CLINICAL GUIDANCE

PERFORMING ORAL AND NASAL SUCTION IN THE COMMUNITY

For use in: Target Audience: Purpose Document Author: Approved by: Ratified by: Policy Index No: Version Number: Effective From: Review Date: Statutory and legal requirements Implementation Lead Implementation Process Paediatric and Adult Community Health Services All Trust Clinical Staff caring for patients and children requiring oral and nasal suction Safe Delivery of Care Alison Sutch Clinical Guidelines Group or Equivalent Policy Sub-Committee (PSC) HStHCL277 2.0 February 2011 February 2014 Policy based on recommendations from the NHS Litigation Authority Alison Sutch Refer to attached dissemination plan

The Trust is committed to creating an environment that promotes equality and embraces diversity, both within our workforce and in service delivery. This document should be implemented with due regard to this commitment. This document seeks to uphold the duties and principles contained within the Human Rights Act. All Staff within the PCT should be aware of its implications. If clinical activity takes place i.e. examination, hand decontamination should take place before and after the procedure by following February 2014. After this date, this guidance and associated process documents may become invalid. All users should ensure that they are consulting the current version of this document.

Key individuals involved in developing the document (Internal Staff Only) Name(s) Alison Sutch Sally Adams Annette Dunning Designation Specialist Nurse Children with Disabilities Community Matron Childrens Community Nurse

Distributed to the following for approvals and comments Committee(s) Members of the Policy Sub Committee (PSC) Members of the Clinical Policies Guidelines Group (CPG) Individual(s) (Include email address of external individuals (NON NHS)) Carol Kerry Eleanor Marsh Denise Hogg Karen Twamley Sally Adams Sue Gray Viv Dunmore Lorraine Hodson Sue Davison Designation

Manager Physio /OT Services Manager Therapy Services Community Childrens Nurse Manager School Health Nurse Inclusion Lead Community Matron Special School Nurse (Halton) Special School Nurse Lead (St Helens) Clinical services manager Clinical services manager

Revision History and Version Control Revision Date Reason for Change Version No. By Who Version No.

10/02/2010 Reference update old Policy out of date review of procedures

1.0

A Sutch

2.0

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Table of Contents Introduction .................................................................................................................................. 4 Rationale...................................................................................................................................... 4 Audit............................................................................................................................................. 4 Glossary of Terms........................................................................................................................ 4 Equipment Required .................................................................................................................... 4 Catheter Sizes ............................................................................................................................. 5 Suction Pressures ........................................................................................................................ 5 Any other relevant information ..................................................................................................... 5 Assessing the need - for children/young people and adults not already receiving suction......... 5 Indication for Suction.................................................................................................................... 6 Training ........................................................................................................................................ 6 Consent........................................................................................................................................ 6 Equipment.................................................................................................................................... 7 Oral Suction-Yankuer Catheters .................................................................................................. 8 Oral Suction - Catheters............................................................................................................... 9 Procedure Naso-Pharyngeal Suction ......................................................................................... 10 Disposal/ reuse of equipment..................................................................................................... 12 References................................................................................................................................. 13 Appendix 1 ................................................................................................................................. 14 Appendix 2 ................................................................................................................................. 15 Appendix 3 ................................................................................................................................. 16 Appendix 4 ................................................................................................................................. 18 Appendix 5 ................................................................................................................................. 19 Appendix 6 ................................................................................................................................. 20 Appendix 7 ................................................................................................................................. 21

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INTRODUCTION
These guidelines have been devised to ensure that children/young people (aged 0-19 years) and adults who require suction are cared for safely within the provision of a holistic care package. These guidelines will provide clinicians with standardized, up to date, evidence based guidance on care of patients requiring suction. Normally people keep their airways clear by coughing, sneezing and blowing their noses. If a child, young person or adult is able to clear their airway independently by repositioning or encouraging the child to cough, this is always more pleasant. Suction can be traumatic and therefore should only be used where less invasive treatments are ineffective. Consideration should be given to alternatives such as medication to reduce secretions via a consultation with a paediatrician, consultant or General Practitioner. Suction is a method of removing excessive secretions and vomit from the airway, when the child, young person or adult is unable to do so themselves, preventing choking and aspiration and maintaining a clear airway.

RATIONALE
The rationale of this protocol is to promote good practice in performing oral and nasal pharyngeal suction within the community. The guidelines aim to ensure safe procedure by professionals working within the children/young people and adults services within Halton and St Helens undertaking this role. Suction is a skilled procedure that requires appropriate training and competence

AUDIT
This policy will be audited annually using audit tool (appendix 2) Monitoring of near misses/clinical incidents in line with PCT policy using form IR1 (available from service manager) Review of training to update skills annually (appendix 3)

GLOSSARY OF TERMS
Refer to Appendix 1. Glossary of terms.

EQUIPMENT REQUIRED
Suction Machine Suction Catheters/Yankeurs Connection Tubing Cool Previously Boiled Water (stored in a clean container with a lid) Gloves (clean or sterile) Hand gel Leaflet/information for correct cleaning of suction machine All equipment should be used and discarded according to the manufactures guidelines.
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All catheters and equipment should be checked for size and expiry date

Catheter Sizes
The catheter size should be recorded in the clients care plan

AGE

CATHETER SIZE

Premature baby Baby to 1 yr Toddler Preschooler School age Adolescent/ Adult

6 fr 8fr 10 fr 10fr 10-12 fr (normally 10) 12-14 fr

Suction Pressures
The suction pressure to be used should be recorded in the clients care plan
AGE SUCTION PRESSURES

Premature baby Baby to 1 yr toddler preschooler School age Adolescent/adult

80-100mmhg 80-100mmhg 100-120mmhg 100-120mmhg 100-120mmhg 120-150mmhg

ANY OTHER RELEVANT INFORMATION Assessing the need - for children/young people and adults not already receiving suction
a. It is the responsibility of the multi-disciplinary team to assess the need for suction. This should be completed in collaboration with the patients consultant, G.P. physiotherapist and fully discussed with the child parents/guardian.

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b. Careful consideration needs to made when considering long term suction in the community. Where possible alternatives such as medication to dry secretions, postural drainage and positioning should be contemplated in the first instance. c. Children young people and adults who have difficulty clearing their airways must also be assessed for the correct equipment such as seating and sleep systems

Indication for Suction

A child, young person or adult may need suction when: a. They are having difficulty dealing with their own secretions, or have excessive secretions. b. To prevent recurrent chest infections. c. They are unable to expectorate secretions adequately due to reduced function, such as Duchennes Muscular Dystrophy or COPD. d. To be used when necessary with other equipment such as Cough Assists to prevent infections and maintain clear airways e. Nasopharyngeal suction may only be considered for extreme life threatening incidents due to the invasive nature of this suction

Training
a. Staff will be trained and assessed as competent to administer suction by the Registered Community Nurse on an individual named child basis in childrens services. In adult services staff must be trained and competent to undertake this procedure. b. It is the responsibility of the trainee to keep their training up-to-date c. Nurses are responsible for maintaining and developing their competency and performance in line with NMC.

ACTION 1.

RATIONALE

Consent

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a. Consent should be obtained prior to each episode of suction verbally from the client where possible b. Consent should be obtained by the patient or the child / young persons guardian before undertaking the procedure and recorded in the health record. c. The consent should include; type of suction, size, correct pressure and type of suction catheter. (Appendix 5)

In line with Halton & St Helens PCT (2009) Consent to Examination or Treatment Policy

To ensure there is an agreed care plan. d. Each client should also have a care plan written out lining their specific needs

2.

Equipment
a. Halton and St Helens PCT should supply a suction machine for the use of the individual client b. Staff must ensure that the machine has been serviced and is working, with full instructions c. Please refer to suction pressure chart to ascertain the pressure for nasal suction on page 5. d. All the equipment for performing suction at home will be supplied by the childs General Practitioner, Health Visitor, District Nurse or the Community Childrens Nurses this includes:i. Suction catheters of the correct size and type for the individual. Choose smallest size possible. See chart on page 5 for
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To ensure that safety is maintained.

To reduce the degree of trauma caused to the mucosal wall.

catheter sizes. ii. The connection tubing (change used tubing at home every day) Gloves

iii. 3.

Oral Suction-Yankuer Catheters

i. Assess the need for suction by assessing the clients respiratory system, observing for increased effort of breathing, changes in colour and/ or increased pulmonary secretions. Reassure the client. Explain procedure. Put client in appropriate position Wash and dry hands according to infection control policy. Assemble the equipment: Turn suction machine on and check that it is working. Open yankaur and attach to suction tubing without removing cover completely. Put glove on your dominant hand. Hold the yankaur in the gloved hand and the vent in the nongloved hand without letting the yankaur touch anything. If the yankaur is unvented bend the connection tube in the ungloved hand to prevent sucking. With the thumb over the vent but not covering, insert the catheter gently into the mouth, clear secretions from buccal spaces and the back of the mouth. Put the thumb over the vent to suck secretions Do NOT pass the yankaur past the back of the teeth/buccal space Discard yankaur inside the glove To ensure that a base line assessment has taken place so that the client can be continually assessed throughout the procedure for any complications and to ensure that suction is required. To gain co-operation of client. To reduce the risk of aspiration To reduce risk of infection in accordance with PCT policy.

ii.

iii. iv. v. vi.

vii. viii.

To maintain hygiene

ix.

Avoid over stimulating the gag reflex. To avoid vomiting

x.

xi.

To ensure early detection of any

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xii.

xiii.

xiv.

xv.

xvi.

without touching the catheter. Yankaurs will be changed according to need and clients specific care plan Assess the need for further suction. Allow client to rest for 35 breaths before repeating the procedure-if required Monitor type and amount of secretions obtained, observing for changes in colour and consistency. Monitor client during and immediately after suction procedure, observing for any changes in respiratory status such as changes in colour and breathing pattern. If the client deteriorates during the suction procedure. Stop suction and call for help. Initiate resuscitation measures until childs baseline observations are normal. Flush suction tubing with cooled boiled water/sterile water and switch off suction machine.

complications of suction that may require intervention.

To prevent further deterioration and promote full recovery

In order to maintain good hygiene and maintenance of the machine. To discourage growth of micro organisms

4.

Oral Suction - Catheters

i. Assess the need for suction by assessing the clients respiratory system, observing for increased effort of breathing, changes in colour and/ or increased pulmonary secretions. Wash and dry hands according to infection control policy. Assemble the equipment: Position client, explain that they are going to have suction. Turn suction machine on and check that it is working. Open suction catheter and attach to suction machine without removing cover completely. Put glove on your dominant hand. Remove cover from suction catheter To ensure that a base line assessment has taken place so that the client can be continually assessed throughout the procedure for any complications and to ensure that suction is required. To maintain safe hygiene To reduce the clients distress

ii. iii. iv. v. vi.

To maintain hygiene

vii.

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viii.

ix.

xvii.

x.

xviii.

xix.

xx.

xxi.

xxii.

Hold the catheter in the gloved hand and the vent in the nongloved hand without letting the catheter touch anything. With the thumb over the vent but not covering, insert the catheter gently into the mouth, clear secretions from buccal spaces and the back of the mouth. Do NOT pass the suction catheter past the back of the teeth/buccal space. Avoid over stimulating the gag reflex Discard suction catheter inside the glove without touching the catheter. Assess the need for further suction. Allow client to rest for 35 breaths before repeating the procedure-if required Monitor type and amount of secretions obtained, observing for changes in colour and consistency. Monitor client during and immediately after suction procedure, observing for any changes in respiratory status such as changes in colour and breathing pattern. If the client deteriorates during the suction procedure. Stop suction and call for help. Initiate resuscitation measures until clients baseline observations are normal. Flush suction tubing with cooled boiled water/sterile water and switch off suction machine.

To avoid vomiting

To ensure early detection of complications such as infection To ensure early detection of any complications of suction that may require intervention.

To prevent further deterioration and promote full recovery

In order to maintain good hygiene and maintenance of the machine. To discourage growth of micro organisms

5.

Procedure NasoPharyngeal Suction

i. Assess the need for suction by assessing the clients respiratory system, observing for increased effort of breathing, changes in colour and/ or increased pulmonary secretions. Wash and dry hands according To ensure that a base line assessment has taken place so that the client can be continually assessed throughout the procedure for any complications and to ensure that suction is required. To maintain safe hygiene In order to maintain good hygiene and

ii.

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iii. iv. v. vi.

vii.

viii.

ix.

x. xi.

xii. xiii.

xiv. xv.

xvi. xvii.

to infection control policy. Assemble the equipment: Position client, explain that they are going to have suction. Turn suction machine on and check that it is working. Open suction catheter and attach to suction tubing without removing cover completely. Put glove on your dominant hand. Gently withdraw the catheter from the packaging ensuring the part of the catheter that will enter the nose does NOT touch anything Hold the catheter in the gloved hand and the vent in the nongloved hand without letting the catheter touch anything. With the thumb over the vent but not covering pass the suction catheter into the nostril along the top of the nose as this allows the catheter to follow the angle of the nostril Pass catheter only till a cough is solicited Cover the vent hole with the nongloved hand and withdraw the catheter. Gently rotate catheter between thumb and index finger while suctioning and withdrawing. DO NOT SUCTION FOR MORE THAN 10 SECONDS AT A TIME AND ALLOW RESTS BETWEEN SUCTION PERIODS Repeat in second nostril. Check the clients mouth; if secretions appear then gently suction the back and sides of mouth with a new suction catheter. Avoid over stimulating the gag reflex Discard suction catheter inside the glove without touching the catheter. Wash hands. Assess the need for further suction. Only repeat the process if necessary. Allow client to rest

maintenance of the machine. To discourage growth of micro organisms

To maintain safe hygiene

Too prevent stimulation of vagus nerve Prolonged suction can produce contraction of the laryngeal muscle, slow pulse and irregular heartbeats due to vagal nerve stimulation and loss of oxygen. During suction the client receives less oxygen than normal therefore the process should not be prolonged.

Too frequent suction leads to over stimulation of secretions.

To ensure early detection of complications

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xxiii.

xxiv.

xxv.

xxvi.

xviii.

for 3-5 breaths before repeating the procedure-if required Monitor type and amount of secretions obtained, observing for changes in colour and consistency. Monitor client during and immediately after suction procedure, observing for any changes in respiratory status such as changes in colour and breathing pattern. If the client deteriorates during the suction procedure. Stop suction and call for help. Initiate resuscitation measures until clients baseline observations are normal. Flush suction tubing with cooled boiled water/sterile water and switch off suction machine. Observe breathing rate and effort, and the sound of the breathing

such as infection To ensure early detection of any complications of suction that may require intervention.

To prevent further deterioration and promote full recovery

In order to maintain good hygiene and maintenance of the machine. To discourage growth of micro organisms

6.

Disposal/ reuse of equipment

a. The suction catheters are single use only. They may be used on a single occasion of suction. b. The suction tubing is changed daily or assessed on an individual bases in line with infection control policy. c. The suction bottle is washed with warm soapy water everyday. The outside may be cleaned with alcohol. The suction bottles are for single patient use only. To maintain safe hygiene in line with the PCT Waste Management Policy and Infection Prevention & Control Policy No1 Standard Precautions.

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REFERENCES
Reference Birmingham East And North (2009) Oral and Tracheostomy Suction Policy Halton & St Helens PCT (2009) Infection Prevention & Control Policy No 1 Standard Precautions Halton & St Helens PCT (2009) Infection Prevention and Control Policy No 24 Waste Management Halton & St Helens PCT (2009) Consent to Examination or Treatment Policy Herd. L. (2006) Information For Carers and Young People Who Require. Oral Suction. The Coventry and Warwickshire's Children's and Young People's Teaching and Assessment Framework Herd, L., (2007) Information for Young Peoples Who Require Nasopharngeal Suction. The Coventry and Warwickshire's Children's and Young People's Teaching and Assessment Framework Huband Sand Trigg E (2000) Practices in Childrens Nursing Guidelines for Hospital and Community. Churchhill Livingstone, Edinburgh Moore T (2003) Suction techniques for the removal of respiratory secretions, Nursing Standard, 18,9,47-53 Relevance (whole document or section, please state) Whole Whole Evidence Grade E E

Whole

Whole Whole

E E

Whole

Whole

Whole

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APPENDIX 1
Glossary of Terms
Buccal Space The buccal space is the area between the cheek and gums, or between the teeth and the buccal mucosa or buccal membrane Yankauer suction catheter A rigid hollow plastic tube with a curve at the distal end to facilitate the removal of thick pharyngeal secretions during oral pharyngeal suctioning Non-registered staff Staff not registered with Nursing and Midwifery Council. Community setting Any setting within the community, such as home, school, nursery. Named carers Staff specifically trained for a named individual. Child/young person A person aged between 0-19 years.

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APPENDIX 2

CLINICAL GUIELINES FOR THE CLIENT REQUIRING ORAL OR NASAL SUCTION IN THE COMMUNITY AUDIT TOOL

Date.

ACTION A consent form has been signed (appendix 8) or record held of verbal consent.

NURSES SIGNATURE

Client has an up to date care plan.

Update training has been carried out or arranged

Date equipment has been serviced.

It is the responsibility of the Registered Nurse to ensure that annual audit of practice is carried out on all children/young people and adults requiring oral or nasal suction in the community setting.

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APPENDIX 3

TRAINING CHECKLIST FOR ORAL/NASOPHARYNGEAL SUCTION OF CLIENTS IN THE COMMUNITY CHECKLIST

NAME OF TRAINEE

DATE OF TRAINING

Knowledge & Technique

Understanding the reasons for suctioning a client. Able to recognise when suction is necessary. Be familiar with the mechanics and equipment. Understand the adverse effects of nasopharyngeal suction.

Date/Trainers Signature

Date/ Trainee Signature

Observe and Demonstrate

Approach and explain procedure at the clients level of understanding. Wash hands, wear gloves when handling sterile catheter. Correct entry with catheter (no suction) to correct depth. Correct withdrawal of catheter, applying
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suction whilst rotating catheter between finger and thumb Correct disposal of catheter and rinsing of tube Comfort and reassure the client Observe effect of suction and respiratory rate Document event and effect. Maintain cleaning routine of machine and equipment

REMEMBER: If the clients condition deteriorates and causes concern summon medical assistance or call 999

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APPENDIX 4

Oral and Nasal Suction

Authorisation for designated carer to undertake the task of Oral Suction / and or Nasal Suction when appropriate. (Delete where appropriate) Name of carer The above carer has received training and is competent to undertake the technique of Oral Suction / Nasal Suction (Delete where appropriate)

Trainer

Signature

Date ..

Agreement by carer I Agree that I have received training and feel confident to undertake the technique of Oral / Nasal Suction

Carers signature

Date

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APPENDIX 5

INDIVIDUAL CONSENT FORM

Please tick where appropriate 1. Administration of oral suction using a yankuer suction catheter as required by trained carers 2. Administration of oral suction using a size.suction catheter as required by trained carers 3. Administration of nasal suction using a sizesuction catheter as required by trained carers The pressure setting on the suction machine should not exceed . mmhg I/we hereby give consent for my/our child..to receive suction / I give consent to receive suction as indicated above whilst in community setting or whilst transported to and from community setting.

Signature. Print.. Relationship to child Date..

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APPENDIX 6
EQUALITY IMPACT ASSESSMENT TOOL
To be completed with the corporate document when submitted to the appropriate committee for consideration, approval and ratification. Yes/No 1. Does the corporate document affect one group less or more favourably than another on the basis of: Race Ethnic origins (including gypsies and travellers) Nationality Gender Culture Religion or belief Sexual orientation including lesbian, gay and bisexual people Age Disability - learning disabilities, physical disability, sensory impairment and mental health problems No No No No No No No No yes Each person would need to be assessed on an individual basis Comments

2. 3.

Is there any evidence that some groups are affected differently? If you have identified potential discrimination, are there any exceptions valid, legal and/or justifiable? Is the impact of the policy/guidance likely to be negative? If so can the impact be avoided? What alternative are there to achieving the policy/guidance without the impact? Can we reduce the impact by taking different action?

No No

4. 5. 6. 7.

No

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APPENDIX 7
DISSEMINATION AND TRAINING PLAN
To be completed with the corporate document when submitted to the appropriate committee for consideration, approval and ratification. The status column must be given a Red, Amber or Green rating with evidence to demonstrate an action has been completed. DISSEMINATION PLAN
Title of document: PERFORMING ORAL AND NASAL SUCTION IN THE COMMUNITY Date finalised: 10/02/2010

Dissemination Lead: Alison Sutch Lorraine Hodson Proposed action to retrieve out-of-date copies of the document: To be disseminated to: Childrens community services District Nurses Trust Times Team Brief Training sessions (Give Details Below) Other (Give Details Below)

Previous document already being used? If yes, in what format and where? Paper Withdraw from the internet/intranet/portal Disseminated by whom? Alison Sutch Lorraine Hodson Timescale (Date) Feb 2011 Status

Yes

RAG

Paper or Electronic Electronic

Comments

To be place on the Document Portal on the intranet

IMPLEMENTATION PLAN
Training Timescale Owner Status

RA G
Training Event (Please provide details of available training venues/dates to educate staff about this document) Training will be provided on an individual basis

Training Plan Lead (Please provide details of staff who will be responsible for overseeing this training) Compliance Monitoring Timescale Owner Status

RA G
Methodology to be used for monitoring/audit (please include PCT Audit Proposal Form) Responsibilities for conducting monitoring/audit Audit tool with appendices 12 months Practitioners

Practitioners

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Frequency of monitoring/audit (e.g. annually, 6 monthly etc) Process for reviewing/reporting results

Annually Within Clinical Supervision, peer review

Denotes: Action not yet taken or deadline for action not met. Action plan to address this must be provided. Denotes: Action partially implemented. Denotes: Action complete.

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