Advances in multidisciplinary tracheostomy care and their impact on the safety and quality of care in the critically ill

Tracheostomy is one of the first recorded surgical procedures and refers to an incision into the windpipe at the front of the neck, classically performed by surgeons to relieve airway obstruction. A tracheostomy tube can be inserted to maintain airway patency. The majority of tracheostomies are now performed the critically ill, typically whilst dependent on invasive respiratory support. Analysis of tracheostomy-related critical incidents helped to understand the frequency, nature and severity of problems that can occur at initial placement or during subsequent use. If problems occur, significant harm may rapidly develop, especially in the critically ill. Recurrent themes that contributed to avoidable mortality include poor emergency management and limitations in infrastructure, equipment provision, staff training and education. Many of the problems identified are amenable to prospective, multidisciplinary quality improvement strategies. This thesis describes my published work in this area. An underlying challenge to improving care lies in the fact that care requires input from many clinical disciplines. Complex patients need care in specialised settings that are not always adequately trained and supported in delivering safe tracheostomy care. My research has evaluated the impact of a co-ordinated multidisciplinary approach using bespoke resources, staff education, infrastructure changes and patient champions to direct healthcare improvements. I have critically appraised my bespoke resources and evaluated and justified the use of a variety of quality and safety metrics to define better care, both at patient-level and using institutional process measures, reflecting better coordination of care, contributing to significant cost savings. Further opportunities to build understanding of the nature of tracheostomy problems in ICU and the success of quality improvement initiatives will be discussed. Future aims are to not only improve care but also to perform a detailed economic analysis and capture knowledge on how to best implement necessary changes rapidly in today’s complex NHS