On the Right Trach Celebrating Success St Georges

On the Right Trach? Celebrating Success St George’s Tracheostomy Group 1995 ish- present…. .

@ncepod #tracheostomy 2

NCEPOD 2014 - Complications 3

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 25 th February and 12 th May 2013 l The patients were identified at the time of tracheostomy insertion on the intensive care unit or in theatre l Subsequently these patients were followed through their hospital stay until death, decannulation or discharge to home or another hospital l

NCEPOD Audit SGH (Results) l 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) l l 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 l 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), Mc. Kissock (n=4) with a tracheostomy in situ l 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

Tracheostomy care at St George’s l l l MDT group Policy Clinical Guidance (v 5) In-patients cohorted ICP Education l l Video/DVD Competence assessment l l l MDT ward rounds Consultation (internal and external) Product development Discharge package Out-patient clinic Incident review

NCEPOD 2014 – Hospital Policy 7

Policy (‘thou shalt’) l l Roles and responsibilities Patient management l l l l 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 l Equipment l l l l Education and training l l Hardware Consumables Procurement Location Emergency pack Supply into the community Availability of staff Competence ( basic and advanced) Study days Documentation l l l Inpatient Discharge LAS

Tracheostomy care at St George’s l l l MDT group Policy Clinical Guidance (v 5) In-patients cohorted ICP Education l l Video/DVD Competence assessment l l l MDT ward rounds Advice (internal and external) Product development Discharge package Out-patient clinic Incident review

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

http: //tracheostomy. org. uk/

Tracheostomy care at St George’s l l l MDT group Policy Clinical Guidance (v 5) In-patients cohorted ICP Education l l Video/DVD Competence assessment l l l 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…. l 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 (p 25 -6, tables 2. 9 &2. 10)

Tracheostomy wards l l l Marnham Florence Nightingale ADU Kent Brodie Mc. Kissock l l l Belgrave Ben Weir Caroline CTICU NICU GICU

Process to achieve ward competence (pilot) l Adequate exposure l 180 bed days l Adequate skill l 80% nurses trained with basic competency complete

Tracheostomy care at St George’s l l l MDT group Policy Clinical Guidance (v 5) In-patients cohorted ICP Education l l Video/DVD Competence assessment l l l MDT ward rounds Advice (internal and external) Product development Discharge package Out-patient clinic Incident review

NCEPOD 2014 –Ward care 19

NCEPOD 2014 - Critical care 40% 21% 18% 1% 20

NCEPOD 2014 -Training in blocked or displaced tubes 21

NCEPOD 2014 - Resuscitation Training 22

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 l l l MDT group Policy Clinical Guidance (v 5) In-patients cohorted ICP Education l l Video/DVD Competence assessment l l l 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 Consultant Respiratory Medicine Royal North Shore Hospital Office: 94632833 Page: 41342 Alexander. Slattery@health. nsw. gov. au

Our response…. . Alex Pleased 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 Regards Deborah

Tracheostomy care at St George’s l l l MDT group Policy Clinical Guidance (v 5) In-patients cohorted ICP Education l l Video/DVD Competence assessment l l l MDT ward rounds Advice (internal and external) Product development Discharge package Out-patient clinic Incident review

Discharge from hospital l SLT developed MDT discharge package crossing the secondary/primary interface l l l 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 Primary reason for tracheostomy Number Head and neck tumour 34 Vocal cord palsy 10 Neurological 6 Tracheal damage 7 Weaning from ventilation 1 Data from 3/6 -3/12

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)