Tracheostomy Practices in Adult Intensive Care Units: A Multicenter Point-Prevalence Study in Izmir (IZ-TRACH)

Overview

This completed observational study describes physician-reported reasons for postponement among adults with an established tracheostomy who were present in participating intensive care units (ICUs) on a single survey day. The survey was conducted in eleven adult ICUs in six hospitals in Izmir, Turkey, on 8 September 2025. The census comprised 282 adults; 46 had a tracheostomy. All 46 contribute to the prevalence numerator. The main descriptive sample comprises 42 patients whose tracheostomy was established during the current admission; four patients with tracheostomies created before admission are excluded from patient-level clinical and outcome summaries. Previous clinical and procedural information was collected retrospectively, and postponement reasons were obtained from primary treating physicians. Mortality was assessed 30 days after the index day, on 8 October 2025. Analyses describe reason categories, total intubation-to-tracheostomy intervals, patient and procedural characteristics, recorded complications, and post-index in-hospital mortality. They cannot establish the duration attributable to family decision-making, preventability of postponement, or effects on outcomes. Registration and this clarification occurred after study completion; no prospective specification of the revised analyses is claimed.

Design and populations This was a multicenter point-prevalence survey on 8 September 2025 with a subsequent mortality assessment on 8 October 2025. The census included all 282 adults present in eleven participating ICUs across six hospitals. Forty-six had an established tracheostomy and contribute to the point-prevalence numerator. During manuscript revision, the main descriptive sample was restricted to the 42 patients whose tracheostomy was established during the current admission. Four patients with tracheostomies created before admission remain in the census and prevalence counts but are excluded from patient-level summaries of indications, technique, postponement, complications and outcomes. Patients who died or left the ICU before the index day and patients who had not undergone tracheostomy are absent from the main sample. Physician-reported reasons and intervals Primary treating physicians reported reasons for performing tracheostomy later than the ICU team intended. Recorded categories were a family-related reason, hemodynamic instability, awaiting surgical eligibility and bleeding diathesis. A family-related reason described the physician's report of additional deliberation or agreement after discussion with relatives or a surrogate decision-maker; it does not establish inappropriate family conduct or avoidable delay. No patient had more than one reason reported. Multiple reasons would have been recorded if reported; investigators did not choose a predominant reason from several reported reasons. No reported reason does not establish that no postponement occurred. The measured interval is total time from intubation to tracheostomy. Intended procedure dates, recommendation dates, discussion/agreement dates and clinical readiness dates were unavailable, so time attributable to an individual reason cannot be calculated. Complications and mortality Complications were identified retrospectively from existing records through the index day. Early and late categories followed the data dictionary (within 7 days and after 7 days of tracheostomy, respectively). Individual event dates and uniform procedure-based observation periods were unavailable. Mortality was assessed over 30 days from 8 September to 8 October 2025 using local records and the hospital information system. This is post-index in-hospital mortality, not mortality within 30 days of tracheostomy or ICU admission. Individual calendar death dates and discharge/transfer indicators were unavailable in the available analysis dataset. Procedure-to-death intervals are described only among decedents; corresponding procedure-to-censoring intervals for survivors are unavailable. Analysis and revision status The revised analyses use counts and percentages with explicit denominators and medians with interquartile ranges. Patient-level summaries use the 42 current-admission patients. Outcome summaries for family-related reasons, no reported reason, and other physician-reported reasons are post hoc and exploratory. Admission APACHE II scores are summarized by vital status; outcomes by technique are descriptive. No hypothesis tests, adjusted comparisons, causal effects or equivalence claims are presented in the revised manuscript. Earlier ROC/cutoff and early-versus-late timing analyses are not retained after methodological review. The APACHE II outcome entry below documents this change explicitly. Registration chronology The study was completed on 8 October 2025. Its initial registry submission was on 5 February 2026 and first posting on 11 February 2026. That entry stated actual enrollment of 30 tracheostomy patients in seven ICUs and listed mortality within 30 days after tracheostomy as its only structured outcome. The authors confirm that the initial data compilation omitted data from additional ICUs within one participating center. These data were subsequently incorporated, and the analyses were rerun using the expanded dataset. An amendment submitted on 16 June 2026 and posted on 22 June 2026 changed the enrollment field to the 282-patient census, described eleven ICUs in six hospitals and the 46-patient tracheostomy subgroup, changed the mortality anchor to the index date, and added other structured outcomes. The current public registry version already describes this 282-person census and the 46-patient tracheostomy subgroup; the 30-patient/seven-ICU description belongs to the initial historical version. The change from 30 to 282 also changes the population represented by the enrollment field, from a tracheostomy subgroup to the full ICU census; it should not be interpreted solely as an increase in the number of tracheostomy patients. This present update documents clarifications and descriptive analysis changes adopted during manuscript revision after study completion. These entries do not establish prospective specification. Historical versions and their dates remain part of the public record.