Tracheostomies during COVID-19: Training Junior Doctors to Safely Respond to Airway Emergencies
21 December 2020 | Ellie Quek
As a fourth-year doctor in core medical training, I was apprehensive about starting my first rotation in the intensive care unit (ICU) during the COVID-19 pandemic. I soon found myself on my first night shift looking after a ward of critically unwell patients, with a number of patients breathing through a precariously positioned tube in the neck. During my time at medical school and the years training as a doctor since, I had never really looked after a patient with a tracheostomy. Thankfully, I had a team of experienced ICU nurses to guide me through the shift, but needless to say I did not feel in my comfort zone. I realised from speaking to fellow junior doctors new to ICU that this feeling of discomfort was not unique to me.
During the pandemic, there was an unprecedented rise in the number of patients requiring support through invasive ventilation, with a significant proportion requiring an extended period on the ventilator to allow time for the lungs to recover. A tracheostomy facilitates this by securing another airway through an artificial opening in the front of the neck into the windpipe, performed surgically by ear, nose and throat (ENT) and ICU doctors. A small tube can be inserted through this opening to breathe through, and allows the patient to begin weaning from ventilation.
We know that tracheostomy patients have a much higher risk of morbidity and mortality. 50% of airway related deaths in ICU are tracheostomy-related, many due to tubes becoming blocked or displaced from the windpipe.
The need for hospitals to increase their capacity to provide ICU level care for COVID patients meant that there were a number of healthcare workers redeployed to work in critical care areas, many of whom would have been unfamiliar with how to look after tracheostomy patients. To address this, the National Tracheostomy Safety Project (NTSP) worked in collaboration with the Academic Health Science Network (AHSN) to publish The Safe TrachyCare Toolkit, which aims to provide guidance for healthcare staff looking after this particularly complex and vulnerable subset of patients.
I surveyed the non-airway trained doctors in my ICU, and found that over 95% reported feeling under-confident in managing a tracheostomy emergency. With non-airway trained doctors comprising more than half of the trainees, it was important that they were equipped to recognise and manage tracheostomy emergencies while an airway-trained doctor was en-route.
Training junior doctors through simulation
Results from the survey showed that doctors felt simulation (SIM) based teaching would provide the best way of learning how to manage a tracheostomy emergency in a high-stress situation. I worked in collaboration with UCLPartners on a quality improvement project to devise a programme of bedside simulation-based teaching sessions. During these sessions, an intensivist demonstrated the National Tracheostomy Safety Project emergency algorithm on a SIM dummy. This included recognising airway red flags, confirming the correct position of the tracheostomy tube, and how to effectively oxygenate the patient if the tube was found to be displaced from the windpipe. Trainees then had hands-on experience during simulations of common emergency scenarios, such as blocked or displaced tracheostomies.
After SIM training, all surveyed doctors reported feeling more confident managing a tracheostomy emergency (see graph below), and results from tests assessing knowledge post-teaching showed significant improvement. One consultant trainer noted that after the session, many trainees ‘appeared relieved to know what to do in an emergency’.
In a time where COVID-19 has put intense pressure on time and resources, supporting healthcare workers to engage in quality improvement initiatives is a key way of identifying and addressing gaps in training that have a potential to impact patient safety. We hope that our project encourages other hospitals to adopt similar training strategies to ensure that staff new to ICU are equipped with the skills to care for tracheostomy patients safely.