D/C planning for new trach

kukukajoo, LPN · Apr 16, 2007

i think discharge instructions for care would be really necessary. good for you for taking the initiative to find out about this. i used to do peds home health coordinating and i have to say that the hospitals would not discharge without home care in place for teaching and training.

http://www.headandneckcancer.org/patienteducation/docs/tracheostomy.php

http://www.tracheostomy.com/care.htm

http://cms.clevelandclinic.org/headandneck/body.cfm?id=159

edgwow · Apr 16, 2007

First, is this peds or adults?

The concern with d/c to home is the reason for the trach

Is it secretion management?

Severe/advanced disease

Are they going to be eligible for a home care, shift nurse 8 hours a day?

If a patient is unable to suction themselves tracheally, does the primary caregiver have a respid provider for themselves? This is a safety issue, I may be the wife of a patient sent home with a trach, but what happens after a few days of vigilantly watching my loved one, how am I supposed to sleep? Will they gag on their own secretions, with the trach they will be unable to summon you for help if you are asleep?

First you will need to set the family up with a respiratory equiptment company that delivers/ services your area, then you should call them to find out what equiptment they will need to meet their needs, O2, suction machines, trach care kits, suction catheters, saline and sterile water bottles, sterile Q tips for doing trach care, guaze spnges for trach care, ambu bag, humidity set up . Have the equiptment company inservice the discharge planning team. Velcro trach ties are used with all types of trach with almost all adults that i have worked with in home care. Some trachs with inner cannulas are cleaned by family, while other trachs do not have an inner cannula.

There are respiratory equpitment companies that cover the cost of the durable medicle supplies such as the suction machine and all above supplies. The suction machine comes with tubing to go from the compressor on the back to the machine and a tubing that the suction catheter gets attached to. In home care we use a portable suction machine that is rinsed after every 16 hours with hot soapy water and then about 15 cc of white vinegar is put at the bottom of the suction canister. The suction tubing is just rinsed with hot water every 16 hours and hung to dry for up to 3 hours. The O2 set up starts with a compressor, depending on the supplier, then there is tubing that can be many feet long for easy mobility around the house. This is arranged through the oxygen supply company. There will usually be a back up oxygen set up in case 1 runs out or there is a loss of power. There are alot of different types of compressors and O2 set ups.

The independent care needs to be evaluated by a written checklist that each part was explained, that the caregiver can verbalize the directions , supervision of skill by nurse with cues, supervision by nurse without cues. We had a protocol that a family was not ready to take a trach patient home, until they have had 10 successful independent sign offs in each area:

1.How to assess obstructed airway

2.What are the steps to follow to remove an obstruction ie: secretions

3.What is done if the patient continues to cough and your measures are ineffective

4. emergency procedures for tracheal suctioning with when is it an emergency? What measures do you take? Ambu bag with adapter, what if the ambu O2 doesn't go in, what next? mucous plug

5.When do you call 911

You usually need a case manger to coordinate the equiptment company with the patient, sometimes the social worker does it.

Research in google scholar, best practice for tracheostomy care for home care/ O2 therapy

Daytonite, BSN, RN · Apr 16, 2007

i've listed some links i have on respiratory and trach teaching materials. tracheostomy.com (aaron's page) is a great resource and is a site set up by the mother of a child who has a trach and wants to share what she learned with the rest of the world. many of the hospitals, particularly pediatric ones, have online patient teaching materials related to trach care. you just have to find them. also, check the patient teaching resources on the patient education resources forum on allnurses: https://allnurses.com/forums/f63/ for possible links that might be of help for you. you should also search the medline plus site as well: http://www.medlineplus.gov/

http://www.thoracic.org/sections/education/patient-education/index.html - gateway to teaching materials presented online by the american thoracic society. here is a listing of links to their patient education materials http://www.thoracic.org/sections/education/patient-education/patient-education-materials/index.html . lot of information on copd, the child with a chronic tracheostomy and information about the icu experience.

http://www.thoracic.org/sections/education/patient-education/patient-education-materials/patient-information-series/oxygen-therapy.html - a 2-page patient information sheet on oxygen therapy for patients. from the american thoracic society patient information series.

http://www.jhhs.org/myjewishhospital/encyclopediahtml/922.html - patient teaching literature on tracheostomy from jewish hospital & st. mary's healthcare in louisville, ky

KellieNurse06 · Apr 16, 2007

Based on my own personal experience with my child.....me & her dad had to learn how to suction, and especially how to change a trach tube, and so forth before discharge was even considered from the hospital. We were taught & observed several times, and when the doctor & his nurse from his office felt we were ok to go , then we got discharged.

Not all people who have trachs have oxygen..I am doing homecare on a patient who doesn't have 02 (not even for emergencies, none in the house at all) but has a trach/vent ...the whole thing.

Also I think mostly it depends on how independant the patient is....peds or adult? Adults will be able to suction themselves or at the least cough good enough to clear their secretions unless they are unable to move their extremities or are really elderly....it really depends on the situation pretty much.

Not all people with trachs get home nursing care, again it depends on the situation, ability of the client & or caregivers etc. And sadly the insurance company (they determine how much supplies the person gets per month etc........and yes also how many nursing hours as well). Everything has a pricetag attached nowadays sadly enough......

IngyRN · Apr 17, 2007

Thanks for all the replies!

I am the case manager- and have ordered the equipment thru a resp company w/assistance from their RT.

However, I keep getting mixed suggestions form other case managers re: sending him home via ambulance ( he lives 40 minutes form hospital) vs pt's family taking him home vs sending him to a nursing home. I was wondering what other facilities do since I cant seem to get a straight answer from my hospital. Do you routinely send them home via ambulance otherwise what setup w/the portable O2 are they sent with?? ( The RT suggested venti mask w/portable O2 tank as it only uses 3l but what about humidification?)

I am so anxious about sending this particular patient home w/trach. He is a 46 yo male w/HIV and laryngeal Ca. His caregiver is his sister in law who is a physical therapist. She is very anxious about suctioning secondary to blood tinged sputum and potentially being exposed. He has done trach care/ suctioning w/RN supervision. (He did well but only did it once). MD is pushing to get him out-tried to expalin pt/family not ready-just got attitude from the MD. Pt is independent w/ambulation/ADL's would not qualify for rehab and understanably so, does not want to got to NH (as suggested by my boss who wants to get him out too)

I have only sent trach pt to rehab/NH in the past. My colleagues either make me feel incompetent for asking for guidance or make it seem like Im worrying too much ( hello this is airway management!!) or suggest to send him via ambulance to cya or NH. Not very helpful I feel at a loss---Thanks for your help!!

kukukajoo, LPN · Apr 17, 2007

I would see if insurance will cover for a aide or nurse to come into the home upon dishcarge. I have never heard of a new trach being sent home with no support- usually we got new trachs and they had good hours approved for teaching and care, etc. If t he docotor orders this, it will be easier to get covered.

IngyRN · Apr 17, 2007

He is set up w/homecare. But as I explained to family, pt/family must be independent w/care as nurse is not readily available in the middle of the noc lets say.

edgwow · Apr 17, 2007

As I posted earlier, concern about the sister in law doing care

24 X7 . Though I dont believe he is ready for D/C yet, when ready, I would be OK sending him home via car if sister in law is sitting in back with him and there is another driver for the car.

Is there any other caregiver that needs to be trained.

Did you check into hospice services for him, his diagnosis probably would qualify him for services?

IngyRN · Apr 17, 2007

Not eligible for hospice as he will still be undergoing chemo next few months.

KellieNurse06 · Apr 23, 2007

They just sound nervous to me....and understandably so. When my daughter 1st got her trach I was scared to death...I literally stood over her for 3 days..only leaving her side to run to the bathroom...this is when she came home. Now I look back.....and can't believe how comfortable I am compared to then.

Most people who are new to trachs are scared because that's an airway (obviously) in an abnormal place,but they don't really realize that it's actually safer because there is the airway right there with easy access.....if they needed help breathing hook up the old ambu bag and you're good to go..it's easier & no trauma versus checking airway,etc etc etc......

Maybe someone can sit down and have a talk with what their fears are etc... I can understand the blood thing but they'd be putting gloves on to suction, correct??? As long as there are no open cuts or anything on their hands I think the chance of contacting anything is next to nothing....

The doctor who is getting mad needs to snap out of it.......he isn't the one who has to be there providing care at home....he gets to go home & leave his work behind......but these people are living it 24/7......some doctors forget this and it's sad.......

Let us know how it goes...I am very interested in how things work out.....