INTRODUCTION
Tracheostomy refers to an opening into the trachea where an artificial airway (the tracheostomy tube) is inserted. This is usually performed to protect the patient from accidentally inhaling food, fluid or saliva. Such an airway may be necessary for patients when prolonged ventilation is required, or when an extended coma is anticipated. It may also be placed surgically to maintain the structure of the trachea–when threatened by cancer, infection or trauma, Placement of a tracheostomy is mainly used during the acute phase of an illness and later removed.
In my place of employment, there is an increasing incidence of chest infection associated with the use of tracheostomy tubes. The blame is placed on the apparent lack of knowledge of the nursing staff regarding tracheostomy care. It is time to seriously rethink, redesign, redevelop and reinvigorate the way governance is practiced in my current place of employment.
This paper presents the problems of increasing incidence of chest infection in my current place of employment and how this problem can be solved by providing solutions designed for the apparent cause of the problem. I will also provide a personal analysis on the presented problem and provide recommendations on how the quality of care can be improved in my place of employment regarding the particular problem.
BODY
A client may have a tracheostomy to bypass an upper airway obstruction, prevent aspiration, manage tracheobronchial secretions, or allow for prolonged mechanical ventilation. Whatever the reason for tracheostomy, the client should be provided standardized care in tracheostomy management. Lately, the rising incidence of chest infections in patients undergoing tracheostomy in my place of employment had been largely blamed on the part of the nurses. The nurses’ apparent lack of knowledge and unsafe practices about tracheostomy care are among the most significant reasons in the development of chest infection in clients.
Such poor quality of practice is a no-no in the healthcare field. As nurses who are not aware of the recommended and safe procedure, we are jeopardizing the lives of our clients.
Tracheal suctioning is an important part of effective airway management and is a routine and necessary nursing intervention. Therefore, it is essential for nurses to realize the risks and complications ranging from trauma and bronchoconstriction to hypoxaemia, cardiac arrest and death. Tracheostomy care is also important.
Quality in healthcare service and practice provision is very important. The method of quality measurement used by health economists is the QALY. QALY stands for Quality Adjusted Life Year. It is a term developed by health economists for an approach that is concerned with evaluating both effectiveness of treatments and their cost-effectiveness. The outcomes are measured according to a generic scale whereby if a client’s treatment is felt to be effective and long-lasting as well as cost-effective, then the patient can increase his/her score on the quality-of-life measure. This technique supports treatments that show improved quality-of-life over a long time and for the least cost.
Implementation of shared governance initiatives or other structures that promote autonomy, control of practice, and empowerment of nurses have been identified as key strategies to continue to improve the work environment of nurses. This could in turn improve how the nurse delivers care to the clients.
In a shared governance model, each person has an obligation to ensure that his or her skills and knowledge make a positive contribution and to work efficiently and effectively.
For a shared governance model to work, the nursing leaders must develop skills that go beyond facilitating team and group decision making and assume a transformational role of disrupting the status quo, particularly in situations where evidence-based practice clearly points to a need for rapid change and improvement. Nursing leaders must translate the demand for change into a clear, understandable plan, as well as help staff members handle the chaos and uncertainty that accompany rapid change.
The SWOT analysis table shows that although the hospital is equipped with competent staff, there is still an increase in chest infection in tracheostomy care since majority of the nursing staff are unaware of the recommended practice regarding tracheostomy care resulting to unsafe practice. Good clinical facilities for the tracheostomy procedure are also present in my place of employment.
Coming up with recommendations and implementing them at my place of employment is the most logical thing to do. Surely, there will be an improvement for tracheostomy care and a decrease in chest infection incidence because health authorities and the staff themselves highly support the idea of providing the nursing staff the education they need to know about tracheostomy care.
Hong Kong’s healthcare profession is challenged by the shortage of healthcare professionals. This presents a threat to my area of practice. If there is a decrease in the number of nursing staff that are competent enough to handle tracheostomy care, the problem regarding the increase in chest infection associated with tracheostomy would not be solved.
It seems that there is also an apparent poor quality of management and leadership in this case resulting to the poor quality of service. To improve quality, organizations have to apply ‘Total Quality Management’ (TQM) to their organizations to help them plan their efforts. The promise of superior performance through continuous quality improvement has attracted a wide spectrum of business to TQM, with applications reported in many domains including healthcare.
RECOMMENDATIONS
Since the problem in itself roots on the apparent lack of knowledge on the part of the nursing professionals regarding the recommended practice of tracheostomy care, solutions must be also directed on them. In the next few paragraphs I have outlined the proper way of performing tracheostomy care as well as the rationale behind each step. The literature is taken from Potter & Perry’s Fundamentals of Nursing book.
1. Signs and symptoms should be observed if there is a need to perform tracheostomy care. These include soiled/loose ties or dressing, nonstable tube, and excessive secretions. The rationale for dong this is that a client with a tracheostomy tube is at increased risk due to loss of natural airway protection of the upper airway.
2. Before removing the gloves the nurse is using, the soiled tracheostomy dressing should be removed and discarded in glove with coiled catheter. This removes secretions so as not to occlude outer cannula while the inner cannula is removed. This reduces the need of the client to cough and prevents aspiration of retained secretions.
3. The following sentences outline the procedures that should be followed in preparing equipment. Two packages of cotton-tipped swabs should be opened and normal saline poured on one package and hydrogen peroxide on the other. The next step is to open the sterile tracheostomy package. The sterile basin should be unwrapped and about 2 cm of hydrogen peroxide is poured into it. The small sterile brush package would then be opened and place aseptically into the sterile basin. If a large roll of twill tape is used, the appropriate length of tape should be cut and laid aside in a dry area. The hydrogen peroxide and normal saline should not be recapped. The rationale of this preparation procedure is that preparation and organization of the equipment allows the nurse to complete tracheostomy care procedure efficiently and then re-connect client to oxygen source in a timely manner.
4. The next thing for the nurse to do is to apply gloves and keep the dominant hand sterile throughout the procedure. This reduces the transmission of microorganisms. The next step is to remove the oxygen source and apply it loosely over tracheostomy if the clients desaturates during the procedure. Doing this helps reduce the amount of desaturation. It is important to stabilize the tracheostomy tube at all times during tracheostomy care to prevent injury and unnecessary discomfort.
5. If a nondisposable inner cannula is used, the following procedures should be followed. Remove the inner cannula with the nondominant hand while touching only the outer aspect of the tube. The inner cannula is then dropped into the hydrogen peroxide basin. The inner cannula is removed for cleaning. Hydrogen peroxide is used to loosen secretions from the inner cannula.
6. The tracheostomy collar or T tube and the ventilator oxygen source are then to be placed over or near the outer cannula. This maintains the oxygen supply to the client. The T tube and ventilator oxygen devices cannot be attached to all outer cannulas when the inner cannula is removed.
7. To prevent oxygen desaturation in affected clients, the inner cannula should be quickly picked up and a small brush should be used to remove secretions inside and outside the cannula. The tracheostomy brush provides mechanical force to remove thick or dried secretions. The inner cannula should be held over the basin and rinsed with normal saline, using the nondominant hand to pour. This removes secretions and hydrogen peroxide from the inner cannula. The inner cannula should then be replaced and secured with the “locking mechanism.” Ventilator or oxygen sources will then be reapplied.
8. If a disposable inner cannula is used, the following procedures should be followed. First, the cannula is removed from the manufacturer’s packaging. Then, withdraw the inner cannula and replace with a new cannula while touching only the outer aspect of the tube. Lock into position. The contaminated cannula is then disposed in an appropriate receptacle and the oxygen source is applied. This prevents unnecessary oxygen desaturation.
9. Using hydrogen peroxide-prepared cotton-tipped swabs and 4 x 4 gauze, the nurse should clean the exposed outer cannula surfaces and stoma under the faceplate. This aseptically removes secretions from stoma use. Using normal saline-prepared cotton-tipped swabs and 4 x 4 gauze again, the nurse should rinse hydrogen peroxide from tracheostomy tube and skin surfaces. Rinsing hydrogen peroxide from surfaces prevents possible irritation. Using a dry 4 x 4 gauze, the nurse should then pat lightly at skin and exposed outer cannula surfaces. The rationale behind this is that dry surfaces prohibit the formation of moist environment from growth of microorganisms and skin excoriation.
10. If an assistant is available, he or she should be instructed to hold the tracheostomy tube securely in place while the ties are cut. This promotes hygiene, reduces the transmission of microorganism and secures the tracheostomy tube. The assistant must not release hold on the tracheostomy tube until new ties are firmly tied to reduce the risk of accidental extubation. If there is no assistant present, the old ties should not be cut until the new ties are in place and securely tied. If manufacturer’s guidelines for some types of ties are available, it is better to follow it.
11. The length of the twill tape should be cut long enough to go around the client’s neck two times. The cut ends should be diagonal as this will aid in inserting tie through the eyelet. One end of the tie should be inserted through the faceplate eyelet and the ends pulled even. Then slide both ends of tie behind head and around neck to other eyelet, and insert one tie through second eyelet. This should then be pulled snugly to secure the tracheostomy tube in place. The ends should be tied securely in a double square knot, with space allowed for only one finger to tie. One-finger slack prevents ties from being too tight when tracheostomy dressing is in place.
12. A fresh tracheostomy dressing will then be inserted under the clean ties and faceplate. This absorbs drainage and dressing prevents pressure on clavicle heads. The client should be positioned comfortably and assessed of his or her respiratory status. Some clients may even require post-tracheostomy care suctioning.
13. Any oxygen delivery services should then be replaced to maintain oxygen therapy. The nurse should then remove and discard gloves and perform hand hygiene. Respiratory assessments before and after the procedure should be compared to identify any changes in the presence and quality of breath sounds after tracheostomy care procedure. The depth and position of tubes should also be observed in order to verify that it is correct. The security of the tape should be assessed by tugging at the tube. The artificial airway normally should not move. The skin around the mouth and the oral mucosa and tracheostomy stoma should also be assessed for drainage, pressure and signs of irritation. Normally, skin breakdown and/or irritation should not be present.
In order for each and every staff to be educated and aware of this proper procedure, training or educational programs must be made available in my place of employment. Every nurse must be required to attend such educational training program. Once all the nursing staff are thoroughly educated and properly equipped with the knowledge of the recommended practice regarding tracheostomy care, their performance has to be monitored every now and then. They will be assessed on how they perform such care and evaluated if there is a change on how they perform it. It is not enough that after the initial educating sessions they will then be left to do the procedure. Monitoring has to be done in order to ensure that there is a demonstration of safe and proper practice of tracheostomy care.
As I have already presented in my analysis, there is an all-out support for this endeavor on the part of healthcare authorities and staff. That in itself would help make this project a success. Since they support the project of decreasing the incidence of chest infection, it follows that they would also support this plan of educating the nurses on how to properly perform tracheostomy care. We have already established that this is a major factor in client’s developing chest infection.
I propose a one month time frame for properly educating the nursing staff on tracheostomy care. Granting that we have the nurses have their hearts in the education process, they will easily learn the recommended practice for tracheostomy care.
The period of monitoring would be the longer period in my recommended strategy. I propose a six-month to one year monitoring period. This would include assessing how each nurse performs the tracheostomy care and also observations on the incidence of client’s admission to intensive care unit because of chest infections.
To effectively carry out all of these, strategic planning has to be developed. Strategic planning is crucial in the management of healthcare organizations, even when the characteristics of the healthcare systems vary.
Shared governance should be used as the nursing practice model for this. Shared governance is a dynamic process that promotes collaboration, shared decision making, and accountability for practice through workforce empowerment. Although the principles of shared governance are universal, structure and process generally follow the needs of an organization based on its core values, mission, vision, and philosophy.
In moving to a shared governance model in my place of employment, ownership becomes both individual and team ownership because optimal outcomes cannot be achieved without integrated team effort. This transition requires new knowledge and behaviors at each level and results in a paradox as team members have to perform efficiently while practicing new skills that are unfamiliar and uncomfortable.
Nursing leaders are needed to guide the nursing staff in the education or training process. They must be able to translate the demand for change in the particular field of tracheostomy care into a clear, understandable plan, as well as help nursing staff members handle the chaos and uncertainty that accompany the rapid change.
In achieving what is needed to be able to provide quality of care to the clients, the nursing staff should also act as a team. If a nurse learns something that is proven to be beneficial in the client’s care, then it is encouraged that they will share this with the other members of the nursing staff or if applicable, to the whole healthcare profession with the area of employment.
Management also plays an integral part in all of these. The quality of care delivered after the education and monitoring period could be measured using QALY. Evaluations can be done after the proposed strategies have been implemented.
The expected outcome of my recommendations should be a decrease in the incidence of tracheostomy clients developing chest infections. As I have already pointed out in the first few paragraphs of this paper, the reason why there is an increase in the incidence of clients developing chest infections is because of improper tracheostomy management on the part of the nurses. Therefore, my recommendations are also aimed at the nursing staff.
CONCLUSION
In my place of employment, there is a growing problem regarding the development of infection in tracheostomy patients. It has been found out that the reason for this is the apparent lack of knowledge of the majority of our nursing staff regarding the recommended and safe practice for tracheostomy care.
As part of the large whole of the healthcare organization, and as nurses who are in the frontline of delivering care to clients, it is our duty and responsibility to provide the best quality of care to our clients. But this has not been the case in my place of employment.
To summarize, I have recommended a training or education program for the nursing staff. This program will educate the nurses on the recommended practice of tracheostomy care. Every procedure that is involved will be taught and the rationale behind the procedure will also be given. After the initial education program, the staff will be periodically monitored. The incidence of chest infection will likewise be monitored and observed if there is a significant decrease since implanting the recommended strategy. Monitoring the implementation of health policy and evaluating the impact of the outcome has to be well developed.
To effectively carry out the recommendations and in the process improve the quality of care in tracheostomy patients, there should be a collaboration and support of healthcare professionals within my place of employment. Strategic planning should also be employed. Change can result if there is unity within the organization.
Credit:ivythesis.typepad.com
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