On the Right Trach?

Celebrating SuccessSt George’s Tracheostomy Group1995ish- present…..

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@ncepod

#tracheostomy

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NCEPOD 2014- Complications

NCEPOD Audit data collection

Data collected as part of the national NCEPOD observational study of patients receiving a tracheostomy as part of their treatment during an in-patient stay between 25th February and 12th May 2013

The patients were identified at the time of tracheostomy insertion on the intensive care unit or in theatre

Subsequently these patients were followed through their hospital stay until death, decannulation or discharge to home or another hospital

NCEPOD Audit SGH (Results)

22 patients received a tracheostomy, 59% (n=13) were male with a mean age of 58 years (SD 19.36) and 41% (n=9) were female with a mean age of 63 years (SD 18.74)

59% (n=13) percutaneous and 41% (n=9) surgical tracheostomy 89% (n=8) of the surgical patients went to ICU post procedure and 11%

(n=1) went directly to a ward

21 patients had an ICU stay, 62% (n=13) patients were discharged to one of four wards (Brodie n=2, Florence (n=6), Kent (n=1), McKissock (n=4) with a tracheostomy in situ

349 tracheostomy bed days (mean 15.86; SD 8.59); 185 ICU tracheostomy bed days (mean 8.80; SD 7.35), many of these patients required additional bed days being cared for pre and post decannulation

Table One - Reason for procedure

0

2

4

6

8

10

12

14

Respiratory wean Head and Neck Surgery Airway protection

Table Two - Outcome

0

2

4

6

8

10

12

Decannulated inICU

Decannulated onward

Home withtracheostomy

Repatriated withtracheostomy

Died In ICU

Tracheostomy care at St George’s

MDT group Policy Clinical Guidance (v5) In-patients cohorted ICP Education

Video/DVD Competence

assessment

MDT ward rounds Consultation (internal

and external) Product development Discharge package Out-patient clinic Incident review

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NCEPOD 2014 – Hospital Policy

Policy (‘thou shalt’)

Roles and responsibilities Patient management

Admission from home Transfer within the hospital

(cohort) Discharge with a tracheostomy Clinical advice Tube changes Guidelines for care –’evidence

suggests’ or ‘expert opinion is’ Follow up

Equipment Hardware Consumables Procurement Location Emergency pack Supply into the community

Education and training Availability of staff Competence ( basic and

advanced) Study days

Documentation Inpatient Discharge LAS

Tracheostomy care at St George’s

MDT group Policy Clinical Guidance (v5) In-patients cohorted ICP Education

Video/DVD Competence

assessment

MDT ward rounds Advice (internal and

external) Product development Discharge package Out-patient clinic Incident review

https://www.stgeorges.nhs.uk/gps-and-clinicians/clinical-resources/tracheostomy-guidelines/

http://tracheostomy.org.uk/

Tracheostomy care at St George’s

MDT group Policy Clinical Guidance (v5) In-patients cohorted ICP Education

Video/DVD Competence

assessment

MDT ward rounds Advice (internal and

external) Product development Discharge package Out-patient clinic Incident review

Small numbers, high risk, multiple professionals in multiple locations….

The number of wards where nurses caring for patients with a tracheostomy who report not being competent to suction, measure cuff pressure or manage blocked/displaced tubes (p25-6, tables 2.9 &2.10)

Tracheostomy wards

Marnham Florence Nightingale ADU Kent Brodie McKissock

Belgrave Ben Weir Caroline CTICU NICU GICU

Process to achieve ward competence (pilot)

Adequate exposure180 bed days

Adequate skill80% nurses trained with basic competency

complete

Tracheostomy care at St George’s

MDT group Policy Clinical Guidance (v5) In-patients cohorted ICP Education

Video/DVD Competence

assessment

MDT ward rounds Advice (internal and

external) Product development Discharge package Out-patient clinic Incident review

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NCEPOD 2014 –Ward care

20

40%

20% 21%18%

1%

NCEPOD 2014- Critical care

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NCEPOD 2014 -Training in blocked or displaced tubes

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NCEPOD 2014- Resuscitation Training

Emergency Algorithims

‘The greatest difficulty lies not in persuading people to accept new ideas, but in persuading them to abandon old ones’

John Maynard Keynes

Tracheostomy care at St George’s

MDT group Policy Clinical Guidance (v5) In-patients cohorted ICP Education

Video/DVD Competence

assessment

MDT ward rounds Advice (internal and

external) Product development Discharge package Out-patient clinic Incident review

A request…..

Dear Deborah,I am a CNC from Royal North Shore Hospital in Australia and am currently reviewing

the management of tracheostomies in our area health. The NHS resources that your team have developed are fantastic and I am hoping to

integrate them into our practice. Are you able to tell me if I need formal permission from the authors to use the resources they have made available, or is there an understanding from you that since the material is open access then it may be used?

I am looking at the ‘Integrated Care Pathway’ in particular, however, with the abundance of resources I would probably also reference other material on the site.

Thank you for your time, I look forward to hearing from you soon.Regards,Alex Slattery

Acting Clinical Nurse ConsultantRespiratory MedicineRoyal North Shore HospitalOffice: 94632833     Page: 41342

Alexander.Slattery@health.nsw.gov.au

Our response…..

AlexPleased that you have found our resources useful, I plan to pop them on the

GTC website, so happy for anyone to use. Our Trust has issued us with guidance on what constitutes acceptable use as follows:

The following both constitute acceptable use:Hyperlinking from your corporate website to ours.Copying content from our website and reproducing it on yours, provided it is

used verbatim and with credit to the trust and/or its website.The following constitutes unacceptable use:Any change in wording, whether or not this is credited or uncredited.I also enclose an updated ICP we are currently piloting, if you have any

problems accessing links let me know and I can send you the content directly.

Kind RegardsDeborah

Tracheostomy care at St George’s

MDT group Policy Clinical Guidance (v5) In-patients cohorted ICP Education

Video/DVD Competence

assessment

MDT ward rounds Advice (internal and

external) Product development Discharge package Out-patient clinic Incident review

Discharge from hospital

SLT developed MDT discharge package crossing the secondary/primary interface Referral to the community team Competency assessed training of ‘carers’ and

patient Identification and procurement of essential

equipment/consumables Guidance on how to manage an emergency Letter to emergency services Pre-booked follow up appointment

Tracheostomy Clinic

Data from 3/6-3/12

Primary reason for tracheostomy Number

Head and neck tumour 34

Vocal cord palsy 10

Neurological 6

Tracheal damage 7

Weaning from ventilation 1

Tracheostomy Clinic Data from 3/06-3/12

Procedure No.(pts)

Tracheostomy change by nurse 363 (52)

Supervised change by carer 21 (4)

Supervised change by patient 23 (2)

Bespoke tube arranged 7 (3)

Fibreoptic nasendoscopy 17 (12)

Wound care 137 (43)

Community liaison 78 (38)

Weaning advice 24 (11)

Treatment for granulation 27 (9)

Communication advice 58 (24)

Medical review 66 (30)

Cough management 18 (7)

Nutritional advice 28 (17)

General advice 78 (35)