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member of the team. The Consultant will ensure that clinical standards are
maintained and that any necessary deviation from this policy is
documented and explained in the medical notes.
Heads of Nursing
Heads of Nursing have a responsibility to ensure that this policy is
disseminated to Matrons and Ward Managers to inform clinical staff of
their responsibilities in the safe care of patients who are neck breathers. In
collaboration with Matrons and Ward Managers, Heads of Nursing must
ensure that adverse clinical incidents in relation to the care of patients who
are neck breathers in their clinical areas are reported and investigated and
action plans produced to prevent future occurrence.
Matrons and Ward Managers
Matrons and Ward Managers have a responsibility to ensure that any staff
responsible for caring for patients who are neck breathers receive training
on their care and management and recognise when to escalate care to the
appropriate people. Matrons and Ward Managers have a responsibility to
ensure that all clinical staff have access to equipment and documents for
providing safe care for patients who are neck breathers.
Bed Managers
Bed Managers must ensure that patients with a tracheostomy/
laryngectomy admitted to a general ward from a critical care area,
specialised ward or from any community setting must be cared for in the
designated areas. These areas will be identified following a Trust-wide
consultation process.
Critical Care/Specialist Ward clinical staff
Most patients with a tracheostomy discharged from a specialist ward
should have an uncuffed tracheostomy tube with an inner cannula sited.
Exceptions to this must be clearly justified (reduced conscious level,
excessive secretions, inability to protect the airway). Standardising or
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limiting the different types of tubes available may make teaching easier
and reduce potential confusion with tubes. At least 24 h notice should be
given to the receiving ward when a patient is being discharged from a
specialist area. This will ensure the receiving ward can make all necessary
preparations to safely accept responsibility for the patient with a
tracheostomy.
A tracheostomy Care Plan will be completed by the discharging team, and
be communicated to the receiving ward nurse and agreed on before the
patient is discharged from the Critical Care/Specialist Ward. This will
ensure that a full handover of care is given and the receiving ward can
maintain a safe environment for the patient with a tracheostomy. A risk
assessment should be completed and agreed on with the receiving ward.
Any problems with the tracheostomy should be clearly communicated (see
draft risk assessment).
Receiving ward clinical staff
The receiving ward should ensure that the patient with a tracheostomy/
laryngectomy is nursed in a bed that is observable from the nursing station
and, wherever possible, not in a side room. As a general rule, the patient
should be nursed in an open observation area, rather than a side room
(unless continuous 1 : 1 staffing is provided). Discussion with infection
control teams should take place, as close observation for airway
compromise is likely to take priority over use of a side room for infection
control purposes. The receiving ward should ensure that patients with a
tracheostomy/laryngectomy must have access to a nurse call bell and other
communication aids, if they are able to use them.
If patients do not have adequate means of communication because of their
clinical state, then adequate provision for one-to-one care must be
adopted. The receiving ward should ensure that patients with a
tracheostomy or laryngectomy requiring oxygen must have an oxygen
supply and suction equipment at the bedside, and that the oxygen is
prescribed on their prescription chart. Any patient with a tracheostomy/
laryngectomy who is oxygen dependent should have their oxygen warmed
and humidified. The receiving ward should ensure that the patient with a
tracheostomy has the emergency airway box at the patient's bedside at all
times. The appropriate bedhead sign should be completed describing the
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details of the tracheostomy. This form will be completed by the person
performing the tracheostomy or by a competent member of staff if a
patient is admitted to the Trust with an existing tracheostomy.
Patients with a tracheostomy/laryngectomy must have regular checks
carried out as per the tracheostomy/laryngectomy Care Plan and patient
bedside checklist. The receiving ward should ensure that the patient with a
tracheostomy/laryngectomy has been referred to the Physiotherapy and
Speech & Language teams if appropriate.
Critical Care Outreach Team
Some hospitals have ‘Outreach Teams’ who are well placed to support
and assist ward staff with caring for neck-breathing patients and often play
a vital educational role. Systems need to be in place to notify Outreach
Teams if a neck-breathing patient is admitted or transferred.
Emergency teams
Any patient with a tracheostomy or laryngectomy who develops breathing
difficulties or displays any of the ‘Tracheostomy Red Flags’ need prompt
assessment by someone trained to do so. For tracheostomy/laryngectomy
problems (or where clinical deterioration may be related to the airway) the
patient must be seen by the ENT or MaxFax team (for ENT or MaxFax
patients), or by the relevant medical team, within 30 min. Contact details
are displayed on the appropriate bedhead signs. For an emergency related
to the airway, decide in advance who should be called (depending on your
hospital setup)
Hospital Incident Reporting System (HIRS)
Most hospitals have a system for recording adverse events and facilitating
subsequent investigation. If a patient's care is affected by a failure to
provide appropriate infrastructure or not following a local policy, then the
Hospital Incident Reporting System (HIRS) system is a useful way of
recording this and improving the systems.
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Standards and key performance
indicators and process for monitoring
compliance
The following standards and key performance indicators could be used for
monitoring compliance to a tracheostomy policy, monitored via audit.
• The Critical Care Outreach Team (or similar) have been informed
of any patient nursed on a general ward within the Trust with a
tracheostomy or laryngectomy.
• A tracheostomy/laryngectomy Discharge Plan has been completed
for patients discharged from a specialist area.
• The patient is cared for in a designated area.
• The designated area has been given 24 h notice before the patient
has been admitted from a specialist area.
• Any patient with a tracheostomy tube will have an uncuffed
double-cannulae tube sited (if appropriate).
• Time of discharge from a specialist area is not between 22.00 and
07.00.
• A tracheostomy/laryngectomy Care Plan is in use and completed
correctly.
• An emergency airway box is always at the patient's bedside.
• Emergency algorithms are displayed above the patient's bed where
appropriate.
• Suction equipment is connected correctly and working.
• An oxygen supply is available at the bedside.
• other emergency equipment is available on the ward
• The patient is nursed in a bed that is easily observable to nursing
staff.
• If administering oxygen via a stoma it is humidified.
• A referral is made to physiotherapy for a daily and weekend visit.
• An adequate supply of all necessary equipment is available on the
receiving ward.
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Dissemination, implementation and access to this
document
All staff working on a receiving ward will receive documented training
and education on the care of the patient with a tracheostomy or
laryngectomy on a regular basis.
Risk assessment
The following risk factors must be taken into consideration when
determining an appropriate clinical environment for a patient with a
tracheostomy.
• Patient discharged from critical care within last 48 h
• Tracheostomy less than 7 days old
• Patients requiring a single-lumen tracheostomy tube for clinical
reasons
• Patient known to have a complex airway and/or difficult
endotracheal intubation or tube insertion (bedhead sign)
• Patients unable to call for help (including unable to use call system)
• Patients at risk of self-decannulation:
• Delirious
• Agitated
• Patients with an obstructed upper airway (dependent on their
tracheostomy for breathing) or dependent on ventilatory support.
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
that should be determined by the lead clinician for the risk assessment for
the patient.
Care plans
The tracheostomy care pathway will vary from Trust to Trust. We have
again viewed many excellent local examples and provided a summary that
you may wish to consider for reference if updating your own pathways.
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Any care pathway should be used in conjunction with the bedhead sign,
detailing essential details about the tracheostomy, including any major
incidents, such as decannulation, tube obstruction, and so on. An example
care plan is shown in Figure 10.1.
Figure 10.1 Draft care plan.
Intensive Care Society (2008). Reproduced with permission from the UK
Intensive Care Society.
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The pathway should include the following:
• Record of tracheostomy tube insertion and changes (and how easy/
hard these were)
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• Tracheostomy equipment checklist
• Tracheostomy weaning plan
• Daily care record.
We have reviewed several coronial inquests and serious untoward incident
investigations regarding tracheostomy or laryngectomy care. It is useful to
consider any documentation from the point of view of an external agency
trying to establish the following facts after an event.
• When was the tracheostomy suctioned?
• Was the inner tube changed today?
Your documentation should make this easy to record and establish. The
daily care record should therefore include the following aspects.
• Type of tube inserted
• Cuff up/down? Speaking valves?
• Inner tube cleaning
• Suction performed
• Humidification
• Oxygen
• Stoma care/dressing
• Securing the tube
• Nutrition/hydration.
It should also be easy to locate tracheostomy-specific documentation and
instructions relating to the following points.
• SALT/swallowing assessment/instruction
• Plans for cuff deflation/downsizing/decannulation
• Physiotherapy plans
• Risk assessments (which may alter during the course of the
inpatient stay).
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Chapter 11
Competencies for staff caring for patients with tracheostomies or
laryngectomies
The following document has been adapted from the NTSP resources and
is used at Central Manchester NHS Foundation Trust (FT). The document
is reproduced here with permission. Other documents are available from
the NTSP website www.tracheostomy.org.uk.
Tracheostomy care:
competency assessment
criteria
COMPETENCY STATEMENT
Demonstrates safe practice for patients requiring a tracheostomy and dealing
with tracheostomy emergencies
Key skills Assessment criteria
1. Demonstrates an
understanding of the anatomy
and physiology of the
respiratory system
Identify the main structures of the respiratory
system
Discuss the position of these structures in
relation to their function
Discuss the mechanics of respiration
Discuss the process of oxygen delivery
2. Describes indications for
tracheostomy
Identify reasons for the insertion of a
tracheostomy tube
Discuss the benefits to the patient
Discuss the different techniques used for
tracheostomy insertion
Describe the investigations that are required
prior to insertion
3. Demonstrates and discusses
choice of tube
Identify the different tubes available and the
reason for the choice of tube
Discuss the principles of cuff safety
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4. Demonstrates the ability to
assist with insertion and can
discuss potential complications
Preparation and explanation to the patient as
required
Discuss issue of consent
Assemble the correct equipment and perform
safety checks prior to procedure
Ensure chest radiograph is ordered and
reviewed post insertion (if required)
Discuss possible complications following this
procedure, for example, pneumothorax,
bleeding, tube inserted incorrectly
5. Demonstrates the ability to
assist with decannulation and
can discuss potential
complications
Can state the standards for decannulation
Assemble the correct equipment for
decannulation
Identifies personnel required to assist/support
during the procedure
Demonstrates the procedure safely and correctly
Discuss possible complications following this
procedure, for example, ineffective cough,
aspiration, exhaustion
6. Demonstrates the ability to
perform tracheal suctioning
Identify the need for suction
Assemble the correct equipment – including
correct size catheters
Demonstrate and understand the need for
aseptic technique throughout
Explain the procedure to the patient
Discuss complications and interventions to
reduce risk
Demonstrate good suction technique
Evaluate effectiveness of suctioning
Demonstrate correct documentation and
reporting as necessary
7. Demonstrates and discusses
the nursing care for a patient
with a tracheostomy tube
Discuss the importance of humidification
Demonstrate the ability to care for
tracheostomy tube, including cleaning of inner
tube
Discuss the care of the stoma, including
appropriate selection of dressings and tapes
Patient positioning and comfort
Discuss issues with communication
Discuss the role of speech therapy in assessing
the swallow reflex
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