Basic Tracheostomy, Tracheostomy Care

Tracheostomy Simulation Lab

tracheostomy simulation lab

Each year more and more tracheostomy procedures are performed and in the current setting of Covid-19 we can expect more procedures being performed.  However, clinicians often lack knowledge surrounding the area of tracheostomy in terms of adequate care and safety. Lack of education can result in inadequate care and potentially can lead to a preventable adverse event.  Tracheostomy simulation labs have been show to be effective tools for hands on learning without causing harm to a patient.

 

Patients with tracheostomy can be classified as high risk patients, having a high potential for injury if they do not receive adequate care. Although adverse events are rare, when they do occur they have the potential to lead to significant patient compromise. A study by McGrath (2009) found that 75% of the 453 incidents with tracheostomy were associated with patient harm.

 

Sample Training for a Tracheostomy Simulation Lab

Simulation training for patients with tracheostomy can include tracheostomy care such as cleaning the inner cannula, stoma care, suctioning, cuff inflation/deflation, cuff management, changing a tracheostomy tube and speaking valves.

Emergency situations can also be trained such as airway obstruction or accidental removal of the tracheostomy tube. There can be a displaced tube scenario where the tube is occluded with tape and placed under the chest flap of the manikin. The airway can be partially blocked for a difficult reinsertion. The goal would be for the clinician to recognize that the tube is not in the airway and to critically think.

Sample educational objectives can include checking the respiratory rate, placing a pulse oximeter, providing oxygen to a patient with tracheostomy. The patient with a cuffed tracheostomy tube will mostly breathe through the tracheostomy tube and therefore the oxygen should be placed at the site of the tracheostomy tube. If the patient is in distress, oxygen can be placed on both the tracheostomy site and the upper airway (mouth/nose).

In order to determine competency, a simulation training may utilize pre and post-testing to determine if the training improved retention of key skills. Patients and family members may also benefit from simulation training prior to discharging from the facility.

Types of Tracheostomy Simulation Devices

Simulation training can be accomplished using a partial or full manikin, with anatomically accurate placement of a tracheostomy tube.

pediatric tracheostomy simulation
Kahn, E. et al 2020. https://doi.org/10.15766/mep_2374-8265.10994

There is also computer simulations and virtual reality where learners are immersed in a realistic clinical situation and learners physically interact with the environment as they would in real life. SAVE-ME is a free educational tool to provide virtual patient scenarios with mechanical ventilation. Patient populations include asthma, COPD, acute lung injury, restriction, and pneumonia. https://math.vanderbilt.edu/crookeps/CANVENT/upload.html

ICU Learning is another free resource for mechanical ventilation simulation. https://iculearning.com/

Another means of simulating tracheostomy related information is through providers or employing trained actors to simulate real patients.

Case Scenarios for a Tracheostomy Simulation Lab

Accidental Decannulation:

The following case scenario was presented by Kahn, et al 2020, When in Doubt, Change It out”: A Case-Based Simulation for Pediatric Residents Caring for Hospitalized Tracheostomy-Dependent Children.  

Primary Learning Obectives

  • 1. Identify when the child’s status is deteriorating based on color change, neurological response, coughing, and work of breathing.
  • 2. Demonstrate correct steps to reestablishing patent airway following decannulation.
  • 3. Demonstrate emergency action steps including bag-trach ventilation.

Initial Presentation: “It’s 0300 during your call shift, and you are headed to evaluate a patient with asthma needing spacing of albuterol. While walking down the hallway, you encounter a nurse who stepped into the hallway to call for help. The nurse states she was doing routine vitals check and diaper change when she noticed that the patient looks pale, anxious, and is working harder to breathe.”

Initial vital signs

See Appendix D Case Scenario Visual Cards: vital signs 2.1

HR 170/min

BP 100/60

RR 55/min

Sat 83% on 2LPM

Overall Setting and Appearance

 

See Appendix D Case Scenario Visual Cards: vital signs 2.1

Pale/Dusky

Anxious

Eyes open

Increased WOB

Extremely diminished aeration

Confederates (e.g., standardized participants) and their roles in the room at case start

Facilitator: to guide learner through case stages

Learner(s): 1-3 resident physicians, each taking turns “leading” each scenario while others provided back-up as “helpers” when called upon by lead resident

HPI

 

This is a 10-month-old term infant with subglottic stenosis secondary to traumatic intubation who is now tracheostomy-dependent. He has been in usual state of health, awaiting discharge criteria of educating home providers.

 

Past Medical/Surgical History

Medications

Allergies

Family History

Term, previously healthy, intubated 2 months ago in setting of RSV infection with respiratory failure, critical upper airway

None

None

None

 

 

Instructor Notes – Changes and CASE Branch Points

 

STAGE

VITAL SIGNS 2.1

PHYSICAL EXAM

PARTICIPANTS’ REQUIRED ACTS

NOTES TO OPERATOR

Initial assessment

HR 170/min

BP 100/60

RR 55/min

Sat 83% on 2LPM

Pale/Dusky

Anxious

Eyes open

Increased WOB

Extremely diminished aeration

 

 

Check airway/trach.

0.     Does not perform correctly

1.     Performs correctly with guidance or prompting

2.     Performs correctly without assistance [visualizes trach entering stoma]

 

Child to have decannulated tracheostomy tube with tube stuck under trach ties. Suction available.

 

If resident moves to any other step, prompt: Do you believe the airway is fully intact? And/or Is the tracheostomy tube entering the stoma?

 

STAGE

VITAL SIGNS 2.2

PHYSICAL EXAM

PARTICIPANTS’ REQUIRED ACTS

NOTES TO OPERATOR

Intervention: Replace decannulated trach

HR 175/min

BP 100/60

RR 60/min

Sat 80% on 2LPM

Blue

Anxious

Eyes open

Increased WOB

Extremely diminished aeration

Replaces trach.

0.     Does not perform correctly

1.     Performs correctly with guidance or prompting

2.     Performs correctly without assistance [replaces dislodged trach]

 

Resident recognizes that child is decannulated and replaces trach. Resident moves to using obturator if unable to replace trach.

 

If resident moves to any other step, prompt: Would you like to try re-inserting the displaced tracheostomy tube first?

 

STAGE

VITAL SIGNS 2.2

PHYSICAL EXAM

PARTICIPANTS’ REQUIRED ACTS

NOTES TO OPERATOR

Intervention: Suctioning

HR 175/min

BP 100/60

RR 60/min

Sat 80% on 2LPM

Blue

Anxious

Eyes open

Increased WOB

Extremely diminished aeration

 

 

Resident suctions trach.

0.     Does not perform correctly

1.     Performs correctly with guidance or prompting

2.     Performs correctly without assistance [suctions with sterile technique]

 

Resident recognizes that child’s status is unchanged and suctions trach.

 

If resident moves to any other step, prompt: Would you like to try suctioning before moving on?


STAGE

VITAL SIGNS 2.2

PHYSICAL EXAM

PARTICIPANTS’ REQUIRED ACTS

NOTES TO OPERATOR

Intervention: Change trach

HR 175/min

BP 100/60

RR 60/min

Sat 80% on 2LPM

 

Blue

Anxious

Eyes open

Increased WOB

Extremely diminished aeration

Changes trach.

0.     Does not perform correctly

1.     Performs correctly with guidance or prompting

2.     Performs correctly without assistance [changes to new trach with “helper”]

 

Resident recognizes that child’s status is unchanged and changes trach.

 

If resident moves to any other step or unsure of what to do, prompt: Do you believe the airway is fully intact? And/or Would you like to try changing the tracheostomy tube?

 

STAGE

VITAL SIGNS 2.3

PHYSICAL EXAM

PARTICIPANTS’ REQUIRED ACTS

NOTES TO OPERATOR

Intervention: Bag-trach ventilation

HR 160/min

BP 90/55

RR 50/min

Sat 80% on 2LPM

 

Blue

Anxious

Eyes open

Increased WOB

Somewhat improved aeration but still diminished

Bag-trach ventilation.

0.     Does not perform correctly

1.     Performs correctly with guidance or prompting

2.     Performs correctly without assistance [bags through trach, may ask for advice on PEEP settings]

Resident begins bag-trach ventilation and child begins to recover.

 

If resident moves to any other step or unsure of what to do, prompt: Do you believe the patient is ventilating well? And/or Would you like to try giving a few breaths through the tracheostomy tube?

 

STAGE

VITAL SIGNS 2.4

PHYSICAL EXAM

PARTICIPANTS’ REQUIRED ACTS

NOTES TO OPERATOR

Child recovers

HR 140/min

BP 100/60

RR 40

Sat 97%

Improved color

Improved aeration

Resident can stop bag-trach ventilation and put child back on trach collar set up.

End of simulation, enter debriefing.

 

 

 

 

Summary

Simulation enables healthcare workers to improve their technical skills to provide safe care without harming the patient. Aviation training has been successful in its use of simulation training and is now increasingly being used in healthcare enviroments.

“I hear, and I forget. I see, and I remember. I do, and I understand.”– Confucius

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