Quality improvement in tracheostomy care: A multidisciplinary approach to standardizing tracheostomy care to reduce complications.

PURPOSE: Develop a model for quality improvement in tracheostomy care and decrease tracheostomy-related complications. METHODS: This study was a prospective quality improvement project at an academic tertiary care hospital. A multidisciplinary team was assembled to create institutional guidelines for clinical care during the pre-operative, intra-operative, and post-operative periods. Baseline data was compiled by retrospective chart review of 160 patients, and prospective tracking of select points over 8 months in 73 patients allowed for analysis of complications and clinical parameters. RESULTS: Implementation of a quality improvement team was successful in creating guidelines, setting baseline parameters, and tracking data with run charts. Comparison of pre- and post-guideline data showed a trend toward decreased rate of major complications from 4.38% to 2.74% (p = 0.096). Variables including time to tracheotomy for prolonged intubation, surgical technique, day of first tracheostomy tube change, and specialty performing surgery did not show increased risk of complications. There were increased tracheostomy-related complications in cold months (p = 0.04). CONCLUSIONS: An interdisciplinary quality improvement team can improve tracheostomy care by identifying system factors, standardizing care among specialties, and providing continuous monitoring of select data points.

Pitfalls in the use of epinephrine for anaphylaxis: patient and provider opportunities for improvement.

BACKGROUND: Epinephrine remains the mainstay of treatment for life-threatening allergic reactions. A number of challenges are encountered with epinephrine, resulting in underutilization and misutilization of epinephrine. The purpose of this study was to identify the scope of epinephrine pitfalls and opportunities for improvement in the management of allergy emergencies. METHODS: A PubMed search from 1990 to 2015 was performed to identify all cases and reports pertaining to the use and misuse of epinephrine for anaphylaxis. Studies were assessed for obstacles or complications related to proper administration of epinephrine for treatment of allergic reactions, and were divided into problems originating with patients compared to healthcare providers. RESULTS: There were 1840 publications related to epinephrine use, of which 61 reports met inclusion criteria for pitfalls in the use of epinephrine. The most common problems reported related to lack of autoinjector availability (22), inadequate education of patients or providers (9), uncertainty about when or how to administer epinephrine (9), concern for systemic effects (13), failure to administer (8), and accidental administration (2). Responsibility for errors was divided among patients (18), providers (39), or both (4). CONCLUSION: Epinephrine is a potent medication with lifesaving indications and is the standard of care for treatment of anaphylaxis. The delivery of epinephrine in both trained and untrained populations carries certain pitfalls and complications that can have serious consequences. Identification of the scope of the problem is an important step in improving education for both providers and patients who are tasked with use of epinephrine for allergy emergencies.