TRACHEOSTOMY CARE AND FACULTY TEACHING

Literature Review
Simulation and Tracheostomy Care
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Literature Review
Simulation and Tracheostomy Care
Tracheostomy and tracheal suctioning are important and high-risk procedures, which are administered to patients presenting with emergency conditions. However, it is often found that nurses, whether they are experienced or novice, are unable to adhere to evidenced based guidelines for tracheostomy care. Such deviations are due to improper knowledge and also due to overestimation of self-competence of experienced nurses. These patients are not only confined to emergency departments, but tracheostomy care may be needed in general nursing units also (Boye & Morris, 2010). Therefore, all nursing personnel should be educated and trained thoroughly, on the evidenced based guidelines related to tracheostomy care. Since tracheostomy induces high risk in a patient, improper or inefficient care may cause complications and delay prognosis with negative health care outcomes (McGrath et al, 2012). These patients are at increased threat of obstruction in airways, impairment in ventilation and chances of life-threatening infections. Therefore, skilled emergency and bedside nursing is highly desired to avert such complications.

Tracheostomy is a technique whereby an opening is made in the trachea within 2nd and 3rd cartilage rings. Tracheostomy is done for facilitating mechanical ventilation, preventing or draining the trachea-bronchial secretions, during chronic upper airway obstruction and for bypassing acute upper airway obstruction.

Tracheostomy is of two types; temporary and permanent. Temporary tracheostomy is performed in the case of long-term respiration needs due to their inability to maintain the opening of the respiratory tract. When the patient heals from such conditions the tracheostomy tube is removed. On the other hand, permanent tracheostomy is done by bringing the trachea on the surface of the skin and suturing to the wall of the neck. The formation is kept for the rest of the life by rigid tracheal cartilages. The connection between he nasopharynx and the trachea is cut off, for rest of the life in a patient (Chulay, 2010).
The tracheal tube may contain a one or a double lumen and it may or may not be cuffed, or it may be fenestrated or non-fenestrated. Each variation of tracheostomy procedure needs specific skills and training. For example, to administer a fenestrated tracheostomy the inner tube should be plain, otherwise suction catheters may puncture the tube. Therefore, the positioning of the tracheostomy tube is one of the basic training skills that need to be incorporated in staff nurses. Apart from positioning skills suctioning process requires assessment, oxygenation management, and use of appropriate suction pressures. Moreover, skills are required to liquefy the secretions, having adequate knowledge on using the proper-sized catheter and insertion distances, the holistic positioning of the patient during administration of the tracheostomy procedure and finally the evaluation of the patient for their response to the procedure. All such checkpoints should be carefully followed, and therefore, nursing personnel must comply with evidenced based guidelines (Lewis et al, 2010).
Apart from direct interventions, there are certain indirect requirements associated with tracheostomy interventions. These include care of the tracheostomy site and dressing changes. Proper tracheostomy dressing is needed to maintain and promote the normal skin integrity and for preventing infection at the opening of the tracheal tube and associated respiratory tract infections. This is because secretions can cause macerations and infection risk is increased by the loose fibers. Care should be ensured in preventing accidental dislodgement of the tracheal tube (Hamaguchi & Nakajima, 2012). Due to the importance of monitoring and maintenance of tracheostomy care, highly skilled nursing interventions are endorsed by various guidelines. The issue with training and education is the availability of appropriate models, for developing skills on tracheostomy. As the patients who require tracheostomy interventions are serious and under emergency conditions, they cannot be intervened or used for training purposes. Therefore, simulation models are necessitated for education and training purposes in tracheostomy procedure. The competency of nursing personnel has been questioned through various studies (Masoudifar, Aghadavoudi, & Nasrollahi, 2012).
A study was done to assess the efficacy of health care workers administering tracheostomy procedure. The study was also done to evaluate the need for an effective multidisciplinary education program through the use of patient simulation. The study was a prospective randomized observational study which included 87 health-care providers who were responsible for extending and managing tracheostomy services in a tertiary care hospital. Self-assessment questionnaires and objective type multiple questions were implemented on these subjects before and after completion comprehensive educational course on tracheostomy simulation. The assessment outcomes were measured from the pre-course and post-course questionnaire test scores. The measurements were complemented and reassessed through observational data, which were collected during the simulation sessions. Before the educational course on tracheostomy simulation was implemented, the average comfort level of the individuals was of 3.3 on the 5 point Likert Scale. The Likert scale was intervened for assessment across 10 categories related to care of tracheostomy process. After the intervention with the training program the average comfort level on the Likert scale increased to 4.4. The results were statistically significant (p<0.0001). The mean test scores of the subjects improved from 56% to 91% (pre-course versus post-course questionnaire test scores). These results were statistically significant too (p<0.0001). Various deficiencies were noted through the observational studies during the patient simulation procedures. The deficiencies were unfamiliarity of the nursing personnel with different tracheostomy tubes and their appropriate use, the appropriate condition warranting the appropriate tracheostomy procedure, misunderstanding of speaking valve physiology, delayed recognition and management of a plugged or dislodged tracheostomy tube promptly. The study indicated that education and training on tracheostomy is needed across different healthcare personnel belonging to different nursing units. The study further indicated that patient simulation programs significantly improve the skills and competency levels in staff nurses engaged in tracheostomy interventions. Implementation of patient simulation programs are effective in increasing the confidence of care providers, increasing the competence of care providers, increased knowledge, and increased skills associated with tracheostomy interventions (Dorton, Lintzenich, & Evans, 2014)
Another study was done to evaluate the efficacy of an education curriculum on care approaches with tracheostomy. Such a study was done to evaluate the effectiveness of the education program on the comfort level of health care providers in administering tracheostomy. The study was a cross-sectional study that was done in an academic medical institution. Cross-sectional questionnaires (included 25 multiple choice questions having true/false options) were extended to Non-Otolaryngology health care providers. The health care providers included staff nurses and consulting physicians who were routinely engaged in tracheostomy care. After the questionnaires were administered it was followed up with an educational program and the set of questions were repeated. The participants were evaluated for their comfort level in administering tracheostomy care. The comfort levels were measured on a 1-100 point scale. The measurements were done before and after the intervention of the educational module. 94 individuals participated in the educational program. These included fifty physicians, thirty-seven nurses and seven final year medical students. The average numbers of correct answers were increased by 3.1. These results were statistically significant (p<0.0001). Moreover the level of tracheostomy care improved by 18.8 points (p<0.0001). After the 6-month period, there was an increased response to the number of correct answers and increased confidence level, compared to the pre-education levels (p<0.02). However, there was no significant improvement in the in the number of correct answers and the confidence level compared to the post-education scores, after the 6-month evaluation periods. The study indicated the need for a standardized educational model for teaching tracheostomy care. These curriculums based on education and care is highly essential for academic hospital settings where multiple specialties are engaged in tracheostomy interventions (Yelverton & Nguyen, 2014).
In one study, a wearable Tracheostomy Overlay System (TOS) designed by students of engineering and nursing were used for standardized patients. The simulation device was designed to improve the education of health professionals and students who were engaged in learning and intervening tracheostomy procedures. The initial assessment was performed on nursing students (n=57), who were evaluated on tracheostomy care and suctioning procedures. They were evaluated by the traditional teaching method (the mannequin model of teaching) and with the novel TOS system. Self-efficacy scores were collected and the clinical behavior of the nursing personnel were observed and quantified by two skilled and independent observers. The survey results indicated positive clinical interaction with the TOS procedure (19.7 + 8.34 for TOS versus 4.0 + 4.8 for the mannequin, p<0.05). Moreover, self-correction abilities were also higher for the TOS procedure (3.04 + 1.95 for TOS versus 0.43 + 0.73 for mannequin, p<0.05). The study concluded that TOS can act as a suitable simulation procedure, for teaching and developing skills in health providers engaged in tracheostomy procedure (Coperthwait, 2015).
A laboratory simulation model for tracheostomy is discussed below (Goodfellow, & Garret, 2015)
A Simulation Model of Tracheostomy Care
Mannequin observed at the emergency department
Assumed age of Mannequin is 60 years requiring mechanical ventilation
Had a PC tracheostomy performed 6 days before, and has a single lumen cuffed tracheostomy in situ which is unchanged.
The heart rate is 120/min and respiratory rate 45/min with sPO2 levels at 86%.
Training Goal 1: Assessment of patency of tracheostomy
Performing the ABC approach
Potentially patent upper airway, therefore apply upper airway algorithm
Administer 100% oxygen to face through new face mask
Add 100% oxygen to tracheostomy by first of all turning up the FIO2 of the CPAP circuit
Checking for the tracheostomy cuff inflation
Assess the breathing through listening ( set to no breathing in mannequin)
Capnography should be intervened
Checking the patency of tracheostomy with suction catheter ( setting the mannequin in semi-fowlers position )
Suction catheter made unable to pass through
Remove, unblock and replace the inner tube
Tracheostomy tube deflated and again assessed fro breathing (mannequin set to 0 spontaneous breathing).
Condition of patient deteriorates with sPO2 76%, even at 100% oxygen

Training Goal 2: Removing tracheostomy tube and administering oxygenation.
Making the mannequin unable to be ventilated and stop breathing
Removing blocked tracheostomy
Ventilation reassessed through stoma and mouth
Mannequin made to turn bradycardic with cardiac arrest
Engage CPR with adrenaline bolus
Airway addressed, and continue with arrest till tracheostomy tube taken out.
sPO2 of mannequin made to fall at 70%
Perform oral intubation (Mannequin starts to be ventilated) – However, apnea remains to be induced in the mannequin. Need for an uncut tube beyond the stoma SPO2 starts to improve ( make mannequin at SPO2 90%).

Stoma intubation to be attempted with re-insertion of new tracheostomy tube (mannequin made to fail ventilation with oral intubation).
Training goal 3: Stabilization and further management
Sedate and ventilate
Formally redoing the tracheostomy procedure once again
References
Bove MJ, & Morris LL. (2010). Complications and emergency procedures. In: Morris LL,
Afifi MS, eds. Tracheostomies: The Complete Guide. NY: Springer Publishing
Co LLC; 277-302.
Coperthwait, A. (2015). Tracheostomy Overlay System: An Effective Learning Device Using Standardized Patients. Clinical Simulation in Nursing, 11(5), 253–258
Chulay M. (2010). Suctioning: endotracheal or tracheostomy tube. In: Wiegand
DJ, Carlson KK, eds. AACN Procedure Manual for Critical
Care. 6th ed. Philadelphia, PA: Elsevier Saunders; 62-70.
Dorton, L; Lintzenich, C; & Evans, A. (2014). Simulation Model for Tracheotomy Education for Primary Health-Care Providers HYPERLINK “https://www.researchgate.net/journal/0003-4894_The_Annals_of_otology_rhinology_and_laryngology” The Annals of otology, rhinology, and laryngology 123(1),11-8.
Goodfellow, L & Garret, B. AMSN-203: Tracheostomy Care. Centre of Excellence for Simulation Education & Innovation. HYPERLINK “http://www.cesei.org” www.cesei.org. Accessed 27 December 2015.
Hamaguchi S, & Nakajima Y (2012). Two cases of tracheoinnominate artery fistula
following tracheostomy treated successfully by endovascular embolization
of the innominate artery. J Vasc Surg.;55(2),545-547
Lewis SL, Dirksen SR, Heitkemper MM, Bucher L, & Camera I. (2010). Medical-
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McGrath BA, Bates L, Atkinson D, & Moore JA.(2012). Multidisciplinary guidelines
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Masoudifar M, Aghadavoudi O, & Nasrollahi L. (2012).Correlation between timing
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Wiegand DJ, & Carlson KK. (2010). AACN Procedure Manual for Critical
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Yelverton, J & Nguyen, J. (2015). Effectiveness of a Standardized Education Process for Tracheostomy Care. The Laryngoscope, 125, 2.