The benefits of tracheostomy specialist nurses

The increase in the number of patients requiring a tracheostomy means it has become impractical for them all to be cared for on ear, nose and throat (ENT) wards. As a result, nurses working on general wards are now required to care for tracheostomy patients.

Although basic nursing skills provide holistic care, specialist training is necessary when, for example, selecting the most appropriate tracheostomy tube, changing a tube or knowing when to start the process of tube removal. The tracheostomy nurse specialist can provide this expert knowledge and is fast becoming an important member of the multidisciplinary team.

Heafield et al (1999) found a knowledge deficit in tracheostomy care among nurses on general wards. Since morbidity and mortality are associated with inappropriate or inadequate tracheostomy care, the need for specialised support is obvious.

Russell (2000) highlighted that the inability to care for a tracheostomy is a significant factor in the readmission of a patient to intensive care. The tracheostomy specialist can ensure that all patients receive a high standard of evidence-based care by appropriately trained and supported staff. The staff also benefit - by empowering general nurses to care effectively for the tracheostomy patient, nurses' fears are reduced and their clinical skills are kept up to date.

At Addenbrooke's NHS Trust in Cambridge, regular clinical audit and research projects over the past two years have enabled the continual development of the tracheostomy service. Patients being nursed in areas where staff are unfamiliar with tracheostomy care are assessed by a tracheostomy specialist so that the ward team can be appropriately trained and supported. This has required not only an evidence-based knowledge of tracheostomy management but also the ability to communicate effectively. Leadership skills are also needed when entering new clinical settings with the aim of implementing change.

Audit data has shown that the support of a specialist tracheostomy nurse has cut the number of discharge delays and reduced readmission rates. This demonstrates the need for improved tracheostomy care and shows how specialist nurses can be cost effective.

Benefits of the role
The tracheostomy nurse follows up patients discharged from intensive care and ensures that there is effective communication on the care plans of patients with a tracheostomy. After the appointment of a tracheostomy nurse at the trust, intense training and support programmes have taken place on respiratory medicine, plastic surgery, ENT, neurosurgery and rehabilitation wards.

The specialist tracheostomy nurse benefits ward staff in two substantial ways. First, patients are nursed on appropriate wards and cared for by staff who are trained and supported in tracheostomy care. Second, the tracheostomy nurse facilitates collaborative discussions with the multidisciplinary team to coordinate the way each patient is managed. Other benefits include:

- The specialist nurse maintains continuity of care from the intensive care unit onwards, supporting the patient through to discharge, with or without the tracheostomy, into the most appropriate care environment;

- The pressure on intensive care beds can be alleviated by creating a safe clinical environment outside ICU for a tracheostomy patient to be nursed by competent staff;

- The specialist nurse helps to provide training and support for ward nurses in assessing, planning, delivering and evaluating tracheostomy care in all clinical settings;

- Psychological care before and after a tracheostomy is available, along with realistic information on a patient's rehabilitation;

- A nurse's confidence and clinical competence can positively influence the patient's response to living with a tube;

- Long and short-term speech and swallowing rehabilitation can be encouraged, aiding safe weaning and decannulation of the tracheostomy;

- Good liaison with community services ensures that support is in place at home for the patient. The specialist nurse also offers training and advice to carers. Ensuring a collaborative approach with community nurses and GPs can reduce readmissions and improve a patient's quality of life;

- The specialist nurse can ensure that current information on tracheostomy products is available and keep a small stock of various sized tubes;

- Expert knowledge is available if a patient is not tolerating a certain type of tube and requires individual modifications;

- The specialist nurse can evaluate and filter the number of referrals to ENT medical staff by changing the tubes of patients who have had the tube inserted by either a percutaneous or surgical technique (Harkin, 1998).

Conclusion
The use of a collaborative approach has been essential to ensure the safe management of patients with a tracheostomy at Addenbrooke's NHS Trust. Close working links with the multidisciplinary team have offered the specialist nurse an insight into the different assessment criteria of speech and language therapists, respiratory physiotherapists, intensivists, chest and ENT medical staff, while promoting the skills and aims of the tracheostomy nurse post. This has ensured appropriate and speedy referrals within the team.

A national network of nurse specialists, especially those involved in tracheostomy management, have acted as clinical supervisors to this new role. It is important to establish a definition of the post and set clear aims and objectives, ensuring that methods are in place to monitor and evaluate outcomes.

The tracheostomy nurse's main purpose is to provide continuity of patient care in support of evidenced-based practice in both clinical and community settings.

This type of continuous care is ensured by offering specialist training and advice to all staff, carers and patients, which aims to optimise patient rehabilitation - ensuring that each patient is cared for in an appropriately equipped environment with fully trained and supported staff.

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