Which action may be delegated to the PSW regarding the care of a patient with tracheostomy?

Posted by Steve Jones

Sat, Oct 18, 2014

Under Ontario law, certain actions, called controlled acts, may only be performed by qualified health professionals, such as nurses, physical therapists or doctors. These include such diverse activities as diagnosing diseases, setting fractured bones, prescribing drugs, and dental work. Each medical professional is authorized to perform the acts of their profession, but not those of other professions. You wouldnt want a cardiac surgeon to perform a root canal, or a dentist to operate on your heart.

Under certain circumstances, however, controlled acts can be delegated to others to ensure that you receive health care in a timelier manner or to optimize resources and personnel. When someone is receiving personal care support in their home, certain acts require a registered nurse or other health professional, such as a physical therapist, to perform them, even though it might be inconvenient or cost-prohibitive to pay a nurse to do them.

Ontario law allows a personal support worker (PSW), under certain circumstances, to perform some of these acts, including:

• Administering medication, especially by injection, inhalation or insertion
• Exercises for range of motion, strength and balance
• Wound and ostomy care
• Catheter care
• Bowel routines and colonic irrigation
• Applying compression stockings
• G-tube feeding
• Using specialized equipment

There are several requirements for delegating controlled acts:

1. The act must be routine for the client. It must be something done on a regular basis, such as insulin injections and using asthma inhalers, not necessarily every day but routinely.
2. The clients condition must be stable. For instance, a PSW would not be authorized to give insulin injections to a newly diagnosed diabetic whose blood sugar is not yet under control. The consequences of too much or too little insulin are severe, possibly even life-threatening.
3. The expected result of performing the act is known, thus the PSW can observe the client for any unusual or irregular reactions.
4. The PSW must be fully trained to perform the act. Training involves one to three teaching sessions in the clients home with the appropriate professional demonstrating the procedure and then supervising the PSW while they perform the task. Only when all parties feel comfortable that the training is sufficient can the PSW perform the task without direct supervision. Each delegated task is individualized, not only to the task itself, but also to the client for whom it is performed.

Considerations for Clients

How do you know when to trust a PSW to perform the tasks that are normally reserved for trained professionals? How do you,the client, know that the PSW is up to the task? Here are a few things to look for when selecting someone to help with such critical job:

• Learn the policies of the PSWs employer. Does the agency provide the same PSW each day or are PSWs rotated and scheduled based on who is available, rather than a specifically assigned person or team?
• Is the PSW supervised by a registered nurse or other professional health care provider?
• Is the PSW fully trained? Did they receive training in your presence or just a generalized this is what you do… session when they were hired?

At Qualicare, every case is managed by a registered nurse, so we are in a unique position to set policies and develop care plans that include teaching and monitoring our PSWs so that they are legally permitted to perform controlled ac

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In any airway emergency, oxygenation is the priority. It might be necessary to re-insert a new tracheostomy tube or other tube into the airway, but often, a patient can be (re)oxygenated by less invasive means. A stable, more oxygenated patient is in a much better position to tolerate airway procedures.

If a tracheostomy tube is removed, it can be difficult to know where and how to apply oxygen, as you have two potential airways to manage. Tracheostomy patients may have an altered upper airway which can make delivery of oxygen via the nose and mouth difficult or impossible.

If a patient is breathing spontaneously, applying oxygen to the stoma can be life saving. If they are not breathing, a small or paediatric face-mask, or supraglottic airway (such as a Laryngeal Mask Airway) can be applied to the stoma. This generates the seal required to deliver ventilation breaths. Gas may escape via the upper airways, and a second responder may need close the mouth and nose to allow effective ventilation.

Of course, if the patient has had a laryngectomy, then the stoma is the only route for delivering oxygen to the lungs.

If these methods fail, then attempt face-mask oxygenation or ventilation via the upper airways. [link to the ventilation via the face page]. More invasive methods of managing the airway may be required, such as re-insertion of a new tracheostomy or small endotracheal tube into the stoma, or intubation of the upper airways. These techniques may be difficult and require specialist equipment and staff.

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