What criteria should I use to determine when to refer a patient with a tracheostomy to secondary care for further evaluation?

The provided UK guidelines primarily address acute situations, such as major trauma or the deterioration of acutely ill adults in hospital, rather than routine referral criteria for patients with a tracheostomy in general practice. However, based on these guidelines, a patient with a tracheostomy should be referred to secondary care for further evaluation if they exhibit signs of acute deterioration or require urgent life-saving interventions.

• Physiological Deterioration or Clinical Emergency: Any patient identified as being at risk of clinical deterioration, or experiencing a 'clinical emergency', should trigger an urgent response from a team with critical care competencies and diagnostic skills NICE CG50. This includes situations where there is haemodynamic instability or severe respiratory compromise NICE NG39.
• High-Score Group on a Track and Trigger System: Although primarily for hospital settings, the principles of a high-score group (indicating significant deterioration) would necessitate an emergency call to a team with critical care competencies and diagnostic skills, including a medical practitioner skilled in advanced airway management and resuscitation NICE CG50.
• Need for Advanced Airway Management or Critical Care: If the patient requires interventions such as drug-assisted rapid sequence induction of anaesthesia and intubation, or other life-saving interventions that cannot be delivered in primary care, immediate transfer to a major trauma centre or trauma unit would be indicated in an acute trauma setting NICE NG39,NICE NG40. For a patient with an existing tracheostomy, this translates to any acute airway compromise requiring specialist intervention.
• Specific Indications for Intubation/Ventilation: While primarily for head injury, indications such as coma (GCS score of 8 or less), loss of protective laryngeal reflexes, ventilatory insufficiency (hypoxaemia or hypercarbia), or irregular respirations would necessitate immediate specialist intervention and transfer NICE NG232.