Abstract
Objective
To evaluate open bedside tracheostomy (OBT) and compare it with open operating room (OR) tracheostomy and bedside percutaneous dilatational tracheostomy (PDT) in complications and cost. To determine the tracheostomy practice patterns of academic otolaryngology programs.
Study Design
Retrospective cohort study and cross-sectional study.
Setting
Public hospital and tertiary care hospital.
Methods
Otolaryngology program directors were surveyed to determine their institutions’ tracheostomy practice patterns and the factors preventing the implementation of open bedside tracheostomies. A retrospective chart review was done of tracheostomies performed at our institutions from 2009 to 2019 for prolonged mechanical ventilation. Complications, length of intubation, comorbidities, body mass index, demographics, mortality rates, and decannulation rates were recorded. A cost analysis between OBT and PDT was conducted.
Results
Data from 802 patients were analyzed for 449 OBTs, 206 PDTs, and 147 open OR tracheostomies. Complication rates were low. PDTs were more likely to have perioperative tracheal bleeding (P = .028) and mucus plugging (P = .006). OBTs were performed on sicker patients with a higher Charlson Comorbidity Index than PDT and OR tracheostomies. The cost of OBT was less than that of PDT. The survey response rate of tracheostomy practice patterns was 46%. The otolaryngologists at the responding programs all conducted OR tracheostomies, while 52.7% did OBTs and 30.9% PDTs.
Conclusion
OBT can be done safely in patients with multiple comorbidities and has a cost that can be less than PDT. Despite these benefits, only 50% of academic institutions routinely performed OBT.
Level of Evidence
3
Tracheostomy is a frequently performed procedure that can be done in the intensive care unit (ICU) or in the operating room (OR). 1 Indications include prolonged mechanical ventilation, airway obstruction, and pulmonary toilet among others. 2 Traditionally, otolaryngologists have conducted open tracheostomy in the OR.
Bedside tracheostomy performed in the ICU percutaneously and open has been shown to be equally safe with similar mortality and short-term complication rates as OR tracheostomy.3-14 While percutaneous dilatational tracheostomy (PDT) is often contraindicated in certain patient demographics (obese, previous tracheostomy, nonpalpable anatomy), open bedside tracheostomy (OBT) does not have such restrictions.9,11,15,16
Tracheostomy in the ICU has several advantages over OR tracheostomy: avoiding risks associated with transporting critically ill patients, improved resource utilization and cost savings, and reduced consult-to-procedure time.17-19 Cobean et al demonstrated that PDT resulted in approximately $1645 in cost savings when compared with OR tracheostomy. 20 OBT may be even more cost-effective: Grover demonstrated cost savings of $2194 vs OR tracheostomy and $180 vs PDT.18,21
Since 2000, there has been a growing trend toward conducting bedside PDT.3-14 However, it is unknown if otolaryngologists are contributing to this trend, as there have not been any large-scale studies that have examined nationwide practice patterns. Furthermore, given the benefits of bedside tracheostomy, the literature is also lacking data regarding why bedside tracheostomy is done less commonly than OR tracheostomy.
In this study, we sought to (1) determine the nationwide tracheostomy practice patterns of otolaryngologists at institutions with a residency program and (2) demonstrate systems for successful implementation of bedside tracheostomy protocols from 2 hospitals.
Methods
Nationwide Tracheostomy Practice Patterns
To accomplish our first aim, a cross-sectional survey of tracheostomy practice patterns was sent to the program directors of otolaryngology residency programs in the United States. Surveys were disseminated via RedCap. The survey queried the institution type, the tracheostomy techniques performed at the institution, and the reasons why certain tracheostomy modalities were excluded (see Appendix, available online). The University of Southern California Institutional Review Board exempted this study.
Selection of Cohort
To determine if implementation of bedside tracheostomy protocols were successful at the Keck Hospital of the University of Southern California and the Los Angeles County Hospital (LAC; our second aim), the complication rates, mortality rates, and costs of OBT and PDT were compared with OR tracheostomy. Keck Hospital is a private academic center and LAC is a public safety net hospital. Patients who underwent tracheostomy for prolonged mechanical ventilation at these 2 institutions between August 2009 and August 2019 were included in this retrospective cohort study. Tracheostomies for other indications were excluded.
A total of 815 tracheostomies were performed. Demographics, body mass index (BMI), length of intubation, Charlson Comorbidity Index (CCI), tracheostomy tube size, operative times, complications (intra-, peri-, and postoperative), decannulation rate, and mortality rate were reviewed. The CCI score was calculated with preoperative comorbidities and age. Perioperative complications occurred within 7 days of surgery. Postoperative complications occurred after postoperative day 7.
Statistical Analysis
The correlations between the tracheostomy technique and demographics, preoperative CCI and BMI, length of intubation, complication rates, decannulation rates, and mortality rates were calculated with the Kruskal-Wallis test and Fisher exact test. Any variables with a P < .1 in the univariate analysis were placed into a multivariate logistic regression best-fit model to determine if complication and mortality rates varied among tracheostomy modalities. Statistical significance was defined as P < .05. All P values were reported as 2-sided. Statistical analysis was conducted with Stata 15 (StataCorp).
Cost Analysis
A cost analysis was done for OBT, PDT, and OR tracheostomy for both institutions. At Keck Hospital, OBT is added to the OR board. When OR staff are available, which include the surgical technician and nurse circulator, they bring equipment from the OR and set up at bedside. The attending on call performs the tracheostomies with a postgraduate year 4 (PGY 4) resident in between clinic or OR cases. Hence, OBT is carried out with an attending physician, resident physician, surgical technician, nurse circulator, ICU nurse, and ICU respiratory therapist. Anesthesia and the intensivist are usually not involved. The ICU nurse administers anesthetic medications. The ICU respiratory therapist helps with endotracheal tube removal and connecting the tracheostomy with the ventilator circuit after placement. To determine the personnel cost, the physician fee schedule on cms.gov/medicare was used to calculate the surgeon’s fee, and the average institutional hourly rate was used to calculate the fees of the surgical technician and nurse circulator. The rate of the resident was estimated by the average hourly rate of $15.70. This was based on the average annual salary of PGY 1-5 residents and an 80-hour workweek. While the average OBT takes 20 minutes, the OR staff time required to retrieve the tracheostomy supplies, set up at bedside, and clean up after the procedure was estimated at 2 hours. At LAC, OR staff are not used. The resident physician brings equipment to bedside. OBT is performed with 1 attending physician, 2 resident physicians (postgraduate levels 1 and 2), and 1 ICU nurse. Again, anesthesia and the intensivist are not involved. There are 4 teams of 2 residents at LAC, and call is every 4 days. Tracheostomies are done with the on-call team before or after clinic. To calculate the cost of an OBT, the surgeon’s fee, the resident’s hourly rate, and the institutional cost of tracheostomy equipment were considered ( Table 1 ). The cost of tracheostomy tray sterilization was estimated through existing data by Grover, as our institution does not process the tracheostomy tray individually and cannot provide a cost estimation. 18 The depreciation of the tracheostomy tray per use was calculated at $2.1. Mhlaba et al estimated that each instrument depreciation was $ 0.06 per use. 22 There are 35 instruments in our tracheostomy trays. The hourly rates of the ICU nurse and respiratory therapist were not calculated, as they are assigned to the patient and did not attain additional pay for being involved in the procedure.
Estimated Costs for Tracheostomy Modalities. a
Abbreviations: OBT, open bedside tracheostomy; OR, operating room; PDT, percutaneous dilatational tracheostomy.
Blank cells indicate not applicable.
The cost of the tracheostomy tray is the cost of tracheostomy tray sterilization + the cost of equipment depreciation. The sterilization of the tracheostomy tray was estimated from an article by Grover.18 Each piece of equipment is estimated to depreciate by $ 0.06 per use based on an article by Mhlaba et al.22 There are 35 instruments in the tracheostomy tray, so depreciation is approximately $2.1 per use.
The cost calculation for OR tracheostomy included all the parts of the OBT in addition to the cost to anesthesia and OR staff. The average time to conduct an OR tracheostomy was greater at 33 minutes, and the OR turnover time was considered. Hence, the time estimate for OR staff was calculated at 3 hours. At Keck Hospital, only the physician fee from cms.gov/medicare for a staff anesthesiologist was added to the cost. The cost for OR staff was increased from 2 to 3 hours.
At Keck Hospital, PDT is carried out with an attending intensivist, 2 pulmonary critical care medicine (PCCM) fellows, the ICU respiratory therapist, and the ICU nurse. One PCCM fellow does the tracheostomy with the attending intensivist while the other PCCM fellow does the tracheoscopy/bronchoscopy. At LAC, PDT is conducted with just the attending intensivist and the PCCM fellows without the assistance of the ICU respiratory therapist. For PDT, the following were taken into consideration: physician’s fee for a tracheostomy for an intensivist, institutional cost of a disposable tracheostomy tray, medications, bronchoscopy cost, and sterile equipment. PDTs are usually performed with the assistance of 2 fellows; thus, the average hourly rate of a PGY 4-6 resident was used to calculate the pulmonary fellows involved in PDT. This ended up being $18.10 and was added to the cost analysis. The bronchoscope cost was estimated with data from Sohrt et al, which included purchasing, cleaning, and repair costs. 23
Results
Nationwide Tracheostomy Practice Patterns
The tracheostomy practice pattern survey was sent to the program directors of 121 residency programs in the United States. Fifty-six programs responded for a response rate of 46%. Most institutions identified as academic centers. All performed OR tracheostomy, as opposed to 52.7% for OBT and 30.9% for PDT. Lack of staffing was cited as the most common reason why OBT was not conducted, followed by concern for procedural complications. Even in institutions where OBTs were performed, they accounted for only 21.5% of tracheostomies. Concern for procedural complications and concern for long-term complications were the most common reasons why PDTs were not performed. In institutions where PDTs were performed, they accounted for 30.3% of tracheostomies ( Table 2 ).
Nationwide Practice Patterns.
Abbreviations: OBT, open bedside tracheostomy; OR, operating room; PDT, percutaneous dilatational tracheostomy.
Mean (SD).
Description of Cohort
Of the 815 tracheostomies, 802 had complete data and were included in our analysis. The breakdown by procedure modality was as follows: 449 (56%) OBTs, 147 (18%) OR tracheostomies, and 206 (25.7%) PDTs. The average cohort age was 56.7 years (range, 6.4-99.6), and there was a higher mean age for OBT than for the other 2 techniques (P = .015; Table 3 ). Most patients were male (61.4%), which did not differ among techniques. Patients who underwent PDT had a longer length of intubation (18.2 days) than OR tracheostomy (18 days) and OBT (16.1 days, P = .0016). Those with a higher CCI were more likely to undergo OBT (OR 3.1 vs OBT 4.4 vs PDT 3.2, P = .0001), and those with a higher BMI were more likely to undergo OR tracheostomy (OR 30 vs OBT 27.4 vs PDT 26.6, P = .0022). The mean operative time for the OR tracheostomy was 32.4 minutes (range, 7-108) vs 20 minutes (range, 4-135) for OBT at Keck Hospital. Procedural times for PDT and OBT at LAC were not recorded. The otolaryngology department did most of the OR tracheostomies and OBTs, while PCCM service placed the majority of PDTs ( Table 4 ).
Cohort Demographic Characteristics.
Abbreviations: BMI, body mass index; COPD, chronic obstructive pulmonary disease; OBT, open bedside tracheostomy; OR, operating room; PDT, percutaneous dilatational tracheostomy.
Analysis of variance and chi-square test. Bold indicates P < .05.
Intra- and Postoperative Tracheostomy Characteristics.
Abbreviations: OBT, open bedside tracheostomy; OR, operating room; PDT, percutaneous dilatational tracheostomy.
Analysis of variance and chi-square test. Bold indicates P < .05.
Complications
Tracheostomy complications were divided into intra-, peri-, and postoperative complications. Intraoperative complications were rare at 1.1% to 2.4%, and no differences were noted among the tracheostomy techniques on multivariate analysis. The most common intraoperative complication was severe desaturations, defined as saturations dipping <85% for >1 minute or having a respiratory code. One patient had severe desaturations with a resultant cardiac arrest requiring chest compressions but experienced return of spontaneous circulation and did not develop any long-term complications. Two patients had intraoperative bleeding that resulted in the procedure being aborted: 1 patient (OBT) was taken to the OR due to excessive bleeding, and 1 PDT was converted to an OBT. PDT and OBT were attempted on 1 patient with a history of tracheostomy and rigid cartilage due to scarring, but both were unsuccessful. The patient ultimately required an OR tracheostomy. No permanent or long-term complications resulted.
Overall perioperative complications were rare at 3.4% to 5.8%. No differences in overall perioperative complications were noted among the modalities studied. This was true with multivariate regression models accounting for BMI and size as confounders. However, peristomal and tracheal bleeding happened more frequently after PDTs when compared with OR tracheostomies and OBTs (P = .048). Additionally, OR tracheostomies showed a trend toward increased frequency of accidental decannulations (P = .051).
Regarding long-term postoperative complications, OBTs showed a trend toward fewer complications when compared with PDTs and OR tracheostomies (P = .052). After accounting for preoperative BMI and tracheostomy tube size, OBT had fewer postoperative complications (P = .042; Table 5 ). Higher BMI was associated with greater complications (P = .045), and having a size 8 tracheostomy tube was associated with fewer complications (P = .010). Mucus plugging occurred more frequently in PDTs than OBTs and OR tracheostomies (P = .002). Granulation tissue was the most common postoperative complication, followed by accidental decannulation. One tracheostomy-related mortality occurred in the postoperative period due to a trachea-innominate fistula on postoperative day 9 following OR tracheostomy ( Table 4 ). The tracheostomy-related and 30-day all-cause mortality rates were similar for all 3 tracheostomy modalities.
Multivariate Regression for Long-term Postoperative Complications. a
Bold indicates P < .05.
Cost Analysis
The hospital cost for OBTs, PDTs, and OR tracheostomies is shown in Table 1 . At LAC, OBT costs approximately $443.30, which is less than PDT ($1054.79) and OR tracheostomy ($1023.68). OBT at LAC is performed at less cost than at Keck Hospital, as it does not require OR staff. At Keck Hospital, OBT costs $628.88 and accounts for 2 hours of circulator and surgical technician usage. At both hospitals, PDT is similar in cost to OR tracheostomy due to the usage and maintenance of bronchoscopes.
Discussion
This is the first study to examine nationwide tracheostomy practice patterns at institutions with residency programs. Otolaryngologists at responding institutions performed OR tracheostomy. However, 52.7% and 30.9% of program directors did OBT and PDT, respectively. This percentage is assumed to be lower in community hospitals.
The 2 most common reasons for not doing OBT were lack of staffing and concern for complications. In this study, we provide 2 models for OBT that can be safely performed without increased risk of complication and 1 model that is appropriate for low-resource settings. At LAC, OBT is carried out with 1 attending otolaryngologist, 2 junior otolaryngology residents, and an ICU nurse to administer medications. The PGY 1 resident is at the head of the bed to remove the endotracheal tube and connect it to the ventilator. This job can also be done by the ICU nurse or a respiratory therapist. The PGY 2 resident assists the attending physician with the procedure. At community hospitals without residents, this can be done with an advanced practice provider or a surgical technician to assist the attending physician. Sending staff to the ICU increases OR availability and saves resources on patient transportation.
Approximately 36% of survey respondents saw procedural complications as a barrier for OBT. In our study, OBTs were noted to be as safe as OR tracheostomies. This is well supported in the literature.12,19,24 Our study showed similar intraoperative complications among 3 modalities (P = .44). Halum et al also found no difference in intraoperative complications. Their overall intraoperative complication rate was 1.4%, which is consistent with our 1.4% for OR tracheostomy and 1.1% for OBT. 25 Overall rates of perioperative complication were also similar between OR tracheotomy and OBT at 3.4% and 3.6%, respectively. This is similar to a previously reported rate of 5.6%. 25 Interestingly, there is a trend that OR tracheostomies are more likely to result in accidental decannulation, which makes intuitive sense as patients require transfer from the OR table to ICU bed postprocedure and transport back to the ICU. Previous studies have shown that more patient movement increases accidental decannulations.26,27 Finally, OBT had a lower overall postoperative complication rate than OR tracheostomy on multivariate analysis accounting for BMI and tracheostomy size (P = .042). Previous studies have shown that longer length of intubation and higher BMI resulted in more complication rates.25,28,29 In our study, OR tracheostomy had a longer average length of intubation than OBT (18 vs 16.1 days) and higher mean BMI than OBT (30 vs 27.4). In summary, OBT is as safe as OR tracheostomy with similar, if not better, complication and mortality rates.
The 2 most common reasons why PDTs were not performed included concern for procedural complications and concern for long-term complications. In our study, procedural or intraoperative complication rates for PDT were similar to OBT and OR tracheostomy. This is consistent with the current literature, which shows similar intraoperative complications among all 3 modalities.25,30,31
The data for long-term postoperative complications for PDT vs OR tracheostomy and OBT are more controversial. For complications within 7 days, multiple studies support the finding that PDT and OBT have similar complication rates.4,7 While a meta-analysis by Delaney et al suggests that open tracheostomy, whether at bedside or in the OR, has a greater chance of bleeding than PDT, our study found the opposite and noted that tracheal bleeding was more common with PDT than OBT. 4 We hypothesize the reasoning to be that surgical tracheostomy has better visualization of the tract to the trachea, allowing for better intraoperative hemostasis. Furthermore, previous literature indicates that usage of multidisciplinary teams in PDT is associated with decreased complication rates. 32 The teams at LAC and Keck Hospital are multidisciplinary, with the participation of the ICU nurse and respiratory therapy during the surgery and the intensivist and speech language pathologists postoperatively. Regarding long-term complications, some studies state that PDT has a lower complication rate than OBT,4,31 while other studies note that PDT has more complications.7,33 We believe that these conflicting data are due to the lack of long-term follow-up with patients after tracheostomy.
Regarding cost, our study shows that OBT is less expensive than OR tracheostomy and PDT. This finding has not reached consensus in the literature. Some studies show that OBT is the least costly. One study found that OBT saves $2194 when compared with OR tracheostomy while PDT saves only $180. 18 Others have demonstrated that PDT is the modality that offers the lowest cost option. 34
Limitations
The retrospective nature of the study is one limitation. Our data were dependent on the accuracy of the patient records available for review. Additionally, few patients had follow-up after hospital discharge. Among the patients who were not decannulated and who were alive 30 days postprocedure, just 26.3% had documented follow-up in clinic. Therefore, long-term complications may not be adequately assessed. Furthermore, the cost of the bronchoscope for PDT was estimated from the literature and may not represent the actual cost for the institution. Finally, the survey response rate is 46%, and we looked only at academic institutions, which might not be representative of the practice patterns of all the hospitals. We surmise that the actual rate of OBT is much lower in the community.
Conclusion
OBT is underutilized in academic centers nationwide. Those who did not do OBTs were concerned about lack of staffing and procedural complications. However, our study shows that OBT is a safe and low-cost option that can be performed with minimal staffing and in low-resource settings. OBT should be more readily adopted across academic, public, and private hospital settings.
Supplemental Material
sj-docx-1-oto-10.1177_01945998221091905 – Supplemental material for Open Bedside Tracheostomy: Safe and Cost Saving but Underutilized Nationally
Supplemental material, sj-docx-1-oto-10.1177_01945998221091905 for Open Bedside Tracheostomy: Safe and Cost Saving but Underutilized Nationally by Liyang Tang, Jonathan West, Esther Lee, Khush Kharidia, Steven Hasday, Tamara Chambers, Niels Kokot, Mark Swanson and Karla O’Dell in Otolaryngology–Head and Neck Surgery
Footnotes
Acknowledgements
We thank Melissa Lee Wilson, PhD, MPH, for statistical consultation and assistance with the analysis of the research project. We also thank Joon Choi, MD, for assistance with the analysis and presentation of the research article.
Author Contributions
Disclosures
Supplemental Material
Additional supporting information is available in the online version of the article.
References
Supplementary Material
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