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Epperson MV, Mahajan A, Sethia R, Seim N, VanKoevering K, Morrison RJ. A deployable curriculum with 3D printed skills trainers for altered airway management. BMC MEDICAL EDUCATION 2024; 24:39. [PMID: 38191417 PMCID: PMC10773045 DOI: 10.1186/s12909-023-05013-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/26/2023] [Accepted: 12/26/2023] [Indexed: 01/10/2024]
Abstract
BACKGROUND Altered Airway Anatomy (AAA), including tracheostomies and laryngectomies, may represent an area of unease for non-Otolaryngology trainees, due to a lack of exposure, structured education, or dedicated training in altered airway management. Inability to effectively stabilize an altered airway is associated with significant risk of patient morbidity and mortality. This study aims to assess the efficacy of a concise curriculum using three-dimensional (3D) printed airway models for skill training in improving Anesthesiology trainees' competency in AAA management. METHODS A prospective cohort of 42 anesthesiology residents at a tertiary care institution were guided through a 75-min curriculum on AAA, including case discussion, surgical video, and hands-on practice with tracheostomy and laryngectomy skills trainers. Pre- and post- course surveys assessing provider confidence (Likert scale) and knowledge (multiple choice questions) were administered. Additionally, an observed skills competency assessment was performed. RESULTS Self-perceived confidence improved from a summative score across all domains of 23.65/40 pre-course to 36.39/40 post-course (n = 31, p < 0.001). Technical knowledge on multiple choice questions improved from 71 to 95% (n = 29, p < 0.001). In the completed skills competency assessment, 42/42 residents completed 5/5 assessed tasks successfully, demonstrating objective skills-based competency. CONCLUSIONS This study demonstrates an improvement in anesthesiology resident self-assessed confidence, objective knowledge, and skills based competency surrounding management of patients with AAA following a 75-min simulation-based curriculum.
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Affiliation(s)
- Madison V Epperson
- Department of Otolaryngology-Head & Neck Surgery, University of Michigan, 1500 E. Medical Center Drive, Ann Arbor, MI, 48109-4241, USA.
| | - Arushi Mahajan
- University of Michigan Medical School, Ann Arbor, MI, USA
| | - Rishabh Sethia
- Department of Otolaryngology-Head & Neck Surgery, The Ohio State University, Columbus, OH, USA
| | - Nolan Seim
- Department of Otolaryngology-Head & Neck Surgery, The Ohio State University, Columbus, OH, USA
| | - Kyle VanKoevering
- Department of Otolaryngology-Head & Neck Surgery, The Ohio State University, Columbus, OH, USA
| | - Robert J Morrison
- Department of Otolaryngology-Head & Neck Surgery, University of Michigan, 1500 E. Medical Center Drive, Ann Arbor, MI, 48109-4241, USA
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2
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Schiff E, Propst EJ, Balakrishnan K, Johnson K, Lounsbury DW, Brenner MJ, Tawfik MM, Yang CJ. Pediatric Tracheostomy Emergency Readiness Assessment Tool: International Consensus Recommendations. Laryngoscope 2023; 133:3588-3601. [PMID: 37114735 PMCID: PMC10710770 DOI: 10.1002/lary.30674] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2022] [Revised: 02/17/2023] [Accepted: 03/07/2023] [Indexed: 04/29/2023]
Abstract
OBJECTIVE To achieve consensus on critical steps and create an assessment tool for actual and simulated pediatric tracheostomy emergencies that incorporates human and systems factors along with tracheostomy-specific steps. METHODS A modified Delphi method was used. Using REDCap software, an instrument comprising 29 potential items was circulated to 171 tracheostomy and simulation experts. Consensus criteria were determined a priori with a goal of consolidating and ordering 15 to 25 final items. In the first round, items were rated as "keep" or "remove". In the second and third rounds, experts were asked to rate the importance of each item on a 9-point Likert scale. Items were refined in subsequent iterations based on analysis of results and respondents' comments. RESULTS The response rates were 125/171 (73.1%) for the first round, 111/125 (88.8%) for the second round, and 109/125 (87.2%) for the third round. 133 comments were incorporated. Consensus (>60% participants scoring ≥8, or mean score >7.5) was reached on 22 items distributed across three domains. There were 12, 4, and 6 items in the domains of tracheostomy-specific steps, team and personnel factors, and equipment respectively. CONCLUSIONS The resultant assessment tool can be used to assess both tracheostomy-specific steps as well as systems factors affecting hospital team response to simulated and clinical pediatric tracheostomy emergencies. The tool can also be used to guide debriefing discussions of both simulated and clinical emergencies, and to spur quality improvement initiatives. LEVEL OF EVIDENCE 5 Laryngoscope, 133:3588-3601, 2023.
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Affiliation(s)
- Elliot Schiff
- Albert Einstein College of Medicine, Bronx, New York, USA
| | - Evan J Propst
- Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Karthik Balakrishnan
- Lucile Packard Children's Hospital, Stanford University School of Medicine, Palo Alto, California, USA
| | - Kaalan Johnson
- Department of Otolaryngology - Head and Neck Surgery, University of Washington/ Division of Pediatric Otolaryngology - Head and Neck Surgery, Seattle Children's Hospital, Seattle, WA, USA
| | - David W Lounsbury
- Albert Einstein College of Medicine, Bronx, New York, USA
- Department of Otorhinolaryngology-Head and Neck Surgery, Montefiore Medical Center, Bronx, New York, USA
| | - Michael J Brenner
- Department of Otolaryngology-Head and Neck Surgery, University of Michigan Medical School, Ann Arbor, Michigan, USA
| | | | - Christina J Yang
- Albert Einstein College of Medicine, Bronx, New York, USA
- Department of Otorhinolaryngology-Head and Neck Surgery, Montefiore Medical Center, Bronx, New York, USA
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3
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Duggal R, Davis RJ, Appachi S, Tierney WS, Hopkins BD, Bryson PC. Interdisciplinary assessment of tracheostomy care knowledge: An opportunity for quality improvement. Am J Otolaryngol 2023; 44:103865. [PMID: 37004318 DOI: 10.1016/j.amjoto.2023.103865] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Accepted: 03/19/2023] [Indexed: 04/03/2023]
Abstract
PURPOSE A 2013 AAOHNS consensus statement called for reduced variation in tracheostomy care. Multidisciplinary approaches and standardized protocols have been shown to improve tracheostomy outcomes. This study aims to identify inconsistencies in knowledge in order to design standardized education targeting these areas to improve quality of care. MATERIALS AND METHODS An online, multiple-choice tracheostomy care knowledge assessment was administered to nurses and respiratory therapists in ICUs, stepdown units, and regular nursing floors, as well as residents in otolaryngology, general surgery, and thoracic surgery. The survey was administered and data were recorded using the Select Survey online platform. RESULTS 173 nurses, respiratory therapists, and residents participated in this study. Over 75 % of respondents identified correct answers to questions addressing basic tracheostomy care, such as suctioning and humidification. Significant variation was observed in identification and management of tracheostomy emergencies, and appropriate use of speaking valves. Only 47 % of all respondents identified all potential signs of tracheostomy tube displacement. Respiratory therapists with over 20 years of experience (p = 0.001), were more likely to answer correctly than those with less. Nurses were less likely than respiratory therapists to have received standardized tracheostomy education (p = 0.006) and were less likely than others to choose the appropriate scenario for speaking valve use (p = 0.042), highlighting the need for interdisciplinary education. CONCLUSIONS An interdisciplinary assessment of tracheostomy care knowledge demonstrates variation, especially in identification and management of tracheostomy emergencies and appropriate use of speaking valves. Design of a standardized educational program targeting these areas is underway.
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Affiliation(s)
- Radhika Duggal
- Cleveland Clinic Lerner College of Medicine, Case Western Reserve University, Cleveland, OH, United States of America.
| | - Ruth J Davis
- Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, United States of America
| | - Swathi Appachi
- Department of Otolaryngology-Head and Neck Surgery, Cleveland Clinic Head and Neck Institute, Cleveland, OH, United States of America
| | - William S Tierney
- Department of Otolaryngology-Head and Neck Surgery, Cleveland Clinic Head and Neck Institute, Cleveland, OH, United States of America
| | - Brandon D Hopkins
- Department of Otolaryngology-Head and Neck Surgery, Cleveland Clinic Head and Neck Institute, Cleveland, OH, United States of America
| | - Paul C Bryson
- Department of Otolaryngology-Head and Neck Surgery, Cleveland Clinic Head and Neck Institute, Cleveland, OH, United States of America
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4
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St-Laurent A, Zielinski D, Qazi A, AlAwadi A, Almajed A, Adamko DJ, Alabdoulsalam T, Chiang J, Derynck M, Gerdung C, Kam K, Katz SL, MacLusky I, Mehta K, Mateos D, Nguyen TTD, Praud JP, Proulx F, Seear M, Smith MJ, Wensley D, Amin R. Chronic tracheostomy care of ventilator-dependent and -independent children: Clinical practice patterns of pediatric respirologists in a publicly funded (Canadian) healthcare system. Pediatr Pulmonol 2023; 58:140-151. [PMID: 36178281 DOI: 10.1002/ppul.26171] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2022] [Revised: 09/06/2022] [Accepted: 09/25/2022] [Indexed: 01/11/2023]
Abstract
OBJECTIVES To describe the current clinical practice patterns of Canadian pediatric respirologists at pediatric tertiary care institutions regarding chronic tracheostomy tube care and management of home invasive ventilation. METHODS A pediatric respirologist/pediatrician with expertise in tracheostomy tube care and home ventilation was identified at each Canadian pediatric tertiary care center to complete a 59-item survey of multiple choice and short answer questions. Domains assessed included tracheostomy tube care, caregiver competency and home monitoring, speaking valves, medical management of tracheostomy complications, decannulation, and long-term follow-up. RESULTS The response rate was 100% (17/17) with all Canadian tertiary care pediatric centers represented and heterogeneity of practice was observed in all domains assessed. For example, though most centers employ Bivona™ (17/17) and Shiley™ (15/17) tracheostomy tubes, variability was observed around tube change, re-use, and cleaning practices. Most centers require two trained caregivers (14/17) and recommend 24/7 eyes on care and oxygen saturation monitoring. Discharge with an emergency tracheostomy kit was universal (17/17). Considerable heterogeneity was observed in the timing and use of speaking valves and speech-language assessment. Inhaled anti-pseudomonal antibiotics are employed by most centers (16/17) though the indication, agent, and protocol varied by center. Though decannulation practices varied considerably, the requirement of upper airway patency was universally required to proceed with decannulation (17/17) independent of ongoing ventilatory support requirements. CONCLUSION Considerable variability in pediatric tracheostomy tube care practice exists across Canada. These results will serve as a starting point to standardize and evaluate tracheostomy tube care nationally.
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Affiliation(s)
- Aaron St-Laurent
- Department of Paediatrics, Division of Respiratory Medicine, Children's Hospital-London Health Sciences Centre, London, Ontario, Canada
| | - David Zielinski
- Division of Pediatric Respirology, Department of Pediatrics, Montreal Children's Hospital/McGill University, Montreal, Quebec, Canada.,Research Institute of the McGill University Health Centre, Montreal, Quebec, Canada
| | - Adam Qazi
- Department of Pediatrics, The Division of Respiratory Medicine, Toronto, The Hospital for Sick Children, Ontario, Canada
| | - Aceel AlAwadi
- Mubarak Al-Kabeer Hospital, Ministry of Health of Kuwait, Jabriya, Kuwait
| | - Athari Almajed
- Mubarak Al-Kabeer Hospital, Ministry of Health of Kuwait, Jabriya, Kuwait
| | - Darryl J Adamko
- Department of Pediatrics, Division of Respiratory Medicine, Jim Pattison's Children's Hospital, Saskatoon, Saskatchewan, Canada
| | - Tareq Alabdoulsalam
- Section of Pediatric Respirology, Department of Pediatrics and Child Health, HSC Winnipeg Children's Hospital/University of Manitoba, Winnipeg, Manitoba, Canada
| | - Jackie Chiang
- Department of Pediatrics, The Division of Respiratory Medicine, Toronto, The Hospital for Sick Children, Ontario, Canada
| | - Michael Derynck
- Department of Pediatrics, Kingston Health Sciences Centre/Queen's University, Kingston, Ontario, Canada
| | - Chris Gerdung
- Stollery Children's Hospital, Department of Pediatrics, The Division of Respiratory Medicine, University of Alberta, Edmonton Alberta, Canada
| | - Karen Kam
- Department of Pediatrics, Section of Respiratory Medicine, Alberta Children's Hospital, Calgary, Alberta, Canada
| | - Sherri L Katz
- Department of Pediatrics, Division of Respiratory Medicine, Children's Hospital of Eastern Ontario/University of Ottawa, Ottawa, Ontario, Canada.,Children's Hospital of Eastern Ontario Research Institute, Ottawa, Ontario, Canada
| | - Ian MacLusky
- Department of Pediatrics, Division of Respiratory Medicine, Children's Hospital of Eastern Ontario/University of Ottawa, Ottawa, Ontario, Canada
| | - Kevan Mehta
- Department of Pediatrics, Division of Respirology, McMaster Children's Hospital, Hamilton, Ontario, Canada
| | - Dimas Mateos
- Department of Pediatrics, Pediatric Respirology, IWK Health Centre, Halifax, Nova Scotia, Canada
| | - The Thanh D Nguyen
- Department of Pediatrics, Division of Respirology, CHU Sainte-Justine, Montreal, Quebec, Canada
| | - Jean-Paul Praud
- Division of Respiratory Medicine, Department of Pediatrics, University of Sherbrooke, Quebec, Canada
| | - Frederic Proulx
- Department of Pediatrics, Division of Respirology, CHUL et Centre Mère-Enfant Soleil, Quebec, Quebec, Canada
| | - Michael Seear
- Division of Pediatric Respiratory Medicine, Department of Pediatrics, University of British Columbia, Vancouver, Canada
| | - Mary Jane Smith
- Department of Pediatrics, Faculty of Medicine, Memorial University of Newfoundland, St. John's, Canada
| | - David Wensley
- Division of Pediatric Respiratory Medicine, Department of Pediatrics, University of British Columbia, Vancouver, Canada
| | - Reshma Amin
- Department of Pediatrics, The Division of Respiratory Medicine, Toronto, The Hospital for Sick Children, Ontario, Canada
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5
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Baddour K, Mady LJ, Schwarzbach HL, Sabik LM, Thomas TH, McCoy JL, Tobey A. Exploring caregiver burden and financial toxicity in caregivers of tracheostomy-dependent children. Int J Pediatr Otorhinolaryngol 2021; 145:110713. [PMID: 33882339 DOI: 10.1016/j.ijporl.2021.110713] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2021] [Revised: 03/31/2021] [Accepted: 04/08/2021] [Indexed: 11/15/2022]
Abstract
OBJECTIVE Measure the prevalence of and factors associated with financial toxicity (FT) and caregiver burden in families of tracheostomy-dependent children. FT is defined as the objective and subjective patient-level impact of the costs of medical care and has been associated with lower quality of life, decreased compliance with treatment, and increased mortality. METHODS A medical record review was performed on all children with a tracheostomy tube placed from 2009 to 2018 at a tertiary children's hospital to identify and include children younger than 18 years old, not deceased, and not decannulated at the time of review. Eligible children's caregivers were contacted to fill out a 36-item questionnaire and three validated instruments: The Comprehensive Score for Financial Toxicity (COST) and the Financial Distress Questionnaire (FDQ), both addressed to the parent/primary caregiver, and the Burden Scale for Family Caregivers - short version (BSFC-s). RESULTS Of the 140 eligible tracheostomy patients identified, 45 caregivers (32.1%) returned the survey. The average COST score was 18 ± 1.7 with 73.3% of caregivers reporting high toxicity based on FDQ, and 75.6% having severe-to-very severe caregiver burden. Significant increase in FT was seen in households where an adult had to leave a paid position (p = 0.047) or work less (p = 0.002) because of their child's condition; or needed to omit some of the child's medical services or medications due to cost-prohibitive reasons (p<0.001). Financial toxicity was associated with caregiver burden (by BSFC-s) [r = -596; beta coefficient = -0.95, t(43) = -4.87, p<0.001] and financial distress (by FDQ; p<0.001). CONCLUSION Caregivers of children with medically complex, tracheostomy-dependent conditions suffer from FT and caregiver burden. As a result, harmful financial coping mechanisms such as missing necessary care components or forgoing prescribed treatments, may be adopted for cost-prohibitive reasons.
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Affiliation(s)
- Khalil Baddour
- Department of Otolaryngology, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Leila J Mady
- Department of Otorhinolaryngology-Head and Neck Surgery, University of Pennsylvania, Philadelphia, PA, USA.
| | - Hannah L Schwarzbach
- Department of Otorhinolaryngology-Head and Neck Surgery, University of Pennsylvania, Philadelphia, PA, USA
| | - Lindsay M Sabik
- Department of Health Policy and Management, University of Pittsburgh Graduate School of Public Health, Pittsburgh, PA, USA
| | - Teresa H Thomas
- Department of Health Promotion and Development, University of Pittsburgh School of Nursing, Pittsburgh, PA, USA
| | - Jennifer L McCoy
- Department of Otolaryngology, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA; Children's Hospital of Pittsburgh, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Allison Tobey
- Department of Otolaryngology, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA; Children's Hospital of Pittsburgh, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
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6
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Ahmed ST, Yang C, Deng J, Bottalico DM, Matta-Arroyo E, Cassel-Choudhury G, Yang CJ. Implementation of an Online Multimedia Pediatric Tracheostomy Care Module for Healthcare Providers. Laryngoscope 2021; 131:1893-1901. [PMID: 33459406 DOI: 10.1002/lary.29400] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2020] [Revised: 12/10/2020] [Accepted: 01/04/2021] [Indexed: 11/08/2022]
Abstract
OBJECTIVES/HYPOTHESIS To investigate the effect of a multimedia educational module on provider attitudes toward pediatric tracheostomy care. We also describe the process of module development and dissemination at an academic children's hospital. STUDY DESIGN Prospective observational study. METHODS The pediatric airway committee at an urban tertiary care center developed a multimedia pediatric tracheostomy care module. Nurses, respiratory therapists, as well as resident, fellow, and attending physicians caring for pediatric patients with tracheostomies were eligible. Managers and clinical supervisors from various units recruited participants to complete the pediatric tracheostomy care electronic module and pre- and postassessment knowledge quizzes and surveys. Provider confidence was analyzed using Kruskal-Wallis H-test and Mann-Whitney U-test, and paired t-test was used to compare pre- and postmodule quiz scores. RESULTS A total of 422 participants completed the module. A total of 275 participants completed the premodule survey, 385 completed the premodule quiz, 253 completed the postmodule survey, and 233 completed the postmodule quiz. Participants included providers in the neonatal intensive care unit, pediatric intensive care unit, pediatric emergency department, and pediatric wards. Postmodule surveys demonstrated a significant reduction in the average percentage of participants indicating lack of confidence with regards to changing an established tracheostomy, responding to accidental decannulation of established tracheostomy, and responding to accidental decannulation of fresh tracheostomy (P < .001). Average quiz scores increased by 5.6 points from 83.0% to 88.6% (P < .00001). CONCLUSIONS A multimedia educational module can improve provider perception of their knowledge and confidence surrounding pediatric tracheostomy management. LEVEL OF EVIDENCE 3 Laryngoscope, 131:1893-1901, 2021.
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Affiliation(s)
- Sadia T Ahmed
- Albert Einstein College of Medicine, Bronx, New York, U.S.A
| | - Catherina Yang
- Department of Otorhinolaryngology, Montefiore Medical Center, Bronx, New York, U.S.A
| | - Junwen Deng
- Albert Einstein College of Medicine, Bronx, New York, U.S.A
| | - Danielle M Bottalico
- Department of Otorhinolaryngology, Montefiore Medical Center, Bronx, New York, U.S.A
| | - Esther Matta-Arroyo
- Division of Respiratory and Sleep Medicine, Children's Hospital at Montefiore, Bronx, New York, U.S.A
| | - Gina Cassel-Choudhury
- Albert Einstein College of Medicine, Bronx, New York, U.S.A.,Division of Pediatric Critical Care Medicine, Children's Hospital at Montefiore, Bronx, New York, U.S.A
| | - Christina J Yang
- Albert Einstein College of Medicine, Bronx, New York, U.S.A.,Department of Otorhinolaryngology, Montefiore Medical Center, Bronx, New York, U.S.A
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7
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Jones JW, Whiting ZG, Gabay EM, Rana MS, Rutter MJ, Reilly BK. Novel use of lip balm under tracheostomy ties to prevent skin irritation in the pediatric patient. Int J Pediatr Otorhinolaryngol 2020; 138:110280. [PMID: 32798832 DOI: 10.1016/j.ijporl.2020.110280] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2020] [Revised: 07/25/2020] [Accepted: 07/25/2020] [Indexed: 11/16/2022]
Abstract
OBJECTIVES To study the effectiveness of lip balm in reducing skin irritation and preventing pressure induced injury in tracheostomy dependent children. METHODS The skin of tracheostomy patients presenting to a pediatric otolaryngology clinic over a 12 month period from 2018 to 2019 was assessed and categorized as hyperemic blanchable (abnormal pre-pressure injury), hyperemic non-blanchable, partial thickness skin loss, or full thickness skin loss. Caregivers were instructed to apply lip balm to the skin under soft ties three times per day and with tracheostomy tie changes. Patients were followed prospectively by a tracheostomy care nurse. RESULTS 24 patients enrolled and reported daily adherence with lip balm use. Median age was 7.3 years (interquartile range, IQR, = 1.3-12.4) with 10 females and 14 males. The majority of patients (n = 20) were identified as having hyperemic blanchable skin. 96% (23/24) of caregivers reported a subjective benefit. 79.2% (95% CI: 57.8%-92.9%) of patients with hyperemic skin (n = 24) demonstrated complete resolution with continued application, and was found to be significant: all patients had skin hyperemia before application, while 20.8% (5/24) continued to have hyperemia after application (P < .001). Infants and ventilation dependent patients demonstrated recovery rates of 88.9% and 75% respectively. Median duration of follow-up was 6.3 months (IQR = 3.4-11.3). There were no documented allergic reactions, accidental decannulations, or skin deterioration in the cohort. CONCLUSIONS Lip balm appears to be a low cost, hydrophobic, and friction-reducing agent that is potentially useful in preventing at risk pressure injuries in tracheostomy dependent pediatric patients.
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Affiliation(s)
- Joel W Jones
- Department of Otolaryngology, Children's National Health System, 111 Michigan Ave NW, Washington, DC, 20010, USA.
| | - Zachariah G Whiting
- Department of Otolaryngology, Children's National Health System, 111 Michigan Ave NW, Washington, DC, 20010, USA
| | - Elyse M Gabay
- Department of Otolaryngology, Children's National Health System, 111 Michigan Ave NW, Washington, DC, 20010, USA
| | - Md Sohel Rana
- Department of Otolaryngology, Children's National Health System, 111 Michigan Ave NW, Washington, DC, 20010, USA
| | - Michael J Rutter
- Department of Otolaryngology, Cincinnati Children's Hospital, 3333 Burnet Ave, Cincinnati, OH, 45229, USA
| | - Brian K Reilly
- Department of Otolaryngology, Children's National Health System, 111 Michigan Ave NW, Washington, DC, 20010, USA
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8
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McGrath BA, Wallace S, Lynch J, Bonvento B, Coe B, Owen A, Firn M, Brenner MJ, Edwards E, Finch TL, Cameron T, Narula A, Roberson DW. Improving tracheostomy care in the United Kingdom: results of a guided quality improvement programme in 20 diverse hospitals. Br J Anaesth 2020; 125:e119-e129. [DOI: 10.1016/j.bja.2020.04.064] [Citation(s) in RCA: 39] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2019] [Revised: 03/17/2020] [Accepted: 04/17/2020] [Indexed: 11/26/2022] Open
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9
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Abstract
Over the last few decades, greater numbers of tracheostomies have been performed in medically complex and fragile children to manage upper airway obstruction, progressive neuromuscular disorders, abnormal ventilatory drive and to facilitate airway clearance. The optimal timing of tracheostomy tube placement and methods to determine suitable patients for the procedure remain unclear. Caring for children with tracheostomies can have a considerable financial and psychosocial impact on a family. Pediatric patients with tracheostomies have a 2-3 fold greater morbidity and mortality compared to adult patients. Clinicians should provide as much clarity as possible for families on the positive and negative aspects of pediatric tracheotomies and long term mechanical ventilation prior to tracheostomy placement. Tracheostomies are often placed as a bridge, whilst time for healing, growth and other therapies are needed to help overcome the indication for tracheostomy. Suitable investigations used to determine the optimal timing of decannulation remain physician and institution dependent.
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Affiliation(s)
- Frances Flanagan
- Division of Pulmonary and Respiratory Diseases, Boston Children's Hospital, 333 Longwood Avenue, Boston, 02115, USA.
| | - Fiona Healy
- Children's Health Ireland at Temple Street, Dublin 1, Ireland.
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10
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McKelvie BL, Lobos AT, Chan J, Momoli F, McNally JD. High Rate of Medical Emergency Team Activation in Children with Tracheostomy. J Pediatr Intensive Care 2019; 9:27-33. [PMID: 31984154 DOI: 10.1055/s-0039-1695733] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2019] [Accepted: 07/19/2019] [Indexed: 10/26/2022] Open
Abstract
Pediatric in-patients with tracheostomy (PIT) are at high risk for clinical deterioration. Medical emergency teams (MET) have been developed to identify high-risk patients. This study compared MET activation rates between PITs and the general ward population. This was a retrospective cohort study conducted at a tertiary pediatric hospital. The primary outcome (MET activation) was obtained from a database. Between 2008 and 2014, the MET activation rate was significantly higher in the PIT group than the general ward population (14 vs. 2.9 per 100 admissions, p < 0.001). PITs are at significantly higher risk for MET activation. Strategies should be developed to reduce their risk on the wards.
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Affiliation(s)
- Brianna L McKelvie
- Division of Critical Care, Department of Pediatrics, Faculty of Medicine, Western University, Children's Hospital-London Health Sciences Centre, London, Ontario, Canada
| | - Anna-Theresa Lobos
- Division of Critical Care, Department of Pediatrics, Faculty of Medicine, University of Ottawa, Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada
| | - Jason Chan
- Children's Hospital of Eastern Ontario Research Institute, Ottawa, Ontario, Canada
| | - Franco Momoli
- Children's Hospital of Eastern Ontario Research Institute, Ottawa, Ontario, Canada
| | - James Dayre McNally
- Division of Critical Care, Department of Pediatrics, Faculty of Medicine, University of Ottawa, Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada.,Children's Hospital of Eastern Ontario Research Institute, Ottawa, Ontario, Canada
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11
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Roberson DW, Kirsh ER. Systems Science. Otolaryngol Clin North Am 2019; 52:1-9. [DOI: 10.1016/j.otc.2018.08.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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12
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Barron CL, Elmaraghy CA, Lemle S, Crandall W, Brilli RJ, Jatana KR. Clinical Indices to Drive Quality Improvement in Otolaryngology. Otolaryngol Clin North Am 2018; 52:123-133. [PMID: 30390736 DOI: 10.1016/j.otc.2018.08.008] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
A Pediatric Tracheostomy Care Index (PTCI) was developed by the authors to standardize care and drive quality improvement efforts at their institution. The PTCI comprises 9 elements deemed essential for safe care of children with a tracheostomy tube. Based on the PTCI scores, the number of missed opportunities per patient was tracked, and interventions through a "Plan-Do-Study-Act" approach were performed. The establishment of the PTCI has been successful at standardizing, quantifying, and monitoring the consistency and documentation of care provided at the authors' institution.
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Affiliation(s)
- Christine L Barron
- The Ohio State University College of Medicine, 370 West 9th Avenue, Columbus, OH 43210, USA
| | - Charles A Elmaraghy
- Department of Pediatric Otolaryngology, Nationwide Children's Hospital, 555 South 18th Street, Suite 2A, Columbus, OH 43205, USA; Department of Otolaryngology-Head and Neck Surgery, Wexner Medical Center at Ohio State University, 915 Olentangy River Road, Columbus, OH 43212, USA
| | - Stephanie Lemle
- Quality Improvement Services, Nationwide Children's Hospital, 700 Children's Drive, Suite 2A, Columbus, OH 43205, USA
| | - Wallace Crandall
- Quality Improvement Services, Nationwide Children's Hospital, 700 Children's Drive, Suite 2A, Columbus, OH 43205, USA; Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Ohio State University College of Medicine, Nationwide Children's Hospital, 700 Children's Drive, Columbus, OH 43205, USA
| | - Richard J Brilli
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Ohio State University College of Medicine, Nationwide Children's Hospital, 700 Children's Drive, Columbus, OH 43205, USA
| | - Kris R Jatana
- Department of Pediatric Otolaryngology, Nationwide Children's Hospital, 555 South 18th Street, Suite 2A, Columbus, OH 43205, USA; Department of Otolaryngology-Head and Neck Surgery, Wexner Medical Center at Ohio State University, 915 Olentangy River Road, Columbus, OH 43212, USA.
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Higgs A, McGrath BA, Goddard C, Rangasami J, Suntharalingam G, Gale R, Cook TM. Guidelines for the management of tracheal intubation in critically ill adults. Br J Anaesth 2017; 120:323-352. [PMID: 29406182 DOI: 10.1016/j.bja.2017.10.021] [Citation(s) in RCA: 458] [Impact Index Per Article: 65.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2017] [Revised: 10/23/2017] [Accepted: 10/25/2017] [Indexed: 12/17/2022] Open
Abstract
These guidelines describe a comprehensive strategy to optimize oxygenation, airway management, and tracheal intubation in critically ill patients, in all hospital locations. They are a direct response to the 4th National Audit Project of the Royal College of Anaesthetists and Difficult Airway Society, which highlighted deficient management of these extremely vulnerable patients leading to major complications and avoidable deaths. They are founded on robust evidence where available, supplemented by expert consensus opinion where it is not. These guidelines recognize that improved outcomes of emergency airway management require closer attention to human factors, rather than simply introduction of new devices or improved technical proficiency. They stress the role of the airway team, a shared mental model, planning, and communication throughout airway management. The primacy of oxygenation including pre- and peroxygenation is emphasized. A modified rapid sequence approach is recommended. Optimal management is presented in an algorithm that combines Plans B and C, incorporating elements of the Vortex approach. To avoid delays and task fixation, the importance of limiting procedural attempts, promptly recognizing failure, and transitioning to the next algorithm step are emphasized. The guidelines recommend early use of a videolaryngoscope, with a screen visible to all, and second generation supraglottic airways for airway rescue. Recommendations for emergency front of neck airway are for a scalpel-bougie-tube technique while acknowledging the value of other techniques performed by trained experts. As most critical care airway catastrophes occur after intubation, from dislodged or blocked tubes, essential methods to avoid these complications are also emphasized.
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Affiliation(s)
- A Higgs
- Anaesthesia and Intensive Care Medicine, Warrington and Halton Hospitals NHS Foundation Trust, Cheshire, UK(8).
| | - B A McGrath
- Anaesthesia and Intensive Care Medicine, University Hospital South Manchester, Manchester, UK(9)
| | - C Goddard
- Anaesthesia & Intensive Care Medicine, Southport and Ormskirk Hospitals NHS Trust, Southport, UK(8)
| | - J Rangasami
- Anaesthesia & Intensive Care Medicine, Wexham Park Hospital, Frimley Health NHS Foundation Trust, Slough, UK(8)
| | - G Suntharalingam
- Intensive Care Medicine and Anaesthesia, London North West Healthcare NHS Trust, London, UK(10)
| | - R Gale
- Anaesthesia & Intensive Care Medicine, Countess of Chester Hospital NHS Foundation Trust, Chester, UK(11)
| | - T M Cook
- Anaesthesia and Intensive Care Medicine, Royal United Hospitals Bath NHS Foundation Trust, Bath, UK(12)
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CASASOLA-GIRÓN M, BENITO-OREJAS JI, BOBILLO-DE LAMO F, PARRA-MORAIS L, CICUÉNDEZ-ÁVILA R, MORAIS-PÉREZ D. Proyecto de seguridad del paciente traqueotomizado procedente de una unidad de cuidados críticos. REVISTA ORL 2017. [DOI: 10.14201/orl.16932] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
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15
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McGrath BA, Lynch J, Bonvento B, Wallace S, Poole V, Farrell A, Diaz C, Khwaja S, Roberson DW. Evaluating the quality improvement impact of the Global Tracheostomy Collaborative in four diverse NHS hospitals. BMJ QUALITY IMPROVEMENT REPORTS 2017; 6:bmjqir.u220636.w7996. [PMID: 28607676 PMCID: PMC5457966 DOI: 10.1136/bmjquality.u220636.w7996] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Tracheostomies are predominantly used in Head & Neck Surgery and the critically ill. The needs of these complex patients frequently cross traditional speciality working boundaries and locations and any resulting airway problems can rapidly lead to significant harm. The Global Tracheostomy Collaborative (GTC) was formed in 2012 with the aim of bringing together international expertise in tracheostomy care in order to bring about rapid adoption of best practices and to improve the quality and safety of care to this vulnerable group. The primary aim of this project was to improve the safety and quality of care delivered to adult patients with new or existing tracheostomies. We implemented changes guided by the GTC using multiple PDSA cycles over a 12-month period. Interventions were across three themes: educational, patient-centred (earlier vocalisation and enteral intake) and organisational. We hypothesised that systematic healthcare improvements would reduce the severity of harm resulting from tracheostomy-related safety incidents and improve surrogate markers of the quality of patient-centred care. Furthermore, we hypothesised that raising the quality and safety of healthcare services would lead to more efficient care, measured by earlier tracheostomy decannulation times and reduced hospital lengths of stay. This Quality Improvement project implemented the GTC into four diverse NHS Trusts in Greater Manchester. Key drivers implemented included multidisciplinary tracheostomy steering groups, ward rounds and bedside teams, standardisation of tracheostomy protocols, staff education and meaningful involvement of patient and family. Surrogates for the quality and safety of care were captured for all patients using a bespoke database. Implementing the GTC into four NHS Trusts rapidly and positively impacted on patient safety metrics and surrogates for the quality of care delivered. It is likely that the comprehensive resources of the GTC will be of benefit to other NHS hospitals and indeed other healthcare systems around the world.
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Affiliation(s)
| | | | | | | | - Val Poole
- University Hospital South Manchester, UK
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16
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McGrath BA, Haley D. Tracheostomy – The forgotten difficult airway? TRENDS IN ANAESTHESIA AND CRITICAL CARE 2017. [DOI: 10.1016/j.tacc.2016.10.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Watters K, O'Neill M, Zhu H, Graham RJ, Hall M, Berry J. Two-year mortality, complications, and healthcare use in children with medicaid following tracheostomy. Laryngoscope 2016; 126:2611-2617. [PMID: 27060012 DOI: 10.1002/lary.25972] [Citation(s) in RCA: 77] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2015] [Revised: 01/18/2016] [Accepted: 02/16/2016] [Indexed: 11/10/2022]
Abstract
OBJECTIVES/HYPOTHESIS To assess patient characteristics associated with adverse outcomes in the first 2 years following tracheostomy, and to report healthcare utilization and cost of caring for these children. STUDY DESIGN Retrospective cohort study. METHODS Children (0-16 years) in Medicaid from 10 states undergoing tracheostomy in 2009, identified with International Classification of Diseases, Ninth Revision, Clinical Modification procedure codes and followed through 2011, were selected using the Truven Health Medicaid Marketscan Database (Truven Health Analytics, Inc., Ann Arbor, MI). Patient demographic and clinical characteristics were assessed with likelihood of death and tracheostomy complication using chi-square tests and logistic regression. Healthcare use and spending across the care continuum (hospital, outpatient, community, and home) were reported. RESULTS A total of 502 children underwent tracheostomy in 2009, with 34.1% eligible for Medicaid because of disability. Median age at tracheostomy was 8 years (interquartile range 1-16 years), and 62.7% had a complex chronic condition. Two-year rates of in-hospital mortality and tracheostomy complication were 8.9% and 38.8%, respectively. In multivariable analysis, the highest likelihood of mortality occurred in children age < 1 year compared with 13+ years (odds ratio [OR] 7.3; 95% confidence interval [CI], 3.2-17.1); the highest likelihood of tracheostomy complication was in children with a complex chronic condition versus those without a complex chronic condition (OR 3.3; 95% CI, 1.1-9.9). Total healthcare spending in the 2 years following tracheostomy was $53.3 million, with hospital, home, and primary care constituting 64.4%, 9.4%, and 0.5% of total spending, respectively. CONCLUSION Mortality and morbidity are high, and spending on primary and home care is small following tracheostomy in children with Medicaid. Future studies should assess whether improved outpatient and community care might improve their health outcomes. LEVEL OF EVIDENCE 4. Laryngoscope, 126:2611-2617, 2016.
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Affiliation(s)
- Karen Watters
- Department of Otolaryngology and Communication Enhancement, Boston Children's Hospital, Boston, Massachusetts. .,Harvard Medical School, Boston, Massachusetts.
| | - Margaret O'Neill
- Department of General Pediatrics, Boston Children's Hospital, Boston, Massachusetts.,Harvard Medical School, Boston, Massachusetts
| | - Hannah Zhu
- Department of Pediatrics, Addenbrooke's Hospital, Cambridge University Hospitals, Cambridge, United Kingdom
| | - Robert J Graham
- Department of Anesthesia, Perioperative and Pain Medicine, Boston Children's Hospital, Boston, Massachusetts.,Harvard Medical School, Boston, Massachusetts
| | - Matthew Hall
- Children's Hospital Association, Overland Park, KS, U.S.A
| | - Jay Berry
- Department of General Pediatrics, Boston Children's Hospital, Boston, Massachusetts.,Harvard Medical School, Boston, Massachusetts
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The UK National Tracheostomy Safety Project and the role of speech and language therapists. Curr Opin Otolaryngol Head Neck Surg 2014; 22:181-7. [PMID: 24670488 DOI: 10.1097/moo.0000000000000046] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW Tracheostomy care is evolving, with the majority of procedures now performed percutaneously to facilitate weaning from mechanical ventilation in the critically ill. Traditional surgical indications remain, but surgical tracheostomies are increasingly performed in more complex patients and procedures. This brings unique challenges for the multidisciplinary professional team in which speech and language therapists (SLTs) have a key role. RECENT FINDINGS Reviews of tracheostomy-related critical incidents have identified recurrent themes associated with adverse outcomes for this high-risk population. Recent research has highlighted the impact of tracheostomy on communication and swallowing, along with the contribution of SLTs to the multidisciplinary professional team, prompting new guidance for SLTs. The UK National Tracheostomy Safety Project has developed educational and practical resources that have been shown to improve care. Similar approaches from around the world led to the newly formed Global Tracheostomy Collaborative. SUMMARY Patients with tracheostomies can benefit from a co-ordinated, truly multidisciplinary approach to care. SLT-specific expertise in assessing and managing communication and swallowing needs is a vital part of this process.
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Abstract
Educational aimsTo understand the current challenges in the care of tracheostomy patientsTo understand principles of quality improvement collaboration and how this can improve the quality of care for tracheostomy patientsSummaryThe UK National Confidential Enquiry into Patient Outcomes and Death illustrates that there remains significant morbidity and mortality relating to patients with a tracheostomy, with much preventable harm. Challenges include the inherent complexity of the patient's underlying condition, wide variations in tracheostomy management, variable delivery of education for staff, patients and families, and difficult coordination of care between such a variety of individuals involved in performing, managing and ultimately removing tracheostomies.Quality-improvement collaboratives are groups of institutions with a common purpose who work together to drive positive change. They help support clinicians in developing skills and teams necessary to design and sustain quality-improvement cycles. They are a cost-effective way of rapidly disseminating improvement strategies and engaging in shared learning across institutions around the world. The Global Tracheostomy Collaborative aims to improve quality of care and outcomes through five interdependent key drivers: coordinated multidisciplinary team care, education, institution-wide protocols, family and patient-centred care, and metrics and outcomes using a specifically designed database.
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Yelverton JC, Nguyen JH, Wan W, Kenerson MC, Schuman TA. Effectiveness of a standardized education process for tracheostomy care. Laryngoscope 2014; 125:342-7. [DOI: 10.1002/lary.24821] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2014] [Revised: 06/10/2014] [Accepted: 06/13/2014] [Indexed: 11/08/2022]
Affiliation(s)
- Joshua C. Yelverton
- Department of Otolaryngology-Head and Neck Surgery; Virginia Commonwealth University; Richmond Virginia U.S.A
| | - Josephine H. Nguyen
- Department of Otolaryngology-Head and Neck Surgery; Virginia Commonwealth University; Richmond Virginia U.S.A
| | - Wen Wan
- Department of Biostatistics; Virginia Commonwealth University; Richmond Virginia U.S.A
| | - Michael C. Kenerson
- Department of Otolaryngology-Head and Neck Surgery; Virginia Commonwealth University; Richmond Virginia U.S.A
| | - Theodore A. Schuman
- Department of Otolaryngology-Head and Neck Surgery; Virginia Commonwealth University; Richmond Virginia U.S.A
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Zhu H, Das P, Roberson DW, Jang J, Skinner ML, Paine M, Yuan J, Berry J. Hospitalizations in children with preexisting tracheostomy: A national perspective. Laryngoscope 2014; 125:462-8. [PMID: 24986601 DOI: 10.1002/lary.24797] [Citation(s) in RCA: 58] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2013] [Revised: 05/05/2014] [Accepted: 05/28/2014] [Indexed: 11/10/2022]
Affiliation(s)
- Hannah Zhu
- Department of Paediatrics; Addenbrooke's Hospital, Cambridge University Hospitals NHS Trust; Cambridge
| | - Preety Das
- Hammersmith Hospital, North West Thames Foundation School; London U.K
| | - David W. Roberson
- Department of Otolaryngology; Boston Children's Hospital; Department of Otology & Laryngology, Harvard Medical School; Boston
| | - Jisun Jang
- The Clinical Research Center, Boston Children's Hospital; Boston
| | - Margaret L. Skinner
- Department of Otolaryngology-Head and Neck Surgery; Johns Hopkins School of Medicine; Baltimore Maryland
| | - Melody Paine
- Department of Otolaryngology and Cardiology; Boston Children's Hospital; Boston
| | - Jennifer Yuan
- Ferkauf Graduate School of Psychology; Yeshiva University; New York New York U.S.A
| | - Jay Berry
- Division of General Pediatrics; Boston Children's Hospital, Boston, Harvard Medical School; Boston Massachusetts
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22
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Global Tracheostomy Collaborative: The Future of Quality Improvement Strategies. CURRENT OTORHINOLARYNGOLOGY REPORTS 2013. [DOI: 10.1007/s40136-013-0034-5] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Flynn AP, Carter B, Bray L, Donne AJ. Parents' experiences and views of caring for a child with a tracheostomy: a literature review. Int J Pediatr Otorhinolaryngol 2013; 77:1630-4. [PMID: 23953483 DOI: 10.1016/j.ijporl.2013.07.020] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2013] [Revised: 07/16/2013] [Accepted: 07/19/2013] [Indexed: 10/26/2022]
Abstract
OBJECTIVES To review the published/reported experiences and views of parents' whose child has had a tracheostomy. To date, no review has focused specifically on parents' experiences and views of having a child with a tracheostomy. METHODS MEDLINE, CINAHL, PsycINFO and Embase were systematically searched from 1990 to 2012 and a review of reference lists was conducted. The review draws on articles where parents' views of caring for their child's tracheostomy were either the sole focus of the research or where parental views of caring for their child's tracheostomy have been sought as a subsidiary aim. Studies relating to the aims of the review were examined using quality appraisal tools and in line with criteria for inclusion of studies. Studies were excluded if findings were about adults, studies that only focused on children's or sibling's views were not based on empirical work (e.g. literature reviews or expert commentary) or were not published in the English language. Findings were summarised under thematic headings. RESULTS The systematic database search identified 442 citations of which 10 were eligible for inclusion in the review. Of those 10 studies six were quantitative and four qualitative. Only one paper published qualitative data specifically on parents' experiences about their tracheotomised child. The three main themes identified were parents' experiences of caregiving, their social experiences and experiences of service delivery of having a child with a tracheostomy. Although parents encountered emotional and social challenges, some positive responses to these challenges were reported. CONCLUSION This review identifies a lack of qualitative research on parents' views of having a child with a tracheostomy. Issues surrounding parental management of tracheostomy require further investigation. This review has identified the need to elicit parents' longitudinal experiences of having a child with a tracheostomy.
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Affiliation(s)
- A P Flynn
- Department of ENT, Alder Hey Children's NHS Foundation Trust, Liverpool, UK.
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24
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Mitchell RB, Hussey HM, Setzen G, Jacobs IN, Nussenbaum B, Dawson C, Brown CA, Brandt C, Deakins K, Hartnick C, Merati A. Clinical consensus statement: tracheostomy care. Otolaryngol Head Neck Surg 2012; 148:6-20. [PMID: 22990518 DOI: 10.1177/0194599812460376] [Citation(s) in RCA: 232] [Impact Index Per Article: 19.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
OBJECTIVE This clinical consensus statement (CCS) aims to improve care for pediatric and adult patients with a tracheostomy tube. Approaches to tracheostomy care are currently inconsistent among clinicians and between different institutions. The goal is to reduce variations in practice when managing patients with a tracheostomy to minimize complications. METHODS A formal literature search was conducted to identify evidence gaps and refine the scope of this consensus statement. The modified Delphi method was used to refine expert opinion and facilitate a consensus position. Panel members were asked to complete 2 scale-based surveys addressing different aspects of pediatric and adult tracheostomy care. Each survey was followed by a conference call during which results were presented and statements discussed. RESULTS The panel achieved consensus on 77 statements; another 39 were dropped because of lack of consensus. Consensus was reached on statements that address initial tracheostomy tube change, management of emergencies and complications, prerequisites for decannulation, management of tube cuffs and communication devices, and specific patient and caregiver education needs. CONCLUSION The consensus panel agreed on statements that address the continuum of care, from initial tube management to complications in children and adults with a tracheostomy. The panel also highlighted areas where consensus could not be reached and where more research is needed. This consensus statement should be used by physicians, nurses, and other stakeholders caring for patients with a tracheostomy.
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Affiliation(s)
- Ron B Mitchell
- Department of Otolaryngology, UT Southwestern Medical Center, Dallas, Texas 75207, USA.
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McGrath BA, Bates L, Atkinson D, Moore JA. Multidisciplinary guidelines for the management of tracheostomy and laryngectomy airway emergencies. Anaesthesia 2012; 67:1025-41. [DOI: 10.1111/j.1365-2044.2012.07217.x] [Citation(s) in RCA: 135] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Husain T, Gatward JJ, Hambidge ORH, Asogan M, Southwood TJ. Strategies to prevent airway complications: a survey of adult intensive care units in Australia and New Zealand. Br J Anaesth 2012; 108:800-6. [PMID: 22416062 DOI: 10.1093/bja/aes030] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND There is growing evidence that airway complications are relatively common in critical care. Strategies have been suggested to decrease their incidence. METHODS We conducted a telephone survey of all adult intensive care units (ICUs) in Australia and New Zealand to establish the current practice regarding strategies used to reduce airway complications in five key areas: (i) use of capnography; (ii) care of oral tracheal tubes; (iii) care of tracheostomy tubes; (iv) difficult and failed intubation; and (v) training and medical staffing. RESULTS Of 176 ICU meeting inclusion criteria, 171 agreed to participate. Capnography is used during tracheal intubation in 88% of ICUs and for continuous monitoring in 64%. Protocols for advancing or partially withdrawing malpositioned tracheal tubes are used by 54% of units, with most allowing repositioning by unaccredited nurses. A small minority of ICUs use bed head signs to identify patients with 'critical airways' or laryngectomy, while only 8% have specific protocols for the care of these high-risk patients. Tracheostomy emergency algorithms are available in 13% of ICUs. At night, a doctor is exclusively assigned to 73% of units, although in 72%, the night doctor is not required to have prior anaesthetic/airway training. In 97% of the institutions surveyed, the senior doctor relied upon for airway emergencies at night is either non-resident or working elsewhere in the hospital. CONCLUSIONS Our data suggest that several possible strategies for avoiding airway complications in ICU patients dependent on an artificial airway are poorly implemented. This may expose these patients to avoidable risk.
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Affiliation(s)
- T Husain
- Department of Anaesthetics and Intensive Care, Northwick Park Hospital, Watford Road, Harrow HA1 3UJ, UK.
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Cetto R, Arora A, Hettige R, Nel M, Benjamin L, Gomez CMH, Oldfield WLG, Narula AA. Improving tracheostomy care: a prospective study of the multidisciplinary approach. Clin Otolaryngol 2012; 36:482-8. [PMID: 21838807 DOI: 10.1111/j.1749-4486.2011.02379.x] [Citation(s) in RCA: 58] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
OBJECTIVES Suboptimal standards in tracheostomy care have been highlighted as a growing concern in view of the increasing demands for intensive care services. Our objective is to assess the impact of our model for tracheostomy care on patients with short-term tracheostomies (<4 months in situ) following their discharge from the intensive care unit. The model has three components: The St Mary's tracheostomy care bundle checklist, a dedicated tracheostomy multidisciplinary team and an educational programme. DESIGN A 38-month prospective cohort study. SETTING A London Teaching Hospital. PARTICIPANTS A total of 102 patients with tracheostomy within the 19-month pre-intervention cohort and 95 patients in the 19-month post-intervention cohort. MAIN OUTCOME MEASURES The number of clinical incidents, mean time taken for decannulation, mean total tracheostomy time and total number of days spent in the intensive care unit were assessed before and after the intervention. RESULTS Time to decannulation following intensive care unit discharge decreased from 21 to 11 days, as did the mean total tracheostomy time, from 34 to 25 days (both statistically significant with a P < 0.0001 Mann-Whitney U-test). The number of critical incidents, which included all patients prior to exclusion, substantially declined following the introduction of intervention from 58 to 7 in the second year after intervention. CONCLUSIONS A multidisciplinary care model significantly expedited the decannulation process and reduced the overall time that a tracheostomy was in situ. The intervention was associated with a reduction in clinical incidents and shorter intensive care unit admissions, which can be associated with significant monetary savings.
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Affiliation(s)
- R Cetto
- Department of Otorhinolaryngology, St. Mary's Hospital, Imperial College Healthcare NHS Trust, London, UK.
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Paul F. Tracheostomy care and management in general wards and community settings: literature review. Nurs Crit Care 2010; 15:76-85. [PMID: 20236434 DOI: 10.1111/j.1478-5153.2010.00386.x] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
AIMS AND OBJECTIVES To identify current perspectives and areas for research regarding care and management of tracheostomized adult patients discharged to general wards and the community. BACKGROUND The increased number of tracheostomies being performed has led to more tracheostomized patients being discharged to non-specialized areas. Staff within these diverse areas may care for this patient group on an infrequent basis, and may lack the skills, knowledge and confidence to provide safe tracheostomy care. Although several guidelines and quality improvement initiatives have been developed to guide and improve tracheostomy care, concerns continue to be raised regarding this aspect of care. These factors inadvertently create significant risks for example, tube displacement in addition to the risks associated with procedures such as tracheal suctioning. SEARCH STRATEGY Database searches of MEDLINE, BRITISH NURSING INDEX and CINAHL (1998-2009). Inclusion criteria was literature regarding tracheostomized adult patients discharged to non-specialized areas. Exclusion criteria was paediatric literature. CONCLUSIONS Although best practice is applied to the care of tracheostomized adult patients in some areas, including support for ward staff from specialist nurses or teams, this is not always formalized or consistent. Furthermore studies indicate a lack of medical follow-up once the patient is discharged from specialized areas with a tracheostomy. Research is very limited in relation to the care and management of tracheostomized adult patients outside specialized areas, yet there is morbidity and mortality associated with this patient group. Staff education is widely recommended, but further development is needed to determine the best methods of delivering education, especially for health care professionals who care for tracheostomized patients on an infrequent basis. RELEVANCE TO CLINICAL PRACTICE More tracheostomized patients are being discharged to non-specialized areas, and issues have been raised regarding risks to patients. Research is required to determine the best methods of promoting best practice to improve tracheostomy care.
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Affiliation(s)
- Fiona Paul
- School of Nursing and Midwifery, University of Dundee, 11 Airlie Place, Dundee. DD1 4HJ.
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Arora A, Hettige R, Ifeacho S, Narula A. Driving standards in tracheostomy care: a preliminary communication of the St Mary’s ENT-led multi disciplinary team approach. Clin Otolaryngol 2008; 33:596-9. [DOI: 10.1111/j.1749-4486.2008.01814.x] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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