TRACHEOSTOMY: A MULTIPROFESSIONAL HANDBOOK
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Ensure a safe environment by a. Developing local guidelines for practice b. Establishing emergency procedures and making them available within all inpatient areas may include radiology, physiotherapy c. Providing comprehensive education program for patients and carers d.
Why use Humidifed High Flow therapy for Tracheostomy patients?
Providing continuing education to ensure all staff are competent especially in regards to emergency interventions e. Ensuring patients are located in wards where appropriate numbers of competent nursing staff are available 3. Minimise the risk of healthcare associated infections HAI by ensuring that: a. Inner tracheostomy cannulaes are not cleaned at hand basins 7. In ICU this would be the intensive care team Registered nurse Tracheostomy referral team Tracheostomy tube Videofluoroscopic swallowing study Work of breathing 1 For further information please refer to Between the Flags program Detect Training.
Additionally, their care may be highly complex involving a number of clinicians across different healthcare specialties; highlighting the need for good communication, coordination, team functioning and documentation. In , the Clinical Excellence Commission released a report that found that patients with a tracheostomy were experiencing significant adverse events as a result of deficits in their care.
Specifically, these deficits were related to the competencies of clinical staff and lack of appropriate action especially after hours.
System of Care H. Complications and emergencies B. Patient Preparation I. Nutrition C. Maintaining a patent airway D. Prevention of infection E. Swallowing F. Facilitating communication J. Education K. Transfer of care L. Appendices M.
Optiflow+ Tracheostomy interface features
References G. A systematic literature review was not possible because of a lack of experimental research. These reviews were undertaken in groups of two or more. For the purposes of this guideline, the term tracheostomy will be used. This CPG has been developed to assist hospitals and LHDs to develop clinical practices for patients with a tube inserted into the stoma. There are a number of indications for a tracheostomy tube including: Maintenance of airway patency for patients with mechanical obstruction of the upper airways e.follow url
Swallowing - St George's University Hospitals NHS Foundation Trust
These may include: Bypassing normal gas humidification processes Normal mucociliary clearance is altered by - Presence of tube obstructing upward movement of mucus - Dry inspired air changes ciliated epithelium to squamous epithelium Disruption of normal communication and eating Pooling of oropharyngeal secretions above the cuff leading to microaspiration and increased risk of nosocomial pneumonia. For patients, the experience of having a tracheostomy tube is difficult with many complex physical sensations and emotions to deal with .
Patients are comforted when they are assured that the clinicians caring for them are competent. Additionally communication and information needs are particularly important because this is a new experience accompanied by a fear of the unknown. Patients experience significant uncertainty, worry and long term anxiety over the frequency of tube changes, length of wound healing and the dread of being reliant on a small plastic tube to breathe .
The diversity of emotions experienced suggests that patient preparation and information given should be tailor-made to match individual needs . Most patients with a tracheostomy tube will have healthcare needs that cover several healthcare disciplines and the complexity of this care means ideally an experienced clinician or a tracheostomy team will be required to coordinate this care Table 4 Clinician scope of practice type.
Because hospital case mix varies, each hospital will need to examine local conditions to make appropriate decisions to ensure that patients receive person-centred time sensitive-care in a safe environment. Elements include: Environment of care Plan of care and communication Patient assessment Essential equipment Transport and transfer Scope of practice Many patients with tracheostomy tubes have complex care needs with a resulting long length of stay LOS and high cost diagnostic related group DRG .
There are two groups of patients with tracheostomies in acute care settings. The first group is mostly homogenous and comprises patients who have a tracheostomy tube inserted electively by an ENT surgeon with the aim of treatment for a specific ENT problem. These patients are admitted to a limited number of tertiary hospitals and generally cared for in a specialist ward setting by clinicians with significant expertise in the care of tracheostomies.
The second group is heterogeneous with a broad spread of diagnoses where a tracheostomy is inserted to either aid weaning from the ventilator or to protect their airway or both. This second group of patients are cared for in multiple ward settings with variable tracheostomy expertise available. Furthermore these patients may have other significant clinical problems that require ongoing management by multiple healthcare care specialties and clinicians.
It should be noted however that these are general statements only that may not reflect the case mix in all settings.
Table 4 outlines the scope of practice for each of the healthcare disciplines. This list is not exhaustive and many roles may overlap depending on institution. In addition, home modifications may also be necessary to facilitate discharge planning In regional settings, the task of coordinating the care of tracheostomised patients is most often undertaken by the intensive care team, predominantly the CNC or CNE where available.
Tracheostomy: A Multi-Professional Handbook
A TRT has been established by a number of Australian institutions in order to coordinate the care of patients who are discharged from ICU with a tracheostomy. A TRT includes a number of clinicians who are able to provide expert clinical care including assessment and intervention for the patient. The literature review revealed an emerging evidence base suggesting that such teams are able to reduce time to decannulation; adverse events; and hospital LOS .
Additionally, there is an enhancement in the use of communication strategies. Importantly there is an improvement in outcomes for patients with spinal injuries  and severe head injuries  with significant cost savings. Teams are able to: review patients on a regular basis and coordinate care of the many healthcare professionals caring for the patient provide just in time and structured education enabling clinical staff to become more confident and provide better care Care of Adult Patients in Acute Care Facilities with Tracheostomy Clinical Practice Guideline PAGE 7.
The recommendations outlined in the following pages emphasise the need for acute care facilities to create a safe clinical environment for patients with tracheostomy tubes insitu. It is organised into the following sections: Environment of care Plan of care and communication Patient assessment Essential equipment Patient transport between clinical areas.
Tracheostomy: A Multi-Professional Handbook
Care of patients with a tracheostomy requires a coordinated multidisciplinary approach 2. The TRT will work collaboratively with the primary care team to devise a management plan for the patient. To ensure optimal patient outcomes hospitals without a TRT or relevant medical, nursing or allied health expertise should develop close links with the TRT or specialist clinicians at their LHD tertiary referral centre.
All hospitals must have specific policies and procedures to guide the clinical management of patients with tracheostomies. These documents must be available at point of care. All LHDs are to provide continuing professional development programs that are appropriate to patient case mix, to ensure the competence of staff caring for patients with tracheostomies see Section J.
All hospitals are to have documented action plans that identify how to deal with tracheostomy tube emergencies see Section H.
Patients with tracheostomy tubes are to be cared for in ward areas that are able to provide care appropriate to the patient s general clinical condition and where adequate members of nursing staff have been assessed as being competent to care for these patients  there is adequate equipment to facilitate monitoring the patient is under close observation.
All LHDs must monitor and evaluate the outcomes of patients with a tracheostomy. At a minimum this should include regular and systematic evaluation using incident monitoring systems i. IIMS All patients with a tracheostomy tube must have a documented plan of care including discharge plan specific to tracheostomy care that is developed on insertion, reviewed on a regular basis and updated as required . Where available, the TRT assists the primary care team and the patient or designated proxy to develop this plan.
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All changes to the plan should t be written and verbally communicated to the primary care team and nurse caring for the patient. Grade of All HCP must maintain contemporaneous patient documentation. When transferring care between clinicians ideally a visual, verbal and written handover should occur including: Patient history including reason for TT, airway anatomy, physiology, Tracheostomy tube insertion date, type of tube, method of insertion, size and method of anchoring Date of next tube change Secretion management amount, colour, consistency, ability to cough and suction requirements Humidification method Oxygen requirements - current method, FiO 2 and SpO 2 target range Nutrition Communication method Patient Assessment s All healthcare professionals directly involved in patient care must complete and document patient assessment at Grade of intervals appropriate for the patient s general clinical condition; and pertains to the HCP scope of practice seetable 4 For nursing staff, this patient assessment should include: Airway patency includes evaluation of tracheostomy tube patency, effectiveness of stabilization method and cuff pressure Breathing includes chest auscultation Level of consciousness and orientation 1.
Patients should have a complete set of vital signs, including respiratory rate, blood pressure, heart rate, and temperature and oxygen saturation, at intervals appropriate for their general clinical condition.
Intensive care and high dependency: as clinical condition dictates Ward areas: - Routine post operative observations and - Tracheostomy observation chart - Stable post op period and patients discharged from ICU: Observations a minimum of 4 hourly for first 48 - Thereafter as clinically indicated, however, this interval is not to be greater than eight hours  When moved to a different clinical or diagnostic area. Continuous pulse oximetry should be in place where clinically indicated. Typically this may include patients: Grade of With a new or recently changed TT Receiving continuous oxygen 4lpm Experiencing an unstable respiratory status Changes in TT management Ventilatory support Essential Equipment s The type of mask required may vary if patient under droplet or airborne precautions humidification devices as appropriate appropriate waste receptacles for general and clinical waste bottle of sterile water to clean suction tubing after use labelled with date and changed daily spare inner cannula where dual lumen tracheostomy tubes are Care of Adult Patients in Acute Care Facilities with Tracheostomy Clinical Practice Guideline PAGE Sites may consider a cuffed TT is required in case of emergency tracheal dilators may also be considered To facilitate optimal clinical care and intervention under emergency circumstances, the following equipment should be available within wards where patient with a tracheostomy are cared for AND checked each shift and after use to ensure availability: Emergency trolley including resuscitation bag and airway equipment Patient monitor Tracheal dilators Patient Transportation between Clinical Areas This group of recommendations concerns movement between clinical areas including transfer to new ward settings, theatre or diagnostic units.