Pros and Cons
Although Kevin D. Pereira, MD, MS, professor of otorhinolaryngology-head and neck surgery and director of pediatric otolaryngology at Baltimore’s University of Maryland School of Medicine, agrees with most of the document’s points, he believes that several of the statements actually leave the door open for continued ambiguity instead of achieving the purported aim of the consensus statement to reduce variability in tracheostomy care.
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February 2013For example, he said that statement five is too ambiguous and fails to offer any real strength of direction on who should normally change an initial tracheostomy tube. “The statement says that an experienced physician should be present at the first change, but one problem with this statement is defining who an experienced physician is,” he said. “Is it the attending otolaryngologist, an otolaryngology chief resident or fellow or an intensivist who routinely manages tracheostomies?”
Ideally, he said, he thinks this physician should be a member of the surgical team who is familiar with how that particular procedure was performed and aware of any variations in technique or complications that occurred during the procedure. “Outside of that,” he said, “I think the next best possible person would be another otolaryngologist.”
Although Dr. Pereira thinks the consensus statement is helpful in providing an overall general standard of care for both adult and pediatric tracheostomy care, he thinks there will be areas that people will not agree on. He also emphasized that the real success in standardizing tracheostomy care will come at the institutional level. “Right now, many hospitals have multidisciplinary teams to perform tracheostomies and have standardized care and technique within their hospitals,” he said, adding that this hospital-specific approach to standardizing care is better than a national effort because it allows institutions to evaluate their approach against outcomes.
Need for Local-Level Standardization
The Johns Hopkins University School of Medicine in Baltimore is one such institution. The hospital has developed and implemented a standardized approach to tracheostomy care over the past four or five years. According to Nasir Bhatti, MD, director of the university’s Johns Hopkins Adult Tracheostomy and Airway Service in the department of otolaryngology-head and neck surgery, the inclusion and participation of all stakeholders in its development and implementation has been critical to the success of the approach. Stakeholders include representatives from otolaryngology, head and neck surgery, general surgery, pulmonology, internal medicine and emergency medicine, as well as nurses, respiratory therapists and speech therapists.