Trach dislodged

AnnieOaklyRN, BSN, RN, EMT-P · Nov 2, 2014

I think you did great!! The patient was deteriorating with his oxygen saturation, you didn't have time to go find the correct size trach. The only other option would have been to insert the old trach that fell out, although I am not sure if it was plugged or not.

I say :cheeky: to the doctor, you didn't have minutes to think about it, you had milliseconds!

HPRN

MunoRN, RN · Nov 2, 2014

The rule with all the trach's I've worked with is that they need to have their trach type and size posted at the head of the bed with an obturator and spare inner cannulas ready to go, a trach box with full supplies also has to be in the room.

Personally I wouldn't have seen a sat that's holding at 83% as being a need for emergently replacing the trach without knowing the size or anything else about the patient, I would have deferred to the patient's primary RN or RT so long as the sat stayed >80%.

What is it that the doctor preferred you would have done instead?

MendedHeart · Nov 2, 2014

Well...place the old one back in or the correct size one however the old one was still inflated and the patients supplies were a mess thrown all over the sink. I just assumed that the correct size was in there and tje patient was hsving a hard time breathing. He was on i think 45% FiO2. I just went with my gut. He is ok npw but the doctor is very not happy

MendedHeart · Nov 2, 2014

Oh btw it was holding there. It went from 85% to 83% in like 30 seconds. The first nurse heard the pulse ox beeping. She went in and came out for help. I then went in and his sats were dropping

Loo17 · Nov 2, 2014

If the trach size had just been downsized that day I am not sure what the problem is if you put in the old size that was still at the bedside. I am sure RT and RN were busy and that is why the bedside supplies were not changed out but that isn't your problem or fault. I would have no problem being confident in telling the doctor that you were not caring for the patient and just happened to be walking by to see the patient deteriorating and did what any good nurse would have done and inserted the spare trach that was at the bedside.

JustBeachyNurse, LPN · Nov 2, 2014

The bigger issue in my opinion is that there was not an emergency trach kit & BVM at the head of the bed. The supplies in a mess by the sink is a disaster waiting to happen.

Could you not look at the dislodged trach to check the size, especially if the supplies were strewn about? What if you grabbed a trach 2 sizes smaller instead of one larger thus reducing the patient's airway size and possibly the stoma size?

I've never seen a trach that does not have the size written on the flange by the manufacturer.

firstinfamily, RN · Nov 2, 2014

You responded appropriately in an emergency situation. It is not your fault the pt did not have the correct trach kit at the bedside. There is most likely a breach in policy here as when the trach was downsized the new size should have been put at the bedside. There will most likely be an "internal investigation". Were you suppose to take the time to find the correct size of trach while the pt continued to desat?? I think not. Plus, if the trach was just downsized it most likely did not really make a huge difference, it may extend the pts stay by one day and that may be an insurance issue, thus why the MD is mad. HE will get over it. Any acute facility I have been always has a correct size trach, obturator, kelly clamps at the bedside, usually at the head of the bed, so it is the break in P & P that may be the concern. Whether the RT or RN were able to change that out or not, you responded to an emergency. Were you to wait any longer the pt may have gone into resp distress and you might have been doing a code. Give yourself a pat on the back and let the MD stew a little. Make sure you have your story straight so that when you are questioned by management you are consistent with your responses. Put your brave face on. You did good!!! The P & P should be clear as to who, RT or RN should put the correct size of trach at the bedside. To me, Resp can take this responsibility, they are the ones who should be monitoring the trach sizes, yes, Nursing is primarily responsible, but so is Resp.

MendedHeart · Nov 2, 2014

Thanks for all the input. Ill update when it comes to a head probably tomorrow mornimg when my boss comes in

icuRNmaggie, BSN, RN · Nov 2, 2014

You should have handed the MD the box for the size he wanted and said do you need anything else.....

JustBeachyNurse, LPN · Nov 2, 2014

If you need to do an incident report or process improvement form be certain to state the correct trach size was not obviously noted, no emergency equipment at the head of the bed. (Current size trach, one size smalle, tape, ties, clamp, obturator, gauze, water based lub in a red kit. BVM extra oxygen tubing, etc)

If my other post came off as accusatory, I apologize. You did the best with what you had in front of you especially not knowing the patient. Somewhere the ball was dropped from no emergency trach kit, a mess of supplies by the sink, no emergency patient information readily available...

GrannyRRT · Nov 2, 2014

If a dirty trach has to be put back into a patient, RT and/or nursing have failed in preparation.

The fact you got a bigger trach back in is lucky and maybe a good thing for the patient. If the other one was covered in mucus or secretions, the patient may not have been ready for downsizing. Or, the doctor may have made a mess of the trach change the day before and was hoping no one would notice hence the blood.

We keep the same size and a size smaller trach at the bedside in a large zip lock bag. We also have a grease pen card for writing pertinent dates and other valuable info like whether it is a tracheostomy_ or otomy_ and if there is a TE_ opening.