A Multidisciplinary Focus on Tracheostomy Management
Tracheostomy can be an intermittent treatment for children until they outgrow ventilator dependence or undergo surgical correction of an anatomic obstruction to breathing. For others, tracheostomy may be a long-term part of life. Susannah E. Hills, MD, is a pediatric otolaryngologist and ENT airway surgeon with the Department of Otolaryngology – Head and Neck Surgery at NewYork-Presbyterian/Columbia University Irving Medical Center. In 2018, Dr. Hills led the development of a Pediatric Tracheostomy Care Program, one of only a few such comprehensive tracheostomy programs in the country.
“With the creation of an outpatient tracheostomy care clinic for children, we established a standardized and consistent way of managing patients with tracheostomies to ensure that they receive the follow-up that they need, that we are closely monitoring them when they leave the hospital, and that they’re safe when they go home,” says Dr. Hills, who specializes in endoscopic airway surgery, airway reconstruction, and tracheostomy care. She and her colleagues care for children who are tracheostomy-dependent for a wide range of reasons, some with a history of extreme prematurity and underdeveloped lungs, others with congenital airway obstruction, laryngotracheal stenosis, tracheomalacia, or chronic neuromuscular disorders.
Through the program, which is located at NewYork-Presbyterian Morgan Stanley Children’s Hospital, patients and their families are provided with a support system that features a comprehensive team of specialists to promote optimal breathing, feeding, and speech/language development. A tracheostomy care coordinator helps families bridge the transition from inpatient to outpatient care, ensuring they have the proper training to care for their child at home and are able to obtain home equipment, services, and other resources to support their child.
“We want to make the program as valuable for patients as we possibly can,” notes Dr. Hills. “So, we collaborate with pulmonologists to address breathing disorders, as well as with speech and language pathologists for associated swallowing and voice concerns. Importantly, we see the patients together in our clinic to form a coordinated plan and have a conversation among all of the providers who are most involved with the patient’s airway care. We also communicate as a group to the family in a cohesive and comprehensive way that is good for the patient. The approach relieves some of the burden on the families, minimizing their travel back and forth to the hospital for appointments with three or four different providers.”
“One of the most important lessons we’ve learned in starting this multidisciplinary approach to tracheostomy management is how much patients and their families value seeing their providers together and how much more streamlined care can be when we’re all in the same place, talking about the same patient,” continues Dr. Hills. “Patients can move forward more quickly when we’re all there to talk and ask the right questions. The depth of care given to patients is enhanced by having a multidisciplinary conversation with perspective of all specialists involved in developing the plan of care.”
On the inpatient side, Dr. Hills and her team have developed protocols and a teaching program for nurses, respiratory therapists, and physicians on how to manage particularly complicated cases.
A Foundation for Addressing COVID-19
With the arrival of COVID-19, Dr. Hills and her colleagues quickly transitioned their services to attend to the overwhelming number of adults being admitted to the hospital needing breathing support. “When the pandemic hit, we performed 150 tracheostomies over the span of one month, which is about as many as we do in a year in the adult hospital,” says Dr. Hills. “The COVID-19 pandemic demanded and inspired a team-oriented response. We came together from across our hospital system to form a tracheostomy care team in expectation of the dozens – possibly hundreds – of patients we would need to care for in the coming weeks. The team included airway surgeons, thoracic surgeons, critical care surgeons, anesthesiologists, intensive care doctors, speech and language pathologists, and respiratory therapists. Because there was such high volume and because patients were located in different parts of the hospital and not necessarily in ICUs, we deployed nurses and physicians who had varying levels of expertise with tracheostomy care.”
“Having already developed a tracheostomy care program for children, we had a template on how we could approach care for patients on the adult side. Our pediatrics program became the foundation for that care,” continues Dr. Hills. “We spoke with colleagues across the country and in different parts of the world, learning from each other's experiences and sharing practices that seem to work.”
Dr. Hills also led a team in postoperative management of the hospital’s tracheostomy patients.
“Once we had the tracheostomies in place, the challenge was keeping those patients safe.” A rotating team, including Dr. Hills, an attending surgeon, and a physician assistant, conducted the post-tracheostomy care. They followed patients the first week after their surgeries and would check in periodically while the patient was on the ventilator. The team also developed a protocol to help patients decannulate in a safe but expedited way.
“On a typical day amid this outbreak, the rotating surgical and anesthesia teams would go from patient to patient at bedside – sometimes as many as seven or eight – surgically entering the airway and placing the tracheostomy tube,” describes Dr. Hills. “The other surgical team members, along with physician assistants and residents, would go from bed to bed, checking on the patients that already underwent surgery, making sure their tubes were secure and that they had the supplies they need nearby.”
As volume began to decline and some patients became well enough to have their tracheostomy tubes removed, the teams initiated afternoon decannualtion rounds. “Our goal was to keep patients safe after surgery and then to discharge them either to their home or more often to a rehabilitation facility without the trach tube,” notes Dr. Hills. “All of our efforts on the pediatric and the adult side stem from our desire to give our patients the very best care that we possibly can and to keep them safe during their hospital stay. But we’re also striving to address all of the important quality-of-life issues, such as swallowing and voice and working towards decannulation when it’s possible. Families need to be supported with resources and education so that they don’t feel alone. Those have been our primary goals in establishing our tracheostomy care programs.”