This case involves an elderly female patient who had a tracheostomy tube placed following a neck surgery. The patient was transferred to a skilled nursing facility and placed under the care of a nurse practitioner. The nurse practitioner did not inform the team that the patient’s airway was tenuous due to her recent surgery. The nurse practitioner also failed to formulate a plan for handling potential airway problems in this particular patient. During the patient’s time at the facility, a floor nurse suspected that the patient’s tracheostomy tube had become displaced. In spite of this suspicion, no X-rays were taken. The floor nurse called the respiratory therapist about the displaced tube and the respiratory therapist attempted to advance the tube. The nurse practitioner was present for this. The patient began to desaturate and a code was called but the nurse practitioner did not arrive. In spite of resuscitation attempts, the patient passed away.
Question(s) For Expert Witness
- 1. What is your experience caring for patients with tracheostomy tubes status post neck or airway surgery?
- 2. How is the primary care provider supposed to communicate to the team about a patient with a tenuous airway?
- 3. If a patient with a tenuous airway needs to have that airway manipulated, what are the appropriate precautions and personnel that need to be available?
- 4. What safeguards are in place to mitigate against the complications that occurred in this case?
Expert Witness Response E-053622
I am a board-certified family nurse practitioner with 17 years of experience in trauma, ED, primary care and addictions medicine. I have a Ph.D. in nursing and teach advanced health assessment to nurse practitioners at the doctoral level across programs, including acute care nurse practitioners and certified registered nurse anesthetists. I supervise nurse practitioner students in an emergency room clinical experience at a university teaching hospital as well as various clinical sites in the community including rehab, primary care, long term care and community health. I have registered nurse-level experience caring for patients in acute care settings s/p neck or airway surgery and nurse practitioner-level experience in the primary care setting with this type of patient. There should be a written plan of care posted in the patient’s chart and should be reviewed by the patient/family, primary care physician, and the entire caregiving team. The care plan needs to be based on established clinical practice guidelines for post-surgical patients with a tracheostomy. There should be emergency resuscitation staff called on site as soon as possible before manipulation of the airway and the provider on call should be notified and called to the bedside. In terms of safeguards to mitigate against these complications, there should be a specific protocol in place: xray to confirm placement, routine recording of 02 saturation, routine and documented assessments of the pts airway.
Expert Witness Response E-125535
I am certified as an adult nurse practitioner and work in long-term acute care with many patients with tracheostomies. I have worked with patients who have had complex neck surgeries and/or wounds to the neck and surrounding the tracheostomy. The primary care physician should provide instructions both verbally and in writing for patients with unusual or complex care needs. Airway manipulation depends on the qualifications of staff available, the emergent nature of the need and practice guidelines in the facility. It is appropriate for the respiratory therapist to manipulate an airway in many settings, especially in an urgent setting. Xray is one method of ensuring the airway is in the correct location as is direct visualization using FEES or other scope. The facility has a responsibility for accepting appropriate patients whose needs can be met adequately. Appropriate guidelines need to be in place on the part of the facility. Customizing these guidelines to the need of the individual needs of the patient is essential if the patient’s needs exceed the guideline. Communication from facility staff to the provider is also essential, preferably prior to an emergent event.