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Objectives/Hypothesis To gather qualitative and semiquantitative information about catastrophic complications during and following tracheotomy. Study Design National survey distributed to American Academy of Otolaryngology–Head and Neck Surgery members via the Academy weekly email newsletter during April and May 2011. Methods A total of 478 respondents provided estimates of the number of four specific tracheotomy-related complications (innominate artery fistula, esophageal fistula, acute tracheotomy occlusion, and obstructing granuloma), all catastrophic events, and events resulting in death or permanent disability encountered during their careers. There were 253 respondents who provided 405 free-text descriptions of specific events. Results The respondents experienced approximately one catastrophic event every 10 years and one event resulting in death or permanent disability every 20 years. More than 90% occurred more than 1 week after surgery. Categories of physicians who experienced more events per year included academic physicians and laryngologists. Pediatric otolaryngologists had twice as many innominate artery fistulas per year of practice as others. Qualitative (free-text) descriptions of the most serious events demonstrated that more of these events involved loss of airway and volume bleeds, usually from innominate or carotid artery erosion. Many of the events due to airway loss involved potentially correctable deficits in family education, nursing care, home care, and other structural factors. Conclusions Even when we allow for selection bias, these data suggest that a substantial number of tracheotomy complications leading to death or permanent disability occur at a national level. The vast majority of events occur more than 1 week after the procedure. Many of the described events were caused by factors that should be amenable to prospective system improvement strategies.

2b.

Reducing fragmentation between different parts of the health system is a key priority for the National Health Service (NHS) and for health systems internationally, if they are to meet the challenges they face. One of the deepest fault-lines in the NHS is the disconnection of mental healthcare from the rest of the system; this has to be addressed as part of efforts to improve integrated care. 1 Developing integrated approaches towards mental and physical health is increasingly becoming a policy priority; the report of the independent mental health taskforce to the NHS identified this as one of the top three priorities for the next five years. There has been recent investment in integrating mental and physical health within secondary care, for example, liaison psychiatry in acute general hospitals and perinatal mental healthcare. 2 While such investment is also crucial, we believe that there is great unrealised opportunity for integration in developing new approaches to mental health within primary care.Mental health problems are very common in the community; 90%of adults with mental health problems are supported largely or exclusively by primary care. 2 Mental health problems often co-exist with physical health problems; the King's Fund highlighted that 12-18%of NHS expenditure on long-term conditions is linked to anxiety, depression or other mental health problems. 3 Furthermore, as the UK population ages, we will see an increase in the number of people with co-existing physical and mental health problems. Alongside diagnosable mental health problems, subthreshold symptoms are common in primary care and often co-exist with high levels of complexity and challenging social circumstances, such as unemployment and poor housing. 1 Medically unexplained symptoms and substance abuse disorders are also highly prevalent in primary care.Unfortunately, these kinds of problems are often poorly managed through current arrangements.

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There is marked variability in the surveillance and management of tracheotomy patients. There exists opportunity to improve care through standardization of surveillance and management of these patients.

Background Self-binding directives instruct clinicians to overrule treatment refusal during future severe episodes of illness. These directives are promoted as having the potential to increase autonomy for individuals with severe episodic mental illness. Although lived experience is central to their creation, the views of service users on selfbinding directives have not been investigated substantially. This study aimed to explore whether reasons for endorsement, ambivalence, or rejection given by service users with bipolar disorder can address concerns regarding self-binding directives, decision-making capacity, and human rights.Methods This qualitative study used data from an internet-based survey distributed to the mailing list of the UK charity Bipolar UK, which contained multiple closed and open questions on advance decision making for patients with bipolar disorder. We included participants who reported that they have been diagnosed with bipolar disorder by a professional (doctor or psychiatrist). In a previous study, quantitative analysis of a closed question about self-binding directives had shown endorsement among a high proportion of participants with bipolar disorder who completed the survey. In this study, we did a thematic analysis of responses from those participants who answered a subsequent open question about reasons for their view. Research was done within a multidisciplinary team, including team members with clinical, legal, and ethical expertise, and lived experience of bipolar disorder. Ideas and methods associated with all these areas of expertise were used in the thematic analysis to gain insight into the thoughts of individuals with bipolar disorder about self-binding directives and associated issues.

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.