Provox HME System for Laryngectomy Patients

1. Provox HME System for Laryngectomy Patients Dani Donegan ENT Clinical Nurse Operating Theatre NWRH Tasmanian Health Organisation: North West • Project Outline and Communication Strategies • After attending a Laryngectomy Rehabilitation Workshop in July 2012, I realised there was a far better system available to manage our laryngectomy patients. An audit of the number of laryngectomy patients on the NW coast was conducted. Information regarding funding projects for this particular system was gathered from Hobart and NSW. The key stakeholders at this hospital were approached and the project was launched. • Education sessions were rolled out for staff and a workshop was held. The workshop was multidisciplinary and included 3 laryngectomy patients, the ENT surgeon and speech pathologists. This workshop was used to educate the patients, carers and staff on how to correctly use this system and the benefits of it. The 3 attending patients were given the system to trial with close follow up and support. • Following the success of the workshop and submission of the business plan for funding, approval to use the Provox Heat & Moisture Exchanger (HME) system was given by the General Manager to use on future laryngectomy patients. • Historically, laryngectomy patients have only ever received vocal rehabilitation1. Modern thinking indicates that a more comprehensive rehabilitation involving vocal, pulmonary & olfactory rehabilitation should be provided2. The nose conditions (heats, moistens & filters) inhaled air but this is lost following total laryngectomy. Breathing unconditioned air leads to: increased mucous production, coughing, forced expectoration, chest infections, symptoms of anxiety & depression, sleeping problems, social withdrawal, decreased breathing resistance (suboptimal blood-gas exchange), pulmonary function and overall quality of life. The Provox HME system plays a central part in pulmonary rehabilitation, becoming an ‘artificial nose’, providing inhaled air that is warmed & moistened. Studies have shown the use of HMEs, significantly reduce these pulmonary, physical and psychological problems, while improving pulmonary function, improving speech and overall quality of life3. • The use of HMEs for pulmonary rehabilitation has become the gold standard in many countries throughout the world & current post operative management offered at THO-North West did not meet this standard4. • Evaluation • A staff survey was conducted to evaluate the Provox HME system, the results of which were extremely positive with staff stating the overwhelming benefits for patients and nursing staff. • A letter of recommendation was submitted by one of the laryngectomy patients who had been introduced to the Provox HME system at the workshop. • Informal surveys from the patients and carers using the system indicated the benefits of using this system compared to previous practice. • Project Objectives • To provide the Provox HME system to current and future laryngectomy patients at minimal cost to them • To improve patient outcomes following laryngectomy with the implementation of the Provox HME system • To reduce post operative complications and readmission to hospital rates • To improve the patients quality of life following a laryngectomy • To reduce the laryngectomy patients hospital length of stay thereby decreasing costs to the organisation Project Outcomes & the difference this has made to patient quality of life There are currently 12 people in the North West community who have been laryngectomised for a number of years, of these, there are 2 who have been using the Provox HME system since November 2012 and one since March 2013. Prior to using the Provox HME system, these patients required frequent suctioning in their post- operative phase, due to the copious amounts of sputum they produced. They needed frequent nebulisation and humidification and often had a lot of dried secretions around their stoma which inhibited wound healing. As a result of the surgery, the patients felt socially isolated because of poor vocalisation, the visual aspects of the stoma, the embarrassment associated with the amount of sputum produced and concerns regarding hygiene/infection control risks from touching the stoma. All of these patients had frequent chest infections with some requiring hospital admissions. Since implementing the Provox HME system these patients have had significant improvement in their quality of life, with a significant reduction in sputum production and chest infections. They no longer require nebulisers nor humidification and report that their sleep has had a dramatic improvement. They report no longer feeing socially isolated as they are no longer embarrassed about the stoma. The Provox HME system provides a cover that is more hygienic and socially acceptable and, they have had a dramatic improvement in voicing. We have one patient who had a laryngectomy in May 2013 and received the Provox HME system at time of surgery. The patient did not require ventilation in the immediate post operative period and was transferred to the ward after spending one night in the HDU. He did not require humidification nor nebulisation while he was an inpatient and was only suctioned 3 times in total in the 12 nights he was admitted. The nursing staff surveyed found the system to be a huge improvement for patient care and easy to use. • Project Outputs • Guidelines incorporating a clinical pathway for the Laryngectomy patient. • Ongoing education for staff and patients • Funding for continued provision of existing and future laryngectomy patients • Better quality of life and reduced complications for our laryngectomy patients and families • Provision of a follow up and support service Person with the HME Provox system Example of the Provox HME system Conclusion The Provox system has revolutionised the way in which we manage our laryngectomy patients. The system has had a dramatic impact on their lives in that some people can return to work and they no longer feel socially isolated. They experience less psychological trauma and anxiety in the post operative phase and therefore have a more positive patient journey through the health care system. This system also provides a outpatient support service which was previously unavailable or provided ad hoc. Key Stakeholders EDON Nursing & Midwifery THO- NW Karen Linegar & ENT Specialist Mr Ghali Co Director Nursing Hayley Elmer General manager Denise Parry NWRH Theatre NUM Bill Kerr Acknowledgements Judy England senior Speech Pathologist NWRH. Molly Leatherbarrow Clinical Nurse Educator, surgical ward NWRH References: Bien S, Rinaldo A, et. al., History of voice rehabilitation following laryngectomy, Laryngoscope, 2008, Mar, 118(3):453-8.  Hilgers F, A practical guide to postlayngectomy vocal, pulmonary & olfactory rehabilitation, 4th ed. The Netherlands Cancer Institute. Clinical Affairs, Provox HMEs literature review, Atos MedicalAB, March 2012  Bien S, Okla S, et al, The effect of a heat and moisture exchanger (Provox HME) on pulmonary protection after total laryngectomy: a randomized controlled study, Eur. Arch. Otorhinolaryngol. (2010) 267:429-435. . Dani Donegan ENT Clinical Nurse Operating Theatre Brad Birleson NW Community Equipment Scheme Manager Judy England Senior Speech Pathologist Molly Leatherbarrow CNE Surgical Ward Patients & Community