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Assessment on basic post-operative tracheostomy care in intensive care unit

Article · January 2016

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Kepala Batas Hospital & Seberang Jaya Hospital, Penang, Malaysia
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 Post-operative tracheostomy care in an intensive care unit

Authors
Azlina, Azizan 1, Chee Peng, Hor 1,2, Rohaiza, Abd Razak 1, Suvana, Puang 1, Shalilah,
Ahmad 1, Nur Aslina, Bahakodin 1, Norsidah, Ismail 3, Haslinda, Md Taha 4
1
Kepala Batas Hospital, Jalan Bertam 2, 13200 Kepala Batas, Penang, Malaysia;
2
Clinical Research Centre, Seberang Jaya Hospital, Jalan Tun Hussein Onn, 13700 Perai,
Penang, Malaysia;
3
Penang State Health Department, 35th Floor, KOMTAR, 10590 Georgetown, Penang,
Malaysia;
4
Department of Otorhinolaryngology, Bukit Mertajam Hospital, Jalan Kulim, 14000 Bukit
Mertajam, Penang, Malaysia.

Corresponding Author
Chee Peng, Hor
Kepala Batas Hospital, Jalan Bertam 2, 13200 Kepala Batas, Penang, Malaysia
cheepengh@yahoo.com

Lead Consultant
Haslinda, Md Taha, Visiting Consultant Otorhinolaryngologist to Kepala Batas Hospital and
Head of Department of Otorhinolaryngology, Bukit Mertajam Hospital, Jalan Kulim, 14000 Bukit
Mertajam, Penang, Malaysia.

The Online Journal of Clinical Audits. 2016; Vol 8(2).

Published May 2016

To subscribe to The Online Journal of Clinical Audits go to:

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Abstract
Introduction - Tracheostomy care is essential in management of patients after tracheostomy procedure,
especially during initial postoperative period to ensure optimum benefits for patients. Such care can be
complex requiring good communication and coordination amongst nursing team. We evaluated the
standard of tracheostomy care for patients in intensive care unit (ICU) at Kepala Batas Hospital (KBH),
according to the international guidelines, as local national guideline is yet to be available.
Methods - This was a mixed retrospective and prospective audit involving 29 patients, whom
tracheostomy were performed for prolonged ventilation, in ICU. Patients’ charts of whom admitted
between January and December 2012 were hand-searched for retrospective evaluation. A checklist for
standard tracheostomy care was developed for a prospective audit from January till October 2013. The
nurses’ knowledge on tracheostomy care was surveyed.
Results - Up to 35% had limited information on tracheostomy dressing documented in 2012 as
compared to 100% in 2013. Checking of cuff pressure was not documented in 2012 while it achieved
94% in 2013. About 70% developed bleeding after suction between day 3 and 6 post-operatively in 2012,
and it was reduced to 19% in 2013. Survey responses revealed half of the nurses were unaware of
suitable pressures for tracheostomy cuff and suction, and depth of sterile catheter insertion during care
process.
Conclusion- Tracheostomy nursing care remained inconsistent in local setting, partly due to lack of
standardized guideline. A checklist of tracheostomy care has been developed to guide and ensure
standard care for ICU patients. We recommend organizing educational and practical workshops on
tracheostomy care for nursing staffs.

Post-operative tracheostomy care in an intensive care unit

Introduction

Tracheostomy care is essential in management of patients after tracheostomy

especially during initial postoperative period to ensure optimum benefits for patients.
Such care can be complex requiring good communication and coordination amongst
nursing team.

Thorough care is required in order to minimize potential complications and risks to

patients. Airway occlusion is the most serious complication among patients with
tracheostomy. 1 Tracheostomy care and tracheal suctioning are high risk procedures. 2
Besides, ensuring cuff pressure to be maintained within the range of 20 – 25 mmHg is
essential. 3 High cuff pressure (>25 – 33 mmHg) can lead to mucosal ischaemia and
trachea stenosis, while lower cuff pressure of less than 18 mmHg increases the risk of
nosocomial pneumonia. 3 Hence nurses caring for patients with tracheostomy should
be knowledgeable, skilled and competent in various aspects of tracheostomy care.
However, it was observed that nursing care for tracheostomy patients in our local
intensive care unit (ICU) focuses mainly on dressing of tracheostomy, and they might
not be aware of different components of tracheostomy care. Besides, the national
guideline for tracheostomy care is yet to be made available at the time of this audit.

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Aims

We aimed to evaluate the standard of post-operative tracheostomy care provided by

nurses in ICU at Kepala Batas Hospital (KBH) in accordance to available international
clinical practice guidelines. These guidelines are:
i. South East Wales Critical Care Network (May 2009), Tracheostomy
Guidelines. [Accessible via http://respira.com.mx/docs/f1287506745-0.pdf]
ii. Doncaster and Bassetlaw Hospital, NHS Foundation Trust (December 2011,
version 3). Tracheostomy Adult Care Policy (Guidelines for Best Practice).
iii. Salmon N. and Herzberger S. (21st December 2012). Update on
Tracheostomy Care. [Accessible via www.rn.com/getpdf.php/1839.pdf]

Audit Standards

All patients in ICU with newly inserted tracheostomy should receive optimal post-
operative care post-operative. The standard for the adherence was set at 100% for
correct suction and dressing technique, as well as checking for cuff pressure.
Adherence of at least 90% was considered acceptable.

Methods

All patients, whom tracheostomy were performed for prolonged ventilation between 1st
January 2012 and 31st October 2013 were included in this audit. This audit employed
universal sampling method. A total of such 31 patients were identified from the ICU
admission system. Twenty nine patients fulfilled the inclusion criteria with two excluded
due to abnormal coagulopathy, which could affect the bleeding tendency and care
process. 4

This audit composed of both a retrospective review and a prospective

assessment. Health records for 17 patients admitted between 1st January 2012 and 31st
December 2012 were reviewed retrospectively on the documented dressing change
and post-operative complications. This was followed by a prospective audit on
tracheostomy care process on another 12 patients who were subsequently admitted
between 1st January and 21st October 2013 using a checklist for core procedure skills.
Only members of the audit team were exposed to this checklist and no specific training
was planned for the ICU nurses at time of this audit. This checklist (Figure 1) composed
of basic and essential tracheostomy care process and was developed with references
to the three international guidelines as stated above. The basic suction skills include
application of proper size of suction tube, correct suction pressure, sterility of suction
procedure as well as pre- and post-suction oxygenation. Meanwhile, usage of sterile
set, key hole dressing and changing tie were basic requirement for dressing skills. In
addition, checking cuff pressure was also an essential step in the care process.

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Date
Name
Patient No
Skill Assist Comment Verified
AM PM ON AM PM ON AM PM ON
1 SUCTION:
1.1 Proper suction size
1.2 Correct suction pressure
1.3 Correct technique
1.4 Maintain sterility
1.5 Pre & post oxygenation
2 DRESSING:
2.1 Sterile set
2.2 Key hole dressing
2.3 Change tie
3 Check cuff pressure
Figure 1: Sample checklist for tracheostomy core procedure skill used in prospective audit for tracheostomy care process ICU
(columns abbreviated and re-adapted for presentation in this manuscript)

Formula used to calculate for the total number of checklists (N) was number of
patients multiplied with their length of stay. The “n” represents number of checklist, i.e.
n=1 referred to single observation per nursing care shift for 1 patient per day. For
instance, 3 observations were made in a day throughout 3 nursing care shifts (morning,
afternoon and night). In addition, a survey was conducted among 22 staff nurses in ICU
to evaluate their general knowledge towards tracheostomy care. Microsoft Excel was
used for data entry, compilation and analyses.

Results

In 2012, among 226 patients admitted to ICU, 17 (7%) patients had tracheostomy
performed for prolonged ventilation. Between January and October 2013, 12 (6%) of
198 ICU patients underwent tracheostomy.

A total of 127 observations made each with a checklist filled up by the audit team while
retrospectively reviewing documented information on tracheostomy care on 17 patients
in 2012. With the prospective audit in 2013, a total of 72 observations were made by
the audit team while observing nurses performing tracheostomy care on 12 patients.

Assessment on standard tracheostomy care

In 2012, only 65% tracheostomy dressing process were documented while none
documented for cuff pressure check (Table 1). Documentation on the dressing process
was limited and lack of essential details as outlined in the checklist.

On the other hand, by 2013, all patients received optimal care in term of proper suction
size used, sterility maintained throughout care process, given pre- and post-
oxygenation, using sterile set and key hole dressing, as well as changing the dressing
tie. Up to 94% their cuff pressure checked and documented during the care process.
However, 79% had their suction pressure applied incorrectly and 21% with wrong
technique.

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Key: Adherence Adherence Adherence
≥ 90% 75% – 89% ≤ 75%

N N /
No Standard Compliance 2012 Compliance 2013
2012 2013
All patients with tracheostomy should receive
the following care process on suction:
1. Proper suction size 127 0% 72 100% ↑
2. Correct suction pressure 127 0% 72 21% ↑
3. Correct technique 127 0% 72 79% ↑
4. Maintain sterility 127 0% 72 100% ↑
5. Pre- and post-oxygenation 127 0% 72 100% ↑
All patients with tracheostomy should receive
the following care process on dressing:
6. Use of sterile set 127 0% 72 100% ↑
7. Use of key hole dressing 127 0% 72 100% ↑
8. Change of dressing tie 127 0% 72 100% ↑
9. Check on cuff pressure 127 0% 72 94% ↑
Table 1: Key findings on audit for tracheostomy care process in ICU
“N” represents number of checklist, i.e. 1 checklist referred to single observation per nursing care process for one patient per day.

Post-operative bleeding around tracheostomy site is common up to 48 hours. About

70% developed bleeding after suction between day 3 and day 6 post operatively in
2012, while it reduced to 19% in 2013.

Knowledge on tracheostomy care

All were aware of complications of poor tracheostomy care and incorrect suctioning
technique (Table 2). At least 70% knew about suction practices and checking
tracheostomy cuff. Half were unaware of suitable pressures for tracheostomy cuff and
suction, and the depth of sterile catheter insertion during care process. Additionally,
40% were unaware of safe fit of tracheostomy tie.

Knowledge assessment n (in %)

Complications of poor tracheostomy care 100
Complications of incorrect suctioning procedure 100
Why the wet tape must be used in dressing tracheostomy wound 90
If patient required further suction, what have to be done 90
Document the checking of tracheostomy cuff 80
What have to be done prior to suctioning 70
Suitable pressure of tracheostomy cuff 50
Using the recommended suction pressure 50
How deep sterile catheter should be inserted 50
Safe fit of tracheostomy tape 40
Table 2: Findings on assessment of general knowledge on tracheostomy care among nurses in ICU

Discussion

While tracheostomy care covers a broad range of processes such as identification and
management of emergency obstruction, major bleeding and tube dislodgement 4, our
audit focuses on basic steps in post-operative care which include suction and dressing
practices. We have identified areas of good practice where the ICU nurses were
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capable to perform basic trancheostomy care process, such as employing proper size
of the suction tube, maintaining procedural sterility, providing pre- and post-
oxygenation during suction, using key hole dressing and changing tie. However, it was
noted some applied high pressure during the suction process (79%), while some
employed incorrect suctioning technique (21%), which corresponded to the knowledge
gaps identified through the survey.

The drastic improvement in documentation and performance of tracheostomy care in

2013 could possibly be confounded by the exposure of the newly developed care
checklist to the nursing staffs. This clinical audit involved multiple observations which
were resource-intensive, in term of time and human resources. Future audit requires
modifications on frequency of observations made. Future audit should evaluate
tracheostomy care performed by nursing staffs at general wards to identify areas for
good practice and areas for improvement.

Conclusions

Tracheostomy nursing care remained inconsistent in local setting, partly due to lack of
standardized guideline and training. The knowledge gaps could have led to pitfalls in
management, which are amendable with training exposure. A checklist of tracheostomy
care has been developed to guide and ensure standard care for ICU patients during
this audit project.

Recommendations

A national Tracheostomy Care Clinical Practice Guideline is in need to provide

standardized and evidence-based guidance to nursing staffs involving in tracheostomy
care. We recommend periodic attachment and training for these nursing staffs at
Otorhinolaryngology Department of nearest training hospital. Regular educational and
echo training sessions on tracheostomy care should be conducted for other healthcare
professionals whom might involve in caring for patients with tracheostomy.
Implementation of tracheostomy care checklist to guide clinical care process in local
hospital across all units, including general wards, is needed.

References

1.Higgins D. Basic nursing principles of caring for patients with a tracheostomy. Nursing times.
2009;105(3):14-5.
2.Nance-Floyd B. Tracheostomy Care: An evidence-based guide to suctioning and dressing changes.
American Nurse Today. 2011;6(7):14-6.
3.De Leyn P, Bedert L, Delcroix M, Depuydt P, Lauwers G, Sokolov Y, et al. Tracheotomy: clinical review
and guidelines. European Journal of Cardio-Thoracic Surgery. 2007;32(3):412-21.
4. Durbin C, Cahill T, White C, Grooms DA. Panel discussion: Care of tracheostomy tubes and trach
patients. Perspectives on Recovery Strategies from the OR to Home. 9(3):2-7.

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