BACKGROUND: Multidisciplinary tracheostomy teams have been successful in improving operative outcomes; however, limited data exist on their effect on postoperative care. We aimed to determine the effectiveness of a multidisciplinary tracheostomy service alone and following implementation of a post-tracheostomy care bundle on rates of decannulation and tolerance of oral diet before discharge. METHODS: Prospective data on all subjects requiring tracheostomy by any trauma/ critical care surgeon were collected from January 2011 to December 2013 following development of a tracheostomy service and continued following implementation of the post-tracheostomy care bundle. Rates of decannulation and tolerance of oral diet were compared between all groups: pre-tracheostomy service (baseline, historical control), tracheostomy service alone, and tracheostomy service with post-tracheostomy care bundle. RESULTS: Three hundred ninety-three subjects met the criteria for analysis with 61 in the baseline group, 124 following initiation of a tracheostomy service, and 208 after the addition of the post-tracheostomy care bundle. There were significant overall differences between all groups in the proportion of subjects decannulated, proportion of subjects tolerating oral diet, and number of subjects receiving speech evaluations. Pairwise comparisons showed no differences in decannulation or tolerance of oral diet following implementation of the tracheostomy service alone but significant improvement with the addition of the posttracheostomy care bundle compared with baseline. (P ؍ .002 and P ؍ .005, respectively). Likewise, the number of speech language pathologist consults significantly increased compared with baseline only after the post-tracheostomy care bundle (P ؍ .004). Time to speech evaluation significantly decreased with the post-tracheostomy care bundle compared with baseline and tracheostomy service (P < .013). CONCLUSIONS: The addition of a post-tracheostomy care bundle to a multidisciplinary tracheostomy service significantly improved rates of decannulation and tolerance of oral diet.
Long-term home-based invasive ventilation in patients with motor neurone disease/amyotrophic lateral sclerosis (MND/ALS) remains rare in the UK. We describe a case of an MND/ALS patient who was treated with long-term invasive ventilation at home but subsequently requested its withdrawal despite a seemingly stable period of his illness. We also discuss the impact of the delivery of this treatment and its withdrawal on his carers, primary healthcare team, community trust managers and specialist palliative care team.
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