ACI Tracheostomy Point of Care Audit tool

Point of care Audit tool – ward areas

Instructions:

1. Where multiple elements exist the answer must be yes to all items unless specified

  1. Can be used to evaluate multiple patients across a ward or hospital setting or care of individual patients across their stay
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Possible answers

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1

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2

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3

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4

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5

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6

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7

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8

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9

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10

1 /

Communication – patient has communication strategy in place AND call bell within reach (yes for part 2 if patient is unconscious

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Yes/No

/ / / / / / / / / / 2 /

Patient has documented Tracheostomy plan in place which has been reviewed within last 24hrs

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Yes/No

/ / / / / / / / / / 3 /

Patient assessment (see below) for past 24 hrs

 clinical observations have been documented and actioned in accordance with clinical status

  • documentation of evaluation of need for and outcomes of suctioning
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Yes/No

/ / / / / / / / / / 4 /

Nurse caring for patient is an enrolled nurse or registered nurse AND has or is supervised by a registered nurse who has completed a tracheostomy training program within past 2yrs

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Yes/No

/ / / / / / / / / / 5 /

All safety equipment (see below) is available, functional and has been checked within past 24 hours

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Yes/No

/ / / / / / / / / / 6 / The tracheostomy tube is secure /

Yes/No

/ / / / / / / / / /

1. Tapes changed within last 24 hrs (NA if < 24 hrs since insertion)

2. TT does not move more than 1cm in any direction

3. Able to insert small finger between tapes

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4. If Tube is an Adjustable flange

  1. Flange position marked & documented in notes
  2. Inspected & documented within past shift

7 /

Cuff pressure

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1. Has been checked & documented within last 4 hours AND

2. between 20-30cmH2O

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Yes/No/NA

/ / / / / / / / / / 8 / Humidification /

 Heat moisture exchanger (HME) – clean & checked within last 2hrs OR

 Active – Temp > 37 C, H2O level > 1/3

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Yes/No

/ / / / / / / / / / 9 /

Inner Cannulae

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1. is patent

2. cannulae has been cleaned within last 4hrs AND

3. spare clean & dry inner cannulae within bed area

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Yes/No/NA

/ / / / / / / / / / 10 /

Stoma

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 Dressing attended within past 24 hours AND Dressing clean & dry OR

 No dressing - Stoma clean & dry with no secretions

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Yes/No

/ / / / / / / / / / Patient Assessment – must be undertaken in accordance with Between the Flags Program / Safety equipment – wards should clearly identify what equipment should be available in specific areas
  • Airway patency (includes evaluation of tracheostomy tube patency, effectiveness of stabilization method and cuff pressure)
  • Breathing (includes chest auscultation)
  • Level of consciousness and orientation
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  • Routine post operative observations and
  • Tracheostomy observation chart
  • Stable post op period and patients discharged m 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 / Within bed area
  1. Oxygen
  2. Suction equipment
  3. Spare inner cannula (where applicable)
  4. Sterile water
  5. Humidification devices as appropriate
  6. Emergency response plan
/ Immediately adjacent to bed area
  1. Cuff manometer & 10ml syringe
  2. PPE
  3. Waste receptacles
  4. Spare tracheotomy tubes
+/- tracheostomy transport box / Within ward
  1. Resuscitation trolley (includes intubation equipment and tracheal dilators)
  2. Patient monitor

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