Percutaneous Tracheostomy Performed by Medical Intensivists: Implementation and Outcomes

PURPOSE: Tracheostomy has traditionally been considered a procedure performed by those with surgical training. Herein, we report our experience with implementing a medical intensivist-led percutaneous dilational tracheostomy (PDT) service at our institution. METHODS: We developed a training and credentialing process for medical intensivists in performing PDT by collaborating with our acute care surgery service in 2010. At the bedside, our PDT team consists of a medical intensivist leader, with team members including critical care fellows, bronchoscopist, respiratory therapist, bronchoscopy technician and critical care nurse. The acute care surgery service provided backup for surgical tracheostomy requirement. All PDTs were performed with the Ciaglia Blue Rhino kit under bronchoscopic guidance. Patients were followed until the first tracheostomy tube change, or until discharged from the hospital. We further developed a patient registry to record our experiences with PDT. RESULTS: To date, the PDT service is led by three medical intensivists. Our PDT registry currently consists of 171 patients, 53% male, age 57.7±17.1 years, BMI 28.0±8.3, and SOFA score 8.4±3.9 on the day of PDT. Patients were on mechanical ventilation for 12.1±8.2 days prior to PDT, with 11.7% requiring vasopressor at time of PDT. The most frequent intra-procedural complications were minor bleeding (8.8%, n=15) and tracheal ring fracture (8.8%, n=15). PDT was unsuccessful in one patient due to major bleeding. No patient required conversion to surgical tracheostomy and there was no mortality attributable to PDT. CONCLUSIONS: We demonstrate that medical intensivists can successfully initiate and maintain a PDT service in the medical ICU. In addition, we have enhanced our service by implementing peri-procedural quality and safety measures, trained fellows in PDT, and are exploring more efficient techniques, such as ultrasound-guided PDT. We plan to further expand our service into a multi-disciplinary and hospital-wide PDT program. CLINICAL IMPLICATIONS: Medical intensivists can implement an effective PDT service with the potential to improve patient care, efficiency, and outcomes for patients requiring long-term mechanical ventilation.