Any clinical area can potentially look after neck-breathing patients, but these areas must be:

• adequately staffed
  
• adequately trained
  
• adequately equipped
  
• adequately supported.

In order to do this effectively, most Trusts will have to cohort patients with tracheostomies together into designated wards. This allows training and equipment to be targeted and concentrates expertise and experience. Nominated areas would typically include:

• critical care areas
  
• head and neck wards
  
• designated respiratory/medical/surgical wards.

Patients with tracheostomies or laryngectomies should not be cared for outside these areas. This has implications for the flow of patients into, out of and around a hospital, and the bed managers will need to be adequately involved in planning patient movement. Patients can also come directly from the community or through the emergency department.

Given here are the key areas to consider for those designated wards.

With regard to inter-hospital transfer between acute hospital sites, it is the responsibility of the transferring/discharging hospitals/units to ensure that the patient transfer is communicated to the relevant team(s) within the receiving Trust. Adult patients with tracheostomies should only be transferred to hospital sites where there is appropriate arrangement in place to adequately care for the patient’s needs.

The policy detailed here is an example based on amalgamated policies from several hospitals in the North West Region of England. Clearly, hospital policies will vary, but this is included to give the reader a framework if you were considering writing your own tracheostomy policy. It may be useful to designate specialist areas (ICU; HDU, high-dependency unit or a head and neck unit), non-specialist areas (nominated, trained, adequately staffed and equipped to care for patients with tracheostomies) and then all other clinical areas.

Duties within the organisation

Chief Executive

The Chief Executive is responsible for ensuring the requirements within this policy are fulfilled and operational responsibilities are in place when patients who are ‘neck breathers’ are nursed on general wards.

Chief Nurse

The Chief Nurse is responsible for ensuring requirements within this policy are fulfilled and that this policy is disseminated to all Heads of Nursing for appropriate action.

Executive Medical Director

The Medical Director is responsible for ensuring that this policy is disseminated to Consultants who supervise medical staff in training and that education and training facilities are available to ensure medical staff can maintain the level of clinical standards to appropriately manage patients who trigger on the Modified Early Warning Score (MEWS).

General Managers

The General Managers will ensure that adequate resources are available within their divisions to make provisions within this policy feasible.

Consultant (or lead clinician)

The Consultant is the professional with the overall clinical responsibility for patients, and therefore will ensure patients cared for in a designated area other than their allocated ward will receive a daily visit from a member of the team. The Consultant will ensure that clinical standards are maintained and that any necessary deviation from this policy is documented and explained in the medical notes.

Heads of Nursing

Heads of Nursing have a responsibility to ensure that this policy is disseminated to Matrons and Ward Managers to inform clinical staff of their responsibilities in the safe care of patients who are neck breathers. In collaboration with Matrons and Ward Managers, Heads of Nursing must ensure that adverse clinical incidents in relation to the care of patients who are neck breathers in their clinical areas are reported and investigated and action plans produced to prevent future occurrence.

Matrons and Ward Managers

Matrons and Ward Managers have a responsibility to ensure that any staff responsible for caring for patients who are neck breathers receive training on their care and management and recognise when to escalate care to the appropriate people. Matrons and Ward Managers have a responsibility to ensure that all clinical staff have access to equipment and documents for providing safe care for patients who are neck breathers.

Bed Managers

Bed Managers must ensure that patients with a tracheostomy/laryngectomy admitted to a general ward from a critical care area, specialised ward or from any community setting must be cared for in the designated areas. These areas will be identified following a Trust-wide consultation process.

Critical Care/Specialist Ward clinical staff

Most patients with a tracheostomy discharged from a specialist ward should have an uncuffed tracheostomy tube with an inner cannula sited. Exceptions to this must be clearly justified (reduced conscious level, excessive secretions, inability to protect the airway). Standardising or limiting the different types of tubes available may make teaching easier and reduce potential confusion with tubes. At least 24 h notice should be given to the receiving ward when a patient is being discharged from a specialist area. This will ensure the receiving ward can make all necessary preparations to safely accept responsibility for the patient with a tracheostomy.

A tracheostomy Care Plan will be completed by the discharging team, and be communicated to the receiving ward nurse and agreed on before the patient is discharged from the Critical Care/Specialist Ward. This will ensure that a full handover of care is given and the receiving ward can maintain a safe environment for the patient with a tracheostomy. A risk assessment should be completed and agreed on with the receiving ward. Any problems with the tracheostomy should be clearly communicated (see draft risk assessment).

Receiving ward clinical staff

The receiving ward should ensure that the patient with a tracheostomy/laryngectomy is nursed in a bed that is observable from the nursing station and, wherever possible, not in a side room. As a general rule, the patient should be nursed in an open observation area, rather than a side room (unless continuous 1 : 1 staffing is provided). Discussion with infection control teams should take place, as close observation for airway compromise is likely to take priority over use of a side room for infection control purposes. The receiving ward should ensure that patients with a tracheostomy/laryngectomy must have access to a nurse call bell and other communication aids, if they are able to use them.

If patients do not have adequate means of communication because of their clinical state, then adequate provision for one-to-one care must be adopted. The receiving ward should ensure that patients with a tracheostomy or laryngectomy requiring oxygen must have an oxygen supply and suction equipment at the bedside, and that the oxygen is prescribed on their prescription chart. Any patient with a tracheostomy/ laryngectomy who is oxygen dependent should have their oxygen warmed and humidified. The receiving ward should ensure that the patient with a tracheostomy has the emergency airway box at the patient’s bedside at all times. The appropriate bedhead sign should be completed describing the details of the tracheostomy. This form will be completed by the person performing the tracheostomy or by a competent member of staff if a patient is admitted to the Trust with an existing tracheostomy.

Patients with a tracheostomy/laryngectomy must have regular checks carried out as per the tracheostomy/laryngectomy Care Plan and patient bedside checklist. The receiving ward should ensure that the patient with a tracheostomy/laryngectomy has been referred to the Physiotherapy and Speech & Language teams if appropriate.

Critical Care Outreach Team

Some hospitals have ‘Outreach Teams’ who are well placed to support and assist ward staff with caring for neck-breathing patients and often play a vital educational role. Systems need to be in place to notify Outreach Teams if a neck-breathing patient is admitted or transferred.

Emergency teams

Any patient with a tracheostomy or laryngectomy who develops breathing difficulties or displays any of the ‘Tracheostomy Red Flags’ need prompt assessment by someone trained to do so. For tracheostomy/laryngectomy problems (or where clinical deterioration may be related to the airway) the patient must be seen by the ENT or MaxFax team (for ENT or MaxFax patients), or by the relevant medical team, within 30 min. Contact details are displayed on the appropriate bedhead signs. For an emergency related to the airway, decide in advance who should be called (depending on your hospital setup)

Hospital Incident Reporting System (HIRS)

Most hospitals have a system for recording adverse events and facilitating subsequent investigation. If a patient’s care is affected by a failure to provide appropriate infrastructure or not following a local policy, then the Hospital Incident Reporting System (HIRS) system is a useful way of recording this and improving the systems.

Standards and key performance indicators and process for monitoring compliance

The following standards and key performance indicators could be used for monitoring compliance to a tracheostomy policy, monitored via audit.

• The Critical Care Outreach Team (or similar) have been informed of any patient nursed on a general ward within the Trust with a tracheostomy or laryngectomy.
  
• A tracheostomy/laryngectomy Discharge Plan has been completed for patients discharged from a specialist area.
  
• The patient is cared for in a designated area.
  
• The designated area has been given 24 h notice before the patient has been admitted from a specialist area.
  
• Any patient with a tracheostomy tube will have an uncuffed double-cannulae tube sited (if appropriate).
  
• Time of discharge from a specialist area is not between 22.00 and 07.00.
  
• A tracheostomy/laryngectomy Care Plan is in use and completed correctly.
  
• An emergency airway box is always at the patient’s bedside.
  
• Emergency algorithms are displayed above the patient’s bed where appropriate.
  
• Suction equipment is connected correctly and working.
  
• An oxygen supply is available at the bedside.
  
• other emergency equipment is available on the ward
  
• The patient is nursed in a bed that is easily observable to nursing staff.
  
• If administering oxygen via a stoma it is humidified.
  
• A referral is made to physiotherapy for a daily and weekend visit.
  
• An adequate supply of all necessary equipment is available on the receiving ward.

Dissemination, implementation and access to this document

All staff working on a receiving ward will receive documented training and education on the care of the patient with a tracheostomy or laryngectomy on a regular basis.

Risk assessment

The following risk factors must be taken into consideration when determining an appropriate clinical environment for a patient with a tracheostomy.

• Patient discharged from critical care within last 48 h
  
• Tracheostomy less than 7 days old
  
• Patients requiring a single-lumen tracheostomy tube for clinical reasons
  
• Patient known to have a complex airway and/or difficult endotracheal intubation or tube insertion (bedhead sign)
  
• Patients unable to call for help (including unable to use call system)
  
• Patients at risk of self-decannulation:
  
  
  
  • Delirious
    
  • Agitated
  
  
• Patients with an obstructed upper airway (dependent on their tracheostomy for breathing) or dependent on ventilatory support.

Any of these factors place the patient at a greater risk of airway obstruction, requiring more frequent observation by trained and competent staff and greater visibility at all times. These should form the principles that should be determined by the lead clinician for the risk assessment for the patient.

Care plans