RESUMEN
BACKGROUND: Percutaneous tracheostomy is a common procedure in the intensive care unit and, on patient transfer to the wards, there is a gap in ongoing tracheostomy management. There is some evidence that tracheostomy teams can shorten weaning to decannulation times. In response to lengthy weaning to decannulation times at Trillium Health Partners - Credit Valley Hospital site (Mississauga, Ontario), an interprofessional tracheostomy team, led by respiratory therapists and consisting of speech-language pathologists and intensive care physicians, was implemented. OBJECTIVE: To evaluate the interprofessional tracheostomy team and its impact on time from weaning off mechanical ventilation to decannulation; and time from weaning to speech-language pathology referral. METHODS: Performance metrics were collected retrospectively through chart review pre- and post-team implementation. The primary metrics evaluated were the time from weaning off mechanical ventilation to decannulation, and time to referral to speech-language pathology. RESULTS: Following implementation of the interprofessional tracheostomy team, there was no improvement in decannulation times or time from weaning to speech-language pathology referral. A significant improvement was noted in the average time to first tracheostomy tube change (36.2 days to 22.9 days; P=0.01) and average time to speech-language pathology referral following initial tracheostomy insertion (51.8 days to 26.3 days; P=0.01). CONCLUSION: An interprofessional tracheostomy team can improve the quality of tracheostomy care through earlier tracheostomy tube changes and swallowing assessment referrals. The lack of improved weaning to decannulation time was potentially due to poor adherence with established protocols as well as a change in mechanical ventilation practices. To validate the findings from this particular institution, a more rigorous quality improvement methodology should be considered in addition to strategies to improve protocol compliance.
HISTORIQUE: La trachéostomie percutanée est une intervention fréquente dans l'unité de soins intensifs. Au transfert des patients au service d'hospitalisation, la continuité de la prise en charge de la trachéostomie pose un problème. Selon certaines données, les équipes de trachéostomie peuvent réduire le temps accordé au sevrage avant la décanulation. En réponse au long temps accordé sevrage avant la décanulation du Credit Valley Hospital des Trillium Health Partners (Mississauga, Ontario), une équipe interprofessionnelle de trachéostomie, dirigée par des inhalothérapeutes et composée d'orthophonistes et d'intensivistes, a été formée. OBJECTIF: Évaluer l'équipe interprofessionnelle de trachéostomie et ses effets lors du temps accordé entre le sevrage de la ventilation mécanique et la décanulation ainsi que sur le temps accordé entre le sevrage et l'orientation vers l'orthophonie. MÉTHODOLOGIE: Les chercheurs ont recueilli rétrospectivement les mesures de performance par une analyse des dossiers avant et après la formation de l'équipe. Les mesures primaires évaluées étaient le temps accordé entre le sevrage de la ventilation mécanique et la décanulation, et le temps accordé avant l'orientation vers un l'orthophonie. RÉSULTATS: Après la formation de l'équipe interprofessionnelle de trachéostomie, il n'y avait pas de réduction du temps accordé avant la décanulation ou l'orientation vers l'orthophonie. Le temps accordé, en moyenne, avant le premier changement de canule de trachéostomie a considérablement diminué (passant de 36,2 jours à 22,9 jours; P=0,01), de même que le temps accordé, en moyenne, avant l'orientation vers une orthophonie après l'insertion de la première trachéostomie (passant de 51,8 jours à 26,3 jours; P=0,01). CONCLUSION: Une équipe interprofessionnelle de trachéostomie peut améliorer la qualité des soins de trachéostomie grâce au changement plus rapide de la canule de trachéostomie et à l'orientation vers une évaluation de la déglutition. L'absence de réduction du temps accordé entre le sevrage et la décanulation pouvait être causée par une mauvaise compliance aux protocoles établis et à un changement aux pratiques de ventilation mécanique. Pour valider les observations provenant de cet établissement, il faudrait envisager une méthodologie d'amélioration de la qualité plus rigoureuse en plus de stratégies pour améliorer la compliance au protocole.
RESUMEN
INTRODUCTION: There is a paucity of data about the clinical characteristics that help identify patients at high risk of influenza infection upon ICU admission. We aimed to identify predictors of influenza infection in patients admitted to ICUs during the 2007/2008 and 2008/2009 influenza seasons and the second wave of the 2009 H1N1 influenza pandemic as well as to identify populations with increased likelihood of seasonal and pandemic 2009 influenza (pH1N1) infection. METHODS: Six Toronto acute care hospitals participated in active surveillance for laboratory-confirmed influenza requiring ICU admission during periods of influenza activity from 2007 to 2009. Nasopharyngeal swabs were obtained from patients who presented to our hospitals with acute respiratory or cardiac illness or febrile illness without a clear nonrespiratory aetiology. Predictors of influenza were assessed by multivariable logistic regression analysis and the likelihood of influenza in different populations was calculated. RESULTS: In 5,482 patients, 126 (2.3%) were found to have influenza. Admission temperature ≥38°C (odds ratio (OR) 4.7 for pH1N1, 2.3 for seasonal influenza) and admission diagnosis of pneumonia or respiratory infection (OR 7.3 for pH1N1, 4.2 for seasonal influenza) were independent predictors for influenza. During the peak weeks of influenza seasons, 17% of afebrile patients and 27% of febrile patients with pneumonia or respiratory infection had influenza. During the second wave of the 2009 pandemic, 26% of afebrile patients and 70% of febrile patients with pneumonia or respiratory infection had influenza. CONCLUSIONS: The findings of our study may assist clinicians in decision making regarding optimal management of adult patients admitted to ICUs during future influenza seasons. Influenza testing, empiric antiviral therapy and empiric infection control precautions should be considered in those patients who are admitted during influenza season with a diagnosis of pneumonia or respiratory infection and are either febrile or admitted during weeks of peak influenza activity.