ITCProject:Non-medicalcompetenciesfortracheostomy/laryngectomycare-Templateforlocaladaptation.NTSP2018.Coe,B.,McGrath,B.,Lynch,J.,Firn,M.
Non-medical Competencies for Tracheostomy and Laryngectomy
care
BarryCoe,BrendanMcGrath,JamesLynch,MikeFirn,2018
ITCProject:Non-medicalcompetenciesfortracheostomy/laryngectomycare-Templateforlocaladaptation.NTSP2018.Coe,B.,McGrath,B.,Lynch,J.,Firn,M.
Non-medicalCompetenciesforTracheostomyandLaryngectomyCare
Background:
TheNationalTracheostomySafetyProject (NTSP) is aUK charitydedicated to improving thequality and safety of care for patients with tracheostomies and laryngectomies througheducation.TheGlobalTracheostomyCollaborative(GTC)isaQualityImprovementCollaborationbetween hospitals around theworldwith similar aims to theNTSP, but providing additionalresources to support change in our healthcare systems. The NTSP secured funding from theHealthFoundationtoimplementtheGTCresourcesinto20diverseUKhospitalsin2016.ThisprojectiscalledImprovingTracheostomyCare(ITC).
During2017, aspartof the ITCProject,weundertookanumberofqualitative exerciseswithChampions from our 20 participating NHS trusts, in order to gauge levels of support andresources required to successfully improve tracheostomycareacrossavarietyofhospitals.ArapidDelphiconsensusexerciseranked ‘competencies’as thesingle interventionwithhighestagreement.AfurtherexercisedemonstratedthatlessthanhalfofsitesinvolvedintheProjecthadmandatedcompetenciesfornursingstaff.
However, we found little consensus regarding the format and assessment process that acompetencydocumentshouldadopt.Duringtheproject,wehavelearnedthateachsitehasitsowninternalandexternalfactorswhichmayaffecthowchangecanbeadopted,aswellasitsownspecifictracheostomypopulationwiththeirownspecificneeds;alackofconsensusisthereforeunsurprising.However,thereremainsaneedfornationallyagreedtracheostomycompetenciesandthefollowingdocumentcanbeusedasaguideortemplateforthis,andwhendevelopinglocalcompetenciesfortracheostomycare.
Competencydevelopment:
TheITCprojecthostedanumberofmeetingsformultidisciplinarystaffinvolved,representingthe participating NHS sites. Draft themes were developed by consensus and presented forfeedback.Evidenceinthemedicalliteraturewasusedwherepossible,buthighquality,relevantpeerreviewedliteratureislackinginthisarea.Muchofthisdocumentrepresentsopinion,buttheopinions are taken from a multidisciplinary expert panel, and determined through a formalconsensusexercise.
Itisanticipatedthatnotallofthesecompetenciesarerelevanttoallindividualsortoallstagesoftraining,andsomesitesmayhavecomprehensive,existingresources.Thecompetenciesprovidedherearealsodeliberatelydetailed,intheanticipationthattheywillbeadaptedbythoseusingthemtosuittheirlocalneeds.
ITCProject:Non-medicalcompetenciesfortracheostomy/laryngectomycare-Templateforlocaladaptation.NTSP2018.Coe,B.,McGrath,B.,Lynch,J.,Firn,M.
TheAssessmentProcess:
Inordertoimprovethesafetyofcare,theNTSPrecommendslimitingthenumberofwardsorlocationswithin an organisation that patientswith tracheostomies or laryngectomieswill bemanaged. These locations are commonly referred to as cohort wards. The aim for anytracheostomy cohort ward should be to have at least one nurse (or healthcare providerappropriate to the setting)per shift tobe competent (Level3) ineach relevant tracheostomyrelatedcompetency.
Eachofthefollowingcompetenciescanbeassessedforhealthcarestaffinregular,directcontactwithtracheostomyorlaryngectomypatients.Incertainareasandoncertainwardssomeofthefollowingcompetenciesmaynotbeappropriate.Similarly,notallofthefollowingcompetencieswillbeappropriateforcertainmembersofthemultidisciplinaryteam.
Themethodofachievingcompetenceandtheevidencerequiredforthisshouldalsobelocallyagreed.Thefollowingdocumentallowsforself-assessmentandmultiplefurtherassessmentsinorder to highlight individual learning needs and demonstrate progression. However, oneassessmentprocessmaybeallthatisrequiredtodeemapractitionercompetent.Werecommendthatbeforeimplementingacompetencyframework,thesecompetenciesshouldbereviewedbyalocal,multidisciplinary,expertpanel.
LevelsofCompetence1to5(novicetoexpert):
Novice-Level1Noviceshavenoexperienceofthesituationtheyfindthemselvesin,andtheyoperatebycloselyfollowingruleslaiddownbyothers.Theyperformaseriesoftaskswithoutunderstanding,orreferringto,thecontextwithinwhichtheyareoperating.
AdvancedBeginner-Level2Advancedbeginnershavehadexposuretothesituationtheyfindthemselvesin.Thiscouldbethroughacombinationofclinicalpractice,simulationworkshops,studysessionsore-learningthatenablesthemtodiscussordemonstrateanunderstandingofthecompetency.
Competent-Level3TheNursingandMidwiferyCouncil(2010)definecompetenceas“thecombinationofskills,knowledgeandattitudes,valuesandtechnicalabilitiesthatunderpinsafeandeffectivenursingpracticeandinterventions”.Competentpractitionersuseconscious,analyticalcontemplationofthesituationtoplanandimplementtheappropriateactiontoensurethemostsatisfactoryoutcome.
Proficient-Level4Proficientpractitionersusetheirexpertisetocriticallyanalyseandevaluatesituations.Theycanidentifythemostimportantandrelevantelementsofacomplexsituationandmakedecisionsbaseduponabroadperspectiveandknowledge.
Expert-Level5Expertsareabletofocusonarelevantpartofasituationusingintuitiveskillstofollowanappropriatecourseofaction.Anexpertpractitionerwilldevelopa‘feel’forasituationandhaveaplanforanygivenoutcome.
(AdaptedfromBenner,1984)
ITCProject:Non-medicalcompetenciesfortracheostomy/laryngectomycare-Templateforlocaladaptation.NTSP2018.Coe,B.,McGrath,B.,Lynch,J.,Firn,M.
Exampleofcompetencyassessmentrecordsheet:
4.1 DateofAssessmentKnowledge 01/01/01 02/02/02 Demonstrateanunderstandingoftheindicationsforandrisksassociatedwithendotrachealsuction.
2JL 4JL
Skills 01/01/01 02/01/01 Demonstratethecorrectprocedureforperformingendotrachealsuctionincludingselectionofappropriatesuctioncatheters
1JL 3JL
Recordoftrainersignature:
Anymemberofstaffwhoassessesacolleagueasbeingcompetentshouldsignthefollowingtable.
Name Role Signature Initials
ITCProject:Non-medicalcompetenciesfortracheostomy/laryngectomycare-Templateforlocaladaptation.NTSP2018.Coe,B.,McGrath,B.,Lynch,J.,Firn,M.
Tracheostomy&Laryngectomycompetencies:1. Safesuctioning2. Bedheadsigns3. Emergencyalgorithms4. “Redflags”andcomplications5. Innertubecare6. Humidification7. Anatomyandphysiology8. Tubechange:
a. Electivetubechangeb. Emergencytubechange
9. Cuffmanagement10. Stomaandskincare11. Communicationandspeakingvalves12. SwallowingandSALTguidelines13. Transfer14. Documentation15. Weaning16. Family17. Laryngectomy-specific18. Sub-glotticsuctioning19. Discharge
Notes
• SA–Self-Assessment• Initial,MidandFinalareassessmentsatdifferentstagesoftrainingthatmayor
maynotbeapplicabletothelearner
ITCProject:Non-medicalcompetenciesfortracheostomy/laryngectomycare-Templateforlocaladaptation.NTSP2018.Coe,B.,McGrath,B.,Lynch,J.,Firn,M.
Skill/Knowledge Assessment1. Effectivelyandsafelyperformsuctioningofa
tracheostomy/laryngectomytube.SA Initial Mid Final
1.1 Candemonstratetheabilitytocheckandprepareallnecessaryequipment
1.2 Ensurespatientisinformedandreassureaboutthesuctioningtobeperformed
1.3 Performssuctioneffectivelyinaccordancewithlocalprocedure
1.4 Disposeofallwastematerialeffectively 1.5 Ensurepatientiscomfortablepost
procedure.
1.6 Candiscussthemaincomplicationsoftracheostomy/Laryngectomysuctioning
A. Trauma/BleedingB. HypoxiaC. BradycardiaD. BronchospasmE. Pain/anxiety
Skill/Knowledge Assessment2.Bedheadsigns SA Initial Mid Final2.1 Candiscusstheimportanceofthecorrect
use,positionanddocumentationofabedheadsign
2.2 CandescribethebasicdifferencesoftheAdultTracheostomyandLaryngectomybedheadsigns
2.3 CandescribethebasicdifferencesofthePaediatricTracheostomyandAdultbedheadsigns(whereapplicable)
ITCProject:Non-medicalcompetenciesfortracheostomy/laryngectomycare-Templateforlocaladaptation.NTSP2018.Coe,B.,McGrath,B.,Lynch,J.,Firn,M.
Skill/Knowledge Assessment3.Emergencyalgorithm SA Initial Mid Final3.1 Hassuccessfullycompletedanemergency
algorithmtrainingsession.
3.2 Candemonstratewheretofindacolourcopyofthecorrecttypeofbedheadsignwithattachedemergencyalgorithm
3.3 Candiscussanddemonstratetheabilityandneedtocallforexpertairwayhelp
3.4 CandemonstrationtheabilitytoassesstheTracheostomy/Laryngectomypatientsbreathing.
3.5 CanassesstheabilitytoassesstheTracheostomy/Laryngectomytubepatency
A. SpeakingvalvecapremovalB. CanpassasuctioncatheterC. CandeflatethecuffD. Re-assessbreathing
3.6 CandemonstratetheabilitytoremovetheTracheostomy/Laryngectomytube
3.7 Candemonstratetheabilitytoperformprimaryemergencyoxygenation.
StandardairwaymanoeuvresA. CoverthestomaB. Bag-valve-MaskC. OralorNasalairwayadjunctsD. Subglotticairwaydevices
TracheostomystomaventilationA. PaediatricfacemasktostomaB. LMAappliedtostoma
CandescribeNOoralairwaywithLaryngectomypatients
3.8 CandiscussthedifferencesbetweentheAdult,PaediatricandLaryngectomyalgorithms(whereapplicable)
ITCProject:Non-medicalcompetenciesfortracheostomy/laryngectomycare-Templateforlocaladaptation.NTSP2018.Coe,B.,McGrath,B.,Lynch,J.,Firn,M.
Skill/Knowledge Assessment4.Effectiveandearlyrecognitionoftracheostomy“RedFlags”andcomplications
SA Initial Mid Final
4.1 Canidentifyandallemergencyequipment.
A. Suctionandcorrectsuctioncatheters
B. Oxygenwithcorrectdeliverysystem(tracheostomymask,paediatricmask,Bag-Valve-Mask,T-pieceorWaterscircuitasapplicable)
C. TracheostomyBox,asperlocalstandard.
D. Resus/advancedairwaytrolley
4.2 Candemonstratetheknowledgeandabilitytocallforexpectairwayhelp.
4.3 Candiscussthetracheostomy“RedFlags”A. AirwayB. BreathingC. Tracheostomy-specificD. General
4.4 Candiscussthegeneralcomplicationsofatracheostomy/laryngectomy,anddemonstratetheeffectiveandearlytreatmentof
A. TubeBlockageB. TubedisplacementC. Increasedviscosity/drysecretionsD. IncreasedchestinfectionsE. Bleeding
ITCProject:Non-medicalcompetenciesfortracheostomy/laryngectomycare-Templateforlocaladaptation.NTSP2018.Coe,B.,McGrath,B.,Lynch,J.,Firn,M.
Skill/Knowledge Assessment5.Caneffectivelyandsafelyperformtracheostomyinnertubechange/carefordouble-lumentracheostomytubes
SA Initial mid final
5.1 Candiscusstherationaleforinnertubechange.
5.2 Demonstratestheabilitytosafelyremove,cleanandre-insertatracheostomyinnertube
A. Ensurethatthepatientisinacomfortableposition
B. AllequipmentispreparedC. Theinnertubeischangedasper
localprocedureD. The“removed”tubeiscleaned
andstoredasperlocalpolicyE. Thepatientisobservedpost
procedureforanysignsofcomplications
5.3 Demonstratestheabilitytoreplace“used”innertubeeffectively
5.4 Candescribetheminimumfrequencythattheinnertubeneedstobereplaceasperlocalpolicy
Skill/Knowledge Assessment6.Humidification SA Initial mid final6.1 Candescribethenormalanatomical
humidificationprocesses
6.2 Discusstheimportanceofhumidificationinapatientwithatracheostomyorlaryngectomyanddescribeappropriatemethodsofhumidification
6.3 Candescribe,discussandapply(setup)thedifferentmethodsofhumidification.
A. WarmhumidificationB. ColdbathhumidificationC. HumidificationandMoisture
Exchangers(HME’s)eg.Swedishnose
D. LaryngectomybibE. Nebulisers
6.4 Canassessanddocumenttheeffectivenessoftheappliedhumidification
ITCProject:Non-medicalcompetenciesfortracheostomy/laryngectomycare-Templateforlocaladaptation.NTSP2018.Coe,B.,McGrath,B.,Lynch,J.,Firn,M.
Skill/Knowledge Assessment7. Anatomyandphysiology SA Initial mid final7.1 Candiscusstheanatomyandphysiology
oftheupperairway
7.2 Candiscusstheindicationsforatracheostomy/laryngectomy
7.3 Candiscussthealteredanatomyandphysiology,ofthepatientwithtracheostomy
7.4 CandiscussthealteredanatomyandphysiologyoftheLaryngectomypatient
7.5 CandiscussthedifferencesinmanagementofLaryngectomyandTracheostomypatients
ITCProject:Non-medicalcompetenciesfortracheostomy/laryngectomycare-Templateforlocaladaptation.NTSP2018.Coe,B.,McGrath,B.,Lynch,J.,Firn,M.
Skill/Knowledge Assessment8a.CansafelyandeffectivelyperformaROUTINEtracheostomytubechange.
SA Initial Mid Final
8a.1 Canpreparethepatientandenvironmentfortheroutinetracheostomytubechange.
8a.2 Caneffectivelyaccessanduseallemergencyequipment
8a.3 Canidentifyandcontactthecorrectexpertairwaypersonnelasnecessary
8a.4 Cansafely/effectivelyperformaroutinetracheostomytubechangeasperlocalprocedure
8a.5 Cansafely/effectivelyperformaroutinetracheostomytubechangeasperlocalprocedure(localchecklistcompleted)
8a.6 Canensurethatthepatientisreassuredandcomfortablepostprocedure,ensurethatanyproblems,concernsorheightenedobservationarehighlightedtothecorrectpersonnel.
Skill/Knowledge Assessment8b.CansafelyandeffectivelyperformanEMERGENCYtracheostomytubechange.
SA Initial Mid Final
8b.1 Caneffectivelyaccessanduseallemergencyequipment
8b.2 Cansafely/effectivelyperformanemergencytracheostomytubechangeasperlocalprocedure(Localchecklistcompleted)(Thismaybedemonstratedonamanikin)
8b.3 Canidentifyandcontactthecorrectexpertairwaypersonnelasnecessary
8b.4 Canensurethatthepatientisreassuredandcomfortablepostprocedure,ensurethatanyproblems,concernsorheightenedobservationarehighlightedtothecorrectpersonnel.
8b.5 Candiscusshowtoreferthepatienttoahigherlevelofcare,andarrangesafetransfertothesame.
ITCProject:Non-medicalcompetenciesfortracheostomy/laryngectomycare-Templateforlocaladaptation.NTSP2018.Coe,B.,McGrath,B.,Lynch,J.,Firn,M.
Skill/Knowledge Assessment9.Cansafelymanageaninflatedtracheostomytubecuff.
SA Initial mid final
9.1 Candescribea“normal”tracheostomytubecuffpressurereading
9.2 Canidentifyandsafelyuseacuffpressuremanometerwhereapplicable.Thisincludescheckingafluidorfoam-filledcuffappropriately
9.3 Canaccuratelydocumentroutinetracheostomycuffpressureobservations
9.4 Candescribethesymptomsofatracheostomycuffleak,anddiscussthereportingandcorrectremedialactionsofthesame
9.5 Canaccuratelydocumentanytracheostomycuffleakissues,andactiontaken
Skill/Knowledge Assessment10.Canperformeffectivetracheostomy/laryngectomystomaandskincare
SA Initial Mid Final
10.1 Caneffectivelycleanandassessskinconditionofthetracheostomyorlaryngectomystomaasperlocalpolicy/procedure
10.2 Cansafelyperformroutinewoundswaboftracheostomyorlaryngectomystoma
10.3 Cansafelyselectandapplytheappropriatetracheostomyorlaryngectomystomadressing
10.4 Candiscusstracheostomy/laryngectomyskinandstomaproblems,andcorrectlyreferfortissueviabilityinput
ITCProject:Non-medicalcompetenciesfortracheostomy/laryngectomycare-Templateforlocaladaptation.NTSP2018.Coe,B.,McGrath,B.,Lynch,J.,Firn,M.
Skill/Knowledge Assessment11Candiscusstheeffectiveuseaspeakingvalve,anddifferentformsofcommunicationforapatientwithatracheostomy/laryngectomy
SA Initial mid final
11.1 Candiscussthedifferenttypesofspeakingvalvesavailablelocally
11.2 Canexplainhowone-wayvalveswork 11.3 Candiscusswhentheyareandarenot
appropriatetouseincludinglocalpoliciesforhead/neckorENTsurgery
11.4 Candemonstratehowtosafelyattachanddetachvalve
11.5 Candemonstratehowtocleanandstorethevalves(aspermanufacturersguidance)
11.6 Candiscussdifferentcommunicationmethodsi.e.penandpaper,iPad,picturechartsoralphabetcharts
11.7 KnowswhenandhowtorefertoSaLTforspecialistassessmentoradviceoncommunicationdifficulties
Skill/Knowledge Assessment12.Candemonstrateknowledgeoftheimportanceofexpertspeech,voiceandswallowinginputwiththetracheostomyorlaryngectomypatient
SA Initial mid final
12.1 Candiscussthephysicalandpsychologicalimpactofatracheostomyonapatient’sspeechandswallowing
12.2 Demonstratesunderstandingthatideally,alltracheostomypatientsshouldbereferredtoSaLTassoonasthedecisiontoweanfromsedationismade
12.3 KnowshowtorefertoSaLTlocally,andcandiscusswhentorefertoSaLT,asperlocalguidelines.
12.4 CollaborateswiththelocalSaLTteamtodevelopanindividualisedplanofcare
ITCProject:Non-medicalcompetenciesfortracheostomy/laryngectomycare-Templateforlocaladaptation.NTSP2018.Coe,B.,McGrath,B.,Lynch,J.,Firn,M.
Skill/Knowledge Assessment13.Cansafelytransferapatientwithatracheostomyorlaryngectomy
SA Initial Mid Final
13.1 Caneffectivelyidentifyandassemblethecorrectequipmentrequiredtosafelytransferapatientwithatracheostomyorlaryngectomy
13.2 Ensurealltheequipmentisingoodworkingorder
13.3 Canidentifyandensuretheallthepersonnelrequiredforasafetransferarepresent(whereapplicable)
13.4 Ensurethatthereceivingdepartment/ward/unitareawareofthepatienttransferareaware,andinagreementpriortotransfer
13.5 Effectivelyhandoverpatient,ensuringanyongoingissueswiththepatient’stracheostomyorlaryngectomyareidentifiedandunderstood
Skill/Knowledge Assessment14.Canaccuratelycompleteallrelevantlocaltracheostomy/laryngectomydocumentation
SA Initial Mid Final
14.1 Ensurethatafullcolourandcorrecttypeofbedheadsigniscorrectlycompletedandisclearlyobservableatthepatientbedspace.
14.2 Canaccuratelyrecordalltracheostomy/laryngectomyobservations
14.3 Demonstratestheabilitytoensurethatallrelevanttracheostomyorlaryngectomycareplansarekeptuptodate
14.4 Demonstratestheabilitytoensurethatanyissueswiththetracheostomyorlaryngectomyareclearlydocumentedinthemedicalandnursingnotesandhandovertotheappropriatestaff
ITCProject:Non-medicalcompetenciesfortracheostomy/laryngectomycare-Templateforlocaladaptation.NTSP2018.Coe,B.,McGrath,B.,Lynch,J.,Firn,M.
Skills/Knowledge Assessment15.Candemonstratetheknowledgerequiredtoeffectivelyweanapatientwithtracheostomyfrommechanicalventilatorysupport(ifapplicabletorole)
SA Initial mid final
15.1 Candiscusswhenitisappropriatetocommenceweaning
15.2 Canexplainwhoisresponsibleformakingtheweaningplans(localguidance)
15.3 Canexplainthestagesofweaning 15.4 Candiscusswhentodiscontinueweaning
programmes
15.5 Canexplainhowtomonitorthepatientduringweaning,includingsignsofrespiratorydistressorfatigue
Skill/Knowledge Assessment16.Candemonstrateknowledgeofthesupportthefamilyofatracheostomyorlaryngectomypatientrequires
SA Initial mid final
16.1 Candiscussthepsychosocialimpactonthefamily
16.2 Demonstratesawarenessoflocalfamilyeducationpolicyforthosethatwillbedischargedwithtracheostomyorlaryngectomy
16.3 Candiscussavailablefamilysupportafterdischargefromhospital
Skill/Knowledge Assessment17.Candemonstratetheskillsrequiredtocareforalaryngectomypatient(ifapplicabletorole)
SA Initial mid final
17.1 Candiscusstheanatomicalchangestotheairwayfollowingalaryngectomy
17.2 Candiscussthedifferenttypesoflaryngectomystomaequipment;
- Stomabutton- ‘Larytubes’- BaseplatesandHMEcassettes
17.3 Candemonstratehowtocleanavoiceprosthesis(aspermanufacturersguidance)
17.4 Canexplainhowtoidentifywhenavoiceprosthesismayneedchanging
17.5 Canidentifyandcontactthoseresponsibleforchangingtheprosthesis
17.6 Candiscussothermethodsofcommunicationi.e.electrolarynx,
ITCProject:Non-medicalcompetenciesfortracheostomy/laryngectomycare-Templateforlocaladaptation.NTSP2018.Coe,B.,McGrath,B.,Lynch,J.,Firn,M.
oesophagealspeech,ipadcommunicationapps
Skill/Knowledge Assessment18.Canperformsafesub-glotticsuction(ifapplicabletolocalpractice)
SA Initial mid final
18.1 Candescribeidentifythesub-glotticport 18.2 Candemonstratetheabilitytosafely
suctionthesub-glotticportasperlocalpolicy
18.3 Canaccuratelydocumentthesub-glotticportaspirates
Skill/Knowledge Assessment19. Can demonstrate awareness of ensuring safedischarge from hospital of a patient with atracheostomyorlaryngectomy
SA Initial mid final
19.1 Candiscussthedischargeprocess:- Registerwithambulanceservice- Contactelectricitycompanyto
prioritiseinpowercut- Set-upaccountwithconsumables
supplier- Follow-upappointmentfortube
change- GPandDistrictNursereferral- TracheostomySafetybox
19.2 Canexplainhowtoobtainaportablesuctionmachine/nebuliser/otheressentialequipment
19.3 Canexplaintheprocessofobtainingthenecessaryconsumables
19.4 Candiscusswhichconsumablesshouldbesentwiththepatientondischarge
19.5 Candiscusswhichcontactdetailswillbegivenshouldissuesariseondischarge(forexampleward,nursespecialist,physiotherapist)
ITCProject:Non-medicalcompetenciesfortracheostomy/laryngectomycare-Templateforlocaladaptation.NTSP2018.Coe,B.,McGrath,B.,Lynch,J.,Firn,M.
Acknowledgements:
Thankstothosethatsharedtheirexistinglocaldocumentswithus,namely:
EricaEveritt-TracheostomyNurseSpecialist,NorfolkandNorwichUniversityHospitalTrust.
PaulTwose-ICUleadPhysiotherapist,CardiffandValeUniversityHealthBoard.
AndrewHolroyd-CNSHeadandNeck,UCLHFoundationTrust.
ChristinaLamont-TracheostomyNurseSpecialist,RoyalLiverpoolandBroadgreenUniversityHospitalTrust.
SarahWallace-SaLTlead,ITCproject,ManchesterUniversityNHSFoundationTrust.
ToofthemultidisciplinarystaffandsiteleadsthattookpartintheITCresearchmeetings.
Majorreferences
ThorpeV,WallaceS,MorrowN,GinnellyA,McGowanS,ClarkeL,ReidK.‘RCSLTTracheostomyCompetencyFramework2014’https://www.rcslt.org/members/publications/publications2/tracheostomy_competency_framework
NCEPOD:Ontherighttrach?(2014)http://www.ncepod.org.uk/2014tc.html
ComprehensiveTracheostomyCare,theNTSPhandbook.Availablefromwww.tracheostomy.org.uk