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Tracheostomy Care Takes a Team

Nurses' role in helping restore patients' speech

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Too often, tracheostomy patients literally do not have a voice in their own care. But nurses are in a position to help patients discover their voice and to conduct research to strengthen evidence-based practice and improve patient outcomes. 

The Global Tracheostomy Collaborative (GTC, http://www.globaltrach.org/) is a multidisciplinary group of professionals from around the world focused on a single goal: improved quality and safety for tracheostomy patients. In tracheostomy care, each member of the team provides a valuable perspective, because each of us has unique training and expertise. When we come together, we can accomplish great things.

I recently worked with a few advanced practice nursing students after their clinical rotation with me to describe different strategies for restoration of speech in the tracheostomy patient in an article, "Restoring Speech to Tracheostomy Patients," published in Critical Care Nurse. 1

Research into Best Practices
Many of these strategies have safety implications. For example, capping is one simple strategy to allow a patient to speak. Capping forces the patient to breathe around the tracheostomy tube, so that air reaches the vocal cords. But if the tube is too large, the patient will be unable to get enough air to breathe comfortably. And if the tube has a cuff, it can cause too much resistance to breathe comfortably, even when the cuff is completely deflated. Therefore, we recommended that, with two exceptions, cuffed tubes should never be capped.

Tracheostomy care provides a wealth of opportunities for nursing research. Surprisingly, nurses have been doing tracheostomy care the same way for years and years, with little research to support our practice. For example, there has been no best practice identified for cleaning tracheostomy tubes. Instead, we have been relying on manufacturers' recommendations. Other research opportunities include the best method of cleaning the stoma, securing the tracheostomy tube, prevention of pressure ulcers around the stoma, frequency of changing the inner cannula, etc. Tracheostomy care lies in the realm of nursing expertise, and we need research to support our practices.tracheostomy tubing

Patients' Views on Tracheostomy
We recently did a qualitative study on body image in patients with a tracheostomy in which we asked them open-ended questions to identify their concerns about what others might think about their tracheostomy and their feelings during social situations. We found that most patients were not embarrassed nor emotionally uncomfortable and did not avoid social situations. Themes of their responses fell into four categories: patient feelings, patient perception of others' feelings, interaction with others, and social activity. Patients described initial discomfort with social situations, but tended to disregard the (negative) reactions of others over time. Some of their responses include2:

I see people stare at me all the time, I just smile and move on.  I don't let people bother me.

Sometimes I gaze into the dark hole during trach changes I almost feel sick.  I have tried to accept my trach but I hate that I can't swim anymore and I miss how my throat useto look and I hate how it hurts so often and how it gets infected.  I am grateful that having it saves my life but there's a definite cost.

Mostly other people were more uncomfortable and would look away that made me more self-conscious.

Sometimes people would stare at it (the bandage).  I would just smile.  It was my badge of courage along with my surgery scar.

One time while shopping in Sam's Club, I had a little girl and her mother walking towards me in the isle (sic). As the little girl approached me, I seen her starring (sic) at my neck.  I just smile and continued to walk down the aisle.  I heard the little girl ask her mother what was on my neck.  I overheard the little girl's mother tell her daughter that is what happens to people who smoke.  I wasn't embarrassed or uncomfortable.  I have never smoked or drank in my life.  Needless to say I was upset and since I was in uniform, I felt it wise not to express my feelings on the matter.2

Intersection of Specialties
I recently presented at the Third International Tracheostomy Symposium, held at Johns Hopkins in Baltimore. The GTC co-sponsored this event with the Tracheostomy Review and Management Service (TRAMS), Melbourne, Australia. One of my favorite quotes of the 2016 conference was from David Roberson, MD, president and founder of the
GTC, "A tracheostomy is a piece of plastic at the intersection of 10 specialties." 

SEE ALSO: Earn CE: Sedation for an Intubated Patient

Conference attendees included speech-language pathologists, nurses, physiotherapists, respiratory therapists, and physicians and surgeons from a variety of specialties. At the heart of this team are our patients, so there were separate sessions for patients and family members as well.

Since the first planning meeting of the GTC in Scotland, it has been an honor to work with these multidisciplinary professionals to improve quality and safety for tracheostomy patients. Nurses are at the heart of patient safety, and patients look to us for answers and education about important aspects of their care.

The GTC is an opportunity for healthcare professionals to make a difference in tracheostomy patient outcomes. Membership is free for individuals, and hospitals are encouraged to join. Their mission is to partner with hospitals and providers around the world, working together to improve the care, safety, and quality of life of every individual with a tracheostomy or laryngectomy. Hospital members will have access to webinars and evidence-based resources to improve care at your facility. Start the discussion in your organization and change the world.

References

1. Morris L, et al. Restoring speech to tracheostomy patients. Critical Care Nurse 2015, 35(12):13-28.

2. Morris L. et al. Perception of body image after tracheostomy. Crit Care Med, 2013, 41(12) Suppl: 832.

Linda Morris is a tracheostomy specialist/consultant and associate professor of clinical anesthesiology, Feinberg School of Medicine, Northwestern University, Chicago.

 

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