On the Right Trach?
Celebrating Success
St George’s Tracheostomy Group
1995ish- present…..
@ncepod
#tracheostomy
2
NCEPOD 2014- Complications
3
NCEPOD Audit data collection

Data collected as part of the national
NCEPOD observational study of patients
receiving a tracheostomy as part of their
treatment during an in-patient stay between
25th February and 12th May 2013
 The patients were identified at the time of
tracheostomy insertion on the intensive care
unit or in theatre
 Subsequently these patients were followed
through their hospital stay until death,
decannulation or discharge to home or another
hospital
NCEPOD Audit SGH (Results)

14
Table One -a
Reason
for procedure 59% (n=13) were male with a
22 patients received
tracheostomy,
mean age of 58 years (SD 19.36) and 41% (n=9) were female with a
mean age of 63 years (SD 18.74)
12
10

59% (n=13) percutaneous and 41% (n=9) surgical tracheostomy
 89% (n=8) of the surgical patients went to ICU post procedure and 11%
6
(n=1) went directly to a ward
8
4
2

0
Table Two - Outcome
21 patients had 12
an ICU stay, 62% (n=13) patients were discharged to
one of four wards
(Brodie n=2, Florence (n=6), Kent (n=1), McKissock
10 Head and Neck Surgery
Respiratory wean
Airway protection
(n=4) with a tracheostomy in situ
8

6
349 tracheostomy
bed days (mean 15.86; SD 8.59); 185 ICU
4
tracheostomy bed days (mean 8.80; SD 7.35), many of these patients
2
required additional
bed days being cared for pre and post decannulation
0
Decannulated in
ICU
Decannulated on
ward
Home with
tracheostomy
Repatriated with
tracheostomy
Died In ICU
Tracheostomy care at St George’s

MDT group
 Policy
 Clinical Guidance (v5)
 In-patients cohorted
 ICP
 Education


Video/DVD
Competence
assessment






MDT ward rounds
Consultation (internal
and external)
Product development
Discharge package
Out-patient clinic
Incident review
NCEPOD 2014 – Hospital Policy
7
Policy (‘thou shalt’)


Roles and responsibilities
Patient management







Admission from home
Transfer within the hospital
(cohort)
Discharge with a tracheostomy
Clinical advice
Tube changes
Guidelines for care –’evidence
suggests’ or ‘expert opinion is’
Follow up

Equipment







Education and training




Hardware
Consumables
Procurement
Location
Emergency pack
Supply into the community
Availability of staff
Competence ( basic and
advanced)
Study days
Documentation



Inpatient
Discharge
LAS
Tracheostomy care at St George’s

MDT group
 Policy
 Clinical Guidance (v5)
 In-patients cohorted
 ICP
 Education


Video/DVD
Competence
assessment






MDT ward rounds
Advice (internal and
external)
Product development
Discharge package
Out-patient clinic
Incident review
https://www.stgeorges.nhs.uk/gps-and-clinicians/clinicalresources/tracheostomy-guidelines/
http://tracheostomy.org.uk/
Tracheostomy care at St George’s

MDT group
 Policy
 Clinical Guidance (v5)
 In-patients cohorted
 ICP
 Education


Video/DVD
Competence
assessment






MDT ward rounds
Advice (internal and
external)
Product development
Discharge package
Out-patient clinic
Incident review
Small numbers, high risk, multiple
professionals in multiple locations….

The number of wards where nurses caring for
patients with a tracheostomy who report not
being competent to suction, measure cuff
pressure or manage blocked/displaced tubes
(p25-6, tables 2.9 &2.10)
Tracheostomy wards






Marnham
Florence Nightingale
ADU
Kent
Brodie
McKissock






Belgrave
Ben Weir
Caroline
CTICU
NICU
GICU
Process to achieve ward
competence (pilot)

Adequate exposure


180 bed days
Adequate skill

80% nurses trained with basic competency
complete
Tracheostomy care at St George’s

MDT group
 Policy
 Clinical Guidance (v5)
 In-patients cohorted
 ICP
 Education


Video/DVD
Competence
assessment






MDT ward rounds
Advice (internal and
external)
Product development
Discharge package
Out-patient clinic
Incident review
NCEPOD 2014 –Ward care
19
NCEPOD 2014- Critical care
40%
20%
21%
18%
1%
20
NCEPOD 2014 -Training in
blocked or displaced tubes
21
NCEPOD 2014- Resuscitation
Training
22
Emergency Algorithims
‘The greatest
difficulty lies not in
persuading people
to accept new
ideas, but in
persuading them
to abandon old
ones’
John Maynard Keynes
Tracheostomy care at St George’s

MDT group
 Policy
 Clinical Guidance (v5)
 In-patients cohorted
 ICP
 Education


Video/DVD
Competence
assessment






MDT ward rounds
Advice (internal and
external)
Product development
Discharge package
Out-patient clinic
Incident review
A request…..
Dear Deborah,
I am a CNC from Royal North Shore Hospital in Australia and am currently reviewing
the management of tracheostomies in our area health.
The NHS resources that your team have developed are fantastic and I am hoping to
integrate them into our practice. Are you able to tell me if I need formal permission
from the authors to use the resources they have made available, or is there an
understanding from you that since the material is open access then it may be
used?
I am looking at the ‘Integrated Care Pathway’ in particular, however, with the
abundance of resources I would probably also reference other material on the
site.
Thank you for your time, I look forward to hearing from you soon.
Regards,
Alex Slattery
Acting Clinical Nurse Consultant
Respiratory Medicine
Royal North Shore Hospital
Office: 94632833 Page: 41342
Alexander.Slattery@health.nsw.gov.au
Our response…..
Alex
Pleased that you have found our resources useful, I plan to pop them on the
GTC website, so happy for anyone to use. Our Trust has issued us with
guidance on what constitutes acceptable use as follows:
The following both constitute acceptable use:
Hyperlinking from your corporate website to ours.
Copying content from our website and reproducing it on yours, provided it is
used verbatim and with credit to the trust and/or its website.
The following constitutes unacceptable use:
Any change in wording, whether or not this is credited or uncredited.
I also enclose an updated ICP we are currently piloting, if you have any
problems accessing links let me know and I can send you the content
directly.
Kind Regards
Deborah
Tracheostomy care at St George’s

MDT group
 Policy
 Clinical Guidance (v5)
 In-patients cohorted
 ICP
 Education


Video/DVD
Competence
assessment






MDT ward rounds
Advice (internal and
external)
Product development
Discharge package
Out-patient clinic
Incident review
Discharge from hospital

SLT developed MDT discharge package
crossing the secondary/primary interface






Referral to the community team
Competency assessed training of ‘carers’ and
patient
Identification and procurement of essential
equipment/consumables
Guidance on how to manage an emergency
Letter to emergency services
Pre-booked follow up appointment
Tracheostomy Clinic
Primary reason for tracheostomy
Number
Head and neck tumour
34
Vocal cord palsy
10
Neurological
6
Tracheal damage
7
Weaning from ventilation 1
Data from 3/6-3/12
Tracheostomy Clinic Data from 3/06-3/12
Procedure
No.(pts)
Tracheostomy change by nurse
363 (52)
Supervised change by carer
21 (4)
Supervised change by patient
23 (2)
Bespoke tube arranged
7 (3)
Fibreoptic nasendoscopy
17 (12)
Wound care
137 (43)
Community liaison
78 (38)
Weaning advice
24 (11)
Treatment for granulation
27 (9)
Communication advice
58 (24)
Medical review
66 (30)
Cough management
18 (7)
Nutritional advice
28 (17)
General advice
78 (35)