Trachs in the Pool!

The Ranken Jordan Pediatric Bridge Hospital team has found yet another way to provide Care Beyond the Bedside by taking a patient with a tracheostomy (trachs) into the pool for the first time at the hospital.

This incredible advancement in therapy was possible through careful planning, research and dedication from team members who are committed to safety—and playful healing for patients.

Ranken Jordan is the only pediatric hospital in the area to offer this opportunity to children with trachs. Pool therapy for kids with trachs isn’t common because of the risk of getting water in the airway, but a few hospitals around the country do it successfully. Ranken Jordan is now one of those.

Safety is paramount in the effort.

Combining Expertise to Keep Kids Safe

The goal to get kids with trachs in Ranken Jordan’s warm water therapy pool began in earnest in February 2020 after Sally Katz, PT, a physical therapist at Ranken Jordan, took a professional course focused on how to safely provide therapy in the pool for patients on ventilators.

“This spurred me to look into the idea further,” Sally says.

Sally has extensive aquatic therapy training and experience since she began at Ranken Jordan in 2004. Determined to help more kids experience pool therapy benefits, she turned to her colleague, Gabe Wood, BHS, RRT, respiratory therapy educator. Sally and Gabe then co-led a work group to research and plan a pool policy for kids with trachs at Ranken Jordan. The work group included eight Ranken Jordan team members from a cross-section of areas.

Gabe wears many hats as an educator, including onboarding new respiratory therapists, and educating nurses, medical staff, child life specialists, recreation therapists and other health care providers about how to keep kids on a ventilator safe when they are out of their rooms. He also provides caregiver training.

In addition, Gabe is co-chair of Ranken Jordan’s Emergency Response Team. He is responsible for preparing Ranken Jordan team members for emergencies and identifying where more training and education is needed.

The combination of a safety focus and therapeutic expertise that Gabe and Sally bring provided a solid foundation to build a pool policy for kids with trachs.

“With fresh eyes, we sat together and looked over other successful policies line by line,” Sally says. Sally also did extensive research and talked to experts around the country.

“This has been a goal for us for a while so we’re excited to finally do it,” Gabe says. “My role is focused on safety and emergency responses. I also help identify which patients with trachs are most appropriate for pool therapy.”

The pandemic slowed their efforts but the work group developed a pool protocol that rolled out in 2022 based on policies and experiences of other leading institutions. The policy was reviewed internally as well as by an expert physiatrist in the country who wrote a book on how to safely take patients with trachs in the pool.

The Ranken Jordan policy follows stringent requirements to keep kids with trachs safe. Two trained people must be in the pool at all times and a respiratory therapist or nurse must stand ready poolside along with an assortment of lifesaving emergency equipment. Trachs are covered by a Thermovent — a special filter — and children can’t be in water above mid-chest. No other kids are allowed in the pool while a child with a trach is in the water. Each child’s physician must approve aquatic therapy.

The team also developed criteria about who is eligible for pool therapy. Children must be able to follow commands, tolerate being off their ventilator, and be medically stable with no infections, diarrhea or active skin disease.

“Getting kids with trachs in the pool requires extra time and coordination,” Sally says. “It takes real teamwork.”

Expanding Pool Therapy Benefits

With a growing number of patients using trachs or ventilators, the policy is right on time to open the door for more kids.

“Nine out of 10 kids here are on trachs or ventilators so that brings limitations,” Sally says. “But I’m excited that now we can get more kids in the pool to move so they can get stronger and have more sensory experiences to help in development.”

The benefits of aquatic therapy are far-reaching. Ranken Jordan’s warm water therapy pool is maintained at 92°F — like a warm bathtub.

“Many kids are scared of new things because they haven’t had as many opportunities to try new things, especially if they’ve lived with a trach,” Sally explains. “The warm water is relaxing and calming and the buoyancy of the water allows children to float and move more easily.”

In addition, she says the hydrostatic pressure — the pressure the body feels in the water — helps children develop a sense of awareness about where their body is and improves the blood return to the heart.

“Kids at Ranken Jordan are often delayed in their sensory awareness.” Sally says. “Or if they’ve had a spinal cord injury, sometimes they have to relearn things. In the pool, they feel safer. The water holds them up and they learn to plan their movements. Plus it’s fun.”

The water resistance also helps strengthen muscles and helps with breathing.

“When a child has been in bed for a long period or is non-weight bearing, the muscles may not fully develop or are weakened,” Gabe says. “The pool helps to build muscle and movement, including improving respiratory muscle strength, and it speeds healing.”

A Wave of Smiles and Splashes

The first patient with a trach to enjoy the pool was 5-year-old Lisa, a long-term patient. Sally has worked with Lisa since she was 1. Born with a severe heart defects, Lisa was extremely fragile when she arrived at Ranken Jordan four years ago. She couldn’t sit up or communicate and was dependent on a ventilator to help her breathe.

Through diligent therapy and daily play, Lisa made remarkable progress. By the time she left Ranken Jordan in November 2022, Lisa could walk and breathe on her own, although she still had a trach in place.

Before Lisa went home, Sally and the team made it their mission to help Lisa get into a pool for the first time in her life.

“We all wanted to make it happen for her,” Sally says. “Everyone wanted Lisa to be the first child to do this. Her smile just makes your day and she was a good candidate for it.”

Since a pool was a new experience for Lisa, Sally introduced her to the water slowly. “First she sat at the edge of the pool and kicked her feet. Then she was ready and had no anxiety. Lisa loved it. She couldn’t jump on land but she could bounce in the water.”

“This is something Lisa never got to do before,” Gabe adds. “She was all smiles while she did therapeutic games. After 40 minutes, she didn’t want to get out of the pool. The experience justified to us that this is important to do and it can be done safely.”

Team members from across the hospital came to watch Lisa swim for the first time. “It was a mix of nervousness and excitement,” Gabe says. “We were constantly on alert. When Lisa was done, we had lots of hugs, tears and high-fives with the team.”

Lisa’s mom wasn’t able to be there to watch Lisa in the pool in person so the child life team arranged to livestream it so her mom could watch virtually.

Gabe says when parents go home with their child, some want to take them to the pool. “We teach them to do it safely rather than learning by watching YouTube videos.”

Sharing Knowledge and Experience to Help More Kids

Ultimately, the Ranken Jordan team plans to collect data and share their knowledge about pool therapy and safety for kids with trachs with other health care professionals and organizations.

“This new pool opportunity for kids with trachs fits with our mission and is another example of Care Beyond the Bedside,” Gabe says. “Our goal is to allow kids to do more things in life and get them out of bed. At Ranken Jordan, we’re working on a ‘Can Do’ program to help kids do more than they ever thought they could. We allow kids to be kids.”

He continues: “This pool experience breaks past barriers and shows we can do scary things in a safe way. And we’re the right team to push this forward with the goal of benefiting more kids. We hope it catches on with other hospitals as we show them what’s possible.”