| Long term acute care facilities ( LTAC's) in many | | | | RT's? If RT's are the designated first responders, are |
| ways are like hospitals: they care for critically ill patients | | | | they trained and competent to intubate patients - one |
| who sustain strokes, brain injuries, and other serious | | | | of the most fundamental aspects of airway |
| conditions. Frequently these patients are transferred to | | | | management? |
| LTAC's artificial airways in place, such as an | | | | Intubation is the process of inserting a breathing tube |
| endotracheal (ETT) or, more commonly, a | | | | into a patient's mouth or nose and into their upper |
| tracheostomy tubes. Because these patients are | | | | airway in order to provide oxygen to the lungs. |
| ventilator dependent, artificial airways are their "lifeline" | | | | Surprisingly, some LTAC's do not train their RT's to |
| for supplying oxygen to their vital organs. If artificial | | | | intubate, even when there is no physician-responder |
| airways are dislodged or compromised for any reason, | | | | available on site. |
| brain damage or death can occur within a matter of | | | | LTAC emergency response protocols are even more |
| minutes. | | | | critical when a fresh trach becomes dislodged. The |
| LTAC's must have clear guidelines in place as to how | | | | surgical hole or "stoma" in the trachea created by the |
| staff will respond to airway emergencies. However, in | | | | original tracheostomy surgery will close rapidly if the |
| our experience, some LTAC's give little thought to | | | | tube is dislodged, because the hole has not matured. A |
| preventing airways from being dislodged, while others | | | | serious risk of re-inserting any trach tube is misplacing |
| are unprepared to provide safe emergency airway | | | | it into the tissues surrounding the patient's trachea, |
| management when airways become dislodged. | | | | known as "false passage" placement. This results in |
| PREVENTING DISLODGED AIRWAYS Airways can | | | | forcing oxygen into the patient's face, neck, and chest |
| become dislodged during patient turning or repositioning | | | | instead of the lungs, and is a serious and life |
| when staff causes excessive tension on the airway | | | | threatening complication. |
| tube or the ventilator tubing (which connects the | | | | Because of this risk, some facilities prohibit RT's from |
| airway tube to the ventilator). Surprisingly, some | | | | attempting to place any trach tube into a fresh trachea |
| LTAC's allow nurses' aides to turn artificial airway | | | | hole. Instead, many facilities require that RT's call a |
| patients without supervision of a nurse or respiratory | | | | "Code Blue" and provide oxygen through a bedside |
| therapist (RT). Whether the LTAC has a written policy | | | | oxygen "AMBU" bag rather than attempt an |
| mandating the presence of a nurse or an RT during | | | | emergency trach tube change. |
| patient turns is a crucially important question for | | | | Amazingly, some LTAC's permit RT's to attempt the |
| patients' families to ask LTAC staff. If there is no such | | | | dangerous practice of inserting a new trach tube into a |
| policy, it is a red flag that the LTAC has not adopted a | | | | fresh tracheostomy hole. |
| "prevention first" mentality to patient airway safety. | | | | To summarize, any LTAC accepting patients with |
| Equally important is whether the LTAC has a written | | | | artificial airways should be prepared to answer the |
| policy requiring staff to post signage that a patient's | | | | following questions: |
| tracheostomy is "fresh" or new, commonly defined as | | | | 1. Do you allow nurses aides to turn patients with |
| one that is 7-10 days old. If a fresh trach becomes | | | | airways with no nurse or RT supervision? |
| dislodged, it is a medical emergency requiring | | | | 2. Do you require special signage above patients' beds |
| immediate action to restore an open airway and | | | | warning staff of a fresh or new trach? |
| provide life sustaining oxygen. Some LTAC's have | | | | 3. Do you have a physician on hand at all times to |
| written policies requiring "fresh trach" signage to be | | | | respond to airway emergencies? |
| placed above the patient's bed as an additional | | | | 4. Are your RT's competent to intubate patients |
| warning to staff. Lack of mandatory signage is | | | | who've lost their airway for whatever reason? |
| another red flag that the LTAC does not fully | | | | 5. Do you prohibit your RT's from re-inserting or |
| appreciate the hazards associated with these | | | | replacing a dislodged fresh trach? |
| vulnerable airways. | | | | The more "No" answers you receive, the more you |
| RESPONDING TO AIRWAY EMERGENCIES | | | | should consider whether the LTAC is equipped to |
| "Airway management" is the process of ensuring that | | | | competently handle a broad spectrum of airway |
| a patient has a patent or open airway for life | | | | emergencies. Given that the maximum foreseeable |
| sustaining oxygen. When any airway becomes | | | | harm of a dislodged airway is brain damage or death, |
| dislodged, staff must act immediately to restore or | | | | there is no excuse for an LTAC's systemic lack of |
| open the airway. Obvious questions to ask staff are: | | | | preparedness when it comes to patient airway safety. |
| Who are the first responders to any airway | | | | Their lack of foresight should not expose your loved |
| emergency? Does the LTAC have an in house | | | | one to increased risks while recuperating from a |
| physician to respond to an emergency at all times, or is | | | | serious illness. |
| troubleshooting this emergency delegated to in house | | | | |