Austin Health Tracheostomy Cognitive Aids

The Global Tracheostomy Collaborative (GTC) has been instrumental in improving the safety and quality of care for patients with tracheostomies(1). Its initiatives promote best practices, support education, and foster a collaborative approach to managing tracheostomy care globally.  One notable contribution from a GTC member site, Austin Health in Melbourne, Australia, is a cognitive aid which is based on the NTSP (National Tracheostomy Safety Project) guidelines and tracheostomy emergency algorithm(2). The Austin Emergency Tracheostomy Management Cognitive Aid was published in 2021(3).

The Austin cognitive aid includes three different emergency pathways encompassing: (1) ventilation or breathing difficulty, (2) complete tube removal or decannulation and (3) bleeding. It also prompts clinicians to consider diagnoses for breathing difficulty not directly related to the tracheostomy and provides guidance on the immediate use of a bronchoscope in an emergency. It is intended to be used by a designated cognitive aid reader who can assist the leader to guide the team.

The Austin Emergency Tracheostomy Management Cognitive Aid is an A3 poster which is two sided. The front side of the cognitive aid is used by Primary Responders who are bedside staff who manage the emergency before the arrival of advanced responders.  The front side also includes essential information on tracheostomy and upper airway management. The reverse side of the cognitive aid is to be used by Advanced Responders who are the code blue team who respond to airway emergencies and in critical care environments including intensive care, the emergency department and the operating room.

The Advanced Responders side of the cognitive aid is intended to be used as follows (4):

• First, check through the ‘in all cases section’, on the far right, to confirm: that this is a tracheostomy not laryngectomy patient, the patency of the upper airway, use of capnography and oxygen and consideration of help required.
• Then, determine which of the three pathways to follow. The first pathway ‘Difficulty breathing or ventilating via tracheostomy tube' is the most common. The second pathway should only be chosen if the tracheostomy tube is completely out of the neck. The third pathway is for bleeding.
• It is important to appreciate that, in the first two pathways, there is a directive to "Stop when patient is stable," indicating the priority of stabilizing the patient before proceeding with further interventions. The bleeding pathway requires all steps to be completed.

The cognitive aid was designed with understanding that there is significant variability in staff tracheostomy experience. Each step on both sides is clearly titled and numbered, with further actions detailed in lighter background descriptions. This structure allows experienced users to quickly identify necessary actions while providing detailed explanations for less experienced teams

The Austin Emergency Tracheostomy Management Cognitive Aid is an essential tool for managing tracheostomy emergencies. By providing structured guidance, it enhances preparedness, supports effective management during crises, and facilitates post-event reflections. The development and implementation of such cognitive aids highlights the importance of a holistic, multidisciplinary approach to tracheostomy care, ultimately improving patient outcomes and safety. Further education and detail on emergency tracheostomy management can be found here, on the Austin Health, Tracheostomy Review and Management Service (TRAMS) website.

The Global Tracheostomy Collaborative provides a platform to integrate expertise and resources from around the world, such as the cognitive aid developed by Austin Health and illustrates the significant benefits of collaborative efforts in enhancing tracheostomy care. This collaborative approach ensures that both routine and emergency care are consistently managed with the highest standards, reducing the risk of complications and improving the overall quality of life for patients with tracheostomies.

1. Brenner MJ, Pandian V, Graham DA, Milliren CE, Zaga C, Morris LL, et al. Global Tracheostomy Collaborative: data-driven improvements in patient safety through multidisciplinary teamwork, standardisation, education, and patient partnership. British journal of anaesthesia. 2020;125(1):e104-e8.
2. McGrath BA, Bates L, Atkinson D, Moore JA. Multidisciplinary guidelines for the management of tracheostomy and laryngectomy airway emergencies. Anaesthesia. 2012;67(9):1025-41.
3. Graham JM, Fisher CM, Cameron TS, Streader TG, Warrillow SJ, Chao C, et al. Emergency tracheostomy management cognitive aid. Anaesthesia and intensive care. 2021;49(3):227-31.
4. Graham J, Gregson P, Fisher C. Tracheostomy emergency cognitive aid. ANZCA Bulletin. 2024(Autumn):33-5.
   
   
   

Link to the Austin Emergency Tracheostomy Management Cognitive Aid PDF