title: Changing practice and improving care using a low-risk tracheotomy clinical pathway.
abstract: OBJECTIVE
  Tracheotomy is a common procedure. Postoperative care is usually managed by nonexpert clinicians. Prolonged decannulation is associated with a high incidence of complications. At present, no clinical protocol exists to guide clinicians through decannulation. To address this deficiency, we developed a low-risk tracheotomy clinical pathway.
  
  
  OBJECTIVE
  To determine the effect of our low-risk tracheotomy clinical pathway on the time to decannulation and to determine its safety and sustainability by assessing the incidence of adverse events.
  
  
  METHODS
  Our study combined retrospective and prospective cohorts from July 1, 2008, through January 31, 2012. Low-risk adult patients undergoing tracheotomy at a tertiary care hospital constituted the study population. A baseline cohort of 26 patients underwent retrospective assessment. After development of the pathway, a pilot group of 34 consecutive patients underwent evaluation; of these, 13 were ineligible because of high-risk factors, which included potential upper airway obstruction, unfavorable neck anatomy, or medical factors such as coagulopathy. To assess the sustainability of the pathway, a follow-up cohort underwent assessment. Of 107 consecutive patients, 39 met the low-risk criteria. Length of follow-up was 30 days after decannulation.
  
  
  METHODS
  The low-risk tracheotomy clinical pathway, which provides a stepwise approach to decannulation.
  
  
  METHODS
  Total time to decannulation (in days). We hypothesized that the pathway would reduce the total time to decannulation. The secondary outcome constituted adverse events. All hypotheses were formulated before data collection.
  
  
  RESULTS
  Mean (SD) total time to decannulation in the baseline cohort was 15.50 (12.08) days. After implementation of the pathway in the pilot cohort, mean (SD) total time to decannulation decreased to 5.74 (2.79) days (P < .001). In the follow-up cohort, mean (SD) total time to decannulation was 8.13 (7.09) days (P = .003). We found no association between adverse events and use of the pathway.
  
  
  CONCLUSIONS
  Our low-risk tracheotomy clinical pathway is associated with a sustainable decrease in total time to decannulation without any associated increase in adverse events. We therefore believe that this pathway is a safe and effective tool to guide clinicians in the management of tracheotomy.
authors.affiliation: Ohlson Research Initiative, Division of Otolaryngology-Head and Neck Surgery, Department of Surgery, University of Calgary, Calgary, Alberta, Canada.
authors.forename: Kristine A
authors.initials: KA
authors.lastname: Smith
authors.affiliation: Ohlson Research Initiative, Division of Otolaryngology-Head and Neck Surgery, Department of Surgery, University of Calgary, Calgary, Alberta, Canada.
authors.forename: T Wayne
authors.initials: TW
authors.lastname: Matthews
authors.affiliation: Department of Respiratory Therapy, Calgary Zone, Alberta Health Services, Calgary, Alberta, Canada.
authors.forename: Mirette
authors.initials: M
authors.lastname: Dubé
authors.affiliation: Department of Respiratory Therapy, Calgary Zone, Alberta Health Services, Calgary, Alberta, Canada.
authors.forename: Gerald
authors.initials: G
authors.lastname: Spence
authors.affiliation: Ohlson Research Initiative, Division of Otolaryngology-Head and Neck Surgery, Department of Surgery, University of Calgary, Calgary, Alberta, Canada.
authors.forename: Joseph C
authors.initials: JC
authors.lastname: Dort
mesh_terms: D015331:Cohort Studies; D019091:Critical Pathways / Q000639:trends*; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D008297:Male; D008875:Middle Aged; D012189:Retrospective Studies; D013997:Time Factors; D014140:Tracheotomy / Q000009:adverse effects