A standardized, closed-loop system for monitoring pediatric tracheostomy-related adverse events

The Laryngoscope
Mallory McKeonKaren F Watters

Abstract

Advancement in neonatal and pediatric intensive care has increased the need for chronic-care interventions, including tracheostomy. It is well established that children with a tracheostomy are at a high risk for adverse events, many of which are preventable. Despite this, there is no standardized method of monitoring tracheostomy-related adverse events (TRAEs). Our objective was to describe and assess a standardized, closed-loop system for monitoring TRAEs. Prospective Study. A specific tracheostomy-related category was established within the adverse event reporting system in January 2015. Monthly TRAE reports were supplied to the multidisciplinary tracheostomy team (MDT) with descriptions of event type, severity, and preventability. The MDT reviewed events and discussed necessary follow-up. The frequency of events was standardized by inpatient tracheostomy days (ITDs) using an automated monthly list. Adverse events were tracked using a control chart. Aggregated data were divided into biannual reports for analysis. Eighty-five TRAEs were reported between January 2015 and June 2017, averaging 5.75 per 1,000 ITDs. Most common events include unplanned decannulation (50%) and improper use of tracheostomy supplies (21%). The frequen...Continue Reading

References

Jun 15, 2011·Critical Care Medicine·Andrew Conway MorrisTimothy S Walsh
Feb 12, 2013·American Journal of Infection Control·Ihn Sook JeongSu Jin Lee
May 3, 2014·Otolaryngology--head and Neck Surgery : Official Journal of American Academy of Otolaryngology-Head and Neck Surgery·Charles LiuDavid Roberson
Nov 26, 2015·Intensive & Critical Care Nursing : the Official Journal of the British Association of Critical Care Nurses·Janet M Galiczewski
Jul 3, 2016·International Journal of Pediatric Otorhinolaryngology·Ozgul GerginReza Rahbar
Oct 21, 2016·Clinical Otolaryngology : Official Journal of ENT-UK ; Official Journal of Netherlands Society for Oto-Rhino-Laryngology & Cervico-Facial Surgery·H Mortimer, H Kubba
May 27, 2017·Respiratory Care·Karen F Watters

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Citations

Mar 25, 2020·Otolaryngology--head and Neck Surgery : Official Journal of American Academy of Otolaryngology-Head and Neck Surgery·Thida OngKaalan E Johnson
Nov 14, 2020·Journal of Pediatric Nursing·Amber R MisraLeila S Ledbetter

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