Download Clinical Pathway for the Laryngectomy Patient

Clinical Pathway for the Laryngectomy Patient
Anna Choi-Farshi, MS, CCC-SLP
Voice and Speech Laboratory, Massachusetts Eye and Ear Infirmary, Boston, MA
INTRODUCTION
DISCUSSION (cont.)
Pre-operative Clinical Pathway
A clinical pathway is “an optimal sequencing and timing of interventions by physicians,
nurses, and other staff for a
Assessment
and
Evaluation
Diagnostics/
Procedures
particular diagnosis or procedure designed to minimize delays and resource utilization to maximize quality of care” .
Visually through a timeline, it outlines assessments, tests, safety, activity, medications, patient and family teaching, and
Pain Management
Treatments
Diet/
Fluids
Activity/
Safety
Multidisciplinary
Education and
Assessment
discharge planning. Clinical pathways were implemented in the healthcare system in the 1980’s, driven largely by
changes in hospital reimbursement associated with managed care, including minimizing costs, mainly in terms of
reducing length of stay (LOS)1 Trends towards standardization, and a more multidisciplinary model of patient care
supported their use. Laryngectomy clinical pathways (LCP) were developed2,3. This poster will look at a clinical
Teaching (SLP)
pathway for laryngectomy with variances or detours, from the pre-operative assessment to rehabilitation after surgery
 Patients with a TE prosthesis receive training on procedures for prosthesis expulsion, cleaning and check for peri
and intra prosthesis leakage
 Primary TE puncture typically is placed with a 20 French 12 mm sterile indwelling prosthesis (InHealth
Technologies, Carpinteria, CA)10
 Initial use with primary TE prosthesis may occur as early as the 3rd to 4th week post-laryngectomy
 Secondary TE puncture and prosthesis placement may be deferred several weeks, or months pending need for
radiation/chemotherapy and success with oral feeding
Initial Assessment
History and physical examination at the Medical Unit
Insurance authorization
Pre-operative labs
Chest x-ray, CT, MRI, angiography, carotid artery studies
EKGfor cardiac history
Baseline assessment
Determine pre-op AM meds
General nutritional condition
Baseline assessment
Psychosocial assessment by social work
Visit to the inpatient floor and meeting with laryngectomee
volunteer
Assess barriers to new learning
Pre-operative counseling with patient and significant other
Initiate process to obtain electrolarynx
Baseline assessment
Quality of Life (QOL) instrumentation in the LCP
focusing primarily on the speech-language pathologist’s role.
DISCUSSION
Perioperative/Inpatient Clinical Pathway
 Diagnosis and surgery have been established by the head and neck surgeon
 Consists of testing for medical clearance
 Pre-operative speech therapy session focusing on patient education and counseling, informal assessment of
patient’s speech, language, cognition, overall function and help patients to obtain their own electrolarynx
 Social work conducts a psychosocial assessment: review patient resources, strengths, coping skills, and availability
of supports.
 A tour of the adult inpatient unit and meeting with a laryngectomee volunteer are offered.
Variances
• Patient motivation/health status
• Accessibility to the facility (i.e. transportation issues)
 Stay in the intermediate care unit for a typically length of 2 days
 Main concerns: pain management, nutrition, communication, and emotional care5
 On post-operative day 2 or 3 training with the electrolarynx with the intra-oral speaking tube is initiated with
review of education materials.
 Usually patients cannot communicate at the maximum functional level at the time of discharge and continued
speech therapy services are recommended for discharge to home, with a speech pathologist through a home
healthcare, or to a rehabilitation unit
 NPO with enteral feeding through temporary NG, or via primary tracheoesophageal (TE) puncture if done, or
more established PEG
 Patients are generally discharged prior to initiation of an oral diet and greater burden is placed on the patient and
family to continue with tube feedings, along with stoma care, and monitoring of the health of the patient.
Assessment
and
Evaluation
Diagnostics/
Procedures
Pain Management
Treatments
Diet/
Fluids
Operative Day
Pre-operative
assessments
IMCU Day 1
Assess bowel sounds, lung
sounds
Day 2
Evaluate for move to regular
room
Day 3
Day 4
Pre-operative labs
Chem 7
CBC
Utilize pain assessment screen
Medicate based on pain scale
Monitor I & O and daily
weight
Utilize pain scale and assess
effectiveness of pain
medication, q 1-2 hours
Monitor I & O and
daily weight
Assess pain every 2
hours
Laryngeal Stoma care q 1-2
hours with sterile suctioning
Bronchopulmonary hygiene
every 4 hours
Oxygen (cool mist) based on
patient’s
ti t’ oxygen saturation
t ti
levels
DC foley catheter and check
urine output in 6-8 hours
Daily weight
NGT or feeding tube via TE
puncture to gravity q 8 hours
Clamp every 4 hours > 100cc>gravity
Check residuals every 4 hours
>100cc ->gravity
Assist patient OOB to chair x3
Ambulate x2
Physical therapy assessment
Teach oral suctioning
Encourage deep breathing
Social Service educational goal
(sign sheet)
Teach laryngeal stoma care
every 2 hours with sterile
suctioning
Oxygen (cool mist) based on
the patient’s oxygen saturation
l l
levels
Suture line care every 2-4
hours
Daily weight
Monitor I & O and daily
weight
Utilize pain scale and
assess effectiveness of
pain medication, q 1-2
hours
Laryngeal stoma care
every 2 hours with sterile
suctioning
Oxygen (cool mist) based
on the patient’s oxygen
saturation
t ti levels
l l
Perform suture line care
every 2-4 hours
Begin tube feedings using
protocol
Titrate IV fluids
IV to saline lock when
tolerating tube feeding
well
Assist patient OOB to chair x3
Ambulate x2
Receive MD orders for speech
therapy
Review laryngectomy discharge
sheet with patient and /or
significant other
Consult continuing care nurse
Commence electrolarynx
training
Continue review of
laryngectomy discharge sheet
Develop pain
management plan with
MD
Baseline weight
Confirm NPO after
midnight
Start IV
Activity/
Safety
Multidisciplinary
Education and
Assessment
Identify patient and
educate patient on ID
band
Identify and confirm
operative site with
patient
Complete
multidisciplinary
teaching tool
Teaching (SLP)
Discharge Planning
Complete advance
directive
Patient and significant other
watch laryngeal stoma care,
tube feeding and suctioning
video
Return demonstration
Day 5
Educate on use of
portable suction
equipment for home
Monitor I & O and
daily weight
Assess pain every 2
hours
Day 6
Consult MD for barium
swallow date
Day 7
Monitor I & O and daily
weight
Assess pain every 2 hours
Discontinue I & O and
daily weight
Apply wet gauze (BIB)
over stoma all times
Wet gauze (BIB) over
stoma all times
Continue TF
Apply cool mist
oxygen at 33 percent
via collar at night only
Apply wet gauze
(BIB) over stoma
d i the
during
th day
d
Encourage patient to
swallow saliva
Discontinue oral suctioning
Continue TF
Continue TF
Continue TF
Assist patient OOB to
chair x3
Ambulate x2
Reinforce TF teaching
and self-care
Reinforce laryngeal stoma
teaching and self-care
Self-activity
Self-activity
Self-activity
Self-activity
Continue doing own tube
feeding up to daily
recommendation
Continue doing own tube
feeding up to daily
recommendation
Continue electrolaryx
training
Continue review of
laryngectomy discharge
sheet
Continue
electrolaryx training
Document discharge
plan and progress
with self care
Confer with
continuing care
nurse
Continue electrolaryx
training
Review all discharge care
instruction with patient
/significant other
Schedule outpatient visit
Apply cool mist
oxygen at 33 percent
to stoma via collar
Perform suture line
care every 4 hours
Continue to
motivate self care
Variances


Medical complications (i.e. myocardial infarction, tachycardia, pneumonia, acute alcohol withdrawal/delirium
tremens, infection, etc.)
Laryngectomy specific variances: pharyngocutaneous fistula requiring surgical repair or hyperbaric oxygen
therapy, wound infection, wound dehiscence, flap failure, peristomal infection, and/or stomal revision
Factors that may impact new learning, like cognition and language deficits
Provide written discharge
sheet
Week 2
Week 3
Week 4-5
Assessment
and
Evaluation
Skin and stoma
assessment
Pain assessment
Weight
Radiographic study to
rule out
pharyngocutaneous
fistula
Skin and stoma
assessment
Pain assessment
Weight
Consult with radiation
oncology if starting
regime
*Clear liquids pending
radiographic study
results
Continued
Upgrade diet based on
patient status
Initiate/continue
electrolarynx teaching
Initiate teaching on
heat moisture
exchange system
Continue
electrolarynx/HME
teaching
Initiate TEP speech
for primary punctures
Diagnostics/
Procedures
 Oral intake typically occurs around 7 days if there is no history of radiation/chemotherapy and 14 day after
salvage laryngectomy, if pharyngocutaneous fistula is ruled out by barium swallow
 Literature varies on of onset of oral intake range from 2 days6 to 5 days7 post-surgery
 Greater severity of dysphagia is associated with pharyngolaryngectomy8 or laryngopharygoesophagectomy9 and
initiation of PO intake may be deferred several weeks after an MBS with a speech pathologist
 Oral intake typically starts with a clear liquid diet and is upgraded in a progressive fashion
 All patients initially cont. electrolarynx training and review tracheostoma care
 Heat moisture exchange (HME) systems depends on peristomal area presentation and plan for
radiation/chemotherapy if necessary
Diet/
Fluids
Multidisciplinary
Education and
Assessment
Teaching (SLP)
Week
5-8
Skin and stoma
assessment
Pain assessment
Weight
Week
8-12
Skin and stoma
assessment
Pain assessment
Weight
Week
12-16
Week
16-20
Taube insufflation test
Secondary TE
puncture
*time varies depending
on radiation therapy
Treatments
Radiation therapy/
chemotherapy
Upgrade diet based on
patient status
Location, size and type of reconstruction based on tumor burden
History of radiation/chemotherapy (dosing, field)
Time elapsed between radiation/chemotherapy and surgery



Difficult to account for all variability in a laryngectomy surgery course
“Cookie cutter” or “checklist” approach to patient care
Unclear whether the LCP can increase patient safety
• LCP may help delivery of care by increasing timeliness of assessment/diagnostics and interventions
best case scenario
scenario” of hospital course and increasing
• is a construct to provide an overview of the “best
awareness and communication between the disciplines
• may be an educational tool within and across disciplines, as well as for patient and family members
• limited in being able to account for all variability generated from staging and spread of the
disease, extent of reconstruction, and prior history of radiation/chemotherapy
• may be reflective of patient selection, the culture within an institution, and surgeon practice patterns
REFERENCES
Post-operative/Outpatient Clinical Pathway
(Post laryngectomy)



CONCLUSION
Continue electrolaryx
training
Complete
Discharge paperwork
Variances

 Definition of QOL as “ a state of well-being which is a composite of two components: 1) the ability to perform
everyday activities which reflect physical, psychological, and social well-being, and 2) patient satisfaction with levels
of functioning and the control of disease and/or treatment-related
treatment related symptoms”
symptoms 11
 May be used as a screening tool to identify problems in speech and swallowing and generate proper referrals to
other disciplines.
 immediately post-surgery to 6-12 months afterwards as they are regaining function during this time
 There are many QOL instruments with items specific to swallowing and speech function in the head and neck
cancer patient12 , like the University of Washington Quality of Life13
 Literature review suggests only the European Organization for Research and Treatment of Cancer head and neck
module14, the University of Michigan Head and Neck Quality-of-Life Questionnaire15, and the Head and Neck
Cancer Inventory16, fulfill the criteria laid out by the Scientific Advisory Committee of the Medical Outcomes
Trust17
Radiation therapy/
chemotherapy
Upgrade diet based on
patient status
Radiation therapy/
chemotherapy
Radiation therapy/
chemotherapy
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
Introduce
tracheostoma valve for
primary TEP
Initiate HME teaching
and TE speech for
secondary TE
punctures if radiated
12.
13.
14.
15.
16.
17.
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