1. On the Right Trach? Celebrating Success St George’s Tracheostomy Group 1995ish- present…..

2. 2 @ncepod #tracheostomy

3. 3 NCEPOD 2014- Complications

4. NCEPOD Audit data collection Data collected as part of the national NCEPOD observational study of patients receiving a tracheostomy as part of their treatment during an in-patient stay between 25th February and 12th May 2013 The patients were identified at the time of tracheostomy insertion on the intensive care unit or in theatre Subsequently these patients were followed through their hospital stay until death, decannulation or discharge to home or another hospital

5. NCEPOD Audit SGH (Results) 22 patients received a tracheostomy, 59% (n=13) were male with a mean age of 58 years (SD 19.36) and 41% (n=9) were female with a mean age of 63 years (SD 18.74) 59% (n=13) percutaneous and 41% (n=9) surgical tracheostomy 89% (n=8) of the surgical patients went to ICU post procedure and 11% (n=1) went directly to a ward 21 patients had an ICU stay, 62% (n=13) patients were discharged to one of four wards (Brodie n=2, Florence (n=6), Kent (n=1), McKissock (n=4) with a tracheostomy in situ 349 tracheostomy bed days (mean 15.86; SD 8.59); 185 ICU tracheostomy bed days (mean 8.80; SD 7.35), many of these patients required additional bed days being cared for pre and post decannulation

6. Tracheostomy care at St George’s MDT group Policy Clinical Guidance (v5) In-patients cohorted ICP Education Video/DVD Competence assessment MDT ward rounds Consultation (internal and external) Product development Discharge package Out-patient clinic Incident review

7. 7 NCEPOD 2014 – Hospital Policy

8. Policy (‘thou shalt’) Roles and responsibilities Patient management Admission from home Transfer within the hospital (cohort) Discharge with a tracheostomy Clinical advice Tube changes Guidelines for care –’evidence suggests’ or ‘expert opinion is’ Follow up Equipment Hardware Consumables Procurement Location Emergency pack Supply into the community Education and training Availability of staff Competence ( basic and advanced) Study days Documentation Inpatient Discharge LAS

9. Tracheostomy care at St George’s MDT group Policy Clinical Guidance (v5) In-patients cohorted ICP Education Video/DVD Competence assessment MDT ward rounds Advice (internal and external) Product development Discharge package Out-patient clinic Incident review

11. https://www.stgeorges.nhs.uk/gps-and-clinicians/clinical- resources/tracheostomy-guidelines/

13. http://tracheostomy.org.uk/

14. Tracheostomy care at St George’s MDT group Policy Clinical Guidance (v5) In-patients cohorted ICP Education Video/DVD Competence assessment MDT ward rounds Advice (internal and external) Product development Discharge package Out-patient clinic Incident review

15. Small numbers, high risk, multiple professionals in multiple locations…. The number of wards where nurses caring for patients with a tracheostomy who report not being competent to suction, measure cuff pressure or manage blocked/displaced tubes (p25-6, tables 2.9 &2.10)

16. Tracheostomy wards Marnham Florence Nightingale ADU Kent Brodie McKissock Belgrave Ben Weir Caroline CTICU NICU GICU

17. Process to achieve ward competence (pilot) Adequate exposure 180 bed days Adequate skill 80% nurses trained with basic competency complete

18. Tracheostomy care at St George’s MDT group Policy Clinical Guidance (v5) In-patients cohorted ICP Education Video/DVD Competence assessment MDT ward rounds Advice (internal and external) Product development Discharge package Out-patient clinic Incident review

19. 19 NCEPOD 2014 –Ward care

20. 20 40% 20% 21% 18% 1% NCEPOD 2014- Critical care

21. 21 NCEPOD 2014 -Training in blocked or displaced tubes

22. 22 NCEPOD 2014- Resuscitation Training

23. Emergency Algorithims

25. ‘The greatest difficulty lies not in persuading people to accept new ideas, but in persuading them to abandon old ones’ John Maynard Keynes

26. Tracheostomy care at St George’s MDT group Policy Clinical Guidance (v5) In-patients cohorted ICP Education Video/DVD Competence assessment MDT ward rounds Advice (internal and external) Product development Discharge package Out-patient clinic Incident review

27. A request….. Dear Deborah, I am a CNC from Royal North Shore Hospital in Australia and am currently reviewing the management of tracheostomies in our area health. The NHS resources that your team have developed are fantastic and I am hoping to integrate them into our practice. Are you able to tell me if I need formal permission from the authors to use the resources they have made available, or is there an understanding from you that since the material is open access then it may be used? I am looking at the ‘Integrated Care Pathway’ in particular, however, with the abundance of resources I would probably also reference other material on the site. Thank you for your time, I look forward to hearing from you soon. Regards, Alex Slattery Acting Clinical Nurse Consultant Respiratory Medicine Royal North Shore Hospital Office: 94632833 Page: 41342 Alexander.Slattery@health.nsw.gov.au

28. Our response….. Alex Pleased that you have found our resources useful, I plan to pop them on the GTC website, so happy for anyone to use. Our Trust has issued us with guidance on what constitutes acceptable use as follows: The following both constitute acceptable use: Hyperlinking from your corporate website to ours. Copying content from our website and reproducing it on yours, provided it is used verbatim and with credit to the trust and/or its website. The following constitutes unacceptable use: Any change in wording, whether or not this is credited or uncredited. I also enclose an updated ICP we are currently piloting, if you have any problems accessing links let me know and I can send you the content directly. Kind Regards Deborah

29. Tracheostomy care at St George’s MDT group Policy Clinical Guidance (v5) In-patients cohorted ICP Education Video/DVD Competence assessment MDT ward rounds Advice (internal and external) Product development Discharge package Out-patient clinic Incident review

30. Discharge from hospital SLT developed MDT discharge package crossing the secondary/primary interface Referral to the community team Competency assessed training of ‘carers’ and patient Identification and procurement of essential equipment/consumables Guidance on how to manage an emergency Letter to emergency services Pre-booked follow up appointment

31. Tracheostomy Clinic Data from 3/6-3/12 Primary reason for tracheostomyNumber Head and neck tumour34 Vocal cord palsy10 Neurological6 Tracheal damage7 Weaning from ventilation 1

32. Tracheostomy Clinic Data from 3/06-3/12 ProcedureNo.(pts) Tracheostomy change by nurse363 (52) Supervised change by carer21 (4) Supervised change by patient23 (2) Bespoke tube arranged7 (3) Fibreoptic nasendoscopy17 (12) Wound care137 (43) Community liaison78 (38) Weaning advice24 (11) Treatment for granulation27 (9) Communication advice58 (24) Medical review66 (30) Cough management18 (7) Nutritional advice28 (17) General advice78 (35)