Tracheostomy Care on the Wards

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TRACHEOSTOMY CARE ON THE WARDS

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CONTENTS

QUICK REFERENCE GUIDE

1.INTRODUCTION

2.PURPOSE

3.SCOPE

4.DEFINITIONS

5.DUTIES AND RESPONSIBILITIES

6.PROCESS

7.TRAINING REQUIREMENTS

8.REFERENCES AND ASSOCIATED DOCUMENTATION

9.EQUALITY IMPACT STATEMENT

10.MONITORING COMPLIANCE WITH PROCEDURAL DOCUMENTS

EQUALITY IMPACT SCREENING TOOL

QUICK REFERENCE GUIDE

What to do if a patient with a tracheostomy is admitted to the ward

(NB also refers to admission of patient with a laryngectomy)

1. INTRODUCTION

Patients who require tracheostomies are generally managed on the head and neck unit or the Intensive Care Unit (ICU) by the respective specialist teams. Some patients however may be discharged from the ICU with a tracheostomy still in place and therefore will need to be managed on a general ward with specialist input. The tracheostomy will be reviewed regularly by the Tracheostomy Support Team (TST) and as needed by ICU outreach, however daily nursing care of the tracheostomy will be provided by ward staff.

The tracheostomy may still be needed for airway protection in the case of neurological conditions leading to a reduced level of consciousness or the inability to protect the airway (e.g. stroke, head injury). The tracheostomy may also be needed to aid secretion clearance in patients who have an ineffective cough due to muscular weakness (e.g. prolonged ICU stay) or an underlying neurological condition (e.g. multiple sclerosis). Patients who have a tracheostomy for an upper airway obstruction will mostly be managed on the specialist head and neck unit.

Most of the tracheostomies placed on the ICU are temporary, and may stay in for a couple of days up to a few months. Occasionally some patients require a long term tracheostomy. While the tracheostomy is in place it needs to be cared for to maintain the patency of the tube, to prevent infections and to prevent or manage complications associated with a tracheostomy. In the case of temporary tracheostomies there will be ongoing assessment as to when the tracheostomy can be removed, a process called decannulation.

The elements of care associated with a tracheostomy together form a care bundle and fall under the following headings.

1. Assessment of patient

1. Maintenance of the tracheostomy and stoma
2. Humidification to prevent secretions blocking the tracheostomy
3. Regular cleaning and inspection of inner tube to prevent narrowing and blockage
4. Regular suctioning to prevent secretion build up
5. Change of tracheostomy dressing and attention to tracheostomy tapes/ties

1. Infection control
2. Correct method of suctioning to avoid introduction of infection
3. Regular assessment of tracheostomy stoma
4. Regular assessment of respiratory secretions

1. Safety
2. Check list of essential bedside equipment
3. Bedside emergency algorithms with key contact numbers
4. Use of bedhead signs containing key information regarding the tracheostomy for use in an emergency

2. PURPOSE

This document has been developed to:

• Guide all staff in the care of adult patients with temporary tracheostomies within Portsmouth Hospitals Trust.
• To provide best available local/national evidence for the management of temporary tracheostomies.
• To help reduce potential complications associated with tracheostomies.
• To provide clear guidance in who to contact in the event of an emergency.

3. SCOPE

This guideline applies to all patients within Portsmouth Hospitals Trust who have a tracheostomy in place, excluding patients on the Intensive Care Unit. For patients on the head and neck unit who have a surgical tracheostomy placed as part of their treatment, the document may be used alongside departmental guidelines. The principles of the care and safety bundle are applicable to patients with temporary as well as long term tracheostomies.

This guideline does not apply to paediatric patients with tracheostomies.

4. DEFINITIONS

Tracheostomy: A tube placed through an incision at the base of the neck into the trachea.

Airway: This refers to the structures that air passes through leading from the nose and mouth down to the lungs.

Patent airway: An airway that allows free flow of air down to the lungs, and allows expelled air to pass from the lungs back out again is called a patent airway.

Obstructed airway: This is an airway where there is complete or partial obstruction to the free flow of air. This could be due to a blockage (e.g. tumour, swelling) or due to reduced muscular tone leading to the collapse structures.

Protected airway: This is an airway where reflexes are in place to prevent fluid (e.g. stomach contents, drink) going into the lungs. An airway can be patent yet not protected.

Tracheostomy support team: This is a multi-disciplinary team who will review at least once a week, all in patients who have a tracheostomy in place. They will guide the management and care of the tracheostomy till the tracheostomy is either removed, or the patient is discharged with the tracheostomy. Contact is made via the Critical Care outreach team.

5. DUTIES AND RESPONSIBILITIES

The authors and Tracheostomy Support Team

6. PROCESS – see following

1. ASSESSMENT OF PATIENT

As part of patient assessment at the start of each shift, the tracheostomy should be specifically discussed and important points communicated.

When taking over the care of a patient with a tracheostomy: Think TRACHE

2. MAINTENANCE OF TRACHEOSTOMY AND STOMA

A. Humidification

Inadequate humidification may lead to life-threatening blockage of the tracheostomy tube

Self ventilating patient requiring oxygen therapy

• Minimal/loose secretions

• Thick/dry secretions
• Difficult to clear secretions
• Evidence of consolidation

Self-ventilating patient not requiring oxygen therapy

This can be shown as a ‘humidification ladder’ with a stepwise increase, or degree in the intensity of humidification depending on the clinical situation.

Humidification ladder (modified from National Tracheostomy Safety Project 2013)

B. Care of inner cannula

The inner cannula must be removed, inspected and cleaned at least 4 hourly to prevent narrowing and blockage.

C. Suctioning

Any difficulty in passing the suction catheter should lead to consideration that the tube may be partially blocked or misplaced and requires immediate attention.

Note: If the patient is able to cough secretions to the opening of the tracheostomy then a Yankeur sucker can be used to suction the secretions from the opening rather than perform a deep suction

Pre procedure

Sequence of events

1. Insert suction catheter without applying suction until approximately 1/3 of the catheter is in situ or until the patient coughs
2. Withdraw the catheter 0.5-1cm and apply suction by occluding the suction port with gloved thumb
3. Continue withdrawing the catheter applying continuous suction until it is removed from the tracheostomy tube
4. The entire process should not exceed 10 seconds
5. Remove the glove from the dominant hand by inverting over the used catheter and dispose of in a clinical waste bag
6. Reattach oxygen within 10 seconds
7. If another suction is needed a new sterile catheter and sterile glove must be used
8. Do not do more than 3 episodes of suctioning in succession
9. If oxygen was increased prior to suctioning then return to previous levels
10. Flush through the connection tubing with clean water and wash hands after
11. Record procedure and secretions on tracheostomy care chart

If the suction catheter will not pass easily

• Do not force it
• Withdraw and ensure the patient’s head is in alignment
• If the catheter will still not pass check inner tube for blockages
• If the catheter will still not pass call for senior assistance
• If tube occluded and patient in respiratory distress call 2222 and follow the emergency algorithm

If blood noted on suctioning

• Ensure oxygen applied, check observations, call for senior assistance
• If patient in respiratory distress or haemodynamically unstable call 2222 and follow the emergency algorithm

D. Tracheostomy dressing and ties

This is a two person procedure which needs to be performed at least once per 24 hour period. The tracheostomy should be adequately secured to prevent displacement.

• Purulent discharge
• Pain
• Odour
• Abscess formation
• Cellulitis and discolouration

E. Cuff pressure check

The cuff pressure should be checked a minimum of once every 8 hour shift

3. SAFETY

Essential bedside equipment

This must be checked and documented at the beginning of each shift

• Spare tracheostomy tubes: same size as in place plus one size smaller, CUFFED AND UNFENESTRATED

• 10ml syringe

• Tracheal dilators

• Bag valve mask (BVM)

• Lubricating gel

• Spare inner cannula

• Working suction unit (80 -150mmHg unless otherwise directed)

• Appropriately sized suction catheters (see formula below)

• Yankeur sucker x 2

• Personal protective equipment: sterile and non sterile gloves, apron/eye protection

• Sterile water and container

• Tracheostomy mask/Swedish nose

• Humidified oxygen (if indicated)

• Tracheostomy dressing, tapes/ties

• Tissues for patient (if appropriate)

• Working call bell or other means of communication

• Bedside documentation

Formula for suction catheter size

Tube size x 3 divided by 2

e.g. tube size 8 x 3 = 24 divided by 2 = size 12

BEDHEAD SIGNS

These should be in place for every patient with a tracheostomy or laryngectomy. They will be completed by the tracheostomy support team, critical care/anaesthetic team or ENT staff and on one side will indicate that the patient has a tracheostomy or laryngectomy and on the reverse will have further information needed by the specialist responder.

RED FLAGS

These are warning signs that there is a potential problem related to the tracheostomy. They should trigger a reassessment of the patient and their tracheostomy and a call for more senior help if needed.

Ward care charts

7. TRAINING REQUIREMENTS

Training will be disseminated through the Tracheostomy Support Team/Critical Care outreach team.

A ‘Guide to tracheostomies on the ward’ providing further background reading is also available.

Tracheostomy competencies have been developed and a link person for tracheostomies will be created on the wards where patients with tracheostomies are likely to be admitted.

8. REFERENCES AND ASSOCIATED DOCUMENTATION

Documents used when preparing this care bundle are:

1. National Tracheostomy Safety Project
2. Standards for the care of adult patients with a temporary tracheostomy. Intensive Care Society 2008.

This document will be updated as further evidence becomes available.

9. EQUALITY IMPACT STATEMENT

Portsmouth Hospitals NHS Trust is committed to ensuring that, as far as is reasonably practicable, the way we provide services to the public and the way we treat our staff reflects their individual needs and does not discriminate against individuals or groups on any grounds.

This policy has been assessed accordingly

Our values are the core of what Portsmouth Hospitals NHS Trust is and what we cherish. They are beliefs that manifest in the behaviours our employees display in the workplace.