Course Objectives • Identify key roles and members of the team. • Discuss how the team can impact outcomes of the tracheostomized and/or ventilator dependent patient. • List three goals of an interdisciplinary tracheostomy management team. • Describe how the use of the Passy-Muir® Valve may be integrated into a weaning/decannulation protocol.

The Practice of Medicine Has Changed In the 70’s

21st Century

– Doctor • Nurse

– Everyone else » patient

• Patient centered care • Teamwork • Evidenced Based Practice • Patient Safety • Best Practice • Multidisciplinary Care • Protocols

(Dean Hess 2010)

Course Outline Gail M. Sudderth RRT Clinical Specialist Passy-Muir Inc. [email protected] (949) 833-8255

• Why do you need an airway management team? • Facts, Figures, Complications of Tracheostomy Tubes & Cuffs • Benefits of a Team Approach • Who is on the Team? What is the Process? • Collaborative Protocols • Documentation • Review Team Process • Resources, Web links, Decannulation Protocol (upon request)

Benefits of a Multidisciplinary Team • Tobin, et al. 2008 • Teaching hospital over four year period after implementation of multidisciplinary trach team – Length of stay after ICU discharge decreased from 30 to 19 days – Decannulation days after ICU discharge decreased to 7 from 14 days



Benefits of a Multidisciplinary Team • Le Blanc, et al. 2009 • Level I Tertiary Trauma Center – Time to decannulation decreased by 6.49 days – Length of stay decreased by 37.8 days • Earlier discharge to rehabilitation facility • Earlier intervention by SLP • Earlier use of Passy-Muir® Valve

To Improve Outcomes

What’s In A Name?

• First, we need to recognize the nature of the problem. • Second, most hospitals have the experts available t develop to d l teams, t just j t nott (working ( ki ttogether) th ) att the bedside. • Third, we need to take what we know-scientific knowledge- along with what we think we knowexpert consensus-to develop team based protocols. Heffner, 2008

Are Tracheostomized Patients Safe on the Regular Hospital Wards ?

Team Work

Why You Need a Trach Team

……”tracheostomized patients should be followed by a dedicated multidisciplinary team that continues to evaluate for decannulation, provides continuity of tracheostomy care and manages emergency situations.” it ti ”

“A big job ain’t nothin’ but a whole lot  of little jobs laid end to end”

1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13.

Communication Patient Safety Risk of Aspiration Risk Associated with Trach Tube Infection Control Mechanical i Ventilation i i Long-Term Trach Placement Education Staff Confidence/Knowledge Plan of Care Continuity of Care Quality of Care Quality of Life

Wilcox, et al. RESPIRATORY CARE • DECEMBER 2009 VOL 54 NO 12



Why You Need a Trach Team • Why is this patient still trached? • We are ALL part of the rehab process and responsible for the patient’s SAFETY

Complications of Tracheostomy •

– Trauma – Laryngeal anchoring – Reduced airway closure

No Airflow to upper pp airway y – reduced sensation – reduced taste/smell – loss of voice


• • • • • • • • • •

Prolonged intubation Need for long-term mechanical ventilation Need for permanent tracheostomy tube Inability to intubate - trauma Ai Airway protection/secretion t ti / ti removall Airway anomaly Patient comfort Facilitates weaning Options for oral feeding and communication A tracheostomy alone is not the treatment for aspiration

“Study the past if you would define the future”

Loss of positive airway pressures – – – –

Indications for Tracheotomy



peep cough swallow valsalva

‐ Confucius ‐

Anatomical Complications/Risk

Benefits of an Interdisciplinary Team

Identify the Needs of Your Facility Survey: -Staff knowledge and comfort levels -Patient satisfaction Review: -Present protocols -Statistics -Events related to tracheostomy tube



Team Members “Strength lies in differences, not in similarities”

Team Goals • • • •

How will it function? Who will lead the team? How will it evolve? Get help organizing and resolving conflicts

Team: Ongoing There is no “I” in team!

1. Daily Rounds • Who will perform? • Documentation in medical record • Recording for quality improvement 2. Monitor Compliance • Encourage Reporting • Identify Barriers 3. Education • Patients & Families • Staff

Team Members • • • • • • • • • • •

Nursing – at bedside, activities of daily living (ADL), medication RCP – mechanical ventilation, weaning & BPH SLP – swallow evaluation and treatment, speech OT/PT – Range of Motion (ROM), rehabilitation & strength, ADL Case Manager – discharge planning Wound Specialist – stoma care Family – emotional support Physician – orders, consults Ancillary Staff – anyone who cares for the patient Co-treat & cross train Educate

Team: Initial Plan • Identify a Champion • Organize the Team • D Develop l C Collaborative ll b ti Protocols & Competencies

Team: Follow-up • Who will lead the team? • Members’ Roles/Responsibilities • Meeting Plans • Goals and Target Dates • Plans for Daily Rounds

• Review and maintain Stats – Who, What, Why ?

• Continuing Education and Competencies y • Review and Revise Processes as Necessary • Team Meetings: ongoing – Monthly/Quarterly

• Educate Staff • Start! GO TEAM!



Team Process: Review

Sample Documents

Decannulation Algorithm: Phase I

Collaborative Protocols

Tracheostomy Algorithm

Decannulation Algorithm: Phase II

Suggested Protocols 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12.

Timing of tracheotomy Types of tubes/cuffs used Communication Method Decannulation Pathway SLP Consults RT Consults OT/PT Consults Nutrition Consults Wound/Stoma Management Trach changes/downsizing Cuff maintenance Oral care

13. 14.  15. 16. 17. 18. 19. 20. 21. 22. 23. 24.

Bed Control/patient placement Suctioning/BPH Oxygen and humidity Discharge Planning Patient/Family Education Aspiration/VAP prevention Patient Transport Standards Passy‐Muir® Valve Use MD Responsibilities  Staff Competencies Standard/standing Orders Emergency Procedures



Decannulation Algorithm: Phase III

Emergency Trach Box (At Bedside/Easy Access) • • • • • • • • • • • •

Standard Order Set •

Tracheostomy Protocol (for emergency items at bedside, Trach Team Consult and general plan of care) Tracheostomy tube

Tracheostomy tube secured

Tracheostomy tube plans for initial tube change (when and who will perform) Oxygen and humidity Suctioning and BPH Trach/Stoma Care Oral Care Consults - #1 SLP for swallow and communication Physician responsible for emergencies/second call

• • • • • •

– Size/type – Cuff (up/down) – Cuff pressure

– If sutures, when and who will remove

Tracheostomy Tubes – assorted sizes Spare Inner Cannulae – assorted sizes Sterile Suction Catheters – assorted sizes Sterile Gloves – assorted sizes Tracheostomy tube securing device Saline Bullets/Sterile H2O 10 cc syringe Scissors/Kelly clamps/Dilator Cricoid Hook Oral suction Water soluble lubricant Not to be used for routine tracheostomy changes

Bedside Checklist • • • • • • • • • • •

(Laminated/On Clipboard)

Daily Rounds (not part of the medical record) • • • • • • • • • • • • • • •

Date of initial and present tracheostomy Tracheostomy tube size and type Sutures present/plan for removal Decannulation (per order or self) Cuff pressure or cuff deflated Trach security y method Condition of tube/stoma/mouth/ lips/other tissue Ventilator/respiratory status Nutritional status Method of communication Cough/secretion management Emergency equipment at bedside Subjective reports Findings/recommendations/care plan Documentation in medical record

Daily Rounds Record

Resuscitation bag and mask with filter and cap Suction source Suction catheters Saline bullets/Bottle of Sterile H20 S Spare ttracheostomy h t tube(custom) t b ( t ) Spare inner cannulae Obturator 10cc syringe Suture removal kit Instructions for transport/O2 set-up Emergency Trach Box at bedside



Team Process: Review12 Steps 1. Identify needs

7. Educate Staff

2. Champion/Members

8. Cross-train

3. Organize Team

9. Team Rounds

4. Present to Administration

10. Documentation

5. Identify Barriers

11. Monitor Compliance

6. Develop Protocols

12. Reach Goal

Course Objectives • Identify key roles and members of the team • Discuss how the team can impact outcomes of the tracheostomized and/or ventilator dependent patient • List three goals of an interdisciplinary tracheostomy management team • Describe how the use of the Passy-Muir® Valve may be integrated into a weaning/decannulation protocol

Key Points •

The management of tracheostomy patients is multidisciplinary and requires active collaboration by all health care professionals

Assessment and reassessment by the team is crucial for ensuring i safe, f effective ff ti weaning i and d decannulation d l ti

The strength of the team lies in the differences of the members, not the similarities

A team approach can significantly impact weaning, rehab, decannulation time, length of stay (LOS), cost and quality of life of the tracheostomized/ventilator dependent patient

Gail M. Sudderth RRT Clinical Specialist Passy-Muir Inc. [email protected] (949) 833-8255

Additional Educational Opportunities • Self-study webinars available on demand – – – – –

Getting Started Ventilator Application Swallowing Pediatric Special Populations

• Live group webinars • www.passy-muir.com • Passy-Muir Inc. is an approved provider of continuing education through ASHA , AARC, CMSA and California Board of Nursing Credit