Transferring a patient with an UWSD

Transfer of Care must be in line with bedside handover requirements and include verbal and written documentation.

All patients being transported from Operating Theatre, Radiology or Emergency Department with an UWSD bottle must have an RN escort or Enrolled Nurse (EN) who is accredited to care for UWSD.

• Never clamp an UWSD tube while transporting a patient.
• The UWSD bottle/s needs to remain below the patient's chest at all times.
• MO must document if a patient can come off suction for transfer to and the duration of a procedure. In the case of CXR — a portable CXR will be required unless removal of suction and adequate time off suction has been documented by MO.
• If suction is required during a procedure — arrangements must be made for suction to be set up prior to transfer.
• For showering a patient, extension tubing may be applied to existing tubing or a MO must document that suction may be paused during showering.
• Large bore catheter attached to UWSD must have clamp(s) available on transfer - note for use only in an emergency situation.
• Small bore catheter can use the three way tap (if present) or locking mechanism for use in an emergency situation during transfer.
• Provide handover including instructions on care of the specific UWSD.

Observations

Patient Observations

Frequency — minimum four hourly

Physical assessment to include particular attention to the respiratory status:

• observe for the development of respiratory distress
• chest auscultation to listen for bilateral air entry
• RR, SpO2, HR, BP, temperature and capillary refill
• pain assessment
• record baseline observations of the drainage system
• bowel motions when narcotic and codeine based analgesia is ordered.

Observation of UWSD

Regular and accurate observation of air leak, oscillation and drainage which is documented on an UWSD chart is essential.

Limitations for Practice. Observations are performed by an RN or EN (an EN must be specifically instructed in the procedure and the RN remains responsible reviewing the observations and for interpretation of measurements). See Appendix 6 Guidance for assessing competency in pleural procedures for advanced trainees and specialist nurses.

• Observations are recorded on UWSD Chart. See Appendix 7 Chest drain observation chart.
• Frequency recommended hourly.
• Check insertion site and tube for dislodgement each time UWSD observations are performed to ensure patient safety.
• Measure and record depth of ICC insertion at the skin 4/24.
• If suction is applied — check suction is set at the correct pressure.

Air leak

Air leak is indicated by bubbling in UWSD bottle.

A sudden large volume air leak may indicate bronchopleural fistula.

Sudden cessation of air leak may indicate malfunction of UWSD system — look for tube occlusion, tube disconnection, patient sitting on the tube or kinking.

Documenting air leak

++++

Large amount, bubbling all the time e.g. large pneumothorax, large excessive intra thoracic pressures on inspiration and expiration

+++

Moderate amount, bubbling on every spontaneous expiration, or positive ventilated breath in patients receiving mechanical ventilation

++

Minimal amount, bubbling when talking or small air leak, occasionally on spontaneous or ventilated breath (mechanical breath)

+

Bubbling on forced expiration e.g. cough

Nil

No Bubbles

Oscillation (Respiratory Swing)

Oscillation reflects changes in intrathoracic pressure during breathing and is indicated by movement of fluid in the tube.

Oscillation is observed when the patient is NOT on suction.

Record oscillation as present - it is not necessary to quantify oscillation.

When suction is applied

• Removal of suction for observations should only performed when this is clearly defined and documented within a unit or facility protocol and the instruction and frequency is clearly documented
• Oscillation does not occur when suction is applied (UNLESS patient has had major thoracic surgery with large intrathoracic volumes)
• Where a patient is on suction, staff generally do not disconnect from suction to check for oscillation but document 'on suction' on the UWSD observation chart. Measurement of fluid level in UWSD must be performed on suction and documented as such.
• Removal of suction breaks the seal and delays patient progress.

Absence of Oscillation

If Oscillation is absent, it may mean one of four things:

• The patient is lying on the tube, leading to occlusion of the drain.
• The tube is blocked. If examination reveals no kinking and changing the patient's position does not rectify the problem, the absence of a swing should be reported to the medical officer.
• The chest tube has been dislodged and is no longer within the pleural space.
• The lung has fully expanded.