From smartphone to bed-side: exploring the use of social media to disseminate recommendations from the National Tracheostomy Safety Project to front-line clinical staff.

Traditional methods used to disseminate educational resources to front-line healthcare staff have several limitations. Social media may increase the visibility of these resources among targeted groups and communities. Our project aimed to disseminate key clinical messages from the National Tracheostomy Safety Project to those caring for patients with tracheostomies or laryngectomies. We commissioned an external media company to design educational material and devise a marketing strategy. We developed videos to communicate recommendations from the safety project and used Facebook, Twitter, YouTube and LinkedIn to deliver these to our target users. We recorded 629,270 impressions over a paid 12-week campaign. Our YouTube channel registered more than a five-fold increase in views and watch time during the campaign as compared with the previous year. Around two-thirds of views across all platforms were from peer-to-peer sharing. We spent £4140 on social media advertising, with each view and click costing £0.02 and £0.67, respectively. This intelligence-led approach using social media is an effective and efficient method to disseminate knowledge on the principles of safe tracheostomy care to front-line clinical staff. Similar strategies may be effective for other patient safety topics, especially when targeting groups that do not use medical journals or other traditional means of dissemination.

Multidisciplinary guidance for safe tracheostomy care during the COVID-19 pandemic: the NHS National Patient Safety Improvement Programme (NatPatSIP).

The COVID-19 pandemic is causing a significant increase in the number of patients requiring relatively prolonged invasive mechanical ventilation and an associated surge in patients who need a tracheostomy to facilitate weaning from respiratory support. In parallel, there has been a global increase in guidance from professional bodies representing staff who care for patients with tracheostomies at different points in their acute hospital journey, rehabilitation and recovery. Of concern are the risks to healthcare staff of infection arising from tracheostomy insertion and caring for patients with a tracheostomy. Hospitals are also facing extraordinary demands on critical care services such that many patients who require a tracheostomy will be managed outside established intensive care or head and neck units and cared for by staff with little tracheostomy experience. These concerns led NHS England and NHS Improvement to expedite the National Patient Safety Improvement Programme's 'Safe Tracheostomy Care' workstream as part of the NHS COVID-19 response. Supporting this workstream, UK stakeholder organisations involved in tracheostomy care were invited to develop consensus guidance based on: expert opinion; the best available published literature; and existing multidisciplinary guidelines. Topics with direct relevance for frontline staff were identified. This consensus guidance includes: infectivity of patients with respect to tracheostomy indications and timing; aerosol-generating procedures and risks to staff; insertion procedures; and management following tracheostomy.

Guidelines for the management of tracheal intubation in critically ill adults.

These guidelines describe a comprehensive strategy to optimize oxygenation, airway management, and tracheal intubation in critically ill patients, in all hospital locations. They are a direct response to the 4th National Audit Project of the Royal College of Anaesthetists and Difficult Airway Society, which highlighted deficient management of these extremely vulnerable patients leading to major complications and avoidable deaths. They are founded on robust evidence where available, supplemented by expert consensus opinion where it is not. These guidelines recognize that improved outcomes of emergency airway management require closer attention to human factors, rather than simply introduction of new devices or improved technical proficiency. They stress the role of the airway team, a shared mental model, planning, and communication throughout airway management. The primacy of oxygenation including pre- and peroxygenation is emphasized. A modified rapid sequence approach is recommended. Optimal management is presented in an algorithm that combines Plans B and C, incorporating elements of the Vortex approach. To avoid delays and task fixation, the importance of limiting procedural attempts, promptly recognizing failure, and transitioning to the next algorithm step are emphasized. The guidelines recommend early use of a videolaryngoscope, with a screen visible to all, and second generation supraglottic airways for airway rescue. Recommendations for emergency front of neck airway are for a scalpel-bougie-tube technique while acknowledging the value of other techniques performed by trained experts. As most critical care airway catastrophes occur after intubation, from dislodged or blocked tubes, essential methods to avoid these complications are also emphasized.

Multidisciplinary guidelines for the management of paediatric tracheostomy emergencies.

Temporary and permanent tracheostomies are required in children to manage actual or anticipated long-term ventilatory support, to aid secretion management or to manage fixed upper airway obstruction. Tracheostomies may be required from the first few moments of life, with the majority performed in children < 4 years of age. Although similarities with adult tracheostomies are apparent, there are key differences when managing the routine and emergency care of children with tracheostomies. The National Tracheostomy Safety Project identified the need for structured guidelines to aid multidisciplinary clinical decision making during paediatric tracheostomy emergencies. These guidelines describe the development of a bespoke emergency management algorithm and supporting resources. Our aim is to reduce the frequency, nature and severity of paediatric tracheostomy emergencies through preparation and education of staff, parents, carers and patients.

Assessment of scoring systems to describe the position of tracheostomy tubes within the airway - the lunar study.

BACKGROUND: Malposition of tracheostomy tubes is difficult to detect at the bedside and may contribute to eventual device misplacement. Endoscopic examination can be undertaken via tracheoscopic (T-view) or trans-laryngeal (L-view) approach, offering more precise detail regarding positioning within the airway. The aims of this study were to evaluate inter-rater agreement between bespoke T and L view scoring systems and subsequently whether T-views could predict L-views. METHODS: Adult intensive care unit patients with percutaneous or surgical tracheostomies were included and paired T and L-views of their tracheostomy tube within the airway were taken on up to four occasions. Images were later scored by five independent raters using bespoke scoring systems. The primary outcome was to determine the T and L view scoring system with the best inter-rater agreement, defined by weighted kappa and intra-class correlation coefficients. The secondary outcome was to assess agreement between T and L-view scoring systems. RESULTS: Seventy-one T-views and 43 L-views were obtained from a total of 20 patients. Images were scored by five raters, resulting in 355 T-view scores, 215 L-view scores and 215 paired T and L-view scores for comparison. There was good inter-rater agreement (highest T-view k = 0.84, L-view k = 0.72). There was poor agreement between T and L-view scores for each of the paired images (highest k = 0.25) although extreme-to-extreme misclassification rates remained acceptable. CONCLUSIONS: Whilst our data demonstrated good inter-rater agreement between scoring systems, it is not possible to reliably predict the T-view orientation and position of a tracheostomy tube within the airway from the paired L-view. CLINICAL TRIAL REGISTRATION: NCT01356719.

Contamination of single-use bronchoscopes in critically ill patients.

Disposable bronchoscopes such as the Ambu aScopeTM 3 are marketed as 'single use' The risks of contamination from prolonged device storage before possible re-use are unknown. Following clinical bronchoscopy in patients whose lungs were mechanically ventilated, 20 aScopeTM 3's bronchoscopes received a standard 'social clean' and were then stored. Subsequent paired saline flush and swab samples were taken at time zero, and at 24 h and 48 h. Positive microbiological cultures were obtained from at least one time point from 16 of the 20 bronchoscopes. Pathogens considered at high risk of causing pneumonia were isolated from seven bronchoscopes, with significant quantities from six of them. Our study demonstrates that aScopeTM 3's should not be re-used on the same patient, as clinically significant growth of micro-organisms occurs frequently, despite adequate social cleaning. Culture of bronchoscopes themselves may be a potentially useful diagnostic tool in the context of pulmonary infection. Our data make it clear that these devices are single use and not single patient use.

The localization of kisspeptin and kisspeptin receptor in the canine ovary during different stages of the reproductive cycle.

Kisspeptin is a neuropeptide involved in the hypothalamic regulation of reproduction in many species. Recent studies have revealed kisspeptin within the ovaries of rats, Siberian hamsters and humans, indicating a local role in reproduction. However, the role of kisspeptin in the ovary is poorly understood in the bitch. This study investigated the presence and location of kisspeptin protein (KISS1) and kisspeptin receptors (KISS1R) in the canine ovary during different stages of the reproductive cycle (pre-pubertal, anoestrus and cycling) by means of immunohistochemical staining. Ovaries from 24 bitches presented at local veterinary clinics for routine ovariohysterectomy were collected and grouped based on reproductive stage (pre-pubertal, anoestrus and cycling (proestrus, oestrus and dioestrus)). The presence or absence of immunoreactive KISS1 and KISS1R was recorded without any quantification of the levels of expression within cells. Immunoreactive KISS1 was found in the oocytes during all stages of the oestrous cycle, in the granulosa cells during all stages except anoestrus and in the corpus luteum (CL) during dioestrus. KISS1 was absent in the ovaries of pre-pubescent bitches. Immunoreactive KISS1R were consistently found in the oocytes, primordial follicles, the granulosa cells and CL in cycling bitches. The finding of KISS1R in the granulosa cells is suggestive that kisspeptin and progesterone may be linked as this pattern of staining is seen in animals that show preovulatory luteinisation of follicles during oestrus, KISS1R were also observed in the ovaries of pre-pubescent and anoestrous bitches, suggesting a possible role of kisspeptin in oocyte proliferation, development and maturation of granulosa cells, and progesterone production. This study provides a starting point for the establishment of a canine model for kisspeptin regulation within the ovary.

A comparison of ventilator-associated pneumonia rates determined by different scoring systems in four intensive care units in the North West of England.

Ventilator-associated pneumonia is a common healthcare-associated infection with significant mortality, morbidity and healthcare cost, and rates have been proposed as a potential quality indicator. We examined ventilator-associated pneumonia rates as determined by different diagnostic scoring systems across four adult intensive care units in the North West of England. We also collected clinical opinions as to whether patients had ventilator-associated pneumonia, and whether patients were receiving antibiotics as treatment. Pooled ventilator-associated pneumonia rates were 36.3, 22.2, 15.2 and 1.1 per 1000 ventilator-bed days depending on the scoring system used. There was significant within-unit heterogeneity for ventilator-associated pneumonia rates calculated by the various scoring systems (all p < 0.001). Clinical opinion and antibiotic use did not correlate well with the scoring systems (k = 0.23 and k = 0.17, respectively). We therefore question whether the ventilator-associated pneumonia rate as measured by existing tools is either useful or desirable as a quality indicator.

Characterizing the relationship between gonadotropin releasing hormone (GnRH), kisspeptin, and RFamide related peptide 3 (RFRP-3) neurons in the equine hypothalamus across the estrous cycle and in the anovulatory seasons.

To understand better the role that kisspeptin plays in regulating seasonal and estrous cycle changes in the mare, this study investigated the number, location and interactions between GnRH, kisspeptin and RFRP-3 neurons in the equine hypothalamus. Hypothalami were collected from mares during the non-breeding season, vernal transition and various stages of the breeding season. Fluorescent immunohistochemistry was used to label the neuropeptides of interest. GnRH cells were observed primarily in the arcuate nucleus (ARC), while very few labeled cells were identified in the pre-optic area (POA). Kisspeptin cells were identified primarily in the ARC, with a small number of cells observed dorsal to the ARC, surrounding the third ventricle (3V). The mean number of kisspeptin cells varied between animals and typically showed no pattern associated with season or stage of estrous cycle, but a seasonal difference was identified in the ARC population. Small numbers of RFRP-3 cells were observed in the ARC, ventromedial hypothalamus (VMH) and dorsomedial hypothalamus (DMH). The mean number of RFRP-3 cells appeared higher in pre-ovulatory animals compared to all other stages. The percentage of GnRH cell bodies with kisspeptin appositions did not change with season or stage of estrous cycle. The percentage of kisspeptin cells receiving inputs from RFRP-3 fibers did not vary with season or stage of estrous cycle. These interactions suggest the possibility of the presence of an ultra-short loop feedback system between these three peptides. The changes in RFRP-3 neurons suggest the possibility of a role in the regulation of reproduction in the horse, but it is unlikely to be as a gonadotropin inhibitory factor.

Feasibility of a virtual reality course on adult tracheostomy safety skills.

The National Tracheostomy Safety Project has run high-quality, face-to-face skills courses since 2009. The aim of this project was to produce a virtual reality version of the established course and evaluate its impact on participant learning, and participant and faculty satisfaction. Healthcare staff and students were recruited and randomised to attend one of (1) a face-to-face traditional course (control); (2) a virtual reality course at a conference centre with on-site technical support; (3) a fully remote virtual reality course; the virtual reality groups were combined for the analysis of learning outcomes and satisfaction. The primary outcome was the difference in pre/post-course knowledge scores on a 30-item questionnaire; secondary outcomes included knowledge retention, usability, comfort/side effects and participant performance in a simulated tracheostomy emergency. Thirty-seven participants and 15 faculty participated in this study. There was no significant difference between mean pre/post-course scores from the face-to-face (from 21.1 to 23.1; +2) and combined virtual reality (from 17.1 to 21.1; +4) groups, with both showing improvement (p = 0.21). The mean System Usability Scale score for virtual reality was 76.8 (SD 12.6), which is above average; the median Simulator Sickness Questionnaire score was 7.5 (IQR 3.7-22.4), indicating minimal symptoms. All participants resolved the primary clinical problem in the simulated emergency, but the virtual reality (VR) group was slower overall (mean difference 61.8 s, p = 0.003). This technical feasibility study demonstrated that there was no difference in participant knowledge immediately after and 4 weeks following face-to-face and virtual reality courses. Virtual reality offers an immersive experience that can be delivered remotely and offers potential benefits of reducing travel and venue costs for attendees, therefore increasing the flexibility of training opportunities.

Multidisciplinary guidelines for the management of tracheostomy and laryngectomy airway emergencies.

Adult tracheostomy and laryngectomy airway emergencies are uncommon, but do lead to significant morbidity and mortality. The National Tracheostomy Safety Project incorporates key stakeholder groups with multi-disciplinary expertise in airway management. , the Intensive Care Society, the Royal College of Anaesthetists, ENT UK, the British Association of Oral and Maxillofacial Surgeons, the College of Emergency Medicine, the Resuscitation Council (UK) the Royal College of Nursing, the Royal College of Speech and Language Therapists, the Association of Chartered Physiotherapists in Respiratory Care and the National Patient Safety Agency. Resources and emergency algorithms were developed by consensus, taking into account existing guidelines, evidence and experiences. The stakeholder groups reviewed draft emergency algorithms and feedback was also received from open peer review. The final algorithms describe a universal approach to managing such emergencies and are designed to be followed by first responders. The project aims to improve the management of tracheostomy and laryngectomy critical incidents.

Practice of tracheostomy in patients with acute respiratory failure related to COVID-19 - Insights from the PRoVENT-COVID study.

OBJECTIVE: Invasively ventilated patients with acute respiratory failure related to coronavirus disease 2019 (COVID-19) potentially benefit from tracheostomy. The aim of this study was to determine the practice of tracheostomy during the first wave of the pandemic in 2020 in the Netherlands, to ascertain whether timing of tracheostomy had an association with outcome, and to identify factors that had an association with timing. METHODS: Secondary analysis of the 'PRactice of VENTilation in COVID-19' (PRoVENT-COVID) study, a multicenter observational study, conducted from March 1, 2020 through June 1, 2020 in 22 Dutch intensive care units (ICU) in the Netherlands. The primary endpoint was the proportion of patients receiving tracheostomy; secondary endpoints were timing of tracheostomy, duration of ventilation, length of stay in ICU and hospital, mortality, and factors associated with timing. RESULTS: Of 1023 patients, 189 patients (18.5%) received a tracheostomy at median 21 [17 to 28] days from start of ventilation. Timing was similar before and after online publication of an amendment to the Dutch national guidelines on tracheostomy focusing on COVID-19 patients (21 [17-28] vs. 21 [17-26] days). Tracheostomy performed ≤ 21 days was independently associated with shorter duration of ventilation (median 26 [21 to 32] vs. 40 [34 to 47] days) and higher mortality in ICU (22.1% vs. 10.2%), hospital (26.1% vs. 11.9%) and at day 90 (27.6% vs. 14.6%). There were no patient demographics or ventilation characteristics that had an association with timing of tracheostomy. CONCLUSIONS: Tracheostomy was performed late in COVID-19 patients during the first wave of the pandemic in the Netherlands and timing of tracheostomy possibly had an association with outcome. However, prospective studies are needed to further explore these associations. It remains unknown which factors influenced timing of tracheostomy in COVID-19 patients.