Tracheostomy Care Guidelines - · PDF file4 SH CP 214 Tracheostomy Care Guidelines Version: 1 October 2017 Tracheostomy Guidance 1. Introduction This document is intended to

1 SH CP 214 Tracheostomy Care Guidelines Version: 1 October 2017

SH CP 214

Tracheostomy Care Guidelines

Version: 1

Summary: These guidelines identify the principles and procedures for management of

patients with a tracheostomy within the community environment.

Keywords: Tracheostomy, Tracheostomy tube, stoma. Dilators. Suction. Suction catheter, humidification, airway

Target Audience: All clinical community staff within Southern Health who care for patients with a tracheostomies

Next Review Date: November 2020

Approved & Ratified by:

Patient Safety Group Date of meeting: 18 August 2017

Date issued: October 2017

Author: Sharon Guy, Lead Clinical Educator

Director: Clinical Director


Version Control

Date Author Version Page Reason for Change

Reviewers / contributors

Name Position Version Reviewed &

Date

Theresa Lewis Lead Infection and Prevention Nurse V1 05/2016

Hannah Connell Practice Educator V1 03/2017

Carol Adcock Associate Director of Nursing V1 03/2017

Christine Hayden Matron Integrated Service Division East V1 03/2017

Simon Johnson Head Of Essential Training V1 04/2017

Steve Coopey Head of Clinical Development Band 5-9 V1 07/2017

Jacky Hunt Infection Control Nurse V1 Sept 2017


Contents

Section Title

Page

1. Introduction 4

2. Definitions 4

3. Duties / Responsibilities 6

4. Main Guidance 7

5. Infection Control 12

6. Referral Process 13

7. Training Requirements 14

8. Monitoring compliance 15

9. Quality Standards 15

10. Policy Review 15

11. Associated Documents 15

12. References 16

Appendices

A1 Referral form/checklist for accepting patient for community 17

A2 Dressing change 20

A3 Tracheostomy tube change 21

A4 Tracheostomy clean and inner tube change 23

A5 Care of tracheostomy site 24

A6 Suctioning 25

A7 Humidification 27

A8 Infection Prevention 31

A9 Emergency Decannulation 32

A10 Competencies 33

A11 Training Needs Analysis 37

A12 Equality Impact Assessment Tool 38


Tracheostomy Guidance

1. Introduction

This document is intended to minimise the risks associated when caring for a patient with a tracheostomy in the community by ensuring that tracheostomy care guidance is available for staff to follow. This will support the delivery of high quality care and evidence-based practice. All clinical staff involved in caring and supporting patients with a tracheostomy should be aware of and adhere to the guidelines and associated procedures that provide information relating to the use of, changing of and maintenance or a tracheostomy tube and stoma site. These guidelines will enable the user to reduce the risk to patients and staff.

For patients these risks include, airway obstruction, tube displacement, infection and a wound dressing

For staff, risks include occupational exposure to infected sputum.

To maintain airway patency.

To prevent infection Procedures which support this guidance can be downloaded through the Trusts staff website include: Cleaning the stoma/changing the dressing/changing tapes Changing the tubes Applying suction as appropriate Applying humidification system as appropriate Management of accidental decannulation Purpose The purpose of these guidelines are to ensure the provision of evidence based practice, to all registered and non-registered staff including carers, which will ensure that all patients who have a tracheostomy have the best quality of care, minimising infection risk and /or obstruction of their airway and other side effects and maximising quality of life. Scope This guideline extends to cover those people who are registered with General Practitioners within the geographical Boundaries of Southern Health Foundation Trust (SHFT) and the responsibilities of those staff providing such service. This guideline refers to tracheostomy care in adults only.

2. Definitions

Aseptic Technique- Is defined as a means of preventing or minimising the risk of introducing harmful micro-organisms onto key parts or key sites of the body when undertaking clinical procedures. (Refer to the Aseptic Technique and Clean Technique Policy). Carina – A downward and backward projection of the lowest tracheal cartilage, forming a ridge between the openings of the right and left principal bronchi. Cuffed Tracheostomy Tube – these have a soft balloon around the distal end of the tube that can be inflated to allow for mechanical ventilation in patients with respiratory failure.


Decannulation – removal of a tracheostomy tube Encrustation – dried, hardened mucous. Fenestrated Tracheostomy Tube – these have an opening in the tube that permits speech through the upper airway when the external opening is blocked, even if the tube is too big to allow airflow around the outer cannula Humidification- Humidification may be defined as increasing the moisture content of the air. Hypoxia – abnormally low levels of oxygen in the inspired gases. Infection - The entry of a harmful microbe into the body and it’s multiplication in the tissues. Key sites - An area belonging to the service user where pathogenic organisms can enter the body and cause infection e.g. wounds, urinary tract, cannula insertion site. Key Parts Refers to the key sterile equipment parts. These key parts are the pieces of equipment that are manufactured sterile and would be in direct contact with the key sites of the service user or other key parts. They have the potential to transmit bacteria and / or microorganisms if they become contaminated. During aseptic technique procedure key parts must be protected from contamination. The principle is that you cannot infect a key part if it is not touched. Any key part must only come into contact with other key parts (e.g. sterile glove, sterile syringe tip and needle hub) non-key parts can be gripped firmly. Lumen – inner wall of a tube. Respiratory Distress – difficulty with breathing and the psychological distress associated with this. Speaking Valve – is a one way valve that allows air to enter through the tracheostomy tube and is expired past the vocal chords so speech is possible. Stoma A stoma is an ‘opening’ within the body which has been surgically created. Suctioning Is the insertion of a catheter and removal of secretions from a respiratory system. Tracheomalacia – is a condition characterized by flaccidity of the tracheal support cartilage which leads to tracheal collapse especially when increased airflow is demanded. Tracheostomy - A tracheostomy is a surgically created opening in the neck leading directly to the trachea. It is maintained open with a hollow tube called a tracheostomy tube. The tracheostomy tube is curved to accommodate the anatomy of the trachea. As well as helping someone to breathe, a tracheostomy can also be used to remove unwanted fluids produced by the lungs/throat. Tracheal Dilator -A tool that is inserted closed, into the visualised stoma, with care taken not to rest the dilators on the posterior tracheal wall. They are then opened at either 3 o’clock or 9 o’clock position by squeezing the dilator arms together until slight pressure is exerted upon the tracheal opening. The dilators will support the tracheal cartilage rings


open and prevent rapid stoma closure. Do we need to say this if we are just defining these terms? Are we expecting staff to use this tool? Tracheostomy tube -An artificial airway inserted in to the trachea to maintain patency of the airway. Uncuffed Tracheostomy Tube - maintains airway once aspiration risk has passed, and increase airflow to the larynx. This can be used in permanent or long term tracheostomy patients. Used for patients with poor or inadequate cough effort that require clearance of their secretions and who do not require a seal. Weaning – the process of gradually reducing the patient’s reliance on the tracheostomy tube by performing cuff deflation. At each stage in the weaning process the cuff deflation criteria should be met prior to commencing the next.

3. Duties and Responsibility The Director for Nursing, Allied Health Professionals and Quality has overall

responsibility for ensuring these guidelines are implemented. Tracheostomy care forms an integral part of patient care for which health care

professionals will be expected to maintain and develop their competence in accordance with the NMC The Code of Professional standards of practice and behaviour for nurses and midwives (2015). Competency will be demonstrated through the use of the current competency framework (available via the Southern Health intranet and attached to this guidance).

3.1 Registered Nurses must always refer to the current guidelines and competency

framework. 3.2 It is the responsibility of Registered Nurses transferring from other Trusts to demonstrate

competence prior to completion of the current Southern Health Foundation Trust Competency Framework. (Refer to Competency Framework on the Southern Health intranet, Appendix 10)

3.3 It is a requirement that Registered Nurses undertake training if competency cannot be

demonstrated or a need for training is identified. 3.4 All Health Care Professionals have a responsibility to work within the scope of their

practice, job description and must demonstrate current competency at their appraisal. 3.5 Line managers have a responsibility to support staff in the acquisition of training and

maintenance of competency. There is operational management responsibility for ensuring that there are sufficient mentors in practice to assess staff completing theoretical training. Line managers must ensure that appropriate equipment is available, maintained and stored correctly.

3.6 It is a general legal and ethical principle that Health Care Professionals obtain valid

informed consent prior to commencing treatment. That consent is based upon being given accurate information that is confirmed as having been understood, either verbally or in writing or by gesture. Consent must be documented in the patient’s notes. The Health Care Professional must adhere to the principles of the Mental Capacity Act 2005.

3.7 All record keeping must adhere to standards set out by the NMC The Code of

Professional Standards (2015) and Southern Health Record Keeping Standards and Audit Policy.


3.8 All Health Care Staff must be up to date with statutory and mandatory. 3.9 All Health Care Staff have a responsibility to work with in accordance to all relevant Policies and Guidelines which support patients with tracheostomy care 4. Main guidance 4.1 Assessment and eligibility for patients should be assessed and reviewed regularly by a

registered nurse. This should include a risk assessment of the environment and access to communication tools

4.2 Tracheostomy care may be provided to all adults over 18 years registered to a GP

practice in the Southern Health. Referrals will be triaged by the Community Care Teams and Community Hospitals as appropriate. The nurse must be fully informed and agrees to accept the referral. (See referral pathway and checklist appendix 1). Tracheostomy care referral must include the provision of equipment for the first seven days following transfer to the community environment.

4.3 The GP or Hospital Clinician has been consulted and documents that the patient’s

medical condition is suitable for the referral to be accepted. 4.4 Within a home setting, tracheostomy care must be compatible with the patient’s needs

and level of dependency and the capability of the Community Care Team: the expectation should be that tracheostomy care should not need to be undertaken more than twice daily.

4.5 Equipment required to perform the task must be provided by the referring acute

hospital or prior to discharge through the equipment store. 4.6 Within the Community, GP cover must be available and Out Of Hours medical cover

as required. 4.7 The patient’s general and mental health must be considered for home care to ensure

safe airway maintenance. 4.8 A risk assessment of the ability to receive this service at home must be completed,

including consideration of appropriate social circumstances and the patient must have access to a telephone or suitable communication device

4.9 Written information will be provided to the patient with details of how to access out of

hours support and education will be given regarding care of the tracheostomy by the named health care professional visiting them

4.10 Indications for Tracheostomy A tracheostomy can be temporary or permanent. It may be carried out:

To provide and maintain an airway for respiratory support (in a patient with a decreased level of consciousness, upper airway obstruction, coma, or neuromuscular disorders).

To enable the removal of tracheo bronchial secretions due to excessive secretions or inadequate cough.

To bypass any possible or actual upper respiratory tract obstruction (tumours, inflammation, trauma, or foreign bodies)

To aid in weaning patients from ventilatory support.


4.11 Communication

Normal pathway of communication is not possible when a tracheostomy tube is in place. Which means patient may not be able to speak once tube is in place. Patient and families should have been seen by a speech therapist prior to insertion of tracheostomy to advise them of different ways of communication that are available to them to promote communication It is advised that a simple means of communication between the patient and others should be agreed such as call bell, blinking, pen and paper/alphabet board, lip-reading. This allows the patient to communicate their wishes and enables them to maintain their identity and independence. Tracheostomy tubes with speaking valves may be available for the patient to be used. This will need to be assessed on an individual basis. Long-term supportive communication devices should be offered to the patient. On discharge home a risk assessment should be completed to determine patients access to communication sources especially for emergency support.

4.12 Equipment

All equipment required for a tracheostomy tube change, suctioning and humidification should be immediately available at all times for a patient with a tracheostomy in the event of the tube needing to be replaced urgently.

Suction unit, tubing and yankauer sucker (should be checked daily in an in-patient setting.

Sterile suction catheters (a selection of sizes)

Sterile water, sterile bowl for suctioning

Sterile and non-sterile gloves,

Aprons, eye/face protection ( Universal precautions)

2 spare sterile tracheostomy tubes (one should be the same type as the one inserted and the other one – a size smaller).

Tracheostomy securing tapes/ribbon

Tracheal dilators (sterile)

Tracheostomy mask

Oxygen cylinder and humidifier

10ml syringe

Normal saline

Dressing

Clinical waste bag (orange).

Nebuliser mask and tubing. (May be required) 4.13 Tracheostomy tubes 4.13.1 The main components of a tracheostomy tube are universal across the range of

designs. 4.13.2 There is a shaft that is arc shaped designed to be either a single cannula or a dual

cannula (inner and outer) tracheostomy tube. Tubes may be cuffed to provide an air tight seal to facilitate positive pressure ventilation and reduce the risk of aspiration. Each tube has an obturator for ease on insertion.


4.13.3 There is a neck flange which helps secure the tracheostomy tube to the skin of the neck and stabilise its position

4.13.5 Tracheostomy tubes come in a variety of sizes. The length and the diameter of the

trachea are roughly proportionally to the size of the individual. Selection of tracheostomy tube size should be according to the outer diameter, the inner diameter and the length of the tube, rather than the manufacturer’s size, which is not standardised between models and manufacturers

4.13.6 The outer diameter of the tracheostomy tube should be 2/3 to ¾ of the tracheal

diameter. 4.13.7 General rule: Most female adults can accommodate a tube with an outer diameter of

10mm, for most males outer diameter size would be 11mm. 4.13.8 A tube should be no wider than necessary to minimize trauma to the tracheal wall and

long term complications 4.13.9 The inner diameter of the tracheostomy tube will influence the work of breathing in a

spontaneously breath. 4.13.10 Special care is needed when checking the inner diameter of a tracheostomy tube. In the

case of a dual cannula tube with the inner cannula in place, the quoted inner diameter on the packaging may or may not reflect this and may be much smaller than anticipated.

4.13.11 In accordance with the International Standards Organisation System for size designation,

when the 15mm connector is part of the outer cannula, the manufacturer is not obliged to quote the inner diameter of the inner cannula, of which use is optional.

4.13.12 The ideal length of a tracheostomy tube is such that the tube tip lies a few centimeters

above the Carina 4.13.13 A tube which is too short carries a higher risk of accidental decannulation or partial airway

obstruction, due to poor positioning.

4.13.14 A tube which is too long may impinge on the carina leading to discomfort and coughing.

4.13.15 The tracheostomy tube should be fastened securely to the patient’s neck with neck ties 4.13.16 Ventilator tubing should be supported to reduce leverage on the tube with risk of tracheal

injury and accidental decannulation 4.13.17 A non-fenestrated single cannula tube with an air-filled cuff is suitable for most adult

patients who require a temporary tracheostomy during critical illness.1

4.13.18 Dual cannula tubes are inherently safer as the inner cannula may be removed quickly in

the event of obstruction and are therefore preferred for patients who continue to require a tracheostomy tube after discharge from the Critical Care Unit.1

4.13.19 Staff caring for these patients should be knowledgeable about the design and function of

these tubes. The type and size of a tracheostomy tube should be reviewed continuously as a patient’s condition changes. A wide range of specialty tubes are employed to optimise vocalization and comfort.

4.13.20 Fenestrated tubes may be considered for patients undergoing weaning from ventilation,

as they facilitate speech and reduce the work of breathing in comparison to non-fenestrated tubes.

https://www.stgeorges.nhs.uk/gps-and-clinicians/clinical-resources/tracheostomy-guidelines/tracheostomy-tubes/#ref



4.13.21 Staff should be aware that two types of inner cannula are supplied with fenestrated tubes; one with a fenestration to promote air flow and speech; and one without a fenestration for suctioning.

Due to the risk of surgical emphysema during positive pressure ventilation even when the non-fenestrated inner cannula is in place, the use of fenestrated tracheostomy tubes is not recommended in newly-formed stomas and should be limited to such time as the wound has healed sufficiently.

4.13.22 Cuffed tracheostomy tubes

To reduce the risk of tracheal injury, cuff management should include careful inflation technique to the minimal occlusion volume (MOV), followed by monitoring of inflation volume and cuff pressure. The cuff pressure should be maintained between 25-34 cmH2O, but preferably at the bottom end of this range, in order to minimize the risks of both tracheal wall injury and aspiration. Regular monitoring of cuff pressure is recommended at every shift (8-12 hourly), after any tracheostomy-related intervention, after any change in the cuff volume or upon development of an air leak. Common causes of excessive cuff pressure include undersized tracheostomy tube, poor tube positioning, and overinflated cuff and reduced lung compliance.

4.13.23 Uncuffed tracheostomy tubes These tubes are usually used for patients who can protect their own airway, have an adequate cough reflex and most importantly can manage their own secretions. They remove the risk of tracheal damage caused by inflation of the cuff, may aid swallowing and communication with the concomitant use of a speaking valve A speaking valve can only be used in patients who have airflow through their pharynx into their nose and mouth. Uncuffed tracheostomy tubes are frequently used for patients being cared for in the community or a hospital ward. A dual cannula uncuffed tube is preferred for safety and comfort as removal of the inner cannula for cleaning is not traumatic to the patient. Some tubes have low profile openings to make the tube more discreet.

4.13.24 Standard and longer length tracheostomy tubes Tracheostomy tubes are available in both standard and longer lengths. Standard length tubes are generally designed to accommodate patients with normal airway anatomy. However, the length and angulation of standard design tracheostomy tubes may be too short and unsuitable for some critical care patients, risking complications.6 Longer tracheostomy tubes are available with a fixed or adjustable flange (fixed or adjustable length). Fixed longer length tubes may be elongated in either the proximal portion (between the stoma and the trachea) or the distal portion of the tube (within the trachea). Extra proximal length is needed for patients with deep set tracheas i.e. large neck due to obesity, goiter, neck mass. Extra distal length is needed for patients with tracheal problems but normal neck anatomy i.e. tracheomalacia, tracheal stenosis. A flexible (reinforced) tracheostomy tube with an adjustable flange can be used in any of the above patients, although the locking mechanism of the neck flange may prove cumbersome for the patient, making it less suitable for long term use. In these cases, a dual cannula fixed longer length tube with the appropriate proximal or distal extension for the patient’s anatomy may be more comfortable.



Tracheostomy tubes must be used and maintained correctly, following the manufactures guidance and documented.

4.13.25 Changing a Tracheostomy Dressing (two members of staff may be required for this procedure. See appendix 3)

4.13.26 It is important that adequate infection control procedures are in place when caring for a

person with a tracheostomy as these people are at high risk of developing an infection 4.13.27 The stoma site should be assessed and cleaned daily or more often if required,

especially if the patient is expectorating secretions. 4.13.28 Soiled, moist dressings can contribute to infection and breakdown of the stoma

site. 4.13.29. The stoma should be assessed for slough/exudate, redness/cellulitis,

inflammation, and erosion/ulceration and bleeding. Red, excoriated or exuding stomas should be swabbed for culture and sensitivity. As per wound formulary guidance

4.13.30 A pre-cut foam dressing should be used due to their absorbency. 4.13.31 The tracheostomy dressing can be renewed without removing the tube. If

underneath the dressing the skin is sore or excoriated, a no-sting barrier cream should be used.

4.13.32 Patient monitoring Patients receiving Tracheostomy Care must be monitored using Physiological observation

chart (Adult Track and Trigger Tool). Physical observations to be decided upon according to individual patient assessment and therapy required and recorded in the patients care plan.

4.13.33 Because of the possible adverse effects of suction, the patient’ Oxygen saturation, respiratory rate, pattern and heart rate should be monitored closely.

4.13.34 Sputum yielded on suction should also be assessed for colour, viscosity and amount. Precautions

Pulmonary oedema Clotting disorders

4.13.35 Documentation

Documentation to incorporate the following when changing a Tracheostomy tube

Date

Time tube changed

Type of tube and size Suctioning required pre and post suction tube change

Any complication occurred

Physical observations 4.13.36 Removal This should be decided by the patient’s consultant. This procedure should not be carried out in the community 4.13.37 Humidification (See appendix 7)

Usually inspired air is filtered, warmed and moistened by the nose and the upper respiratory tract. Patients with a tracheostomy have this mechanism by passed, requiring


them to have artificial humidification to ensure the upper respiratory pathway remains moistened.

Inadequate humidification can lead to blockage of the tracheostomy tube. There are several alternatives to receive humidification and each patient will have their

own and should be aware of how it is to used and applied in accordance with the manufactures guidelines. (See appendix 7).

4.13.38 Suctioning (See appendix 6) Tracheal suctioning is required for secretion control which may be audible or visible, it is

required for maintaining patency of the tube. The use of routine suctioning should be avoided as suctioning can be hazardous to the patient. The frequency of suctioning should be assessed on the patient’s individual needs and should be documented. Factors that should be assessed are:

Patient’s ability to cough

The amount and consistency of secretions

The patient’s oxygen saturation levels.

Whether infection is present

Selection of correct suction catheter size

Risk factors associated with suctioning

Staff need to be aware of the hazards of suctioning

Hypoxia. Suctioning will diminish the amount of oxygen the patient is receiving. Each suctioning procedure should take no longer than 10-15 seconds to decrease the risk of trauma and hypoxia. Mucosal trauma. This can occur when the size of catheter is incorrect, when there is poor technique, or when suctioning is excessively high. The recommended suction pressure is 80-150mm Hg or 11-20 kPa for adults. Cardiac arrhythmias. This can occur due to hypoxaemia, or a vagal reflex brought about by the use of suction catheter. Raised intracranial pressure. This can occur if the suction catheter causes excessive tracheal stimulation resulting in coughing and an increase in intrathoracic pressure, both can compromise cerebral venous drainage. Infection risk. Both the patient and the caregiver are at risk of infection when suction is performed. Adhering to the trusts infection prevention policy and an aseptic technique will minimise this.

The person caring for the tracheostomy should personally make a record of what they have done as soon as possible after the event.

5. Infection control 5.1 All tracheostomy tube changes, wound care and suction administration requires the use of

an aseptic technique, in an inpatient setting and for the community a clean technique which allows the use of warm boiled tap water for cleansing in tracheostomies that are more than 72 hours old.

5.2 A tracheostomy tube, inducer, or suction catheter may be contaminated by the patient’s

skin flora at the insertion site or by the introduction of other organisms via the tracheostomy itself. The potential consequences of infection could lead to respiratory


distress. It is therefore important that staff undertaking this procedure must maintain excellent IPC standards at all times.

5.3 When performing hand hygiene the Health Care Professional must be bare below the

elbow with no nail varnish or false nails, plain wedding band only – no stoned rings. Skin should be intact and healthy – any cuts and abrasions must be covered with secure waterproof dressing.

5.4 It is important to decontaminate hands with soap and water or alcohol gel before and after

each patient contact and before applying / removing gloves. (EPIC 2014) 5.5 Aseptic technique requires risk assessment to determine use of sterile or non-sterile

gloves. If there is a likelihood of the health care professional touching the key parts of the system then sterile gloves must be worn. Please refer to table below from Aseptic Technique Policy 2014

6. Referral procedure 6.1 Treatment Pathway and discharge planning for community care teams 6.2 When a suitable patient has been identified a referral is to be made to the Community Care Teams via their referral point. 6.3 Seven days of equipment required to perform the care must be provided by the hospital on discharge from the hospital. 6.4 All hospital discharge information must be faxed or telephoned through to the patient’s GP. 6.5 A member of the Community Care Team will assess the patient to ensure the eligibility

criteria are met. 6.6 Patient to be assessed for suitability and risk prior to discharge. 6.7 Once the nurse is satisfied the patient meets all the criteria:

The service will be introduced to the patient and information provided. The patient will be given the opportunity to discuss the service with the member of staff before making the informed decision to have Tracheostomy care at home

6.8 Whenever possible the Community Nurse should be invited to the discharging hospital

to be involved with the discharge planning. This provides a useful opportunity for the nurse to familiarise his/herself with the patient’s Tracheostomy and tube If this is not possible then there should be a minimum of 48 hour notice of a patient’s discharge.


6.9 Referral information to the Community Care Team should include the tracheostomy size and requirements for suctioning. All information should be documented using the referral form (See Appendix 1).

6.10 Telephone referrals can also be made using the same referral form. A copy must be

faxed to the patient’s GP. All new referrals to be triaged by the Community Care Team and will be accepted following eligibility criteria and workflow capacity.

Tracheostomy Care Pathway

7 Training requirements 7.1 Initial Training: Prior to undertaking Tracheostomy care, all staff must be able to

demonstrate clinical competence in accordance with relevant current Southern Health policies and have a clear understanding of the underlying principles of practice. This will be achieved by Nursing and other health care staff:

Staff must maintain currency of the Basic Life Support and Anaphylaxis training. All staff should have completed Aseptic Technique e-presentation and successfully completed the Aseptic Technique e-assessment available via the LEaD website.

7.2 Continuing Professional Development:

Demonstrate competency in practice using the Southern health Foundation Trust competency framework tool.

Patient in an Acute Setting requiring Tracheostomy support at Home

Integrated community services.

Complete Tracheostomy Community Referral Form, Risk Assessment, Eligibility Criteria.

Refer to

Accept?

Patient not eligible for Tracheostomy care/support – refer back to Acute Hospital Trust. Consider alternative care environment

No

Yes

Community Care Team

Community Hospital

Assessment

GP/ Doctor accepts patient

Referral Form completed

Equipment available

Skills to support care in place


Staff who have been trained and practiced in a previous post may be allowed to demonstrate an equivalent level of competency through a period of supervised practice and the successful completion of the competency framework including knowledge and application of the policy.

Medical staff will demonstrate on-going professional development through annual appraisal and revalidation

8. Monitoring compliance

9. Quality Standards 9.1 All care should be delivered in accordance with evidence based practice. 9.2 All teams follow the Southern Health Complaints and PALS Policy; this includes

openness, transparency and the effective use of clinical incidents as a learning process 9.3 This policy will be reviewed 3 years from the date of approval or sooner in the event of

significant safety issues or changes of practice.

10. Policy Review This policy will be reviewed within 3 years 11. Associated trust documents 11.1 This guideline needs to be read in conjunction with the current organisational policies for:

Aseptic Technique and Clean Technique Procedure

Hand Hygiene Procedure Documents

Standard Precautions Procedure and Personal Protective Equipment

Handling and Disposal of Healthcare Waste Policy

Mental Capacity Guidance and Deprivation of Liberties Policy

Patient Identification Policy

Consent to Examination and Treatment policy

NMC The Code 2015

Physical Assessment and Monitoring Policies and procedures

Record Keeping Policies and associated documents

Medical Emergency Policy

Element to be

monitored

Lead Tool Frequency Reporting

arrangements

Competency in Tracheostomy care

Line manager

Competency Framework tool

Every two years

Annual appraisal

Competency in Tracheostomy tube change

Line manager


Every two years

Annual appraisal

Competency in suctioning a tracheostomy tube

Line Manager


Every two years

Annual appraisal


12. References

Burglass E (1999) Tracheostomy Care: Tracheal Suctioning and Humidification. British Journal of Nursing. 8(8) 500-504. Department of Health (DH) (2007) Saving Lives: Reducing Infection, Delivering clean and safe care, London, DH. Dancer S (2007) EPIC2: National Evidence-Based Guidelines for Preventing Health care associated Infections in NHS Hospitals in England, The Journal Of Hospital Infection, 65 (1) Supplement Feber T (2000) Safe Suctioning, Registered Nurse Griggs A (1998) Tracheostomy : Nursing Standard; 13(2): 49 Hough A (2001) Physiotherapy in Respiratory Care 3rd Ed, Nelson Thornes Higgins D (2005) Tracheal Suctioning. Nursing Times, 101: 8, 30-37 Macintyre & Branson (2001) Mechanical Ventilation. Saunders Manual of Clinical Nursing procedures, Marsden 11th ED, Blackwell Publishing, Oxford NMC (2015) The Code: Professional Standards of Practice and Behaviour for nurse and midwives, London. Pryor J, Prasad A (2001) Physiotherapy in Respiratory Care. Third Edition. Cheltenham. Nelson Thornes. St Georges Health Care NHS Trust (2011), Guidelines for the care of patients with Tracheostomy tube. Serra A (2000) Tracheostomy Care. Nursing Standard; 14: 42, 45-52.


Appendix 1 – Referral form checklist-for accepting a patient with a tracheostomy

Patient Sticker if available NHS

Name ……………………………..

DOB …………………………….. NHS No ……………………………..

Discharging unit/ward ………………………………

Consultant ……………………………... Date of Discharge ……………….......

Type of Tracheostomy (tick) Temporary /Permanent Date inserted

Reason for Tracheostomy

Type of tube in situ at transfer

Name of tube inserted

Rationale for tube chosen

Size of tube Cuffed/uncuffed……

If cuffed pressure and cuff regime

Single / dual-------------------------------------------

Management at discharge

Oxygen conc……………………. % Delivery system Humidification

� Thermovent

� Trache mask � HME

� T-Piece � Sodium chloride Nebs

� Cold Water Humidification

Date tube changed: Type of tube

Is speaking valve in place if so which type

Condition of stoma site

Wet Red Excoriated Ulceration

Has a wound swab been taken Yes/ No Date Result


Type of stoma dressing being used

Sputum Amount Colour of sputum

Is patient able to exporate by themselves?

Patients swallowing ability

No problems may eat and drink Yes No

Nil by mouth awaiting speech therapy assessment Yes/ No

Speech Therapy advice recorded in notes Yes/ No


Check list

Yes No If No, action required

The GP or hospital clinician has determined that the patient medical condition is stable for this treatment in the community setting and that the first tracheostomy change has taken place

Unable to accept for community

The GP or Hospital clinician is prepared to accept the medical responsibility agreed on the medicine referral form.


Patient has capacity to give and has given consent for discharge and airway maintenance


Patient has access to a telephone. Unable to accept for community

The patient’s social circumstances are appropriate to accepting a patient with a tracheostomy.

Unable to accept for community Care

The treatment regime can be sustained by the service with appropriate skills and staffing levels

Consider switch to other

treatment if clinically effective. Seek advice from Respiratory Nurse Specialist if required

Referral accepted by: _________________________________________________


Appendix 2 Tracheostomy Dressing Change

No Action Rationale

1 Explain the procedure to the patient.

To gain consent and co-operation

2 Extend the patient’s neck; do not lay the patient flat. To gain access to the tracheostomy dressing. Promote patient comfort.

3 Decontaminate hands, apply clean non sterile gloves, apron and eye/face protection. Refer to Infection Prevention and Control Policy

To minimise the risk of infection.

4 Loosen tracheostomy ties on one side with one assistant supporting the tracheostomy tube. (if competent this procedure can be carried out by one trained nurse or with support of a carer)

To gain access to dressing, to maintain placement of tracheostomy tube.

5 Using a non-touch technique remove old dressing and place into clinical waste bag

To avoid patient discomfort and prevent infection from occurring.

6 Remove gloves and decontaminate hands and apply new pair of non-sterile gloves

Prevent cross infection

7 Moisten a gauze swab with warmed boiled tap water (if stoma less than 72hrs old or in an inpatient setting, use sterile normal saline) gently wipe from the stoma outwards. Use a fresh piece of gauze each time.

To prevent excoriation of the skin surrounding the tracheostomy and to minimise the risk of infection.

8 Let stoma dry and apply a new dressing using aseptic technique

To minimise infection

9 Re-attach tracheostomy ties (again two person technique). Ensuring it is not too tight.

To secure the tube.

10 Ensure the new dressing is comfortable for the patient.

Promote patient comfort at all times.

11 Dispose of equipment appropriately. Refer to Infection prevention and Control Policy Standard and waste disposal policy

To ensure safe disposal of waste

12 Remove and dispose of gloves and apron and decontaminate hands

To prevent cross-infection.

13 Record action in patients’ care plan


Appendix 3 Changing a Tracheostomy Tube

No Action Rationale

1 Explain the procedure to the patient. To gain consent and co-operation.

2 Sit patient upright, slightly extend the neck. ( or in a position that they feel comfortable in

To ensure comfort and patient airway. Extending the neck will make removal and insertion of tracheostomy tube easier.

3 Observe patients vital signs and pre-oxygenate and suction of necessary

To monitor patient’s condition throughout the procedure

4 Prepare the new or replacing tracheostomy tube.

Ensuring it is kept clean at all times.

Prepare new dressing using a clean technique.

This should be an ‘aseptic technique’ in order to minimise infection, also it ensures all equipment is available.

5 Decontaminate hands, put on non-sterile gloves, apron and eye/face protection.

To minimise the risk of infection

6 Prepare the tracheostomy tube: thread the tape/Velcro ties through the slits in the flange so that the tape passes behind the flange next to the stoma.

Tape is kept behind the tracheostomy tube to prevent it occluding the tracheostomy tube.

7 Put the tracheostomy dressing around the tube, if required.

To prevent abrasion of the patient’s skin by the tube.

8 If lubricate is recommended by manufacturers guidelines use sparingly.

To facilitate insertion of the tube.

9 Loosen tube and clean around the stoma site, with warmed tap water. (in an inpatient setting or if stoma is less than 72 hours old use sterile normal saline) If the patient is able to have tube removed with no evidence of stoma closure or distress, tube could be removed here

To remove superficial organisms/crusts to prevent infection

10 Remove the soiled tube, (deflate cuff prior to removal if the tube is a cuffed tube), whilst asking the patient to breathe out.

Place soiled tube in to :

For inpatients and for stomas less than 72 hours old, place in to clean container with sterile normal saline.

For community patients, place tube in to a clean container with warmed tapped water.

Conscious expiration relaxes the patient and reduces the risk of coughing.

(Coughing can result in unwanted closure of the stoma)

11 Using an aseptic non touch techniques insert the new tube:

Remove introducer

Inflate cuff on a cuffed tube

To maintain airway

12 If the tube has an inner tube, insert this in to the main tracheostomy tube this in and secure as recommended by manufacturers.

Ensure patient has a patent airway, by asking them to

The inner tube can be changed whenever necessary, thus minimising the risk of trauma.

Confirming that tube is in correct


breathe out of their tube on to the back of your hand Position and patient has good air flow through it

13 Secure the tapes /ties at the side of the neck, ensuring that there is enough space to get two fingers in to.

To secure tube.

Ensure tapes are not too tight causing potential damage to skin integrity

14 Ensure patient is comfortable Patient comfort should be maintained at all times

15 Clean soiled tube under running water in line with manufacturer’s guidelines, if in a community setting.

For inpatient, clean as per manufacturer guidance with sterile water.

Dry using single use paper towel and store in an airtight container by patient’s bedside.

For inpatient settings store in a single patient use sterile container cover with a lid/sterile paper towel.

All single use tubes must be disposed of in accordance with Organisation Waste Management policy

To remove debris that could occlude the tube.

Reduce the risk of infection

17 Clear away equipment and dispose of correctly.

Ensure correct disposal of waste

18 Dispose of protective clothing and decontaminate hands

Prevent infection

19 Check patient vital signs To monitor patient condition following procedure

20 Record procedure in patients notes Maintain continuity of care and promote communication between staff/carers

Assessment

GP/ Doctor accepts patient

Referral Form completed

Equipment available

Skills to support care in place


Appendix 4 Changing and cleaning the inner cannula (tube)

No Action Rationale


2 Decontaminate hands and apply apron, non-sterile gloves and eye/face protection.

Pour warmed clean tap water in to a clean bowl.

In inpatient setting or for stoma less than 72 hours old use sterile water

To minimise the risk of infection

Cleaning solution for inner tube

3 Position patients neck slightly extended To gain access to the tracheostomy tube and for patient comfort

4 Monitor patients vital signs and pre-oxygenate and suction of necessary

Monitor patient vital signs through the procedure.

Maintain patient comfort

6 Gently remove the inner tube and place in the bowl of warmed clean tap water.

In inpatient setting or for stoma less than 72 hours old use sterile water

To loosen any crusts and mucous from the inner tube

7 Insert clean inner tube, following the manufacturers guidelines

To maintain tube patency

8 Reusable tubes should be cleaned using warmed clean tap water and as per manufacturers guidelines. Dry with a clean paper towel or as recommended by manufacturer. Store in a n airtight container or as recommended by manufacture

For community, this could be a clean airtight plastic container.

For inpatient setting this should be in a sterile receiver covered with a sterile paper towel,

Single use tubes should be disposed of appropriately depending on the patient environment.

Inpatient setting – in clinical waste

Community setting as per local authority guidelines

To remove excess mucous or crusting.

Maintain cleanliness

Ensure correct disposal of waste

9 Check the patient is comfortable and air way is clear To ensure patent airway

10 Dispose of equipment appropriately, remove gloves and aprons and decontaminate hands

To ensure safe disposal of waste and to minimise cross infection.

11 Document action and care given To promote communication between staff, maintain patient safety and continuity of care


Appendix 5 Care of tracheostomy stoma site

No Action Rationale


2 Decontaminate hands and apply an apron To minimise the risk of infection

3 Prepare equipment using a clean technique To ensure good preparation of performing a clean technique

4 Put on a clean pair of clean non sterile gloves To minimise the risk of infection

5 Remove soiled dressing and discard appropriately To prevent contamination

6 Remove soiled gloves, decontaminate hands and put on a pair of sterile gloves

To minimise the risk of infection.

7 Using sterile gauze clean the tracheostomy site with normal saline if in an inpatient setting, or with boiled tap water if in the community.

To remove exudate and or tried secretions

8 Using sterile gauze pat the stoma site dry To maintain skin integrity

9 Clean any dried excretions from base plate of tracheostomy tube in the same way as action 7&8

To remove superficial organisms/crusts to prevent infection

10 Assess the wound for any signs of infection, excoriation or over granulation

To prevent infection or abnormal healing

11 Apply a skin barrier if required and allow to dry Maintain skin integrity

12 Apply an appropriate tracheostomy dressing as per manufacturers guidelines

To prevent infection and promote would healing

13 Ensure patient is comfortable Maintain comfort

14 Remove gloves and apron and dispose of them appropriately and decontaminate hands

Minimise infection

15 Dispose of waste appropriately To ensure correct waste disposal

16 Document dressing change and any observation made To promote communication between staff, maintain patient safety and continuity of care


Appendix 6 Procedure for suctioning

Action

Rationale

Explain procedure to patient.

Encourage deep breathing (or pre oxygenate if O2 therapy required)

To reduce anxiety for patient, to gain consent and co-operation.

To reduce hypoxia and risk of alveolar collapse. (Higgins 2005)

Suctioning should be taught to the patient/carer if they are able.

Ensure patient can carry out this procedure safely prior to them practicing independently.

The patient may need suction at a time when the community nurses are not present.

To reduce the risks of complications.

Patients should use a 0.9% sterile saline nebuliser as required.

Do not instil bolus of saline in to tracheostomy tube. (Ackermann 1985)

To ensure secretions are not tenacious/ dry. A saline nebuliser can assist in loosening dry/thick secretions.(Hough 2001)

Reduces gaseous exchange.

Monitor patient vital signs To establish patient’s condition

Decontaminate hands and put on disposable apron, non-sterile gloves and eye/face protection.

To minimize risk of cross infection. Eye protection is important as patients can accidentally cough directly ahead at the nurse.

Ensure that the suction machine is set to the appropriate level. (60-150mmHG)

Ensure the suction apparatus is free from dust and debris and in working order.

Recommended suction pressure is 60-150mmhg or 8-20Kpa for adults (Pryor & Prasad 2001)

Excessive suction pressures can lead to Atelectasis, hypoxia and trauma to the mucosa (Feber 2000)

To reduce risk of infection

Select the correct size suction catheter using an appropriate calculation. As a guide the diameter of the suction catheter should be half the internal diameter if the tracheostomy tube. (Griggs 1998, Hough 2001)

To reduce the risk of Hypoxia and trauma during the procedure. (a catheter that is too large will increase this)

To ensure that suctioning is effective. (a catheter that is too small will be ineffective)

Hold the catheter at the opening of the packaging with the non-dominant hand and remove the catheter from the sleeve. Place the dominant hand on the suction catheter at about 15 cm from the distal end.

To prevent cross infection

Holding the catheter at this distance gives you a guide of how much catheter has entered the tracheostomy.

Gently insert the catheter into the tracheostomy tube. Aim to pass the catheter just past the end of the

Over insertion can cause the catheter to hit the Carina or enter the right main bronchus. This can increase the risk of


tracheostomy tube tip.

Do not apply suction on insertion – Ensure that the suction catheter has a suction port control.

trauma to the mucosa, as well as increase the risk of Vagal nerve stimulation and coughing.

Research has shown that every single insertion will cause some degree of trauma (feber 2000)

To prevent the catheter from causing trauma to the mucosa.

Apply suction by placing the thumb over the suction port control and withdraw the catheter gently.

Do not fold the catheter as a means to stop suction.

Do not suction the patient for more than one breath cycle 10-15 seconds. (Macintyre and Branson 2001)

Most suction catheters have multiple eyes at the suction end. It is not recommended that suction catheters are rolled between the fingers when suctioning.

Prolonged suction increases the risk of hypoxia, cardiac arrhythmias (vagal nerve stimulation) and the patient experiencing a feeling of choking. In a study it was found that 79% of patients felt this (Oermann et al 1983)

Folding the catheter and then releasing it applies a very rapid vacuum to the catheter tip.

Reduces the risk of trauma to the mucosa.

Assess patient and secretions that have been cleared.

Clear secretions away from around the tracheostomy site, use yankauer sucker if needed.

To determine if suction was effective or further suction is required.

To assess for infected, blood stained secretions.

Wrap catheter around gloved hand then pull back glove over soiled catheter, thus containing catheter in glove, then discard into clinical waste bag.

To reduce the risk of cross infection.

If patient requires further suction repeat, allowing enough time between each suction for the patient to recover. Use nebuliser as needed.

To prevent hypoxia

To increase humidity and aid removal of secretions.

Rinse suction tubing with sterile water and store suction unit as per manufacturer’s guidelines. Remember to change the suction receptacle as specified

To clear suction tube and reduce risk of cross infection.

Remove PPE and decontaminate hands Prevent infection


Appendix 7 Humidification

Usually inspired air is filtered, warmed and moistened by the nose and upper respiratory tract. Patients with a tracheostomy have the process by passed, meaning they require humidification to ensure the upper airway remains moist.

Inadequate humidification can lead to life threatening blockage of the tracheostomy, therefore the provision of adequate humidification of inspired gases is essential and can be provided to patients with minimal or low oxygen requirements using a heat moisture exchanger (HME) or cold water venture humidor system connected to a T piece or tracheostomy mask.

Reduction in temperature and humidity

Individual without Tracheostomy Individual with Tracheostomy

Air that has passed through upper respiratory tract has a

Temp: 36 – 37 degrees C

Humidity: 98% saturation

Air passing through the tracheostomy has a

Temp: 20 degrees C

Humidity: 42% saturation

Drying of the mucous membrane – (this comprises 95% water) causes:

Drying and crusting of the viscous layer, destruction of the cilia, damage to the mucous glands and mucosal ulceration.

Sputum retention – as a result of the above

Atelectasis

Reduced activity of surfactant

Increased risk of infection

There is considerable heat and moisture loss from the body via the tracheostomy.

All patients in the community setting who have a tracheostomy will need humidification.

It is vital that some form of humidification and filtration device is used. Providing patients with a means of filtering and humidity will prevent complications such as tube occlusion. Serra (2000).

Humidity and Filtering Devices for Ambulant Patients

Heat/Moisture Exchangers (HME)

There are many devices available and are known as Heat/moisture exchangers (HME). These conserve heat and moisture during expiration and return them to the inspired gas or air. There are many HME systems available on prescription (free for tracheostomy patients)

Examples of HME Devices (HME)


Benefits of HME

They offer effective humidification - Research has shown that by using such a device the temperature and humidity of inspired air can significantly be improved.

Individuals without a Tracheostomy

Tracheostomy tube without HME device

Tracheostomy with HME device

Inspired air temp in trachea: 36-37 degrees C

Humidity in trachea: 98% saturation

Inspired air temp in trachea: 20 degrees C


Inspired air in trachea:

29 degrees C


Most fit standard tubes with 15mm male connector.

Most offer an oxygen port.

Most offer a suction port (only to be used if suction is needed)

Most have a built in speech valve

Some have inbuilt bacterial filters.

Patients can be mobile.

Points to consider when using a HME system with your patients

The full benefits of the HME’s are only gained if used correctly. Encourage patients to:

Take the HME off when coughing up secretions – If it is full of secretions it will not work effectively. It can be replaced again if it is clean.

If it is removed for a short period e.g. during Nebulisers, coughing, place it is a clean area to reduce the risk of infection.

Replace regularly – Maximum recommended use time is 24 hrs or less if needed.


Patients may need some advice with regards to the products they are using. It is often the case that patients don’t fully understand how to use the products effectively. It is also important to be sure that you understand the products and how to reorder correctly. There are many HME systems available. Make sure you note the exact product codes you require.

Other types of Humidification Aids

Bibs or Protectors made from hydrolox foam acts as a filter and a heat/moisture exchanger. They can sometimes be hand-washed and reused (up to three times depending on the manufacturer)

Hot and Cold Water Mechanical Humidifiers

There are many mechanical humidifiers that provide hot or cold humidified air. Patients that tend to use these have permanent respiratory support. If you have patients with these systems it is important that you ensure the reservoirs are changed every 24hrs, with sterile water, to reduce the risk of infection. (Brown et al cited in Feber 2000)

Saline Nebulisers

Saline nebulisers provide a mist of droplets at room temperature. It provides the patient with moisture. This is ideal for loosening secretions and clearing the tracheostomy tube. They should be used in connection with HME systems.

The nebuliser pot and mask should be washed in hot soapy water and dried between uses. This reduces the risk of infection. Feber (2006)

All patients discharged to the community with tracheostomy should have a nebuliser machine. This is sourced prior to discharge via the GP practice, or purchased from a reputable pharmacy. These often run on compressed air, unless the patient requires oxygen therapy.

Each patient will need to be assessed with regards to frequency of nebulisers.

Nebulisers should be maintained as per manufacturer’s guidance and should only have sterile products used in them.

Factors that affect Humidity and Filtering requirements

Patients leaving the hospital environment will have become used to their humidification routine. On discharge however their needs for humidification may increase/decrease as a result of other factors outlined overleaf

Central heating/dehumidifiers in the home environment – Central heating systems can produce a dry atmosphere. This often differs to that of the hospital.


Pets or dust in the home environment can have an effect on patients, this could cause increased amounts of secretions, Patients may need to change their humidification aids more often.

Systemic hydration state – If a patient is dehydrated the mucus membrane will be drier, causing reduced mucocilliary transport causing retention of secretions.

These factors need to be taken into account and patients may need advice or guidance.


Appendix 8 Infection Prevention Tracheostomy Stoma

Care

Topic Best Practice Source of Recommendation

Stoma site

inspection

Regularly (at least daily or every visit) observe for signs of infection (e.g. pain, swelling, redness, exudate, fever. Document findings and actions in the patient’s notes.

Hand hygiene An aseptic or clean technique must be used for all Tracheostomy Care care. Decontaminate hands (using soap and water or alcohol hand gel/rub) before and after all tracheostomy care and when accessing the system.

EPIC 2014

Protective clothing Single use non-sterile disposable gloves, plastic aprons and protective eye /face wear must be used when caring for the tracheostomy tube and or stoma.

EPIC 2014

Choosing the right dressing

Use a sterile foam dressing

Frequency of

dressing changes.

Dressing should be changed daily or more frequently if soiled or wet

Local best practice

Stoma site

cleaning when changing tube.

Sterile normal saline should be used to clean stoma area unless the stoma belongs to a patient in the community with a stoma >72hrs (in which case tap water can be used as part of a clean technique)

Tube replacement Tube should be replaced as per manufacturer guidelines.

Aseptic technique should be used to replace tracheostomy tube.

Inner tubes should be replaced as per manufacturer’s guidelines.

Tubes should be stored as recommended by manufacturers guidelines

Suctioning of tracheostomy tube or stoma site

Aseptic technique should be used when suctioning a tracheostomy tube

Wear non sterile gloves as it’s the sterile suction catheter tip that is entering the key site and not the gloved hand


Appendix 9 Procedure for Emergency Decannulation

Action

Rationale

Reassure patient and try and keep them calm.

To control the situation and to maintain oxygen saturation levels

Assess patient airway, They may be able to breathe through stoma, especially if it is well healed and a good size. They may be able to breathe through the nose and mouth if there is no severe obstruction above the tracheostomy site

Maintain airway and oxygen saturation levels Establish if there is an airway as this will give time prepare to replace tube Reassure patent

Use tracheostomy dilators to maintain opening of stoma. Be careful when inserting dilators as they can cause trauma

To prevent the stoma from constricting and to maintain the airway.

Prevent trauma

Replace tracheostomy tube. The original one can be reused in an emergency, until it is safe to replace a clean/new tube

Maintain airway

If stoma site is to small and or you are unable to insert tracheostomy dilators, you can insert an cut off suction catheter to maintain an airway

Maintain airway and oxygen saturation levels

If you unable to replace existing size tracheostomy tube, try a smaller size tube

Smaller tube may be easier to insert

If you are having difficulty inserting tube with obligator, you can remove the obligator and place a cut off suction catheter in to stoma site (if you have not already done so) and then gently pass the tube over the suction catheter to try and insert it

Maintain oxygen saturation levels whilst trying to insert tube. Constriction may reduce

Once tracheostomy tube is replaced, ensure the patient is comfortable and settles and then record their physical observation and record on the physical observation chart.

To determine patient health and recovery Clinical decision to be made on how frequently the patient needs to be monitored

Determine why decannulation occurred. Risk assesses the potential of it happening again. Put procedure in place where possible to prevent it happening again

Reduce risk of situation happening again Early detection of potential safeguarding requirements

Record and document event in patients notes. Discuss with relevant MDT members as appropriate

Effective communication

If these procedures are not successful, then you must implement the Medical Emergency Procedure

Preserve patient life


Appendix 10 Tracheostomy clinical competencies

Name:

Role:

Base:

Date initial training completed:

Competency Statement:

The participant demonstrates clinical knowledge and skill in tracheostomy care without assistance and/or direct supervision (level 3 - see level descriptors). Assessment in practice must be by a Registered Nurse who can demonstrate competence at level 4 or above.

Performance Criteria Assessment Method Level achieved

Date Assessor/self-assessed

The Participant will be able to:

1. Demonstrate the knowledge and skill in meeting patient’s respiratory care needs

a) Demonstrate a good knowledge of anatomy and physiology related to the upper respiratory tract

Questioning

b) Discuss the following complications in relation to the anatomical and physiological changes in patients with tracheostomy.

I) Reduced airway temperature and humidity ii) Increased risk of atelectasis and chest infection iii) Reduced respiratory effort iv) Difficulties with speech v) Difficulties with swallowing vi) Possible reduction in cough reflex vii) Reduced sense of smell and taste

Questioning

c) Give a clear definition of a tracheostomy and the difference between this and other neck breathers e.g. laryngectomy

Questioning

d) Demonstrate knowledge and understanding of indications for tracheostomy

Questioning

e) Discuss the difference between Percutaneous and Surgical formed tracheostomy

Questioning

f) Discuss the advantages and disadvantages of these in relation to tube changing and stoma care issues

Questioning

g List complications that occur as a result of tracheostomy, giving rationale

Questioning

h) Demonstrate individual patient/client care to reduce or prevent complications occurring

Questioning


I) Discuss the advantages/disadvantages of single lumen and Double lumen tubes

Questioning

k) Discuss the purpose of a Fenestration and situations in which they should not be use

Questioning

2. Demonstrate practical knowledge and skill in tracheostomy care

a) Demonstrate safe inner tube removal and replacement

Observation

b) Demonstrate effective cleaning of the inner tube.

Observation

c) Discuss the rationale for tube changing and maximum recommended time for a tube to be left in situ

Questioning

d) Demonstrate a good working knowledge of all equipment that may be needed in tube changes e.g. Tracheal dilators, Tracheostomy tubes/holders/tapes, Cuff manometer (Only for cuffed tubes)

Observation

e) Demonstrate ability to identify potentially difficult tube changes and liaise as required with other members of the MDT

Questioning

f) Demonstrate effective tube changing technique

Observation

g) Demonstrate effective securing of the tracheostomy tube

Observation

h) Record all relevant details of tube change in Patients/Clients notes.

Observation

I) Demonstrate an understanding of Strategies that can be used in difficult tube changes

Questioning

j) Demonstrate the ability to teach and give rationale to Patients/Clients with regards to the above

Observation / questioning

3. Demonstrate practical knowledge and skill in humidification

a) Demonstrates an in-depth knowledge and understanding of the need for humidification

Questioning

b) Demonstrate the ability to recognise when humidification is inadequate and take appropriate action

Observation

c) Demonstrate accurate documentation in patient/clients notes to ensure continuity of care with regards to humidification needs

Observation

d) Practitioner demonstrates an ability to teach and give rationale to patients/clients with regards to the following:

I) Care/Storage/Cleaning of all

Observation


humidification equipment

ii) Factors that affect Humidity requirements

iii) Use of Humidification aids (HME) and appropriate use

e) Demonstrate accurate documentation in patient/clients notes to ensure continuity of care with regards to humidification needs

Observation

4. Demonstrate practical knowledge and skill in suctioning

a) Demonstrate knowledge of the complications associated with tracheal suction

Questioning

b) Discuss ways in which patients can be helped to expectorate without the use of suction

Questioning

c) Demonstrate ability to liaise appropriately with other members of the MDT as required

Observation

d) Demonstrate research based safe and effective suction technique including the following:

I) Ability to select the correct size suction catheter, giving rationale

ii) Use of correct inner tube in tracheostomy, giving rationale

iii) Demonstrates correct suction technique and suction pressure

iv) Care/Storage/Cleaning of Suction equipment

v) Ability to teach Clients/Patients/Carers all of the above

Observation

5. Demonstrate practical knowledge and skill in care of the stoma

a) Demonstrate knowledge of the effects of a tracheostomy on the surrounding skin and has an awareness of the complications that can occur

Questioning

b) Perform skin care and change dressings appropriately using research based practice and correct aseptic technique

Observation

c) Demonstrate a good working knowledge of any dressings/creams used

Observation

6. Demonstrate practical

knowledge and skill in meeting the patient’s communication needs


Source: SUHT

Date all elements of Competency Tool completed to level 3________

Name _______________________ Signature _______________ Status ___________ Date _______

I confirm that I have assessed the above named Registered Nurse and can verify that he/she demonstrates competency in

tracheostomy care

Assessor ______________________ Signature _______________ Status ___________ Date _______

a) Demonstrate a detailed knowledge of speech aids and their appropriate use including risks and contraindications.

Questioning

b) Demonstrate an ability to identify when patients/clients are producing speech as a result of tube occlusion and can take immediate appropriate action

Questioning

7. Demonstrate practical

knowledge and skill in managing resuscitation and risk

a) Demonstrate knowledge of resuscitation on a tracheostomy patient or other neck breathers (Laryngectomy), outlining the differences from non-tracheostomy patient.

Questioning

b) Demonstrate an understanding of tube management during resuscitation (cuffed tube)

Questioning

c) Demonstrate and clearly explain to patients/clients the need for caution when bathing etc.

Questioning

Review

Dates:

Competent

Yes / No

Registered Nurse

Signature

Verifier signature Comments


Appendix 11

Training Needs Analysis

If there are any training implications for your policy please complete the form below and contact the Learning, Education and Development department (LEaD) on 02380874091 before the policy is approved.

Training programme: Tracheostomy Care

Frequency: Once only

Course length: 6 hours

Delivery method: Face to face

Trainer(s) Clinical training team

Recording attendance: MLE

Strategic and operational responsibility:

Paula Hull

Divisional Director of Nursing

Division Target audience

Adult Mental Health Not applicable

Learning Disabilities Not applicable

Older Persons Mental Health All Health Care Professionals required to provide Tracheostomy care as part of their job description

Specialised Services Not applicable

TQtwentyone Not applicable

Adult Physical Health All Health Care Professionals required to provide Tracheostomy Care as part of their job description

Children’s Not applicable

Corporate (HR, Governance, Estates, etc.)

Not applicable


Appendix 2: Equality Impact Assessment

The Equality Analysis is a written record that demonstrates that you have shown due regard to the need to eliminate unlawful discrimination, advance equality of opportunity and foster good relations with respect to the characteristics protected by the Equality Act 2010.

Stage 1: Screening

Date of assessment: 13/03/17

Name of person completing the assessment: Steve Coopey

Job title: Head of Clinical Development

Responsible department: LEaD

Intended equality outcomes: Service users are able to access this service as identified solely by clinical need and therefore this policy does not discriminate against service users

Who was involved in the consultation of this document?

Infection Control

Please describe the positive and any potential negative impact of the policy on service users or staff.

In the case of negative impact, please indicate any measures planned to mitigate against this by completing stage 2. Supporting Information can be found be following the link: www.legislation.gov.uk/ukpga/2010/15/contents

Protected Characteristic Positive impact Negative impact

Age x

Disability x

Gender reassignment x

Marriage & civil partnership x

Pregnancy & maternity x

Race x

Religion x

Sex x

Sexual orientation x

Stage 2: Full impact assessment

What is the impact? Mitigating actions Monitoring of actions

http://www.legislation.gov.uk/ukpga/2010/15/contents