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Article Excerpt
The study aim was to determine the current management patterns of clinicians across various settings in Australia and examine these practices with respect to levels of clinical consistency and evidence-based practice. A questionnaire was sent to 90 speech pathologists with experience in tracheostomy management. Sixty-eight clinicians responded, and their data were analyzed in relation to majority patterns and level of clinical consistency as per Mathers-Schmidt and Kurlinski (2003). Overall, the results suggested a moderate to high level of clinical consensus for the majority of issues examined. In most cases clinical practice was consistent with existing expert opinion, scientific research evidence, or national practice guidelines. There were, however, some aspects of clinical care that had little clinical consensus. Lack of consensus appeared to stem from either conflicting expert clinical opinion or absent/emerging scientific support. Some aspects of clinical care, including working in teams and the use of instrumental procedures in dysphagia assessment, were found to be inconsistent with best practice, based on current available research evidence. The current data highlight the need for more research evidence in order to establish true evidence-based practice guidelines and optimize clinical consistency of speech pathology management for the tracheostomized patient.
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While speech pathologists have traditionally managed the communication and swallowing impairments of patients with a tracheostomy, there has been a noted expansion of this specialized clinical caseload in recent years. This heightened clinical demand can be attributed in part to an increased number of tracheostomy procedures being performed. American studies report that tracheostomy is now one of the most common hospital surgeries in the United States (Kasper, Stubbs, Barton, & Pierson, 1996; Manley, Frank, & Melvin, 1999). In Australia, a recent center-based study reported that up to 200 tracheostomy procedures were performed annually within one 26-bed intensive care unit (Choate, Barbetti, & Sanford, 2003). Patient numbers also appear to be increasing as more patients are transferred with a tracheostomy from intensive care wards to acute care and high-dependency units, due to demands for critical care beds (Day, Farnell, Haynes, Wainwright, & Wilson-Barnett, 2002). Choate et al. (2003) noted that between 5 to 15 patients with a tracheostomy were being cared for on general wards at any one time in their tertiary care hospital (Choate et al., 2003). In addition to increased patient numbers, the scope of speech pathology practice has expanded, contributed to by the increasing awareness of the benefits of early rehabilitation for patients in intensive care and high-dependency units (Schwartz-Cowley, Swanson, Chapman, Kitik, & Mackay, 1994). Consequently, clinicians have become increasingly involved in dysphagia assessment and management with patients in more acute health states, including the management of multifaceted, complex patients such as those mechanically ventilated. The past decade has also seen our clinical role in dysphagia management for these populations expand, with increasing numbers of clinicians being involved in determining suitability for decannulation (Thompson-Ward, Boots, Frisby, Bassett, & Timm, 1999).
In light of the expanding and changing clinical responsibilities of the speech pathologist working with tracheostomized patients, Manley et al. (1999) conducted the first formal study of the clinical knowledge base and confidence levels of speech pathologists working with this population. They surveyed 228 American speech pathologists on a series of questions identified as "necessary knowledge for any speech-language pathologists providing services to tracheostomised patients" (p. 172) and found that only half the participants felt confident in managing this population, and between half to one third of the group failed a number of core questions. Other authors have examined the related issue of consistency in clinical practice. Kasper et al. (1996) conducted a retrospective study of the care received by 109 tracheostomy patients within an urban university teaching hospital and identified variable clinical practice. They found speech pathology had performed swallowing evaluations in only 41% of the tracheostomy admissions. Australian studies have also reported inconsistency in clinical management of trachesotomy. The Western Hospital (Hyland & Lee, 2003) and The Alfred Hospital (Choate et al., 2003) have recently undertaken policy change in the area of tracheostomy management motivated by staff dissatisfaction with current practices. In attempts to address clinical inconsistencies, both hospitals have developed tracheostomy management groups to enable a coordinated and integrated approach to patient care (Choate et al., 2003; Hyland & Lee, 2003).
The recently released Tracheostomy Management Position Paper (Speech Pathology Australia, 2005) reported that differential practices exist within the profession in Australia, noting that there continues to be little consensus on issues relating to the role of the speech pathologist and other team members; swallowing assessment in tracheostomy patients, including the use of blue dye; our role in decannulation; cuff management; involvement in suctioning; and choice of tracheostomy tubes. The purpose of the current study was to formally examine the extent of clinical consensus on these and other aspects of tracheostomy management among clinicians working with the tracheostomy population in Australia. The second aim was to examine patterns of practice in light of current research to determine if clinical consensus was aligned with the current evidence base.
METHODS
Questionnaire
The questionnaire design was based on existing clinical practice questionnaires (Manley et al., 1999; Mathers-Schmidt & Kurlinski, 2003) and examined clinical management issues relating to clinical roles and responsibilities, dysphagia assessment and management, decannulation procedures, clinician education and training, and clinician confidence levels with the trachesotomy population. The final questionnaire consisted of a total of 51 questions. Only 35 of these questions relating to participant demographics, clinical roles and responsibilities, dysphagia assessment and management, and decannulation will be discussed in the current article (see the Appendix). Questions were determined from published research literature and other sources such as the recent Tracheostomy Management Position Paper (Speech Pathology Australia, 2005). Three speech pathologists with clinical experience in tracheostomy management were involved in designing the structure and content of the questionnaire to maximize the clarity and content validity of the research instrument. The content validity of the final questionnaire was evaluated by a further two speech pathologists with experience in tracheostomy management, resulting in further refinement of the questionnaire. All questions followed either a multichoice or dichotomous format, allowing the responses to be quantified and comparable. Additional open-ended comment sections were provided on a number of items to allow for further extrapolation if required.
Participants
Only speech pathologists with prior experience managing the tracheostomized population were invited to complete the questionnaire in order to minimize potentially confounding information from inexperienced clinicians. Experienced speech pathologists were primarily recruited from the Tracheostomy Interest Group of Australia (TIGA), a nationwide, voluntary, nonfunded organization designed to link speech pathologists interested in the management of patients with a tracheostomy. Additional experienced clinicians were recruited via snowball sampling (participants recruiting other suitable participants) instigated by TIGA members. A total of 90 clinicians nationwide consented to participate in the current study. Of these, 68 completed questionnaires were returned, representing a response rate of 75.6%.
Analysis
Data from the deidentified questionnaires were entered directly into a Microsoft Access database and analyzed using descriptive statistics. To simplify the data, the "usually" and "always" options were combined, and the "seldom" and "never" options were also combined, resulting in three main responses: usually/always, half the time, and seldom/never. The response rate for questions ranged between 66.2% (45/68) and 100% (68/68). Where responses were not provided for any question they were identified as a percent nonresponse (% NR). Questions relating to clinical activities were also classified according to the level of clinical consensus using the clinical consistency scale reported by Mathers-Schmidt and Kurlinski (2003), which states that 75% or more of respondents indicating a similar response represents high clinical consensus (HCC), 50-75% agreement is moderate clinical consensus (MCC), and less than 50% represents no clinical consensus (NCC). The qualitative data generated by some questions were analyzed using thematic coding. Three clinicians reviewed the qualitative responses, collectively agreed on the main themes in the data, and coded each response.
RESULTS
Participant Demographics
The majority of respondents had received a bachelor's degree in speech pathology within Australia (91% bachelor's program in Australia, 1.5% bachelor's overseas, 3% higher degree Australia, 3% higher degree overseas, 1.5% NR), and more respondents (41.9%) had completed their bachelor's degree in Queensland than in other states (22.6% New South Wales, 19.3% Victoria, 9.7% Western Australia, 6.5% South Australia). The mean number of years postgraduation from a bachelor's degree was 11 years (range 1-30 years). Most (72%) had been working as a speech pathologist for more than 6 years (28% 1-5 years, 35% 6-10 years, 13% 11-15 years, 24% >15 years), and 82% indicated that they were currently working more than 4 days a week (3% 1-9 hours, 8.8% 10-19 hours, 4.4% 20-29 hours, 54.4% 30-39 hours, 27.9% >40 hours, 1.5% NR). Respondents were working in all states and territories of Australia (39.7% Queensland, 16.2% New South Wales, 17.6% Victoria, 5.9% Western Australia, 5.9% Northern Territory, 4.4% South Australia, 4.4% Australian Capital Territory, 1.5% Tasmania, 4.4% NR). The majority worked with the adult population (adults/seniors), and most managed patients with a tracheostomy in acute care settings (Table 1). The majority (78%) of respondents spent less than 25% of their total clinical time with patients with a tracheostomy (47% 1-9% of time; 31% 10-24% of time; 10% 25-49% of time; 12% >50% of time). Only a few respondents (7.4%) had no prior experience with ventilated patients, with over half the group reporting experience with more than 10 patients (33.8% 1-10 patients, 30.9% 11-50 patients, 27% >50 patients).
Clinical Roles and Responsibilities
There was high clinical consensus (HCC) that swallowing assessment was often a primary reason for referral (see Table 1). There was only moderate clinical consensus (MCC) that evaluating suitability for decannulation was a primary reason for referral. There was HCC that most clinicians were receiving referrals less than 10 days following the tracheostomy being performed (11.8% 20 days, 10.3% NR) and that the timing of referrals are mostly to always appropriate and consistent (11.8% always, 64.7% mostly, 19.1% sometimes, 2.9% seldom, 1.5% NR). Most clinicians thought that a proportion of tracheostomy patients were not being referred (36.8% thought 60%, 4.4% NR), with only three (4.4%) clinicians commenting that this was not an issue as they had a blanket referral system in their setting. There was moderate-high consensus (73.5%) that the number of referrals was increasing.
There was no real consistency between respondents regarding wards in which the speech pathologists felt they had a defined role (50.8% Neurological/Neurosurgery, 44.6% Intensive Care Unit, 36.9% Ear Nose and Throat, 24.6% Respiratory, 24.6% General Medical, 15.4% General Surgical, <10% other ward types). The respondents commented that the lack of defined roles across many wards in which they worked was often the result of few tracheostomy patients being seen on these wards and/or ward/medical staff not recognizing the need for speech pathologists to be involved in tracheostomy management. There was no...
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