In our cohort, we report a hospital mortality after ICU tracheostomy of 35% which is comparable to the 30–35% previously reported by Liu et al. in their systematic review on early vs. late tracheostomy in ICU [11]. Similarly, our secondary mortality outcomes such as ICU mortality and 1-year mortality were also on par with those reported in other studies [7, 12]. Additionally, over one third of patients undergoing tracheostomy who survived to hospital discharge were then unable to return to their original living arrangements and required new institutionalization despite completing an intensive inpatient rehabilitation program. This is an important patient-centered outcome which has been minimally explored in ICU tracheostomy populations.

In a recent article, Lee et al. explored short- and long-term outcomes exclusively amongst elderly patients undergoing tracheostomy in the ICU of a Canadian university-affiliated hospital. Our work further corroborates and expands on their findings. Our results were comparable with regards to ICU length of stay (41 days vs. 31 days), hospital length of stay (85 days vs. 81 days), as well as ICU mortality (19% vs. 26%). Our cohort, however, experienced lower hospital mortality (35% vs. 45%) and new institutionalization (35% vs. 53%) which may be attributed to our mean cohort age being almost a decade younger than theirs. Additionally, our cohort experienced a higher successful decannulation incidence (82% vs. 25%) however decannulation status was assessed both as inpatient and outpatient, whereas Lee et al. evaluated this metric only during the hospital stay. Lastly, while our patients were relatively evenly split between the two indications of tracheostomy, 75% of Lee et al.’s cohort were tracheostomized for prolonged ventilation, and they do not report on the different incidence of institutionalization based on tracheostomy indication, a finding that could have important implications for patients and their surrogate decision makers’ decision to proceed with tracheostomy and/or their expectations around patients’ outcomes. Ultimately our findings corroborate those of Lee et al. and we feel that our data can further contribute to enhancing meaningful discussions as patients undergoing ICU tracheostomy experience challenging clinical courses both during and after their hospitalizations [10].

While timing of tracheostomy, impact of BMI and age on patient outcomes have been extensively studied, there is a paucity of data reporting on how the indication of tracheostomy impacts long-term outcomes [7, 8, 9, 11, 12, 13, 14]. For this reason, we decided to create two pre-specified groups based on tracheostomy indication. The indication for tracheostomy was found to be an important predictor of short- and long-term patient outcomes. Patients receiving a tracheostomy for secretion management were more likely to survive their ICU admission, however, experienced a significantly longer hospital stay and were twice as likely to be discharged to a new institution compared to patients receiving a tracheostomy for prolonged ventilation.

We found that the prolonged ventilation group had significantly higher ICU mortality than the secretion management group, which is consistent with the patient comorbidity profile and acute physiology in this group. This is further supported by our finding that patients in the prolonged ventilation cohort had significantly longer duration of ventilation both prior to and after tracheostomy. Our findings suggest that there may be two distinct and separate patient groups who ultimately require ICU tracheostomy and future work in this field may consider using this classification.

In recent years, there has been growing interest in exploring patient-important outcomes in critical care medicine [15]. A study looking at trends in tracheostomies from 1993 to 2015 found that while hospital mortality decreased over the years, so too did the proportion of patients able to be discharged home directly [13]. In our study, 35% of survivors required new institutionalization which is comparable to the range of 32–81% previously reported in the literature [8, 10, 13, 14, 16, 17]. In general, discharge disposition is a challenging outcome to compare between studies, given the heterogeneity of reporting in the literature. Studies often consider discharge to rehabilitation centers or to other acute hospitals as new institutionalization, but in reality, these are temporary interim stays where patients are then discharged home or placed at a long-term care facility after their stay. In our study, we only considered patients who were discharged to a long-term care facility following rehabilitation or hospital transfer as new institutionalization. While previous studies with cohorts based on age, length of ICU stay or obesity found no statistically significant difference in discharge disposition between the cohorts [8, 14, 16], our study found that indication for tracheostomy was a clinically and statistically significant predictor for new institutionalization.

In Montreal where our hospital is based, there are local community service centres run by the provincial healthcare system that provide free and accessible home care services for tracheostomy patients, therefore it is unlikely that the higher incidence of new institutionalization is explained by lack of outpatient resources. The higher incidence of new institutionalization for secretion management patients may be attributed to their underlying medical conditions such as dementia or cognitive disorders, both of which were more common numerically but not statistically in the secretion management group, or new neurological limitations which are known to frequently require long-term institutionalization [18]. This is an important finding as new institutionalization can have a significant negative impact on quality of life, and ultimately may not align with patients’ long-term goals. Studies show that institutionalized elderly report a lower quality of life than their community-dwelling counterparts [18]. A study by McDougall et al. found that 27.1% of individuals aged 65 and older living in institutions had clinically significant depression compared to 9.3% of community dwelling adults of the same age [19]. This is further compounded by the fact that critically ill patients who survive to discharge often already experience significant physical and functional impairments [10, 20]. Several studies found that ICU survivors reported lower health-related quality of life (HRQOL) after ICU discharge compared to their pre-admission characteristics-matched and age-matched, healthy counterparts [21, 22, 23]. In light of these findings, future studies should assess HRQOL using a validated tool like the SF36 questionnaire for all patients having undergone a tracheostomy in the ICU. This would ensure adequate assessment and homogenous reporting in the literature of the impact new institutionalization may have on ICU survivors.

Our study’s strengths include comprehensive inclusion of all tracheostomies in a university-affiliated hospital with a patient population similar to many North American ICUs, which would allow our findings to be generalizable to similar institutions. There were, however, several limitations to our study. Our cohort was single-center and does admit post-operative cardiac surgery patients, which may limit generalizability. Additionally, we had a number of patients lost to follow-up. All efforts to locate these patients were undertaken, and while we have no reason to believe the loss to follow-up and difference between the two groups was anything other than random, we cannot exclude a resultant potential bias in our conclusions. Furthermore, decision for institutionalization may be influenced by patient’s financial or family situation, factors we were unable to ascertain in our cohort design.

To our knowledge, our study is the first to explicitly explore the indication for tracheostomy and its impact on outcomes and new institutionalization for ICU survivors. Patients and surrogate decision makers do not view mortality as the only important metric on which to base decisions impacting patient treatment and care. The patient-centered outcomes that we explored, among others, may therefore provide important information for ICU clinicians to use as part of their discussions with patients and their surrogate decision makers prior to undergoing tracheostomy. The incidence of new institutionalization as well as other patient-centered outcomes should be prospectively explored in future studies of critical care tracheostomy.