CRITICAL CARE & TRACHEOSTOMY DISCUSSION AND EBP GROUP

EXTRAVAGANZA 2011

EVA NORMAN, KLINT GOERS (CO-LEADERS)

Does the CAT need E3BP to help get out of the bag?

Current clinical practice and opinion in tracheostomy swallowing management

2011 Review

Held Tracheostomy Education day – April 2011 (now bi-annual)

Participation survey completedNew directions

Considered E3BP to compliment our current exploration of evidenceCase presentations/discussionHot topicsRe-establishment of the listserve

Commenced review of past CATs – evidence updateNo new clinical question for 20102010 CAT hangover!!

Review of 2010 CAT

Does the presence of a tracheostomy tube impact on swallow function?

Limited and low level evidence indicates that the presence of a tracheostomy tube alone (cuff deflated, with no occlusion via cap or speaking valve) has no causal effect on the parameters of swallow function investigated.

It is suggested that the patients underlying diagnoses and co morbidities are the cause of any dysphagia.

But some of us couldn’t let it go!!!

Why?

• Historical teachings

• Comfort zone

• New evidence

• Potential change in practice

• Contesting views

• How are you going to educate other MDT members?

So what did we do?

Group discussion and debrief• Recognised the evidence was limited, but replicated and too

significant to not ignore• Recognised clinical practice differs to research environment• Awareness of a typical gap between research and clinical

practice

• Realised a need to examine:• current opinion/clinical practice to identify what the gap is• whether research evidence has trickled down to clinical practice

• if not then why?• if so then has the research evidence changed clinical practice?

Survey developed

• To assess current clinical opinion• Determine barriers to EBP• Determine awareness of the evidence regarding tube presence and

swallow function• Provide the evidence to those who are not familiar• Assess whether the evidence has or may change clinical practice

• Survey had 3 parts:• Part 1: Current clinical practice, opinion and thoughts on EBP• Part 2: Respondents were asked to read the 2010 CAT• Part 3: Awareness of the research evidence and practice change

Survey Demographic

38 ReponsesRespondents across private, community, metro,

tertiary and rural sites60% had 6 + years experienceRespondents across H & N, neurological and

respiratory populations

Nice demographic, so what were the results………

Part 1: Thoughts on EBP

Major trends:

70% feel inadequate research out there80% feel they have the skills to evaluate literature70% are willing to try new things clinically based on

research evidence

Assuming adequate alertness at what stage for the majority of time do you receive a swallowing referral for a patient with a tracheostomy

At what stage do Speech Pathologists become involved?

Assuming there is medical clearance and adequate level of alertness for oral trials, do you wait until the tracheostomy is decannulated before conducting a swallowing

assessment ?

How long do we wait to assess swallowing function?

What about therapy?

Have you noticed a difference in swallowing status pre and post decannulation?

Do you think an open uncuffed tracheostomy tube affects swallow function?

Survey Results: Part 2 & 3

Respondents were asked to read 2010 CAT and then answer questions regarding clinical implications

80 % reported evidence not new 8.6% found it completely new The remaining respondents had heard of the

research but were not aware of specifics.

Clinical practice change

46% reported they had already changed clinical practice based on the evidence

42 % reported the evidence would make them consider their current clinical practice

3% reported the evidence would make them change practice

9% reported the evidence is not strong enough to change practice

Survey Results: Part 2 & 3 (continued)

13% of respondents only receive referral post decannulation however 95% of respondents feel that we can offer input i.e. therapy prior to decannulation

16% hold the clinical opinion that a tracheostomy causes the dysphagia – more experienced clinicians primarily comprised this group. All were aware of the research evidence

0% reported the tracheostomy has no effect on swallow function!

So is there a gap between research evidence and clinical opinion/practice? For an uncuffed open tracheostomy tube…

CAT says tube has no causal effect on swallow function and studies report no change in swallow pre and post decannulation.

Clinical opinion says tube causes dysphagia (16%) OR has a subtle effect on swallow function (79%) but does not cause dysphagia.

Lets look at the gap with E3BP

Dollaghan 2007; Adapted by Dr Elise Baker 2009

Best external evidenceBest external evidence

Best internal evidence(from client factors & preferences)Best internal evidence(from client factors & preferences)

Best internal evidence(from clinical practice)Best internal evidence(from clinical practice)

E3BP data collection plan

8 clinicians/hospital sites across NSW willing to be involved in data collection

3 month collection period Feb – April 2012

Clinicians will document swallow function pre and post decannulation in the clinical environment and note any changes.

Variables will be difficult to control but there are variables in clinical practice, and this is natural

Analysis mid 2012 and dissemination of results at Extravaganza 2012

So the CAT is still in the bag….