When a patient is identified as requiring a long-term or permanent tracheostomy, the focus of the discharge planning for the healthcare team will be dominated by the care provision and safety issues surrounding a neck breather. The effectiveness of the planning will ultimately determine the success of the discharge and may be essential in preventing critical incidents or readmission to hospital.

An individual who is reliant on a tracheostomy to breathe may be a challenge to the healthcare team in order to ensure a safe discharge. These patients will be classified as highly vulnerable. The safety of this particular group of patients will be dependent on identifying the individuals particular care needs, effective communication between the hospital team and community, and education and training.

The preparation for a patient to be discharged home with a tracheostomy will need to address physical and psychological responses to this life changing health condition. The tracheostomy may impact on their general health, psychological well being, lifestyle and relationships. These considerations define the complexities associated with long term tracheostomy and will be at the core of the discharge plan.

Why do you need a permanent Tracheostomy?
The indication for the tracheostomy will have a direct influence on the content and emphasis of care and education required following the discharge (Wilson, 1990). As each tracheostomy is different, they will require information on why the tracheostomy is required and the type of tracheostomy the individual has (e.g. cuffed or uncuffed, plain or fenestrated).

The following factors are indications for a long-term or permanent tracheostomy (Scase 1 2004):

• The tracheostomy provides access to mechanical ventilation for respiratory support
• The tracheostomy bypasses a long-term or permanent upper airway obstruction (e.g. congenital abnormalities, tumour, vocal cord palsy)
• The tracheostomy provides access to chest secretions in the event of respiratory insufficiency (i.e. impaired cough reflex/weakened respiratory muscles)
• The tracheostomy protects from aspiration in the event of impaired swallow reflex (e.g. neuromuscular disorders)

Education and Training
Ideally, in order for an individual to be discharged home with their tracheostomy, they should be independent with their care needs. They will be required to perform intricate and complex physical skills to care for their tracheostomy safely and effectively. Tracheostomy care also demands understanding of the management and complications of the tube. Cognitive impairment or any anticipated decline in function would question their ability to self care. A successful lifestyle with a tracheostomy will depend on the individual's aptitude, motivation and attitude towards the tracheostomy in order to manage day to day routine and appropriate response to problems.

An alternative to self-care in the event of not being able to fulfil these criteria will be to identify a key carer who will be responsible for providing the tracheostomy care needs. This individual will need to be capable of providing the physical care needs of the tracheostomy, available to commit to the needs of the particular individual and most importantly, willing to adopt the role. Depending on the level of input the carer will be providing there may be a financial impact to consider. If the patient is to require constant supervision (e.g. they are unable to carry out vital aspects of their care) the carer concerned may have to stop working. Available resources and support in terms of financial assistance and respite care should be investigated.

The individual or carer will be required to carry out all aspects of tracheostomy care competently before discharge home. However, it is unusual for family members to perform skilled clinical care while the individual is still in hospital (Haddad 2001). They will be required to perform routine care, complication management and emergency scenarios.

An ‘Educational Planner’ (Scase 2 2004) provides a useful record of progress in the training programme:

Word Document Version PDF Document Version

Community Team
Hospital based staff will need to ensure the community nurses have a knowledge and skills base to provide routine care needs, for example stoma care and dressings, tape/collar changes. It will be critical to include information to explain why the individual requires the tube and what the function of the tube will be. This will influence the content and emphasis of care and education required following the discharge (Wilson 1990). Does the tube serve as a primary airway for the individual or do they still have a functioning upper airway? This information will be vital in an airway emergency. The community team will also be required to be able to identify complications and be proficient in first line management of the problem. This emphasises the importance of nurses being adequately trained and fully competent in the care of an individual with a tracheostomy (Bunglass 1999)

Following discharge, the community team will be responsible for ordering ongoing supplies and equipment, including tracheostomy tubes for continuing tube changes. To ensure a smooth transition from hospital to home the discharging ward should provide a 7-14 day supply of disposable supplies for the individual to take home.

Follow-up Care
Ongoing care needs should be established to include ongoing tracheostomy reviews and access to support services in the event of complications. What is the prognosis for the individual and what is the management plan?

Arrangements for routine tube changes should be agreed. This provision will be essential in ensuring tube function and avoiding potential infection or tube blockage. Tube changes will be the area which causes the most concern to nurses managing patients with a tracheostomy (Barnett 2005). The history of the patient’s previous tube changes and current clinical needs should be considered to identify the suitability for community based tube changes and the potential risk of the procedure. It may not be appropriate for carers or community nurses to carry this out and arrangements for hospital based tube changes may be required.

References
Barnett M. Tracheostomy management & care. J Community Nursing 2005; 19(1):4-8.
Bunglass E. Tracheostomy care: tracheal suctioning and humidification. British J of Nursing 1999; 8(8): 500-504
Haddad A. Ethics in action. Regist Nurs 2001; 64(7): 21-22
Scase C (1). Longterm tracheostomy and continuing care. In Russell C, Matta B (eds). Tracheostomy A Multiprofessional Handbook. London: Greenwich Medical Media Ltd; 2004; Chapter 16: 285
Scase C (2). Longterm tracheostomy and continuing care. In Russell C, Matta B (eds). Tracheostomy A Multiprofessional Handbook. London: Greenwich Medical Media Ltd; 2004; Chapter 16: 294-295
Wilson EB, Malley N. Discharge planning for the patient with a new tracheostomy. Crit Care Nurs 1990; 10(7): 73-74, 76-79.