Pre‐procedure

ActionRationale

1. 1.Show
   Introduce yourself to the patient, explain and discuss the procedure with them, and gain their consent to proceed.
   To ensure that the patient feels at ease, understands the procedure and gives their valid consent (NMC [198], C).
2. 2.Show
   Ensure enough nurses are present. This is a clean procedure and requires two nurses.
   To ensure patient safety and reduce the risk of accidental decannulation or loss of the patient's airway (Dawson [58], C).
3. 3.Show
   Cleanse hands with an alcohol‐based handrub.
   To minimize risk of infection (NHS England and NHSI [179], C).
4. 4.Show
   Help the patient to sit in a semi‐recumbent position with the neck slightly extended.
   To ensure patient comfort and allow easy access to the neck area (NTSP [206], C).
5. 5.Show
   Prepare the dressing tray or trolley for the procedure. Open the sterile procedure pack and open the tracheostomy dressing and tapes/ties onto the sterile sheet. Pour the cleaning solution over the gauze.
   To ensure all equipment required is available and prepared prior to starting the procedure. E

Procedure

1. 6.Show
   Cleanse hands with an alcohol‐based handrub and put on disposable plastic apron, gloves and eye protection.
   To minimize the risk of cross‐infection (NHS England and NHSI [179], C).

   Manipulation of the patient's airway may cause the patient to cough. Eye protection should therefore be worn (NICE [193], C).
2. 7.Show
   The first nurse holds onto the tracheostomy tube while the second nurse removes the tracheostomy tube tapes/ties.
   To ensure the tracheostomy tube is not accidentally dislodged during the procedure (Dawson [58], C).
3. 8.Show
   The first nurse continues to hold onto the tracheostomy tube (until the end of step 12) while the second nurse removes the soiled dressing from around the tube and disposes of it directly into the clinical waste bag.
   To minimize the risk of cross‐infection (NICE [191], C).
4. 9.Show
   The second nurse cleans around the stoma with 0.9% sodium chloride using gauze, and allows it to air dry.
   To remove wet or dried secretions from the stoma site (ICS [116], C).
5. 10.Show
   The second nurse applies barrier cream if required.
   To protect the skin (Dawson [58], C).
6. 11.Show
   The second nurse replaces the tracheostomy dressing.
   To increase patient comfort and protect the skin (Everitt [75], C).
7. 12.Show
   The second nurse reapplies or replaces the tracheostomy tapes/ties, checking that one or two fingers can be placed between the tapes/ties and the neck once the tapes/ties are secure.
   To secure the tracheostomy tube, ensuring it is not too loose or too tight (Dawson [58], C).
8. 13.Show
   Ask the patient whether the tracheostomy dressing and tapes/ties are comfortable.
   To ensure patient comfort. E
9. 14.Show
   Remove apron, gloves and eye protection and dispose of them in a clinical waste bag. Cleanse hands with soap and water or an alcohol‐based handrub.
   To minimize the risk of infection (NHS England and NHSI [179], C).

Post‐procedure

1. 15.Show
   Monitor the patient's respiratory status and observations/NEWS. Escalate any concerns or deterioration in condition or NEWS immediately.
   To identify any concerns or clinical deterioration early, and ensure timely escalation to senior staff if required (RCP [230], C).