Trach Management Protocol No Trach Left Behind A Guide to improved patient care Joel Ray RRT...
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Trach Management Protocol “No Trach Left Behind” A Guide to improved patient care Joel Ray RRT Harborview Medical Center Seattle, WA
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Trach Management Protocol
“No Trach Left Behind”
A Guide to improved patient care
Joel Ray RRT
Harborview Medical Center
Seattle, WA
ObjectivesObjectives
Comments in the literature that support using a “Trach Protocol”.
Why Harborview benefits from a protocol
Order sheet review
Overview of Trach Management Protocol (TMP) algorithm.
Future goals
HeffnerHeffnerJuly 1999
“……..For most medical centers and hospitals (community or academic), the most important task is to organize a group of interested, multidisciplinary people to come up with a guideline or practice protocol”.
John E. Heffner, MDJohn E. Heffner, MD Department of Medicine Department of Medicine
University of South Carolina University of South Carolina
Respiratory Care: July 1999 VOL 44 No 7
John E. Heffner, MDJohn E. Heffner, MD Department of Medicine Department of Medicine
University of South Carolina University of South Carolina
“..........The exact elements of the protocol are perhaps less important than having a protocol in place that can be monitored and adjusted on the basis of monitored results”.
Respiratory Care: July 1999 VOL 44 No 7
April 2005
Kent Christopher MD RRTDepartment of MedicineUniversity of Colorado
“The tracheostomy tube decannulation process is well suited for therapist-implemented protocols”.
ObjectivesObjectives
Comments in the literature that support using a “Trach Protocol”.
Why Harborview benefits from a protocol
Order sheet review
Overview of Trach Management Protocol (TMP) algorithm.
Future goals
How Many Trachs a How Many Trachs a Year?Year?
October 2006 thru October 2007 324 trach patients
Who does the trachs at HMC?Who does the trachs at HMC?
Surgery ( 3 teams )Surgical, percutaneous
Otolaryngology (OTO)surgical
Oral Maxillofacial Surgery (OMFS)surgical
Neuro Critical Care (NCCS)Primarily percutaneous
Challenges of variabilityChallenges of variability
Services performing trachs have differing management styles.
Care plans aren’t consistent.
Therapist skill level varies
Common problemsCommon problems • Sutures in too long
• Inexperienced residents performing first trach change
• Variable physician knowledge or follow through
Current trach practicesCurrent trach practices
Trach Team: 1) Meets every Tuesday for one hour
2) Consists of RT, Speech Path, Clinical RN Educator
3) the month of January averaged over 20 trachs a meeting
Common denominator of HMC Common denominator of HMC trach patients?trach patients?
Respiratory TherapyRespiratory Therapy
Patient w/ Trach
Tolerate cuff deflation > 24 hours
Possible reason to not decannulate
Decannulation
Proceed with Cuff deflation trial
Yes
Yes
Trach ManagementProtocol (TMP)
Complete Trach Discharge Teaching
Trach Order Sheet signed by procedural MD.
Procedural MD 5-10 day assessment to include suture removal, possible trach change and completion of Trach orders. Include goals, discharge plans and possible Speech Therapy consult.
Considerations for PATIENT ASSESSMENT
· Ventilation required (see Ventilator Pathway)· Desaturation Episodes· Excessive Sputum (BHP) or ineffective cough / gag· Injury assessment a) future surgeries b) confounding issues · Mental Status· Difficult intubation or suspected
anatomical issues
Considerations for CUFF DEFLATION ASSESSMENT
· Increased cough and/or secretions a) Suctioning requirements and need for hyperinflation · Increased WOB· Anxiety· O2 requirements
Patient Assessment issues resolved?
PassedAirway Assessment
w/ adequate air movement(Includes 15 minute cuff deflation )
Considerations for AIRWAY ASSESSMENT
· Patient Assessment considerations have resolved as needed
· Evaluate need for downsize if inadequate air movement or voice
· Anxiety· Mental Status
Contact Speech Pathology for swallow eval as indicated on Order Sheet
YES
Change to Cuffless trach , start 24-48 plugging trial as medically appropriate
Tolerated?
Decision to not decannulate
No
Reasons for Long Term Tracheostomy
· Bronchial hygiene· Ventilation· Pending OR· Mental Status· Anatomical need for trach including
laryngeal involvement
· Set care plan· Intervene with required therapy· Evaluate possible discharge date
and potential discharge w/ trach
NO
Set plan/action based on cuff
deflation assessment
NoLong Term
Cuffed Trach
Yes
No
Order needed for decannulation
Contact Primary Team to order Speech Pathology consult
Adequate air movement
Downsize tube, if appropriate
No
Yes
No
Yes
Yes
Yes
No
No
Patient w/ Trach Trach ManagementProtocol (TMP)
Trach Order Sheet signed by procedural MD.
Procedural MD 5-10 day assessment to include suture removal, possible trach change and completion of Trach orders. Include goals, discharge plans and possible Speech Therapy consult.
Considerations for PATIENT ASSESSMENT
· Ventilation required (see Ventilator Pathway)· Desaturation Episodes· Excessive Sputum (BHP) or ineffective cough / gag· Injury assessment a) future surgeries b) confounding issues · Mental Status· Difficult intubation or suspected
anatomical issues
Patient Assessment issues resolved?
· Set care plan· Intervene with required therapy· Evaluate possible discharge date
and potential discharge w/ trach
NO
Getting Started
What’s next?What’s next?
PassedAirway Assessment
w/ adequate air movement(Includes 15 minute cuff deflation )
Considerations for AIRWAY ASSESSMENT
· Patient Assessment considerations have resolved as needed
· Evaluate need for downsize if inadequate air movement or voice
· Anxiety· Mental Status
Contact Speech Pathology for swallow eval as indicated on Order Sheet
Contact Primary Team to order Speech Pathology consult
Adequate air movement
Downsize tube, if appropriate
No
Yes
No
Yes
Home stretchHome stretch
Tolerate cuff deflation > 24 hours
Possible reason to not decannulate
Decannulation
Proceed with Cuff deflation trial
Yes
Yes
Complete Trach Discharge Teaching
Considerations for CUFF DEFLATION ASSESSMENT
· Increased cough and/or secretions a) Suctioning requirements and need for hyperinflation · Increased WOB· Anxiety· O2 requirements
Change to Cuffless trach , start 24-48 plugging trial as medically appropriate
Tolerated?
Decision to not decannulate
No
Reasons for Long Term Tracheostomy
· Bronchial hygiene· Ventilation· Pending OR· Mental Status· Anatomical need for trach including
laryngeal involvement
Set plan/action based on cuff
deflation assessment
NoLong Term
Cuffed Trach
Yes
No
Order needed for decannulation
Yes
Yes
No
No
Patient w/ Trach
Tolerate cuff deflation > 24 hours
Possible reason to not decannulate
Decannulation
Proceed with Cuff deflation trial
Yes
Yes
Trach ManagementProtocol (TMP)
Complete Trach Discharge Teaching
Trach Order Sheet signed by procedural MD.
Procedural MD 5-10 day assessment to include suture removal, possible trach change and completion of Trach orders. Include goals, discharge plans and possible Speech Therapy consult.
Considerations for PATIENT ASSESSMENT
· Ventilation required (see Ventilator Pathway)· Desaturation Episodes· Excessive Sputum (BHP) or ineffective cough / gag· Injury assessment a) future surgeries b) confounding issues · Mental Status· Difficult intubation or suspected
anatomical issues
Considerations for CUFF DEFLATION ASSESSMENT
· Increased cough and/or secretions a) Suctioning requirements and need for hyperinflation · Increased WOB· Anxiety· O2 requirements
Patient Assessment issues resolved?
PassedAirway Assessment
w/ adequate air movement(Includes 15 minute cuff deflation )
Considerations for AIRWAY ASSESSMENT
· Patient Assessment considerations have resolved as needed
· Evaluate need for downsize if inadequate air movement or voice
· Anxiety· Mental Status
Contact Speech Pathology for swallow eval as indicated on Order Sheet
YES
Change to Cuffless trach , start 24-48 plugging trial as medically appropriate
Tolerated?
Decision to not decannulate
No
Reasons for Long Term Tracheostomy
· Bronchial hygiene· Ventilation· Pending OR· Mental Status· Anatomical need for trach including
laryngeal involvement
· Set care plan· Intervene with required therapy· Evaluate possible discharge date
and potential discharge w/ trach
NO
Set plan/action based on cuff
deflation assessment
NoLong Term
Cuffed Trach
Yes
No
Order needed for decannulation
Contact Primary Team to order Speech Pathology consult
Adequate air movement
Downsize tube, if appropriate
No
Yes
No
Yes
Yes
Yes
No
No
