Reduction in harm from tracheostomy‐related patient safety incidents following introduction of the <scp>N</scp>ational <scp>T</scp>racheostomy <scp>S</scp>afety <scp>P</scp>roject: Our experience from two hundred and eighty‐seven incidents

McGrath, Brendan A.; Calder, Nicholas; Laha, Shondipon; Perks, A.G.B.; Chaudry, I.; Bates, Lucy; Moore, J. A.; Atkinson, D.

doi:10.1111/coa.12177

Cited by 38 publications

(38 citation statements)

References 9 publications

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“…Over the last decade, a few adult institutions have shown that with truly integrated multidisciplinary tracheostomy care, it is possible to radically reduce adverse events and significantly improve care for patients with tracheostomy. 109,112,113 In 2009, Cameron et al 114 reported that implementation of a tracheostomy review and management service program resulted in significantly improved outcomes, with patients having a shorter length of hospital stay (median stay decreased from 60 to 41.5 d), vocalizing earlier and more often (speaking valve usage increased from 35 to 82%), and having a shorter time to decannulation (median decrease of decannulation from 22.5 to 16.5 d). Significantly, annual cost savings were also 8 times greater than the cost of program provision.…”

Section: Multidisciplinary Team Approachmentioning

confidence: 99%

Tracheostomy in Infants and Children

2017

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Over the last decade, tracheostomy has been increasingly performed in children, aligned with the improvements in neonatal and pediatric ICU care. Nowadays, the majority of children with tracheostomy represent a very complex cohort of patients with sustained reliance on tracheostomy and related medical technology for long-term survival. Tracheostomy is one of the most commonly performed procedures in the adult ICU. Contrary to adult practice, tracheostomy is a much less common procedure in the pediatric ICU, being performed in < 3% of patients. There is no definite consensus about the length of time a child should remain endotracheally intubated before the placement of a tracheostomy. Tracheostomy in children also continues to remain a predominantly surgical procedure, with percutaneous tracheostomy being performed infrequently and only considered feasible in older children. The indications, preoperative considerations, and procedure types for tracheostomy in children are reviewed. There is also a lack of consensus on an optimal pediatric decannulation protocol. The literature discusses a myriad of protocols that use varying combinations of in-patient/out-patient resources, specialized tests, and procedures An ideal decannulation protocol is presented, as well as review of recently published decannulation algorithms. Finally, children with tracheostomy have a higher risk of adverse events and mortality, which are largely secondary to their comorbidities rather than the tracheostomy. The majority of the tracheostomy-related events are in fact potentially preventable. There is a recognized need for improvement and coordination of care of pediatric patients with tracheostomy. A multidisciplinary coordinated approach to tracheostomy care has already shown promising results. This paper seeks to review the pertinent literature regarding quality improvement initiatives for tracheostomy care, including review of the recently established Global Tracheostomy Collaborative.

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Section: Multidisciplinary Team Approachmentioning

confidence: 99%

Tracheostomy in Infants and Children

2017

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“…In direct comparison with the baseline year, there was a significant decrease in harm in subsequent individual years with the exception of 2014, although we saw the lowest number of overall incidents that year. Similar interventions in adult practice have demonstrated a reduction in harm from 82% to 57% following implementation of NTSP guidelines . In our paediatric study, the baseline was lower at 57%, which we feel reflects a propensity for identifying more near misses in the paediatric setting.…”

Section: Discussionmentioning

confidence: 52%

“…The aims of the Working Party are to reduce morbidity and mortality in children living with a tracheostomy . This reflects the NTSP adult work with publication of emergency guidelines and comprehensive resources, the implementation of which resulted in a reduction in the frequency and severity of tracheostomy incidents …”

Section: Introductionmentioning

confidence: 82%

“…6 This reflects the NTSP adult work 7 with publication of emergency guidelines and comprehensive resources, the implementation of which resulted in a reduction in the frequency and severity of tracheostomy incidents. 8 This study aimed to evaluate the impact of implementing tracheostomy-related guidelines and a number of other local interventions as a bundle of care by retrospectively examining the reported tracheostomy-related patient safety incidents reported between 2010 and 2015 at a single tertiary paediatric centre.…”

Section: Introductionmentioning

confidence: 99%

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Reduction in harm from tracheostomy‐related incidents after implementation of the paediatric National Tracheostomy Safety Project resources: A retrospective analysis from a tertiary paediatric centre

Doherty

Bowler

Monks

et al. 2017

Clinical Otolaryngology

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“…Por lo tanto, mejorar las competencias de los cuidadores y profesionales vinculados en el cuidado de los niños con traqueostomía resulta primordial para mejorar la seguridad y promover la inclusión social de este grupo de niños. [1][2][3][4] La traqueostomía es un procedimiento muy antiguo 5 que consiste en abocar la tráquea a la piel de manera de asegurar la vía aérea y su abertura se sostiene mediante una cánula de traqueostomía. En las últimas déca-das, como contracara de los avances en los cuidados críticos pediátricos y neonatales, el número de niños que ha requerido una traqueostomía se ha incrementado.…”

Section: Introductionunclassified