To deliver safe and effective tracheostomy care within a neuro rehab setting, discipline, vigilance and communication are all essential elements that must be respected. The complex nature of the input that patients with tracheostomies receive exemplifies the importance of planning, organisation and frequent monitoring.
Watch a summary of our article:
If this structure is adopted by the professionals managing these patients, concurrently with the relevant guidance being followed strictly across the whole team, then the risk of potentially fatal outcomes is significantly reduced (Eibling and Roberson, 2012). Getting the basics right can mean that patients have the best opportunities to enjoy a more positive quality of life and work towards their own specific rehab goals.
However, the National Confidential Enquiry into Patient Outcome and Death (NCEPOD) in their 2014 report, On the Right Trach? A review of the care received by patients who underwent a tracheostomy, found that there were often shortcomings in tracheostomy care across the UK, and the care regularly failed to reach safe standards. A significant part of these failings was found to be due to a lack of training, with 28% of hospitals shown not to be providing sufficient training for staff to deal with blocked and/or displaced tracheostomy tubes (Everitt E 2016a).
A common issue with tracheostomies is a build-up of secretions within the inner cannula, which can create sudden or gradual blockages. Blockages may then result in difficulties with breathing, while the continual build-up of secretions can also lead to infection. For reasons such as these, the integrity of the tube needs to be checked at regular intervals and maintained through the necessary interventions.
Good tracheostomy care depends on monitoring the individual regularly, cleaning and/or replacing the tube as required and suctioning the secretions out. Without appropriate training, as well as regular refreshers and close supervision, staff who care for tracheostomy patients will not meet or retain the required level of competence in these areas. Consequently, this can lead to poor practice, either through a lack of confidence or complacency, resulting in unnecessary errors or complications for the patient.
The Trach at Adderley Green Care Centre
Adderley Green Care Centre is a modern, purpose-built, specialist neuro-rehab centre which has been designed specifically to support the needs of individuals who have complex care and rehabilitation needs. The centre is comprised of two buildings, Moorcroft Manor and Gladstone House. Moorcroft Manor provides services for men and women with complex care and/or neurological rehabilitation needs. Peacock unit, within Moorcroft Manor, is the specialist tracheostomy unit.
Renjith Eettickal Reghu (Raj), is Therapy Lead/Lead Physiotherapist at Adderley Green. With more than 15 years’ experience as a qualified physiotherapist, Raj has spent much of his career supporting patients with neurological conditions. His expertise extends to providing respiratory management for those residents who present with complex respiratory conditions including those who require tracheostomies.
From 2015, Raj has played a key role in the development and operation of Adderley Green’s first specialist tracheostomy care unit. In the beginning, he created a bespoke training programme for the multi-disciplinary team that works on the unit, so that everyone involved in patient care holds at least the minimum set of competencies to support people with a tracheostomy.
A fundamental focus of the training is the importance of checklists and schedules. Raj explains the need for a disciplined, meticulous approach; completing the checklists and keeping to schedules is the difference between a well-cared for patient and a patient at risk. In practice, examples include routine examination of the inner cannula to ensure this is clear of secretions and checking the air pressures within the inflatable cuffs, where these are being utilised to reduce the amount of oral secretions entering the patients’ lungs.
Beyond that, routine interventions, in the form of nebulisers and suctioning, must also be carried out, again with the objective of managing the patients’ secretions and respiratory function. All of these components are explained, demonstrated and discussed as part of the training programme, while the skills themselves are assessed by Raj against a competency framework of his own design.
Raj says: “Some people can initially react to tracheostomies with concern, tension or anxiety – which is understandable. We’re not used to seeing tubes in the throat area. Plus, there’s lots of equipment and accessories that go with them. It’s such a high-risk area and if you don’t have specific training in how to provide tracheostomy care then it can be a bit daunting.
But actually, once you have knowledge and experience of tracheostomy care then you become desensitised to it. You realise it is all a matter of organisation and discipline. If all elements of care and their checks are done on time and effectively, then you can take something that is quite complex and make it look easy. It takes a lot of training and planning to reduce risks and make a unit run smoothly, but it can be done.”
In doing so, Raj affirms, both trust and confidence have been built amongst the staff on the unit.
Whilst they form the backbone of the input provided on Peacock unit, routine checks and maintenance are not the only focus of Raj’s training. To develop a wider scope of practice within the nursing team, as well as the therapy team, the tracheostomy training also looks at weaning – the process whereby some patients progress towards having their tracheostomy removed. The majority of this work is carried out by the therapy team, through various trials and assessments. However, it remains important for the nursing team to have an understanding of where a patient is in the process, given the potential implications for their everyday care.
Communication in Tracheostomy Care
Increased knowledge and experience of tracheostomy care not only improves the patient experience, but also has multiple benefits for colleagues at all levels. In particular, it contributes significantly towards prompting clear and efficient communication. To deliver effective care, team members must fully appreciate the need for detailed communication with each other and the requirement for collaborative working.
Raj says: “We’ve seen a big improvement in how our teams communicate with each other. Everyone is aligned in their thinking, they know what needs to be done, how it needs to be done and most crucially, the benefit that this has for the patient.
Clear and effective communication in tracheostomy care is vital because it reduces risks as there is proper patient and tube management. It means all checks are completed on schedule and we run into far fewer difficulties because we are always anticipating and problem-solving together as a team.”
As time has passed, Raj has completed annual audits to record the effectiveness of his training package and has also formulated a dedicated admissions process, which ensures that care planning is specific and patient-centred prior to their arrival. The team at Adderley Green works closely with their regional NHS commissioning teams and local acute hospital teams who, in turn, demonstrate their confidence in the service with the number of people placed for complex packages of care. Currently, Adderley Green enjoys a CQC rating of Outstanding for Responsive Care, and Good overall.
Tracheostomies are typically inserted to manage at least one of two core issues; either the respiratory function of the patient is impaired, or they are unable to independently manage their own secretions. In some cases, both may apply following an acquired brain injury. Given the range of backgrounds and aetiologies within the ABI caseload, each person presents with their own uniqueness. As such, each one requires a personalised care plan so that their individual needs are supported in the best possible way, and so that the care team are working towards the most appropriate outcomes for each individual.
The patient-centred approach to care can only be delivered by a team of experts working together. On Peacock unit at Adderley Green, Raj supervises a team of dedicated therapists and care staff who together run the unit, look after the patients, and liaise with the wider multidisciplinary team across a variety of external agencies. Raj believes that knowing the service is run with a multidisciplinary approach reassures the referral teams that they are placing patients within a competent organisation.
He says: “When a patient joins us at Adderley Green and the referring team know that we specialise in tracheostomy care, it gives them confidence that we can meet the needs of the patient first and foremost.
Peacock itself is a relatively unique unit, given it is based in a community setting. We run our whole unit on the principle of preparation. We carry out our preadmission assessment and subsequently complete a report afterwards, so whenever somebody new joins us we’re immediately able to adjust and adapt to their requirements and ensure they can settle in with us quickly.
Our extensive internal team, as well as the wider team we maintain contact with, are able to ensure the patient does not encounter any problems if the tube remains in place for an extended period of time. Sometimes patients will require long-term enteral feeding, so we work with an external dietician for regular nutrition assessments and to make sure there are no concerns about dietary intake.
Our philosophy is that our team composition, who our patients see and work with, is flexible and must reflect the patient’s needs. This means that we tailor our approach to care for each individual that we support, and it helps provide good continuity of care – we always have the expert knowledge and support available when the patient needs it.”
Support for the family too
As part of the holistic approach to care, the needs of the patients’ families must also be considered. Often, invasive surgical procedures are the result of a traumatic injury or a sudden incident. Consequently, families may not have had time to come to terms with the implications of a tracheostomy and what the long-term impact is for family life and/or relationships. Raj elaborates on how a holistic approach has helped families understand and process what has happened to their loved ones.
He says: “Our approach really benefits the family too. Typically, their loved ones have been through a lot – a significant trauma or a long stay in hospital – and the tracheostomy can be new for them too. So the family can often have some anxiety or confusion from not really understanding why the tracheostomy is there and what it is doing.
We’re able to explain everything to them in more detail and discuss different elements of tracheostomy care with them. Like why we need to do frequent checks and what the benefit is for their loved one. They really appreciate getting the chance to talk this through, and the good thing is that all of our team have received thorough training, at least at a basic level, so if the family have any questions then each staff member on the unit can either respond themselves or refer these questions to the relevant professions, if these are beyond their scope of practice.”
Psychological support and wellbeing
Whilst residing at Adderley Green, patients are supported to engage in bespoke person-centred treatment plans and therapeutic intervention. For patients who have a tracheostomy in situ, this can often involve psychological support and intervention specifically focused around the placement of, and procedures related to, the tracheostomy. Plus the implications that this may have around their daily routine and social interactions.
Patients are offered access to formal psychological input focused around their own specific concerns, which often involves exploration of low mood or anxiety, and considers concepts such as self-esteem and acceptance. Typically, psychological support sessions related to tracheostomy care will feature some level of psychoeducation, anxiety management, and support for the patient to develop a positive post-illness identity, alongside more formal psychotherapeutic approaches such as Cognitive Behavioural Therapy (CBT).
Within the wider MDT, psychological wellbeing is supported continually via the interactions that staff have with the patient and their family. The team draws upon a holistic approach to meet the care needs of the patient, by understanding what is meaningful to them and adapting their approach appropriately. Staff remain vigilant to the needs of the patient and involve the patient and their family within decisions related to any change of care or therapy needs.
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:
Eibling D, Roberson D (2012) Managing tracheotomy risk: time to look beyond hospital discharge. Laryngoscope; 122: 1, 23-24.
Everitt E (2016a) Tracheostomy 1: caring for patients with a tracheostomy. Nursing Times; 112: 19, 16-20.