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Tiu RA, Meyer TK, Mayerhoff RM, Ray JC, Kritek PA, Merati AL, Sardesai MG. Tracheotomy care simulation training program for inpatient providers. Laryngoscope Investig Otolaryngol 2022; 7:1491-1498. [PMID: 36258878 PMCID: PMC9575083 DOI: 10.1002/lio2.912] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2022] [Accepted: 08/18/2022] [Indexed: 11/30/2022] Open
Abstract
Objectives Tracheotomy complications can be life‐threatening. Many of these complications may be avoided with proper education of health care providers. Unfortunately, access to high‐quality tracheotomy care curricula is limited. We developed a program to address this gap in tracheotomy care education for inpatient providers. This study aimed to assess the efficacy of this training program in improving trainee knowledge and comfort with tracheotomy care. Methods The curriculum includes asynchronous online modules coupled with a self‐directed hands‐on simulation activity using a low‐cost tracheotomy care task trainer. The program was offered to inpatient providers including medical students, residents, medical assistants, nurses, and respiratory therapists. Efficacy of the training was assessed using pre‐training and post‐training surveys of learner comfort, knowledge, and qualitative feedback. Results Data was collected on 41 participants. After completing the program, participants exhibited significantly improved comfort in performing tracheotomy care activities and 15% improvement in knowledge scores, with large effect sizes respectively and greater gains among those with little prior tracheotomy care experience. Conclusion This study has demonstrated that completion of this integrated online and hands‐on tracheotomy simulation curriculum training increases comfort and knowledge, especially for less‐experienced learners. This training addresses an important gap in tracheotomy care education among health care professionals with low levels of tracheotomy care experience and ultimately aims to improve patient safety and quality of care. This curriculum is easily transferrable as it requires only access to the online modules and low‐cost simulation materials and could be used in other hospitals, long‐term care facilities, outpatient clinics, and home settings. Level of evidence 4.
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Affiliation(s)
- Ryan Alyson‐Yao Tiu
- Department of Otolaryngology – Head and Neck Surgery University of Washington Seattle Washington USA
| | - Tanya Kim Meyer
- Department of Otolaryngology – Head and Neck Surgery University of Washington Seattle Washington USA
| | - Ross M. Mayerhoff
- Department of Otolaryngology – Head and Neck Surgery Henry Ford Health System Detroit Michigan USA
| | - Joel C. Ray
- Manager of Ancillary Services UW‐Valley Medical Center Renton Washington USA
| | - Patricia A. Kritek
- Division of Pulmonary, Critical Care and Sleep Medicine University of Washington Seattle Washington USA
| | - Albert Lincoln Merati
- Department of Otolaryngology – Head and Neck Surgery University of Washington Seattle Washington USA
| | - Maya Guirish Sardesai
- Department of Otolaryngology – Head and Neck Surgery University of Washington Seattle Washington USA
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2
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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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3
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Swords C, Bergman L, Wilson-Jeffers R, Randall D, Morris LL, Brenner MJ, Arora A. Multidisciplinary Tracheostomy Quality Improvement in the COVID-19 Pandemic: Building a Global Learning Community. Ann Otol Rhinol Laryngol 2020; 130:262-272. [PMID: 32680435 PMCID: PMC7369399 DOI: 10.1177/0003489420941542] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
OBJECTIVES To report experience with a global multidisciplinary tracheostomy e-learning initiative. METHODS An international multidisciplinary panel of experts convened to build a virtual learning community for tracheostomy care, comprising a web-based platform, five distance learning (interactive webinar) sessions, and professional discourse over 12 months. Structured pre- and post-webinar surveys were disseminated to global participants including otolaryngologists, intensivists, nurses, allied health professionals, and patients/caregivers. Data were collected on audio-visual fidelity, demographics, and pre- and post-tutorial assessments regarding experience and skill acquisition. Participants reported confidence levels for NICU, pediatric, adult, and family care, as well as technical skills, communication, learning, assessment, and subdomains. RESULTS Participants from 197 institutions in 22 countries engaged in the virtual education platform, including otolaryngologists, speech pathologists, respiratory therapists, specialist nurses, patients, and caregivers. Significant improvements were reported in communication (P < .0001), clinical assessments (P < .0001), and clinical governance (P < .0001), with positive impact on pediatric decannulation (P = .0008), adult decannulation (P = .04), and quality improvement (P < .0001). Respondents reported enhanced readiness to integrate knowledge into practice. Barriers included time zones, internet bandwidth, and perceived difficulty of direct clinical translation of highly technical skills. Participants rated the implementation highly in terms of length, ability for discussion, satisfaction, applicability to professional practice, and expertise of discussants (median scores: 4, 4, 4, 4 and 5 out of 5). CONCLUSIONS Virtual learning has dominated the education landscape during COVID-19 pandemic, but few data are available on its effectiveness. This study demonstrated feasibility of virtual learning for disseminating best practices in tracheostomy, engaging a diverse, multidisciplinary audience. Learning of complex technical skills proved a hurdle, however, suggesting need for hands-on experience for technical mastery. While interactive videoconferencing via webinar affords an engaging and scalable strategy for sharing knowledge, further investigation is needed on clinical outcomes to define effective strategies for experiential online learning and virtual in-service simulations.
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Affiliation(s)
- Chloe Swords
- Department of Otolaryngology - Head & Neck Surgery, West Suffolk Hospital, Bury St Edmunds, UK
| | | | | | - Diane Randall
- Joe DiMaggio Children's Hospital, Memorial Healthcare System, Hollywood, FL, USA
| | - Linda L Morris
- Shirley Ryan AbilityLab, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Michael J Brenner
- Department of Otolaryngology - Head & Neck Surgery, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Asit Arora
- Department of Otolaryngology - Head & Neck Surgery, Guy's and Saint Thomas' NHS Foundation Trust, London, UK
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4
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Brenner MJ, Pandian V, Milliren CE, Graham DA, Zaga C, Morris LL, Bedwell JR, Das P, Zhu H, Lee Y. Allen J, Peltz A, Chin K, Schiff BA, Randall DM, Swords C, French D, Ward E, Sweeney JM, Warrillow SJ, Arora A, Narula A, McGrath BA, Cameron TS, Roberson DW. Global Tracheostomy Collaborative: data-driven improvements in patient safety through multidisciplinary teamwork, standardisation, education, and patient partnership. Br J Anaesth 2020; 125:e104-e118. [DOI: 10.1016/j.bja.2020.04.054] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2019] [Revised: 03/17/2020] [Accepted: 04/17/2020] [Indexed: 01/15/2023] Open
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5
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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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6
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Lamb CR, Desai NR, Angel L, Chaddha U, Sachdeva A, Sethi S, Bencheqroun H, Mehta H, Akulian J, Argento AC, Diaz-Mendoza J, Musani A, Murgu S. Use of Tracheostomy During the COVID-19 Pandemic: American College of Chest Physicians/American Association for Bronchology and Interventional Pulmonology/Association of Interventional Pulmonology Program Directors Expert Panel Report. Chest 2020; 158:1499-1514. [PMID: 32512006 PMCID: PMC7274948 DOI: 10.1016/j.chest.2020.05.571] [Citation(s) in RCA: 72] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2020] [Revised: 05/19/2020] [Accepted: 05/30/2020] [Indexed: 01/08/2023] Open
Abstract
Background The role of tracheostomy during the coronavirus disease 2019 (COVID-19) pandemic remains unknown. The goal of this consensus statement is to examine the current evidence for performing tracheostomy in patients with respiratory failure from COVID-19 and offer guidance to physicians on the preparation, timing, and technique while minimizing the risk of infection to health care workers (HCWs). Methods A panel including intensivists and interventional pulmonologists from three professional societies representing 13 institutions with experience in managing patients with COVID-19 across a spectrum of health-care environments developed key clinical questions addressing specific topics on tracheostomy in COVID-19. A systematic review of the literature and an established modified Delphi consensus methodology were applied to provide a reliable evidence-based consensus statement and expert panel report. Results Eight key questions, corresponding to 14 decision points, were rated by the panel. The results were aggregated, resulting in eight main recommendations and five additional remarks intended to guide health-care providers in the decision-making process pertinent to tracheostomy in patients with COVID-19-related respiratory failure. Conclusion This panel suggests performing tracheostomy in patients expected to require prolonged mechanical ventilation. A specific timing of tracheostomy cannot be recommended. There is no evidence for routine repeat reverse transcription polymerase chain reaction testing in patients with confirmed COVID-19 evaluated for tracheostomy. To reduce the risk of infection in HCWs, we recommend performing the procedure using techniques that minimize aerosolization while wearing enhanced personal protective equipment. The recommendations presented in this statement may change as more experience is gained during this pandemic.
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Affiliation(s)
- Carla R Lamb
- Department of Medicine, Division of Pulmonary and Critical Care, Lahey Hospital and Medical Center, Burlington, MA
| | - Neeraj R Desai
- Chicago Chest Center, AMITA Health, Lisle, IL; Department of Medicine, Division of Pulmonary, Critical Care, Sleep and Allergy, University of Illinois at Chicago, Chicago, IL
| | - Luis Angel
- Department of Medicine, Division of Pulmonary and Critical Care, New York University Langone Health, NY
| | - Udit Chaddha
- Division of Pulmonary, Critical Care and Sleep Medicine, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Ashutosh Sachdeva
- Department of Medicine, Division of Pulmonary and Critical Care, University of Maryland School of Medicine, Baltimore, MD
| | - Sonali Sethi
- Respiratory Institute, Division of Pulmonary and Critical Care, Cleveland Clinic, Cleveland, OH
| | - Hassan Bencheqroun
- Department of Medicine, Division of Pulmonary and Critical Care, University of California Riverside, CA
| | - Hiren Mehta
- Division of Pulmonary and Critical Care and Sleep Medicine, University of Florida, FL
| | - Jason Akulian
- Division of Pulmonary and Critical Care, UNC Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, NC
| | - A Christine Argento
- Department of Medicine, Division of Pulmonary and Critical Care, Northwestern University, Feinberg School of Medicine, Chicago, IL
| | - Javier Diaz-Mendoza
- Division of Pulmonary and Critical Care, Henry Ford Hospital and Department of Medicine, Wayne State University, Detroit, MI
| | - Ali Musani
- Division of Pulmonary Sciences and Critical Care Medicine, University of Colorado, Denver, CO
| | - Septimiu Murgu
- Division of Pulmonary and Critical Care Medicine, The University of Chicago, Chicago, IL.
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7
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Cherney RL, Pandian V, Ninan A, Eastman D, Barnes B, King E, Miller B, Judkins S, Smith AE, Smith NM, Hanley J, Creutz E, Carlson M, Schneider KJ, Shever LL, Casper KA, Davidson PM, Brenner MJ. The Trach Trail: A Systems-Based Pathway to Improve Quality of Tracheostomy Care and Interdisciplinary Collaboration. Otolaryngol Head Neck Surg 2020; 163:232-243. [PMID: 32450771 DOI: 10.1177/0194599820917427] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
OBJECTIVE To implement a standardized tracheostomy pathway that reduces length of stay through tracheostomy education, coordinated care protocols, and tracking patient outcomes. METHODS The project design involved retrospective analysis of a baseline state, followed by a multimodal intervention (Trach Trail) and prospective comparison against synchronous controls. Patients undergoing tracheostomy from 2015 to 2016 (n = 60) were analyzed for demographics and outcomes. Trach Trail, a standardized care pathway, was developed with the Iowa Model of Evidence-Based Practice. Trach Trail implementation entailed monthly tracheostomy champion training at 8-hour duration and staff nurse didactics, written materials, and experiential learning. Trach Trail enrollment occurred from 2018 to 2019. Data on demographics, length of stay, and care outcomes were collected from patients in the Trach Trail group (n = 21) and a synchronous tracheostomy control group (n = 117). RESULTS Fifty-five nurses completed Trach Trail training, providing care for 21 patients placed on the Trach Trail and for synchronous control patients with tracheostomy who received routine tracheostomy care. Patients on the Trach Trail and controls had similar demographic characteristics, diagnoses, and indications for tracheostomy. In the Trach Trail group, intensive care unit length of stay was significantly reduced as compared with the control group, decreasing from a mean 21 days to 10 (P < .05). The incidence of adverse events was unchanged. DISCUSSION Introduction of the Trach Trail was associated with a reduction in length of stay in the intensive care unit. Realizing broader patient-centered improvement likely requires engaging respiratory therapists, speech language pathologists, and social workers to maximize patient/caregiver engagement. IMPLICATIONS FOR PRACTICE Standardized tracheostomy care with interdisciplinary collaboration may reduce length of stay and improve patient outcomes.
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Affiliation(s)
- Rebecca L Cherney
- University of Michigan Hospital and Health Center, Ann Arbor, Michigan, USA.,University of Michigan School of Nursing, Ann Arbor, Michigan, USA
| | | | - Ashly Ninan
- University of Michigan Hospital and Health Center, Ann Arbor, Michigan, USA.,Johns Hopkins School of Nursing, Baltimore, Maryland, USA
| | - Debra Eastman
- University of Michigan Hospital and Health Center, Ann Arbor, Michigan, USA
| | - Brian Barnes
- University of Michigan Hospital and Health Center, Ann Arbor, Michigan, USA
| | - Elizabeth King
- University of Michigan Hospital and Health Center, Ann Arbor, Michigan, USA
| | - Brianne Miller
- University of Michigan Hospital and Health Center, Ann Arbor, Michigan, USA
| | - Samantha Judkins
- University of Michigan Hospital and Health Center, Ann Arbor, Michigan, USA
| | - Alfred E Smith
- Global Tracheostomy Quality Improvement Collaborative, Raleigh, North Carolina, USA
| | - Nan M Smith
- Global Tracheostomy Quality Improvement Collaborative, Raleigh, North Carolina, USA
| | - Julie Hanley
- University of Michigan Hospital and Health Center, Ann Arbor, Michigan, USA
| | - Eileen Creutz
- University of Michigan Hospital and Health Center, Ann Arbor, Michigan, USA
| | - Megan Carlson
- University of Michigan Hospital and Health Center, Ann Arbor, Michigan, USA
| | - Kevin J Schneider
- Department of Otolaryngology-Head and Neck Surgery, University of Michigan Medical Center, Ann Arbor, Michigan, USA
| | - Leah L Shever
- University of Michigan Hospital and Health Center, Ann Arbor, Michigan, USA.,University of Michigan School of Nursing, Ann Arbor, Michigan, USA
| | - Keith A Casper
- Department of Otolaryngology-Head and Neck Surgery, University of Michigan Medical Center, Ann Arbor, Michigan, USA
| | | | - Michael J Brenner
- Global Tracheostomy Quality Improvement Collaborative, Raleigh, North Carolina, USA.,Department of Otolaryngology-Head and Neck Surgery, University of Michigan Medical Center, Ann Arbor, Michigan, USA
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8
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Gettelfinger JD, Paulk PB, Schmalbach CE. Patient Safety and Quality Improvement in Otolaryngology-Head and Neck Surgery: A Systematic Review. Laryngoscope 2020; 131:33-40. [PMID: 32057101 DOI: 10.1002/lary.28538] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2018] [Revised: 12/04/2019] [Accepted: 01/03/2020] [Indexed: 12/12/2022]
Abstract
OBJECTIVE The current landscape of patient safety/quality improvement (PS/QI) research dedicated to Otolaryngology-Head and Neck Surgery (OHNS) has not been established. This systematic review aims to define the breadth and depth of PS/QI research dedicated to OHNS and to identify knowledge gaps as well as potential areas of future study. METHODS The study protocol was developed a priori using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) process. A computerized Ovid/Medline database search was conducted (January 1, 1965-September 30, 2019). Similar computerized searches were conducted using Cochrane Database, PubMed, and Google Scholar. Articles were classified by year, subspecialty, PS/QI category, Institute of Medicine (IOM) Crossing the Chasm categories, and World Health Organization (WHO) subclass. RESULTS Computerized searches yielded 11,570 eligible articles, 738 (6.4%) of which met otolaryngology PS/QI inclusion criteria; 178 (24.1%) were not specific to any one subspecialty. The most prevalent subspecialty foci were head and neck (29.9%), pediatric otolaryngology (16.9%), and otology/neurotology (11.0%). Studies examining complications or risk factors (32.0%) and outcomes/quality measures (16.3%) were the most common foci. Classification by the IOM included effective care (31.4%), safety (29.9%), and safety/effective care (25.3%). Most research fell into the WHO categories of understanding causes (28.5%) or measuring harm (28.3%). CONCLUSION Most OHNS PS/QI projects (32.0%) focus on reporting complications or risk factors, followed by outcomes/quality measures (16.3%). Knowledges gaps for future research include healthcare disparities, multidisciplinary care, and the WHO category of studies translating evidence into safer care. LEVEL OF EVIDENCE NA Laryngoscope, 131:33-40, 2021.
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Affiliation(s)
- John D Gettelfinger
- Department of Otolaryngology-Head and Neck Surgery, Indiana University School of Medicine, Indianapolis, Indiana
| | - P Barrett Paulk
- Department of Otolaryngology-Head and Neck Surgery, Lewis Katz School of Medicine at Temple University, Philadelphia, Pennsylvania, USA
| | - Cecelia E Schmalbach
- Department of Otolaryngology-Head and Neck Surgery, Indiana University School of Medicine, Indianapolis, Indiana.,University of Alabama at Birmingham School of Medicine, Birmingham, Alabama
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9
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Kligerman MP, Saraswathula A, Sethi RK, Divi V. Tracheostomy Complications in the Emergency Department: A National Analysis of 38,271 Cases. ORL J Otorhinolaryngol Relat Spec 2020; 82:106-114. [PMID: 32036376 DOI: 10.1159/000505130] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2019] [Accepted: 11/28/2019] [Indexed: 12/20/2022]
Abstract
BACKGROUND Greater than 100,000 tracheotomies are performed annually in the USA, yet little is known regarding patients who present to the emergency department (ED) with tracheostomy complications. OBJECTIVES To characterize patient and hospital characteristics, outcomes, and charges associated with tracheostomy complications and to identify predictors of admission and mortality. METHODS The 2009-2011 Nationwide Emergency Department Sample (NEDS) was queried for patients with a principle diagnosis of tracheostomy complication. A descriptive analysis was performed and multivariable logistic regression was used to identify predictors of admission and mortality. RESULTS A total of 69,371 nationwide visits to the ED had tracheostomy complication as an associated ICD-9 diagnosis, of which 55.2% (n = 38,293) carried a primary diagnosis of tracheostomy complication. Unspecified tracheostomy complications were most common (61.4%), followed by mechanical complications (31.3%), and lastly by tracheostomy infections (7.3%). Pediatric patients were significantly more likely to have tracheostomy infections than adults (p < 0.0001). A total of 35.5% of patients with tracheostomy complications were admitted to the hospital, and death occurred with 1.4% of visits. Patients from higher-income ZIP codes had increased odds of admission (adjusted odds ratio [OR]: 1.35; p = 0.0009), as did patients with tracheostomy infections (OR: 4.425; p < 0.0001). Patients with tracheostomy infections (OR: 3.14; p = 0.0062) and unspecified tracheostomy complications (OR: 2.00; p = 0.0076) had increased odds of mortality. CONCLUSION These findings may help improve overall outcomes amongst patients with tracheostomies by preventing unnecessary ED admissions and improving healthcare provider preparedness and awareness.
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Affiliation(s)
- Maxwell P Kligerman
- Department of Otolaryngology - Head and Neck Surgery, Stanford University, Stanford, California, USA,
| | - Anirudh Saraswathula
- Department of Otolaryngology, Johns Hopkins University, Baltimore, Maryland, USA
| | - Rosh K Sethi
- Department of Otolaryngology, University of Michigan, Ann Arbor, Michigan, USA
| | - Vasu Divi
- Department of Otolaryngology - Head and Neck Surgery, Stanford University, Stanford, California, USA
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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: 0] [Impact Index Per Article: 0] [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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Twose P, Jones G, Lowes J, Morgan P. Enhancing care of patients requiring a tracheostomy: A sustained quality improvement project. J Crit Care 2019; 54:191-196. [PMID: 31521015 DOI: 10.1016/j.jcrc.2019.08.030] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2019] [Revised: 07/15/2019] [Accepted: 08/29/2019] [Indexed: 10/26/2022]
Abstract
INTRODUCTION Within the UK approximately 5000 surgical and 12,000 percutaneous tracheostomies are performed annually. Whilst an essential component of patient care, the presence of a tracheostomy is not without concern. Landmark papers have demonstrated recurrent themes related to the provision of training, staff and equipment, leading to avoidable patient harm, life-altering morbidity and mortality. The development of the Global Tracheostomy Collaborative (GTC) and the Improving Tracheostomy Care (ITC) project have provided the necessary infrastructure to make improvements, with individual organizations responsible for its implementation. METHOD This quality improvement project, funded by the NHS Wales Critical Care and Trauma Network, developed a dedicated tracheostomy team to improve the quality of care provided to those patients requiring a tracheostomy through staff education, equipment standardisation and multidisciplinary tracheostomy ward rounds. Global Tracheostomy membership was funded through involvement in the ITC project. RESULTS Formal tracheostomy teaching was delivered by the tracheostomy team to 165 clinicians involved in tracheostomy care. Improvements in self-assessed confidence with knowledge and were observed for all aspects of tracheostomy care. Standardisation and centralisation resulted in reduction in waste and unnecessary variation. Compliance with 'emergency tracheostomy blue box' availability with an increase from 5% to 100%. Comparison of data from the QI period against baseline data, demonstrated improvement in rates of decannulation, and non-significant improvements in time to decannulation, critical care and hospital length of stay. Additionally, there were associated reductions in adverse events. CONCLUSION This QI project, supported by involvement with the GTC and ITC, resulted in reductions in adverse events, improved patient safety, non-significant reduction in time to achieve weaning milestones and a reduction in hospital length of stay.
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Affiliation(s)
- Paul Twose
- Physiotherapy Department, University Hospital of Wales, Heath Park, Cardiff CF14 4XW, UK; School of Healthcare Sciences, Cardiff University, Cardiff CF14 4XN, UK.
| | - Gemma Jones
- Speech and Language Department, Royal Glamorgan Hospital, Llantrissant CF72 8XR, UK.
| | - Jennifer Lowes
- Critical Care, University Hospital of Wales, Heath Park, Cardiff CF14 4XW, UK.
| | - Paul Morgan
- Critical Care, University Hospital of Wales, Heath Park, Cardiff CF14 4XW, UK.
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12
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Holmes TR, Cumming BD, Sideris AW, Lee JW, Briggs NE, Havas TE. Multidisciplinary Tracheotomy Teams: An Analysis of Patient Outcomes and Resource Allocation. EAR, NOSE & THROAT JOURNAL 2019; 98:232-237. [PMID: 30939910 DOI: 10.1177/0145561319840103] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
We sought to establish the effect of introducing a multidisciplinary tracheotomy management team (MDT). Tracheotomies are high-cost interventions with potentially devastating complications. Multidisciplinary teams have been introduced in many hospitals with the aim of reducing complications, however, data supporting them are lacking. There is currently insufficient evidence to conclude MDTs reduce length of hospital or intensive care unit (ICU) stay, and there is little information on cost analysis. A chart review identified patients who had a tracheotomy inserted at a major metropolitan teaching hospital with an acute spinal medicine service 2 years before and after the MDT was implemented. The primary outcome was time to decannulation. Other outcomes included tracheotomy complications, the proportion of patients decannulated, length of ICU and hospital stay, and admission cost. Our search identified 174 (78 prior and 96 post-MDT) patients. Baseline demographics were similar between groups. There was no difference in time to decannulation, the decannulation rate, or the length of hospital or ICU stay. Complication rates were low in both groups. There was an increase in the proportion of patients who received speaking valves and a reduction in cost of admission in a subgroup of patients who did not undergo head and neck surgery. There is insufficient evidence to support the widespread introduction of tracheotomy MDTs. Institutions considering introducing a tracheotomy team should carefully consider their case-mix, volume, and available resources as well as the structure and responsibilities of the team, and the timing of its activities within the working week. The potential benefits of MDTs including teaching of staff, and collaboration of teams should be acknowledged. Given the potentially significant implications for cost to the health system, a randomized trial is needed to guide policy in this area.
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Affiliation(s)
- Timothy R Holmes
- 1 Department of Otolaryngology-Head and Neck Surgery, Prince of Wales Hospital, Sydney, New South Wales, Australia
| | - Benjamin D Cumming
- 1 Department of Otolaryngology-Head and Neck Surgery, Prince of Wales Hospital, Sydney, New South Wales, Australia
| | - Anders W Sideris
- 1 Department of Otolaryngology-Head and Neck Surgery, Prince of Wales Hospital, Sydney, New South Wales, Australia
| | - Jennifer W Lee
- 1 Department of Otolaryngology-Head and Neck Surgery, Prince of Wales Hospital, Sydney, New South Wales, Australia
| | - Nancy E Briggs
- 2 Mark Wainwright Analytical Centre, University on New South Wales, Sydney, New South Wales, Australia
| | - Thomas E Havas
- 1 Department of Otolaryngology-Head and Neck Surgery, Prince of Wales Hospital, Sydney, New South Wales, Australia
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A pilot study on the provision of tracheostomy healthcare and patient engagement in quality improvement measures: a global perspective. The Journal of Laryngology & Otology 2019; 132:1093-1096. [DOI: 10.1017/s0022215118002177] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
AbstractBackgroundWork describing patient and family outcomes after tracheostomy has indicated that patients do not feel prepared at the time of discharge.ObjectivesTo assess healthcare professional–patient interactions in tracheostomy care and the current provision of care.MethodA global electronic survey was disseminated via e-mail.ResultsThe majority of respondents were nursing or speech and language staff, from over 10 countries. Only 23 per cent of respondents’ institutions routinely offered patients the ability to meet people with a tracheostomy pre-operatively. Only 31 per cent consistently provided or co-ordinated full nursing and equipment requirements on discharge. Only half of the institutions participated in tracheostomy quality improvement initiatives; less than one-third of these involved patients.ConclusionThe provision of tracheostomy care in hospital and at discharge can be improved. The current practice of clinician-led audit is becoming less viable; future initiatives should focus upon patient-centred outcomes to ensure excellence in healthcare delivery.
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Doherty C, Neal R, English C, Cooke J, Atkinson D, Bates L, Moore J, Monks S, Bowler M, Bruce IA, Bateman N, Wyatt M, Russell J, Perkins R, McGrath BA. Multidisciplinary guidelines for the management of paediatric tracheostomy emergencies. Anaesthesia 2018; 73:1400-1417. [PMID: 30062783 DOI: 10.1111/anae.14307] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/14/2018] [Indexed: 01/09/2023]
Abstract
Temporary and permanent tracheostomies are required in children to manage actual or anticipated long-term ventilatory support, to aid secretion management or to manage fixed upper airway obstruction. Tracheostomies may be required from the first few moments of life, with the majority performed in children < 4 years of age. Although similarities with adult tracheostomies are apparent, there are key differences when managing the routine and emergency care of children with tracheostomies. The National Tracheostomy Safety Project identified the need for structured guidelines to aid multidisciplinary clinical decision making during paediatric tracheostomy emergencies. These guidelines describe the development of a bespoke emergency management algorithm and supporting resources. Our aim is to reduce the frequency, nature and severity of paediatric tracheostomy emergencies through preparation and education of staff, parents, carers and patients.
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Affiliation(s)
- C Doherty
- Department of Paediatric Anaesthesia, Manchester University NHS Foundation Trust, Manchester, UK
| | - R Neal
- Paediatric Intensive Care Medicine, Paediatrics, Birmingham Children's Hospital, Birmingham, UK
| | - C English
- Department of Paediatric ENT, Manchester University NHS Foundation Trust, Manchester, UK
| | - J Cooke
- Department of Paediatric Otolaryngology, Great Ormond Street Hospital, London, UK
| | - D Atkinson
- Department of Anaesthesia and Intensive Care Medicine, Manchester University NHS Foundation Trust, Manchester, UK
| | - L Bates
- Department of Anaesthesia and Intensive Care Medicine, Royal Bolton Hospital, Bolton, UK
| | - J Moore
- Department of Anaesthesia and Intensive Care Medicine, Manchester University NHS Foundation Trust, Manchester, UK
| | - S Monks
- Department of Anaesthesia, East Lancashire Hospitals NHS Trust, Burnley, UK
| | - M Bowler
- Department of Paediatric Anaesthesia, Manchester University NHS Foundation Trust, Manchester, UK
| | - I A Bruce
- Department of Paediatric Otolaryngology, Royal Manchester Children's Hospital, Manchester, UK
- Manchester Academic Health Science Centre, Manchester, UK
- Division of Infection, Immunity and Respiratory Medicine, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
| | - N Bateman
- Department of Paediatric Otolaryngology, Royal Manchester Children's Hospital, Manchester, UK
| | - M Wyatt
- Department of Paediatric Otolaryngology, Great Ormond Street Hospital, London, UK
| | - J Russell
- Department of Paediatric ENT, Our Lady's Children's Hospital, Dublin, Ireland
| | - R Perkins
- Department of Paediatric Anaesthesia, Manchester University NHS Foundation Trust, Manchester, UK
| | - B A McGrath
- Department of Anaesthesia and Intensive Care Medicine, Manchester University NHS Foundation Trust, Manchester, UK
- Division of Infection, Immunity and Respiratory Medicine, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
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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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Zanata IDL, Santos RS, Marques JM, Hirata GC, Santos DAD. Speech-language pathology assessment for tracheal decannulation in patients suffering from traumatic brain injury. Codas 2017; 28:710-716. [PMID: 28001270 DOI: 10.1590/2317-1782/20162014086] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2014] [Accepted: 09/01/2014] [Indexed: 11/22/2022] Open
Abstract
Purpose To describe the effect of Speech-Language Pathology (SLP) management on the tracheal decannulation process in patients with traumatic brain injury (TBI). Methods Prospective controlled clinical study. Two groups of patients with TBI confirmed by computed axial tomography were included in the study group (G1) and control group (G2) composed of 30 individuals each, with 25 (83.3%) male and 5 (16.7%) female individuals in both groups. Patients' age ranged from 18 to 53 years old - mean age was 32 years. A SPL assessment tool was developed for tracheostomized patients with TBI, composed of investigation of awareness level, cognition and swallowing (annex 1) and conduct. G1 underwent the assessment proposed by the study, and G2 was assessed by retrospective analysis of medical records without SLP evaluation. In this population, the variables time with tracheostomy and total days of hospitalization were the measurement markers for the effect of SLP conduct with this instrument. Results It was verified that G1 presented mean reduction of 4.2 days with tracheostomy and of 4.4 days in length of hospital stay when compared to G2. However, these figures are not statistically significant (p = 0.2031). Conclusion The group that was evaluated and received the SLP conduct proposed in the instrument presented a reduction in the time of permanence with tracheostomy, as well as in hospital stay.
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Leonhard M, Assadian O, Zumtobel M, Schneider-Stickler B. Microbiological evaluation of different reprocessing methods for cuffed and un-cuffed tracheostomy tubes in home-care and hospital setting. GMS HYGIENE AND INFECTION CONTROL 2016; 11:Doc02. [PMID: 26958456 PMCID: PMC4766923 DOI: 10.3205/dgkh000262] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Background: Manufacturers’ recommendations on cleaning of tracheostomy tubes focus on general warning information and non-specific manual cleaning procedures. The aim of this experimental study was to evaluate different reprocessing methods and to determine the mechanical integrity and functionality of tracheostomy tubes following reprocessing. Methods: Sixteen cuffed or un-cuffed tracheostomy tubes obtained from hospital in-patients were reprocessed using one of the following reprocessing methods: a) manual brushing and rinsing with tap water, b) manual brushing followed by disinfection with a glutaraldehyde solution, c) manual brushing followed machine-based cleaning in a dishwasher, and d) manual brushing followed by ultrasound cleaning in a commercially available ultrasound device. Microbial burden of the tubes before and after reprocessing was assessed by measurement of microbial colony-forming units per mL (CFU/mL) of rinsing fluid. After cleaning, tracheostomy tubes were investigated for loss of functionality. Findings: Manual brushing and rinsing with tap water reduced microbial colonization in average by 102 CFU/mL, but with poor reproducibility and reliability. Complete microbial reduction was achieved only with additional chemical or machine-based thermal disinfection. Ultrasound sonification yielded no further microbial reduction after manual brushing. Conclusion: Manual brushing alone will not result in complete eradication of microorganism colonising cuffed or un-cuffed tracheostomy tubes. However, manual cleaning followed by chemical or thermal disinfection may be regarded as safe and reproducible reprocessing method. If a machine-based reprocessing method is used for cuffed tubes, the cuffs’ ventilation hose must be secured in a safe position prior to thermal disinfection.
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Affiliation(s)
- Matthias Leonhard
- Department of Otorhinolaryngology, Medical University of Vienna, Austria
| | - Ojan Assadian
- Institute for Skin Integrity and Infection Prevention, University of Huddersfield, United Kingdom
| | - Michaela Zumtobel
- Department of Otorhinolaryngology, Medical University of Vienna, Austria
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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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Liu C, Heffernan C, Saluja S, Yuan J, Paine M, Oyemwense N, Berry J, Roberson D. Indications, Hospital Course, and Complexity of Patients Undergoing Tracheostomy at a Tertiary Care Pediatric Hospital. Otolaryngol Head Neck Surg 2014; 151:232-9. [PMID: 24788698 DOI: 10.1177/0194599814531731] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2013] [Accepted: 03/25/2014] [Indexed: 11/15/2022]
Abstract
OBJECTIVE The purpose of this study was to review inpatients undergoing tracheostomies at a tertiary care pediatric hospital in a 24-month period and to identify the indications, comorbidities, hospital course, patient complexity, and predischarge planning for tracheostomy care. The goal was to analyze these factors to highlight potential areas for improvement. STUDY DESIGN Case series with chart review. SETTING Tertiary care pediatric hospital. SUBJECTS Ninety-five inpatients at Boston Children's Hospital requiring a primary or revision tracheostomy during the 24-month period encompassing 2010 to 2011. METHODS Inpatients undergoing tracheostomy during the study period were identified using 2 different databases: the Boston Children's Hospital Department of Otolaryngology and Communication Enhancement database and institution-specific information from the Child Health Corporation of America's Pediatric Health Information System (PHIS). We extracted the specified metrics from the inpatient charts. RESULTS Patients undergoing tracheostomy are complex, with an average of 3.4 comorbidities and 13.6 services involved in their care. The tracheostomy was mentioned in 97.9% of physician and 69.5% of nurse discharge notes, and 42.5% of physician discharge notes contained a plan or appointment for follow-up. Of the patients, 33.7% were discharged home (27.3% of the nonanatomic group and 52.4% of the anatomic group). Overall, 8.4% of tracheostomy patients died before discharge. CONCLUSION The complexity of pediatric tracheostomy patients presents challenges and opportunities for optimizing quality of care for these children. Future directions include the introduction and assessment of multidisciplinary tracheostomy care teams, tracheostomy nurse specialists, and tracheostomy care plans in the pediatric setting.
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Affiliation(s)
- Charles Liu
- Harvard Medical School, Boston, Massachusetts Department of Otolaryngology, Boston Children's Hospital, Boston, Massachusetts
| | - Colleen Heffernan
- Department of Ear, Nose, Throat, Head and Neck Surgery, Galway University Hospital, Galway, Ireland
| | - Saurabh Saluja
- Department of Surgery, Weill Cornell Medical College, New York-Presbyterian Hospital, New York, New York
| | - Jennifer Yuan
- Ferkauf Graduate School of Psychology, Yeshiva University, New York, New York
| | - Melody Paine
- Department of Otolaryngology, Boston Children's Hospital, Boston, Massachusetts
| | | | - Jay Berry
- Harvard Medical School, Boston, Massachusetts Complex Care Service, Division of General Pediatrics, Boston Children's Hospital, Boston, Massachusetts
| | - David Roberson
- Harvard Medical School, Boston, Massachusetts Department of Otolaryngology, Boston Children's Hospital, Boston, Massachusetts
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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: 228] [Impact Index Per Article: 19.0] [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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Speed L, Harding KE. Tracheostomy teams reduce total tracheostomy time and increase speaking valve use: a systematic review and meta-analysis. J Crit Care 2012; 28:216.e1-10. [PMID: 22951017 DOI: 10.1016/j.jcrc.2012.05.005] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2012] [Revised: 05/09/2012] [Accepted: 05/13/2012] [Indexed: 10/27/2022]
Abstract
PURPOSE Multidisciplinary tracheostomy teams have been implemented in acute hospitals over the past 10 years. This systematic review of the literature and meta-analysis aimed to assess the effect of tracheostomy teams on patient outcomes. MATERIALS AND METHODS We conducted an electronic search of the literature in the following databases: MEDLINE, CINAHL, EMBASE, and AMED. Inclusion/exclusion criteria were applied, and included articles were assessed against quality criteria. Qualitative synthesis and meta-analysis were completed. RESULTS Seven studies were included. The studies were all pre-post cohort designs of low-moderate quality. Meta-analysis showed that tracheostomy teams were associated with reductions in total tracheostomy time (4 studies; mean difference, 8 days; 95% confidence interval, 6-11; P < .01; I(2) = 0%) and hospital length of stay (LOS) (3 studies; mean difference, -14 days; 95% confidence interval, -39 to 9; P = .23; I(2) = 50%). Reductions in intensive care unit LOS (3 studies) and increases in speaking valve (3 studies) use were also reported with tracheostomy teams. CONCLUSION There is low-quality evidence that multidisciplinary tracheostomy care contributes to a reduction in total tracheostomy time and increase speaking valve use for patients leading to improved quality of life. There is insufficient evidence to determine that multidisciplinary tracheostomy teams reduce hospital or intensive care unit LOS.
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Safety, efficiency, and cost-effectiveness of a multidisciplinary percutaneous tracheostomy program. Crit Care Med 2012; 40:1827-34. [PMID: 22610187 DOI: 10.1097/ccm.0b013e31824e16af] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
OBJECTIVE The frequency of bedside percutaneous tracheostomies is increasing in intensive care medicine, and both safety and efficiency of care are critical elements in continuing success of this procedure. Prioritizing patient safety, a tracheostomy team was created at our institution to provide bedside expertise in surgery, anesthesiology, respiratory, and technical support. This study was performed to evaluate the metrics of patient outcome, efficiency of care, and cost-benefit analysis of the multidisciplinary Johns Hopkins Percutaneous Tracheostomy Program. DESIGN A review was performed for patients who received tracheostomies in 2004, the year before the Johns Hopkins Percutaneous Tracheostomy Program was established, and those who received tracheostomies in 2008, the year following the program's establishment. Comparative outcomes were evaluated, including the efficiency of procedure and intensive care unit length of stay, complication rate including bleeding, hypoxia, loss of airway, and a financial cost-benefit analysis. SETTING Single-center, major university hospital. PATIENTS The sample consisted of 363 patients who received a tracheostomy in the years 2004 and 2008. MEASUREMENTS AND MAIN RESULTS The number of percutaneous procedures increased from 59 of 126 tracheostomy patients in 2004, to 183 of 237 in 2008. There were significant decreases in the prevalence of procedural complications, particularly in the realm of airway injuries and physiologic disturbances. Regarding efficiency, the structured program reduced the time to tracheostomy and overall procedural time. The intensive care unit length of stay in nonpulmonary patients and improvement in intensive care unit and operating room back-fill efficiency contributed to an overall institutional financial benefit. CONCLUSIONS An institutionally subsidized, multi-disciplinary percutaneous tracheostomy program can improve the quality of care in a cost-effective manner by decreasing the incidence of tracheostomy complications and improving both the time to tracheostomy, duration of procedure, and postprocedural intensive care unit stay.
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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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Pandian V, Miller CR, Mirski MA, Schiavi AJ, Morad AH, Vaswani RS, Kalmar CL, Feller-Kopman DJ, Haut ER, Yarmus LB, Bhatti NI. Multidisciplinary Team Approach in the Management of Tracheostomy Patients. Otolaryngol Head Neck Surg 2012; 147:684-91. [DOI: 10.1177/0194599812449995] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Objective To examine whether the implementation of a multidisciplinary percutaneous tracheostomy team decreases complications, improves efficiency in patient care, and reduces length of stay and cost in patients undergoing percutaneous tracheostomy. Study Design Case series with planned data collection. Setting Urban, academic, tertiary care medical center. Subjects and Methods Patients who underwent a percutaneous tracheostomy in 2004 and 2008, before and after the formation of a multidisciplinary percutaneous tracheostomy team, were included in the study. Data for the study were retrieved from a tracheostomy database. Measured outcomes include complications, efficiency, length of stay, and cost. Results Complications such as airway bleeding and physiological disturbances decreased significantly in 2008 as compared with 2004. The percentage of patients who received a tracheostomy within 2 days increased from 42.3% to 92% (2004 vs 2008), showing improvement in efficiency of care. There was no significant difference between the groups in terms of infection rate, length of stay, or mortality. However, in a subanalysis, the length of stay was found to be decreased in patients whose primary diagnosis was a neurological disorder. Finally, despite the necessity of a hospital-based subsidy, the team approach yielded substantial financial benefit to the medical center. Conclusions Airway bleeding, physiological disturbances, and efficiency of care improved after the institution of a multidisciplinary percutaneous tracheostomy team approach and may have a favorable impact on health care costs.
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Affiliation(s)
- Vinciya Pandian
- Percutaneous Tracheostomy Service, The Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - Christina R. Miller
- Department of Anesthesiology and Critical Care Medicine, The Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - Marek A. Mirski
- Department of Anesthesiology and Critical Care Medicine, The Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - Adam J. Schiavi
- Department of Anesthesiology and Critical Care Medicine, The Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - Athir H. Morad
- Department of Anesthesiology and Critical Care Medicine, The Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - Ravi S. Vaswani
- Percutaneous Tracheostomy Service, The Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - Christopher L. Kalmar
- Percutaneous Tracheostomy Service, The Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - David J. Feller-Kopman
- Department of Pulmonary and Critical Care Medicine, The Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - Elliott R. Haut
- Department of Anesthesiology and Critical Care Medicine, The Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
- Department of Surgery, The Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - Lonny B. Yarmus
- Department of Pulmonary and Critical Care Medicine, The Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - Nasir I. Bhatti
- Department of Otolaryngology Head and Neck Surgery, The Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
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Ward E, Morgan T, McGowan S, Spurgin AL, Solley M. Preparation, clinical support, and confidence of speech-language therapists managing clients with a tracheostomy in the UK. INTERNATIONAL JOURNAL OF LANGUAGE & COMMUNICATION DISORDERS 2012; 47:322-332. [PMID: 22512517 DOI: 10.1111/j.1460-6984.2011.00103.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Abstract
BACKGROUND Literature regarding the education, training, clinical support and confidence of speech-language therapists (SLTs) working with patients with a tracheostomy is limited; however, it suggests that many clinicians have reduced clinical confidence when managing this complex population, many face role and team challenges practising in this area, and most are seeking more opportunities for professional development and training. AIMS To investigate the education, training, clinical support and confidence of SLTs in the UK who manage patients with a tracheostomy in order to identify current challenges and inform the future clinical training needs of this professional group. METHODS & PROCEDURES Via an online survey, the clinical training, clinical support and confidence of SLTs with more than one year of clinical experience was examined. A total of 106 SLTs from the UK completed the survey. Within the questionnaire, clinicians were also asked to identify if their workplace had a tracheostomy competency training programme (CTP) to allow further exploration of the preparation, clinical support and confidence of respondents with (43% of respondents) and without (32% of respondents) a CTP. OUTCOMES & RESULTS Most SLTs (71%) were confident managing patients with a tracheostomy. The majority were accessing professional development and receiving expert support, though many identified specific areas where more support and training was needed. Less than half the group felt up to date with the current evidence. Only 35% of clinicians felt they worked in an optimal team for tracheostomy management, and poor recognition of the role of the SLT in managing dysphagia in patients with a tracheostomy was an issue for many clinicians, particularly on more general care wards. SLTs in workplaces with a CTP were found to have received significantly more expert support, on-the-job training, access to evidence-based practice and were significantly more confident in managing ventilator-assisted patients. CONCLUSIONS & IMPLICATIONS SLTs are eager to access further professional development and training; however, such training needs to target specific areas of need. The significant difference in the preparation, support and confidence of SLTs with CTPs in their workplace highlights potential benefits that can be achieved through workplace training and support.
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Affiliation(s)
- Elizabeth Ward
- Division of Speech Pathology, The University of Queensland, St Lucia, Brisbane, QLD, Australia.
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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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Yu M. Tracheostomy patients on the ward: multiple benefits from a multidisciplinary team? CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2010; 14:109. [PMID: 20156313 PMCID: PMC2875494 DOI: 10.1186/cc8218] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
Patients requiring tracheostomies tend to have a longer length of stay due to their underlying disease. After a thorough literature search, Garrubba and colleagues found only three studies assessing the impact of multidisciplinary teams (MDTs) on tracheostomy patients on the ward. One consistent observation was the decreased time to decannulation after institution of MDT care when compared with historical controls. Although a large prospective randomized trial is desirable before MDT is recommended, many institutions may have already formed a team approach to provide coordinated care resulting in improved outcome and length of stay.
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Multidisciplinary care for tracheostomy patients: a systematic review. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2009; 13:R177. [PMID: 19895690 PMCID: PMC2811928 DOI: 10.1186/cc8159] [Citation(s) in RCA: 59] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/20/2009] [Revised: 10/22/2009] [Accepted: 11/06/2009] [Indexed: 12/02/2022]
Abstract
Introduction Appropriate care for patients with tracheostomies in hospital settings is an important issue. Each year more than 7000 patients receive tracheostomies in Australia and New Zealand alone. Many of these tracheostomy patients commence their care in the intensive care unit (ICU) and once stabilised are then transferred to a general ward. Insufficient skills and experience of staff caring for tracheostomy patients may lead to sub-optimal care and increased morbidity. The purpose of this review was to identify whether multidisciplinary tracheostomy outreach teams enable the reduction in time to decannulation and length of stay in acute and sub-acute settings, improve quality of care or decrease adverse events for patients with a tracheostomy. Methods We included all relevant trials published in English. We searched Medline, CINAHL, All EBM and EMBASE in June 2009. Studies were selected and appraised by two reviewers in consultation with colleagues, using inclusion, exclusion and appraisal criteria established a priori. Results Three studies were identified which met the study selection criteria. All were cohort studies with historical controls. All studies included adult patients with tracheostomies. One study was conducted in the UK and the other two in Australia. Risk of bias was moderate to high in all studies. All papers concluded that the introduction of multidisciplinary care reduces the average time to decannulation for tracheostomy patients discharged from the ICU. Two papers also reported that multidisciplinary care reduced the overall length of stay in hospital as well as the length of stay following ICU discharge. Conclusions In the papers we appraised, patients with a tracheostomy tube in situ discharged from an ICU to a general ward who received care from a dedicated multidisciplinary team as compared with standard care showed reductions in time to decannulation, length of stay and adverse events. Impacts on quality of care were not reported. These results should be interpreted with caution due to the methodological weaknesses in the historical control studies.
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Manickavasagam J, Ranganathan B, Ryles J, McConachie J. Rectal catheter as tracheostomy tube introducer. Eur Arch Otorhinolaryngol 2009; 266:1821-2. [PMID: 19727786 DOI: 10.1007/s00405-009-1083-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2009] [Accepted: 08/20/2009] [Indexed: 11/25/2022]
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