University Hospital of South ManchesterWythenshawe

what we’ve done and how we’ve done it.......

John MooreTeaching the teachers

Tracheostomy Safety Project2011

what we’ve done and how we’ve done it.......so far

Need

Developed algorithm

Begin training.......

Training people in the algorithm

• How we started

• How you might want to start...

Teaching programme begins-training interested people

• Day course

• Faculty

• Medics and nurses attend

• Simulator afternoon part to the course

2009-10 Training a trustour experience

CMFT

UHSM

www.tracheostomy.org.uk

First responder course Advanced Practitioners Trainers

Information resource

• On-line• Interactive• Comprehensive• ‘One-stop shop’

2009-10 training a trust

CMFT

UHSM

250 nurses

100 medics

60 nurses

50 medics

First

responder

courses

2009-10

CMFT

UHSM

SRFT

RPH

BOLTON

SRFT

RPH

2010-11

CMFT

UHSMBOLTON

ANWICU

AMICU

NETWORKS

ICS

DAS

NPSA

How to teach a trust

Something new.......

We had a recent problem too..There was no joined up thinkingThere was no standard algorithmPeople hadn’t thought about

Resistance to change..Agenda..What do these guys know..

Never events

When they happen they are catastrophic

The coroner

SRFT – a possible model

Patient safety

initiative

Stakeholdergroup

Training

Tracheostomysteeringgroup

National Tracheostomy Safety Project

INTENSIVE CAREANAESTHETISTS

SURGEONSMEDICS

TracheostomySteering Group

RESUSTRAINERS

LEAD NURSESPRACTICE

EDUCATORSNURSES

MEDICS

PHYSIOS

NEURO REHAB

MANAGEMENT

Tracheostomy Steering GroupAgenda -Trust remit

All elements of tracheostomy care (?)

Where do patients with tracheostomies go

Standardise kit

Programme of training.....Who/ Which to train first

Make it mandatory.....

Agenda1st responder programme

Critical care

Wards that take tracheostomy

Trainers

Training

Trust

• Provide pre-course materialwww.tracheostomy.org.uk

• Short introductory lecture to algorithm and bedhead technology

• Scenario based teaching

1st responder programme

Trainers

Information resource

• On-line• Interactive• Comprehensive• ‘One-stop shop’

Training - Personalise the story

...MG is a 24 year old man with mild learning difficultieswho spends 4 weeks on intensive care following problems with recurrent fittings and subsequent aspiration

he is on minimal oxygen but his cough his felt not to be good enough to tolerate decannulation

..Beds are scare and he is sent to a respiratory ward that takes tracheostomies ..the following night the nurses finds the patientunresponsive, and quickly they discover he is actually had a respiratory arrest....

Training - Personalise the story

The cardio-respiratory team arrives and are unable to intubate or ventilate the patient..

the patient dies...

The tracheostomy is not removed during the arrestand post-mortem examination finds a blocked tracheostomy was the cause of death

what we’ve done and how we’ve done it.......so far

• Website

• Pathway for training • National Tracheostomy day (DAS)

• What do you think...?