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Ventilation version 2 current Draft 2010

1. name of nurse or team if its a teams waste date of closure OoO0 0 0 4 This mini bag is then taken back to the teams office base and no where else 5 This small bag is placed directly into the correct coloured clinical waste bag in a room clinical waste bin back or placed into a fresh correctly coloured clinical waste bag tied amp labelled again and placed directly into the correct external clinical waste bin B Large Quantities of bagged clinical waste 1 Where large quantities of bagged clinical wastes are anticipated to be generated in the Community the clinician service will use the appropriately coloured Clinical waste bag Orange or Yellow to collect the bag waste 2 This larger bag will be transport only in the large 22 litre Red Transport rules complaint Bin which has a resealable lid This is expected to become available May 2010 Guidelines for Children in the community requiring Long Term Ventilation BACHS 2010 Page 31 of 58 3 When the service has been completed the bag will be tied and labelled with o Location school hall etc name o name of nurse or team if its a teams waste o date of closure 4 This clinical waste bag is then transported in the Transport Bin back to the teams office base and no where else 5 This bag will then be placed directly into the correct external clinical waste bin Guidelines for Children in the community requiring Long Term Ventilation BACHS 2010 Page 32 of 5
2. 2 Establish whether this is to be done by 1 or 2 people this will e To ensure the safety of the child be dependant on the child s throughout the procedure ability to self ventilate and will be indicated in the child s care plan 3 Wash hands thoroughly in e To minimize the risk of cross accordance with local PCT infection hand hygiene policy 4 Apply alcohol gel to hands leave to dry before touching e To ensure hand are socially clean equipment and reduce risk of infection 5 Ensure all equipment components are available as follows Bacterial filter Circuit Humidifier dome Humidifier e To enable the task to be completed Ventilator and mains lead Exhalation port Heater humidifier wires Oxygen port if required Swivel elbow Water for irrigation Prescribed ventilator settings 6 Explain the procedure to the e To provide reassurance and gain the Guidelines for Children in the community requiring Long Term Ventilation BACHS 2010 Page 9 of 58 child amp family 7 Prior to changing the circuit assess the child to ensure they are adequately ventilated oxygenated by other means e g Self inflating resuscitation bag alternative circuit oxygen mask Thermovent 8 Ensure sufficient monitoring and observation of the child during procedure 9 Switch humidifier and ventilator off beware of the heating element on the humidifier which will be hot and remove circuit to be replace
3. 17 Attach the ventilator to the child and ensure child is comfortable 18 Clean ventilator circuit according to manufactures guidelines 19 Wash hands in accordance with local PCT hand hygiene policy 20 Complete documentation as appropriate To ensure the ventilator is working and pressures are achieved To resume ventilation To enable child to rest and recover from the procedure To ensure circuit is ready for next change To minimize risk of cross infection To ensure continuity of care and ensure events are recorded Page 11 of 58 Guidelines for Children in the community requiring Long Term Ventilation BACHS 2010 12 Assembling a ventilator circuit without a Fisher Paykell Humidification System dry circuit Action 1 Establish the need to change the ventilation circuit once weekly This will be indicated on the child s ventilation checklist 2 Establish whether this is to be done by 1 or 2 people this will be dependant on the child s ability to self ventilate and will be indicated in the child s care plan 3 Wash hands thoroughly in accordance with local PCT hand hygiene policy 4 Ensure all components are available as follows Circuit Ventilator and mains lead Exhalation port Oxygen port if required Swivel elbow Prescribed ventilator settings Heat and moisture exchange filters 5 Explain the procedure to the child amp family 6 Prior to chang
4. Assessment for appropriate Ventilation There are many different types of ventilation available The Paediatric Ventilation Respiratory Consultant and his team which will include the Childrens Long Term Ventilation Nurse Specialist CLTVNS will assess the child s condition and this will dictate the most appropriate form of ventilation The parents carer will be closely involved in discussions around the most appropriate means of ventilation Guidelines for Children in the community requiring Long Term Ventilation BACHS 2010 Page 5 of 58 The most common types of ventilation used in Bradford amp Airedale are face mask ventilation non invasive and tracheostomy ventilation invasive 8 Training amp Supervision 8 1 Roles and responsibilities It is the responsibility of the Service Manager to ensure the operational implementation of this guideline and associated policies and any subsequent amendments made following care planning reviews Service Managers are responsible for ensuring that the guideline is made available to all staff working in childrens community specialist teams and other teams where there is a child with a long term ventilation need and for ensuring their practice complies with this guideline The Team Leader is responsible for highlighting the importance of the guideline to all staff through induction and regular training and for monitoring the implementation of the guidelines All BACHS staff caring for chil
5. Home care e Increased use of NIV through day and overnight Guidelines for Children in the community requiring Long Term Ventilation BACHS 2010 Page 38 of 58 e Increase IPAP as high as will tolerate during day up to max 18 e Increase IPAP at night according to TcCO2 readings up to a max 22 e Inform local specialist nurse hospital Action If no improvement after 24 hrs or further deterioration then needs admission to hospital Make sure the ventilator and humidifier is brought to the ward with you Additional Support in local Hospital kkkkk needs a careful review looking for the symptoms signs listed in his home care plan First Line Management Start IV antibiotics Consider IV fluids and nutrition Urgent chest physio using NIPPV to increase effectiveness CBG and CXR If there is evidence of altered conscious level fatigue fainting sweating shallow breathing development of an O2 requirement during the day or parental concern then move to Second Line Management Second Line Management Increase use of NIV up to 18 hours day Consider increasing IPAP to a maximum of 20 during day and 24 at night increase EPAP to 6 Use additional O2 to maximum of 4 litres via circuit Contact Dr Chetcuti on 0113 3923622 or Sarah Cozens on 0113 3923220 or PICU team on 0113 3927102 to inform them of s condition and discuss further management If no improvement in 24 hrs or criteria for ICU admission are m
6. To resume ventilation To ensure contemporaneous documentation To minimize risk of cross infection To ensure circuit is prepared for next change Page 13 of 58 Guidelines for Children in the community requiring Long Term Ventilation BACHS 2010 13 Cleaning of mask ventilator circuit re useable wet and dry circuits Action 1 Wash hands in accordance with local PCT hand hygiene policy and wear non sterile latex free gloves Remove circuit from ventilator and disconnect from mask and headgear Weekly Wash circuit and mask in hot water and washing up liquid rinse thoroughly with cold water and dry thoroughly with disposable paper kitchen towels and hang to drip dry Daily Empty water out of humidifier dome and leave disconnected from circuit to dry omit for a dry circuit Wipe mask using a wet cloth using washing up liquid in water then wipe again with cloth and plain water Re assemble when dry following standard precautions re strict hand washing Check prescribed settings and switch ventilator on ensure pressures are achieved when the mask is occluded Attach the circuit to the child when needed and ensure they are comfortable Wash hands in accordance with local PCT hand hygiene policy Document completion of the task on the check list Rationale To minimize the risk of cross infection To enable the task to be completed safely To
7. Transition from paediatric to adult services 7 10 Audit 8 11 Assembling a ventilator wet circuit 9 12 Assembling a ventilator dry circuit 12 13 Cleaning a mask ventilator circuit reusable 14 14 Cleaning a tracheostomy ventilator circuit reusable wet amp dry 15 15 Administration of Nebuliser through a ventilator circuit 16 16 Safe use of battery packs 17 17 Safe management of a child during power failure 19 18 Safe management of a child during outings 20 19 Cleaning a Bivona tracheostomy tube 21 20 References 23 Appendix 1 Development of guidelines consultation 25 Guidelines for Children in the community requiring Long Term Ventilation BACHS 2010 Page 2 of 58 Appendix 2 Clinical waste management 27 Appendix 3 Hazardous waste regulations 30 Appendix 4 Procedure for bagged clinical waste in the community 31 Appendix 5 Pictorials of different circuits 33 Appendix 6 Checklist to go on outings 36 Appendix 7 Example of care pathway 38 Appendix 8 Example of care plan 41 Appendix 9 LTHT Ventilation teaching pack 44 Appendix 10 Competencies 52 Appendix 11 Checklist for overnight visits 54 Appendix 12 Equality impact assessment 55 Appendix 13 Procedural document checklist 58 Guidelines for Children in the community requiring Long Term Ventilation BACHS 2010 Page 3 of 58 1 Introduction and Background Long term non invasive ventilation in the commu
8. and are unreachable for the child e Ensure the child s safety by assuring manual respiratory support available or allowing self ventilation as appropriate Guidelines for Children in the community requiring Long Term Ventilation BACHS 2010 Page 37 of 58 NHS Brad tard and Airedale Community Health Services APPENDIX 7 NAME as kkkkkkkkkkkkkkkkkk DOB kkkkkkkkkkkkkkkk N HS No kkkkkkkkkkkkkkkkkkkk Date Example of Care Pathway for Management of Acute Illness Symptoms that should precipitate further treatment at home Chesty cough Temperature Poor disturbed sleep pattern Reduced appetite Feeling non specifically unwell no other identifiable cause Action Commence home care plan as below Initial Home Care Plan e Achieve and maintain apyrexia with paracetamol e Start oral antibiotic treatment e Encourage coughing and deep breathing e Start NIV for short periods 1 2 hours at a time during the day with an IPAP of 14 EPAP of 5 e Monitor Transcutaneous Carbon Dioxide TcCO2 and Oxygen Saturations SaQ2 Action If no improvement within 24 hours or if more worrying symptoms develop step up home care as below More alarming symptoms Difficulty in breathing Increased secretions sputum Difficulty clearing secretions Altered breathing pattern Rapid deterioration Colour change Low O2 Saturation lt 93 Headaches High TcCO2 gt 8 kpa Lethargy drowsiness Difficulty speaking Poor fluid intake Step up
9. battery supply if connected last longer than a few hours acknowledge alarm Nippaed Ventilator will alarm and Change to battery supply until stop working immediately CALL power is restored FOR HELP and manually ventilate wake child up Saturation Monitor will Carry out spot checks on the child automatically switch over to the saturations unless there is internal battery back up approx concern about the child s colour one hour of continuous use or condition Fisher Paykel Humidifier will stop Consider saline nebulisers if working If the power cut lasts prolonged power cut more than an hour consider changing to portable ventilator circuit with green HME in circuit Portable Suction Unit will work on Use intermittently if battery runs internal battery back up approx out use manual hand pump if one hour of continuous suction suction is needed Portable Nebuliser will not work Nebulise 2 3 hourly until power Connect nebuliser to oxygen supply is restored cylinder using green tubing Oxygen concentrator will stop Calculate number of hours supply working switch to cylinders in cylinders to determine when to move the child to hospital see formula in Appendix B 3 If the power is not reconnected e To provide adequate power within 4 6 hours contact the Local Hospital for admission supply to the child s equipment and maintain their safety Guidelines for Children in the community requir
10. keep circuit clean and minimise risk of infection Do not dry with a towel To keep circuit clean and minimize risk of infection To ensure correct assembly of circuit and prevent risk of cross infection To ensure the ventilator is working and pressures are achieved To resume ventilation To ensure contemporaneous record keeping To minimize risk of cross infection To ensure contemporaneous record keeping Guidelines for Children in the community requiring Long Term Ventilation BACHS 2010 Page 14 of 58 14 Cleaning of tracheostomy ventilator circuits re usable wet and dry circuits Action 1 Wash hands in accordance to local PCT hand hygiene policy and wear non sterile latex free gloves Remove the circuit from ventilator once the child s safety has been established as per assembling circuit guideline Discard HMEF dry Bacterial Filter wet Humidifier Dome wet Swivel Elbow both Exhalation Port both Oxygen Port both Disconnect Heater Wires wet Immerse the circuit in hot water and an appropriate cleaning solution mild detergent such as washing up liquid or Kapitex cleaning powder or an acetic acid solution Submerge the circuit in a bowl designated for this purpose ensuring the solution reaches all parts and soak for 20 minutes Rinse thoroughly in cold water Dry thoroughly with disposable paper kitchen towels and ha
11. service waste code date of closure LEGAL PAPERWORK As a Hazardous waste producer when YOUR waste is handed over to a disposer legal paperwork called a Consignment Note must be raised accurately recording YOUR waste types The Consignment Note is supplied by the driver of the collection vehicle and it is signed on your behalf by a competent person this is a named person who has had instruction The Consignment Note is part of the statutory audit trail and what is written on that document must be accurate hence the need for you to segregate accurately and label bags bins accurately so this can be recorded on the Consignment Note You also need to know where the Consignment Notes are filed and who signs it on your behalf WASTE CONTRACTS CHECK ONE EXISTS It is your teams responsibility to ensure a clinical waste collection exists amp the right type of collection contract prior to moving location or setting up a new service You need to check this with the Waste Manager Anthony Jones Douglas Mill A Pre Audit Questionnaire from the Waste Manager must also be completed prior to the relocation new service start to make sure there is a Contract to meet your service needs otherwise your new relocated service may not be able to proceed BASIC OPERATIONAL PROCEDURES o Bins and bags must never be more than full o You must never place liquids bottles of liquids e g urine bottles previously containing drugs anyt
12. support staff to ensure they receive Ongoing training and support on an annual basis as they support children in the community setting who require long term ventilation The CCSST has an in house mandatory training database all support staff have competency booklets and the Clinical Lead will have access to these in order to ascertain who has or has not undergone training and who has up to date competencies The training theory sessions feedback forms will also provide information on the appropriateness of training in an attempt to meet the needs of the team Guidelines for Children in the community requiring Long Term Ventilation BACHS 2010 Page 6 of 58 It is the responsibility of the child s named nurse to ensure that fire safety checks have been completed by the fire brigade and the nurse will inform the relevant utility company The family receive ongoing support and appropriate training post discharge from hospital by appropriate professionals including the CLTVNS and members of the CCSST It is the responsibility of the appropriate hospital professional to ensure parents and family carers have the appropriate training pre discharge to enable the child to be looked after safely at home It is the responsibility of the appropriate professional from the CCSST to ensure parents carers receive appropriate and timely training to ensure they reach the required standard to enable them to care for their child safely at home 9 Transitio
13. 8 Appendix 5 1 Wet Circuit a a HS 2 Wet Circuit with Oxygen 3 Dry Circuit Guidelines for Children in the community requiring Long Term Ventilation BACHS 2010 Page 33 of 58 4 Dry Circuit 5 Dry Circuit with Oxygen Guidelines for Children in the community requiring Long Term Ventilation BACHS 2010 Page 34 of 58 6 Nebuliser a 7 Nippy Junior 3 Battery Guidelines for Children in the community requiring Long Term Ventilation BACHS 2010 Page 35 of 58 NHS Brad tard and Airedale Communtty Health Services APPENDIX 6 CHECKLIST TO GO ON OUTINGS 1 ASSESS THE CHILD AND ENSURE S HE IS FIT TO GO ON AN OUTING Refer to child s individual care plan No restlessness comfortable breathing Normal O2 saturations Minimum O2 requirements All batteries were fully charged 2 PREPARE EQUIPMENT e Emergency bag essential contents to include Tracheostomy tube same size as in situ Tracheostomy tube one size smaller Scissors Trachy tape K Y Jelly These items must be kept with the child at all times Self Inflating Resuscitation Bag Disposable gloves for suctioning Suction catheters Yankeur sucker Normal saline 5 mls syringes 3 CHECK SUCTION UNIT e Ensure the suction unit is fully charged e Check all connections are available to add to suction machine Remember The portable suction units last for only 1 hour when used continuously consider taking manual h
14. ERIALS Ponies ae tor Amalgam waste is hazardous from 8 White mercury amp to a lesser extent from the 18 01 10 Recovery care other constituents e g silver amp tin Guidelines for Children in the community requiring Long Term Ventilation BACHS 2010 Page 30 of 58 Appendix 4 Procedure for the disposal of Bagged Clinical Wastes in the Community Procedure for Labelling Transportation and Disposal A Small Quantities of bagged clinical waste Where small amounts of bagged clinical waste are created in the Community and the quantity is small enough to fit into the currently issued Clinical Waste Transport boxes the following procedure will be followed 1 Use a small strong clear plastic bag as used in the small office or lavatory bins for paper towels or you use the appropriately coloured clinical waste bag but insertion into the Transport Box may be an issue If you do use an orange or yellow clinical waste bag you follow the labelling and disposal procedure for the below B Large Quantities of bagged clinical wastes points 3 to 5 2 This bag must not be overfilled so that it will not fit into the Transport Box Carrying bagged wastes without being contained in a Transport Box is not permitted legally 3 The bag must be tied and labelled true label or permanent marker pen with State waste classification i e orange bag waste or yellow bag waste Location school hall etc name
15. INHS Bradford and Airedale Community Health Services Guidelines for Children in the Community requiring Long Term Ventilation Responsible head of service Simon Long Name of responsible committee Professional Advisory Sub Committee Name of author Erky Radic Clinical Lead Childrens Community Specialist Services BACHS Contact for further details Erceline radic bradford nhs uk Version 2 Supersedes Guidelines Care of a Child Requiring Long Term Ventilation 2006 Date approved October 2010 Review due September 2012 Key words Ventilation children community Document type Guidelines If you are using a printed copy of this document please be aware that it may not be the latest version To view the latest version visit nww bradford nhs uk extranet Policies Pages default aspx NOTE 1 All clinical guidelines remain valid until notification of an amended policy is placed on the intranet Guidelines for Children in the community requiring Long Term Ventilation BACHS 2010 Page 1 of 58 CONTENTS section topic page 1 Introduction 4 2 Key related documents 4 3 Equality and diversity 4 4 Definition of client group 4 5 Definition of long term ventilation 4 6 Indications for long term ventilation 4 f Assessment for long term ventilation 5 8 Training and supervision 6 9
16. a tracheostomy the air given bypasses the upper respiratory tract therefore it is not warmed and humidified This could cause secretions to dry and become sticky and make breathing uncomfortable Therefore all air going to the patient must be humidified either via a humidification unit such as the Fisher Paykel or via a heat and moisture exchange filter HMEF If required Oxygen can be given through any circuit WET CIRCUIT Guidelines for Children in the community requiring Long Term Ventilation BACHS 2010 Page 46 of 58 The fisher paykel uses a bag of sterile water which is warmed by dripping onto a heated plate This then warms and humidifies air flowing to the patient The ventilator circuit used with this system contains a heater wire that keeps the air warm along the circuit A sensor from the humidifier attaches at the patient end of the circuit this reads the temperature that the air is as it reaches the patient and alters the temperature in the humidifier so that the air reaching the patient is at a constant Further explanation of the fisher paykel humidifier can be found in the PICU resource file As the humidifier requires a constant electrical supply this system can only be used whilst the patient is staying still i e either resting in bed or happy to stay within the confines of the ventilator tubing An exhalation port must always be attached close to the tracheostomy Without one the patient cannot breathe out A catheter moun
17. and pump 4 CHECK VENTILATOR BATTERIES e Ensure fully charged charger light is green see MANUFACTURES GUIDELINES AND GUIDELINES FOR CARE OF VENTILATOR BATTERY PACKS e Ensure enough battery life for trip more than one battery may be needed e Ensure mains lead is available should battery fail and mains point is available nearby 5 DOCUMENTS TO PREPARE e Parental consent e Information sheet stating Medical Consultant telephone number Diagnosis and Resus status e Copy of child s individual care plan 6 CHECK OXYGEN REQUIREMENT e A full D size cylinder contains 340 litres e How to work out requirements Litres in cylinder minutes of oxygen available Litres needed per minute e g 340 litres in cylinder __ 170 minutes available 2 hours 50mins 2 litres per minute needed Guidelines for Children in the community requiring Long Term Ventilation BACHS 2010 Page 36 of 58 Remember Check for leaks Take more than the calculated amount as additional supply in case of an emergency half as much again 7 PREPARE VENTILATOR e See GUIDELINES FOR ASSEMBLING A DRY CIRCUIT and GUIDELINES FOR SAFE USE OF BATTERY PACKS AS WELL AS MANUFACTURES GUIDELINES Waste Management e Ensure suction catheters are NOTE e Whilst on an outing be aware of loose connections e REMEMBER you might not hear the alarm going off keep an eye on the child and the ventilator e Secure all lines and tubing to the chair that they cannot get trapped
18. ans of testing To prevent sudden power surges that may cause the fuse to blow To prevent breakage of cables and battery disconnection Do not rely on time left obtain alternative power source immediately and fully charge the used battery to ensure readiness for emergency use To ensure automatic battery supply in power cut Page 17 of 58 Guidelines for Children in the community requiring Long Term Ventilation BACHS 2010 4 Charging It is essential to plug in the charger lead before switching on the mains power supply The indicator will show a YELLOW light when the battery is correctly connected and is being charged The indicator will show a GREEN light when the battery is charged and ready for use leave connected in this state for best results 5 WARNINGS Do not cover the charger when in use may be left in mesh pocket Batteries may produce explosive gases during charging For best results charge batteries at room temperature The charger is designed for indoor use do not expose to rain or damp Check routinely that the power supply lead is in good condition and that the charger is earthed The power supply should be protected by a 3 Amp fuse 6 Connecting the Battery Switch mains off and disconnect the battery from the power supply Connect the round connector to the Aux power input at the back of the Nippy Junior 3 Turn the vent on The Ext Batt
19. aseload promote safe and effective clinical and management practice comply with relevant legislation alerts and directives e are developed in accordance with an agreed process 4 How has the policy been explained to those most likely to be affected Direct responses made to questions raised at consultation Draft clinical guidelines in community requiring Long Term Ventilation v7 BACHS 2010 Page 54 of 58 are user friendly relevant and workable in practice Collecting and collating existing information and data Please indicate in the table below whether the policy strategy procedure or tender has the potential to impact adversely on the equality target groups Equality target group 1 Is the policy likely to havea 2 How have you arrived at the conclusions in box 1 potential differential impact i Who have you consulted appropriate individuals groups with regards to the equality internally and externally target group listed ii What have they said 0 no iii What information data have you interrogated library 1 little search complaints data PALS research reports local 2 medium studies advice from internal and external specialists 3 high iv Where are the gaps in your analysis v How will your paper promote the equality duties if they apply Age Older people 0 This document has been consulted by regional Childrens community Young people teams who
20. at is suitable for supporting their weight If the batteries have not been used for a few days as the child has not been out they should be checked to ensure they are in good working order Ensure no liquids or rain can spill on the battery use protective bags provided at all times A fully charged battery will power the ventilator for approximately 3 4 hours small battery or 6 8 hours large battery depending on the pressures used It is essential to turn off the mains power supply whenever you are attaching or removing the battery from the charger AND OR ventilator Ensure all cables are secured and do not tangle at the side of the chair Low battery power the alarm will sound and Low battery power will be displayed Silence the alarm to acknowledge and there may be up to 20 minutes power left It is good practice to leave the battery connected to the bedside ventilator and charging at all times Rationale e Safety equipment is necessary for possible power failure e To enable task to be completed See picture 8 in Appendix A e Comments Nippy batteries weigh 5kgs so may be used on most standard pushchairs refer to manufacturer Nippy batteries should be checked once a week by running the ventilator on them for 5 mins and observing full battery sign on screen charger must be turned off for this test To avoid a short circuit This time reduces with the battery life and there are no me
21. atteries how many status and charging o Suction charging and working 120mmhg Need to carry out same checks on spare o Pulse oximeter check alarm limits if in use o Emergency bag contents OBSERVATIONS AND MONITORING Every ventilated child should have at least one set of observations carried out each shift Normally this can be performed at the start with the checklist This should include Guidelines for Children in the community requiring Long Term Ventilation BACHS 2010 Page 48 of 58 Pulse Respiratory rate IPAP EPAP Ti Set rate if applicable Humidifier temperature if applicable Sa02 Fi02 Ventilator alarm limits 00000000 0 0 Each time physio or suction is required this will need to be recorded as will whether or not nebulisers or saline are required Temperature is recorded if indicated and monitored depending on the child s health Tidal volume can be recorded but is often inaccurate due to the leakage around the tracheostomy If the child is awake after an initial set of observations continuous monitoring is not normally required However pulse oximetry is advised if the child is ever left alone or while the child is asleep and especially overnight darkened rooms make it difficult to observe colour Frequency of observations and monitoring are fluid and are entirely dependent on the child s health on your shift and on the carers peace of mind and knowledge of that particular child If the ch
22. ctical Assessment Date Signature Practical Assessment Date Signature Practical Assessment Date Signature Practical Assessment Date Signature Practical Assessment Date Signature ATTEND THEORY SESSION DEMONSTARTE KNOWLEDGE OF INFECTION PREVENTION Hand hygiene Standard precautions Personal Protective Equipment DEMONSTRATE HOW TO SWITCH ON AND SET UP VENTILATOR WITH APPROPRIATE CIRCUIT WITH WITHOUT HUMIDITY DEMONSTRATE HOW TO USE VENTILATOR WITH BATTERY PACK DEMONSTRATE KNOWLEDGE OF ALARMS AND TROUBLESHOOTING DEMONSTRATE HOW TO CARRY OUT amp RECORD SAFTEY CHECKS Guidelines for Children in the community requiring Long Term Ventilation BACHS 2010 Page 51 of 58 DEMONSTRATE HOW TO CHECK amp RECORD DOCUMENT SETTINGS DISCUSS WHEN MANUAL VENTILATION MAY BE REQUIRED amp WHAT COMPLICATIONS MAY ARISE Adapted from Cozens S 2006 Ventilation Document Paediatric Intensive Care Unit LTHNHST www longtermventilation nhs uk CHILDRENS COMMUNITY TEAM ER 3 06 PERSON S RESPONSIBLE FOR TRAINING e LEEDS VENTILATION NURSE SPECIALIST e QUALIFIED NURSE WHO HAS UNDERGONE THE APPROPRIATE TRAINING Guidelines for Children in the community requiring Long Term Ventilation BACHS 2010 Page 52 of 58 Appendix 11 CHECKLIST FOR OVERNIGHT VISITS Date Date Date Date Date Date Date Date Da
23. cy equipment staff capacity Evidence Base Have key sources of information been checked Has relevant evidence been appraised and used appropriately Are key sources referenced Equality impact assessment Has the equality impact assessment being completed and attached as an appendix Consultation Has sufficient consultation been undertaken Implementation and monitoring Is it reasonable to expect immediate implementation of this document Are the stated monitoring arrangements reasonable and achievable Development and consultation Is asummary of the document s development and consultation processes attached as the final appendix Were there any particularly contentious issues to be managed during this process If yes how were they resolved or do they remain contentious Further comments This document was checked by document sponsor Name Title Yes No yes yes yes yes yes yes yes yes yes yes no Date Draft clinical guidelines in community requiring Long Term Ventilation v7 BACHS 2010 Page 58 of 58 Comments
24. d 10 Wash hands in accordance with local PCT hand hygiene policy 11 Apply alcohol gel to hands leave to dry before touching equipment 12 Assemble the clean circuit as shown in Pictures 1 and 2 of Appendix A 13 Protect all endings and avoid contamination minimal handling of ends 14 Wipe all equipment with a clean damp cloth amp clean the airway temperature probe in accordance with manufactures guidelines 15 Connect the new system to the ventilator and humidifier Child s cooperation where possible To ensure adequate ventilation oxygenation is maintained throughout the procedure To detect signs of oxygen desaturation and deterioration To prevent burns scalds To prevent burns and scalds To allow clean circuit to be assembled To ensure correct assembly of circuit and prevent risk of cross infection NB ventilator should be higher than humidifier when in use and humidifier lower than child s tracheostomy to prevent water entering either ventilator or tracheostomy To ensure correct assembly of equipment To minimize risk of infection and prevent contamination To minimize risk of infection and prevent contamination Page 10 of 58 Guidelines for Children in the community requiring Long Term Ventilation BACHS 2010 16 Switch humidifier and ventilator on and check prescribed settings ensure pressures are achieved when the swivel Elbow is occluded
25. d e All training must be documented to ensure child s safety e There is no break in contract and therefore they are covered by the Trust s liability insurance policy e To ensure appropriate equipment available for duration of outing see attached checklist for outings and relevant guidelines e To enable emergency care to be administered at all times e To ensure safe transfer of child and to comply with moving and handling requirements e To ensure safety of child and staff Guidelines for Children in the community requiring Long Term Ventilation BACHS 2010 Page 20 of 58 when in vehicle 10 For longer outings such as daytrips and home visits see Checklists for Overnight Visits Appendix C 11 Prepare enough equipment and materials that will ensure the child s safety should significant delays occur during the outing 12 In case of battery failure despite calculations take child off vent and allow to self ventilate or manually ventilate as appropriate 13 Ensure carer has a working mobile phone with them when taking the child out 14 EMERGENCY ACTION Should the emergency occur whilst travelling in a vehicle ask the driver to pull over and to stop the car until the situation has stabilized fa medical emergency arises commence resuscitation measures as necessary and RAISE THE ALARM for assistance DIAL 999 for an ambulance 15 Upon return The child may rest as nece
26. d plays a role in speech Trachea lined with hairs and folds which propel mucus loaded with dust particles and other debris away from the lungs to the throat where it can be swallowed or spat out Bronchi the right and left primary bronchi are formed by the division of the trachea The bottom of the trachea is called the carina The bronchi divide into many branches which take air to different areas in the lung The smallest of these passages are called bronchioles and each one ends at an alveoli Lungs which contain the alveoli The two lungs occupy most of the thoracic chest area The heart lies between them in the mediastinum central area The left lung has two lobes and the right lung three The walls of the thoracic cavity and the surface of each lung has a lining called a pleural membrane These produce a slippery secretion which allows the lungs to glide over the thorax wall during breathing Alveoli every bronchiole ends with an alveoli Each alveoli lies next to a small blood vessel and the walls of both the alveoli and the blood vessel are very thin Oxygen is able to pass across the walls into the blood stream and carbon dioxide is able to pass out of the blood stream into the alveoli where it is breathed out HOW DO WE BREATHE MECHANICS OF BREATHING Inspiration The intercostals muscles between the ribs contract lifting the ribcage up and out The diaphragm contracts pushing down into the abdominal cavity As the
27. d to a chest infection The dates for the due change are indicated on the monthly to do chart It is important to remember that your patient may not be able to breathe by themselves while you change the circuit so they will either have to be manually ventilated bagged or will be attached to a second circuit Depending on the patients stability and the staffs expertise the procedure can require either one or two people See Ventilation Guidelines BATTERIES The batteries will need charging after use Battery life varies however the most commonly used will last either four or eight hours It is important to keep all spare batteries charging to ensure that the patient has as much freedom as possible The battery packs ideally need charging for 16 hours before each use When going out it is worth taking a spare battery in case of delays or malfunction You can take a partially charged battery as back up but bear Guidelines for Children in the community requiring Long Term Ventilation BACHS 2010 Page 47 of 58 in mind you will not know how long it will last Battery status should be checked with every handover or at the start of every shift See Ventilation Guidelines EMERGENCY BAG BOX Every child with a ventilator should have a bag with them at all times containing a complete kit to deal with any respiratory problem This is normally hung over the back of their chair and accompanies them EVERYWHERE The kit should be checked at the s
28. dren requiring long term ventilation must follow these guidelines Nursing Staff including health support workers must report problems or issues to the Team Leader or nurse in charge Out of hours problems should be reported to the on call manager Problems issues should be reported on the incident reporting system PRISM It is the responsibility of the Childrens Community Specialist services Team CCSST to ensure all staff employed by BACHS who support children with requiring long term ventilation will have access to the appropriate training programme with competency based sessions assessment appendix 10 The Clinical Lead will work with the appropriate specialist professional representative who will deliver practical training on a regular basis at least annually via the in house mandatory training sessions and at other times as requested usually every 12 weeks in order to capture as many staff as possible The training programme is reviewed on an annual basis and coordinated by the Clinical Lead for Childrens Community Specialist Services Team CCSST who will also work collaboratively with the CLTVNS Adult Health Leads within BACHS as well as the Acute Trust Paediatric Practice Development Teams The CLTVNS will work collaboratively with parents carers and the CCSST to ensure advice and support is ongoing The registered staff within the CCSST e g Clinical Lead qualified nurses and physiotherapists will work alongside the healthcare
29. e document sponsor prior to submission to the relevant committee for approval Title of Guidelines for Children in the Community requiring Long term ventilation document Professional Advisory Sub committee To be submitted to which committee Yes No Comments 1 Title Is the title clear and unambiguous yes Is it clear whether the document is a guideline policy protocol or care pathway K 2 Introduction Is the purpose of the document clearly yes stated Is sufficient information given to place the yes document in context 3 Scope Is the target population clear and yes unambiguous Have any key limitations of the scope been yes made clear 4 Key roles and responsibilities Are key roles and responsibilities clear and yes unambiguous 5 Format and style Does the document comply with the standard yes format presented in the policy on the development and management of procedural documents Does the document comply with the style yes guide Is the document in plain English yes Are abbreviations appropriate and have they yes been explained Has the document being spell checked yes Has the document been proof read yes Draft clinical guidelines in community requiring Long Term Ventilation v7 BACHS 2010 Page 57 of 58 10 11 Content Does the document present information in a clear and logical manner Are the requirements of the document reasonable and achievable eg training and competen
30. es to support them in their daily care 5 Definition of Long Term Ventilation Any child who when medically stable continued to need a mechanical aid for breathing which may be acknowledged after a failure to wean 3 months after the institution of ventilation Jardine amp Wallis 1998 from the Childrens Long term Ventilation Working party cited in Noyes amp Lewis 2005 6 Indications for Long Term Ventilation The main indications for long term ventilation in children are highlighted below but this is not an exhaustive list Guidelines for Children in the community requiring Long Term Ventilation BACHS 2010 Page 4 of 58 Box Indications for long term ventilation adapted from Samuels 1996 High cervical trauma E Road traffic accident E Birth injury E Non accidental injury Neuromuscular disease E Spinal muscular atrophy Congenital myopathy E Leigh s disease E Duchenne Muscular Dystrophy Congenital Central Hypoventiltion Syndrome CCHS Ondine s Infection E After encephalitis or myelitis Tumour after surgical resection Congenital brain malformation m Arnold Chiari E Vascular malformations Chronic lung disease E Bronchopulmonary dysplasia E Cystic fibrosis Airway obstruction E Congenital malformations Morbid obesity taken from Noyes amp Lewis 2005 From Hospital to Home Guidance on Discharge Management and Community Support for Children using Long Term Ventilation p1 7
31. et then transfer for more intensive management is required Criteria for Admission to PICU HD 1 Evidence of Lethargy altered conscious level Fatigue O2 gt 4 litres min to maintain O2 sats TcCO2 gt 8 kpa on ventilation Altered Blood gases Which fail to respond to treatment locally within 6 hrs 2 Non specific symptoms which fail to respond to treatment within 24 hrs 3 Use of NIV for more than 18 hrs continuously Contact PICU team to arrange transfer to Leeds or other appropriate facility Guidelines for Children in the community requiring Long Term Ventilation BACHS 2010 Page 39 of 58 Reviewed November 2006 Pathway produced with Thanks to Dr AM Childs Consultant Paediatric Neurologist and Lindsey Pallant Senior Physiotherapist Leeds Neuromuscular Team in conjunction with Sarah Cozens Children s LTV Nurse Specialist LGI and Martin Latham Respiratory Nurse Specialist SJUH Guidelines for Children in the community requiring Long Term Ventilation BACHS 2010 Page 40 of 58 NHS Bradford and Airedale Community Health Services Appendix 8 Example of a care plan Children s Community Specialist Services CARE PLAN Name of Child DOB NHS Number Named Nurse Date Period of review Review date Date Aim of Identified care need Signature iieieuianwes requires overnight ventilation via OET to maintain intermittent positive pressure To undertake procedure safely and in accordance with Trust
32. ger Guidelines for Children in the community requiring Long Term Ventilation BACHS 2010 Page 29 of 58 Appendix 3 Hazardous Waste Regulations Quick Reference Segregation Table Code used for waste Dental Contain cae Pas Segregated Material te Anie ranei colour fi 8 Breg segregated Disposal Method or bin waste Orange Low Infectious and potentially infectious 180103 Alternative treatment Bag healthcare waste excluding body parts Autoclaving a Highly Infectious waste gt Yellow Pae Incineration Bag b Tissues Body parts including blood 180102 i bags and blood preserves gt Offensive wastes Nappies dirty linen Tiger Stripe disposable clothing P NHS guide is use this bag if create more 18 01 04 Landfill 8 than 7kg of waste otherwise its Trade Waste Black Trade Waste Standard domestic amp office Ba waste after removal of any recyclable 2001 03 Landfill 8 components ees haros Low Infectious or potentially infectious rang P sharps that do not contain or contaminated 18 01 03 Alternative treatment Lid Colour f tee with medicines Yellow sharps Highly Infectious or 18 01 03 Lid Colour Any sharps that contain or are Incineration contaminated with non toxic medicines 18 01 09 Any sharp that contains or is contaminated Purple sharps with cytotoxic or cytostatic medicines s Lid Colour Examples are hormonal and chemo 180108 ener medicines OTHER HAZARDOUS MAT
33. guidelines Date Plan of Care Signature Peak Pressure Inspired Time Peep Pressure Expired Time High Flow Alarm Low Flow Alarm Trigger SEE MANUFACTURES GUIDELINES FOR MORE INFORMATION See Team Policy document e Prior to procedure wash amp dry hands in accordance with local PCT hand hygiene policy e Place the ventilator on a clean and level surface Open the lid to access the mains cable Connect the socket to the IEC Connector on the side panel Plug into the mains power supply Guidelines for Children in the community requiring Long Term Ventilation BACHS 2010 Page 41 of 58 e Check that the Input Air Filter is clean in accordance with manufactures instructions Connect the breathing circuit tube to the outlet e Ensure humidifier is connected appropriately and switch on a Water chamber is filled to correct level b Circuit connected to ventilator c Temperatures set to Switch on ventilator as described in user manual Carry out alarm tests as described in user manual e Note If any of the alarms fail to operate DO NOT USE contact nurse on call for advice e Use spare ventilator if appropriate e Switch on the ventilator power switch e The alarm will sound e Ensure the High amp Low Flow alarm and Trigger match Dereden prescription e Ensure the Inspiratory amp Expiratory times and Peak amp Peep pressure match the prescripti
34. he T piece and nebuliser chamber from the circuit and reconnect to patient NB If on a dry circuit remember to replace the HMEF 10 Rinse the nebuliser chamber and T piece in water and leave to dry 11 Wash hands in accordance to local PCT hand hygiene policy 12 Document task in case notes Rationale To reduce the risk of cross infection To ensure safe administration To reassure and gain the child s cooperation where possible To prevent it alarming during the procedure To ensure the nebuliser chamber is correctly placed in the circuit NB Nebuliser chambers must never be connected directly to a tracheostomy always use the T piece To administer drug and to detect any problems To resume normal ventilation To remove any traces of the drug To minimize risk of cross infection To maintain contemporaneous record keeping Guidelines for Children in the community requiring Long Term Ventilation BACHS 2010 Page 16 of 58 16 Safe use of Battery Packs Ni Junior 3 Action 1 Inthe home environment the child on tracheal ventilation requires at least one battery pack for each BiPAP ventilator 2 Equipment needed Lead acid battery with cable to charger unit and cable to round vent connector in blue or black carry bag Charging unit with mains lead in mesh pocket of carry bag 3 General Handling Instructions Always ensure that the batteries are stored in a dry place th
35. hing that might create a sharp or stool samples into the bags o Bins and bags must be securely closed sealed o Closed bins and bags must always be labelled o You are required to place closed sharps bins or bags either into a specified dirty utility room or into the correct external waste bin site dependant o Waste from one site must not be taken to other site o Community generated sharps and bag wastes must only be returned for disposal at the team s office base o Sharps and bag waste transported in a car must always be carried in the approved transport box Guidelines for Children in the community requiring Long Term Ventilation BACHS 2010 Page 28 of 58 WASTES FROM OTHER SITES Schools and Community Sites o Sharps amp Bag wastes placed into the correct container sealed and labelled o Transport these wastes only in the approved transport boxes o Dispose these wastes only at your base check there is a waste contract Patient Homes o Infected or potentially infectious wastes should have a home collection waste contract set up if in bulk o Small amounts can be transported in labelled bags in a transport box back to base o Uninfected waste can go in general household waste Acute Hospital Sites If you provide a service at an Acute other Trust site it is your responsibility to follow their policy and procedures If you have any concerns regarding their procedures contact infection prevention or the Waste Mana
36. ild is unstable observations should be carried out whenever changes in care are made ALARMS Power Fail If the power supply to the ventilator is interrupted an alarm will sound This will continue for five minutes unless cancelled with the mute button Low External Battery When using the external battery the alarm will sound when there is approximately 10 minutes of running time left However this time is not guaranteed and an alternative power source should be found promptly It will also alarm if it self discharges to approximately 75 of its capacity during standby High Pressure If the pressure rises above 120 of the working pressure an audible and visual alarm will start High Flow Alarm Acts as an adjustable disconnect alarm If the ventilator has to give air flow over the limit set to try to achieve the set pressures an audio and visual alarm is activated Potential causes include patient disconnection or circuit disconnection failure Low Flow Alarm Acts as an adjustable blockage alarm If the ventilator has to give air flow under the limit set to achieve the set pressures an audio and visual alarm is activated Potential causes include secretions blocked tracheostomy tube and circuit occlusion Fault if triggered by a fault within the machine this will be displayed on the screen and stored in the fault log Low Internal Battery An intermittent alarm with no onscreen message indicates a depleted mains fail alarm batter
37. ill reduce upset and anxiety for young persons families and staff e Ordering system The ADNT service responsible for individuals care will be responsible for ensuring adequate stock items emergency or otherwise are available prior to hand over to cover ordering problems e Finance early discussions with the appropriate ADNT service line manager for new patients being transferred to their services will ensure there is a cost code for non stock ordering and reduces risk of cost not being transferred in time e Emergency equipment should be made readily available by the ADNT service and held with the patient at the agreed place of care delivery consider ordering extra pieces of kit Guidelines for Children in the community requiring Long Term Ventilation BACHS 2010 Page 7 of 58 10 Training and education The ADNT service can link in with the CCCST and undertake appropriate training to reach the required standard When undertaking care of young person prior to transfer professionals will establish what the young person and family are able to do and provide appropriate support and develop a joint plan of care for the individual patient Training will be time limited to minimize duplication of work and ensure clarity of roles How will staff know how to access and who do they contact e g part of induction Out of hours It is the responsibility of the ADNT service to make their own local arrangements for out of hours s
38. ing Long Term Ventilation BACHS 2010 Page 19 of 58 18 Safe management of a child during outings Action 1 Both the parents and the carer of the child must agree that the child is Clinically well to be taken on an outing and consent given 2 Health support worker to seek advice from qualified nurse 3 The nurse carer or parent accompanying the child must have completed all relevant training and be competent in the care of the child all equipment as well as basic life support skills 4 The outing must occur in a rostered shift or nurse carer MUST flex on duty or work a bank shift for that period 5 Equipment Prepare the equipment as listed on the Checklist for Outings Appendix B Prepare the ventilator according to guidelines for changing onto a dry circuit and using battery packs Calculate the required amount of oxygen for the outing and ensure sufficient oxygen supply 6 Ensure the child s emergency equipment is kept near the child and is accessible at any time e g Do not enter a lift or taxi without them 7 Use wheelchair accessible taxi s 8 Ensure appropriate car seating and safety belts are in place and used 9 Ensure oxygen is in an appropriate carry case or secured appropriately Rationale e To maintain safety of the child There are no legal restrictions in taking the child out if consent has been obtained from parents e To maintain safety of chil
39. ing due to secretions blocking or reducing the air getting to their lungs Children have fewer reserves than adults and therefore react more quickly when they have difficulty breathing HOW VENTILATION WORKS If a child is unable to breathe adequately for themselves then they can be assisted using mechanical ventilation This pushes air with or without oxygen added under pressure into the lungs A child can receive help with breathing either through a mask or through a tube These tubes can be oral via the mouth nasal via the nose or tracheal see attached tracheostomy teaching pack The patients who are long term ventilated will either have mask or tracheal ventilation as these are the most comfortable Terms used in ventilation TV Tidal Volume The amount of air taken in one breath Measured in mls Rate The number of breaths taken in a minute Can be set on the ventilator or spontaneous MV Minute Volume The amount of air taken in during a minute Measured in mls Calculated by TV x rate IPAP Inspired Positive Airway Pressure The top pressure to which air will be delivered into the lungs during inspiration EPAP Expired Positive Airway Pressure The bottom pressure to which lungs are allowed to exhale Also known as PEEP Positive End Expired Pressure Ti Inspiratory Time Guidelines for Children in the community requiring Long Term Ventilation BACHS 2010 Page 45 of 58 Time over which inspi
40. ing the circuit ensure the child is appropriately ventilated oxygenated by other means e g Self inflating resuscitation bag alternative circuit oxygen mask Thermovent 7 Wash hands in accordance with local PCT hand hygiene policy Rationale To ensure task needs to be undertaken e To ensure the safety of the child throughout the procedure e To minimize the risk of cross Infection e To enable the task to be completed e To provide reassurance and gain the child s cooperation where possible e To ensure adequate ventilation oxygenation is maintained throughout e To ensure correct assembly of Guidelines for Children in the community requiring Long Term Ventilation BACHS 2010 Page 12 of 58 8 Assemble the circuit as shown in pictures 3 4 and 5 in Appendix A 9 Protect all endings and avoid contamination 10 Check prescribed settings and switch ventilator on ensure pressures are achieved when the swivel elbow is occluded 11 Attach the circuit to the child and ensure they are comfortable 12 Document completion of the task on the checklist 13 Wash hands in accordance with local PCT hand hygiene policy 14 Clean ventilator circuit according to manufactures guidelines circuit and prevent risk of cross infection To minimize the risk of cross infection and prevent contamination To ensure the ventilator is working and pressures are achieved
41. ity Health Services 2010 Hand Hygiene Policy amp Procedure BACHS Bradford amp Airedale Community Health Services 2010 Infection Control Standard Precautions Policy BACHS Bradford amp Airedale Community Health Services 2010 Infection Prevention Management Policy BACHS DOH 2010 National Framework for Children amp Young People s Continuing Care London DOH DOH DFES 2005 NSF for Children Young People amp Maternity Services Long Term Ventilation London DOH Fischer amp Paykel Unit 16 Cordwallis Park Clivemont Rd Maidenhead SL6 7BU 01628 626136 Great Ormond Street NHS Trust 2005 Clinical Guidelines resource Pack Intersurgical Crane House Molly Millars Lane Wokingham RG41 2RZ 0118 9656300 Kapitex Healthcare Ltd Kapitex House 1 Sandbeck Way Wetherby LS22 7GH 01937 580211 Noyes J Lewis M Barnados 2005 Hospital to Home Guidelines on Discharge Management amp Community Support for Children using Long term Ventilation Barnados Nursing amp Midwifery Council 2002 Guidelines for Administration of Medicines London NMC Portex Ltd Hythe Kent CT21 6JL 01303 260551 ResMed UK Ltd 65 Malton Park Abingdon OX14 4RX 01235 862 997 Guidelines for Children in the community requiring Long Term Ventilation BACHS 2010 Page 23 of 58 Respironics UK Ltd Heath Place Bognor Regis PO22 9SL 0870 770 3434 Ventilation London DOH Widdas D 2006 Preparation Checklist fo
42. light will flash and the alarm will sound displaying running on battery power Mute the alarm to acknowledge The display will show a battery if vent switched on To disconnect the battery switch the vent off press the plug release button on the connector and pull out To prevent a power surge NB DO NOT BOOST A BATTERY AS IT IS OF NO BENEFIT WAIT UNTIL THE GREEN LIGHT SHOWS IF IN DOUBT OF FUNCTION CHARGE FOR AT LEAST 24 HOURS NB The green light is not a reliable indicator of battery state To prevent over heating Charge away from sparks do not smoke near battery whilst charging Check all wiring is well insulated Never pull on any wires See picture 8 in Appendix A There is no need to switch the vent off if in use unplug the mains power supply and the vent will switch over to battery power If vent in use attach a mains lead and power supply will switch to this so the battery can be removed Guidelines for Children in the community requiring Long Term Ventilation BACHS 2010 Page 18 of 58 17 Safe management of child during power failure Action Rationale 1 Always ensure that there is a e To be able to see in event of working torch available close to power failure the child during the night 2 Inthe event of power failure Nippy Junior 3 Ventilator will Ensure second battery is alarm and switch over to external available should the power cut
43. n from Paediatric to Adult Services We are now beginning to see that children young people with high dependency and complex health needs are living into adulthood The process of transition can begin between the ages of 12 19 although there is no hard and fast rule as to when transition should start Royal College of Physicians Transition Steering Group 2008 The Children s Specialist Services Team have agreed that transition needs to be considered about a year in advance of actual discharge from the CSST service to ensure transition is managed smoothly for the young person family and healthcare nursing team The Team will make contact with the relevant Adult District Nursing Team ADNT or other adult service prior to transition to arrange this in a timely manner 9 1 Actions to take into consideration e Contact list of those involved in an individual young person s care e g Paediatricians Soeech amp Language Therapist SLT Dietician and School Nurse should be given to the relevant ADNT or service taking over care e Equipment this is often non stock ordering and is bespoke to individuals it is important that the ADNT relevant professional from adult services are given relevant order numbers and relevant information form the CCSST and can clearly identify via the manufacturer any non stock ordering systems and that the manufactures provide alternatives for items which do not meet the young person s needs as this w
44. ng up to drip dry Store in designated container with lid Wash hands in accordance to local PCT hand hygiene policy Document completion of task on check list Rationale To minimize the risk of cross infection To enable the task to be completed safely To minimize the risk of infection To soften and remove built up dirt To remove soapy residue To prevent risk of legionnaires disease and to keep clean Do not dry with a towel To minimize risk of cross infection To maintain contemporaneous record keeping Guidelines for Children in the community requiring Long Term Ventilation BACHS 2010 Page 15 of 58 15 Administration of a Nebuliser through a ventilator circuit Action 1 Wash hands in accordance with local PCT hand hygiene policy 2 Puton non sterile latex free gloves 3 Check and prepare drug according to local and Trust policies and procedures for administration of medication 4 Explain the procedure to the child amp family 5 Silence the ventilator 6 Put the drug in the nebuliser chamber and attach the T piece on the top as shown in Picture 6 in Appendix A 7 Place the nebuliser and T piece in the ventilator circuit as shown i e after the swivel elbow and before the exhalation port 8 Switch on the nebuliser and reactivate the alarm NB If on dry circuit remember to remove the HMEF 9 When the nebuliser is complete disconnect t
45. nity setting is not a new concept within Bradford and Airedale This service has been provided by childrens specialist services for over 8 years In order to ensure these children and their families continue to receive high quality care there needs to be clear guidance and support for staff and professionals working within Bradford amp Airedale Community Services BACHS Scope of the policy staff working with in the BACHS children s specialist services 2 Key related Documents e National Service Framework for Children Young People and Maternity Services e Disabled Children and Young People and those with Complex Health Needs standard 8 e Care Pathway Long Term Ventilation e National Framework for Children and Young People s Continuing Care 3 Equality and Diversity This policy aims to meet the diverse needs of our service population and workforce ensuring that none are placed at a disadvantage over others It will assist in maintaining patient safety equally across the whole of the BACHS by utilising one nationally approved system Furthermore it has been developed and will be reviewed on the basis that it does not discriminate and is not prejudicial on the grounds of disability gender marital status sexuality colour race nationality ethnic origin religious belief or age 4 Definition of the client group Any child young person 0 19 years who requires ventilation or long term ventilation will need access to servic
46. nnector in cleaning basket then submerge in prepared cleaning solution Soak for about 30 min Remove the tube and inspect the inner lumen and the outside for any stubborn secretions Repeat the soak if tube is not clean In some cases you may need to use the cleaning buds When clean take tube out of basket and rinse with clean water Leave to dry in aclean place Re assemble the tube once clean and dry Store in clean and dry container Label container with the date when the tubes were started Wash hands in accordance to local PCT hand hygiene policy Rationale e Bivona tubes are specifically for ventilator dependent children or those infants with neck access problems and are reusable e The oxygen based powder breaks down the protein plugs occluding the tube Buds can be used to remove stubborn secretions at the cannula tip e Remove 15 mm connector before cleaning wer Re assemble correctly e To ensure contemporaneous record keeping Guidelines for Children in the community requiring Long Term Ventilation BACHS 2010 Page 22 of 58 20 REFERENCES Airedale NHS Trust 2006 Guidelines for Patient with a Tracheostomy tube insitu ANHST B amp D Electromedical 35 Shipston Road Stratford On Avon Warwickshire CV37 7LN 01789 721577 Bradford amp Airedale Community Health Services 2010 Decontamination amp Autoclave Policy BACHS Bradford amp Airedale Commun
47. o You make the decision the waste type that you produce goes into the correct colour coded bag or sharps bin and only the correct one o You must never mix different classes of waste types in the same bag or sharps bin o If you do not know what waste types goes into which bag or bin type you always check or ask o If you have worked previously in an Acute Trust you must follow the clinical waste policy of this Trust on the segregation and disposal of waste since it is likely to be different SEGREGATION EXCEPTION Some community staff produce small quantities of mixed sharps types Therefore these groups of community staff are permitted to use a 0 6 litre purple sharps bin in these circumstances BUT the production of large quantities of same type sharps in the community must go into the correct sharps bin type Guidelines for Children in the community requiring Long Term Ventilation BACHS 2010 Page 27 of 58 MANDATORY AUDIT TRAIL You must complete the Labelling Audit Trail for bags and sharps bins f you open a sharps bin 1st to use it you must immediately record Location Service your name date opened e If you close a sharps bin after being full you must write your name and date of closure If you have provided a service in a clinical room producing bagged wastes and that bag is closed at the end of the session you must ensure personally the bag is labelled with Site or Practice name Clinic name or specific
48. on e Attach the swivel elbow is fitted on the breathing circuit e Ensure n a is comfortable e Attach breathing circuit to i e tracheostomy e Monitor and document readings every 0008 e Ensure circuit is placed below the patient and not above as this will cause backflow of water back to the patient e Wash amp dry hands in accordance to local PCT hand hygiene policy Contact Childrens Community Team to speak to a qualified nurse for advice and support Signature of Nurse Date Signature of Parent Date Please note signature of nurse and parent carer indicates that the care has been negotiated Guidelines for Children in the community requiring Long Term Ventilation BACHS 2010 Page 42 of 58 Appendix 9 x aE Entilar The Leeds Teaching Hospitals NHS NHS Trust VENTILATION TEACHING PACK Sarah Cozens Children s Long Term Ventilation Nurse Specialist Nicola Martin Children s LTV Nurse Guidelines for Children in the community requiring Long Term Ventilation BACHS 2010 Page 43 of 58 Having completed this booklet you will have a working knowledge of the functions of the respiratory system and use of long term ventilation The organs of the respiratory system include the Nose hairs and folds in the nose filter and humidify the air we breathe Pharynx includes the tonsils and adenoids Larynx the voice box routes air and food into the proper channels an
49. r Going Out for a long period of time with a Child Long Term Ventilation Website www kapitex com www longtermventilation nhs uk www nippyventilator com www ResMed co uk www respironics com Guidelines for Children in the community requiring Long Term Ventilation BACHS 2010 Page 24 of 58 Appendix 1 Development of Guidelines These guidelines were developed by the Clinical Lead from the Childrens Community Specialist Services Team Bradford amp Airedale Community Health Services BACHS with input from colleagues for other Childrens community teams a well as colleagues from the acute trust Consultation Group All members of the Professional Advisory Group Tim Hayward Paediatric Consultant PICU Leeds Teaching Hospital NHS Trust Sarah Cozens Children s Long Term Ventilation Nurse Specialist LTNHST Erky Radic Clinical Lead Bradford amp Airedale Community Health Services BACHS Team Leaders Childrens Community Specialist Services BACHS Emma Wilkinson Clinical Support Specialist BACHS Rachel Lyles Paediatric Outreach Team Airedale NHS Trust Rachel Binks Nurse Consultant Critical Care Adults ANHST Fi Knox Practice Development Sister Paediatrics Bradford Teaching Hospitals Trust Helen Hartley Respite Co ordinator Hunslet Health Centre HHC Joanne Young Senior Staff Nurse HHC Amanda Barwick Specialist Nurse Child Health Kirklees Community Health Services Margaret Wadsworth Manager Forget Me Not Tr
50. ratory breath is given Trigger The sensitivity to which the ventilator is set to detect a patients spontaneous effort at breathing The lower the number the more sensitive the ventilator Once detected the ventilator will then deliver a supported spontaneous breath Types of Ventilation IPPV o Intermittent Positive Pressure Ventilation o Set IPAP and Ti o Timed inspiratory breath triggered by the patient o No EPAP patient breathes out to atmospheric pressure via exhalation port BiPAP Pressure Control o Biphasic Positive Airway Pressure o Set IPAP EPAP and Ti o Breaths triggered by the patients respiratory effort o Back up rate takes over in the absence of spontaneous effort BiPAP pressure Support o Biphasic Positive Airway Pressure o IPAP EPAP and back up rate set o Combines a set rate with spontaneous breathing Any spontaneous breaths are assisted to a pre set upper pressure limit o The set rate does not have to be given but acts as a back up rate if the spontaneous rate drops o Ti will be given as half of the back up rate timed breath or a half of the back up rate up to 2 seconds spontaneous supported breath CPAP Continuous Positive Airway Pressure o Spontaneous breathing with set PEEP o No back up rate or inspired pressure VENTILATOR CIRCUITS Different types of ventilator circuits are used depending on where the patient is and what activity they are doing When a person is ventilated via
51. ssary Consider saline nebuliser and return to wet circuit The ventilator is reconnected to the mains supply and the battery recharged All used equipment will be cleaned checked and stored as appropriate To ensure safe transportation of oxygen To ensure all necessary equipment and disposables have been considered To ensure safety during delays such as traffic jams emergency situations If a long period is anticipated consider phoning 999 for a speedier return For communication in all circumstances To enable emergency procedures to be carried out safely The ambulance will take you to the nearest A amp E Dept To maintain child safety and readiness of equipment for when next needed Guidelines for Children in the community requiring Long Term Ventilation BACHS 2010 Page 21 of 58 19 Cleaning a Bivona Tracheostomy Tube Action 1 Bivona tubes are single patient use and can be cleaned and re used for up to 12 months date of insertion is recorded in care plan Equipment needed Kapitex cleaning kit cleaning powder and cleaning tub Kapitex cleaning buds Procedure Wear non sterile latex free gloves and disposable apron Prepare cleaning solution as per instruction using the empty tub with the basket provided Rinse the tube under water to remove as much dirt as possible Remove the 15 mm connector by using a wedge donot pull Place tube and clear 15 mm co
52. support similar children Children Early years Disability Sensory 0 as above disabilities Physical disabilities Learning disabilities Mental health Draft clinical guidelines in community requiring Long Term Ventilation v7 BACHS 2010 Page 55 of 58 Gender Men 0 Women Transgender as above Race Minority ethnic 1 communities Gypsies and travellers Travellers who are on the caseload may leave at short notice and care may be affected if support not coordinated to follow them at next destination Religion or Christian 0 belief Muslim Hindu Buddhist Sikh Jew Other as above Sexual Lesbian 0 orientation Gay men Bisexual as above Summary Is a more full equality impact assessment required No Please describe the main points arising from the initial screening here that support your decision There is no potential adverse impact Prior to the next review of this policy the nurse specialist will gather feedback from patients families who have been receiving this treatment and use their feedback to inform any policy developments Policy lead conducting impact assessment Erky Radic Clinical Lead Approved by member of the equality and diversity team Lynne Carter Date 1 11 10 Draft clinical guidelines in community requiring Long Term Ventilation v7 BACHS 2010 Page 56 of 58 Appendix 13 PROCEDURAL DOCUMENT CHECKLIST To be completed by th
53. t such as a swivel elbow should be attached at the tracheostomy to allow the patient freedom of movement and prevent accidental disconnection A bacterial filter sits between the ventilator and the start of the tubing This prevents dust and particles from being breathed in therefore acting as an additional part of the patients upper respiratory tract It also prevents water from the humidifier entering the ventilator The filter must be changed daily DRY CIRCUIT The HME filter is normally used when the patient is attached to a portable or dry circuit Instead of humidifying the air the filter uses heat and moisture gained from the patients own expiratory breath to warm and humidify their inspiratory breath Therefore the filter must be attached close to the patient between the swivel elbow and the exhalation valve An exhalation port must always be attached close to the tracheostomy Without one the patient cannot breathe out The dry circuit attaches directly to the ventilator the HMEF negates the need for a bacterial filter The HME filter comes in 3 different sizes neonate child and adult It is important that the correct size is used for your patient to prevent over or under humidification The HME filter must be changed every day The dry circuit needs to be changed weekly Guidelines for changing humidified circuit The humidified ventilator circuit must be changed once a week to prevent bacterial build up which could lea
54. tart of every shift and topped up from stock as required It comprises o Ambu bag with oxygen tubing attached Same size spare tracheostomy tube with introducer and Velcro tapes attached Size smaller tracheostomy tube with introducer Spare tracheostomy tapes wedge for bivona tracheostomy tubes only 2x aqua gel sachets Round ended scissors 5x syringes 5x sterile ampoules saline Copy of resus flow chart for child with tracheostomy appropriate to age Yankeur sucker O 00000000 0 CHANGE OF SHIFT CHECKLIST To ensure the child s safety and ensure that the ventilator and related equipment works effectively certain checks should be carried out at the start of each shift These checks are recorded on either the daily or monthly checklists found in the child s file o Tracheostomy tapes check clean and secure o Ventilator circuit clean and connections secure o Ambu bag Intact and attached to oxygen if required o Oxygen cylinders 1 4 full 15ltr heads cylinder and 4ltr concentrator cylinder present if concentrator used All necessary oxygen tubing present and intact Cylinders should be turned off if not in use however if turned off should be turned on and run briefly at 10 litre to check level and then turned off Level will drop quickly if cylinder empty and reading high o Ventilator check settings and alarms on ventilator in use and on spare o Humidifier if in use check settings and water bag o B
55. te Date Date Date Equipment Ventilators Leads x2 Humidifier Battery charger x2 Suction charger x 2 Nebuliser Pump Feed pump Lead Saturation monitor Milk feeds Drugs Chart Inhaler aerochamber Oxygen cylinders Decontamination wipes amp hand hygiene Vent Circuits Documentation Sign Neos Draft clinical guidelines in comm BACHS 2010 nity requiring ton Term Ventilation v7 Page 53 of 58 Appendix 12 EQUALITY IMPACT ASSESSMENT Stage One Screening of a policy procedure tender or strategy 1 Name of policy procedure tender or strategy Is it a policy strategy procedure or practice Guidelines for children in the community on long term ventilation 2 Who has been consulted e Associate directors e Heads of Service and staff in all BACHS business units Head of programmes and the information governance manager e Designated nurse child protection e Equality and diversity team NHSBA via the head of nursing amp professional development Members of the following committees e Clinical risk and governance sub committee e Professional advisory sub committee e Non clinical policy group Infection control committee Health and safety operations group 3 Main aims To ensure that BACHS staff have clear guidance to support client c
56. the Acute and Community settings 2 To ensure care delivered is research based and up to date Guidelines for Children in the community requiring Long Term Ventilation BACHS 2010 Page 26 of 58 Appendix 2 NHS Bradford and Aired NHS Community Heatth services Bradford and Airedale CLINICAL WASTE MANAGEMENT OWNERSHIP OF COMPLYING WITH THE LEGISLATION POLICY AND PROCEDURES FOR CLINCAL WASTE IS YOUR RESPONSIBILITY If through your clinical activity you produce some wastes you personally are defined as a Waste Producer under the Hazardous Waste Regs 2005 You as a Waste Producer have legal responsibilities under this legislation and more under the Environmental Protection Act 1990 and the The Environmental Protection Duty of Care Regulations 1991 This means you have a cradle to grave responsibility for the correct segregation of wastes a completed audit data trail and ensuring correct disposal This includes any appropriate safety requirements and infection prevention requirements Staff who are not waste producers but involved in the disposal or paper records must also adhere to the requirements of law amp PCT policies All staff has a responsibility to report any risks associated with clinical waste to ensure that the risk is managed and made safe YOUR WASTE SEGREGATION OBLIGATIONS You must segregate the wastes correctly for legal contractual and safety reasons You segregation obligations therefore are
57. upport as regards support with the ventilator this can include contact numbers for the Leeds Ventilation Service being made available to staff and patients Audit The attendance of staff and any other agencies who have received training is recorded and held within the CCSST and each session is evaluated by the attendees and will be used to annually audit which staff attend training in a twelve month period Care plans will be audited on an annual basis to look at content of information e g emergency procedures documentation of any changes to the amount of ventilation being given and cross referenced with the documentation audit The Prism reporting system will also be audited to look at types of incidents reported in relation to oxygen therapy and care Guidelines for Children in the community requiring Long Term Ventilation BACHS 2010 Page 8 of 58 11 Assembling a ventilator circuit for use with a Fisher Paykell Humidification system wet circuit NB Normally non sterile latex free gloves are used for these procedures Local Trust risk assessment procedures must be followed and practitioners and patients who may be allergic to latex must be supplied with an alternative to latex and follow local Trust guidelines for latex allergy Action Rationale 1 Establish the need to change e To ensure the task needs to be the ventilation circuit once undertaken weekly This will be indicated on the child s ventilation checklist
58. ust Respite Service Paediatrics Adele Thomas Team Leader Childrens Team Calderdale NHS Trust Date Written April 2010 Review Date April 2012 Objective To review working practices To liaise with other professionals involved in caring for children who require long term ventilation obtaining expert advice To act upon the expert advice obtained and implement accordingly to update clinical practice To ensure continuity of care across the acute and community clinical areas in Leeds Bradford and Airedale Clinical Condition Children who are defined as having a long term ventilation requirement Target Patient Group All children who have long term ventilation requirements either in the acute or community setting Target Professional Group All BACHS staff who will be required to care for children with long term ventilation needs Guidelines for Children in the community requiring Long Term Ventilation BACHS 2010 Page 25 of 58 Adapted from Recommendations Benefits for the Patient Clinical Guidelines for the Transitional Care Unit October 2002 Netty Fabian and Barbara Boosfiled Great Ormond Street Hospital for Children NHS Trust and from East Leeds Primary Care Trust Care of a child requiring long term ventilation September 2006 To circulate guidelines amongst all members of the team and to ensure guidelines constitute as foundation for all future training 1 To ensure continuity of care of patients across
59. volume in the lungs increases it creates a negative pressure i e the air pressure inside the thoracic cavity is less than the air pressure outside Therefore air is sucked into the lungs and we breathe in Expiration In healthy people this is a passive process The intercostals muscles and diaphragm relax and lung volume decreases As pressure inside the lung cavity increases air is forced out CONTROL OF RESPIRATION Guidelines for Children in the community requiring Long Term Ventilation BACHS 2010 Page 44 of 58 All breathing activity is regulated by nerve impulses transmitted to them by the brain from the phrenic and intercostal nerves The rate and rhythm of breathing is mostly determined by the levels of carbon dioxide in the blood As levels increase in the bloodstream we breathe faster thus getting rid of excess waste HOW CHILDREN DIFFER Children are different from adults their lungs and ribcages are still growing and this changes the way they breathe Adults use the muscles between their ribs to breathe however children use their diaphragm Children s bones are generally softer than adults due to the fact that they are still forming and growing therefore their chest walls are softer and more pliable The airways and alveoli continue to develop until about 8 years old This means they have fewer alveoli and narrower and softer airways Because their airways are smaller children are at greater risk of having trouble breath
60. y This can happen if the ventilator is stored for more than a few weeks without being plugged in this allows the internal battery to self discharge The alarm will stop once the battery has been recharged i e once the ventilator has been plugged back in Guidelines for Children in the community requiring Long Term Ventilation BACHS 2010 Page 49 of 58 If the alarm does not stop you will need to contact Sarah Cozens to get the ventilator temporarily replaced ACTION When any alarm sounds the first action must be to assess the patients safety and condition If in any doubt it is advisable to remove the ventilator and commence hand ventilation using the ambu bag If the problem is not immediately apparent it is best to start your assessment from the patient and work back to the ventilator CONTACTS Remember you are never by yourself Sarah Cozens is contactable during the week 0113 3923220 07899988712 Or Martin Latham Leeds Sleep Service 0113 2066040 The child s community team leaders will have day contact and on call numbers in the community file In emergencies LGI PICU will answer at any time of the day or night 0113 3927102 Guidelines for Children in the community requiring Long Term Ventilation BACHS 2010 Page 50 of 58 APPENDIX 10 COMPETENCIES FOR CARE OF A CHILD ON VENTILATION NHS Bradford and Airedale Community Health Services Attend theory Signed Practical Assessment Date Signature Pra

Ventilation version 2 current Draft 2010

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