Feidhmeannacht na Seirbhise Shiinte Health Service Executive

TITLE: HSE-WEST Regional Hospital, Dooradoyle, Limerick Guideline on Tracheostomy Care

Document Document Anne Weeks CNM 1 Reference NG 01/09 Drafted By Mary Dalton AlCPC Number Margaret Moroney SIN Revision New Document M. Fitzgerald, Number Approved By Deputy Director of

Nursing G. Kennedy ADON/NPDC

Approval Responsibility Respiratory Nursing Date For Group & NPDU

Implementation Revision February 2012 Responsibility CPC Author and Date For Evaluation NPDC (NPDU)

And Audit

Pages 11

Title: Nursing Guideline Tracheostomy Care NG 01 /09 Page 1 of 11

TABLE OF CONTENTS

1.0 Policy Statement. .... .... ... ...... .. .. .......... ...... ..... .... .... .. ..... 3

2.0 Purpose............ .................. .... ...... ... .. ...... ... ..... ... . ... .. . 3

3.0 Scope........................ ....................... .... ..... .... ............. 3

4.0 Definitions ......... ............ ...... ......... .... ..... ......... ........ ..... 3

5.0 Roles and Responsibilities........ ....... .. .. .. ...... .. .. ..... .. ........ 3

6.0 Procedure....................... ...... . ...... . ........ ..................... ... 4

7.0 Implementation Plan ......... ........ . ...... ..... .. .. ... ... ............ ... 6

8.0 Evaluation and Audit .................. ........ .. .. ........................ 6

9.0 References.................... .... ... ......... ........ ....... ... ...... ...... 7

10.0 Appendices .. .. .......... .. ...... .. ....... .. ..... .. .... .......... ........... 8

Title: Nursing Guideline Tracheostomy Care NG 01109 Page 2 of 11

1. POLICY STATEMENT

1.1. The nursing care provided to patients with tracheostomies will encompass the assessment, planning, implementation and evaluation of care. Tracheotomy care will include care of the inner cannula, stoma site, tracheostomy dressing and ties as outlined in this guideline.

2. PURPOSE

2.1. To provide guidance to nurses to ensure safe and effective nursing care of a patient with a tracheostomy tube.

3. SCOPE

3.1. This guideline applies to all Staff Nurses and students under direct supervision who provide nursing care for a patient with a tracheostomy tube.

4. DEFINITIONS

4.1. Tracheostomy is the surgical creation of an opening into the trachea through the neck. A tracheostomy incision is below the cricoid cartiliage, through the 2" and 4th tracheal ring (Dougherty and Lister, 2008; SI. James Hospital, 2008) (Appendix 1).

4.2. Tracheostomy Tube is an artificial airway inserted into the trachea during tracheostomy to maintain the patency of the airway and to facilitate the removal of secretions (Dougherty and Lister, 2008). Tracheostomy tubes can have both an outer and inner cannula (Appendix 1).

4.3. Outer Cannula maintains the patency of the airway (Appendix 1).

4.4. Inner Cannula is a removable, disposable or non-disposable tube that fits snugly into the outer cannula. It can be removed to allow cleaning without compromising the airway or stoma site (Dougherty and Lister, 2008; St James's Hospital, 2008) (Appendix 1).

5. ROLES AND RESPONSIBILITIES

5.1. It is the responsibility of the staff nurse to read this guideline and have the necessary knowledge and practical skills to implement the procedure as outlined. The signature sheet must be signed once the guideline is read.

5.2.lt is the responsibility of the Ward/Department Clinical Nurse Manager (CNM), to ensure that staff have read this guideline and to monitor the implementation of same.

Title: Nursing Guideline Tracheostomy Care NG 01/09 Page 3 of 11

5.3. Student nurses may carry out this procedure for appropriate patients under direct supervision once they demonstrate appropriate knowledge and experience. This must be supported by written evidence i.e. Clinica l Nursing Skills Validation Record , (HSE 2008a). The supervising staff nurse is responsible for the care given throughout this procedure.

5.4. Ensure all bed-side equipment is in place and working effectively at the beginning of each shift (Appendix 2)

5.5. The nurse caring for a patient with a tracheostomy must ensure tracheostomy care is perfonmed to maintain patient comfort, a patent airway, prevent infection, maintain skin integrity and to help prevent tube displacement.

5.6. The inner cannula should be monitored for secretions at least 4 hourly or more frequently as required (St. James Hospital, 2008). The frequency of care of the inner cannula is detenmined by the volume, tenacity and viscosity of secretions and the comfort of the patient (Dougherty and Lister, 2008).

5.7.A disposable or non disposable inner cannula can be used. The nurse should establish which type of inner cannula is in place prior to commencing the procedure.

5.8. Care of the stoma site must be carried out daily or more often if required to ensure the surrounding skin remains clean and dry to reduce the risk of skin irritation and peri-stomal infection (Dougherty and Lister, 2008). The tracheostomy dressing can be renewed without removing the inner cannula.

5.9. The tracheostomy ties should be checked frequently to ensure they remain clean and dry. Ties should be renewed as required when soiled and must be changed at least once a week. A velcro or cotton tracheostomy tie may be used.

5.10. Cotton ties should be used for patients at risk of dislodging the tracheostomy tube i.e. confused or agitated patient or patients with an anatomically difficult neck and whose airway would be severely compromised due to tube dislodgement (St. James Hospital, 2008) .

6. PROCEDURE

6.1. Gather and prepare all equipment required for care of the tracheostomy, (Appendix 3).

6.2. Explain the nursing procedure to the patient to gain infonmed, verbal consent and cooperation .

6.3. Ensure patient's privacy and dignity is maintained. Title: Nursing Guideline Tracheostomy Care NG 01 /09 Page 4 of 11

6.4. Assist the patient to a suitable position , the supine or semi-fowlers position is recommended unless contraindicated (Lippincott Williams and Wilking, 2007; Timby, 2009).

6.5. Perform the procedure using an aseptic technique (Dougherty and Lister, 2008)

6.6. Adhere to the hand hygiene hospital policy (Hand Hygiene Policy, 2005).

6.7. Don non-sterile gloves.

6.8. Remove the soiled stomal dressing and discard using standard infection control precautions, (Standard Precautions Guideline, 2007).

6.9. Observe for signs of skin irritation or infection and report as appropriate.

6.10. Perform hand hygiene as per hospital policy (Hand Hygiene Policy, 2005).

6.1 1. Don sterile gloves and adhere to aseptic technique throughout this procedure.

6.12. Remove the inner cannula by turning clockwise. If clean, re-insert and lock into place. If soiled, evaluate secretions for consistency, colour and odour.

6.13. If a disposable inner cannula is being used discard as appropriate. Insert a new inner cannula. Insert into the tracheostomy touching only the outer locking portion and following the manufacture's instructions, lock it securely (Lippincott Williams and Wilking, 2007).

6.14.lf a non-disposable inner cannula is being used remove and clean the cannula with a fleece stem (Clinipak) and 0.9% Saline solution . Fleece stems are for single use only. Dry with sterile low linling gauze and re­insert inner cannula .

6.15. Clean the stoma site, with sterile low linting gauze and 0.9% Sodium Chloride to remove secretions and crusts. Low Linting gauze is utilised to reduce the risk of dressing fragments entering the altered airway (Dougherty and Lister, 2008).

6.16. Replace tracheostomy Lyfoam or keyhole Lyfoam dressing. This dressing aids patient comfort, prevents pressure ulceration which may be caused by the tube or hard flanges and prevents excoriation of the skin from tracheal secretions.

6.17. To change the tracheostomy ties a second nurse should hold the tracheostomy tube securely in place whilst the velcro/cotton ties are

Title: Nursing Guideline Tracheostomy Care NG 01/09 Page 5 of 11

removed and replaced due to the high risk of accidental tube expulsion, (Lippincott Williams and Wilking, 2007).

6.18. Renew the tracheostomy ties. When securing the ties leave a "1 finger space" between the ties and the patient's neck. This ensures that ties are tight enough to avoid accidental dislodgement while preventing skin impairment caused by excessive pressure from ties, (Dougherty and Lister, 2008).

6.19. The tie closure should be placed at the side of the neck allowing ease of access and to prevent skin impairment which may be caused by pressure at the back of the neck from the tie when the patient is recumbent (Lippincott Williams and Wilking, 2007; Timby, 2009).

6.20. Post-Procedure Care

6.20.1. Ensure the patient is comfortable.

6.20.2. Complete or assist the patient to complete oral hygiene care as appropriate.

6.20.3. Monitor for adverse effects.

6.20.4. Discard used equipment as per hospital policy (Standard Precautions Guideline, 2007).

6.20.5. Adhere to the hand hygiene hospital policy (2005).

6.20.6. Care of the tracheostomy, tracheal secretions, stoma and tracheostomy ties must be documented in the Care Pathway or General Surgery Care Plan or the Breathing Care plan, (HSE 2008; HSE-MWRH, 2009). Document the patient's condition in the nursing progress notes.

7. IMPLEMENTATION PLAN

7.1. Following approval of this guideline which has been reviewed by the Respiratory Guideline Group Members and CNM2 Ward 2C, information sessions will be delivered within one month by members of the Respiratory Nursing Guideline Group. The guideline will be issued to all wards and CNMs will be requested to bring this to the attention of nursing staff.

8. EVALUATION AND AUDIT

8.1. This guideline will be audited by the CPC author with the NPDC within one year and action plans will be agreed with managers where necessary in accordance with the cycle of audit and the Clinical Auditor.

Title: Nursing Guideline Tracheostomy Care NG 01/09 Page 6 of 11

9. REFERENCES AND BIBLIOGRAPHY

9.1. An Bord Altranais.(2002) Recording Clinical Practice Guidance to Nurses

and Midwives. An Bord Altranais: Dublin

9.2. Alexander. M.F. Fawcett, J.T. Runciman, P.J. (200S) Nursing Practice

Hospitals and Home. The Adu~ 3'" ed. Churchill Livingstone Elseview

Edinburg.

9.3. Dougherty, L. & Lister, S. (2008) The Royal Marsden Hospital Manual of

Clinical Nursing Procedures Sth Edition Blackwell Publishing: Oxford

9.4. HSE-MWRH (2009) Policy on Documentation and Report Writing

9.5. HSE West Limerick Regional Hospital (2008) Clinical Nursing Skills

Validation Record : BSc General Nursing Students.

9.S. HSE West Limerick Regional Hospital (2008) Nursing Careplan Guideline

9.7. HSE: Mid-western Regional Hospital, (2007) Standard Precautions

Guideline (2007)

9.8. HSE: Mid-western Regional Hospital (2005) Hand Hygiene Policy

Infection Control Manual

9.9. Lippincott Williams and Wilkins (2007) Best Practices: Evidence based

nursing procedures 2"" Edition; Lippincctt Williams and Wilkins: Ambler

9.10. St James's Hospital (2008) Infection Control Manual , Tracheostomy Care

Working Group Guidelines.

9.11 . Timby, B.K. (2007)Fundamentals Nursing Skills and Concepts 9th Ed.

Woner Kluvrere. Philadelphia.

Title: Nursing Guideline Tracheostomy Care NG 01/09 Page 7 0fll

APPENDIX 1: COMPONENTS OF TRACHEOSTOMY TUBE

"'-----~ .--::;;

Tracheostomy in place Components of a tracheostomy

1. Outer tube

2. Inner tube: Fits snugly into outer tube, can be easily removed for cleaning .

3. Flange: Flat plastic plate attached to outer tube - lies flush against the patient's neck.

4. 15mm outer diameter termination: Fits all ventilator and respiratory equipment.

All remaining features are optional

5. Cuff: Inflatable air reservoir (high volume, low pressure) - helps anchor the tracheostomy tube in place and provides maximum airway sealing with the least amount of local compression. To inflate, air is injected via the ...

6. Air inlet valve: One way valve that prevents spontaneous escape of the injected air.

7. Air inlet line: Route for air from air inlet valve to cuff.

8. Pilot cuff: Serves as an indicator of the amount of air in the cuff

9. Fenestration: Hole situated on the curve of the outer tube - used to enhance airflow in and out of the trachea. Single or multiple fenestrations are available.

10. Speaking valve I tracheostomy button or cap: Used to occlude the tracheostomy tube opening (a) former - during expiration to facilitate speech and swallOW, (b) latter - during both inspiration and expiration prior to decannulation

(St James's Hospital, 2008)

Title: Nursing Guideline Tracheostomy Care NG 01109 Page 8 of II

APPENDIX 2: BED SIDE EQUIPMENT Gloves Sterile Non sterile gloves Tray Containing Spare tracheostomy tube of the same size and type as the patient is wearing and a size smaller Tracheal dilator 10ml syringe Tracheostomy ties Stitch cutter Scissors KYgel Sleek tape Humidification Equipment Suctionlng Equipment Apron Fluid shield mask Oxygen therapy Suction apparatus i.e. suction machine (wall source or portable) and tubing . Ensure the vacuum pressure is 80 - 150 mmHg or 11 -20 KPa for adults (Dougherty and Lister, 2008). Sterile suction catheters with thumb control Sterile container and water for flushing the catheter and tubing Receptacle for soiled disposables Spare Inner Cannula Infectious Waste Bag Alternative method of communication Pen & paper etc

APPENDIX 3: EQUIPMENT FOR CARE OF TRACHEOSTOMY Dressing trolley Sterile dressing pack Sterile and non sterile gloves Apron Fluid shield mask Disposable or non-disposal inner cannula as appropriate Low linting gauze 9% sodium chloride Scissors Skin barrier cream Tracheostomy dressing or keyhole dressing Tracheostoimy ties - cotton or Velcro Oral hygiene tray Suction equipment I nfectious waste bag

Title: Nursing Guideline Tracheostomy Care NG 01/09 Page90f ll

Appendix 4: Audit Tool Nursing Guideline Tracheostomy Care (Including Care of Inner Cannula, Stoma Site and Tracheotomy ties) 2009

Ward: ______ _ Date: _______ Time: _ ___ _

Standard 1: Nursing care will be implemented in accordance with this guideline to ensure safe and effective nursing care of a patient with a tracheostomy tube.

1. Has the guideline signature sheet been signed by staff nurse/student providing

care? Ves 0 No 0

2. Is all bed-side equipment present? (Appendix2) Ves 0 NO D

3. Is all tracheostomy bed-side equipment is working effectively? Ves 0 No D

4 . Is correct equipment used for the care of tracheostomy? (Appendix3)Ves 0 NO D

5. Does Nursing documentation provide a record which demonstrates Ves 0 No 0

the frequency of care for the a) Inner Cannula Ves 0 No 0

b) Stoma site Ves 0 No 0

c)Tracheostomy ties Ves 0 No 0

in accordance with the advice in this guideline. Check General Surgery Care

Plan. Breathing Care Plan or Nursing Pathway document as appropriate?

6. Is the condition of the patient is documented in the progress Ves 0 No 0

notes?

Title: Nursing Guideline Tracheostomy Care NG 01109 Page 10 cfll

Signature Sheet:

I have read , understand and agree to adhere to the attached Policy

Printed Name Signature Area of Work Date

Title: Nursing Guideline Tracheostomy Care NG 01/09 Page 11 of 11