TRACHEOSTOMY CARE PATHWAY€¦ · TRACHEOSTOMY CARE PATHWAY PATIENT DETAILS, ASSESSMENT AND CARE...
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Adapted from St Georges ICP with permission April 2015 1 TRACHEOSTOMY CARE PATHWAY PATIENT DETAILS, ASSESSMENT AND CARE PATHWAY FOR PATIENTS WITH TEMPORARY OR PERMANENT TRACHEOSTOMY Patient Name: Or attach PAS label Trust ID Number: Date of birth: Date of Tracheostomy insertion: Reason for insertion: Size & Type of tube: Date of Last Tracheostomy change: Known complications (including infection status): Grade of intubation: Ongoing Tracheostomy tube change record : The tracheostomy tube should be changed every 28 days (medical device). It may be required earlier depending on patient’s clinical needs. (Device sticker must be placed in health records) Type and size Date inserted Fenestrated Yes/ No Cuff Yes/ No Type and size Date inserted Fenestrated Yes/ No Cuff Yes/ No Type and size Date inserted Fenestrated Yes/ No Cuff Yes/ No Type and size Date inserted Fenestrated Yes/ No Cuff Yes/ No Type and size Date inserted Fenestrated Yes/ No Cuff Yes/ No Date of decannulation : Goals of care for a patient with a tracheostomy : 1. To prevent occlusion or accidental decannulation of tracheostomy 2. To be able to manage occlusion or accidental decannulation of tracheostomy 3. To ensure effective secretion management and identify early onset of complications 4. To ensure effective stoma care and identify early onset of complications 5. To ensure the patient has the ability to communicate 6. To implement a successful weaning strategy for decannulation
Transcript of TRACHEOSTOMY CARE PATHWAY€¦ · TRACHEOSTOMY CARE PATHWAY PATIENT DETAILS, ASSESSMENT AND CARE...
Adapted from St Georges ICP with permission April 2015 1
TRACHEOSTOMY CARE PATHWAY PATIENT DETAILS, ASSESSMENT AND CARE PATHWAY FOR PATIENTS
WITH TEMPORARY OR PERMANENT TRACHEOSTOMY
Patient Name: Or attach PAS label Trust ID Number: Date of birth:
Date of Tracheostomy insertion: Reason for insertion: Size & Type of tube: Date of Last Tracheostomy change: Known complications (including infection status): Grade of intubation:
Ongoing Tracheostomy tube change record : The tracheostomy tube should be changed every 28 days (medical device). It may be required earlier depending on patient’s clinical needs. (Device sticker must be placed in health records)
Type and size
Date inserted Fenestrated Yes/ No Cuff Yes/ No
Type and size
Date inserted Fenestrated Yes/ No Cuff Yes/ No
Type and size
Date inserted Fenestrated Yes/ No Cuff Yes/ No
Type and size
Date inserted Fenestrated Yes/ No Cuff Yes/ No
Type and size
Date inserted Fenestrated Yes/ No Cuff Yes/ No
Date of decannulation :
Goals of care for a patient with a tracheostomy : 1. To prevent occlusion or accidental decannulation of tracheostomy 2. To be able to manage occlusion or accidental decannulation of tracheostomy 3. To ensure effective secretion management and identify early onset of
complications 4. To ensure effective stoma care and identify early onset of complications 5. To ensure the patient has the ability to communicate 6. To implement a successful weaning strategy for decannulation
Adapted from St Georges ICP with permission April 2015 2
RISK ASSESSMENT TO DETERMINE THE MOST APPROPRIATE CLINICAL ENVIROMENT FOR A PATIENT WITH A TRACHEOSTOMY The following risk factors must be taken into consideration when determining an appropriate clinical environment for a patient with a tracheostomy. Any of these factors place the patient at a greater risk of airway obstruction, requiring more frequent observation by trained and competent staff and greater visibility at all times. These should form the principles for the risk assessment for the patient that should be determined by the lead clinician. RISK FACTORS include:
o Patient discharged from critical care in last 48 hours o Tracheostomy less than 7 days old o Patients requiring a single lumen tracheostomy tube for clinical reasons o Patients with known complex airway and / or difficult endotracheal intubation or tracheostomy
tube insertion (a bed head sign MUST be used to indicate this) o Patients at risk of self decannulation due to delirium or agitation. o Patients with an obstructed upper airway (who are dependent on their tracheostomy for
breathing) or dependent on ventilatory support.
PLEASE ENSURE PRIOR TO DISCHARGE TO WARD: o The Critical Care Outreach Team (or similar) have been informed o A Tracheostomy Discharge Plan (including weaning assessment) has been completed for
patients discharged from a specialist area. o The patient is cared for in a designated area o The designated area has been given 24 hours notice before the patient has been admitted from
a specialist area. o Any patient with a tracheostomy tube will have a double cannulae tube sited (preferably uncuffed
if appropriate) o Time of discharge from a specialist area, or transfer between wards, is not between 2200 and
0700 (except in emergencies where transfer is into a critical care area) o A tracheostomy care plan is in use and completed correctly. o An emergency airway box is always at the patients bedside o Emergency Algorithms and bedsign are displayed above the patients bed where appropriate o Suction equipment is connected and working o An oxygen supply is available at the bedside o All other emergency equipment is available on the ward. o The patient is nursed in a bed which is easily observable to nursing staff, unless receiving
ongoing 1:1 nursing. o The patient is receiving appropriate humidification. o A referral is made to the physiotherapy team for an assessment, and implementation of a ward
management plan. o An adequate supply of all necessary equipment is available on the receiving ward o A patient transfer form should be completed within the BSUH Safety Documentation booklet
Documentation: Section 1: Handover plan to ward Section 2: Daily bedside checklist Section 3: Care plan & suction record Section 4: Weaning plan MDT notes
Adapted from St Georges ICP with permission April 2015 3
In care plan document: o A (Achieved i.e. actually done) OR o NA (Not applicable) OR o V (Variance i.e not done or statement not achieved) & elaborate in variance
Insert additional sheets as required
STAFF SIGNATURES Please fill in this section prior to making an entry in this document, you only need to do it once. Please mark whether you are trained and competent to care for patients with a tracheotomy.
Print Name Signature Staff number Designation Trachy S/D & Competency Completed Y/N (For WM/CCOT audit)
Adapted from St Georges ICP with permission April 2015 4
Section 1 a: Handover plan for a patient with a tracheostomy from critical care or specialist area to ward See page 1 for insertion details and tracheostomy type Date: Tracheostomy cuff status:……………………………………………. Oxygen therapy: ……………………………………………………….. Target saturations :…………………………………………………….. Communication needs:………………………………………………… Speaking valve: Y /N Length of time:…………… Oral care requirements : ……………………………………………… Nutrition needs:…………………………………………………………. Referred to SLT : Date ……………………………………. Physiotherapy plan:……………………………………………………. ……………………………………………………………………………… Complex weaning : Y / N If Yes team / individual responsible for supervising weaning : …………………………………………………………………………….. Weaning plan:…………………………………………………………… ………………………………………………………………………………. ………………………………………………………………………………… Completed By :……………………….. PRINT NAME…………………………..
Adapted from St Georges ICP with permission April 2015 5
Section 2 : BEDSIDE TRACHEOSTOMY CHECKLIST TO BE COMPLETED AT THE START OF EVERY SHIFT AT BEDSIDE HANDOVER
Patient Name:
Hospital Number:
DATE
SHIFT: DAY NIGHT DAY NIGHT DAY NIGHT DAY NIGHT
TIME:
Non-rebreathe circuit and catheter mount
Availability on ward of Adult Ambu-bag (BVM)
Oxygen flow meter (check function)
Suction unit - check working, set at 20 kpa
Appropriate size of Suction catheter available
2 x Yankeur suction catheters
Bottle of sterile water and pot to flush tubing
Bedside Emergency Box
Spare trachy tubes (same type, 1 same size and 1 one size smaller)
Tracheal dilators
10ml syringe
Stitch cutter
Aquagel / water soluble lubricant
Cuff manometer
Disconnection wedge
Appropriate humidification system
Spare tracheostomy dressing
Spare tracheostomy tapes
Spare, clean and dry inner tube (in pot with lid)
Trachy tube cleaning swabs, sterile water and dish to clean inner tube at bedside
Laminated head of bed sign with details of who to call for tracheostomy emergency
Speaking / Passy Muir valves
Audible nurse-call system within patient reach
Signature
Adapted from St Georges ICP with permission April 2015 6
Section 2 : BEDSIDE TRACHEOSTOMY CHECKLIST TO BE COMPLETED AT THE START OF EVERY SHIFT AT BEDSIDE HANDOVER
Patient Name:
Hospital Number:
DATE
SHIFT: DAY NIGHT DAY NIGHT DAY NIGHT DAY NIGHT
TIME:
Non-rebreathe circuit and catheter mount
Availability on ward of Adult Ambu-bag (BVM)
Oxygen flow meter (check function)
Suction unit - check working, set at 20 kpa
Appropriate size of Suction catheter available
2 x Yankeur suction catheters
Bottle of sterile water and pot to flush tubing
Bedside Emergency Box
Spare trachy tubes (same type, 1 same size and 1 one size smaller)
Tracheal dilators
10ml syringe
Stitch cutter
Aquagel / water soluble lubricant
Cuff manometer
Disconnection wedge
Appropriate humidification system
Spare tracheostomy dressing
Spare tracheostomy tapes
Spare, clean and dry inner tube (in pot with lid)
Trachy tube cleaning swabs, sterile water and dish to clean inner tube at bedside
Laminated head of bed sign with details of who to call for tracheostomy emergency
Speaking / Passy Muir valves
Audible nurse-call system within patient reach
Signature
Adapted from St Georges ICP with permission April 2015 7
Section 3: TRACHEOSTOMY Suction and inner tube change record Patient Name:
Hospital Number:
Remove and clean inner tube at least 4 hourly (IT). Sign time and initial Suction PRN (S) (note secretions, and frequency required) Document findings (using key) & sign
Date
IT S IT S IT S IT S IT S IT S IT S 0100 0200 0300 0400 0500 0600 0700 0800 0900 1000 1100 1200 1300 1400 1500 1600 1700 1800 1900 2000 2100 2200 2300 2400
Tracheal suction Key - secretions
M Mucoid Y Yellow B Blood stained P Purulent T Thick F Frothy Pl Plugs O Other N None + 1 suction ++ 2 suctions Oral suction OR
Adapted from St Georges ICP with permission April 2015 8
Section 3: TRACHEOSTOMY Suction and inner tube change record Patient Name:
Hospital Number:
Remove and clean inner tube at least 4 hourly (IT). Sign time and initial Suction PRN (S) (note secretions, and frequency required) Document findings (using key) & sign
Date
IT S IT S IT S IT S IT S IT S IT S 0100 0200 0300 0400 0500 0600 0700 0800 0900 1000 1100 1200 1300 1400 1500 1600 1700 1800 1900 2000 2100 2200 2300 2400
Tracheal suction Key - secretions
M Mucoid Y Yellow B Blood stained P Purulent T Thick F Frothy Pl Plugs O Other N None + 1 suction ++ 2 suctions Oral suction OR
Adapted from St Georges ICP with permission April 2015 9
Section 3 : TRACHEOSTOMY CARE PLAN To be completed ON EVERY SHIFT Patient Name:
Hospital Number:
DATE:
START OF SHIFT: TIME
Tracheostomy equipment checklist completed (YES / NO)
If using cuffed tube - cuff pressure checked and between 15-25 H2O. If unable to achieve this pressure contact critical care outreach for advice
FiO2 required (YES / NO) If YES state percentage
Humidification device in use (YES/NO ) If YES state which type
How often should respiratory observations be completed?
Is regular suctioning required (YES / NO) If YES state frequency
Recommended frequency of oral care
Signature
END OF SHIFT: TIME
Inner cannula inspected and cleaned at least 4 hourly (YES / NO)
Record of suction completed (YES / NO)
Sputum specimen Sent? (YES / NO)
Stoma condition: describe e.g. healthy, inflamed, oozing, leaking
Wound swab sent? (YES / NO)
Dressing changed? (YES / NO) If more than once state frequency
Tapes changed ? (YES / NO)
Signature
VARIANCES: If routine care is not carried out please state reason clearly
Adapted from St Georges ICP with permission April 2015 10
Section 3 : TRACHEOSTOMY CARE PLAN To be completed ON EVERY SHIFT Patient Name:
Hospital Number:
DATE:
START OF SHIFT: TIME
Tracheostomy equipment checklist completed (YES / NO)
If using cuffed tube - cuff pressure checked and between 15-25 H2O. If unable to achieve this pressure contact critical care outreach for advice
FiO2 required (YES / NO) If YES state percentage
Humidification device in use (YES/NO ) If YES state which type
How often should respiratory observations be completed?
Is regular suctioning required (YES / NO) If YES state frequency
Recommended frequency of oral care
Signature
END OF SHIFT: TIME
Inner cannula inspected and cleaned at least 4 hourly (YES / NO)
Record of suction completed (YES / NO)
Sputum specimen Sent? (YES / NO)
Stoma condition: describe e.g. healthy, inflamed, oozing, leaking
Wound swab sent? (YES / NO)
Dressing changed? (YES / NO) If more than once state frequency
Tapes changed ? (YES / NO)
Signature
VARIANCES: If routine care is not carried out please state reason clearly
Adapted from St Georges ICP with permission April 2015 11
SECTION 4:
WEANING PLAN : This should be an MDT decision to proceed with weaning Ensure patient is in an upright position, suction trachea & oropharynx, oral hygiene before commencing weaning
DATE: Date Time Date Time Date Time
Initials Initials Initials
1. Cuff deflated +/- synchronised cuff deflation
Yes / No If “yes” go to step 2 If “no” – stop to not proceed any further
Yes / No If “yes” go to step 2 If “no” – stop to not proceed any further
Yes / No If “yes” go to step 2 If “no” – stop to not proceed any further
2 . Finger occlusion : Is there air flow through the mouth ?
Yes / No If “yes” go to step 3 If “no” it could indicate an obstruction – do not proceed. Discuss with ENT/ ICU team – consider downsizing tube
Yes / No If “yes” go to step 3 If “no” it could indicate an obstruction – do not proceed. Discuss with ENT/ ICU team – consider downsizing tube
Yes / No If “yes” go to step 3 If “no” it could indicate an obstruction – do not proceed. Discuss with ENT/ ICU team – consider downsizing tube
3. Is there a fenestrated tracheostomy tube in situ ?
Yes/ No If “yes” insert fenestrated inner cannula (will need plain inner tube for suctioning)
Yes/ No If “yes” insert fenestrated inner cannula (will need plain inner tube for suctioning)
Yes/ No If “yes” insert fenestrated inner cannula (will need plain inner tube for suctioning)
4. Apply speaking valve or cap
Speaking valve / cap / neither Speaking valve / cap / neither Speaking valve / cap / neither
5. Planned length of time for:
Cuff down :……………… Speaking Valve:…………… Cap:…………………………
Cuff down :……………… Speaking Valve:…………… Cap:…………………………
Cuff down :……………… Speaking Valve:…………… Cap:…………………………
6. Actual length of time managed for point 5
Hours:…………… Minutes:………….
Hours:…………… Minutes:………….
Hours:…………… Minutes:………….
7. If planned time not achieved – why not (e.g. increased work of breathing , excessive secretions, fatigue)
Comments Comments Comments
8.Suggested progression
Adapted from St Georges ICP with permission April 2015 12
SECTION 4:
WEANING PLAN : This should be an MDT decision to proceed with weaning Ensure patient is in an upright position, suction trachea & oropharynx, oral hygiene before commencing weaning
DATE: Date Time Date Time Date Time
Initials Initials Initials
1. Cuff deflated +/- synchronised cuff deflation
Yes / No If “yes” go to step 2 If “no” – stop to not proceed any further
Yes / No If “yes” go to step 2 If “no” – stop to not proceed any further
Yes / No If “yes” go to step 2 If “no” – stop to not proceed any further
2 . Finger occlusion : Is there air flow through the mouth ?
Yes / No If “yes” go to step 3 If “no” it could indicate an obstruction – do not proceed. Discuss with ENT/ ICU team – consider downsizing tube
Yes / No If “yes” go to step 3 If “no” it could indicate an obstruction – do not proceed. Discuss with ENT/ ICU team – consider downsizing tube
Yes / No If “yes” go to step 3 If “no” it could indicate an obstruction – do not proceed. Discuss with ENT/ ICU team – consider downsizing tube
3. Is there a fenestrated tracheostomy tube in situ ?
Yes/ No If “yes” insert fenestrated inner cannula (will need plain inner tube for suctioning)
Yes/ No If “yes” insert fenestrated inner cannula (will need plain inner tube for suctioning)
Yes/ No If “yes” insert fenestrated inner cannula (will need plain inner tube for suctioning)
4. Apply speaking valve or cap
Speaking valve / cap / neither Speaking valve / cap / neither Speaking valve / cap / neither
5. Planned length of time for:
Cuff down :……………… Speaking Valve:…………… Cap:…………………………
Cuff down :……………… Speaking Valve:…………… Cap:…………………………
Cuff down :……………… Speaking Valve:…………… Cap:…………………………
6. Actual length of time managed for point 5
Hours:…………… Minutes:………….
Hours:…………… Minutes:………….
Hours:…………… Minutes:………….
7. If planned time not achieved – why not (e.g. increased work of breathing , excessive secretions, fatigue)
Comments Comments Comments
8.Suggested progression
Adapted from St Georges ICP with permission April 2015 13
Additional multi disciplinary notes : Date & time
Notes Signature Discipline
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Date & time
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Signature Discipline
