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Original Investigation |

Changing Practice and Improving Care Using a Low-Risk Tracheotomy Clinical Pathway

Kristine A. Smith, MD1; T. Wayne Matthews, MD1; Mirette Dubé, MSc2; Gerald Spence, RRT2; Joseph C. Dort, MD1
[+] Author Affiliations
1Ohlson Research Initiative, Division of Otolaryngology–Head and Neck Surgery, Department of Surgery, University of Calgary, Calgary, Alberta, Canada
2Department of Respiratory Therapy, Calgary Zone, Alberta Health Services, Calgary, Alberta, Canada
JAMA Otolaryngol Head Neck Surg. 2014;140(7):630-634. doi:10.1001/jamaoto.2014.921.
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Importance  Tracheotomy is a common procedure. Postoperative care is usually managed by nonexpert clinicians. Prolonged decannulation is associated with a high incidence of complications. At present, no clinical protocol exists to guide clinicians through decannulation. To address this deficiency, we developed a low-risk tracheotomy clinical pathway.

Objective  To determine the effect of our low-risk tracheotomy clinical pathway on the time to decannulation and to determine its safety and sustainability by assessing the incidence of adverse events.

Design, Setting, and Participants  Our study combined retrospective and prospective cohorts from July 1, 2008, through January 31, 2012. Low-risk adult patients undergoing tracheotomy at a tertiary care hospital constituted the study population. A baseline cohort of 26 patients underwent retrospective assessment. After development of the pathway, a pilot group of 34 consecutive patients underwent evaluation; of these, 13 were ineligible because of high-risk factors, which included potential upper airway obstruction, unfavorable neck anatomy, or medical factors such as coagulopathy. To assess the sustainability of the pathway, a follow-up cohort underwent assessment. Of 107 consecutive patients, 39 met the low-risk criteria. Length of follow-up was 30 days after decannulation.

Intervention  The low-risk tracheotomy clinical pathway, which provides a stepwise approach to decannulation.

Main Outcomes and Measures  Total time to decannulation (in days). We hypothesized that the pathway would reduce the total time to decannulation. The secondary outcome constituted adverse events. All hypotheses were formulated before data collection.

Results  Mean (SD) total time to decannulation in the baseline cohort was 15.50 (12.08) days. After implementation of the pathway in the pilot cohort, mean (SD) total time to decannulation decreased to 5.74 (2.79) days (P < .001). In the follow-up cohort, mean (SD) total time to decannulation was 8.13 (7.09) days (P = .003). We found no association between adverse events and use of the pathway.

Conclusions and Relevance  Our low-risk tracheotomy clinical pathway is associated with a sustainable decrease in total time to decannulation without any associated increase in adverse events. We therefore believe that this pathway is a safe and effective tool to guide clinicians in the management of tracheotomy.

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