Tracheostomy Suctioning Sterile?

Published

I'm a new LPN and I have a question.

I had a patient who was new to the facility. The day shift nurse told me that he needed to be suctioned frequently through his trach. After discussing his care, she informed me that they do not do suctioning as a sterile procedure. When I went into the patient's room, I discovered that she had been using the same catheter for every suction.

I am not comfortable doing this procedure as non sterile. So, I grabbed a kit and suctioned the way I was taught-sterile.

When I contacted the DON, she informed me that it was not to be done as a sterile procedure. Apparently the RT did not do it as sterile, and that is the way we are to do it.

Is this right?

During my time in LTC facilities, I have witnessed the same disposable suction catheter being used for three weeks straight at one particular nursing home. The nursing staff was constantly begging the DON and central supply manager for more trach care supplies, but received responses such as "We'll provide you with stuff tomorrow," or "The supplies are so expensive."

They are expensive when you consider the number used and a LTC facility reimbursement might be fixed. It is not just the LTC facilities that experience the cost. Most hospitals use one type of trach and will not carry the supplies for any other brand. This can get very nasty if the same inner cannula which is meant to be disposable get washed over and over usually with the brush included in a sterile trach care kit that pits or scratches the surface and encourages secretions to cling to the inner cannula. It is also wasteful when some stock many catheters at bedside which much be tossed out when the patient is discharged. The same for all of those "just in case" supplies stored on a dirty suction canister used for an OG/NG tube. thoses also must be thrown away even though the patient never used them and there was no charge initiated to recoup the expense. Some facilities use the red rubber catheters which we keep for some special situations and those can drain a cost center quickly.

Healthcare is like any other business or even like Mom and Dad. As much as you wish you had an infinite amount of money or supplies to give out, it just doesn't work that way. If supplies are a real issue, someone might have to audit the books and cut something else.

Up Vote Up Vote ×
Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma.
It doesn't have to be on a ventilator. It used to make me a little queasy in ICU to go from vent to t-piece and back to vent with the same inline suction catheter also especially since the t-piece was open aerosol. Some ICUs, like mine, no longer change those catheters on a daily bases but as needed or sometimes weekly. This includes all of those circuit disconnects.

Do they have the multiple use catheters for stomas? or perm traches? That what I thought of when the OP asked the question...

Up Vote Up Vote ×
Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma.
During my time in LTC facilities, I have witnessed the same disposable suction catheter being used for three weeks straight at one particular nursing home. The nursing staff was constantly begging the DON and central supply manager for more trach care supplies, but received responses such as "We'll provide you with stuff tomorrow," or "The supplies are so expensive."

Three weeks????:eek::eek::eek: I think even the company says weekly changes....

Up Vote Up Vote ×
Do they have the multiple use catheters for stomas? or perm traches? That what I thought of when the OP asked the question...

Absolutely and that is what we use on the ventilator trach patients in the ICU and stepdown. It is similiar to the one for an ETT but the catheter is shorter but still adapts as a t-piece for off vent weaning or in long term trach faciliites. Some of these facilites that have over 100 trach patients would be crazy, and expensive, if they had to do single use sterile catheters each time especially with the ratio of 1:10 or even 20 trach patients per licensed nurse and no RTs.

For stomas such as for the laryngectomy patients, they prefer the sleeved catheter when they go home if they have to suction at all. Some will keep sterile single use kits around for those suctioning occasions. If the stoma has a regular trach, a t-piece adapter will probably work okay. Some laryngectomy stoma tubes are too short depending on the distance from carina to stoma and will not have a 15 mm adapter to support a t-piece.

http://www.inhealth.com/featuredproductlaryngectomytubes.htm

Up Vote Up Vote ×
Specializes in Vascular Neurology and Neurocritical Care.

Trach suctioning not a sterile procedure!!!!!!!??????????:eek: You want to avoid introducing bacteria into the sterile lower respiratory tract like some of the other posters have said. I was taught in school that it should be a sterile procedure. At my facility, they use the same kit on patients who are on the vent because it has plastic that covers the tubing. The plastic is sterile on the inside and is designed in such a way that it comes into contact with nothing on the outside and when you advance the tube you do it by sliding it along even though it is still inside the plastic lining. Hope that makes sense. You might have to see it to get it, but any how, where I am, it is definite a sterile procedure.

Up Vote Up Vote ×
At my facility, they use the same kit on patients who are on the vent because it has plastic that covers the tubing. The plastic is sterile on the inside and is designed in such a way that it comes into contact with nothing on the outside and when you advance the tube you do it by sliding it along even though it is still inside the plastic lining. Hope that makes sense. You might have to see it to get it, but any how, where I am, it is definite a sterile procedure.

That is the inline suctioning device that I have been discussing. You might want to surf up the CDC sites for the multiple research done on this device over the past 25 years. Change q shift or q week or q month? How clean is it? Sterile after the circuit is broken for bagging, moving or a trip to CT Scan with it left open or "with a glove" on the ICU ventilator? How about when you lay the circuit on the bed with this inline device? However, overall, it was found to offer a decent rating for VAP prevention if some awareness is maintained for how it is handled and along with the other VAP prevention components in place. But, if you go to a long term trach facility you will see dozens of patients with these inline devices open and moved all about as gowns are changed and the patient is wheeled about the patio or shower room.

The inline suction device for ventilators is not different than the multiple use catheter which is used for home care as a trach suction catheter. In fact we use the ventilator inline from ICU to demo to patients and caregivers if we don't have the other one around for their going home introduction.

Up Vote Up Vote ×
Specializes in LTC, ER, ICU, Psych, Med-surg...etc....

As a surveyor, I would expect a sterile procedure. You have residents who are alreday seriously compromised, in a community setting, which increases their risk of acquired infections, especially MRSA, e-coli, pseudomonis, and other things. Most Nursing home trach patients are new trachs which increases the risk even more. Basic nursing procedure calls for a sterile procedure. Medicare plays for one kit a day for ROUTINE care, however if a patient requires more than routine care, the facility can provide substantiating documentation from the physician and they will approve more, however there is paperwork that must be done. In-line suctioning is covered and changed daily and is much more convienent because it is contained within the system.

Up Vote Up Vote ×
As a surveyor, I would expect a sterile procedure.

Does this mean you would cite a hospital or LTC facility for using an inline suction device? These multiple use devices have been used in both LTC and nursing homes for over 25 years. It is also known they are not a sterile device once they have been opened. When the inline device is used on a trach that is not connected to a ventilator, it is an open system with or without an aerosol attached.

Is this for all facilities or which ones do you survey?

Could you please post a link to your site or PM me with this regulation especially where the inline devices must be changed daily?

Up Vote Up Vote ×
Specializes in LTC, ER, ICU, Psych, Med-surg...etc....

I'm sorry... I said that inline suction was convienent and changed daily and was a contained system. I don't understand where a citation came from that. The facilities I see do not use in-line because it is more expensive than the conventional way of using a packaged kit. The conventional way is a sterile procedure and is what is done in places I go. I have never once cited for trach care/suctioning. The nurses I have observed have been extremely competent. The hospitals/LTC that use this system should have a procedure for maintaining its cleanliness when not in use.... it's not like a catheter that's half-coiled and stuck in a piece of a paper wrapper in the top drawer amoungst the hairbrushes, oral swabs, and packets of ky jelly.

Up Vote Up Vote ×
I'm sorry... I said that inline suction was convienent and changed daily and was a contained system. I don't understand where a citation came from that. The facilities I see do not use in-line because it is more expensive than the conventional way of using a packaged kit. The conventional way is a sterile procedure and is what is done in places I go. I have never once cited for trach care/suctioning. The nurses I have observed have been extremely competent. The hospitals/LTC that use this system should have a procedure for maintaining its cleanliness when not in use.... it's not like a catheter that's half-coiled and stuck in a piece of a paper wrapper in the top drawer amoungst the hairbrushes, oral swabs, and packets of ky jelly.

All of the long term care facilities that I am familar with converted to inline suctioning about 15 years ago. At first the surveryors made a big issue out of it and wanted them to change the catheters every shift or q 8 hours. Now that was expensive. But, when you consider the cost of each suction catheter kit to one inline suction device, it is extremely cost effective especially if changed q 72 or longer. Some LTC trach patients can use 16 catheter kits each in 24 hours or more. Even at q2 sx that is 12 catheters. If you have 50 trachs in a LTC facility, that is costly not to mention all the trash created that must also have a cost for disposal even if it is not red bag.

The surveyors also had a problem when the sleeved catheters were used and some would have preferred a "sterile" catheter curled up in a glove.

There are still studies being done especially with the VAP issues and some are still nonbelievers in these devices especially for ICU use and the variations in policies over the years. It is difficult to maintain a totally closed circuit for long term adults and kids who want to be active. Also, these devices are used on patients who just have trachs and no ventilator which makes both the trach and inline "open". Some facilites do have to go through some conflict which is why they usually call a big hospital's Critical Care, RN education and RT departments who taught them about these devices for support. That is why I asked if you had regs or guidelines for inline suctioning devices or if it is just the personal preference of the surveyor.

Up Vote Up Vote ×
Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma.
Absolutely and that is what we use on the ventilator trach patients in the ICU and stepdown. It is similiar to the one for an ETT but the catheter is shorter but still adapts as a t-piece for off vent weaning or in long term trach faciliites. Some of these facilites that have over 100 trach patients would be crazy, and expensive, if they had to do single use sterile catheters each time especially with the ratio of 1:10 or even 20 trach patients per licensed nurse and no RTs.

For stomas such as for the laryngectomy patients, they prefer the sleeved catheter when they go home if they have to suction at all. Some will keep sterile single use kits around for those suctioning occasions. If the stoma has a regular trach, a t-piece adapter will probably work okay. Some laryngectomy stoma tubes are too short depending on the distance from carina to stoma and will not have a 15 mm adapter to support a t-piece.

http://www.inhealth.com/featuredproductlaryngectomytubes.htm

I knew about the in line suction caths for intubated or trached patients.......I didn't know about the stoma patients...thx!!!!

Up Vote Up Vote ×
I knew about the in line suction caths for intubated or trached patients.......I didn't know about the toma patients...thx!!!!

Tracheostoma patients are always a little challenging although you have this big hole looking at you (just like the TV anti-smoking commercial).

For emergencies, you have to be mindful of a Barton-Mayo or Blom-Singer valve (voice prosthesis) in the esophagotracheal fistula. And if there is such a fistula you have to be concerned about passing OG/NG tubes or the trach/ETT (emergent) going astray. The distance from the carina and stoma might be very short so right mainstem is a possibility even with a 6 cm tube. This job usually calls for an adjustable trach. Sometimes a Bivona foam cuff might also be needed to properly seal the fistula to allow ventilation.

Now for a word or two from my favorite anti-smoking "spokesperson" Debi Austin for those who are not familar with a tracheostoma.

Up Vote Up Vote ×
+ Join the Discussion