Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_4773_Библиотеки_им_академика_М_И_Перельмана.pdf
The community team should be contacted after 1 week to confirm tube
style/size, which may have had to be changed during the first week. The
231
progress of supply orders should also be checked. Discussion of respite
and carer support should be broached with the community team. Most
children will be discharged back via their local hospital, which will allow
local services and support to be activated. Negotiations to do this should
begin as soon as the tracheostomy is formed.
The formation of a tracheostomy must be confirmed (usually by
telephone) with the child's:
• Health Visitor (HV)
• General Practitioner (GP)
• Paediatric Community Nurse (PCN)
• school (including school nurse if applicable)
• local hospital.
This should occur as soon as practical following the insertion of the
tracheostomy. An equipment list and introductory letter should be sent so
that equipment can be ordered, minimising potential delays on discharge
from hospital.
However, some children, such as those who have had a planned
tracheostomy or who have been in hospital for a long time, may be
discharged home straight from a tertiary hospital. Some equipment may
have to be provided to facilitate this, which should be discussed
individually with the communities involved. Ensure that the portable
suction unit has been collected from the community team before the day
of discharge, brought to the hospital for the transfer home and the parents
are aware of how it works.
The child's parents, or two main carers, must be taught and be deemed as
competent in the following:
• tracheostomy tube changes (minimum of two)
• tracheostomy tape changes
• stoma care
• suctioning
• resuscitation skills/emergency care
• staying and doing an overnight stay with the child and carry out all
care overnight
• feeling confident in taking the child out of the hospital.
232
Sometimes it is not possible to complete all the training at the primary
hospital and local teams may have to complete some elements of the
training. This should be explicitly communicated. Tracheostomy care and
resuscitation booklets are available to support carer training. The GOSH
booklets are available from the GOSH website, with the links available at
the end of this chapter. All training received must be recorded on the
child's discharge planner and kept in their health record for future
reference.
Parents and carers will need to be taught tracheostomy BLS and
‘mouth-to-trachy’ resuscitation for going home. In addition to the other
equipment required, they must be given a catheter mount 15 mm female,
and two emergency Velcro tapes. Community teams will usually supply
the equipment for the child's discharge home. Depending on the type of
tube inserted, other relevant emergency equipment may include:
• two pairs of Velcro tapes
• two disconnection wedges
• two tracheostomy extensions +/− male-to-female adapters
Parents require both theoretical and practical teaching/practice of both
emergency algorithms, namely, action to take on a blocked tube and
action to take if the tracheostomy tube cannot be replaced (Seldinger
technique).
Follow-up
Follow-up is very important for children with tracheostomies. Practices do
vary, however, and there are often local influences on the decision.
Commonly, an 8-week ENT outpatient appointment will be arranged prior
to discharge (unless indicated otherwise by the medical team). Although
community teams will usually supply the equipment for the child's
discharge home, it is important that parents and carers have the correct
emergency equipment (and knowledge of how to use it) for as soon as the
patient leaves hospital. This starts as soon as the child leaves the ward and
includes the journey home.
233
Further information
General Information
GOSH general information guide (http://www.gosh.nhs.uk/
EasySiteWeb/GatewayLink.aspx?alId=80519): Covering
indications, tubes and humidification
GOSH ‘TRACHE’ poster (Figure 9.30)
Figure 9.30 GOSH ‘TRACHE’ poster.
Reproduced with permission of GOSH.
234
235
GOSH pdf guides and leaflets
• Staff competency—home preparation
• Staff competency—ventilated child
2
• Carer competency—home preparation
3
• Carer competency—ventilated child
4
• GOSH BLS guide for parents and carers—BLS guide
5
• New tracheostomy discharge algorithm
6
• New tracheostomy equipment form
7
Information for parents of a child with new tracheostomy
• Living with a tracheostomy
8
—GOSH webpage
• Living with a tracheostomy
9
—pdf leaflet
1
http://www.gosh.nhs.uk/health-professionals/clinical-guidelines/
tracheostomy-care-and-management-review/
2
http://www.gosh.nhs.uk/EasySiteWeb/GatewayLink.aspx?alId=80518
3
http://www.gosh.nhs.uk/EasySiteWeb/GatewayLink.aspx?alId=80516
4
http://www.gosh.nhs.uk/EasySiteWeb/GatewayLink.aspx?alId=80514
5
http://www.gosh.nhs.uk/EasySiteWeb/GatewayLink.aspx?alId=81820
6
http://www.gosh.nhs.uk/EasySiteWeb/GatewayLink.aspx?alId=80513
7
http://www.gosh.nhs.uk/EasySiteWeb/GatewayLink.aspx?alId=80512
8
http://www.gosh.nhs.uk/medical-conditions/procedures-and-treatments/
living-with-a-tracheostomy/
9
http://www.gosh.nhs.uk/EasySiteWeb/GatewayLink.aspx?alId=81821
236
Chapter 10
Infrastructure considerations
Introduction
In order to safely care for patients with tracheostomies in our hospitals, we
need to address the organisation and infrastructure of the clinical areas
where patients with tracheostomies and laryngectomies will be managed.
This is important outside the hospital in community organisations and the
homes of patients.
As part of this project, we have been able to look at policies and
documentation of many Trusts. We have also been able to view detailed
reports from coronial inquests and serious untoward incident reviews,
which have helped to inform the following pages.
This section includes guidance regarding infrastructure and resources for
hospital inpatient areas, an example tracheostomy policy and risk
assessment. Competencies for tracheostomy care and management are
presented in Chapter 11.
Hospital inpatient
management
Any clinical area can potentially look after neck-breathing patients, but
these areas must be:
• adequately staffed
• adequately trained
• adequately equipped
• adequately supported.
In order to do this effectively, most Trusts will have to cohort patients
with tracheostomies together into designated wards. This allows training
237
and equipment to be targeted and concentrates expertise and experience.
Nominated areas would typically include:
• critical care areas
• head and neck wards
• designated respiratory/medical/surgical wards.
Patients with tracheostomies or laryngectomies should not be cared for
outside these areas. This has implications for the flow of patients into, out
of and around a hospital, and the bed managers will need to be adequately
involved in planning patient movement. Patients can also come directly
from the community or through the emergency department.
Given here are the key areas to consider for those designated wards.
1. Competency and training
a. Staff must have received documented training appropriate to
their duties.
b. Staff must have knowledge of where to find additional
resources (some of the resources presented as part of this
project could be considered ‘just-in-time’ training).
c. Staff must know who to call and what to do in an emergency.
2. Equipment provision
a. Wards must be stocked with airway- and
tracheostomy-specific equipment.
b. Only suitable tubes should be used in non-specialist
locations (uncuffed, inner cannula).
c. There must be immediate access to a fibreoptic endoscope.
d. Bedside emergency equipment must be available at all times
and accompany the patients if they move around the hospital.
e. Equipment must be checked and a means of documenting
this must be in place.
3. Staffing numbers
a. Extra staff may be required if the dependency of a
tracheostomy patient requires it.
b. Consideration of one-to-one nursing/nursing auxiliary on
initial step-down from a higher level of care for 24–48 h.
4. Discharge planning
a. Multi-disciplinary
238
b. Documented.
5. Follow-up
a. Patients who have had a tracheostomy should be followed up
by a clinical team able to:
i. assess for long-term complications;
ii. diagnose and either treat such complications, or have
access to appropriate services.
b. Follow-up should be offered to patients who have been
decannulated and those in whom a tracheostomy tube remains
in situ.
c. Patients with long-term tracheostomies should also undergo
periodic review by a team able to assess and manage potential
long-term complications, and able to assess the ongoing need
for the tracheostomy to remain.
d. Medical and multi-disciplinary follow-up arrangement must
be clear and documented.
6. Documentation
With regard to inter-hospital transfer between acute hospital sites, it is the
responsibility of the transferring/discharging hospitals/units to ensure that
the patient transfer is communicated to the relevant team(s) within the
receiving Trust. Adult patients with tracheostomies should only be
transferred to hospital sites where there is appropriate arrangement in
place to adequately care for the patient's needs.
Draft tracheostomy policy
outline
The policy detailed here is an example based on amalgamated policies
from several hospitals in the North West Region of England. Clearly,
hospital policies will vary, but this is included to give the reader a
framework if you were considering writing your own tracheostomy policy.
It may be useful to designate specialist areas (ICU; HDU,
high-dependency unit or a head and neck unit), non-specialist areas
239
(nominated, trained, adequately staffed and equipped to care for patients
with tracheostomies) and then all other clinical areas.
Duties within the organisation
Chief Executive
The Chief Executive is responsible for ensuring the requirements within
this policy are fulfilled and operational responsibilities are in place when
patients who are ‘neck breathers’ are nursed on general wards.
Chief Nurse
The Chief Nurse is responsible for ensuring requirements within this
policy are fulfilled and that this policy is disseminated to all Heads of
Nursing for appropriate action.
Executive Medical Director
The Medical Director is responsible for ensuring that this policy is
disseminated to Consultants who supervise medical staff in training and
that education and training facilities are available to ensure medical staff
can maintain the level of clinical standards to appropriately manage
patients who trigger on the Modified Early Warning Score (MEWS).
General Managers
The General Managers will ensure that adequate resources are available
within their divisions to make provisions within this policy feasible.
Consultant (or lead clinician)
The Consultant is the professional with the overall clinical responsibility
for patients, and therefore will ensure patients cared for in a designated
area other than their allocated ward will receive a daily visit from a
240