title: Tracheostomy protocol: experience with development and potential utility.
abstract: OBJECTIVE
  To examine the feasibility and potential utility of a tracheostomy protocol based on a standardized approach to ventilator weaning.
  
  
  METHODS
  Prospective, observational data collection.
  
  
  METHODS
  Academic medical center.
  
  
  METHODS
  Surgical intensive care unit patients requiring mechanical ventilatory support.
  
  
  METHODS
  None.
  
  
  RESULTS
  Tracheostomy practice in 200 patients was analyzed in relation to spontaneous breathing trial (SBT) weaning. Decision for, and performance of, tracheostomy occurred (median [interquartile range]) 5.0 (3.75-8.0) and 7.0 (5.0-10.0) days following initiation of mechanical ventilation, respectively. Duration of mechanical ventilation was greater in tracheostomy compared with nontracheostomy patients (15.0 [11.0-19.0] vs. 6.0 [4.0-8.0], p < .001). For patients requiring ventilatory support for > or = 20 days, 100% of patients were maintained via tracheostomy. A protocol based on weaning performance, which included technical considerations, was developed. Individuals who failed preliminary weaning assessment or SBT for 3 successive days following 5 days (nonreintubated patients) or 3 days (reintubated patients) of ventilatory support met tracheostomy criteria. The protocol was implemented on a pilot basis in 125 individuals. Of the 55 (44.0%) patients undergoing tracheostomy, 25 (45.5%) did so consistent with criteria. Eighteen patients (32.7%) underwent tracheostomy before the time interval of data collection targeting weaning protocol performance, and 12 patients (21.8%) passed SBT on one or more occasions, were not extubated, and proceeded to tracheostomy.
  
  
  CONCLUSIONS
  A standardized approach in which the decision for tracheostomy is based on objective measures of weaning performance may be a means of using this procedure more consistently and effectively.
authors.affiliation: Department of Surgery, Washington University School of Medicine, St. Louis, MO, USA. freemanb@wustl.edu
authors.forename: Bradley D
authors.initials: BD
authors.lastname: Freeman
authors.forename: Carie
authors.initials: C
authors.lastname: Kennedy
authors.forename: T Elizabeth
authors.initials: TE
authors.lastname: Robertson
authors.forename: Craig M
authors.initials: CM
authors.lastname: Coopersmith
authors.forename: Marilyn
authors.initials: M
authors.lastname: Schallom
authors.forename: Carrie
authors.initials: C
authors.lastname: Sona
authors.forename: Lisa
authors.initials: L
authors.lastname: Cracchiolo
authors.forename: Douglas J E
authors.initials: DJ
authors.lastname: Schuerer
authors.forename: Walter A
authors.initials: WA
authors.lastname: Boyle
authors.forename: Timothy G
authors.initials: TG
authors.lastname: Buchman
mesh_terms: D000046:Academic Medical Centers; D000465:Algorithms; D019985:Benchmarking / Q000592:standards; D003422:Critical Care / Q000592:standards*; D019091:Critical Pathways / Q000592:standards*; D003661:Decision Support Techniques; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D008923:Missouri; D010865:Pilot Projects; D011446:Prospective Studies; D011785:Quality Assurance, Health Care / Q000592:standards; D014139:Tracheostomy / Q000592:standards*; D015300:Ventilator Weaning / Q000592:standards*