‘Early identification’, ‘early intervention’ and ‘early escalation’ are three phrases that you will hear being used frequently by staff at The Bridge Care Centre in Middlesbrough, where we provide complex care for residents with additional ventilation and tracheostomy needs. This trio of pre-emptive measures act as a guiding framework for The Bridge’s successful approach to tracheostomy care. They epitomise a unique problem-solving approach, followed by the whole team, designed to ensure a positive quality of life for residents.
In particular, the measures aim to remove the occurrence of an emergency tracheotomy change that can sometimes be caused by tube blockage, accidental decannulation or displacement. Replacement of the tube under emergency conditions comes with greater risk to the resident and removing the likelihood of this procedure happening significantly improves resident outcomes and quality of life.
As part of Elysium Neurological’s EveryExpert approach to complex care our team receive specialist training in advanced tracheostomy care management which, as well as covering best practice, supports the learning of this pre-emptive strategy.
Taking the lead on this training is Respiratory Physiotherapist, Nicholas Dougherty, who has a particular interest in Neurological rehabilitation incorporating long term community ventilation.
Nick has experience of working in stroke rehab, intermediate care, acute ICU, long-term neurological conditions including traumatic and degenerative conditions. He has a vast experience both within the NHS and the private sector. Some of his roles include senior therapist on a stroke unit, practice lead for a community and residential rehabilitation services, and national lead for complex ventilation hospital to home provision.
One of Nick’s priorities since joining Elysium Neurological at The Bridge has been to ensure that all colleagues possess the appropriate competencies to provide high quality tracheostomy care within a complex care setting. To achieve this culture of best practice, Nick advocates a problem-solving approach, with early identification of issues and timely interventions, in order to avoid emergency tracheostomy changes.
Nick says: “As soon as a team member joins us, we encourage them to think a little differently about how they provide care within the rehabilitation care centre. We work in an extremely specialised environment – we support individuals with a variety of complex neurological needs ranging from acquired brain injuries, spinal injuries, Parkinson’s, muscular dystrophy to progressive epilepsy, in addition to tracheostomy care.
For example, we often consider whether should we look at their primary condition or are their care needs more with their secondary or tertiary requirements? We may receive a resident who has sustained a complete C-3 traumatic spinal injury causing total paralysis of all 4 limbs from the C-3 region downwards. Predominantly their spinal injury is stable. Therefore our focus, care and goals are aimed towards maintaining safety and homeostasis with their ventilation, tracheostomy care, tone and spasticity management. This allows our residents to achieve their full potential and prevent deterioration.”
This problem-solving approach helps the team within The Bridge Care Centre to remain calm and objectively assess what symptoms a resident is presenting with.
Nick says: “We focus on the importance of analysing the presenting situation, perhaps breaking it down into its different components and thinking logically about how you manage each element of the condition. It’s a type of stage-by-stage approach.
A spinal injury is a complex injury to sustain. The consequences are quite catastrophic and life-changing for many of our residents, especially for the higher C-spine injured residents. For example, residents with a spinal injury may suffer from a condition called Autonomic Dysreflexia (AD); this requires early intervention and escalation as the consequences could be become life threatening. However, throw in the complexity of respiratory complications and staff are required to establish whether the problem is AD or airway.
Here at The Bridge we deliver full classroom workshops and practical work stations to allow new members of the team to experience first-hand some of the complex processes and skills they will be using on the rehabilitation floors. For example, care of a tracheostomy stoma, cleansing and observing for infection or overgranulation, routine dressing and neck tie change, to full tracheostomy changes incorporating emergency processes and steps. This way staff understand the importance of accurate identification of problems, early intervention and early escalation.”
Being early is the key to success
Nick’s mantra of ‘early identification, early intervention and early escalation’ is a guiding principle for The Bridge’s successful approach. According to Nick, a proactive methodology and timely interventions can bring significant improvements to individual outcomes.
Nick says: “With our approach the individual’s needs are prioritised and we are always working towards the most positive outcomes for them. If we can identify an issue early and find an appropriate intervention then we can stop most situations from deteriorating. We can’t prevent every admission into hospital, sometimes for residents with complex needs this is unavoidable. However, when we do need to escalate we do so swiftly and calmly because we have confidence in the various steps that we have taken before we have arrived at this point.
We’ve developed a close partnership with NHS James Cook University Hospital and we know that our interventions can reduce the length of time individuals are required to stay in hospital, so they can return to us as soon as possible. This is really important, because when individuals have more stability and less disruption to their daily routine, it supports their wellbeing and improves quality of life.”
Following best practice
The Bridge’s approach to Tracheostomy care is in line with the National Tracheostomy Safety Project Guidelines whose goal is to improve the safety and quality of care for residents with tracheostomies through education. This enables the team to follow best practice in emergency situations, allowing their interventions and escalations to occur in a timely, concise manner and maximise effectiveness.
Following on from classroom sessions, staff are then able to use their skills on the rehabilitation floors under supervision and observation of competent physiotherapists, OTs, nursing staff and HCAs. This system allows their classroom knowledge to develop into practical skills and abilities.
We follow a full competency-based assessment process where staff members are observed several times in each element, domain or skill and a full sign-off process is completed to deem the staff member competent. This will be reviewed on a six-monthly basis to ensure best practice is being maintained and that all staff members are up to date with current evidence-based practice and innovations.
Continue learning outside of the classroom
In addition to following best practice guidelines, Nick endeavours to make the training as practically applicable as possible.
Nick says: “Our approach is also scenario-based, as it helps our team to put their knowledge into practice. For example, we cover parameters and baselines so everyone understands the appropriate levels for residents and we’ll look at scenarios where this is applicable.
We’ll cover the normal parameters for our residents within the cardiorespiratory system, this then shows what will happen if an individual is above/below or outside these parameters. We’ll look at scenarios where they will encounter abnormal levels and talk through solutions or perhaps suggest a change of direction in that person’s care.
For the qualified nursing staff, this takes place within advanced respiratory training sessions. These scenarios/case studies take into consideration the emergency management of a resident with a deteriorating clinical presentation. Physiotherapy interventions such as postural drainage, percussion, vibrations and manual hyperinflation techniques to remove excess or thick secretions may be used to resolve the immediate concern.
During these sessions staff have a full orientation morning where a nurse is allocated a resident and a full respiratory assessment, treatment and analysis is performed. Then, following the advanced respiratory training session, a full de-brief is performed to identify any further training requirements.”
As Nick explains, the learning does not stop when the training presentation has finished, it’s about adopting a critical mind-set and always asking questions when on the unit.
Nick says: “The most effective way to deliver high-quality tracheostomy care across a unit is to ensure that learning becomes a habit and that as a team we have a problem-solving mind-set. We’re always considering whether we are providing appropriate levels of care and monitoring our residents. Knowledge is not something that should be left in the book; it needs to be put into practice so we can improve resident outcomes.
I have a very hands-on approach. I deliberately make myself available when I’m on the floors and I actively encourage people to ask me questions. If there’s something that a Therapy Assistant, HCA, or Nurse has been dwelling on, perhaps a specific element of an intervention, then it’s always best to talk it through. In doing so we can work through scenarios and ensure that whatever happens we can identify the best possible approach for the individual.”
“It’s also about constantly reviewing your knowledge. Our team will have regular refresher training but in between those formal sessions, a lot can be gained from discussing things on the unit. Testing ones knowledge and putting it into practice as much as possible helps us deliver the best possible care that is tailored to each person’s specific needs.”
Greater benefit to the individual
At Elysium Healthcare we have a very holistic approach to care so all members of our team – be they health care assistants, therapy assistants, nurses or therapists have access to specialist training. This means that there is more flexibility in how our services provide care. As Nick explains, this approach has particular importance when supporting individuals with tracheostomies, because it means we can facilitate additional opportunities for individuals such as take trips out into the community or more varied activities in the service.
Nick says: “There always needs to be at least one person who is trained in advanced tracheostomy care present at all times. If all team members have achieved appropriate competencies in tracheostomy care then we have more flexibility, and resident’s routines can continue normally, without interruption. This is always better for the individual’s wellbeing and ultimately better for their outcomes.
We also aim to work closely with families and involve them in the many aspects of an individual’s care wherever possible. Obviously COVID-19 has meant that we have had to modify the way we do things, but I think families still benefit from our approach to resident care. If we are continually monitoring individual needs and looking for early identification and intervention, we’re better informed as a team and we can pass that information on to families.
Tracheostomies can be quite unsettling, as with many areas of complex care, and families need to adjust to the fact that their loved one now needs an intervention to help them breathe and possibly speak. It can be a lot to take on board, so the more we can explain issues as we encounter them, the more we are thinking ahead and can introduce interventions before an individual’s condition deteriorates, the easier it is for the person and their family.”
Make An Enquiry
If you’d like to make a referral then please get in touch with us here.
You can also visit each service’s profile page to find out more about what our EveryExpert approach to care looks like in practice: