Sarah Tattersall, DipHE, RGN.
Clinical Equipment Nurse Specialist for Salford Primary Care Trust
Patients with a tracheostomy are discharged from hospital increasingly early and require suction to maintain the patency of their airways. Suction machines are therefore an increasingly common piece of clinical equipment in the home setting, and suitable devices that meet the needs of individual patients must be readily available.
The Medicines and Healthcare products Regulatory Agency (2000) predicted a continued growth in the capacity of the community and primary infrastructure to provide acute and intermediate care, inevitably leading to a rise in the use of medical devices to treat patients in the GP surgery or at home.
The MHRA states that operators of any piece of medical equipment must be trained in its use and able to prove they are competent. The launch of the clinical negligence scheme for trusts, a ‘pay-as-you-go’ arrangement in which trusts pay an agreed amount into a central fund each year that can then be drawn on to cover negligence claims, has had a significant impact on some trusts (NHS Litigation Authority, 2004). All staff must be trained in the use of medical devices, especially when they may have to educate and support patients or families using them at home. Standardisation is a major consideration in ensuring staff competence.
Salford PCT recently examined the range of suction machines available for community use.
Suction equipment in the community
Suction machines are required for patients who have difficulty clearing their tracheal secretions. They provide suction through a sterile catheter, which is used to clear the patient’s airway following clinical guidelines and using a sterile technique. This is mainly performed via a tracheostomy - a surgically created stoma on the neck just below the Adam’s apple.
Tracheostomy is commonly recommended for patients with an obstructed airway due to chronic lung disease or a neuromuscular condition causing weakness or paralysis. These diseases, and post-laryngectomy care, are the most common reason for patients to have a tracheostomy in the community.
A suction machine must be ordered from the community loan store to be delivered to the patient’s home in time for discharge.
My role, as clinical equipment nurse specialist for Salford Primary Care Trust, is to provide clinical support to multidisciplinary health- and social-care professionals across Salford. This involves focusing on the evaluation of clinical equipment to facilitate the implementation of evidence-based practice. I also act as a liaison between the supplies department and the community equipment loans store, which is jointly funded by the NHS and social services.
For too long services have been fragmented, underfunded and unresponsive. The NHS Plan (DH, 2000) and National Service Framework for Older People (DH, 2001) set out several key targets, including the requirement to modernise service delivery, combining health and social care provision into single, integrated community equipment services by 2004. Integrating Community Equipment Services (ICES) is a Department of Health-funded health and social care initiative to develop community equipment services in the UK. Its aim is to support the modernisation and integration of services, and remove barriers for equipment users.
I was employed in February 2004, and quickly found that the trust needed to purchase new suction machines. A review of the existing stock revealed that many were old, awaiting repair and difficult to move. Fortunately, Salford PCT has an annual budget of £5000 (funded by the NHS) for suction machines. Because I had joined in February, we had just seven weeks to review, evaluate and purchase the machines before the end of the financial year.
Choosing the most suitable machine
The choice of suction machine must be based on clinical need and consideration of the characteristics of the home in which it will be used. For example, if space is limited or there are stairs in the home, a lightweight portable device may be the appropriate choice. It is also necessary to consider who will use the device, taking into account each patient’s needs (MHRA 2000).
When purchasing a machine, size, weight and ease of use are key considerations, as are decontamination issues and the practicality of following manufacturer’s guidelines in the home.
Review of machines available
Several brands of suction machine were used in Salford PCT, including Oxylitre, Sunrise Medical and Penlon. The main focus was to find a replacement suction machine that would be clinically sound, portable, compact and aesthetically pleasing, while taking into account cost and decontamination issues.
Factors influencing our choice
Salford PCT considered a number of factors in selecting a suction machine (see Boxes), leading to the choice of the Clario Home Care Pump (www.penlon.co.uk). The deivce is designed for home use and thus to be easily used in most settings. It is lightweight, portable and simple in design, weighs about 1.5kg including battery, and comes with a carrying bag. For infection control measures, it has an inbuilt membrane system, which reduces the need for frequent filter changes, and a safety chamber. In the event of malfunction, this collects overflowing secretions and prevents them entering the internal parts of the pump.
It was our final choice because we felt that it best met our patients’ and organisation’s needs. It is portable, so only one pump would be required by each patient. However, some particularly dependent clients may require more than one machine in case of breakdown. Service and maintenance, as well as the cost of replacement parts, such as jars and tubing, should also be considered.
Salford PCT has a rolling training programme on the use of suction machines. This is run in collaboration with a respiratory nurse and community physiotherapist, based in Hope Hospital, Salford. All relevant PCT staff must undergo training; records of attendance are kept as an important part of device management. A resource file, which has recently been ratified by the clinical governance team, is available.
Choosing the wrong suction machine will have major implications. A systematic examination of the features of a device, and how well these meet the needs of both individual patients and the organisation, is vital to ensure selection of appropriate machines. As with all medical devices, training for users is crucial.
Factors to consider when choosing suction equipment for use in patients’ homes
Older people, children, rapid response teams, residential/nursing homes staff, palliative/respite care teams, respiratory nurses and patients cared for by district nurses will have different needs and abilities (see other Box).
The majority of suction machines are used in palliative care or by district nursing services. Consideration was mainly given to patients who would have restricted mobility or were confined to bed. It would not have been beneficial to purchase a suction machine that was not easily portable - particularly as children use them.
The Clario displays all these features, so it was our ideal choice. Patients who have used one are pleased when they compare it with what they have previously had. A large number of Clarios were purchased by the community children’s nursing team; children and parents liked it because of the lack of the ‘clinical look’ and, because the device is to portable and self-contained, it is ideal for children when they go on holiday or to school.
Ease of use
The machine has to be robust and provide enough pressure to clear the airway adequately without causing trauma. Consider the degree of co-ordination and manual dexterity of the person using the device; suction machines should be easy enough for anyone to handle. Limiting the number of functions, buttons and tubing connections reduces potential for confusion and error.
A suitable machine can be expensive. Some trusts advocate the use of two machines per patient: one for use at home and another for travelling.
Before purchasing, it was important to liaise with the Medicines Healthcare products Regulations Agency, National Institute for Clinical Excellence, NHS Purchasing and Supply Agency and NHS Logistics to obtain information and assess potential problems. We needed to find out whether the machine would do the job and whether formal trials had been conducted. It is helpful to ask other trusts about their purchasing choices.
Products that do not require filter changes and have a built-in system to deal with potential overflow are worth considering. Leaking membranes can cause major problems as their function is to prevent secretions from entering internal parts of the device. Advice on infection control should be sought from the infection control team and the manufacturer/supplier. Training is required.
Use of equipment is not restricted to home use alone, such as children going to school. The device must therefore be able to operate from battery or mains adaptors. A carry case or storage device also ensures portability and is a good way of storing leads, batteries and instructions together.
The appearance of the machine is important when it is to be used at home. Children in particular like their equipment to look ‘user-friendly’. Anything that looks very clinical can be off-putting when they are at home or school.
The product must be kite-marked and the company must be able to supply evidence of thorough testing. Routine maintenance will need to be undertaken, so it is vital to ensure that the people responsible have been fully trained. This may be staff from a medical equipment department or the loans store, who have been trained by the manufacturer/supplier. Alternately, the company may provide routine maintenance, but this would be at a negotiated cost. The Clario is service and maintenance free for five years, including a two-year warranty, so failures would be directed to the company within this period.
An assessment of training needs should address clinical and technical specification, to enable it to be tailored to trust requirements. Companies often provide training and support free of charge and, if planned in conjunction with in-house training, this can ensure thorough and effective learning for staff.
Warranties and servicing
The longer the warranty offered, the better as this will help to keep costs down. Client group characteristics
Depending on the client group or users, the following factors need to be factored in when choosing a suction device:
- Physical capabilities - manual dexterity
- Sensory capabilities - vision, hearing
- Previous experience using the same or a similar device
- Cognitive ability
- The patient’s expectations
- Are the instructions clear and concise?
- Too many functions may cause confusion
- Recognition for faults
- Point of contact in an emergency.
Author contact details
Sarah Tattersall, Clinical Equipment Nurse Specialist, Salford PCT. Email: email@example.com
Department of Health. (2000) The NHS Plan. London: The Stationery Office.
Department of Health. (2001)National Service Framework for Older People. London: DH.
Medicines and Healthcare products Regulatory Agency.(2000)Equipped to Care. London: MHRA.
NHS Litigation Authority. (2004)Clinical Negligence Scheme for Trusts: General risk management standards. London: NHSLA