p33-37w19 12/1/05 1:02 pm Page 33

ward patients
art&science
Improving tracheostomy care for
33-37
clinical · research · education
Continuing professional development
Assessing pain in older people 45-52
Author guidelines
Guidelines on writing for
56

Nursing Standard’s art&science

Supplementary prescribing for Multiple-choice self-assessment 53
overactive bladder 38-42 section
Practice profile assessment 54

Improving tracheostomy
care for ward patients
Lewis T, Oliver G (2005) Improving tracheostomy care for ward patients. Nursing Standard. Tracy Lewis RGN, BSc(Hons), is
19, 19, 33-37. Date of acceptance: November 1 2004. practice development nurse,
critical care; Gemma Oliver RGN,
Summary ■ The use of a diverse range of tracheostomy tubes BSc(Hons), DipHE, is critical care
across the trust (three main hospital sites). outreach sister, East Kent
The number of patients with a tracheostomy ■ Poor quality documentation, and little infor- Hospitals NHS Trust, Margate.
being cared for in the ward setting has mation about the tracheostomy tube could be Email: tracy.lewis@ekht.nhs.uk
increased recently as intensive care clinicians gleaned from patient’s notes.
use this procedure to aid early weaning from These issues led to confusion and a lack of parity
mechanical ventilation. As a result, ward of care.
staff are providing the specialist care Another development resulting from Comprehensive
required by patients with a tracheostomy
Critical Care (DH 2000) was the formation of clin-
more frequently. This article describes how
ical networks. These are formal networks by which
the outreach team and the critical care
practice development nurse in one trust services are co-ordinated, resourced and delivered,
collaborated to identify, develop and and they have a large number of informal links to
implement strategies to ensure that patients other parts of the system. The Kent critical care
with a tracheostomy in the ward setting network was developed in 2001. It consisted of
would be cared for by an educated and one strategic health authority and four NHS trusts,
supported team of nurses. of which EKHT is one. Within the network a num- Key words
ber of subgroups were formed including a net-
HE CRITICAL care team in East Kent Hospitals work group of critical care practice development ■ Clinical procedures

T NHS Trust (EKHT) embraced many of the

changes advocated by Comprehensive Critical
Care (Department of Health (DH) 2000). One of
nurses (PDNs). The PDNs had also identified that
there were problems in caring for patients with
tracheostomies across the whole network and not
■ Guidelines

these changes was the establishment of the crit- just in individual trusts, and they were in the process ■ Tracheostomy
ical care outreach team in January 2001. The links of developing visual prompt cards (Figure 1) and These key words are based
developed by the outreach team have raised best practice guidelines (Box 1) to accompany on the subject headings from
awareness of the many issues faced by ward staff patients with a tracheostomy on discharge from the British Nursing Index. This
in caring for patients with, or at risk of, acute ill- intensive care to the ward. article has been subject to
ness. The management of patients with a tra- The outreach team and the PDNs collaborated double-blind review.
cheostomy had been identified as one area that to produce a comprehensive, easy-to-use package
required considerable investment, in terms of edu- on the management of a patient with a tracheostomy.
cation and training, and direct practical support. At the EKHT this package consists of: Online archive
Reasons contributing to this included: ■ A detailed set of guidelines on the specifics of
■ A lack of knowledge, skills and confidence among caring for a patient with a tracheostomy. For related articles and author
ward nursing staff in caring for patients with a ■ A3 laminated visual prompt cards providing a guidelines visit our online
tracheostomy. quick and easy-to-read summary of the care archive at:
■ No trust guidelines for the management of required. These cards would be placed on the www.nursing-standard.co.uk
tracheostomies. wall over the patient’s bed – an easily visible and search using the key
■ A lack of resources to care for a patient with a reference for staff, patients and relatives. words above.
tracheostomy in the ward environment. ■ A set of best practice guidelines.

january
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 Figure 1. An example of a visual prompt card
p33-37w19

Tracheostomy care This tracheostomy was inserted by the anaesthetists Experienced personnel
12/1/05

Anaesthetist via ICU ext 62260

ICU ext 62260
Date inserted Any problems please contact or 62259
Physiotherapists ext 65090

34 nursing standard
ICU ext 62260 or 62259 Outreach ext 65068
1:02 pm

Downloadedjanuary
Non-fenestrated (without holes) Changing tubes Communication In the event of respiratory distress
cuffed double cannula Change at 30 days unless otherwise indicated The tube is not ideal for use with speaking valve.
Page 34

Call for medical help as usual

from RCNi.com
To be changed by outreach nurse or anaesthetist Consider other means of communication, for example,
Remove inner cannula if used
a spelling board
Blue Line Ultra Apply O2, sit patient up
Suction
Care of stoma ◆ Catheter can be passed:
Humidification

19/vol19/no19/2005
Clean with normal saline as required, dry and apply Apply O2, sit patient up
art&sciencerespiratory care

foam dressing (sterile procedure for first four days then Must always be used – see tracheostomy guidelines Proceed to respiratory/cardiac arrest action , if
clean procedure) necessary
◆ Catheter cannot be passed:
Eating and drinking Patient in severe distress
Securing and changing tapes Fast bleep anaesthetist or contact the patient’s team
Ensure tied securely (two fingers between neck and Patients should not eat and drink with a cuff inflated Remove tracheostomy tube – keep stoma open
tape, one finger if neck flexed) unless it is a quality of life issue. Any signs or risk of with tracheal dilators or insert new tube
Inspect tapes 4-hourly aspirating refer patient to speech therapist – coughing Apply O2 via stoma and mouth
Change tapes regularly or when soiled when swallowing, desaturating, or medical concerns
This is a two person procedure regarding swallowing ability

In the event of cardiac arrest

Weaning from tracheostomy
Assess daily, co-ordinate with experienced personnel. Call team 222
Inner cannula use/care of
Consider if: Inflate tracheostomy cuff
◆ Use plain inner cannula in the ward setting ◆ Patient is awake Bag via tracheostomy using high flow O2
Check list ◆ Do not use inner cannula if ventilated ◆ Patient can tolerate cuff deflation
Check chest is rising
Inspect 4 hourly, clean if necessary, with water ◆ Patient is not aspirating
Bed space ◆ Nurse call bell and brush supplied in the pack ◆ Patient can cough
◆ Tracheal dilators Replace if difficult to clean ◆ Patient has a gag reflex
◆ Two cuffed tubes

Copyright © 2015 RCNi Ltd. All rights reserved.

Store in a dry container ◆ Patient on 40% O2 or less – trial period of cuff
– one the same size and one (Change water pots every 24 hours and label) deflation
smaller Tracheostomy patient
– ? tube removal
◆ 10ml syringe
This needs to be done with medical permission
◆ Humidification device Patients with tracheostomies need ongoing assessment
for example, Swedish nose and management of the following:
◆ Oxygen available Suctioning
Bowels
◆ Ambu bag As per hospital guidelines, suction as necessary Nutrition
◆ Suction device/ For additional information on the
Psychological care
catheters/bowl and H2O guidelines for the care of a Physiotherapy
◆ Clean disposable gloves
◆ Plastic aprons Care of cuff if inflated patient with a tracheostomy
◆ Eye protection available please refer to the clinical practice
If an audible leak is heard or the cuff is over or under-
◆ Spare inner cannula
inflated, cuff pressures need to be checked. Use either forum or access the outreach web
◆ Cleaning solution
cuff pressure gauge or minimal occlusive. Contact page via the internet.
On unit/ward ◆ Qualified nurse
either ICU ext 62260 or 62259 or outreach ext 65068
◆ Pulse oximetry

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p33-37w19 12/1/05 1:02 pm Page 35

art&sciencerespiratory care
■ A discharge letter providing information on the This was the aim of the Kent critical care network.
tracheostomy. The PDNs also identified and devised best practice
It was hoped to standardise the type of tracheostomy guidelines and developed a comprehensive dis-
used in each trust to avoid confusion and dispar- charge letter to improve documentation for patients
ity of care. It was also recognised that education with a tracheostomy.
and training for the ward nurses were vital to improve The outreach team and the PDNs wanted to stan-
knowledge and skills and to successfully introduce dardise the type of tracheostomy tube used in the
the new guidelines and visual prompt cards. trust. The Portex® Blue Line Ultra tube was cho-
sen because it was one of the tubes being used in
all of the trusts and most of the consultant anaes-
Evidence
thetists favoured these insertion kits for percuta-
Developing the guidelines An extensive litera- neous tracheostomy. The first time the tracheostomy
ture search was undertaken by the critical care out- needs to be changed is 30 days following inser-
reach team, looking at the care and management tion. An inner cannula can be inserted into the tra-
of patients with a tracheostomy. Morgan (1997) cheostomy tube in a patient who is breathing
believed that guidelines should always be based on spontaneously and this can then be removed for
the highest level of evidence available. cleaning to maintain patency of the tracheostomy
The programmes used for the literature search tube. The latter was essential because it was named
were Cumulative Index to Nursing and Allied Health one of the best practice methods of reducing the
Literature (CINAHL) and Medline. The key words risk of tubes blocking on the wards, which had
that were used were clinical effectiveness, change, previously been an area of concern. The DH (1997)
and tracheostomy, and the years for the literature stated that improving the quality and consistency
search were from January 1995 to January 2004. of the NHS services is an important part of improv-
The literature search revealed no available level one ing the overall health of the population. A mem-
or two evidence. However, it was found that most ber of the network PDN group presented the
guidelines in use were adapted from St George’s guidelines and the rationale for standardising the
Healthcare NHS Trust’s guidelines for the care of choice of tracheostomy tube at a network board
patients with a tracheostomy tube (Laws-Chapman meeting. These were agreed at the meeting by the
et al 2000). Therefore these were obtained and network board and the information was taken
adapted to suit local and trust-wide practices. back to each of the individual hospitals.
Morgan (1997) identified that guidelines should be Completing the tracheostomy package The next
developed by a team that represents all of the pro- step was to inform the ward staff about the guide-
fessional groups involved in that care. The adapted lines and the visual prompt cards, and how to use
guidelines were then sent for comment to mem- them. Lomas (1993) felt that it would be naïve to
bers of the trust’s staff with a vested interest in this assume that when information is made available
area – physiotherapists, speech and language ther- it would automatically be accessed, appraised and
apists, infection control staff, anaesthetists, and applied to practice by professionals. The literature
ward and intensive care nursing staff. It was hoped on persuasive communication and advertising Box 1. Principles of best
that by involving members of the multidisciplinary makes a distinction between communications that practice for the care of
team, the guidelines would be readily accepted increase awareness and those that bring about patients discharged to the
when put into practice. The comments were analysed changes in behaviour, therefore raising awareness ward with a tracheostomy
and used in the policy. The final draft was sent to of the guidelines and prompt cards would help
the clinical practice forum for validation before with their implementation. The guidelines were ■ All patients will have an inner
being made available for use on the wards. Von made available on the outreach team’s website on cannula in situ
Degenberg (1997) stated that evidence-based guide- the hospital intranet site and an e-mail was sent ■ The cuff pressure will be
lines are necessary to turn theory into practice and to all hospital employees informing them of the measured daily and the
to ensure that the NHS rejects ineffective practices guidelines and how to access them. To reinforce tracheostomy tube changed
if persistently high
and uses those that have been shown to work. The this information, the outreach team visited the
development of guidelines would provide clear wards to inform staff of the guidelines, where they ■ The first change of tube
instruction on the management of patients with a were available and how to use them. should be carried out by an
anaesthetist
tracheostomy. The guidelines would also give ward Obtaining information about tracheostomies from
nurses easy access to evidence-based best practice, patients’ notes had proved difficult for the ward ■ These patients have a right to
empowering them to provide clinically effective care nurses and the outreach team. For example, infor- be assessed by a registered
nurse who is competent to
for patients. mation about when the tube was inserted, when
do so
Alongside the guidelines, the network group of the tube was last changed, and problems that had
PDNs developed visual prompt cards. These were been encountered with the tracheostomy was needed. ■ All patients will have a
laminated tracheostomy
based on work by Gray (2003) who was a mem- In the intensive care unit (ICU), this information
guidelines card by their
ber of the network group of PDNs. The DH (1997) was documented on critical care charts that remain
bedside and these guidelines
identified that an essential component of clinical in the ICU when the patient is discharged. Hence will be followed
governance is the sharing of areas of good practice. there was no information available in the patient’s

january
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p33-37w19 12/1/05 1:02 pm Page 36

art&sciencerespiratory care
notes. The PDNs also identified this as an area of patient with a tracheostomy was on the ward.
concern and produced a tracheostomy discharge This encouraged the nurses to apply the theory
letter to be filled in by the ICU staff before the to practice and develop their confidence. Rycroft-
patient is discharged to the ward (Table 1). This Malone et al (2002) propose that facilitators of
information would stay with the patient’s notes. change not only have a key role in affecting the
Fulbrook (1998) stated that high quality nursing context in which the change is taking place but
documentation is vital because it will be used to also in working with the practitioners to make
inform other professionals subsequently involved sense of the evidence being implemented.
in the care of the patient. To lead by example and Because of the overwhelming response to this
encourage accurate documentation, the outreach formal teaching session, more have been planned,
team maintained thorough and concise records on with the aim of using them across the trust and
the management of tracheostomies in their docu- attracting a more multiprofessional audience.
mentation.
Developing knowledge and skills Once the tra-
Challenges
cheostomy package was in place, a study day on
the care of tracheostomy patients in the ward This project to improve the care of patients with a
setting was held to educate the ward staff and tracheostomy has proven to be both rewarding and
to introduce the guidelines and visual prompt challenging. The challenges we encountered were
cards. A half day was used for theoretical input far reaching and frustrating at times.
and skills stations. There was a great demand for Lawrence-Parr (1999) states that the greater the
places, confirming the view that there was a number of people involved in the change of prac-
knowledge deficit in the care of patients with tra- tice, the better the outcome. However, in this pro-
cheostomies among ward nurses. The teaching ject the involvement of a large number of disciplines
session was well received and the feedback was from the multidisciplinary team resulted in con-
positive. The nurses who attended felt well sup- flicting opinions on best practice. Negotiation and
ported and were confident about their newly the use of effective communication and interper-
acquired skills and were keen to put them into sonal skills were paramount. Despite adopting this
practice. In line with trust recommendations, a approach and agreement at network board level
set of competencies was formulated to be com- to standardise the type of tracheostomy tube used
pleted by the ward nurses following this formal in the trust, we still encountered resistance to this
training. In addition, the critical care outreach change in practice. Regan (1998) suggests that it
team assured the ward nurses that they would is reasonable to expect adjustment problems in an
be readily available for teaching and support if a overworked and understaffed profession.
One issue that had not been considered before
Table 1. Critical care tracheostomy discharge information to remain with the starting the project was the educational needs of
patient’s observation charts (EKHT) the critical care staff. Most of the education had
been aimed at the ward nurses. Although the crit-
Name of patient ical care staff had been made aware of the new
guidelines and visual prompt cards at unit meet-
Type of tracheostomy tube ings and through the communication diary, it
became evident that this was not adequate. Inner
Date of insertion cannulas and cleaning brushes in the percutaneous
insertion packs were being thrown in the bin because
Date due for change
staff did not know what they were used for. In addi-
tion, not all of the staff had been made aware of
Reasons for insertion
the visual prompt cards, best practice guidelines
Type and quantity of sputum and discharge letter that were to accompany the
patient to the ward when discharged from ICU. For
Condition of stoma change to be fully effective, all staff involved need
to be well-read and informed (Lawrence-Parr 1999).
Cuff pressure (cmH2O) What seemed like a small-scale initiative has grown
enormously and the time involved to undertake the
Any problems encountered with project and see it through to conclusion has been
the tracheostomy extensive.

Humidification
Benefits
Oxygen requirements
The benefits of the project far outweigh the chal-
Speech and swallowing abilities lenges. We have not audited the effectiveness of
the new guidelines, visual prompt cards and

36 nursing standard
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p33-37w19 12/1/05 1:02 pm Page 37

art&sciencerespiratory care
discharge letters, because they have only just been or until the tracheostomy is decannulated. The
printed and made available for use on the wards. boxes would contain essential equipment required
An audit tool is being developed with the aim for tracheostomy care, for example, tracheal dila-
of using it after a three-month trial of the tra- tors, inner cannulas, dressings and a cuff manome-
cheostomy package. However, the perceived ben- ter. This equipment is currently supplied as necessary
efits are valid and important. They are: by the critical care unit.
■ There is parity across the trust in the care of Patient information leaflets are being developed
patients with tracheostomies. This care is evi- and should be available for distribution across the
dence-based and structured and reflects best network soon. The project has been expanded to
practice. cover community settings because district nurses
■ The study days and the guidelines provide edu- are facing the challenge of caring for patients with
cation, training and support for ward staff in tracheostomies at home. There has been a lack
the care of tracheostomy patients. Combined of preparation for this role and advice and sup-
with continued clinical support from the out- port has been sought from the outreach team.
reach team this will empower nurses to develop Two members of the outreach team have already
their skills and increase their confidence in been into the community to provide skills teach-
practice. ing in this area. In addition, two district nurses
■ The guidelines and visual prompt cards are an from the community attended the tracheostomy
important source of information for health pro- study day and it is envisaged that further educa-
fessionals, patients and relatives. tion and training will be required.
■ One of the greatest benefits is the collaboration
between the outreach nurses and the PDNs which
Conclusion
was rewarding and mutually beneficial. The pro-
ject was advanced by working collaboratively as The collaborative approach to tracheostomy care
a team. The benefit of such a team, as discussed in the ward environment, through the combined
by Pyles and Stern (1983), is to ensure that good efforts of practice development and outreach, has
practice is shared. achieved a great deal, including widely available
guidelines, laminated bedside visual prompt cards,
best practice guidelines, a discharge letter, and a
Future
study day providing lectures and hands-on skills
There are still areas of the project that need to be stations using mannequins. What started as a small-
developed. Once their use is well established, the scale project has grown and resulted in a com-
guidelines, visual prompt cards and discharge infor- prehensive package to educate, develop skills and
mation will need to be assessed for effectiveness, empower ward nurses to provide evidence-based
ease of use and accessibility, and to ascertain whether best practice for patients with a tracheostomy. This
they make a difference to patient care. The guide- collaborative and multifaceted approach to chang-
lines may need to be altered in the light of new ing practice has ensured that, despite many chal-
evidence to reflect best practice and as new prod- lenges, implementation has been effective (Halliday
ucts become available. and Bero 2000). This is an ongoing project that
A bid has been made for funding for equipment will require close evaluation and audit, as well as
to develop tracheostomy boxes that will stay with continued teaching and updating of practices and
the patient in the ward environment until discharge, the assessment of competencies

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Halliday M, Bero L (2000) Getting Pyles S, Stern P (1983) Discovery of 19, 37-39.

january
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