Your browser is no longer supported

For the best possible experience using our website we recommend you upgrade to a newer version or another browser.

Your browser appears to have cookies disabled. For the best experience of this website, please enable cookies in your browser

We'll assume we have your consent to use cookies, for example so you won't need to log in each time you visit our site.
Learn more

Ward skills lacking for tracheostomy care, warns major review


Many ward nurses have been left without the skills and knowledge to care for patients that undergone tracheostomies, potentially putting lives at risk, a report has warned.

A range of concerns, including a lack of training for staff on general wards, were highlighted last week by the National Confidential Enquiry into Patient and Outcome and Death. It gathered data from all hospitals that perform tracheostomies in the UK, except for Scotland.

“I was really surprised at how much we weren’t doing correctly”

Catherine Plowright

NCEPOD highlighted the crucial role of nurses in providing ongoing care for tracheostomy patients, but found many did not have the right training to provide it, or deal with common emergencies. More than a quarter of hospitals did not give staff training on dealing with a blocked airway, while only around half offered training on difficult tube changes.

Catherine Plowright, a consultant nurse in critical care at Medway Foundation Trust, was one of the expert group involved in the NCEPOD review. She said the findings affected “nurses at every single level in an acute organisation”, from the “moment a patient has a tracheostomy put in, to the moment that tracheostomy comes out”.

NCEPOD found at least 12,000 were carried out each year – many in critical care wards as opposed to operating theatres. The review team had been taken aback at the sheer number of tracheostomies undertaken in critical care, said Ms Plowright.

Their report also revealed widespread problems with the care of tracheostomy patients, with good practice followed in only around 40% of cases. The most common issues related to the management of cuffed tracheostomy tubes, monitoring and taking people off tubes.

“I was really surprised at how much we weren’t doing correctly,” said Ms Plowright. “We’re putting in tracheostomy tubes that for a lot of patients are not the right ones, not the right size, not the right length, not the right type.”

Catherine Plowright

Catherine Plowright

She warned these kinds of errors, plus poor ongoing and aftercare, could lead to patients needing further procedures, a prolonged hospital stay and in the worst cases death.

In particular, the report highlighted the dangers of unplanned or night time discharges from critical care for patients with a new tracheostomy or one that has just been removed.

The NCEPOD report called for trusts to provide mandatory training on tracheostomy care and said all bedside staff must be competent in recognising and managing complications.

Ms Plowright said: “There will be some education around tube sizes needed… but there are training packages out there, so we just have to do it.”

She added: “Taking the tubes out is almost as important as putting the tubes in. Critical care outreach nurses have a key part to play with patients out on the general wards.”

Read the full NCEPOD report – Tracheostomy Care: On the Right Trach?



Readers' comments (7)

  • david lowry

    i DEVELOPED THIS PROTOCOL FOR TRACHED PATIENTS AT THE FACILTY I WORK AT. We have also developed a best practice committee with particular focus on cuffed and uncuffed trachs

    Tracheostomy Discharge Best Practice

    Establish if this is going to be placement of a new tracheostomy or chronic established tracheostomy patient. Many patient come to the hospital who are chronic trached patients who are admitted for unrelated issues. This is significant in terms of discharge planning.

    New Tracheostomy Patients:
    EDUCATION prior to discharge is paramount for a safe discharge and to reduce re-admissions
    1. Assessment / Evaluation per Case MGT protocol. Establish the patient’s PCP (and that they have one / follow up established prior to DC). Determine if the patient is currently followed by Pulmonolgy and or ENT prior to admission. Review prior to discharge that follow up has been arranged.
    2. Determine care givers if any and contact numbers.
    3. Determine if the patient has previously or is currently receiving Home Health Services of any kind including current DME and provider.
    4. Determine family home situation. Can the patient be discharged home with a new tracheostomy safely? Do they have family support? Determine the educational need of the patient and care givers. Would the patient benefit from rehabilitation?
    5. Determine the patient’s Health Plan, Commercial, Medicare, Medicaid and HMO’s. This can determine DME and HHS providers and ability to provide services
    6. Will the patient need long term care placement?

    DME: - Basic tracheostomy supplies for DC Home. Discuss with the RT on the floor and the RN
    A. Suction machine
    B. Establish size and type of tracheostomy that has been placed / replaced and ensure a spare trach with inner cannula is sent home with the patient. Ideally include a tracheostomy care kit including ties.
    C. Catheters appropriate to the size of the trach
    D. Catheter and Glove kit ( send at least two ) for cleaning purposes
    E. Does the patient have O2 requirements or need for humidification?

    Home Health Needs:
    1. Establish the patient’s needs for Home Health Services- Will the patient require / qualify for a Nursing Aid or PT/OT. The patient will require HHS Skilled Nursing on DC for new tracheostomy placement for continued education and dressing changes
    2. EDUCATION - Ensure the patient / care giver can effectively use a suction machine and tracheostomy site care prior to discharge. This education will be continued with HHS Skilled nursing. This is probably one of the major reasons for readmission
    3. Establish the patient choice for HHS and DME - However, there may be limitations of choice based upon the patient Health Plan - Medicare/Medicaid HMO’s and certain commercial providers will insist on using in network providers. There may also be occasions when the patient may have no health insurance or insurance of some type is pending. Other limitations may include the patient s geographical location

    Chronic tracheostomy patients who are admitted for unrelated criteria or for tracheostomy change out with other procedures
    1. Follow all the steps as out lined above
    2. Identify any changes to home situation, PCP, ENT/pulmonary visits and home health needs. Patient may qualify for home health services on discharge depending on the reason for their admission, prognosis and change in status.
    3. Change in status - determine if O2 demands have changes and in certain cases the need for home ventilator support.
    4. Education – this remains a single most important aspect of the patient care both as an in-patient and in the home. It is important that follow up education is provided on every admission. This may be the RT educator simply meeting with family for 10 minutes to address any new areas of concern if any
    Other area of possible concern:
    Patients with No insurance and no PCP. These patients must be identified on day one of admission
    Some patient’s are admitted post out-patient procedure secondary to complications. Some are planned admissions, and some are weekend admissions with new and complicated issues. Be aware that new physicians and in particular, ENT and ENT groups now have privileges’ at PHR. These physicians may change the type of tracheostomy that the patient came in with based upon those physicians particular or groups preferences. These groups may provide the tracheostomy, and Palmetto Health Richland may not carry this particular type of tracheostomy. This may also be the case with the patients DME provider. It is important to ensure the patient goes home with a spare tracheostomy and the DME Company has been made aware of any changes prior to the patient leaving.

    Patients can not leave the ICU with a Cuffed Trach

    Unsuitable or offensive? Report this comment

  • Why?

    My colleagues and I sucessfully looked after many patients with a tracheostomy with the support of the physios during normal working hours. it seems there are a lot of skills generalist no longer learn but which are required on general wards.

    Unsuitable or offensive? Report this comment

  • Education best provided by specialist nurses, who are being taken away from their teaching role to work in general wards due to staff shortages.

    Unsuitable or offensive? Report this comment

  • Yet again the deficiencies of "university" based education are exposed .............. exactly what IS taught ?

    Tracheotomy "care" is not difficult and should be part of any "general" nurses skill set. However , such skills will not be learnt by sending students on community or other such low skill assignments.

    I despair

    Unsuitable or offensive? Report this comment

  • I haven't got a bloody clue!

    Unsuitable or offensive? Report this comment

  • Good organisational practice guidelines (remembering that best practice is always dependant on the context e.g. cuffed traches are often seen outside of ICU in some settings), the support of a multidisciplinary team (dedictaed allied health professionals with skills in trache care) and skilled bedside nurses prepared to teach their colleagues (giving novice nurses exposure to traches) would be a start.

    Unsuitable or offensive? Report this comment

  • David Lowry's protocol is excellent. I am an ENT Out Patients Staff Nurse who undertakes tracheostomy changes/management in the department for patients in the community. In my experience, patients who are discharged inadequately prepared either physically, psychologically or with the wrong equipment end up being readmitted after a great deal of suffreing. There seems to be too much pressure to discharge patients quickly from hospital to facilitate patient flow. Sometimes to the detriment of their care management. The only thing on the protocol that is diffrent to what happens in my area is that we do have patients with cuffed trache's in the community. I see that others have mentioned this too. Nevertheless it is a really thorough protocol.

    Unsuitable or offensive? Report this comment

Have your say

You must sign in to make a comment

Please remember that the submission of any material is governed by our Terms and Conditions and by submitting material you confirm your agreement to these Terms and Conditions. Links may be included in your comments but HTML is not permitted.

Related Jobs