The Royal Melbourne Children’s Hospital (RMCH) 

   

Just to prove I was there!
 
Whilst in Boston, Dr Roberson introduced me to Dr Joanne Harrison from RMCH. Joanne has help to coordinate this fly by visit.  

Dr Harrison is a Respiratory Physician @ RMCH, she is also a founding member of the GTC and chair of the programme committee.

My quick visit was as follows:

I was first shown around the hospital by John Kemp (a clinical nurse specialist). The hospital is very modern, it has incorporated lots of open spaces and art designs to distract from the hospital setting. As well as this it has lots of entertainment for the children: Aquarium, Arts Centre, Meerkat enclosure, and a Cinema! to name but a few! They also have some top clinical settings inc. hydro pool, cardio-resp research lab, splinting and bracing etc.

   

 

Then onto business. RMCH only have about 4-5 inpatient tracheostomies at any one time. They have a group of nurse specialists that will support the nursing staff as well as assist in the education of the family and patient.

Sometimes the education may originate from a different clinician e.g. SALT or Physio (who will do the initial education) but then the nurse specialists will continue this education and reinforce it.

There appears to be an MDT approach to beside care, but due to such infrequent numbers of tracheostomy patients they do not do a formalised round with all members.

These patients will be rounded on by their subspecialty only.

Me and John discussed one of their current complex cases. A tracheostomy that will be permanent with permanent ventilation also.

SALT had been working with the ward team on communication with both an in line valve as well as eye gaze technology.

Physio had initially visited to educate the staff and parents on a cough assist machine and chest management.

Now the patient has these set up and the staff and family have their eduction and prescription the patient is not seen by SALT or PT unless they are consulted.

The nurse specialists will continue reinforcing the education as required.

As with all the paediatric teams I have seen, John explained their processes for family education are quite regimented. The families are observed and deemed competent by staff for all the different things their child needs e.g. tube changes, ventilator, cough assist etc.

They also have an education video and some literature, although I didn’t get time to see this formally.

Trache Meeting:

I was lucky enough to attend their weekly tracheostomy meeting.

This meeting discusses all the current inpatient tracheostomies.

Present are the nurse respiratory specialists, home care nurses, physicians from ENT and Respiratory, as well as a member from the ward looking after the patient (e.g. nurse in charge). Physio and SALT are not routinely represented at these meetings.

They will go though the past medical history as well as discussing the patients current progress, making plans and discussing how to progress forward with the patient as appropriate.

This meeting gives the attending physicians the opportunity to know what current patients there are with traches in the hospital.

Due to the small number of traches in the hospital this meeting is generally only short.

After the meeting I was able to speak with Sueellan Jones.

Sueellan is a respiratory nurse specialist also. Her role includes; ventilation, oxygen therapy and home O2, as well as staff education and training.

I had lots of questions after the meeting as Sue was great in taking the time to answer them. The answers are as follows:

If a patient presents into ED with a trache the team is not informed formally. However due to the nurses role and that these patients generally go to one of two wards, they are often picked up by the team quickly for discussion.

The receiving ward will set up the bedside safety equipment, all wards receive training on this, as well as trache care. However the respiratory nurse specialists are on hand to assist as required.

The team do not do formal ward rounds or another meeting at present, however Sue explained that they are about to continue with there tracheostomy working group soon. All the tracheostomies are also discussed at a monthly airway, morbidity and mortality meeting.

I am informed that their tracheostomy team is well received within their hospital and because both respiratory and ENT are both present then the decisions made at the meeting are carried out. Decisions on weening and decanulation are also agreed on.

All the tracheostomy patients that are discharged have both respiratory and ENT follow ups. At this time only the respiratory nurse specialists and home care nurses have a role in continued education and patient education.

They have had some recent success in educating some patients to do their own tube changes, one of which previously had to have a GA due to being so anxious about the change.

Moving forward Sue explains how they wish to develop a tracheostomy clinic with all MDT’s present.

Physio:

Finally I had a quick discussion with one of the ward physios about their involvement in trache care.

In short the answer was that they do not have much involvement in tracheostomy care outside of treatment. Yes if they need a respiratory or physical treatment they will see the patient and educate staff and families, but they do not do tube changes or staff education, they do not set up the equipment and they do not have any involvement in the weaning of a tracheostomy.

The nurses take the management role for all care and education as well as ventilation. The physio team are only consulted if required.

In this case it seems that because there are only a few traches at any one time the physio team do not feel they are needed as a permanent role in a trache MDT. And that there are other professions at RMCH that take on the roles they would preform outside of treatment.

I discussed if they felt a physio would be required in a clinic setting, to assist with weening and respiratory management, to which it was conceded that they maybe more beneficial in this setting, but would have to see.
I was only a quick visit but again everyone was very happy to assist me and was enthused about trache care.  

This is another example of how a hospital is improving its care based on what they require, in terms of caseload and staff expertise, not just on what it is documented a tracheostomy team requires.

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