA-scoping review' guidelines were respected. The eligible studies were analysed and classified by an inductive approach RESULTS: We identified 1429 sources of information, 145 of which were retained for the analysis. Based on these studies, we identified five key elements of interprofessional decision-making in health. The process was found to be influenced by group dynamics, the available information and consideration of the unique characteristics of the patient. An organizational framework and specific training favoured improvements in the process.

CONCLUSION

Decision-making can be based on a willingness of the healthcare organization to promote models based on more shared leadership and to work on professional roles and values. It also requires healthcare professionals trained in the entire continuum of collaborative practices, to meet the unique needs of each patient. Finally, it appears essential to favour the sharing of multiple sources of accessible and structured information. Tools for knowledge formalization should help to optimize interprofessional decision-making in health.

IMPACT

The quality of a team decision-making is critical to the quality of care. Interprofessional decision-making can be structured and improved through different levels of action. These improvements could benefit to patients and healthcare professionals in every settings of care involving care collaboration.

IMPACT STATEMENT

Interprofessional decision-making in health is an essential lever of quality of care, especially for the most complex patients which are a contemporary challenge. This scoping review article offers a synthesis of a large corpus of data published to date about the interprofessional clinical decision-making process in healthcare. It has the potential to provide a global vision, practical data and a list of references to facilitate the work of healthcare teams, organizations and teachers ready to initiate a change.

Providing care for children with tracheostomies: a qualitative interview study with parents and health professionals

OBJECTIVES

To explore the experience of caring for children with tracheostomies from the perspectives of parents and health professional caregivers.

DESIGN

Qualitative semistructured interview study.

SETTING

One region in England covered by a tertiary care centre that includes urban and remote rural areas and has a high level of deprivation.

PARTICIPANTS

A purposive sample of health professionals and parents who care for children who have, or have had, tracheostomies and who received care at the tertiary care centre.

INTERVENTION

Interviews undertaken by telephone or video link.

PRIMARY AND SECONDARY OUTCOME MEASURES

Qualitative reflexive thematic analysis with QSR Nvivo 12.

RESULTS

This paper outlines key determinants and mediators of the experiences of caregiving and the impact on psychological and physical health and quality of life of parents and their families, confidence of healthcare providers and perceived quality of care. For parents, access to care packages and respite care at home as well as communication and relationships with healthcare providers are key mediators of their experience of caregiving, whereas for health professionals, an essential influence is multidisciplinary team working and support. We also highlight a range of challenges focused on the shared care space, including: a lack of standardisation in access to different support teams, care packages and respite care, irregular training and updates, and differences in health provider expertise and experiences across departments and shift patterns, exacerbated in some settings by limited contact with children with tracheostomies.

CONCLUSIONS

Understanding the experiences of caregiving can help inform measures to support caregivers and improve quality standards. Our findings suggest there is a need to facilitate further standardisation of care and support available for parent caregivers and that this may be transferable to other regions. Potential solutions to be explored could include the development of a paediatric tracheostomy service specification, increasing use of paediatric tracheostomy specialist nurse roles, and addressing the emotional and psychological support needs of caregivers.

Speech and language therapy service provision in spinal injury units compared to major trauma centres in England: Are services matched?

BACKGROUND

National UK guidance makes recommendations for speech and language therapy staffing levels in critical care and rehabilitation settings. Traumatic spinal cord injury patients often require admission primarily to critical care services within a major trauma centre prior to transfer to a specialist spinal injury unit but may not receive similar levels of care. Dysphagia and communication difficulties are recognised features of cervical spinal cord injury; however, little is known about access to speech and language therapy services to provide rehabilitation and improve outcomes.

AIMS

The aim of this study was to compare the workforce and clinical practices of speech and language therapy services in eight spinal injury units and four major trauma centres in England through an online survey.

METHODS & PROCEDURES

An online survey was created with 26 multiple-choice questions across seven sub-sections, with options for free-text comments. These were sent to a named speech and language therapy contact at each of the specified units. Responses were uploaded into Excel for analyses, which included descriptive statistics and analysis of themes.

OUTCOMES & RESULTS

Responses were received from 92% (11/12) speech and language therapy services invited, which included seven out of eight spinal injury units and all four major trauma centres. No units met national staffing recommendations. Staff in spinal injury units provided an average of 27 h per week input to the unit compared to 80 h in a major trauma centre. Despite caseload variations, speech and language range of therapy involvement and prioritisation process were equivalent. Access to instrumental assessment varied, with less use of Fibreoptic Endoscopic Evaluation of Swallowing in spinal injury units despite its clinical value to the spinal cord injury caseload.

CONCLUSIONS & IMPLICATIONS

Speech and language therapy services delivering post-acute and long-term rehabilitation to spinal cord injury patients are limited by their resources and capacity, which restricts the level of therapy delivered to patients. This may have an impact on clinical outcomes for communication and swallowing impairments. Further evidence is needed of the interventions delivered by speech and language therapists and outcomes will be beneficial alongside benchmarking similar services.

WHAT THIS PAPER ADDS

What is already known on this subject In England, people who sustain a spinal cord injury are admitted to a major trauma centre prior to transfer to a specialist spinal injury unit. Dysphagia and communication impairments are recognised as a complication of cervical spinal cord injury and benefit from speech and language therapy intervention. National recommendations exist for staffing levels, expertise and competencies for speech and language therapists working in critical care and rehabilitation units. What this study adds This study identified variations in the levels of speech and language therapy staffing, seniority, service delivery and access to instrumental assessments for dysphagia between major trauma centres and spinal injury units. None of the services complied with national staffing recommendations. Clinical implications of this study Speech and language therapy services in spinal injury units are often available part-time or have limited access to diagnostic tools which limits the range and intensity of rehabilitation input available. This has clinical implications for outcomes for swallowing and communication as well as long-term consequences for integrating back into community.

Speech and language therapists' management of ventilated patients and patients with tracheostomy in Israel

BACKGROUND

There is increased involvement of speech and language therapists (SLTs) in critical care and long-term units supporting patients with ventilatory needs and complex dysphagia. SLTs have a range of specialist knowledge in the function of the pharynx and larynx to enable them to support therapeutic interventions and contribute to the management of those patients. In Israel, there are currently no designated courses or training programmes for SLTs to establish advanced clinical skills in tracheostomy and ventilator management. There are currently standards of care for SLT working in designated wards for ventilated patients, however not in acute wards, critical care, and internal medicine wards where ventilated patients can be hospitalized.

AIMS

To identify the skills and expertise of the Israeli SLT workforce working with tracheostomy patients. Specifically, to identify their level of training, access to training, client population, work settings, and level of work confidence.

METHODS

The study involved electronic distribution of a 55-item online survey to SLTs in Israel. The questions included demographic information, training, confidence, and clinical support.

RESULTS

Responses were received from 47 SLTs. The majority (40.4%) spent between 1% and 9% of their clinical time with ventilated patients. Almost 80% work with seniors (≥65 years) and almost 70% work with adults (18-65 years) half the time or more. In inpatient rehabilitation, 46.8% reported that they manage patients with tracheostomy half the time or more. In outpatient rehabilitation settings, 21.3% reported that they manage patients with tracheostomy half the time or more. Prior to managing complex airway patients independently, 55.3% received less than 5 h formal tracheostomy training whilst 68.1% received less than 5 h training on ventilated patients. Multidisciplinary teams (MDTs) existed for tracheostomy patients (85.1%) and ventilated patients (70.2%) and high levels of confidence were reported for managing patients with tracheostomies (mode of 4 in a scale of 0-5, where 5 means fully confident) and ventilated patients (mode of 3 in a scale of 0-5). A significant relationship was found between level of confidence and presence of an MDT.

CONCLUSIONS

Limited training access was found for SLTs working with this complex population. A competency framework needs to be established with access to training and supervision. MDT existence contributes to confidence. Most respondents worked in rehabilitation settings, and very few worked in acute care, critical care, and internal medicine wards. It seems reasonable that in order to change this, minimal standards of care should be established on these wards.

WHAT THIS PAPER ADDS

What is already known on the subject Speech and language therapists (SLTs) have an important role in critical care and long-term units supporting patients with complex dysphagia and undergo formal training and supervision in UK and Australia. What this paper adds to existing knowledge In Israel, most SLTs work with tracheostomy and ventilated adult patients in rehabilitation settings, whilst few work in acute, critical care, and internal medicine wards. There are limited opportunities for formal training and supervision, although MDT support enhances clinical confidence. What are the potential or actual clinical implications of this work? SLTs in Israel would benefit from establishing a competency framework for tracheostomy and ventilator patient management to support training, standards of care, and increase clinical involvement in acute settings. This will enhance clinical outcomes for their large population of complex airway patients.

Tracheostomy management by speech-language pathologists in Sweden

Purpose: Speech-language pathologists' (SLPs) role in tracheostomy management is well described internationally. Surveys from Australia and the United Kingdom show high clinical consistency in SLP tracheostomy management, and that practice follows guidelines, research evidence and protocols. Swedish SLPs work with tracheostomised patients, however, the content and extent of this practice, and how it compares to international research is unknown. This study reports how SLPs in Sweden work with tracheostomised patients, investigating (a) the differences and similarities in SLPs tracheostomy management and (b) the facilitators and barriers to tracheostomy management, as reported by SLPs.Methods: A study-specific, online questionnaire was completed by 28 SLPs who had managed tracheostomised patients during the previous year. This study was conducted in 2018, pre Covid-19 pandemic. The answers were analysed for exploratory descriptive comparison of data. Content analyses were made on answers from open-ended questions.Results: Swedish SLPs manage tracheostomised patients, both for dysphagia and communication. During this study, the use of protocols and guidelines were limited and SLPs were often not part of a tracheostomy team. Speech-language pathologists reported that the biggest challenges in tracheostomy management were in (a) collaboration with other professionals, (b) unclear roles and (c) self-perceived inexperience. Improved collaboration with other professionals and clearer roles was suggested to facilitate team tracheostomy management.Conclusions: This study provides insight into SLP tracheostomy management in Sweden, previously uncharted. Results suggest improved collaboration, further education and clinical training as beneficial for a clearer and more involved SLP role in tracheostomy management.

The Trach Trail: A Systems-Based Pathway to Improve Quality of Tracheostomy Care and Interdisciplinary Collaboration

OBJECTIVE

To implement a standardized tracheostomy pathway that reduces length of stay through tracheostomy education, coordinated care protocols, and tracking patient outcomes.

METHODS

The project design involved retrospective analysis of a baseline state, followed by a multimodal intervention (Trach Trail) and prospective comparison against synchronous controls. Patients undergoing tracheostomy from 2015 to 2016 (n = 60) were analyzed for demographics and outcomes. Trach Trail, a standardized care pathway, was developed with the Iowa Model of Evidence-Based Practice. Trach Trail implementation entailed monthly tracheostomy champion training at 8-hour duration and staff nurse didactics, written materials, and experiential learning. Trach Trail enrollment occurred from 2018 to 2019. Data on demographics, length of stay, and care outcomes were collected from patients in the Trach Trail group (n = 21) and a synchronous tracheostomy control group (n = 117).

RESULTS

Fifty-five nurses completed Trach Trail training, providing care for 21 patients placed on the Trach Trail and for synchronous control patients with tracheostomy who received routine tracheostomy care. Patients on the Trach Trail and controls had similar demographic characteristics, diagnoses, and indications for tracheostomy. In the Trach Trail group, intensive care unit length of stay was significantly reduced as compared with the control group, decreasing from a mean 21 days to 10 (P < .05). The incidence of adverse events was unchanged.

DISCUSSION

Introduction of the Trach Trail was associated with a reduction in length of stay in the intensive care unit. Realizing broader patient-centered improvement likely requires engaging respiratory therapists, speech language pathologists, and social workers to maximize patient/caregiver engagement.

IMPLICATIONS FOR PRACTICE

Standardized tracheostomy care with interdisciplinary collaboration may reduce length of stay and improve patient outcomes.

Elaboration of a tracheostomy conduct protocol in the Amazonas cancer reference hospital

OBJECTIVE

to create a multidisciplinary conducts manual for tracheostomies in adult and pediatric patients in the Amazonas State Oncology Control Center Foundation.

METHODS

we developed a protocol using the modified Delphi method, which consisted in the application of two series of questionnaires to 20 professionals of the unit.

RESULTS

thirteen professionals completed the two steps. In the first stage, there was consensus in 53 out of 92 questions (57.6%). The questions that obtained consensus formed the text of the second stage, divided into eight chapters and evaluated by marking the answers offered on a Linkert scale. All the chapters presented in the second stage obtained consensus, meaning that the sum of the answers "agree" and "fully agree" were above 70%.

CONCLUSION

using the data obtained in the consensus, we elaborated a tracheostomy conduct protocol and a care guidelines manual for the patients and their caregivers.

Tracheostomy Care Practices in a Simulated Setting: An Exploratory Study

PURPOSE/AIMS

Many critically ill patients undergo a tracheostomy. Tracheostomy care is performed to maintain the airway and promote stoma skin integrity. Variation in practices may affect outcomes. The study purpose was to describe tracheostomy care practices of caregivers who perform tracheostomy care in critical care settings and compare practices with published recommendations.

DESIGN

This is a descriptive, exploratory study of tracheostomy care practices of nurses and respiratory therapists using a simulated setting.

METHODS

Staff working in critical care and step-down units were approached to participate in the study. Equipment used for tracheostomy care and the steps performed were observed and video recorded. Observations were compared with recommended practices. Data were analyzed with descriptive statistics.

RESULTS

Fifteen registered nurses (75%) and 5 respiratory therapists (25%) participated. Most participants (80%) were female and held a baccalaureate degree; median experience was 5 years. Equipment used and order of steps varied widely. Only 1 individual performed in the order recommended in a commonly used procedure manual. The most common sequence performed was hand hygiene, clean flange, clean stoma, change inner cannula, change ties, and apply dressing.

CONCLUSION

Wide variability in equipment and practices emphasizes the need for establishing an evidence-based approach for performing tracheostomy care to prevent complications.

Developing the DESCARTE Model: The Design of Case Study Research in Health Care

Case study is a long-established research tradition which predates the recent surge in mixed-methods research. Although a myriad of nuanced definitions of case study exist, seminal case study authors agree that the use of multiple data sources typify this research approach. The expansive case study literature demonstrates a lack of clarity and guidance in designing and reporting this approach to research. Informed by two reviews of the current health care literature, we posit that methodological description in case studies principally focuses on description of case study typology, which impedes the construction of methodologically clear and rigorous case studies. We draw from the case study and mixed-methods literature to develop the DESCARTE model as an innovative approach to the design, conduct, and reporting of case studies in health care. We examine how case study fits within the overall enterprise of qualitatively driven mixed-methods research, and the potential strengths of the model are considered.

Ancillary procedures necessary for translational research in experimental craniomaxillofacial surgery

INTRODUCTION

Swine are often regarded as having analogous facial skeletons to humans and therefore serve as an ideal animal model for translational investigation. However, there is a dearth of literature describing the pertinent ancillary procedures required for craniomaxillofacial research. With this in mind, our objective was to evaluate all necessary procedures required for perioperative management and animal safety related to experimental craniomaxillofacial surgical procedures such as orthotopic, maxillofacial transplantation.

METHODS

Miniature swine (n = 9) were used to investigate perioperative airway management, methods for providing nutrition, and long-dwelling intravenous access. Flap perfusion using near-infrared laser angiography and facial nerve assessment with electromyoneurography were explored.

RESULTS

Bivona tracheostomy was deemed appropriate versus Shiley because soft, wire-reinforced tubing reduced the incidence of tracheal necrosis. Percutaneous endoscopic gastrostomy tube, as opposed to esophagostomy, provided a reliable route for postoperative feeding. Femoral venous access with dorsal tunneling proved to be an ideal option being far from pertinent neck vessels. Laser angiography was beneficial for real-time evaluation of graft perfusion. Facial electromyoneurography techniques for tracing capture were found most optimal using percutaneous leads near the oral commissure.Experience shows that ancillary procedures are critical, and malpositioning of devices may lead to irreversible sequelae with premature animal death.

CONCLUSIONS

Face-jaw-teeth transplantation in swine is a complicated procedure that demands special attention to airway, feeding, and intravascular access. It is critical that each ancillary procedure be performed by a dedicated team familiar with relevant anatomy and protocol. Emphasis should be placed on secure skin-level fixation for all tube/lines to minimize risk for dislodgement. A reliable veterinarian team is invaluable and critical for long-term success.