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Intro: Welcome to UAB MedCast, a continuing education podcast for medical professionals, providing knowledge that is moving medicine forward. Here's Melanie Cole.

Melanie Cole, MS (Host): Welcome to UAB MedCast. I'm Melanie Cole. And we have a panel for you today to highlight UAB's first tracheostomy management team. Joining us is Dr. Harishanker Jeyarajan, he's a head and neck surgeon in the Department of Otolaryngology and an Associate Professor at UAB Medicine; Jennifer Faulkner, she's a physician assistant; and Maddie Golden, she's a certified registered nurse practitioner in Otolaryngology.

Thank you all for being with us today. And Dr. Jeyarajan, welcome back and I'm so glad to have you with us. Tell us a little bit about tracheostomy. How common is this procedure and for what conditions is it generally indicated?

Dr. Harishanker Jeyarajan: Sure. Thanks, Melanie. So, a tracheostomy is essentially a surgical procedure designed to bypass the upper airway, so to provide a conduit to the trachea below the level of the voice box. It is really done for patients who have chronic airway conditions. It's a very common procedure, particularly at academic institutions.

I would say that in general, at UAB-- the girls will be able to give us some better statistics-- but I think in general, at UAB, we do upwards of 600, 700 tracheostomies a year. There are various indications for tracheostomies. The most common is probably for chronic ventilatory support. So, these are patients who are critically ill requiring intensive care services and dependent on mechanical ventilation for a long period of time.

Normally, this is done via a tube that goes through the mouth and through the voice box into the upper airway, but we know that if these types of tubes are present for periods longer than 10 days, especially in high risk patients like those that are obese, are diabetic, are very metabolically unwell that this can lead to long-term problems at the level of the voice box due to scarring. And so, in these patients, if we know that they're going to need to be ventilated for a long period of time, we choose to give them what we call an elective tracheostomy. So again, put that tube below the voice box into the windpipe, and that saves the voice box from long-term complications.

Other common indications for needing a tracheostomy tube are in conditions that lead to obstruction of the airway at the level or above the level of the voice box such as tumors, penetrating and non-penetrating neck trauma, infection to the voice box, paralysis of the vocal cords. And people that have swelling of the voice box or the tissues of the voice box and above, such as those who have idiopathic reactions to conditions that cause swelling, like edema, so just angioedema, and also conditions like burns, patients that get injuries and edema to the upper airway. And finally, those patients had a difficult to ventilate. So, those are the broad categorization of people that require tracheostomy tubes. But yeah, it's a very common procedure. And like I said, it's done by very many surgical specialties and non-surgical specialties.

Melanie Cole, MS: Dr. Jeyarajan, sticking with you for just a minute. Tell us about the team concept and how did this come about. Did you start this team concept? Tell us why this program started. Why did you see the need?

Dr. Harishanker Jeyarajan: So, I started at UAB in 2019, and a few of the earlier things that I did when I was here was form the ENT Consult Service, which is an attending-driven service to manage ear, nose, and throat consults from other inpatient teams during their admission. And we also started the multidisciplinary complex airway team.

 And one of the things that I was getting asked a lot of as part of these two services was to see patients that are having complications related to tracheostomies. Now, this sort of also coincided with COVID during which time we were seeing a lot of airway complications and a lot of people requiring tracheostomy tube insertion. And so, during this time, I realized that there was a significant number of complications I thought were avoidable, and a significant variation or verification in care provided for different tracheostomy patients. And I just thought that this is something that we could do a better job of.

During my time in working in other countries, I had seen similar initiatives taken on. I thought that this was something we could do here at UAB. Given that we are the largest academic center in the state. And we see a lot of these complex patients that require not just acute, but long-term tracheostomy care.

 When I reviewed the data, like I told you, we were averaging between 600 to 700 tracheostomies a year. And our average complication rate at the time was averaging about 8% a year, which was sort of similar to other institutions when comparing Vizient data across the country. But I was seeing that our mortality rate was much higher, and probably reflective of the complex patients that we see.

 And so, as such, I thought that UAB, it would be in their best interest to look at starting a quality improvement project. And so, as a department of ENT, we then petitioned the UAB Quality Care initiative to begin looking at implementing a service. And that's how it started.

Melanie Cole, MS: Thank you so much for telling us about that. So Maddie, tell us a little bit about your background and how it prepared you for this very specific type of work.

Maddie Golden: So, I was a nurse for five years on HMPU here at UAB, and that's where all of the ENT patients are. So, I was taking care of trach patients as a nurse for five years prior to this. So, I think that gave me the perspective of a nurse, and I think that really helped me as a provider, taking care of this patient population.

Melanie Cole, MS: Jennifer, same question to you. How did you get prepared for this type of work?

Jennifer Faulkner: So, I have a background in ENT at another facility. And at that place, I was in charge of taking care of the tracheostomy patients while they were inpatient. So, I had a background in that. And then, when I got here, I had excellent training from Dr. Jeyarajan and from the ENT residents. So, they've really helped as well.

Melanie Cole, MS: Well, that's great. It's such a very unique and important role that you all play. And Maddie, tell us a little bit about the specifics of the clinic. When does the clinic see patients? Is it solely an inpatient service or is it also available for outpatient?

Maddie Golden: So, we have clinic on Wednesday mornings and recently opened a clinic on Thursday afternoon. We see patients that have recently been discharged with trachs that were placed here at UAB. We see patients that are referred from outside facilities, just chronic trach management of those patients. So really, anybody with a trach. We've also seen some patients who have been decannulated who are having complications after decannulation with voicing or wound healing and things like that.

Melanie Cole, MS: Jennifer, Dr. Jeyarajan touched on this in his first answer as far as how many patients this clinic sees. Tell us a little bit about how many patients you treat each day. And I'd like you to speak about the patient experience with this clinic.

Jennifer Faulkner: So, I'm doing research on all of this. So last year, we had a total of 179 patients in clinic. So far, we are up to about 350. I feel like this is an excellent service to our community that we don't have. So many people are discharged with very little education or they don't have the supplies. They just don't have anybody or another doctor or provider who is familiar with tracheostomies and tracheostomy care. So, I've had so many people have told us that this has just been a godsend for them, basically, just such an excellent resource for them.

Melanie Cole, MS: Dr. Jeyarajan, what happens if a patient has complications down the line? How does the highly skilled multidisciplinary team take action to mitigate complications? I mean, you are such an expert in this field. Tell us a little bit about what you do for the patients, but then how your team helps them as well.

Dr. Harishanker Jeyarajan: Sure. So, tracheostomy complications, they're due to a number of factors. You know, some of them are related to the patient's comorbidities, patient's current state of illness. So, those are larger things that we don't have a ton of control over. But some complications are due to the acute care.

And so, that's a huge area where the team can sort of help prevent patients having long-term wound issues, fistula issues, or issues with scarring of the windpipe. And that's through advocating for early placement of the tracheostomy tube, advocating for the right type of tracheostomy tube size in the right type of tube in general, helping with conversion from cuff tracheostomies to non-cuff tracheostomies and eventual decannulation efforts. And these can reduce complications from simple things such as wound issues down to life-threatening things, such as the patient being unable to breathe properly, being unable to get a tracheostomy tube back in when they need to have it changed appropriately. And so, those are a lot of the things that are managed by the day-to-day work of the trach team.

Where I sort of step in, other than to support the team when they have particularly tricky patients that are often related to the patient's comorbid condition. But when I sort of step in is when despite their best efforts, the patient still resulted in complications that we've identified early. And that we work towards managing in a controlled fashion as an outpatient. And these can be ranging from simple things that I do as outpatient procedures where I do telescopic procedures to try and open up the airway above the tracheostomy tube due to scarring that can have occurred or complications from the breathing tube being placed in the voice box, leading to scarring of the voice box all the way down to a multidisciplinary surgery called the tracheal resection, where myself and the thoracic surgeons work together to essentially do an open surgery where we cut out the scarred and damaged airway and sew healthy airway ends back together again to try and improve their long-term airway function, and avoid long-term tracheostomy tube. All these in an effort to not only keep the patient safe, but in an effort to try and eventually you get these patients deccannulated or have the tracheostomy tube removed.

Melanie Cole, MS: Thank you all for joining us and telling us about the importance of this clinic. I'd like to give you each a chance for a final thought here. So, Maddie, why don't you tell us a little bit about what you would like other providers who are referring their patients, who are sending their patients to the clinic, and what you would like them to know about the important work that you're doing for these patients.

Maddie Golden: My biggest thing is the earlier we can be involved, the better. A lot of times we'll see patients not as much now, but in the beginning where we weren't involved in their care. So, a lot of things were missed in the beginning and complications weren't able to be identified as early because we weren't aware of the patient. So, the earlier we can be involved, the better.

Melanie Cole, MS: Jennifer, same question to you. But I'd also like you to let the community know what's so important about this clinic and the education that you're providing, as you mentioned, that the community knows that the education is there.

Jennifer Faulkner: Yes. So, this is one big part of our team, is we have worked on trying to educate patients who are going home with tracheostomies. We have created a checklist, and we've created a three-day education program. And we've seen less complications. We've actually had a 43% reduction in ER visits related to the tracheostomy since the start of this clinic.

So, I think that is a huge, huge service that we're doing. And this is the only trach management clinic in the state of Alabama. And there are people in rural Alabama or people further south who are unaware of us, and we are going to work towards reaching out to those communities in the future. But for people who have chronic tracheostomies, this is crucial to their care that they have a specialist who helps them with this specific issue that they have.

Melanie Cole, MS: Dr. Jeyarajan, last word to you. What would you like the key takeaways to be about your team, the work that you're doing at UAB Medicine?

Dr. Harishanker Jeyarajan: So, I think the key takeaways are that this is the team designed to assist patients with tracheostomies, assist staff looking after tracheostomies, and assist services that manage people with tracheostomy tubes. This is a highly skilled team, whose only job is to help improve outcomes for these patients.

And so, I'd really like for all the services in the hospital to know this and to understand they can reach out at any point and also to increase visibility outside. Now, that we have two clinics going, we want to provide the same service to patients and services outside the hospital as well, because UAB grants us the resources to be able to do that.

Melanie Cole, MS: Thank you all so much for joining us today and telling us about UAB's first tracheostomy management team. And for more information, please visit our website at uabmedicine.org/physician. That concludes this episode of UAB MedCast. I'm Melanie Cole.