Patient Safety/Quality Improvement Primer, Part IV: How to Measure and Track Improvements.

Patient safety and quality improvement (PS/QI) has become an integral part of the health care system, and the ability to effectively use data to track, understand, and communicate performance is essential to designing and implementing quality initiatives, as well as assessing their impact. Though many otolaryngologists are proficient in the methodologies of traditional research pursuits, educational gaps remain in the foundational principles of PS/QI measurement strategies. Part IV of this PS/QI primer discusses the fundamentals of measurement design and data analysis methods specific to PS/QI. Consideration is given to the selection of appropriate measures when designing a PS/QI project, as well as the method and frequency for collecting these measures. In addition, this primer reviews key aspects of tracking and analyzing data, providing an overview of statistical process control methods while highlighting the construction and utility of run and control charts. Lastly, this article discusses strategies to successfully develop and execute PS/QI initiatives in a way that facilitates the ability to appropriately measure their effectiveness and sustainability.

Electronic medical record based tools: Not a panacea in the diagnosis of coin-shaped foreign bodies.

INTRODUCTION: Electronic medical record-based tools have been demonstrated to improve timeliness of x-ray order placement in patients presenting to the emergency department (ED) with coin-shaped foreign body ingestion. Similar efforts directed towards downstream processes are necessary to expedite diagnosis of an esophageal button battery. We predicted that improvement tools such as electronic medical record-based alerts and process standardization could be utilized to expedite x-ray completion. METHODS: Using Plan, Do, Study, Act methodology, iterative interventions were implemented. In July 2017 a previously designed best practice advisory was linked to an automated notification page to the x-ray technician. Next, a standardized process was created where patients were gowned in triage and placed in a designated space awaiting x-ray. Workflow planning began in December 2018 and was formalized in February 2019. Time from arrival to x-ray completion was tracked for patients presenting with coin-shaped foreign body ingestion. Control charts were used to determine special cause variation. RESULTS: An average of 10.1 patients (Range 4-21) presented monthly to the ED with coin-shaped foreign body ingestion. Automated pages to the x-ray technician were not associated with improved time to x-ray completion. Upon initiation of the new patient workflow, median time to x-ray completion decreased from 37.4 to 23.3 min. CONCLUSION: Time to x-ray completion in children presenting to the ED with ingestion of coin-shaped foreign bodies is not improved solely through electronic notification of the imaging technologist. Efforts to standardize processes for patient intake and placement are associated with more timely completion of imaging studies. Generalizability of findings may depend on contextual elements of individual healthcare units.

Quality Improvement Methodology.

Patient Safety and Quality Improvement as a formal discipline has become widely established, with hospitals and health systems dedicating significant resources to improvement science. Physicians have leadership potential in quality and safety due to their clinical expertise and influence with both patients and hospital leadership. Success in such a leadership role, however, requires knowledge of the fundamentals of how to navigate an improvement endeavor from inception through implementation, analysis, and sustainment. Herein, the authors introduce the formal process of improvement science, discuss basic principles of change management, and provide a summary of the elements of scholarly writing to facilitate dissemination of knowledge across institutions.

Use of a Rigid Bronchoscope as the Sole Prebypass Airway During Pediatric Tracheal Tumor Resection: A Case Report.

We describe the anesthetic and operative techniques utilized for a tracheal tumor resection in a pediatric patient with 95% tracheal occlusion. In prior tracheal tumor cases that dictated complete resection, our team had been able to comfortably bypass a tumor with an endotracheal tube. In this case, we could not intubate past the tumor. A rigid bronchoscope was able to be placed past the tumor, so we continued with sternotomy and dissection before cardiopulmonary bypass while ventilating through that bronchoscope as our definitive airway.

Effect of Dedicated In-Person Interpreter on Satisfaction and Efficiency in Otolaryngology Ambulatory Clinic.

OBJECTIVE: In a large academic children's hospital ambulatory clinic, the increasing demand for Spanish interpretation exceeds the Interpreting Services Department capacity, necessitating telephone interpretation. By adding a dedicated Spanish interpreter in the otolaryngology clinic, we aimed to decrease visit times for Spanish-speaking patients and increase satisfaction. Additional aims explored if dedicated Spanish interpreters could increase patients seen per session. METHODS: A quality improvement initiative investigated baseline state compared to 2 tests of change using video interpretation and dedicated, in-person interpretation. Time permitting, interpreters contacted patients before the visit to decrease missed appointments and late arrivals. Measures included clinic visit times, late arrivals, missed appointments, and family/employee satisfaction scores. Actuarial statistics forecasted if on-site Spanish interpreters would affect patients seen per session and the potential addition of sessions. RESULTS: In-person interpretation reduced visit times for Spanish-speaking patients from 55 to 48 minutes (P = .01) and 57 to 48 minutes for all patients (P < .0001). Nearly 50% of video calls experienced technical difficulties. Families and employees preferred in-person over video and phone interpretation. No-show visits decreased by 25% and late arrivals by 17%. DISCUSSION: Implementing dedicated Spanish interpreters may increase productivity and enhance family experience. IMPLICATIONS FOR PRACTICE: Reducing patient visit time by 9 minutes permits 2 additional patients per clinic session (1560 visits, 390 surgeries per year). Applied institution-wide, the intervention could create 29% more capacity in the ambulatory schedule (31,000 additional visits) and reduce actuarial need for ambulatory sessions in the same clinic space.

Efficient Postoperative Disposition Selection in Pediatric Otolaryngology Patients: A Novel Approach.

OBJECTIVE: Pediatric patients undergoing surgery on the aerodigestive tract require a wide range of postoperative airway support that may be difficult predict in the preoperative period. Inaccurate prediction of postoperative resource needs leads to care inefficiencies in the form of unanticipated intensive care unit (ICU) admissions, ICU bed request cancellations, and overutilization of ICU resources. At our hospital, inefficient utilization of pediatric intensive care unit (PICU) resources was negatively impacting safety, access, throughput, and finances. We hypothesized that actionable key drivers of inefficient ICU utilization at our hospital were operative scheduling errors and the lack of predictability of intermediate-risk patients and that improvement methodology could be used in iterative cycles to enhance efficiency of care. Through testing this hypothesis, we aimed to provide a framework for similar efforts at other hospitals. STUDY DESIGN: Quality improvement initiative. METHODS: Plan, Do, Study, Act methodology (PDSA) was utilized to implement two cycles of change aimed at improving level-of-care efficiency at an academic pediatric hospital. In PDSA cycle 1, we aimed to address scheduling errors with surgical order placement restriction, creation of a standardized list of surgeries requiring PICU admission, and implementation of a hard stop for postoperative location in the electronic medical record surgical order. In the PDSA cycle 2, a new model of care, called the Grey Zone model, was designed and implemented where patients at intermediate risk of airway compromise were observed for 2-5 hours in the post-anesthesia care unit. After this observation period, patients were then transferred to the level of care dictated by their current status. Measures assessed in PDSA cycle 1 were unanticipated ICU admissions and ICU bed request cancellations. In addition to continued analysis of these measures, PDSA cycle 2 measures were ICU beds avoided, safety events, and secondary transfers from extended observation to ICU. RESULTS: In PDSA cycle 1, no significant decrease in unanticipated ICU admissions was observed; however, there was an increase in average monthly ICU bed cancellations from 36.1% to 45.6%. In PDSA cycle 2, average monthly unanticipated ICU admissions and cancelled ICU bed requests decreased from 1.3% to 0.42% and 45.6% to 33.8%, respectively. In patients observed in the Grey Zone, 229/245 (93.5%) were transferred to extended observation, avoiding admission to the ICU. Financial analysis demonstrated a charge differential to payers of $1.1 million over the study period with a charge differential opportunity to the hospital of $51,720 for each additional hospital transfer accepted due to increased PICU bed availability. CONCLUSIONS: Implementation of the Grey Zone model of care improved efficiency of ICU resource utilization through reducing unanticipated ICU admissions and ICU bed cancellations while simultaneously avoiding overutilization of ICU resources for intermediate-risk patients. This was achieved without compromising safety of patient care, and was financially sound in both fee-for-service and value-based reimbursement models. While such a model may not be applicable in all healthcare settings, it may improve efficiency at other pediatric hospitals with high surgical volume and acuity. LEVEL OF EVIDENCE: N/A Laryngoscope, 131:S1-S10, 2021.

Resource utilization of intraoperative cultures for pediatric deep neck space abscesses.

INTRODUCTION: Peritonsillar (PT), parapharyngeal (PP), and retropharyngeal (RP) abscesses are common pediatric deep neck space infections (DNSI). Despite established literature on DNSI microbiology, obtaining intraoperative cultures remains commonplace. The objective was to evaluate the resource utilization of intraoperative cultures when draining PT, PP, and RP abscesses. METHODS: Pediatric patients (age <18.0 years) who underwent surgical drainage of a PT, PP, or RP abscess between January 2013 and June 2018 were retrospectively reviewed. Changes in antimicrobials based on intraoperative culture results were assessed by use of Fisher's exact tests or Wilcoxon rank-sum tests, as appropriate. Multivariable linear regression was used to model the association between factors of interest and number of cultures obtained. RESULTS: Eighty-eight patients underwent surgical drainage, of which 80 patients (median age 6.96 years) had intraoperative bacterial cultures (32 PT, 21 PP, and 27 RP). There were no positive fungal or acid-fast bacilli cultures. Seven patients had culture-directed changes in treatment; none of these patients had a PT abscess. Age was inversely associated with culture-directed changes (p = 0.006) while the use of blood cultures (p = 0.012) was positively associated with culture-directed treatment changes. Hospital length of stay (p < 0.001) and history of prior DNSI (p = 0.001) were associated with number of cultures obtained. CONCLUSIONS: Younger children with PP and RP abscesses are most likely to benefit from intraoperative bacterial cultures. Cultures of PT abscesses are unlikely to change clinical management. Fungal and acid-fast bacilli cultures are unlikely to yield clinically useful information. Prudent use of intraoperative cultures may decrease the use of hospital resources and admission-related costs.

Airway Obstruction during Sleep due to Diaphragm Pacing Precludes Decannulation in Young Children with CCHS.

Children with congenital central hypoventilation syndrome (CCHS) have a PHOX2B mutation-induced control of breathing deficit necessitating artificial ventilation as life support. A subset of CCHS families seek phrenic nerve-diaphragm pacing (DP) during sleep with the goal of tracheal decannulation. Published data regarding DP during sleep as life support in the decannulated child with CCHS and related airway dynamics in young children are limited. We report a series of 3 children, ages 3.3-4.3 years, who underwent decannulation. Sleep endoscopy performed during DP revealed varied (oropharynx, supraglottic, glottic, etc.) levels of complete airway obstruction despite modification of pacer settings. Real-time analysis of end tidal CO2 and SpO2 confirmed inadequate gas exchange. Because the families declined re-tracheostomy, all 3 patients rely on noninvasive mask ventilation as a means of life support while asleep. These results emphasize the need for extreme caution in proceeding with tracheal decannulation in young children with CCHS who expect to use DP during sleep as life support. Parents and patients should anticipate that they will depend on noninvasive mask ventilation (rather than DP) during sleep after undergoing decannulation. This information may improve management and guide expectations regarding potential decannulation in young paced children with CCHS.

Publicly Available Databases in Otolaryngology Quality Improvement.

The historical context for quality improvement is provided. Important differences are described between the two overarching types of databases: clinical registries and administrative databases. The pros and cons of each are provided as are examples of their utilization in otolaryngology-head and neck surgery.

Critical care resources utilized in high-risk adenotonsillectomy patients.

OBJECTIVE: Children at high risk for respiratory complication after adenotonsillectomy are often admitted to a pediatric intensive care unit (PICU) postoperatively. Although many patients receive care in such units, it is unknown how many utilize critical care resources. METHODS: A review was conducted to audit intensive care needs of postadenotonsillectomy patients admitted to the PICU at a tertiary, academic, pediatric hospital between July 2013, and March 2017. Demographic information, ICU indication, polysomnogram results, and comorbidities were collected. Patients were defined as needing ICU resources based on supplemental oxygen requirements greater than 2 L between 2 to 24 hours postoperatively, more than two desaturation events in a 2-hour period, or more than hourly nursing intervention. Factors associated with utilization of ICU resources were assessed. RESULTS: One hundred and ten patients were admitted to the PICU after adenotonsillectomy. Median age was 4.2 years, median body mass index was 90.8 percentile, and median apnea hypopnea index (AHI) was 34.3. Twenty patients (18.2%) utilized ICU resources by criteria defined. Of these patients, 14 were known to need such resources by 2 hours postoperatively (70%, negative predictive value 93.8%). Neither AHI nor obesity status was correlated with need for resources; however, resource need was associated with young age, gastrostomy tube status, and neuromuscular disorders (P = 0.048, P = 0.002 and 0.013, respectively). CONCLUSION: Most high-risk adenotonsillectomy patients do not utilize critical care resources despite their increased perioperative risk. Patients with respiratory complications are frequently identifiable within the first 2 hours of surgery. LEVEL OF EVIDENCE: 4 Laryngoscope, 129:1229-1234, 2019.

Electronic medical record-based tools aid in timely triage of disc-shaped foreign body ingestions.

OBJECTIVES/HYPOTHESIS: Children presenting to the emergency department with coin-shaped foreign body (FB) ingestion must be evaluated urgently to rule out a button battery. As many of these ingestions are well-appearing on presentation, delays in triage put patients at risk for further injury. STUDY DESIGN: Quality initiative. METHODS: A quality initiative, utilizing electronic medical record (EMR)-based tools, was implemented at our academic children's hospital. A chief complaint pertaining to coin-shaped FB ingestion was created and was linked to a best practice advisory, instructing assignment of acuity level 2 and the order of a Stat x-ray. A link to the hospital's relevant algorithm was provided. A review was conducted comparing children who underwent FB removal preinitiative (January 1, 2016-January 28, 2017) and postinitiative (January 31, 2017-August 30, 2017). Primary outcomes were frequency of assignment of acuity level 2 and time from patient arrival to x-ray order placement and x-ray completion. RESULTS: Thirty-six patients in the baseline group and 30 in the postintervention group underwent FB removal. The rate of appropriate acuity assignment increased from 63.8% (23/36) pre implementation to 100% (30/30) postimplementation (P = .0003). Median time from arrival to imaging ordered and completed decreased from 36.5 to 4 minutes (95% confidence interval [CI]: -44 to -17) and 59 to 41 minutes (95% CI: -39 to -1), respectively. CONCLUSIONS: Utilization of EMR-based tools was associated with improved timeliness in initiation of care in metallic FB ingestion patients. Further initiatives will be aimed at downstream events in the diagnosis and treatment of these patients. LEVEL OF EVIDENCE: NA Laryngoscope, 128:2697-2701, 2018.

The "Surgeon on Service" Model for Timely, Economically Viable Inpatient Care of Tracheostomy Patients in Academic Pediatric Otolaryngology.

Importance: The traditional practice model for pediatric otolaryngologists at high-volume academic centers is to simultaneously balance outpatient care responsibilities with those of the inpatient service, emergency department, and ambulatory care clinics. This model leads to challenges with care coordination, timeliness of nonemergency operative care, and consistent participation in care and consultation at the attending surgeon level. The "surgeon on service" (SOS) model-where faculty members rotate to manage the inpatient service in lieu of outpatient responsibilities-has been described as one method to address this conundrum. The operational and economic feasibility of the SOS model has been demonstrated; however, its impact on care coordination, time from consultation to surgical care, and length of stay (LOS) have not been evaluated. Objective: To determine the impact of the SOS model on the quality principles of timeliness and efficiency of tracheostomy tube placement and to determine if the SOS model is fiscally feasible in an academic pediatric otolaryngology practice. Design, Setting, and Participants: Medical record review of patients undergoing tracheostomy in a pediatric academic medical center and survey of their treating physician trainees, comparing the 6-month SOS pilot phase (postimplementation, January-June 2016) with the 6-month preimplementation period (January-June 2015). Intervention: Implementation of the SOS model. Main Outcomes and Measures: Time to tracheostomy, frequency of successful coordination of tracheostomy with gastrostomy tube placement, total LOS, productivity measured in work relative value units, and responses to trainee surveys. Results: Of the 41 patients included in the study (24 boys and 17 girls; mean age, 3 years; range, 3 months to 17 years), 15 were treated before SOS implementation, and 26 after. Also included were 21 trainees. Before SOS implementation, median time to tracheostomy was 7 days (range, 2-20 days); after SOS implementation, it was 4 days (range, 1-10 days) (difference between the medians, before to after, -3 days; 95% CI, -5 to 0 days). There was no significant difference in overall LOS or ability to coordinate tracheostomy with gastrostomy tube placement. Preimplementation trainee surveys cited dissatisfaction with the communication channels to the primary team when the consulting surgeon was not immediately available to perform tracheostomy. No challenges were reported after implementation. Productivity was comparable to that in the outpatient setting. Conclusions and Relevance: In this study, the presence of a rotating inpatient pediatric otolaryngologist was a productive approach to patient care associated with more timely performance of tracheostomy. Other benefits were an improved balance of service with education to trainees and a better perception of communication with consulting services.

Responses to errors and adverse events: The need for a systems approach in otolaryngology.

OBJECTIVES/HYPOTHESIS: To report otolaryngologists' reactions to errors and adverse events and determine if temporal changes in physician efforts to assume responsibility; ameliorate patients' conditions; or change personal, group-wide, or hospital practices have occurred. STUDY DESIGN: Mixed-methods analysis of survey entries detailing responses to errors and adverse events. METHODS: Members of the American Academy of Otolaryngology-Head and Neck Surgery were asked to report errors or adverse events. Responses to open- and closed-ended questions from a similar, previously distributed, anonymous national survey were included for analysis. Responses were enumerated and reported descriptively and then analyzed by reviewers using an interpretive phenomenological approach. Responses were compared to those from an identical survey distributed a decade prior. RESULTS: Otolaryngologists reported 226 adverse events. Responsibility was attributed to the physician surveyed in 74 cases (32.0%), to ancillary staff in 58 cases (25.1%), to consulting physicians in 24 cases (10.4%), and to trainees in 16 cases (6.9%). The undertaking of corrective actions was reported by 175 physicians (75.8%). These events led to changes in personal, group/departmental, and hospital practice in 78 (33.8%), 37 (16.0%), and 11 (4.8%) cases, respectively. CONCLUSION: Following errors and adverse events, otolaryngologists continue to employ corrective actions to ameliorate harm. Responses are directed toward ameliorating the patient injury and also toward efforts to change personal practice and/or improve systems performance. Efforts to change personal practice are much more common than efforts to improve systems. Education about systems-based change represents a large opportunity for improvement in our specialty. LEVEL OF EVIDENCE: N/A Laryngoscope, 126:1999-2002, 2016.

Complications of Pediatric Otitis Media.

OBJECTIVE: Otitis media (OM) is a common diagnosis in the pediatric population that is usually managed on an outpatient basis. A small proportion of children are admitted due to a complex disease course. The aim of this study was to investigate the demographics of those patients and the resources utilized during their admissions. STUDY DESIGN: Retrospective review based on the 2009 Kids' Inpatient Database. SETTING: Nationwide administrative database. SUBJECTS AND METHODS: A review based on the 2009 Kids' Inpatient Database was conducted. Inclusion criteria were clinical modification codes for OM (ICD-9 code 382). Data recorded included patient demographics, concurrent discharge diagnosis codes, length of stay, total charges, and frequency of procedures performed. RESULTS: There were 61,783 (92,548 nationally weighted) admissions with OM, which were analyzed. The average age (SD) for the patients was 2.18 (3.49) years, and the average length of stay was 2.88 days. The majority (80.75%) of patients did not have to undergo a procedure during admission, whereas a small proportion (5.4%) underwent a major operating room procedure. There were 21 deaths recorded (0.03%). A diagnosis of mastoiditis, meningitis, venous sinus thrombosis, or intracranial abscess was associated with significantly increased length of stay, incidence of procedures, and total cost of admission. CONCLUSIONS: Complicated pediatric OM remains of concern requiring prompt and thorough management. Major complications include mastoiditis and meningitis, and unfortunately, fatalities still occur in patients with OM. An understanding of resource utilization and socioeconomic implications can identify and drive opportunities for targeted quality improvement.

Postoperative complications in obese children undergoing adenotonsillectomy.

OBJECTIVE: The incidence of obesity in the pediatric population is increasing. To date, data are limited regarding safety of adenotonsillectomy in this patient population. The purpose of this study is to assess perioperative outcomes of adenotonsillectomy in the obese pediatric patient. METHODS: A review of the 2012 Kids' Inpatient Database (KID) was conducted to compare patients with clinical modification codes for adenotonsillectomy plus obesity to patients with clinical modification codes for adenotonsillectomy alone. Elements for comparison included patient demographics and concurrent discharge. An in depth review of risk factors associated with respiratory complications in obese patients was also conducted. RESULTS: A weighted total of 899 obese and 20,535 non-obese patients admitted after adenotonsillectomy were identified. When these two groups were compared, respiratory complications were found in 16.2% of obese and 9.6% of non-obese patients (p<0.0001). A diagnosis of respiratory failure or pulmonary insufficiency was statistically more common in obese patients when compared to non-obese patients (5.0% versus 3.0%, p=0.007). In obese patients, respiratory complications were associated with male gender, low income, and concomitant asthma on multivariate analysis (p=0.01, 0.004, and 0.007 respectively). CONCLUSION: Performing adenotonsillectomy on the obese pediatric patient is safe. When performing adenotonsillectomy on this patient population, one must be aware that respiratory events are the most common type of complication and risk of respiratory complications is higher in males, patients of low socioeconomic status, and patients with comorbid asthma, regardless of race or insurance status.

Comparison of nasal sprays and irrigations in the delivery of topical agents to the olfactory mucosa.

OBJECTIVES/HYPOTHESIS: Sinonasal diseases are often treated with topical agents administered through various application techniques, but few prior studies have examined their distribution to the olfactory mucosa. The purpose of this study was to compare the distribution of nasal irrigations to sprays within the olfactory cleft. STUDY DESIGN: Human cadaveric study. METHODS: Eight cadaveric heads, providing a total of 15 nasal sides, underwent treatment with methylene blue solution. Application utilized a pressurized spray device followed by an irrigation squeeze bottle, both used according to manufacturer instructions. Videos and images from six standardized anatomical positions were recorded by rigid nasal endoscopy prior to and following each method of agent delivery. Using the acquired images, three reviewers blinded to the means of application scored the approximate surface area stained. An image-analysis program was additionally calibrated and used to measure pixel intensity in order to quantify surface delivery of methylene blue. RESULTS: Based on both blinded reviewer ratings and image pixel intensity measurements, irrigations demonstrated a greater extent and intensity of staining than sprays within the sphenoethmoid recess, superior turbinate, and superior olfactory cleft (all P < 0.05). Sprays and irrigations, however, were comparable in the extent of staining at the nasal vestibule (P > 0.05), inferior turbinate (P = 0.04), and middle turbinate (P > 0.05). CONCLUSIONS: Compared to sprays, irrigations provide a more effective method of delivering topical agents to the posterior and superior aspects of the nasal cavity. The thorough distribution of irrigations has important clinical implications for improving the delivery of therapeutic agents to the olfactory mucosa.

Complementary and integrative treatments: swallowing disorders.

Swallowing disorders are associated with many disease processes and are associated with significant morbidity and mortality. This article provides information regarding the various causes of swallowing disorders as well as medical, surgical, and integrative approaches to their management.