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Preventing pediatric accidental decannulation events: A quality improvement initiative.
Cherches, Alexander; Wang, Avivah; Patterson, Rolvix H; Lee, Janet; Cheng, Jeffrey.
Afiliación
  • Cherches A; Duke University School of Medicine, Durham, NC, USA; Department of Otolaryngology - Head & Neck Surgery, University of Colorado, Aurora, CO, USA. Electronic address: alexander.cherches@cuanschutz.edu.
  • Wang A; Duke University School of Medicine, Durham, NC, USA.
  • Patterson RH; Department of Head and Neck Surgery & Communication Sciences, Duke University Medical Center, Durham, NC, USA; Hubert-Yeargan Center for Global Health, Duke University, Durham, NC, USA.
  • Lee J; Department of Head and Neck Surgery & Communication Sciences, Duke University Medical Center, Durham, NC, USA.
  • Cheng J; Department of Head and Neck Surgery & Communication Sciences, Duke University Medical Center, Durham, NC, USA.
Int J Pediatr Otorhinolaryngol ; 183: 112052, 2024 Aug.
Article en En | MEDLINE | ID: mdl-39106759
ABSTRACT

OBJECTIVE:

To describe a quality improvement (QI) method to decrease pediatric accidental decannulation (AD) in the early postoperative period for children under age 3.

METHODS:

A retrospective chart review was conducted on children under age 3 who underwent tracheostomy at Duke University Health System from August 1, 2013 to May 1, 2023 (n = 104). A root cause analysis was used to assess factors associated with AD following pediatric tracheostomy. Based on the factors identified by the research team, retrospective data was collected before (8/1/13 - 1/31/22) and after (2/1/22 - 5/1/23) a single practice change was implemented using twill neck ties, rather than foam neck ties, to secure newly-placed tracheostomy tubes. Twill ties were applied intraoperatively as a visual cue to signal a recent tracheostomy for the interdisciplinary care team. The primary outcome in the pre-intervention and post-intervention period was measured as 30-day incidence of AD per 10 tracheostomy cases.

RESULTS:

Prior to the intervention, a total of 11 ADs occurred in 9 patients across 93 pediatric tracheostomies (1.18 AD per 10 cases). Afterward, 0 ADs occurred across 11 pediatric tracheostomies (0 AD per 10 cases).

CONCLUSION:

This data suggests that the twill tie intervention may prevent AD and the associated morbidity. With the twill tie initiative, we describe 11 ADs and associated risk factors and present a QI intervention that may help prevent AD and improve patient safety in the early postoperative period.
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Texto completo: 1 Colección: 01-internacional Base de datos: MEDLINE Asunto principal: Traqueostomía / Remoción de Dispositivos / Mejoramiento de la Calidad Límite: Child, preschool / Female / Humans / Infant / Male Idioma: En Revista: Int J Pediatr Otorhinolaryngol Año: 2024 Tipo del documento: Article Pais de publicación: Irlanda
Texto completo
Añadir a Mi BVS
Imprimir
XML
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Texto completo: 1 Colección: 01-internacional Base de datos: MEDLINE Asunto principal: Traqueostomía / Remoción de Dispositivos / Mejoramiento de la Calidad Límite: Child, preschool / Female / Humans / Infant / Male Idioma: En Revista: Int J Pediatr Otorhinolaryngol Año: 2024 Tipo del documento: Article Pais de publicación: Irlanda