Harnessing In Situ Simulation to Identify Human Errors and Latent Safety Threats in Adult Tracheostomy Care

BACKGROUND

Tracheostomies are associated with high rates of complications and preventable harm. Safe tracheostomy management requires highly functioning teams and systems, but health care providers are poorly equipped with tracheostomy knowledge and resources. In situ simulation has been used as a quality improvement tool to audit multidisciplinary team emergency response in the actual clinical environment where care is delivered but has been underexplored for tracheostomy care.

METHODS

From July 2021 to May 2022, the study team conducted in situ simulations of a tracheostomy emergency scenario at Montefiore Medical Center to identify human errors and latent safety threats (LSTs). Simulations included structured debriefs as well as audiovisual recording that allowed for blind rating of these human errors and LSTs. Provider knowledge deficits were further characterized using pre-simulation quizzes.

RESULTS

Twelve human errors and 15 LSTs were identified over 20 simulations with 88 participants overall. LSTs were divided into the following categories: communication, equipment, and infection control. Only 50.0% of teams successfully replaced the tracheostomy tube within the scenario's five-minute time limit. In addition, knowledge gaps were highly prevalent, with a median pre-simulation quiz score of 46% (interquartile range 36-64) among participants.

CONCLUSION

An in situ simulation-based quality improvement approach shed light on human errors and LSTs associated with tracheostomy care across multiple settings in one health system. This method of engaging frontline health care provider key stakeholders will inform the development, adaptation, and implementation of interventions.

Update on injection augmentation pharyngoplasty in the treatment of velopharyngeal insufficiency

PURPOSE OF REVIEW

Velopharyngeal insufficiency (VPI) refers to a structural defect resulting in incomplete closure between the soft palate and posterior pharyngeal wall, leading to inadequate speech and deglutition. Traditional surgical options for VPI include sphincter pharyngoplasty, pharyngeal flaps and palatoplasty. Although these procedures have been successfully used over the past several decades, they are associated with complications such as pain, bleeding, infection and obstructive sleep apnoea. They also require postoperative admission. Injection augmentation pharyngoplasty (IAP) is increasingly being viewed as a viable, less invasive surgical option for patients with mild to moderate VPI.

RECENT FINDINGS

Both autologous fat and alloplastic synthetics have been used as injectable materials, with low morbidity and good speech outcomes. However, given the overall lack of standardization across studies, no single material has shown clear superiority.

SUMMARY

IAP is a promising alternative to more invasive surgeries in the treatment of patients with mild to moderate VPI. The purpose of this review is to provide an overview of this approach, with an emphasis on its safety and efficacy.

Evaluating Safety of Awake, Bilateral Injection Laryngoplasty for Bilateral Vocal Fold Atrophy

OBJECTIVE

Office-based injection laryngoplasty (IL) has emerged as a useful procedure for otolaryngologists to correct glottic insufficiency while avoiding the costs and risks of general anesthesia. This is the first study focused on addressing the safety of bilateral IL for bilateral vocal fold (VF) atrophy.

METHODS

Patient records were reviewed from Emory University Hospital Midtown during the period of 2005 to 2017. Patients who underwent awake, bilateral transthyrohyoid, transoral, transcricothyroid, or transthyroid cartilage IL for bilateral VF atrophy were analyzed. All procedures, including repeat injections, were bilateral. Complication rate was used to evaluate safety. Patients with vocal cord paralysis, paresis, scar, and sulcus were excluded from the study.

RESULTS

Total 174 procedures met inclusion criteria. There were four complications, yielding a complication rate of 2.3%. Complications included aborted cases for difficult anatomy or poor patient tolerance, injection material not resorbing, and a VF hematoma. No patients had any airway emergencies or required admission to the hospital or evaluation in the emergency room.

CONCLUSIONS

This study illustrates a low complication rate for awake, bilateral IL in treating bilateral VF atrophy. This supports other studies that promote the safety of this procedure in the awake setting. Complications were associated with patient tolerance, unique anatomy, and in one case, anticoagulant medication. The low complication rate supports the conclusion that bilateral medialization IL is safe to perform in the office-based, awake setting.

Barriers to thyroid cancer screening with ultrasound in patients with familial adenomatous polyposis

OBJECTIVES/HYPOTHESIS

To identify barriers to care in patients with familial adenomatous polyposis (FAP) that have not undergone ultrasound for thyroid cancer (TC) screening.

STUDY DESIGN

Case series and survey.

METHODS

A study was conducted examining referral patterns for thyroid ultrasound (TUS) in FAP patients for TC screening. Patients with FAP seen at our institution were identified using International Classification of Diseases, Ninth Revision and Tenth Revision codes. Chart review was performed for TUS and the results were recorded. Patients and healthcare providers were surveyed to determine barriers to TUS and opportunities for improvement.

RESULTS

Thirteen out of 35 patients surveyed (37%) were told by a healthcare provider that TUS was recommended for TC screening. The incidence for TC in FAP patients ranges from 15 to 12%, whereas the general population risk is 0.02% to 1%. In our series, one patient of 12 (8%) had TC. Barriers to care included poor patient education about the risk of TC in FAP and miscommunication among specialties for referral for TUS. Also, patients enrolled in a FAP registry have improved care, as they are more likely to undergo TUS than those not enrolled.

CONCLUSIONS

FAP patients are at a higher risk of developing TC. Therefore, it is important for these patients to be informed and follow the recommended guideline to get a baseline TUS for screening as well as receive better patient education about the risk of TC and improved communication among specialties. Additionally, patients enrolled in a FAP registry are more likely to undergo ultrasound for TC screening, so there needs to be more centralized coordination for the multidisciplinary care of this disease.

LEVEL OF EVIDENCE

NA Laryngoscope, 129:2436-2441, 2019.

The impact of molecular manipulation in residue 114 of human immunodeficiency virus type-1 reverse transcriptase on dNTP substrate binding and viral replication

Human immunodeficiency virus type-1 (HIV-1) reverse transcriptase (RT) has a unique tight binding to dNTP substrates. Structural modeling of Ala-114 of HIV-1 RT suggests that longer side chains at this residue can reduce the space normally occupied by the sugar moiety of an incoming dNTP. Indeed, mutations at Ala-114 decrease the ability of RT to synthesize DNA at low dNTP concentrations and reduce the dNTP-binding affinity (K(d)) of RT. However, the K(d) values of WT and A114C RT remained equivalent with an acyclic dNTP substrate. Finally, mutant A114 RT HIV-1 vectors displayed a greatly reduced transduction in nondividing human lung fibroblasts (HLFs), while WT HIV-1 vector efficiently transduced both dividing and nondividing HLFs. Together these data support that the A114 residue of HIV-1 RT plays a key mechanistic role in the dNTP binding of HIV-1 RT and the unique viral infectivity of target cell types with low dNTP pools.