Tools and Tips for Training Providers in the Care of Trached and Ventilated Patients at Home.docx

Tools and Tips for Training Providers in the Care of Trached and Ventilated Patients at Home: General Tips Prior to Starting Simulation Scenarios: Encourage learners to communicate and verbalize what they are doing during the sessions. Set expectations (will you be prompting the learner throughout...

Tools and Tips for Training Providers in the Care of Trached and Ventilated Patients at Home: General Tips Prior to Starting Simulation Scenarios: Encourage learners to communicate and verbalize what they are doing during the sessions. Set expectations (will you be prompting the learner throughout the scenario, will there be no prompting/guidance except for during pauses in the scenario or after the scenario is complete).* Initial ABC (Airway, Breathing, Circulation) Assessment: Goal is to prompt learners to complete effective initial assessment of their patient’s airway, breathing, and circulation. Questions to prompt learners in basic assessment of ABCs: Does the patient appear to have a patent airway? What do you notice about the patients breathing? What is your assessment of the patient’s color and pulses? What are the patient’s vital signs? In-depth Airway Assessment: Goal is to prompt learners to complete efficient, effective in-depth assessment of their patient’s airway (including type of airway/trach, positioning/securing of trach, evidence of obstruction of trach, etc.) Questions to prompt learners in an in-depth assessment of the patient’s airway: What type of trach does the patient have? Have you assessed the placement of the trach? Is the trach still secured? Do you have back up traches available? If so where are they and what sizes are they? What is the patient’s respiratory status? Are they in distress? Do you have breath sounds bilaterally? Have you attempted suctioning the trach (with normal saline if ordered)? When you attempted to suction the trach, did the suction catheter advance to expected depth easily? What do the patients secretions look like? Do you have alerts/alarms on your vent? If so, what alerts/alarms? Trach Emergencies: Goal is to prompt learners in their assessment and management of various types of trach-related emergencies (specifically trach occlusion and trach dislodgment). Questions to prompt learners in their assessment and management of a trach dislodgement: If child is in distress, have you attempted to re-insert dislodged trach? Have you attempted to insert a new same sized trach? If having difficulty with inserting the trach, is there a stylet/obturator in the trach? Have you attempted to insert a new downsized trach? Questions to prompt learners in their assessment and management of a trach occlusion: Is there evidence that the trach is obstructed (eg. High pressure alarm on vent, lack of breath sounds on exam, visible secretions in the trach, etc.)? Have you attempted to ventilate the patient using the AMBU bag? Was it difficult to deliver breaths with the AMBU bag? Have you tried suctioning the trach (with normal saline if ordered)? When you attempted to suction the trach, did the suction catheter advance to expected depth easily? Did suctioning result in change of the patient’s clinic status? If you have not had a clinical change after suctioning, have you attempted to exchange the trach with a same-size or a downsized trach? Cardiopulmonary Arrest: Goal is to prompt learners in identification and then immediate management of a patient in cardiopulmonary arrest. Questions to prompt learners in their identification and management of a patient in cardiopulmonary arrest: What is your immediate assessment of the patient’s clinical status (ABCs)? If the patient appears to be in severe distress (including low oxygen saturation, poor color, low heart rate or no pulse), have you called or had someone else call 911? Have you attempted to bag the patient through the trach? Have you attempted an emergency trach exchange? If unable to re-insert trach and trach dislodged, does your patient have a patent upper airway? If so, have you attempted to occlude the stoma and provide breaths with AMBU bag over patients nose and mouth? If your patient does not have a patent upper airway, have you attempted to provide breaths with AMBU bag placed over the patient’s stoma? Did your initial intervention result in improvement? If not, and patient still has ongoing signs of distress (including no improvement in oxygen saturation, no improvement in color, no improvement of heart rate or no pulse), IMMEDIATELY INITIATE CPR with compression-to-ventilation ratio of 30:2! Post-Assessment/Post-Emergency Management: Goal is to prompt learners to take next steps in patient management after assessment of a patient or addressing emergency situation/acute problem. Correct next steps will vary with every different scenario (including but not limited to: calling 911 -if this is needed, should ideally be done early on while simultaneously addressing acute problem; calling home care agency/patient’s physician to alert them of problem; checking if trach is properly secured; reassessment of patient with more in-depth exam; alerting/updating parents of patient on what happened; working to identify cause of decompensation). Questions to prompt learners in their post-assessment/post-emergency management: Have you called 911 (if needed – eg. patient required CPR, patient with ongoing respiratory distress, etc.)? What is your reassessment of the patient’s vitals? What is your exam of the patient now? If your patient’s oxygen saturations improved, but not back at baseline, what additional interventions could you take? Is there a need to use AMBU bag to deliver breaths and restore saturations? Have you re-secured the trach? Have you checked the trach ties? -or- How did you check the trach ties? What was the likely cause of the patient’s decompensation? What are the characteristics of the patient’s secretions? Have you taken steps to intervene if child has thick secretions (eg. Delivering humidified air)? Have you contacted the patient’s doctor? Have you contacted the patient’s parents/family? *All prompting/guiding questions in this document are worded in the present tense as if the trainer is prompting the learner actively during the scenario. All questions could easily be modified to the past tense to be used for prompting or guidance as a part of pauses during a scenario and/or discussion/debrief after a scenario.