This document summarizes the results of a UK-wide survey of intensive care medicine trainees' experience with percutaneous dilatational tracheostomy (PDT) insertion. The survey found that while the majority of trainees feel competent to perform PDT with direct supervision, fewer feel competent with indirect supervision alone. Experience levels varied significantly between trainees at different training levels and in different regions. The results suggest that training opportunities may be inadequate due to declining PDT procedure volumes and inconsistencies between clinical sites. The conclusion calls into question whether PDT insertion should remain a core skill for all intensivists.

1. Intensive Care Medicine Trainees’
experience of Percutaneous Dilatational
Tracheostomy Insertion:
A UK wide survey
DR KAREN ORR, ST7 ICM/ANAESTHETICS, UHD
DR CONN RUSSELL, CONSULTANT INTENSIVE CARE/ANAESTHETICS, UHD
DR CHARLES PHILPOTT, CONSULTANT ANAESTHETICS, UHD

2. • Background
• Outline of survey design
• Results
• All trainees, ST7+ trainees, NI trainees
• Discussion

3. BACKGROUND

4. NCEPOD “On the right Trach?”
(2014)
• Estimated 8000 PDT insertions annually in the UK
http://www.ncepod.org.uk/2014report1/downloads/On%20the%20Right%20Trach_FullRepor
t.pdf

6. • Lethal cases btwn 1985 and 2003
• 71 cases: 0.17% of all pts. or 1 in 600 pts.
• 31% during procedure
• Haemorrhage (38%), airway complications (29.6%),
tracheal perforation (15.5%), PTX (5.6%),
bronchospasm (4.4%), arrhythmia/cardiac arrest
(4.4%) and sepsis (1.5%)
• Bronchoscopic guidance only in 46.5%

11. Competency Level Descriptors

12. Domain 5:
Practical
procedures
ACCS CAT CMT ST Stage 2 Stage 3
5.6 Performs
percutaneous
tracheostomy
0 0 0 1 3 4

15. SURVEY DESIGN

16. Survey Content
• Demographics
• Experience of PDT insertion
• Direct/ indirect supervision
• Self perceived level of competency

17. DEMOGRAPHICS

18. • Approximately 400 UK ICM trainees
• 116 complete responses (29%)
• 6 Northern Ireland responses (75%)
• 39 trainees at ST7 level and above
• All training grades, deaneries and base
specialities represented

19. Number of PDTs performed in career
so far - Direct supervision
4%
3% 7%
All trainees, completed responses only
43%
9% 4%
4%
9%
9%
0%
8% Zero
One
Two
Three
Four
Five
Six
Seven
Eight
Nine
Ten

20. Number of PDTs performed in career
so far- Indirect Supervision
2%
4% 5%
All trainees, completed responses only
71%
9%
2% 2%
1%1%
1% 2%
Zero
One
Two
Three
Four
Five
Six
Seven
Eight
Nine
Ten

21. PERCEIVED COMPETENCY

22. Do you feel competent to perform a
PDT with direct supervision?
All trainees, completed responses only
86%
14%
Yes
No

23. Do you feel competent to perform a
PDT with indirect supervision?
All trainees, completed responses only
44%
56% Yes
No

24. TRAINEES ST7 AND ABOVE

25. Number of PDTs performed in
career so far- Direct supervision
0% 10% Zero
59%
0%
5%
2%
8%
3%
3%
0%
10%
One
Two
Three
Four
Five
Six
Seven
Eight
Nine
Ten
Trainees ST7+, completed responses only

26. Number of PDTs performed in career
so far- Indirect Supervision
51%
15%
8%
5%
2%
3%
0% 5%
3% 3%
5% Zero
One
Two
Three
Four
Five
Six
Seven
Eight
Nine
Ten
Trainees ST7+, completed responses only

27. Do you feel competent to perform a
PDT with direct supervision?
Trainees ST7+, completed responses only
95%
5%
Yes
No

28. Do you feel competent to perform a
PDT with indirect supervision?
Trainees ST7+, completed responses only
69%
31%
Yes
No

29. NORTHERN IRELAND TRAINEES

30. Number of PDTs performed in career
so far- Direct supervision
0%
0% 0% 0% 0% 0%
NI trainees, completed responses only
33%
0%
33%
17%
17%
Zero
One
Two
Three
Four
Five
Six
Seven
Eight
Nine
Ten

31. Number of PDTs performed in career
so far- Indirect Supervision
NI trainees, completed responses only
83%
17%
0%
Zero
One
Two
Three
Four
Five
Six
Seven
Eight
Nine
Ten

32. Do you feel competent to perform a
PDT with direct supervision?
50% 50%
NI trainees, completed responses only
Yes
No

33. Do you feel competent to perform a
PDT with indirect supervision?
NI trainees, completed responses only
17%
83%
Yes
No

34. COMPARISON
ALL TRAINEES V ST7+ V NI

35. All Trainees
ST7+
Trainees
NI Trainees
Career, >2
PDT- Direct
61/116
52.6%
16/39
41.0%
4/6
66.7%
Career, >2
PDT- Indirect
23/116
19.8%
13/39
33.3%
1/6
16.7%
% Self
perceived
competency-
Direct
100/116
86.2%
37/39
94.9%
3/6
50%
% Self
perceived
competency-
Indirect
51/116
44.0%
27/39
69.2%
1/6
16.7%

36. COMMENTS

37. Additional Trainee Comments
• Generally inadequate exposure and training opportunities
lacking- many responses from trainees
• Wide variety in training opportunities
• Seldinger technique is a generic skill and PDT should only
require a small number of supervised observations
• Number of PDTs inserted is falling and with it, exposure for
training
• Some consultants struggling to maintain their own skills with
falling numbers , before training junior staff

38. • Should a small number of consultants in each unit
maintain PDT insertion skills- a specialist rather than
generic skill?
• Skills in managing complications e.g. bleeding are lacking
• Variation between units on focus on training ICM trainees
specifically (above anaesthetic trainees or speciality
doctors for example)
• Uncommon to perform without a consultant present
undertaking bronchoscopy

39. CONCLUSION

40. • 86% of all, 95% of ST7+ and 50% of NI trainees feel
competent to perform PDT insertion with direct
supervision
• 44%, 69% and 17% respectively with indirect supervision
• Some inaccuracies with reported numbers, particularly
ST7+ trainees
• Perceived inadequacy of training opportunities (falling
numbers, consultant skill maintenance, training of non
ICM trainee doctors)
• Should it remain a core skill for all Intensivists?

41. Thanks
• Dr Conn Russell (Consultant Intensive Care,
UHD)
• Dr Charles Philpott (Consultant Anaesthetist,
UHD)