Multidisciplinary guidance for safe tracheostomy care during the COVID‐19 pandemic: the NHS National Patient Safety Improvement Programme (NatPatSIP)

Abstract

The COVID-19 pandemic is causing a significant increase in the number of patients requiring relatively prolonged invasive mechanical ventilation and an associated surge in patients who need a tracheostomy to facilitate weaning from respiratory support. In parallel, there has been a global increase in guidance from professional bodies representing staff who care for patients with tracheostomies at different points in their acute hospital journey, rehabilitation and recovery. Of concern are the risks to healthcare staff of infection arising from tracheostomy insertion and caring for patients with a tracheostomy. Hospitals are also facing extraordinary demands on critical care services such that many patients who require a tracheostomy will be managed outside established intensive care or head and neck units and cared for by staff with little tracheostomy experience. These concerns led NHS England and NHS Improvement to expedite the National Patient Safety Improvement Programme's 'Safe Tracheostomy Care' workstream as part of the NHS COVID-19 response. Supporting this workstream, UK stakeholder organisations involved in tracheostomy care were invited to develop consensus guidance based on: expert opinion; the best available published literature; and existing multidisciplinary guidelines. Topics with direct relevance for frontline staff were identified. This consensus guidance includes:

Tracheostomy for COVID-19: business as usual?

“…33 The pandemic has focused attention and resulted in the rapid roll-out of NHS England's Safer Tracheostomy Care National Patient Safety Improvement Program. 15 It remains to be seen whether higher standards of tracheostomy care will be maintained. Quality improvement programs, such as those advocated by the Global Tracheostomy Collaborative (www.globaltrach.org), should be encouraged, as evidence continues to emerge describing a positive impact on the safety and quality of tracheostomy care.…”

Traqueostomía en pacientes con COVID-19: Recomendaciones actuales

“…Las indicaciones de TQT en paciente con COVID-19 básicamente son las mismas que en los pacientes en general, no obstante, es importante tener en consideración los últimos reportes del compromiso laríngeo directo que genera el SARS-CoV-2, produciendo edema y ulceración, situación que se vería potenciada con el uso de VMI prolongada. Es por esta razón que se recomienda que si durante la laringoscopía se evidencia un importante edema laríngeo se desestime la intubación y se prefiera la TQT 12 .…”

“…Está ampliamente descrito que una TQT temprana disminuye los días de VMI mortalidad y permanencia en UCI en comparación a una TQT tardía, sin embargo, en pacientes infectados con SARS-CoV-2 no está claro el momento adecuado de realizarla. Según los reportes actuales, se recomienda que el manejo quirúrgico de la VA se difiera hasta 10 días y solo realizarlo si es estrictamente necesario, evitando de esta forma, la generación de aerosoles y consecuente riesgo de infección del personal de salud 12 .…”

“…Con respecto a la técnica de TQT percutánea en comparación a la quirúrgica, no existe un consenso en la literatura con respecto a cuál es mejor. Los estudios internacionales reportan que ambas técnicas presentan similar riesgo de complicaciones y mortalidad 12 . En pacientes con COVID-19 no existe una recomendación clara sobre cuál técnica preferir, sin embargo, se debe considerar que en la TQT quirúrgica existiría una menor producción de aerosoles, por lo que sería recomendable esta vía en pacientes con COVID-19, tomando las medidas que se describen en este estudio 12 .…”

Critical Care Guidance for Tracheostomy Care During the COVID-19 Pandemic: A Global, Multidisciplinary Approach

“…6,7 High risks of viral aerosolization attend both the tracheotomy procedure in patients receiving invasive mechanical ventilation and the subsequent tracheostomy management during weaning and after liberation from the ventilator. 8,9 Therefore, it is important for nurses and other providers caring for patients to protect themselves from harm. 10 In this article, we summarize current evidence on caring for patients with a tracheostomy, outlining state-of-the-art consensus guidance while also acknowledging the challenges inherent in providing such care in low-resource health systems.…”