Non-medical Competencies for Tracheostomy and … basic trachy competencies.pdf · The National Tracheostomy Safety Project (NTSP) is a UK charity dedicated to improving the quality

ITCProject:Non-medicalcompetenciesfortracheostomy/laryngectomycare-Templateforlocaladaptation.NTSP2018.Coe,B.,McGrath,B.,Lynch,J.,Firn,M.

Non-medical Competencies for Tracheostomy and Laryngectomy

care

BarryCoe,BrendanMcGrath,JamesLynch,MikeFirn,2018


Non-medicalCompetenciesforTracheostomyandLaryngectomyCare

Background:

TheNationalTracheostomySafetyProject (NTSP) is aUK charitydedicated to improving thequality and safety of care for patients with tracheostomies and laryngectomies througheducation.TheGlobalTracheostomyCollaborative(GTC)isaQualityImprovementCollaborationbetween hospitals around theworldwith similar aims to theNTSP, but providing additionalresources to support change in our healthcare systems. The NTSP secured funding from theHealthFoundationtoimplementtheGTCresourcesinto20diverseUKhospitalsin2016.ThisprojectiscalledImprovingTracheostomyCare(ITC).

During2017, aspartof the ITCProject,weundertookanumberofqualitative exerciseswithChampions from our 20 participating NHS trusts, in order to gauge levels of support andresources required to successfully improve tracheostomycareacrossavarietyofhospitals.ArapidDelphiconsensusexerciseranked ‘competencies’as thesingle interventionwithhighestagreement.AfurtherexercisedemonstratedthatlessthanhalfofsitesinvolvedintheProjecthadmandatedcompetenciesfornursingstaff.

However, we found little consensus regarding the format and assessment process that acompetencydocumentshouldadopt.Duringtheproject,wehavelearnedthateachsitehasitsowninternalandexternalfactorswhichmayaffecthowchangecanbeadopted,aswellasitsownspecifictracheostomypopulationwiththeirownspecificneeds;alackofconsensusisthereforeunsurprising.However,thereremainsaneedfornationallyagreedtracheostomycompetenciesandthefollowingdocumentcanbeusedasaguideortemplateforthis,andwhendevelopinglocalcompetenciesfortracheostomycare.

Competencydevelopment:

TheITCprojecthostedanumberofmeetingsformultidisciplinarystaffinvolved,representingthe participating NHS sites. Draft themes were developed by consensus and presented forfeedback.Evidenceinthemedicalliteraturewasusedwherepossible,buthighquality,relevantpeerreviewedliteratureislackinginthisarea.Muchofthisdocumentrepresentsopinion,buttheopinions are taken from a multidisciplinary expert panel, and determined through a formalconsensusexercise.

Itisanticipatedthatnotallofthesecompetenciesarerelevanttoallindividualsortoallstagesoftraining,andsomesitesmayhavecomprehensive,existingresources.Thecompetenciesprovidedherearealsodeliberatelydetailed,intheanticipationthattheywillbeadaptedbythoseusingthemtosuittheirlocalneeds.


TheAssessmentProcess:

Inordertoimprovethesafetyofcare,theNTSPrecommendslimitingthenumberofwardsorlocationswithin an organisation that patientswith tracheostomies or laryngectomieswill bemanaged. These locations are commonly referred to as cohort wards. The aim for anytracheostomy cohort ward should be to have at least one nurse (or healthcare providerappropriate to the setting)per shift tobe competent (Level3) ineach relevant tracheostomyrelatedcompetency.

Eachofthefollowingcompetenciescanbeassessedforhealthcarestaffinregular,directcontactwithtracheostomyorlaryngectomypatients.Incertainareasandoncertainwardssomeofthefollowingcompetenciesmaynotbeappropriate.Similarly,notallofthefollowingcompetencieswillbeappropriateforcertainmembersofthemultidisciplinaryteam.

Themethodofachievingcompetenceandtheevidencerequiredforthisshouldalsobelocallyagreed.Thefollowingdocumentallowsforself-assessmentandmultiplefurtherassessmentsinorder to highlight individual learning needs and demonstrate progression. However, oneassessmentprocessmaybeallthatisrequiredtodeemapractitionercompetent.Werecommendthatbeforeimplementingacompetencyframework,thesecompetenciesshouldbereviewedbyalocal,multidisciplinary,expertpanel.

LevelsofCompetence1to5(novicetoexpert):

Novice-Level1Noviceshavenoexperienceofthesituationtheyfindthemselvesin,andtheyoperatebycloselyfollowingruleslaiddownbyothers.Theyperformaseriesoftaskswithoutunderstanding,orreferringto,thecontextwithinwhichtheyareoperating.

AdvancedBeginner-Level2Advancedbeginnershavehadexposuretothesituationtheyfindthemselvesin.Thiscouldbethroughacombinationofclinicalpractice,simulationworkshops,studysessionsore-learningthatenablesthemtodiscussordemonstrateanunderstandingofthecompetency.

Competent-Level3TheNursingandMidwiferyCouncil(2010)definecompetenceas“thecombinationofskills,knowledgeandattitudes,valuesandtechnicalabilitiesthatunderpinsafeandeffectivenursingpracticeandinterventions”.Competentpractitionersuseconscious,analyticalcontemplationofthesituationtoplanandimplementtheappropriateactiontoensurethemostsatisfactoryoutcome.

Proficient-Level4Proficientpractitionersusetheirexpertisetocriticallyanalyseandevaluatesituations.Theycanidentifythemostimportantandrelevantelementsofacomplexsituationandmakedecisionsbaseduponabroadperspectiveandknowledge.

Expert-Level5Expertsareabletofocusonarelevantpartofasituationusingintuitiveskillstofollowanappropriatecourseofaction.Anexpertpractitionerwilldevelopa‘feel’forasituationandhaveaplanforanygivenoutcome.

(AdaptedfromBenner,1984)


Exampleofcompetencyassessmentrecordsheet:

4.1 DateofAssessmentKnowledge 01/01/01 02/02/02 Demonstrateanunderstandingoftheindicationsforandrisksassociatedwithendotrachealsuction.

2JL 4JL

Skills 01/01/01 02/01/01 Demonstratethecorrectprocedureforperformingendotrachealsuctionincludingselectionofappropriatesuctioncatheters

1JL 3JL

Recordoftrainersignature:

Anymemberofstaffwhoassessesacolleagueasbeingcompetentshouldsignthefollowingtable.

Name Role Signature Initials


Tracheostomy&Laryngectomycompetencies:1. Safesuctioning2. Bedheadsigns3. Emergencyalgorithms4. “Redflags”andcomplications5. Innertubecare6. Humidification7. Anatomyandphysiology8. Tubechange:

a. Electivetubechangeb. Emergencytubechange

9. Cuffmanagement10. Stomaandskincare11. Communicationandspeakingvalves12. SwallowingandSALTguidelines13. Transfer14. Documentation15. Weaning16. Family17. Laryngectomy-specific18. Sub-glotticsuctioning19. Discharge

Notes

• SA–Self-Assessment• Initial,MidandFinalareassessmentsatdifferentstagesoftrainingthatmayor

maynotbeapplicabletothelearner


Skill/Knowledge Assessment1. Effectivelyandsafelyperformsuctioningofa

tracheostomy/laryngectomytube.SA Initial Mid Final

1.1 Candemonstratetheabilitytocheckandprepareallnecessaryequipment

1.2 Ensurespatientisinformedandreassureaboutthesuctioningtobeperformed

1.3 Performssuctioneffectivelyinaccordancewithlocalprocedure

1.4 Disposeofallwastematerialeffectively 1.5 Ensurepatientiscomfortablepost

procedure.

1.6 Candiscussthemaincomplicationsoftracheostomy/Laryngectomysuctioning

A. Trauma/BleedingB. HypoxiaC. BradycardiaD. BronchospasmE. Pain/anxiety

Skill/Knowledge Assessment2.Bedheadsigns SA Initial Mid Final2.1 Candiscusstheimportanceofthecorrect

use,positionanddocumentationofabedheadsign

2.2 CandescribethebasicdifferencesoftheAdultTracheostomyandLaryngectomybedheadsigns

2.3 CandescribethebasicdifferencesofthePaediatricTracheostomyandAdultbedheadsigns(whereapplicable)


Skill/Knowledge Assessment3.Emergencyalgorithm SA Initial Mid Final3.1 Hassuccessfullycompletedanemergency

algorithmtrainingsession.

3.2 Candemonstratewheretofindacolourcopyofthecorrecttypeofbedheadsignwithattachedemergencyalgorithm

3.3 Candiscussanddemonstratetheabilityandneedtocallforexpertairwayhelp

3.4 CandemonstrationtheabilitytoassesstheTracheostomy/Laryngectomypatientsbreathing.

3.5 CanassesstheabilitytoassesstheTracheostomy/Laryngectomytubepatency

A. SpeakingvalvecapremovalB. CanpassasuctioncatheterC. CandeflatethecuffD. Re-assessbreathing

3.6 CandemonstratetheabilitytoremovetheTracheostomy/Laryngectomytube

3.7 Candemonstratetheabilitytoperformprimaryemergencyoxygenation.

StandardairwaymanoeuvresA. CoverthestomaB. Bag-valve-MaskC. OralorNasalairwayadjunctsD. Subglotticairwaydevices

TracheostomystomaventilationA. PaediatricfacemasktostomaB. LMAappliedtostoma

CandescribeNOoralairwaywithLaryngectomypatients

3.8 CandiscussthedifferencesbetweentheAdult,PaediatricandLaryngectomyalgorithms(whereapplicable)


Skill/Knowledge Assessment4.Effectiveandearlyrecognitionoftracheostomy“RedFlags”andcomplications

SA Initial Mid Final

4.1 Canidentifyandallemergencyequipment.

A. Suctionandcorrectsuctioncatheters

B. Oxygenwithcorrectdeliverysystem(tracheostomymask,paediatricmask,Bag-Valve-Mask,T-pieceorWaterscircuitasapplicable)

C. TracheostomyBox,asperlocalstandard.

D. Resus/advancedairwaytrolley

4.2 Candemonstratetheknowledgeandabilitytocallforexpectairwayhelp.

4.3 Candiscussthetracheostomy“RedFlags”A. AirwayB. BreathingC. Tracheostomy-specificD. General

4.4 Candiscussthegeneralcomplicationsofatracheostomy/laryngectomy,anddemonstratetheeffectiveandearlytreatmentof

A. TubeBlockageB. TubedisplacementC. Increasedviscosity/drysecretionsD. IncreasedchestinfectionsE. Bleeding


Skill/Knowledge Assessment5.Caneffectivelyandsafelyperformtracheostomyinnertubechange/carefordouble-lumentracheostomytubes

SA Initial mid final

5.1 Candiscusstherationaleforinnertubechange.

5.2 Demonstratestheabilitytosafelyremove,cleanandre-insertatracheostomyinnertube

A. Ensurethatthepatientisinacomfortableposition

B. AllequipmentispreparedC. Theinnertubeischangedasper

localprocedureD. The“removed”tubeiscleaned

andstoredasperlocalpolicyE. Thepatientisobservedpost

procedureforanysignsofcomplications

5.3 Demonstratestheabilitytoreplace“used”innertubeeffectively

5.4 Candescribetheminimumfrequencythattheinnertubeneedstobereplaceasperlocalpolicy

Skill/Knowledge Assessment6.Humidification SA Initial mid final6.1 Candescribethenormalanatomical

humidificationprocesses

6.2 Discusstheimportanceofhumidificationinapatientwithatracheostomyorlaryngectomyanddescribeappropriatemethodsofhumidification

6.3 Candescribe,discussandapply(setup)thedifferentmethodsofhumidification.

A. WarmhumidificationB. ColdbathhumidificationC. HumidificationandMoisture

Exchangers(HME’s)eg.Swedishnose

D. LaryngectomybibE. Nebulisers

6.4 Canassessanddocumenttheeffectivenessoftheappliedhumidification


Skill/Knowledge Assessment7. Anatomyandphysiology SA Initial mid final7.1 Candiscusstheanatomyandphysiology

oftheupperairway

7.2 Candiscusstheindicationsforatracheostomy/laryngectomy

7.3 Candiscussthealteredanatomyandphysiology,ofthepatientwithtracheostomy

7.4 CandiscussthealteredanatomyandphysiologyoftheLaryngectomypatient

7.5 CandiscussthedifferencesinmanagementofLaryngectomyandTracheostomypatients


Skill/Knowledge Assessment8a.CansafelyandeffectivelyperformaROUTINEtracheostomytubechange.


8a.1 Canpreparethepatientandenvironmentfortheroutinetracheostomytubechange.

8a.2 Caneffectivelyaccessanduseallemergencyequipment

8a.3 Canidentifyandcontactthecorrectexpertairwaypersonnelasnecessary

8a.4 Cansafely/effectivelyperformaroutinetracheostomytubechangeasperlocalprocedure

8a.5 Cansafely/effectivelyperformaroutinetracheostomytubechangeasperlocalprocedure(localchecklistcompleted)

8a.6 Canensurethatthepatientisreassuredandcomfortablepostprocedure,ensurethatanyproblems,concernsorheightenedobservationarehighlightedtothecorrectpersonnel.

Skill/Knowledge Assessment8b.CansafelyandeffectivelyperformanEMERGENCYtracheostomytubechange.


8b.1 Caneffectivelyaccessanduseallemergencyequipment

8b.2 Cansafely/effectivelyperformanemergencytracheostomytubechangeasperlocalprocedure(Localchecklistcompleted)(Thismaybedemonstratedonamanikin)

8b.3 Canidentifyandcontactthecorrectexpertairwaypersonnelasnecessary

8b.4 Canensurethatthepatientisreassuredandcomfortablepostprocedure,ensurethatanyproblems,concernsorheightenedobservationarehighlightedtothecorrectpersonnel.

8b.5 Candiscusshowtoreferthepatienttoahigherlevelofcare,andarrangesafetransfertothesame.


Skill/Knowledge Assessment9.Cansafelymanageaninflatedtracheostomytubecuff.


9.1 Candescribea“normal”tracheostomytubecuffpressurereading

9.2 Canidentifyandsafelyuseacuffpressuremanometerwhereapplicable.Thisincludescheckingafluidorfoam-filledcuffappropriately

9.3 Canaccuratelydocumentroutinetracheostomycuffpressureobservations

9.4 Candescribethesymptomsofatracheostomycuffleak,anddiscussthereportingandcorrectremedialactionsofthesame

9.5 Canaccuratelydocumentanytracheostomycuffleakissues,andactiontaken

Skill/Knowledge Assessment10.Canperformeffectivetracheostomy/laryngectomystomaandskincare


10.1 Caneffectivelycleanandassessskinconditionofthetracheostomyorlaryngectomystomaasperlocalpolicy/procedure

10.2 Cansafelyperformroutinewoundswaboftracheostomyorlaryngectomystoma

10.3 Cansafelyselectandapplytheappropriatetracheostomyorlaryngectomystomadressing

10.4 Candiscusstracheostomy/laryngectomyskinandstomaproblems,andcorrectlyreferfortissueviabilityinput


Skill/Knowledge Assessment11Candiscusstheeffectiveuseaspeakingvalve,anddifferentformsofcommunicationforapatientwithatracheostomy/laryngectomy


11.1 Candiscussthedifferenttypesofspeakingvalvesavailablelocally

11.2 Canexplainhowone-wayvalveswork 11.3 Candiscusswhentheyareandarenot

appropriatetouseincludinglocalpoliciesforhead/neckorENTsurgery

11.4 Candemonstratehowtosafelyattachanddetachvalve

11.5 Candemonstratehowtocleanandstorethevalves(aspermanufacturersguidance)

11.6 Candiscussdifferentcommunicationmethodsi.e.penandpaper,iPad,picturechartsoralphabetcharts

11.7 KnowswhenandhowtorefertoSaLTforspecialistassessmentoradviceoncommunicationdifficulties

Skill/Knowledge Assessment12.Candemonstrateknowledgeoftheimportanceofexpertspeech,voiceandswallowinginputwiththetracheostomyorlaryngectomypatient


12.1 Candiscussthephysicalandpsychologicalimpactofatracheostomyonapatient’sspeechandswallowing

12.2 Demonstratesunderstandingthatideally,alltracheostomypatientsshouldbereferredtoSaLTassoonasthedecisiontoweanfromsedationismade

12.3 KnowshowtorefertoSaLTlocally,andcandiscusswhentorefertoSaLT,asperlocalguidelines.

12.4 CollaborateswiththelocalSaLTteamtodevelopanindividualisedplanofcare


Skill/Knowledge Assessment13.Cansafelytransferapatientwithatracheostomyorlaryngectomy


13.1 Caneffectivelyidentifyandassemblethecorrectequipmentrequiredtosafelytransferapatientwithatracheostomyorlaryngectomy

13.2 Ensurealltheequipmentisingoodworkingorder

13.3 Canidentifyandensuretheallthepersonnelrequiredforasafetransferarepresent(whereapplicable)

13.4 Ensurethatthereceivingdepartment/ward/unitareawareofthepatienttransferareaware,andinagreementpriortotransfer

13.5 Effectivelyhandoverpatient,ensuringanyongoingissueswiththepatient’stracheostomyorlaryngectomyareidentifiedandunderstood

Skill/Knowledge Assessment14.Canaccuratelycompleteallrelevantlocaltracheostomy/laryngectomydocumentation


14.1 Ensurethatafullcolourandcorrecttypeofbedheadsigniscorrectlycompletedandisclearlyobservableatthepatientbedspace.

14.2 Canaccuratelyrecordalltracheostomy/laryngectomyobservations

14.3 Demonstratestheabilitytoensurethatallrelevanttracheostomyorlaryngectomycareplansarekeptuptodate

14.4 Demonstratestheabilitytoensurethatanyissueswiththetracheostomyorlaryngectomyareclearlydocumentedinthemedicalandnursingnotesandhandovertotheappropriatestaff


Skills/Knowledge Assessment15.Candemonstratetheknowledgerequiredtoeffectivelyweanapatientwithtracheostomyfrommechanicalventilatorysupport(ifapplicabletorole)


15.1 Candiscusswhenitisappropriatetocommenceweaning

15.2 Canexplainwhoisresponsibleformakingtheweaningplans(localguidance)

15.3 Canexplainthestagesofweaning 15.4 Candiscusswhentodiscontinueweaning

programmes

15.5 Canexplainhowtomonitorthepatientduringweaning,includingsignsofrespiratorydistressorfatigue

Skill/Knowledge Assessment16.Candemonstrateknowledgeofthesupportthefamilyofatracheostomyorlaryngectomypatientrequires


16.1 Candiscussthepsychosocialimpactonthefamily

16.2 Demonstratesawarenessoflocalfamilyeducationpolicyforthosethatwillbedischargedwithtracheostomyorlaryngectomy

16.3 Candiscussavailablefamilysupportafterdischargefromhospital

Skill/Knowledge Assessment17.Candemonstratetheskillsrequiredtocareforalaryngectomypatient(ifapplicabletorole)


17.1 Candiscusstheanatomicalchangestotheairwayfollowingalaryngectomy

17.2 Candiscussthedifferenttypesoflaryngectomystomaequipment;

- Stomabutton- ‘Larytubes’- BaseplatesandHMEcassettes

17.3 Candemonstratehowtocleanavoiceprosthesis(aspermanufacturersguidance)

17.4 Canexplainhowtoidentifywhenavoiceprosthesismayneedchanging

17.5 Canidentifyandcontactthoseresponsibleforchangingtheprosthesis

17.6 Candiscussothermethodsofcommunicationi.e.electrolarynx,


oesophagealspeech,ipadcommunicationapps

Skill/Knowledge Assessment18.Canperformsafesub-glotticsuction(ifapplicabletolocalpractice)


18.1 Candescribeidentifythesub-glotticport 18.2 Candemonstratetheabilitytosafely

suctionthesub-glotticportasperlocalpolicy

18.3 Canaccuratelydocumentthesub-glotticportaspirates

Skill/Knowledge Assessment19. Can demonstrate awareness of ensuring safedischarge from hospital of a patient with atracheostomyorlaryngectomy


19.1 Candiscussthedischargeprocess:- Registerwithambulanceservice- Contactelectricitycompanyto

prioritiseinpowercut- Set-upaccountwithconsumables

supplier- Follow-upappointmentfortube

change- GPandDistrictNursereferral- TracheostomySafetybox

19.2 Canexplainhowtoobtainaportablesuctionmachine/nebuliser/otheressentialequipment

19.3 Canexplaintheprocessofobtainingthenecessaryconsumables

19.4 Candiscusswhichconsumablesshouldbesentwiththepatientondischarge

19.5 Candiscusswhichcontactdetailswillbegivenshouldissuesariseondischarge(forexampleward,nursespecialist,physiotherapist)


Acknowledgements:

Thankstothosethatsharedtheirexistinglocaldocumentswithus,namely:

EricaEveritt-TracheostomyNurseSpecialist,NorfolkandNorwichUniversityHospitalTrust.

PaulTwose-ICUleadPhysiotherapist,CardiffandValeUniversityHealthBoard.

AndrewHolroyd-CNSHeadandNeck,UCLHFoundationTrust.

ChristinaLamont-TracheostomyNurseSpecialist,RoyalLiverpoolandBroadgreenUniversityHospitalTrust.

SarahWallace-SaLTlead,ITCproject,ManchesterUniversityNHSFoundationTrust.

ToofthemultidisciplinarystaffandsiteleadsthattookpartintheITCresearchmeetings.

Majorreferences

ThorpeV,WallaceS,MorrowN,GinnellyA,McGowanS,ClarkeL,ReidK.‘RCSLTTracheostomyCompetencyFramework2014’https://www.rcslt.org/members/publications/publications2/tracheostomy_competency_framework

NCEPOD:Ontherighttrach?(2014)http://www.ncepod.org.uk/2014tc.html

ComprehensiveTracheostomyCare,theNTSPhandbook.Availablefromwww.tracheostomy.org.uk

Documents

Non-medical Competencies for Tracheostomy and … basic trachy competencies.pdf · The National Tracheostomy Safety Project (NTSP) is a UK charity dedicated to improving the quality