Download administrative order - the County of Santa Clara

County of Santa Clara
Emergency Medical Services System
EMS System Policy Change Coversheet
EMS SYSTEM POLICY CHANGE COVERSHEET
Policy # and Title:
Santa Clara County Prehospital Care Policy #700-M05: Stoma and
Tracheostomy – Adult & Pediatric
Date:
April 2, 2015 [Change to be effective May 1, 2015]
Staff Contact:
David Sullivan
Policy Development Unit
[email protected]
Background:
It was determined that current policy was not aligned with current scope of
practice for paramedics and EMTs. Policy initially developed for the Critical
Care Transport by Paramedic program which is no longer utilized in Santa
Clara County.
Policy Summary
and Objectives:
The purpose of this policy change is to align with current scope of practice
referenced in the California Health and Safety Code. The suctioning language
was changed to more closely match prehospital utilization. Grammatical and
formatting issues corrected.
Proposed Changes: The sentence discussing tracheostomy tube replacement has been removed.
The sentence discussing suctioning the bronchus while the patient turns their
head has been removed. The suctioning time frame for an adult was changed
from 10 seconds to a range of 5 to 7 seconds. The word hyperventilate was
changed to ventilate. A note was added to the procedure section discussing
tube depth.
Outstanding
Issues:
All EMS System personnel will require notification of this policy change.
Cost:
No material costs anticipated.
Santa Clara County Emergency Medical Services
Prehospital Care Manual
Page 1 of 1
County of Santa Clara
Emergency Medical Services System
ADMINISTRATIVE ORDER
Number:
20150501-02
Title:
STOMA AND TRACHEOSTOMY CARE – ADULT & PEDIATRIC
Effective:
May 1, 2015
Declaration
The Santa Clara County Emergency Medical Services Agency has determined
that revisions to Santa Clara County Prehospital Care Policy are required.
Consistent with Santa Clara County Prehospital Care Policy 109 – Policy
Development and Implementation; emergency changes and Administrative
Orders may be issued as follows:
Administrative Orders will be issued when emergency changes or immediate
implementation of practices is necessary in order to ensure the protection of the
publics’ health and safety. Issuance of Administrative Orders shall bypass the
normal review process.
Administrative Orders will be executed by the Director, and the Medical Director
in matters of medical control, (if of a clinical nature) or their designee, and such
orders may be made effective immediately.
Administrative Orders will either be formalized into Policy or expire one year after
issuance, unless terminated earlier by the Agency.
Statement of Change
1.
The sentence discussing tracheostomy tube replacement has been
removed.
2.
The sentence discussing suctioning the bronchus while the patient turns
their head has been removed.
3.
The suctioning time frame for an adult was changed from 10 seconds to a
range of 5 to 7 seconds.
4.
The word hyperventilate was changed to ventilate.
5.
A note was added to the procedure section discussing tube depth.
Page 2 of 2
Rationale for Change



The policy is being updated to align with current scope of practice
referenced in the Health and Safety Code.
The suctioning language was changed to more closely match prehospital
utilization.
Grammatical and formatting issues corrected.
Revised Documents

Policy #700-M05 Stoma and Tracheostomy Care – Adult & Pediatric
Questions
Please direct questions to Linda Diaz, Clinical Programs Manager, at
[email protected] or 408.885.4250.
Execution
This Administrative Order is effective as of 0001 hours on May 1, 2015.
County of Santa Clara
Emergency Medical Services System
Policy #700-M05
Stoma and Tracheostomy Care – Adult &
Pediatric
STOMA AND TRACHEOSTOMY CARE – ADULT & PEDIATRIC
Effective
Replaces
Review
May 1, 2015
June 2012
November 2017
Introduction
Due to our aging population, advances in ventilator technology, and the tendency
to treat more medical conditions from home, EMS personnel are increasingly
more likely to encounter patients with stomas or tracheostomies in respiratory
distress.
Temporary or permanent placement of a tracheostomy tube is often necessary to
maintain an open airway. Patients with tracheostomy tubes or stomas should not
be intubated orally. Suctioning of surgical airways is often required to attempt to
clear and maintain an open airway. Administration of inhaled medications will
need to be given via the stomas or tracheostomy tubes.
Suctioning
Equipment:
 Appropriate sized suction catheter (Pediatrics use 8-10 F)
 Suction unit with adjustable suction capacity
 BVM with oxygen supply
 5 cc syringe filled with sterile saline
Contraindications:
 Use of demand valve
Procedure:
 Adjust suction to 120-150 mmHg for adults; decrease suction to 80-100
mmHg for pediatrics.
 Apply sterile gloves
 Flush suction catheter with saline to lubricate tip and establish patency of
suction catheter.
 Remove the T-tube if a tracheostomy patient is on humidified oxygen.
 Ventilate the patient with 100% oxygen several times.
Santa Clara County Emergency Medical Services
Prehospital Care Manual Policy 700-M05
Page 1 of 3






Insert the suction catheter into the stoma or tracheostomy opening with the
suction off (the thumb hole open). The short length of the tracheostomy tube
facilitates suctioning.
Apply suction by occluding the thumb hole while slowly withdrawing the
catheter in a twisting motion. Suction of a tracheostomy tube should take no
longer than 5 to 7 seconds for the adult patient, and 3-4 seconds for the
pediatric patient.
If mucus plugs or thick secretions are present, the instillation of 3-5 cc of
sterile saline may be helpful.
Ventilate with 100% oxygen.
Check breath sounds.
Suctioning can stimulate a cough reflex. Allow the patient to cough. Be
prepared to suction or catch secretions from the tracheal opening. Recheck
breath sounds.
Albuterol Administration
Equipment:
 Albuterol
 Sterile normal saline
 Hand-held nebulizer or other FDA approved drug delivery device
 Oxygen tubing and supply
 Additional reservoir tubing (optional)
Procedure:
 Assure clear airway. Suction if necessary.
 Assemble hand held nebulizer as for patient with intact upper respiratory
tract.
 Attach trach collar to reservoir tubing.
 Connect oxygen delivery tubing to oxygen source at sufficient flow rate to
produce misting.
 Fit trach collar over stoma or tracheostomy tube.
 Instruct patient to breathe slowly and deeply.
 Optional: mouthpiece may be replaced by additional reservoir tubing.
Stoma Intubation
Equipment:
 Appropriate sized cuffed and uncuffed ET tubes
 BVM
 Appropriate sized suction catheters
 Oxygen supply
 Suction equipment with adjustable suction capacity
Santa Clara County Emergency Medical Services
Prehospital Care Manual Policy 700-M05
Page 2 of 3
Contraindication:
 Use of demand valve
Procedure:
 Select the largest ET tube that will fit through the stoma without force. Check
the cuff, unless an uncuffed tube is being used on a pediatric patient.
 Oxygenate with 100% oxygen using a BVM with the face mask fitted over the
stoma. Do NOT use a demand valve.
 Wear sterile gloves. Do not use a stylet. It is not necessary to lubricate the
tube.
 Suction, if necessary.
 Pass the ET tube and inflate the cuff (Note: The provider must be mindful of
the depth of ET Tube placement. Passing the ET tube too deep can result in
mainstem bronchus placement. The pharynx has been bypassed, so the tube
will protrude from the neck several inches.
 Hold the tube in place, watch for chest rise with ventilation.
 Secure the tube and hyperventilate.
 Auscultate the lung fields. Check the neck for subcutaneous emphysema
indicating false passage.
Allow no longer than 30 seconds for the procedure.
The table below contains the required documentation elements for every
patient care record when an Endotrachael Tube is utilized.
 Size of ET tube
 Chest rise with ventilation
 Number of attempts
 Suction required
 Ventilation compliance
 Any complications with intubation
 Capnography used
 ETCO2/Capnography reading
 Equality of lung sounds
 Method for securing ET tube
Santa Clara County Emergency Medical Services
Prehospital Care Manual Policy 700-M05
Page 3 of 3
County of Santa Clara
Emergency Medical Services System
Policy #700-M05
Stoma and Tracheostomy Care – Adult &
Pediatric
STOMA AND TRACHEOSTOMY CARE – ADULT & PEDIATRIC
Effective
Replaces
Review
May 1, 2015June 2012
June 2012New
November 20174
Introduction
Due to our aging population, advances in ventilator technology, and the tendency
to treat more medical conditions from home, EMS personnel are increasingly
more likely to encounter patients with stomas or tracheostomies in respiratory
distress.
Temporary or permanent placement of a tracheostomy tube is often necessary to
maintain an open airway. Patients with tracheostomy tubes or stomas should not
be intubated orally. Suctioning of surgical airways is often required to attempt to
clear and maintain an open airway. Administration of inhaled medications will
need to be given via the stomas or tracheostomy tubes.
Tracheostomy tube replacement: A dislodged tracheostomy tube should not be
replaced, unless the paramedic has the skill and training to do so.
Suctioning
Equipment:
 Appropriate sized suction catheter (Pediatrics use 8-10 F)
 Suction unit with adjustable suction capacity
 BVM with oxygen supply
 5 cc syringe filled with sterile saline
Contraindications:
 Use of demand valve
Procedure:
 Adjust suction to 120-150 mmHg for adults; decrease suction to 80-100
mmHg for pediatrics.
 Apply sterile gloves
 Flush suction catheter with saline to lubricate tip and establish patency of
suction catheter.
 Remove the T-tube if a tracheostomy patient is on humidified oxygen.
Santa Clara County Emergency Medical Services
Prehospital Care Manual Policy 700-M05
Page 1 of 3







Ventilate the patient with 100% oxygen several times.
Insert the suction catheter into the stoma or tracheostomy opening with the
suction off (the thumb hole open). The short length of the tracheostomy tube
facilitates suctioning. The catheter may be directed through the right or left
bronchus by having the patient turn his/her head to the opposite side.
Apply suction by occluding the thumb hole while slowly withdrawing the
catheter in a twisting motion. Suction of a tracheostomy tube should take no
longer than 10 5 to 7 seconds for the adult patient, and 3-4 seconds for the
pediatric patient.
If mucus plugs or thick secretions are present, the instillation of 3-5 cc of
sterile saline may be helpful.
Hyperventilate Ventilate with 100% oxygen.
Check breath sounds.
Suctioning can stimulate a cough reflex. Allow the patient to cough. Be
prepared to suction or catch secretions from the tracheal opening. Recheck
breath sounds.
Albuterol Administration
Equipment:
 Albuterol
 Sterile normal saline
 Hand-held nebulizer or other FDA approved drug delivery device
 Oxygen tubing and supply
 Additional reservoir tubing (optional)
Procedure:
 Assure clear airway. Suction if necessary.
 Assemble hand held nebulizer as for patient with intact upper respiratory
tract.
 Attach trach collar to reservoir tubing.
 Connect oxygen delivery tubing to oxygen source at sufficient flow rate to
produce misting.
 Fit trach collar over stoma or tracheostomy tube.
 Instruct patient to breathe slowly and deeply.
 Optional: mouthpiece may be replaced by additional reservoir tubing.
Stoma Intubation
Equipment:
 Appropriate sized cuffed and uncuffed ET tubes
 BVM
 Appropriate sized suction catheters
Santa Clara County Emergency Medical Services
Prehospital Care Manual Policy 700-M05
Page 2 of 3


Oxygen supply
Suction equipment with adjustable suction capacity
Contraindication:
 Use of demand valve
Procedure:
 Select the largest ET tube that will fit through the stoma without force. Check
the cuff, unless an uncuffed tube is being used on a pediatric patient.
 Oxygenate with 100% oxygen using a BVM with the face mask fitted over the
stoma. Do NOT use a demand valve.
 Wear sterile gloves. Do not use a stylet. It is not necessary to lubricate the
tube.
 Suction, if necessary.
 Pass the ET tube and inflate the cuff (Note: The provider must be mindful of
the depth of ET Tube placement. Passing the ET tube too deep can result in
mainstem broncusbronchus placement. The pharynx has been bypassed, so
the tube will protrude from the neck several inches.
 Hold the tube in place, watch for chest rise with ventilation.
 Secure the tube and hyperventilate.
 Auscultate the lung fields. Check the neck for subcutaneous emphysema
indicating false passage.
Allow no longer than 30 seconds for the procedure.
The table below contains is the required documentation elements for every
patient care record that when an Endotrachael Tube is utilized.
Documentation Points
 Size of ET tube
 Chest rise with ventilation
 Number of attempts
 Suction required
 Ventilation compliance

Any complications with intubation
procedureAny complications with
intubation
 Capnography used
 ETCO2/Capnography reading
 Equality of lung sounds
 Method for securing ET tube

Santa Clara County Emergency Medical Services
Prehospital Care Manual Policy 700-M05
Page 3 of 3