Improving the Safety of Patients with a Tracheostomy (Guidelines)

Tracheostomy is a common procedure within the critical care environment.  The majority of tracheostomy patients within the acute hospital setting are cared for within the Intensive care unit (ICU) with the exception of ear, nose and throat (ENT) tracheostomies.  However, the indications for tracheostomy are increasing, resulting in more patients transferred from critical care to ward areas with a tracheostomy in place.  

Whilst tracheostomies offer many benefits, they are not without risk and therefore safety implications need to be considered.  Robust systems and procedures are needed to reduce the likelihood of adverse incidents occurring in this patient group.  

This guidance is designed to aid the health care provider in delivering safe tracheostomy care, and is to be used alongside the expert clinical input.  

The placement of the patient with a tracheostomy is confined to the following areas and is further clarified on the flowchart below 

• ICU 
• ENT ward 
• Medical high dependency unit (MHDU) 
• Surgical high dependency unit (SHDU) 
• 7A Respiratory ward 
• In order to minimise the risk of tracheostomy related incidents, the need for managing patients in the agreed designated areas must take precedence over the clinical diagnoses.  Bed managers responsible for patient placement and bed allocation must be aware of and adhere to the need for placing patients in the designated areas. 
• Agreement on appropriate levels of staff required for each patient prior to transfer needs to be discussed with the Divisional Nurse Manager.  Patients transferred are unlikely to require 1:1 nursing but there is a need to ensure specific allocation of appropriate resource.  
• Self-caring, fully independent patients with a tracheostomy requiring pre-operative care can be nursed in any clinical area.  However, they will require post-operative care as appropriate in one of the designated areas until they have adequately recovered from the effects of sedation/anaesthesia.   

Medical responsibilities 

• The named medical or surgical consultant remains in charge of the care of the patient. At the time of transfer, it must be clear, and documented in the patient's medical notes which team will be responsible for the care of the tracheostomy, particularly, if that team/person is not the speciality with primary responsibility for the patient's care.  

Nursing responsibilities 

• The ICU nursing and medical team have skills in managing tracheostomy care and should be contacted to initiate at least once daily outreach support as per flowchart above.  
• Primary responsibility for the management of tracheostomy care in former ENT patients will rest with the ENT medical and nursing team.  The responsibility of informing the ENT team of patient admission lies with the designated ward area caring for the patient. 

Bed Manager responsibilities

• Awareness of where patients with a tracheostomy can be placed.

Night nurse practitioner responsibilities 

• ICU can be contacted for advice and support at any time including night hours.  However, patients with a tracheostomy in the designated ward areas may also be assessed and managed by paging the night nurse practitioner (NNP) 
• In the event of urgent tracheostomy related issues, the NNP should contact switchboard to page the on call ICU registrar or the on call ENT registrar.  

Physiotherapists role 

• The physiotherapist has an important role in assessment of the patient's respiratory and mobility status.  Physiotherapists can support the patient with secretion clearance and can advise on suction technique, patient positioning and optional respiratory therapy.
• Out of hours service: the on call physiotherapist can be contacted via switchboard.  

Speech and language therapist role 

• The speech and language therapist has an important role in supporting the assessment and management of swallowing and communication in the patient with a tracheostomy. 
• Referral is made by phoning the department where a telephone answering service is available.

Education and training responsibilities

• Primary responsibility for the provision of education and training for nursing staff in ICU, MHDU, SHDU and ward 7A Respiratory lies with the Critical Care Clinical Educator. All trained staff must attend the  foundation training session and attend a tracheostomy update at least every 12 to 18. It is the responsibility of the Senior Charge Nurse in each of the designated areas to request and arrange the relevant training.
• Learning resources are in place to support the designated areas and include emergency guidelines, specific documentation such as tracheostomy observation charts, head of bed signs, tracheostomy care bundle checklists and care plans. Laryngectomy learning material is also available and includes emergency guidelines, head of bed signs and safety checklists.
• Primary responsibility for the provision of education and training support for nursing staff in the ENT ward lies with the ENT Charge Nurse and also the ENT Head and Neck Cancer Nurse

Tracheostomy Care Bundle

The tracheostomy care bundle must be adhered to in all cases, and is made up of the following important elements of care

• Availability of safety equipment
• Humidification 
• Suction 
• Inner tube care 
• Tracheal cuff pressure monitoring 
• Stoma care and security of the tracheostomy tube 
• Communication, speaking valves and swallowing 

Additional safety information

• Tracheostomy masks - these must never be used with a cuffed tracheostomy tube (safety action notice 1998)
• Speaking valves: the tracheostomy cuff must be completely deflated before the speaking valve is connected.
• End-tidal CO2 monitoring: is recommended.
• Tracheostomy tube changes - this procedure will be undertaken by appropriately trained staff 

Multi Disciplinary Team contact details

• ICU (for outreach support) – extension 4446
• ICU Consultant – extension 5352 or page 1129
• ICU Clinical Educator – extension 4057 or 4446
• ENT/Head and Neck Consultant –  extension 6187 or page 7046
• ENT/Head and Neck Charge Nurse –  extension 4445 or ward extension 4545
• ENT/Head and Neck Cancer Nurse –  extension 6344 or page 2179
• Nurse Consultant Sleep and Ventilation Service – 07989 214735
• Practice Development Co-ordinator (Surgical)  mob 07974619634 or speed dial 3037
• Night Nurse Practitioner – extension 4332 or page 5300 Medical or 5200 Surgical
• Lead Physiotherapist – page 2048
• Speech and Language Therapist – extension 5424