Introduction
A tracheostomy is often performed on critically ill patients, those requiring prolonged mechanical ventilation in the intensive care unit (ICU). Bedside tracheostomy is often helpful for avoiding transferring an unstable patient to the OR and/or to help minimize the cost. The aim of this guideline is to standardize and outline the steps necessary to safely perform an open tracheostomy at the bedside in adult ICU patients.
Policy
Blue surgery (trauma and emergency general surgery) may perform open tracheostomy procedures in the intensive care setting with the required staffing, safety procedures and equipment. **Note: The DCN needs 24hrs to make suer the OR tray and DCN are available.
Procedure
1. Staffing for the tracheostomy must include:
a. Attending blue surgery faculty
b. Blue Surgery assistant x2 (fellow, resident, APP): assist procedure-performing provider
c. Trauma Surgical Services Divisional Charge Nurse (DCN): circulating, and cautery safety ** no patient care, this is a safety supervision role**
d. Respiratory Therapist: airway, ventilator management
e. ICU nurse: sedation and patient monitoring only
*Procedures must include all required staffing in order to proceed. If the DCN is unable to be pulled from staffing, the case cannot proceed.
2. Equipment and supplies required: (equipment, trays, consumable supplies)
a. Equipment includes:
i. Electrosurgical unit (ESU)
ii. Headlights
iii. Mayo stand/bedside table x 2
iv. Suction w/ suction tubing
v. Tracheostomy tray (resident/fellow/APP/DCN to obtain tray from Central Sterile (CS) department)
b. Supplies (Appendix 1)
3. Confirm the presence of a completed consent prior to the procedure. Inpatient consents must be done within 48 hours. Refer to policy #A06-000, Consent to Treatment.
4. All sharps and x-ray detectable sponges shall be counted prior to the procedure and upon skin closure in a consistent and visual manner. The DCN will keep a running total of the counted items on the designated count board or a count sheet. All counts are audibly and visually performed by the DCN and the blue surgery assistant or scrubbed team member. Refer to policy #A08-190, Procedural Counts.
5. Adhere to proper and safe use of the ESU per UK policy, #OR 04-03, Electrosurgery. To include safe use of the active electrode, and dispersive electrode during monopolar electrosurgery, and required Electronic Medical Record (EMR) documentation.
Caution should be used during surgery on the head and neck when using an active electrode in the presence of a combustible anesthetic gas and oxygen-enriched environments such as the ICU. Use the lowest possible concentration of oxygen that provides adequate patient oxygen saturation prior to manipulation of trachea. Note: The respiratory therapist (RT) will pre-oxygenate the patient at 100% FiO2, and sustain the oxygenation at 100% during the dissection. RT will then decrease to 21% FiO2 at the instruction of the provider, if the patient is able to tolerate, once proximity to the trachea is reached. This must happen prior to manipulation of the trachea by tracheal hook, sutures or tracheostomy. # RC08-03 Tracheostomy at beside
6. Follow fire safety measures when electrosurgery is in use according to local, state, and federal regulations, and UK policy #A01-090, Surgical Fire Safety.
a. The DCN conducts a fire prevention assessment in collaboration with the surgical team, communicates results, and initiates the fire risk protocol accordingly (Appendix 2); documents assessment score in the EMR
b. Verify nonflammable materials (wet towel, sterile water, or saline) are available on the field to extinguish a fire should one occur, and monitor that moistened sponges are used near the active electrode tip
c. Use a water-soluble gel to cover the patient’s facial hair and use water-soluble eye lubricants
d. Adhere to fire safety strategies related to skin prep, policy #OR 03-06, Procedural Skin Prep
i. Allow skin antiseptic agents to dry completely before sterile drapes are applied and prior to the use of the ESU
ii. Adhere to manufacturer’s recommendations for dry time of antiseptic agent. Maintain strict adherence to recommended dry time of skin preparation; the DCN to use a timer to measure adequate prep dry time prior to activation of the ESU
7. Refer to policy #OR 10-02, Smoke Evacuation. The thermal destruction of tissues from the ESU creates a smoke byproduct called plume and must be evacuated with proper smoke evacuation equipment.
8. Instrument decontamination/sterilization
a. Reusable trays and instrumentation will be covered and transported to the Central Sterile (CS) department for proper cleaning and sterilization as soon as possible after use, by the DCN.
b. In preparation for transport to the decontamination area, sharp instruments must be segregated from other instruments and confined in a puncture-resistant container; to prevent sharps injury, disposable blades will be used and should be discarded appropriately after sharps counts have been completed at the end of the procedure.
c. Keep instruments moist until cleaned.
d. Soiled instruments are to be transported to OR CS in a closed, leak-proof container, and identified with biohazard label.
9. Training and education requirements
a. The DCN/APP will complete facility-required education and competency verification activities related to electrosurgery and fire safety/fire reduction strategies, initially and annually thereafter.
References
Association of periOperative Registered Nurses (AORN). (2020). Guidelines for electrosurgical safety. In: Guidelines for Perioperative Practice. Denver, CO: AORN, Inc.
Association of periOperative Registered Nurses (AORN). (2020). Guidelines for environment of care. In: Guidelines for Perioperative Practice. Denver, CO: AORN, Inc.
Published 10/21/20 (A Bernard/Sue Taylor/Steph Priest/Henrik Berdel); Reviewed 12-17-23
