Critical Care and Tracheostomy EBP Network 2012

1. Critical Care and Tracheostomy EBP Network 2012

2. PRESENTATION OUTLINE • Year in review • 2012 CAT topic • E3BP project

3. YEAR IN REVIEW • Change in leaders (thankyou to Eva and Klint for their hard work) • 50% increase in membership • 6 meetings thisyear • Critical care and tracheostomy discussion list serve remains active withjustunder 200 members. • Includedclinical case discussion to each meeting followingmembersurvey • Interstate collaboration and pending SPA poster presentation in 2013 • ReviewedCAPs on “in critical care patients does intubation effectlaryngealhealth ? ”, withaim to complete CAT early 2013

4. CAT TOPIC – 2012 – FEES IN CRITICAL CARE Background to CAT – there are differencesbetween sites utilising FEES for management in critical care. Some sites are keen to introduce the use of FEES in critical care and itwouldbeideal to have evidence to justify service establishment. Clinical question wasformed to assist in examining the documentedevidencesupporting the use of FEES to identifydysphagia. Is FEES an effective diagnostic tool in critical care for identifyingdysphagia?

6. COMMENTS • Discrepancy in data recorded in some articles • Limited uniformitybetween the patient populations in thesestudies (sometracheostomised, someventilated, post extubationetc) • Speech Pathologistwas not consistently part of the investigating teams • Inter-rater reliabilitywas an issue

7. CAT bottom line “In the critical care population, limited, lowlevelevidencesuggeststhat FEES maybeuseful in identifyingdysphagia. In somestudies, FEES has been shown to be more sensitive thanbedsideAx in detectingsilent aspiration.” Furtherrobustresearchisrequired in order to support the use of FEES in preference to clinicalbedsideax or MBS in the critical care setting

8. CAT bottom line : application to clinical practice • Confirmswhatwe know about FEES ie : • FEES maybeuseful for detection of silent aspiration • Useful for bothtracheostomised and non tracheostomised patients • Suggeststhat FEES canbeuseful for non-mobile and medicallyunstable patients • Consistent withresults of NSW HealthDraftTracheostomyClinical Practice guideline (2012) recommendation: “Where objective assessment of swallowing is required a FEES may be considered as alternative objective assessment to a VFSS. A FEES has been demonstrated to have greater sensitivity than clinical assessment alone to detect aspiration and is particularly useful in critical care environments. FEES may allow earlier commencement of oral intake.”

9. 2012 E3BP PROJECT • E3BP review • Background • Collection in the clinical setting • Themes from collation • Future directions in the clinical setting &beyond

10. E3BP TRIANGLE Best external evidence Clinical expertise Best internal evidence (from clinical practice) Best internal evidence (from client factors & preferences)

11. BACKGROUND TO E3BP PROJECT • 2011 CAT involved review of the literature on the effect of tracheostomy on swallow function • CAT bottom line - “low level evidence to suggest that a tracheostomy tube does not cause dysphagia; rather, the dysphagia is attributed to the underlying diagnoses and co morbidities” • The group identified a significant gap in evidence versus clinician opinion/practice • Decided to use E3BP to enable holistic decision making around trache care • Group then circulated and analysed an online survey to NSW speechies to gauge level of knowledge and ideas on current practice • Survey was also distributed to Vic tracheostomy interest group

12. E3BP collection in the clinical setting Group brainstorming session and development of preliminary data collection table → someconcernsfrom the group regarding the sensitivity and robustness of the tool. Group members and theirdepartmentsstarted data collection Somemembers of group attendedBeyond Basics EBP workshop. Some discussion with Elise Baker. → its not research ! Include“the mess” and keepcollecting! Refined table online during data collection. Easy to use, not time intensive, aim to makeit a part of clinicalassessment.

14. E3BP data trends to date • N = 36 • 6 sites completed (other sites interested but not includedatthis stage) • 5 tertiary sites, 1 metro site • Data collected over last 6 months (May-Nov) • 35 clinicalAxs (only 1 MBS, no FEES) • Last axwithtracheinsitu and first ax post decannulation • Average of 12.86 daysbetweenax’s • Reason for trachy insertion : 30/36 prolonged vent weans, 4/36 low GCS, 1/36 airwaypatency, 1/36 respiratorytoilet • PRELIMINARY TRENDS IN DATA – see table

15. Cohort = 36 Was there a change in swallow between last Ax with trache insitu and first assessment with trache removed? (Eg. Change to diet recommendations, less repeat swallows, reduced aspiration/penetration signs?) YES = 22 No = 14 What caused the improvement? 15 medical improvement 5 trache decannulation 2 Combination other factors? Anxiety, upper airway irritation

16. WHERE TO FROM HERE ? • Continuation of E3BP data collection to increase our body of internal evidence with future trend analysis • Continued liaison with Victorian tracheostomy interest group. Joint submission of poster abstract for 2013 SPA conference re member survey • Finalise the CAT on the effect of intubation on laryngeal health • Hosting tracheostomy education day 2013