Emergency management of neck stoma patients during the coronavirus pandemic: a national nurse survey.

BACKGROUND: Neck stoma patient care involves significant clinical complexity. Inadequate staff training, equipment provision and infrastructure have all been highlighted as causes for avoidable patient harm. AIMS: To establish the perception of knowledge and confidence levels relating to the emergency management of neck stomas among UK nurses during the COVID-19 pandemic. METHOD: A nationwide prospective electronic survey of both primary and secondary care nurses via the Royal College of Nursing and social media. FINDINGS: 402 responses were collated: 81 primary care and 321 secondary care; the majority (n=130) were band 5. Forty-nine per cent could differentiate between a laryngectomy and a tracheostomy; ENT nurses scored highest (1.56; range 0-2) on knowledge. Fifty-seven per cent could oxygenate a tracheostomy stoma correctly and 54% could oxygenate a laryngectomy stoma correctly. Sixty-five per cent cited inadequate neck stoma training and 91% felt inclusion of neck stoma training was essential within the nursing curriculum. CONCLUSION: Clinical deficiencies of management identified by nurses can be attributed to a lack of confidence secondary to reduced clinical exposure and education.

Manejo fonoaudiológico do paciente traqueostomizado no contexto da Covid-19: uma revisão do conhecimento atual / Speech therapy management of the tracheostomized patient in the context of Covid-19: a review of current knowledge / Manejo fonoaudiológico del paciente traqueostomizado en el contexto del Covid-19: una revisión de los conocimientos actuales

Introdução: O SARS-CoV-2 se estabeleceu como um dos principais agentes etiológicos de instabilidade da função pulmonar e repercussões no trato respiratório. Devido à necessidade de suporte ventilatório prolongado, pode ser observado aumento na demanda da indicação da traqueostomia. Objetivo: verificar as evidências disponíveis sobre o manejo fonoaudiológico da traqueostomia em pacientes com COVID-19, através de uma revisão breve do conhecimento atual. Método: As buscas foram realizadas nas bases de dados do Pubmed, Lilacs, Scielo, Web of Science, Scopus e Google Scholar, no período de agosto de 2020, através dos descritores "tracheostomy and COVID-19", extraídos do Medical Subject Headings (MeSH) e dos Descritores em Ciências da Saúde (DeCS). Resultados: seis estudos foram selecionados, de acordo com os critérios de elegibilidade. O processo de desmame do cuff ou troca da cânula da traqueostomia foi sugerido após resultado negativo para COVID-19. Os estudos sugerem avaliação clínica da deglutição, o uso de cânulas sem fenestra, com cuff insuflado. O uso de equipamentos de proteção individual foi fortemente indicado durante os procedimentos. Não há consenso quanto à intervenção fonoaudiológica para pacientes traqueostomizados com COVID-19. Conclusão: Esta revisão não mostrou evidências científicas sobre o manejo fonoaudiológico da traqueostomia em pacientes com COVID-19.

Introduction: SARS-CoV-2 has established itself as one of the main etiological agents of instability of pulmonary function and repercussions in the respiratory tract. Due to the need for prolonged ventilatory support, an increased demand for tracheostomy indication. Objective: to verify the available evidence on the speech therapy management of tracheostomy in patients with COVID-19, through a brief review of current knowledge. Method: Searches were carried out in the databases of Pubmed, Lilacs, Scielo, Web of Science, Scopus and Google Scholar, in the period of August 2020, using the descriptors "tracheostomy and COVID-19", extracted from the Medical Subject Headings (MeSH) and Health Sciences Descriptors (DeCS). Results: six studies were selected, according to the eligibility criteria. The process of weaning the cuff or changing the tracheostomy cannula was suggested after a negative result for COVID-19. Studies suggest clinical evaluation of swallowing, the use of cannulas without fenestra, with inflated cuff. The use of personal protective equipment was strongly recommended during the procedures. There is no consensus regarding speech therapy for patients with tracheostomy with COVID-19. Conclusion:This review did not show any scientific evidence on the speech therapy management of tracheostomy in patients with COVID-19.

Introducción: El SARS-CoV-2 se ha consolidado como uno de los principales agentes etiológicos de inestabilidad de la función pulmonar y repercusiones en el tracto respiratorio. Debido a la necesidad de soporte ventilatorio prolongado, una mayor demanda de indicación de traqueotomia. Objetivo: verificar la evidencia disponible sobre el manejo logopédico de la traqueotomía en pacientes con COVID-19, a través de una breve revisión de los conocimientos actuales. Método: Se realizaron búsquedas en las bases de datos de Pubmed, Lilacs, Scielo, Web of Science, Scopus y Google Scholar, en el período de agosto de 2020, utilizando los descriptores "traqueotomía y COVID-19", extraídos de Medical Subject Headings ( MeSH) y Descriptores de Ciencias de la Salud (DeCS). Resultados: se seleccionaron seis estudios, según los criterios de elegibilidad. El proceso de destete del manguito o cambio de cánula de traqueotomía se sugirió después de un resultado negativo para COVID-19. Los estudios sugieren una evaluación clínica de la deglución, el uso de cánulas sin fenestra, con manguito inflado. Se recomienda encarecidamente el uso de equipo de protección personal durante los procedimientos. No existe consenso con respecto a la terapia del habla para pacientes con traqueotomía con COVID-19. Conclusión: Esta revisión no mostró evidencia científica sobre el manejo logopédico de la traqueotomía en pacientes con COVID-19.

Evidence-Based Care of Children With Tracheostomies: Hospitalization to Home Care.

ABSTRACT: Routine tracheostomy care in children maintains airway patency, minimizes infection, and ensures skin integrity around the tracheostomy stoma to prevent complications. Using evidence-based recommendations for care of the mature tracheostomy limits variation in practice and leads to better patient outcomes in all care settings. Incorporating evidence-based care into practice is especially important because children with tracheostomies are at high risk for morbidity and mortality. The purpose of this review is to summarize the most current, evidence-based literature for pediatric tracheostomy care, including stoma care and tracheostomy suctioning. Rehabilitation nurses can then include these best practices when caring for children with tracheostomies and when educating caregivers who provide tracheostomy care to children at home.

Multidisciplinary Tracheostomy Quality Improvement in the COVID-19 Pandemic: Building a Global Learning Community.

OBJECTIVES: To report experience with a global multidisciplinary tracheostomy e-learning initiative. METHODS: An international multidisciplinary panel of experts convened to build a virtual learning community for tracheostomy care, comprising a web-based platform, five distance learning (interactive webinar) sessions, and professional discourse over 12 months. Structured pre- and post-webinar surveys were disseminated to global participants including otolaryngologists, intensivists, nurses, allied health professionals, and patients/caregivers. Data were collected on audio-visual fidelity, demographics, and pre- and post-tutorial assessments regarding experience and skill acquisition. Participants reported confidence levels for NICU, pediatric, adult, and family care, as well as technical skills, communication, learning, assessment, and subdomains. RESULTS: Participants from 197 institutions in 22 countries engaged in the virtual education platform, including otolaryngologists, speech pathologists, respiratory therapists, specialist nurses, patients, and caregivers. Significant improvements were reported in communication (P < .0001), clinical assessments (P < .0001), and clinical governance (P < .0001), with positive impact on pediatric decannulation (P = .0008), adult decannulation (P = .04), and quality improvement (P < .0001). Respondents reported enhanced readiness to integrate knowledge into practice. Barriers included time zones, internet bandwidth, and perceived difficulty of direct clinical translation of highly technical skills. Participants rated the implementation highly in terms of length, ability for discussion, satisfaction, applicability to professional practice, and expertise of discussants (median scores: 4, 4, 4, 4 and 5 out of 5). CONCLUSIONS: Virtual learning has dominated the education landscape during COVID-19 pandemic, but few data are available on its effectiveness. This study demonstrated feasibility of virtual learning for disseminating best practices in tracheostomy, engaging a diverse, multidisciplinary audience. Learning of complex technical skills proved a hurdle, however, suggesting need for hands-on experience for technical mastery. While interactive videoconferencing via webinar affords an engaging and scalable strategy for sharing knowledge, further investigation is needed on clinical outcomes to define effective strategies for experiential online learning and virtual in-service simulations.

Identifying Caregiver Needs for Children With a Tracheostomy Living at Home.

This study sought to understand caregiver needs of children with tracheostomies (CWT) living at home and inform development of standardized tracheostomy simulation training curricula. Long-term goals are decreasing hospital readmissions following tracheostomy placement and improving family experiences while implementing a medical home model. We recruited caregivers of CWT and conducted semistructured interviews, subsequently recorded, transcribed, and analyzed for emerging themes using NVivo. Demographic data were collected via quantitative surveys. Twenty-seven caregivers participated. Emerging themes included the following: (1) caregivers felt overwhelmed, sad, frightened when learning need for tracheostomy; (2) training described as adequate, but individualized training desired; (3) families felt prepared to go home, but transition was difficult; (4) home nursing care fraught with difficulty and yet essential for families of CWT. Families of CWT have specific needs related to discharge training, resources, support, and home nursing. Provider understanding of caregiver needs is essential for child well-being, patient-/family-centered care, and may improve health outcomes.

The Ventilator-Dependent Child: What Every Home Care Nurse Needs to Know.

As the population of ventilator-dependent children with tracheostomies grows, there are increasing demands to shift the care of technology-dependent children from hospital to home. Home care nurses are an integral part in the continuum of care for these children and their families after hospital discharge. Home care nurses help to facilitate a safe transition from the hospital and allow families and children to thrive in their home and community. The purpose of this article is to describe best practices in caring for children with tracheostomies and invasive home mechanical ventilation. Hypothetical case studies are presented.

Nurse Practitioner-Led Telehealth to Improve Outpatient Pediatric Tracheostomy Management in South Texas.

INTRODUCTION: Pediatric tracheostomy patients are a medically complex population with increased incidence of emergency room use, hospital readmission, tracheostomy-associated complications, and caregiver anxiety, especially within 30 days after discharge. METHOD: The specific aims of this quality improvement initiative include using a nurse-led, interprofessional care team to improve access to care with creation and implementation of a hospital-based discharge protocol and adoption of telehealth follow-up care for newly placed tracheostomy tubes. RESULTS: Telehealth was accessible for patients living more than 150 miles from the primary clinical site. Caregiver knowledge, satisfaction, self-efficacy, and competence in tracheostomy skills increased after protocol implementation. Outcomes included no tracheostomy-associated complications, emergency room visits, or unnecessary hospitalizations. DISCUSSION: Evaluation of this initiative showed promise telehealth was effective in supporting caregivers and refining proficiency caring for tracheostomy-dependent children. This facility's experience with nurse-led telehealth found it to be an accessible, affordable, and valuable health-care service .

Social support of families with tracheostomized children.

OBJECTIVE: To understand the social support of families with tracheostomized children. METHOD: Qualitative study using the Model of Dimensions of Social Support together with the Family System-Illness model as theoretical frameworks, based on the hybrid model of thematic analysis. Nine families with tracheostomized children were interviewed in an outpatient pediatric otorhinolaryngology department of a public hospital in the inner state of São Paulo. RESULTS: The experience of social support to each phase of the family experience was presented in three themes: "Knowing the need for a tracheostomy", "Performing a tracheostomy" and "Living with a tracheostomy". FINAL CONSIDERATIONS: Understanding how the experience of social support occurs can support assessment and intervention strategies, aiming to meet the demands of the family at each phase of its trajectory, collaborating for a continuous and integral nursing care.

Care of the critically ill patient with a tracheostomy.

Tracheostomy insertion and management is increasingly common in critical care units and general wards. Therefore, it is important that nurses are equipped with the appropriate knowledge and skills to meet the individual needs of patients with a tracheostomy safely and competently. This article aims to enhance nurses' understanding of the potential challenges that patients with a tracheostomy may experience, and to guide nurses in providing effective care and support to these patients. It outlines the care that should be provided for patients with a tracheostomy who are critically ill, including methods of humidification and endotracheal suctioning. This article also discusses the effects that a tracheostomy may have on a patient's communication and psychological well-being, and explains the actions that nurses should take in an emergency and if complications occur.

Effect of a game-based virtual reality phone application on tracheostomy care education for nursing students: A randomized controlled trial.

BACKGROUND: A game-based virtual reality phone application is used as a simulation to teach psychomotor skills in nursing education. OBJECTIVE: This study aims at determining the effect of a game-based virtual reality phone application on tracheostomy care education for nursing students. DESIGN: Single-blind randomized controlled trial conducted from March-April 2017. SETTING: Department of Nursing, Faculty of Health Sciences, Central Anatolia of Turkey. PARTICIPANTS: A total of 86 first-year nursing students registered in Fundamentals of Nursing-II were included in this study. The students were divided at random into two groups, control (n = 43) and experimental (n = 43). METHOD: The data were collected with an informative features form, a tracheostomy care knowledge test and skill checklists, and a performance assessment form. The control group commenced the study first so that the students did not affect each other. After the students completed the theoretical class, laboratory class, and small group study, they had their knowledge test and skills evaluation. The application featured tracheostomy care and was designed in support of formal education. It was uploaded to the mobile phones of the experimental group at a different phase of the study from the control group. After the experimental group made use of this application for seven days, their last knowledge test and skills evaluation were conducted. RESULTS: The results of this study determined that the suctioning a tracheostomy tube and peristomal skin care average final test scores of the students in the experiment group were higher than the average scores of the students in the control group; this was statistically significant (p = 0.017, p = 0.003). CONCLUSION: The game-based virtual reality phone application was effective in teaching the skill of suctioning a tracheostomy tube for nursing students in the short term, and it is recommended that this application be used in psychomotor skill training.

Cuidados para a prevenção de complicações em pacientes traqueostomizados / Care for the prevention of complications in tracheostomized patients

Objetivo: analisar as evidências de cuidados para a prevenção de complicações em pacientes traqueostomizados. Método: trata-se de um estudo bibliográfico, tipo revisão integrativa, com análise de artigos publicados entre 2000 a 2017, realizada nas bases de dados MEDLINE, LILACS, CINAHL e BDENF. Compôs-se a amostra por 22 estudos primários nos idiomas inglês, português e espanhol. Realizou-se a avaliação crítica dos estudos por meio do nível de evidência e classificação em relação às temáticas abordadas. Resultados: verificou-se o predomínio de produções internacionais publicadas em idioma inglês e com nível de evidência VII. Identificaram-se os cuidados que envolveram a aspiração da traqueostomia, a umidificação com solução salina, a troca do curativo, a limpeza da pele e do tubo e a educação da equipe de saúde, do paciente e do cuidador. Conclusão: evidenciou-se que fatores relacionados à aspiração endotraqueal, à limpeza do tubo e da pele e à educação em saúde representaram as principais estratégias que minimizam o risco de complicações. Espera-se contribuir para a consolidação da prática baseada em evidências e para o gerenciamento do cuidado com segurança, qualidade e efetividade.(AU)

Boot Camp for Caregivers of Children With Medically Complex Conditions.

BACKGROUND: The safe transition of children with complex medical conditions who are dependent on technology from hospital to home requires that caregivers receive specialized training from qualified health care professionals. Inadequate caregiver training can lead to discharge delays and hospital readmissions, often resulting in caregiver distress. OBJECTIVE: To determine the effectiveness of a structured boot camp-style predischarge training program for caregivers of pediatric patients with complex medical conditions. METHODS: We conducted a quasi-experimental interventional study to compare outcomes before and after implementation of the training program, which involved 34 caregivers. Pre-boot camp data were collected retrospectively from the medical records of 34 control patients. RESULTS: After program implementation, statistically significant decreases were found in mean unit length of stay (92 vs 60 days; P = .02), mean discharge training days (60 vs 16 days; P < .001), and median total parental stress score, expressed as a percentile (49 vs 45; P < .001). More than 90% of caregiver participants were very satisfied with the program. On the basis of minimal length of stay limits, cost savings were estimated at between $53 300 and $69 900 per patient. CONCLUSION: The results of this study indicate that the training program is a valuable tool to track and verify caregiver education, reduce hospital length of stay, increase caregiver satisfaction, decrease caregiver stress, and reduce medical costs.

Score for Predicting Ventilator Weaning Duration in Patients With Tracheostomies.

BACKGROUND: Factors affecting the timing of ventilator liberation among patients requiring prolonged mechanical ventilation (≥21 consecutive days) are poorly understood. After tracheostomy placement, ventilator liberation typically involves daily reductions in ventilator support as patients regain the capacity to breathe independently. OBJECTIVES: To determine the association between ventilator requirements on the day after tracheostomy placement and subsequent weaning duration. METHODS: Retrospective review of medical records of adults with tracheostomies treated at an academic medical center from 2011 to 2015. A new ventilator independence score based on ventilator settings on the day after tracheostomy was developed. Scores range from 0% to 100%; higher scores reflect greater levels of unassisted breathing for a greater proportion of the day. A multi-variable competing-risk survival regression model was used to determine the association between the ventilator independence score and time from tracheostomy placement to ventilator liberation. RESULTS: Of 372 patients, 72% were liberated from mechanical ventilation. The ventilator independence score measured on the day after tracheostomy placement had an area under the receiver operating characteristic curve value of 0.71 (95% CI, 0.65-0.76) for differentiating patients who were liberated within the next 14 days from those who were not. Median time from tracheostomy placement to ventilator liberation was 41 days for patients with a score of 0%, 20 days for scores between 0% and 50%, 15 days for scores between 50% and 75%, and 10 days for scores between 75% and 100%. CONCLUSIONS: A score derived from ventilator settings may help clinicians predict the timing of ventilator liberation in patients requiring prolonged mechanical ventilation.

Principles of suctioning in infants, children and young people.

Suctioning to clear airway secretions is an important part of the nursing care for children with respiratory conditions. While the principles of safe suctioning are known widely, they are not closely adhered to. The adverse effects of suctioning can easily be overlooked to the detriment of the patient. Careful risk assessment and patient observation are needed to ensure that suctioning is performed only when necessary and the risks to the patient are minimised.

Tracheostomy Care Practices in a Simulated Setting: An Exploratory Study.

PURPOSE/AIMS: Many critically ill patients undergo a tracheostomy. Tracheostomy care is performed to maintain the airway and promote stoma skin integrity. Variation in practices may affect outcomes. The study purpose was to describe tracheostomy care practices of caregivers who perform tracheostomy care in critical care settings and compare practices with published recommendations. DESIGN: This is a descriptive, exploratory study of tracheostomy care practices of nurses and respiratory therapists using a simulated setting. METHODS: Staff working in critical care and step-down units were approached to participate in the study. Equipment used for tracheostomy care and the steps performed were observed and video recorded. Observations were compared with recommended practices. Data were analyzed with descriptive statistics. RESULTS: Fifteen registered nurses (75%) and 5 respiratory therapists (25%) participated. Most participants (80%) were female and held a baccalaureate degree; median experience was 5 years. Equipment used and order of steps varied widely. Only 1 individual performed in the order recommended in a commonly used procedure manual. The most common sequence performed was hand hygiene, clean flange, clean stoma, change inner cannula, change ties, and apply dressing. CONCLUSION: Wide variability in equipment and practices emphasizes the need for establishing an evidence-based approach for performing tracheostomy care to prevent complications.

A Quasi-experimental Study to Explore the Effect of Barrier Cream on the Peristomal Skin of Patients With a Tracheostomy.

Peristomal skin problems represent one of the most common complications of a tracheostomy. A quasi-experimental study was conducted among patients ages 18 to 65 years hospitalized in a Turkish university hospital ear-nose-throat clinic between August 15, 2013, and December 15, 2013, to compare the effect of using or not using a barrier cream on the peristomal skin with regard to pH, moisture, temperature, color, odor, turgor, infections, and lesions after tracheostomy surgery. Patients were selected using a purposeful sampling method and included if they had not undergone another operation for a complication (eg, pneumothorax, tube misplacement, hemorrhage) within 24 hours following the tracheostomy operation. In phase 1 of the study, 9 registered nurses were observed 3 times each by the researcher, who completed an observation form. From these observations and related nursing textbooks, the researcher developed a protocol entitled "Nursing Care Steps for Patients with a Tracheostomy." This protocol was followed during phase 2 of the study during which participants were alternately assigned to either the intervention (a barrier cream containing dimethicone, acrylate terpolymer, oils, paraffin, water, dicapryladipate, isopropyl palmitate, and PPG-15 stearyl ether followed by gauze) or control (gauze only) group (n = 30 each) and observed for 7 days. Demographic characteristics were gathered for each patient upon admission to the study. Peristomal skin was assessed in terms of pH, temperature, and moisture (relative humidity [RH]) using a surface pH meter, surface thermometer, and digital skin moisture tester, as well as for lesions, infection, and maceration. Findings were documented on a skin condition assessment form. Twenty-four (24) hours post surgery, the barrier cream plus gauze was applied over peristomal area in the study group and gauze dressing only in the control group. Peristomal skin pH, moisture, and temperature were within the normal range for both groups during all observations throughout the study but closer to normal ranges in the intervention group. Mean peristomal skin pH in the intervention group was significantly higher (5.452 ± 0.043) than in the control group (5.123 ± 0.057; P &.001), mean peristomal skin moisture in the control group (46.90 ± 0.132 RH) was significantly greater than in the intervention group (41.71 ± 0.774 RH; P &.001), and mean peristomal skin temperature in the control group (33.59 ± 1.3˚ C) was significantly higher than in the intervention group (31.64 ± 0.607˚ C; P &.001). In both groups, Staphylococcus epidermidis was the most commonly cultured microorganism, and S aureus was the most cultured pathological microorganism in addition to the normal skin flora. Peristomal skin condition was maintained for both the intervention and control groups. Use of a barrier cream to protect tracheostomy peristomal skin beneath absorbent dressings (eg, gauze) is recommended, but additional short-term and long-term studies are needed.