CARE OF CHILD WITH AN ESTABLISHED TRACHEOSTOMY Type: Clinical Guidelines Register No: 12003 Status: Public Developed in Response to: Best Practice Contributes to CQC Outcome 4 Consulted With Post/Committee/Group Date Children s Urgent and Emergency Group July 2015 Melanie Chambers Lead nurse for Children s and Young July 2015 People Mel Hodge Senior Sister Phoenix Children s Ward July 2015 Consultant Paediatricians July 2015 Lee Seager Resuscitation Department Manager July 2015 Professionally Approved By Dr Manas Datta July 2015 Version Number: 2.0 Issuing Service: Children and Young People Ratified by: Document Ratification Group Ratified on: 7 th December 2015 Trust Executive Sign Off Date: December/January 2016 Implementation Date: 15 th December 2015 Next Review Date: November 2018 Author/Contact for Information Andrea Stanley, Clinical Facilitator Children Policy to be followed by (target staff) All healthcare professionals Distribution Method Intranet & Website Related Trust Policies (to be read in 11046: Children & Young People Observation Policy conjunction with) 09005 Transferring Children Policy 05002 Tracheostomy Care for Adults 04071Standard Infection Precautions 08086 Record keeping Policy 05111 Resuscitation Guidelines Document Review History Version No: Authored/Reviewed by: Active Date: 1.0 Andrea Stanley 27 th January 2012 2.0 Andrea Stanley 15 th December 2015 1
INDEX 1. Purpose 2. Background 3. Scope 4. Roles and Responsibilities 5. Safety Equipment 6. Care of the child with an established tracheostomy 7. Transfer of a child with a tracheostomy 8. Humidification 9. Tracheal suctioning 10. Suction catheter size calculation and depth 11. Equipment required for suctioning a tracheostomy 12. Procedure for suctioning a tracheostomy tube 13. Irrigation of a tracheostomy tube 14. Changing tracheostomy tapes and dressing 15. Equipment needed to change the tracheostomy tapes and dressing 16. Procedure for changing tapes and dressing 17. Cotton tapes 18. Velcro tapes 19. Changing a tracheostomy tube 20. Procedure for changing a tracheostomy tube 21. Emergency procedures 22. Basic Life support 23. Tracheostomy tube occlusion / blockage 24. Staff Training 25. Infection Prevention 26. Monitoring Compliance with policy requirements 27. Implementation and Communication 28. References 2
Appendix 1 Appendix 2 Appendix 3 Appendix 4 Appendix 5 Appendix 6 Appendix 7 Basic Life Support for Babies and Children Algorithm Emergency Paediatric Management Tracheostomy Care Chart Tracheostomy Bedside Daily Checklist Tracheostomy Daily Care Chart Tracheostomy Care Plan Tracheostomy Competency Booklet 3
1.0 Purpose 1.1 To ensure the safety of all infants, children and young people who have an established tracheostomy. 1.2 The policy provides clear guidance for all Trust staff in the care and management of a child in hospital with an established tracheostomy. 2.0 Background 2.1 Children with a compromised airway sometimes require a tracheostomy and this need can arise from a variety of conditions; from an upper airway abnormality to a need for long term ventilation. 2.2 The tracheostomy is inserted surgically in a tertiary centre, but as it is likely to be in place for many months or years the child will go on to be managed in the local hospital and community setting. 2.3 Children and infants with tracheostomies have an increased vulnerability to a range of life threatening complications, and therefore require someone trained in their care with them at all times. 3.0 Scope 3.1 This policy applies to all infants, children and young people (up to their 16 th birthday) admitted to the Trust. 3.2 Throughout this document, infants, children and young people are referred to as children. 3.3 All Healthcare Professionals working within the Trust must adhere to this policy. This includes all medical staff, all registered nurses, healthcare assistants (HCA), and student nurses. 3.4 For older children with tracheostomies it may be necessary to use the adult tracheostomy guideline in conjunction with the paediatric guideline. 4.0 Roles and Responsibilities 4.1 Chief Executive 4.1.1 The Chief Executive is the Accountable Officer of the Trust and as such has overall accountability and responsibility for ensuring safe and effective systems are in place to care for children with established tracheostomies and that staff are fully informed and skilled to carry out their responsibilities. 4.2 Chief Medical Officer and Chief Nurse 4.2.1 The Chief Medical Officer and Chief Nurse are responsible for ensuring that systems are in place to support the implementation of this policy. 4.3 Heads of Nursing and Clinical Directors 4.3.1 The Heads of Nursing and Clinical Directors are responsible for ensuring that systems are in place to support the implementation of this policy. 4
4.4 Lead Nurses 4.4.1 If there are any issues with the care of children with established tracheostomies, and support is required, this should be escalated to the Lead nurse for that area. As a senior member of the team the lead nurse should be able to resolve any issues or escalate to the Head of Nursing as appropriate. 4.5 Medical and Nursing Staff 4.5.1 It is the responsibility of the healthcare professional designated to care for the patient to ensure that they are trained and competent to care for a child with an established tracheostomy and to be accountable for their own practice. 4.5.2 All healthcare professionals who provide care for a child with a tracheostomy must have undertaken a period of supervised practice in the management of a child with a tracheostomy tube. They should be able to provide evidence of competence through assessment by a supervisor who is competent in the management of tracheostomy tubes and completion of the competency training pack (Appendix 7). Evidence of competence should be in the practitioner's personal file. 4.5.3 The number of supervised practices required to achieve competence will be determined by the practitioner and supervisor, taking into account the practitioner's own learning needs. 4.5.4 Healthcare professionals in training can undertake the procedure under the supervision of a practitioner who is competent in the management of tracheostomies. 4.5.6 Evidence of continuing professional development and maintenance of skill level will be required on a regular basis. 4.5.7 In line with all Trust policies, a breach in policy will be acted upon in accordance with appropriate professional Codes of Practice and the disciplinary process may be invoked. 4.6 Ward Sisters 4.6.1 Ensure that all children admitted to the Trust with a tracheostomy will be cared for by competent healthcare professionals 4.6.2 Ensure that staff attend all relevant training 4.6.3 Ensure adequate stocks of equipment required to undertake the management of tracheostomy are maintained. 5.0 Safety Equipment 5.1 Bed area checklist for patients with a tracheostomy 5.2 All bedside equipment and emergency equipment should be checked at the beginning of a shift and on handover of patient care. The nurse responsible for the child must complete a tracheostomy daily checklist. (Refer to Appendix 4) 5
5.3 Essential equipment Oxygen with tracheostomy mask attached Suction machine with tubing attached Appropriate sized suction catheters (one attached to suction tubing) Yankeur sucker Tap Water (in a clean container for flushing suction system) Gloves, aprons, goggles and waste bag Humidification system (Swedish nose) Pulse oximeter (if oxygen therapy is required) 10ml syringe for cuffed tube Spare tracheostomy dressings Sterile galipot Packet of gauze/cotton applicators (used for cleaning the stoma) Tracheal dilators should be available and kept on the resuscitation trolley and only used by competent practitioners 5.4 Emergency equipment Ambu bag / swivel connector (15mm Smiths Medical Portex) (in bag attached to oxygen) The emergency bag / box for a child with a tracheostomy must be kept with the child at all times and consists of the following items and nothing more, if any other equipment is needed it should be carried separately to ensure ease of access to the emergency equipment. Tracheostomy tube the same size and make as the one insitu with Velcro tapes or cotton ties attached for single person emergency use Tracheostomy tube one size smaller (in sealed sterile packet with expiry date on) Suction catheter size appropriate for a tube smaller than the one in situ to use as a guide if unable to insert the smaller tracheostomy tube Spare tracheostomy tapes Lubricating gel Round ended scissors 2 ml syringes Sodium Chloride 0.9% ampoules (5ml or 10ml) 6.0 Care of the Child with an Established Tracheostomy (Refer to Appendix 3, 5 and 6) 6.1 When a child with a tracheostomy is admitted, their bed space will need special preparation to ensure that the child s airway is never compromised through lack of appropriate equipment. 6.2 Staff competent in the management of a tracheostomy must always be available to support other staff members or parents/main carers. The bed should be easily observable at all times. If a child is placed in the bay area they should be supervised in that bay area by a parent, carer or nurse at all times. 6.3 A cubicle should only be used for clinical need e.g. isolation. In this case the child should be very closely supervised (1:1) at all times either by a parent, carer or nurse. All equipment as previously discussed should be placed at the child s bedside. 6
7.0 Transfer of a Child with a Tracheostomy 7.1 A trained member of nursing or medical staff competent in tracheostomy care must escort the child. If a child is moved/transferred to another ward/department, essential equipment must accompany the child at all times due the risk of dislodgement or blockage of the tube. 7.2 For emergency use: Access to functioning oxygen supply Appropriate oxygen adaptors, tubing and mask Catheter mount and self-inflating bag/valve/mask 7.3 Tube change and suction equipment must accompany the child at all times regardless of the nature of the journey or the distance to be travelled. 8.0 Humidification 8.1 Definition: Humidification is defined as increasing the moisture content of air. In health the inspired air is filtered, warmed and moistened by the ciliated lining and mucous of the nose and upper airways (Royal Marsden Manual online 2011). A tracheostomy bypasses this natural humidification system therefore it is essential that this is artificially replaced in these patients. Water humidifiers are particularly useful when there is a higher requirement for humidification. 8.2 Humidifiers: All tracheostomies should have a form of humidification at all times. The types seen will either be via the ventilator if they are long term ventilated or via a heat and moisture exchanger HME. These are kept on the patient at all times; <10kg minivents, >10kg HME Swedish nose. Staff may need to take off for suctioning or there may be a hole at the top for the suction catheter to go through. If oxygen is required, the oxygen tubing is often attached to one of these HME via a side port. The optiflow system with the tracheostomy adaptor is an alternative method of delivering humidified oxygen. 9.0 Tracheal Suctioning 9.1 The upper airway warms, cleans and moistens the air we breathe. The tracheostomy tube bypasses these mechanisms, so that the air via the tube is cooler, dryer and not as clean. In response to these changes the body produces more mucous. The tracheostomy tube is suctioned to remove mucous from the tube and trachea to allow for easier breathing. There may be large amounts of mucous with a new tracheostomy. This is a normal reaction due to the irritation of the tube in the airway. The heavy secretions should decrease in a few weeks. The production of secretions tends to reduce the longer the tracheostomy has been in situ. 9.2 Tracheal suction should only be performed if the child is unable to clear their own secretions and should not be a routine procedure. 9.3 Suction when indicated will help to: Maintain airway patency Prevent collapse of the lung due to small airways becoming blocked by secretion, and prevent potential risk of infections Maintain patient comfort 7
9.4 Frequency of suctioning will depend on the child s needs and will increase with respiratory tract infections, changes in weather, humidity, environment or increased exercise. Too frequent suctioning may cause more secretions to be produced. Frequency of suctioning should be documented on the tracheostomy care record in the evaluation of care. (Refer to Appendix 5) 9.5 Only personnel trained and competent in the techniques involved must perform suctioning of a tracheostomy. 9.6 Suction is required to ensure the tracheostomy tube does not become blocked with secretions and allows maximum air passage for the child. 9.7 Suctioning is indicated in the following situations: If the child is restless Unexplained crying Anxious looking Pale colour Bubbling / rattling sounds from the tracheostomy Coughing 9.8 When suction is indicated this should be carried out promptly to avoid distress. 9.9 More suction may be necessary if the child has a cold or a chest infection. The first sign of this may be an increase in secretions. Secretions may also become yellow/green and smell unpleasant 10.0 Suction Catheter Size Calculation and Depth 10.1 The size of the suction catheter depends on the size of the tracheostomy tube. If the suction catheter is too small it will not aspirate the secretions efficiently. If the catheter is too large it will block off too much of the airway during suction, making the child bradycardic and reducing oxygen saturation levels. Ideally the suction catheter needs to be half the size of the lumen of the tube. For the neonatal and paediatric patient the suction catheter should be no more than double the internal diameter of the tracheostomy tube; e.g. 4.0mm tracheostomy tube will need 8Fg suction catheter. 10.2 Suction depths 10.2.1 Shallow suction suctioning secretions at the opening of the tracheostomy tube that the child has coughed up. 10.2.2 Pre-measured suction suction the length of the tracheostomy tube. 10.2.3 Deep suction insert the suction catheter until resistance is felt. Deep suctioning is usually not necessary unless the child has ineffective cough. 10.3 Suction pressures should be kept to a minimum; as a general guide pressures should not exceed 60-80 mmhg (8-10kpa) for neonates and small infants and up to 120mmHg (16kpa) for children. Higher pressure up to 150mmHg (20kpa) can be used for older children if required. 8
10.4 Saline instillation should not be used routinely as it does not mix well with secretions and can cause oxygen desaturation and excessive coughing. Effective humidification is essential and can be delivered using Heat and Moisture Exchangers (HME s - artificial noses), saline nebulisers and heated water humidifiers. 11.0 Equipment Required for Suctioning a Tracheostomy A functional suction unit wall mounted or portable Sterile suction catheters - size appropriate Personal protection equipment (gloves, apron, goggles/face shield) Tap water (in a clean container labeled for cleaning suction tubing) 10ml 0.9% Sodium Chloride ampoule, 2ml syringe in-case needed Oxygen, wall mounted or cylinder/oxygen tubing /tracheostomy mask Yankuer sucker Universal container for specimen Tissues Bag for disposal of waste 12.0 Procedure for Suctioning a Tracheostomy Tube 12.1 If suction is indicated collect required equipment and ensure that the equipment is working correctly and ready for use. This should be checked at the start of every shift. 12.2 Choose appropriate sized suction catheter. If the catheter is too large it will occlude the tracheostomy which may cause hypoxia, cardiac arrhythmias and severe distress to the child. If it is too small the secretions may block the catheter. 12.3 Explain the procedure to the child and enable the child to give verbal/non-verbal consent. Ensure the child s privacy and dignity throughout the procedure. 12.4 Decontaminate hands as per Trust policy. Put on personal protective equipment. This will reduce the risks of cross infection. 12.5 Monitor oxygen saturations before and during suctioning if oxygen is being administered. Increase oxygen if necessary in order to maintain adequate oxygenation and reduce the risk of hypoxia and arrhythmia. 12.6 Turn on the suction and attach a sterile suction catheter. Ensure that the pressure is checked prior to use. The lowest possible vacuum pressure should be selected based on the size of the child to minimise trauma to the mucosa and potential atelectasis due to increased negative pressure. 12.7 Put glove on dominant hand, only touch suction catheter with this hand to reduce the risk of infection. 12.8 Introduce the suction catheter into the tracheostomy tube. Do not apply suction at this point. Gently but quickly insert it to just beyond the end of the tracheostomy tube or until the child coughs. The catheter should go no further than the carina (the point where the right and left main bronchi divide). 12.9 Withdraw the tip of the catheter approximately 0.5 cm before applying suction (do this only if you have reached the carina). Withdraw the catheter slowly with continuous suction applied. Continuous suction is most effective in clearing secretions, but the catheter must be kept moving to reduce the risk of mucosal damage. 9
12.10 Do not suction for more than 10 seconds. Prolonged suction will result in hypoxia. 12.11 Release the suction, remove the catheter and glove and discard, reapplying the child s oxygen supply immediately if used. 12.12 Observe the child throughout the procedure for any signs of distress or discomfort. 12.13 Observe and document colour, volume and consistency of secretions and document on chart. 12.14 Rinse the suction tubing in order to clean the tubing and reduce the risk of cross infection. Change suction tubing at least daily and ensure suction canister is not overfilled. 12.15 Using a clean glove and suction catheter repeat the procedure until the child is breathing comfortably. Allow sufficient time between suctioning to allow the child to recover especially if oxygen saturations are low. This reduces the risk of hypoxia and minimises distress to the child. 12.16 If secretions are tenacious consider the need for a saline nebuliser as nebulisers can loosen secretions. Contact the medical team and physiotherapist if secretions are thicker than usual. 12.17 Clear away equipment and decontaminate hands in line with trust policy. 12.18 Difficulty passing the suction catheter should lead to consideration that the tube maybe partially blocked, badly orientated or misplaced and requires immediate attention. 13.0 Irrigation of a Tracheostomy Tube 13.1 The instillation of 0.9% sodium chloride may be required periodically but should be determined on an individual patient basis and only undertaken by experienced practitioners. The rationale for the use of sodium chloride is to loosen the secretions, lubricate the suction catheter, enhance a cough and dilute secretions. 13.2 Irrigation involves instilling up to 0.5ml of 0.9% sodium chloride solution into the tracheostomy tube, immediately before performing suction. This procedure may be repeated if necessary. It is a potentially hazardous procedure and must be undertaken with care. (Refer to nursing care plan - Appendix 6) 14.0 Changing Tracheostomy Tapes and Dressing 14.1 The play specialist may be involved in preparing the child for the tape change and may be required for distraction therapy during the procedure. This will help reassure the child and provide optimal co-operation. 14.2 Babies and toddlers are usually swaddled during the tape change to maintain safety and security. All young children will have their tapes changed whilst lying down so that the neck is slightly extended using a rolled towel under the shoulders, the stoma is exposed allowing easier access and if emergency care is needed they are in a safe environment. 10
14.3 Some older children like to assist with the procedure by holding the tracheostomy tube in place and often prefer to be sitting up rather than lying down. 14.4 Indications 14.4.1 The tracheostomy stoma and tapes holding the tracheostomy tube in place should be cleaned assessed and tapes changed at least daily. Tapes should also be changed if they become wet or soiled. This allows you to observe the stoma site and skin under the tapes to ensure that they are healthy and to ensure that neither is red or sore. 14.4.2 This procedure is described as a two person event, however it is understood that this is not always possible in the child s home. Two people should always be present in the hospital setting. 14.4.3 Routine tape changes should be planned to fit in with the child s daily routine, i.e. after a wash or bath, and should not occur too soon after eating or being fed to reduce the risk of vomiting. 14.5 Types of Tapes 14.5.1 The type of tapes used will be individually assessed depending on the needs of the child and family. Generally whatever tapes are used they are only as good as the person applying them so it is important to ensure they are tied correctly and checked regularly. 14.5.2 The type and method used to secure a tracheostomy tube will vary depending on the method parents have been trained to use at the tertiary center their child s care is managed. 14.5.3 Marpac: A one piece tube holder made with comfortable foam with cotton twill ties incorporated. This is the usual method of securing a tracheostomy tube. 14.5.4 Velcro: May be preferred if skin broken or sore. Velcro tapes must only be used once as there is a risk of them stretching when wet. They should not be used if there is a risk of the tapes being undone by the child. 15.0 Equipment Needed to Change the Tracheostomy Tapes and Dressing Oxygen checked and working, O2 mask, self inflating bag/valve/mask Suction checked and working, appropriate size suction catheters, yankeur suction catheter Emergency Tracheostomy Box Personal protective equipment apron, gloves, goggles/face shield Gauze 7.5 cm Normasol (0.9% Sodium Chloride) Gallipot Velcro tapes if used Marpac tube holder Scissors round ended Dressing with key hole Rolled towel to place under the shoulders to extend the neck and expose the stoma Blanket or sheet to swaddle baby or toddler to maintain safety during the procedure Child s own comforter, dummy if needed The older child may prefer to sit and may like to assist by holding the tube 11
Play specialist to distract the older child 16.0 Procedure for Changing Tapes and Dressing 16.1 Two people are required to undertake this procedure either two competent nurses or one competent nurse and a parent or carer. Decide roles before starting one will change the tapes and one will maintain the safety of the tracheostomy tube while unsecured in order to reduce the risk of tube displacement. 16.2 Explain the procedure to the child and parent in order to gain consent and co-operation and reduce the child s anxiety and distress. 16.3 Decontaminate hands as per trust policy. Put on apron and prepare a dressing tray. Use personal protective equipment to reduce the risk of cross infection to the child and self. 16.4 Position the child comfortably with their neck slightly extended. This allows easier access and view of the child s tracheostomy site. 16.5 Place clean tapes behind the child s neck. 16.6 Second nurse or assistant to hold tube in position using index and middle finder to reduce the risk of tube displacement. 16.7 The tape changer should cut the tapes between the knot and the flange on the further side and then the near side of the tube to release the dirty ties and carefully remove. 16.8 Observe the stoma site and neck creases for signs of infection or skin breakdown. Swab the site if concerned. Clean the stoma site with saline and gauze to remove any debris and then dry. If a clean dressing is required, ease into place around the tube and under the flanges of the tube. A dressing absorbs exudate and aids comfort. Record the condition of stoma site and dressing change in patient records. (Appendix 5) 17.0 Cotton Tapes 17.1 Thread new tapes through the flange on the side furthest from the tape changer. This will secure the tube on one side. Tie the tapes using three flat knots. If one knot works loose then two will hold the tube securely. Ensure the tape is flat to the child s skin as twisted tape will cause skin pinching and breakdown. 17.2 Thread tape through the near side flange and tie one knot then a bow. This will secure the tube temporarily on the second side in preparation for the tension check. It is easier to untie a bow rather than a knot. 17.3 Check tape tension by sitting the child up whilst the assistant continues to hold the tube securely. With the child s head bent forward it should be possible to slip one finger comfortably between the ties and the child s neck. This will allow the tapes to be checked for the correct tension for maximum security and comfort. 17.4 If the ties are too tight or too loose lay the child down, undo the bow and readjust. If the tapes are too tight it can reduce venous return from the head causing sclera oedema. Tightness may also irritate the skin. Recheck the tape tension and follow the same procedure until the tension is correct. 12
17.5 When the tension is correct lie the child down and change the bow to three knots by pulling the loops of the bow through to create a second knot, then tie a third knot. By using the loops of the bow the tape tension will not be altered. Cut off excessive tape, leave 2cm to maintain the security of the tube and allow sufficient tape to grasp for the next tape change. 17.6 To maintain the safety of the tube the assistant may only release the tube when told to do so. 17.7 Check the child is breathing comfortably after the procedure and the tube has not been dislodged. 17.8 Clear away equipment and decontaminate hands in line with trust policy. 17.9 Record tape change in patient records. (Refer to Appendix 5) 18.0 Velcro Tapes 18.1 Take a new tape and shape the Velcro into a diagonal making it easier to thread through the tracheostomy flange. Thread the new tapes through the flange on the side furthest from the tape changer, and secure the Velcro down. This will secure the tube on one side in preparation for the second side. 18.2 Then thread through the Velcro tape on the near side flange, and secure the Velcro down. This will secure the tube temporarily on the second side in preparation for the tension check. 18.3 Check tape tension by sitting the child up whilst the assistant continues to hold the tube securely. With the child s head bent forward it should be possible to slip one finger comfortably between the ties and the child s neck. This will allow the tapes to be checked for the correct tension for maximum security and comfort. 18.4 If the Velcro tapes are too tight or too loose lay the child down, undo the Velcro tapes one side at a time and readjust. If tapes are too tight it can reduce venous return from the head causing sclera oedema. Tightness may also irritate the skin. Recheck the tape tension and follow the same procedure until the tension is correct. 18.5 To maintain the safety of the tube the assistant may only release the tube when told to do so. 18.6 Check the child is breathing comfortably after the procedure and the tube has not been dislodged. 18.7 Clear away equipment and decontaminate hands in line with trust policy. 18.8 Record tape change in patient records. (Refer to Appendix 5) 13
19.0 Changing a Tracheostomy Tube 19.1 This should ideally be undertaken as an elective procedure. 19.2 Indications 19.3 It is advisable to change a tracheostomy tube regularly to prevent the gradual buildup of secretions which can block the tube, make suction difficult and cause respiratory distress. The frequency with which a tube needs to be changed depends on the type and size of tube used but it is also affected by how well the child is. 19.4 If a child s secretions are sticky or there is a buildup of debris on the flange of the tube it may be necessary to change the tube more frequently than the manufacturer s guidelines state. 19.5 Although initially unnerving for the inexperienced, a tracheostomy tube change should not be an unpleasant experience for the child. If a calm, relaxed approach using simple explanations is used the child will be adequately prepared and able to co-operate 20.0 Procedure for Changing a Tracheostomy Tube 20.1 Two people are required to undertake this procedure either two competent nurses or one competent nurse and a parent or carer. Decide roles before starting to ensure a smooth procedure where everyone knows exactly what they have to do. One person will maintain the safety of the tracheostomy tube while unsecured in order to reduce the risk of accidental de-cannulation and one will remove the old tube and insert the new tube. 20.2 Explain the procedure to the child and parent in order to gain consent and co-operation and reduce the child s anxiety and distress. 20.3 Decontaminate hands as per Trust policy. Put on apron and prepare a dressing tray. Use personal protective equipment to reduce the risk of cross infection to the child and self. (Refer to point 24.0) 20.4 Prepare equipment to minimise length of time the procedure takes therefore reducing stress to patient and potential risk of de-cannulation. Open the dressing pack and new tracheostomy tube and prepare tube with tapes attached and ensure dressing is to hand. 20.5 Position child so tracheostomy and neck are visible, loosening clothing if necessary. For infants place a neck roll under their shoulders, older children may prefer to sit up. (Swaddling may be beneficial to keep arms out of the way, but distraction therapy may cause less distress). 20.6 Assess the child s need for suction before proceeding further. This reduces the risk of de-cannulation if suction is needed when tapes not secure. 20.7 Check the introducer slides easily out of the tube. Apply a small amount of lubricating gel to the sides of the tip of the new tracheostomy tube (some older children may prefer to have this action omitted). This decreases trauma when a new tube is inserted. Large amounts of gel can irritate and cause coughing and the need for suction. 20.8 Before starting the procedure ensure the assistant is holding the existing tube securely using middle and index finger to reduce the risk of accidental de-cannulation. 14
20.9 Cut the tracheostomy tapes to facilitate removal of the tube and to reassure child. 20.10 Disconnect any speaking values, Swedish noses, humidifiers, ventilators or oxygen connections to facilitate removal of the tube and prevent discomfort to the child. 20.11 The person changing the tube holds the new tube in their dominant hand by the flanges and positions the tip near the child s neck to allow a swift change of tubes. 20.12 The person changing the tube then tells the assistant to take their fingers off the tube and gently removes the old tube following the curve of the tube and the child s neck to maintain comfort and minimise coughing. 20.13 Firmly and gently slide in the new tube following the curve of the tube and the child s neck, and remove the introducer to prevent damage to the trachea. The child will be unable to breathe while the introducer is in situ. 20.14 The assistant secures the tube with their middle and index finger to avoid child coughing out new tube. 20.15 Check the child is breathing easily and has no signs of respiratory distress to avoid any respiratory complications. The child may gasp and cough but this is a natural response and should settle. 20.16 Tie the tapes as previously described in order to secure the tracheostomy tube in place. The assistant should only release the hold on the tube only when it is stated that the tapes are secure and the tension correct. 20.17 Reassess the child for signs of respiratory distress and ensure they are comfortable. 20.18 Clear away equipment and decontaminate hands in line with trust policy. 20.19 Record tube change in patient records. (Refer to Appendix 5) 20.20 If the patient cannot breathe the tube has probably been inserted into the pre tracheal space. Remove the tube and reinsert as above to avoid the child becoming hypoxic. 20.21 If the tube cannot be inserted attempt to insert the smaller size tracheostomy tube found in the Emergency Tracheostomy Box. (Refer to Appendix 1 and 2) 20.22 If the smaller tube cannot be inserted insert a length of suction catheter that is a size smaller than the tracheostomy tube and found in the emergency tracheostomy box to prevent closure of the stoma. 20.23 Thread the tracheostomy tube over a clean suction catheter. Insert the catheter into the stoma to around the same depth you would normally suction to. Gently feed the tracheostomy tube over the catheter and into the stoma. Remove the catheter. 20.24 A suction catheter can be used to deliver oxygen in an emergency through the stoma to avoid hypoxia. Remember to occlude the suction port. This procedure can only be carried out if the child is breathing. 15
20.25 If respiratory function deteriorates the BLS protocol should be followed. Call for help immediately 2222. 21.0 Emergency Procedures 21.1 When de-cannulation is suspected the following emergency procedures should be followed: 21.2 Assess Airway Breathing Circulation Call for help - 2222 Remove the tracheostomy tube Administer oxygen. 21.3 Attempt to replace tracheostomy tube with new same size tube or smaller tube if unable to reinsert. If there is dislodgement of the tube, the old tube may be used when a new tube of same size is unavailable, then secure new tube. 22.0 Basic Life Support Assess Airway Breathing Circulation Call for help, 2222 Suction Remove tube Replace tracheostomy tube Suction Assess Airway Breathing Circulation 22.1 Assess Airway Breathing Circulation Supporting the new tube, place the side of your face over the tracheostomy tube to listen and feel for any breathing. At the same time look at the child s chest to observe any breathing movement. Take up to a maximum of ten seconds to do this. If the child is breathing adequately, give oxygen and keep their airway open by regular suction and await the paediatric cardiac arrest team s arrival. If the child is not breathing (or only making agonal gasps), commence artificial respiration with a bag-valve system directly connected to the tracheostomy tube and administer 5 breaths. This is best achieved with a Smiths Medical (Portex ) 15mm swivel connector attached to the ambu bag. Ensure that the breaths are effective by observing chest rise and fall. 22.2 Basic Life support if not breathing (Refer to Appendix 1) Check for signs of life If the child is showing signs of life but is not breathing continue with rescue breathing at a rate of 30/min If the pulse is absent or is under 60bpm with no other signs of life have been detected, perform chest compressions Remove folded towel from under shoulders Continue with CPR at a ratio of fifteen compressions to two breaths Reassess for signs of life after one minute (or 5 cycles of 15:2) 16
Continue with CPR until the infant shows signs of life (recovers), help arrives or the rescuer becomes exhausted. 22.3 Secure Tapes if successful, observe and reassess 23.0 Tracheostomy Tube Occlusion/blockage 23.1 Tracheostomy tube occlusion is a serious complication which is life threatening. Therefore, it is important to recognise tube occlusion and act promptly to change the tube. Children with thick or large amounts of secretions are particularly prone to occlusion and should be suctioned as clinically indicated 23.2 The following are signs of occlusion: Increased difficulty in breathing Unable to pass a suction catheter easily down the tube Signs of cyanosis or oxygen desaturation Patient distress 23.2 If you believe that the tracheostomy tube is blocked, remove and replace the tube immediately, assess breathing and give oxygen via a tracheostomy mask or bag / valve device (if poor or no respiratory effort) and call for help. 23.3 In any situation that compromises the child s respiratory state call 2222. 24.0 Staff Training 24.1 Staff of all grades should be familiar with how to recognise seriously ill children and be able to perform paediatric life support. They should undergo re-training at the mandatory intervals. 24.2 Training will be provided with periodic retraining made available. A competency based assessment will need to be completed including both clinical and theoretical knowledge with regard to all aspects of caring for children with an established tracheostomy. 24.3 Only trained and competent nursing staff should care for children with an established tracheostomy. (Refer to Appendix 7) 24.4 Registered nurses must comply with NMC standards for maintaining their knowledge and skills. 25.0 Infection Prevention 25.1 All staff should follow Trust guidelines on infection prevention by ensuring that they effectively decontaminate their hands between each patient. 25.2 All equipment will be decontaminated between each patient and disposable single use items used where supplied. 17
26.0 Monitoring Compliance with policy requirements 26.1 Any instances of non-compliance with this guideline should be recorded on a risk event form in accordance with the Incident Policy. This will address any training needs for staff that require updating. 26.2 The documentation audit will assess compliance to these guidelines. 27.0 Implementation and Communication 27.1 The policy will be uploaded on the Trust Intranet site and will be communicated to staff via staff focus. 27.2 The policy will be circulated to the Clinical Lead for paediatrics and Lead Nurse for children and young people for dissemination. 28.0 References Advanced Life Support Group [ALSG] (2011) Advanced paediatric Life Support: The practical Approach Fifth Edition.Wiley-Blackwell publishing: Chichester Cockett A, Day H (Ed) (2010) Children s High Dependency Nursing Wiley-Blackwell publishing West Sussex Brighton and Sussex University Hospitals NHS Trust (2009) Paediatric Tracheostomy guideline Dixon M et al (2009) Nursing the Highly Dependent child or infant. Wiley-Blackwell publishing: West Sussex Great Ormond Street Hospital for Children (2012) Tracheostomy: care and management review Clinical Guideline (online) http://www.gosh.nhs.uk/health-professionals/clinicalguidelines/tracheostomy-care-and-management-review accessed 11/05/2015 Quality Improvement Scotland Best practice statement (2008) Caring for the child/young person with a tracheostomy Nursing and midwifery council (NMC) (2015) The Code Professional standards of practice and behaviour for nurses and midwives (online) http://www.nmc.org.uk/globalassets/sitedocuments/nmc-publications/revised-new-nmccode.pdf accessed 11/05/2015 Resuscitation Council UK (2010) Paediatric Advanced Life Support. RCUK London Royal Marsden Manual online (2015) The Royal Marsden Hospital Manual of Clinical Nursing Procedures 9 th edition. http://www.rmmonline.co.uk/ accessed 22/05/2015 UK National Tracheostomy Safety Project (online) http://www.tracheostomy.org.uk/ accessed 27/05/2015 Wilson M (2005) Paediatric tracheostomy Paediatric Nursing 17, 3, 38-44 18
Appendix 1 Basic Life Support Algorithm 19
Appendix 2 - Emergency Paediatric Tracheostomy Management Tracheostomy Care Chart Appendix 3 20
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Tracheostomy Bedside Checklist Appendix 4 22
Tracheostomy Daily Care Chart Appendix 5 Date: Name: Hospital No: DOB/Age: Ward/Dept: (tick and comment as applicable) Time Tapes changed (daily) 01.00 Tube change (weekly / monthly / emergency) Suction Airway (secretions: amount, colour, consistency) Care of stoma and neck HME (Swedish nose) changed Emergency box checked / resus algorithm available Sign / initial 02.00 03.00 04.00 05.00 06.00 07.00 08.00 09.00 10.00 11.00 12.00 13.00 14.00 15.00 16.00 17.00 18.00 19.00 20.00 21.00 22.00 23.00 24.00 23
Care Plan Appendix 6 Name D.O.B Reg. No Ward Care started Date: Sign Need Needs a tracheostomy tube to maintain their airway. Tracheostomy Tube type and size: Suction catheter size suction to cm Specific instructions: Do Not Leave Child Alone Action Done/continuous Sign:Date:Time D=done C=Continuous Nursing Actions Ensure bedside checklist has been completed every shift and emergency box/equipment is available with the child at all times Ensure the Tracheostomy tube is safely secured, but can be removed swiftly in the event of blockage. Ensure HME (Swedish nose) is connected to the tube at all times Ensure bedside/portable suction unit/suction catheters are available & working. Use correct suction pressure when suctioning Suction the tube as necessary using the appropriate sized, graduated catheters. Insert to the length stated above, applying suction only on withdrawal for no more than 10 seconds. Provide extra humidity other than HME if the secretions are thick Consider the use of saline nebulisers to loosen secretions. If secretions remain sticky irrigation may be necessary. If so instil 0.5ml of normal saline prior to suctioning the tube. Document on tracheostomy daily care chart any changes in colour or consistency of secretions Obtain sputum specimen for MC&S if any change Consider referring to physiotherapist Ensure child is systemically hydrated. Consider referral to dietician If the tube appears to be blocked and suctioning and saline irrigation do not remove secretions perform an emergency tube change and replace with either same size or one size smaller. Reassess patient and inform Drs. Daily Care for patient with Tracheostomy tube Assist parent/carers in changing tracheostomy tapes/velcro ties daily or more often if soiled. Ensure 2 nurses in absence of parent/carer or 1 nurse and one carer for changing tapes. Document on daily care chart. Observe stoma site and clean as necessary with saline and cotton buds. Do not use cotton wool balls. Apply tracheostomy dressing if stoma site looks sore red infected. Document on daily care chart. Assist parent/carers with tracheostomy tube change (weekly/monthly), observing the stoma for signs of infection. Ensure 2 nurses in absence of parents/carers or 1 nurse and 1 parent/carer for tube change. Document on daily care chart. Nurse child in head up tilt and in comfortable position to optimise airway Change HME (humidifier) every day or more often if soiled Negotiate with parents/carers about care and supervision required on a daily basis and support them in caring for their child. Provide information and support for family. 24
Appendix 7 Teaching Pack / Competency Book S:\ ClinicalFacilitatorChildr 25